Early pancreaticogastrostomy: a better and novel approach for high grade traumatic pancreatic injuries - case report from tertiary care centre in India

Traumatic pancreatic injury is a rare entity which is associated with severe morbidity and mortality. The management varies according to the American association for the surgery of trauma-organ injury scale (AAST-OIS) grading of injury, hemodynamic status and time of definitive diagnosis. Non-operative versus operative management has potential risks and benefits and long term debate on the ideal management is still ongoing. A 19-year boy, with severe, generalised pain abdomen was admitted after road traffic accident. Upon admission, the investigations: ultrasonography (USG) and computed tomography (CT) scan abdomen, showed traumatic pancreatic injury (AAST-OIS, grade V), was taken for exploratory laparotomy which revealed lacerated head of pancreas along with normal distal segment of pancreas with no associated injury to nearby hollow viscera, vascular structures. He underwent primary closure of head of pancreas with distal segment pancreaticogastrostomy. Postoperatively he recovered well with no complications. In the present case, as he had traumatic pancreatic injury (AAST-OIS, grade V) and there was no involvement of hollow viscera and vascular structures, the operative intervention can decrease morbidity as by pancreaticogastrostomy we have diverted the pancreatic fluid into stomach, subsequently decreasing the chances of pseudocyst, fistula, necrosis of pancreas. Thus we conclude, high grade blunt traumatic abdomen injuries should be managed with adequate resection and subsequent reconstruction and/or drainage procedure. Pancreaticoduodenectomy, distal pancreatectomy, pancreaticogastrostomy, pancreaticojejunostomy are the available options to be used according to the grading of injury and associated injuries.

Comparison among the Role of Different Imaging Techniques in Diagnosis of Malignant Lesions Causing Obstructive Jaundice

Introduction: The expanding spectrum of therapeutic options for patients with Obstructive /surgical jaundice makes it necessary for the surgeon to precisely assess the etiology, location, level and extent of disease before operation. Aims were to compare the diagnostic accuracy, sensitivity and specificity of different imaging techniques like ultrasonography (USG), Computed tomography (CT) and Magnetic Resonance Cholangiopancreatography (MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in evaluation of patients with malignant obstructive jaundice and correlation of histopathological findings after surgical/ therapeutic intervention. Methods: It was a prospective observational study conducted in the Department of General Surgery and Hepatobilliary unit, Dhaka Medical College Hospital and Bangabandhu Sheikh Mujib Medical University, Dhaka during January 2015 to December 2015 for duration of one year to find out the role of different imaging techniques in diagnosis of malignant lesions causing obstructive jaundice in 50 cases who fulfilled the inclusion criteria. Initial USG evaluation was followed by CT scan, MRCP and ERCP. The results were read by radiologists blinded to other imaging findings. Surgically fit patients with a stage of resectability should be offered the option of surgical resection for cure. For unresectable malignancies, the choice is between surgical palliation/bypass and ERCP with drainage. The characteristic surgical findings or ERCP features and histopathological diagnosis were recorded methodically as final. Results: Malignant obstructive jaundice is the commonest amongst the males and mean age was 47.56 ± 13.191 and the commonest etiology was Ca head of pancreas (30%). Diagnostic accuracy of MRCP (98%) in the diagnosis of malignant obstructive jaundice was relatively high (98%) as compared to ERCP (89.5%), CT (91.43%), USG (89.97%) in malignant obstructive jaundice respectively. In the diagnosis of malignant diseases, MRCP was more sensitive (95.83%) as compared to ERCP (89%), CT scan (91.67%) and ultrasonography (78.17%). Regarding specificity MRCP (100%) was the high in comparison among ERCP (94%), CT (90.91%) and USG (96.15%).Conclusion: It is concluded that malignant obstructive jaundice is the commonest amongst the males. Ca head of pancreas was the commonest malignant etiology in malignant obstructive jaundice. MRCP was superior to among USG, CT scan or ERCP in studying the malignant lesions. J Bangladesh Coll Phys Surg 2021; 39: 233-240

Prognosis of Pancreatic Cancer in Hamadan, Iran (2008-2018): A case Series Study

Background: The present study aimed to determine the prognosis of pancreatic cancer from 2008 to 2018 in Hamadan, Iran. A case series study was conducted retrospectively at Beheshti Hospital in Hamadan, Iran. Methods: A total of 409 cases that had been diagnosed with pancreatic cancer from 2008 to 2018 were assessed. The variables included age, gender, pathological type, location involved, early symptoms, metastasis, prognosis and treatments, was extracted from the files and recorded in checklist. Data were analyzed by using SPSS/20 software. Results: The mean of age was 66.23±13.06 year. The most frequent of pancreatic cancers was Adenocarcinomas (66.7%). The highest frequency of early symptoms was jaundice (53.1%) and weight loss (12.7%). The highest frequency of pancreatic cancer lesions was more in the head of pancreas (68.7%). Most patients had metastasis at the beginning of diagnosis (82.3%). Most metastases were in liver (31.5%) and peritoneum (25.2%). The prognosis of the pancreatic cancer is significantly related to the lesion location and the consumption of alcohol, cigarettes and substance abuse (p <0.05), but it wasn’t correlated with age, sex and pathological type (p> 0.05). The 1-year and 5-year survival rates were (22.3%) and (9.5%), respectively. The lowest and the highest in 5-year survival rate were (7.8%) and (18.8%) in adenocarcinoma and carcinoma type. Conclusion: More preventive considerations were found to be beneficial among this population.

CLINICO-ETIOLOGIC PROFILE OF PATIENTS UNDERGOING ERCP FOR OBSTRUCTIVE JAUNDICE SECONDARY TO MALIGNANCY.

Background: Astudy describing the ERCPprole of the patients undergoing the procedure for malignancy related obstructive jaundice. Aim:To analyse the patients undergoing ERCPfor malignant etiology of obstructive jaundice and characterise the outcomes. Introduction: The etiology of obstructive jaundice can be delineated easily into malignancy vs benign etiology. Benign etiology is dominated by stone disease. Malignancy can be varying from periampullary carcinoma, carcinoma head of pancreas, duodenal tumours, cholangiocarcinoma and others. In this study we attempt to analyse the patient prole and outcomes undergoing the procedure at our centre. Methods: A retrospective observational study, conducted in the Department of Digestive Health and Diseases, Kilpauk Medical College, from September 2018 to July 1st, 2019. All the patients undergoing ERCP for obstructive jaundice with probable malignant etiology diagnosed basing imaging and histopathology modes were included. The demographics and the procedure events were recorded after having obtained the informed consent. Results: A total of 70 patients were included in the study. There was male predominance in the study with 48(74.2%) patients and females comprising 18(25.8%). Atotal of 10(14.2%) patients were below the age of 45yrs and 60(85.17%) were above 45 yrs. The predominant etiology for which patients underwent the procedure was cholangiocarcinoma(n= 34, 48.5%). Sixteen patients (22.8%) had periampullary growth, whereas 10(14.2%) had carcinoma head of pancreas, followed by 4 patients with carcinoma of the gall bladder. 24 (34.2%) patients needed a sphincterotomy, 42(60%) patients could be successfully cannulated. During cannulation 36(51%) could be cannulated with 3 or less attempts whereas rest needed >3. Amongst the cannulated patients a plastic stent was successfully placed. 18(25.7%) needed a dilator (SBDC) for successful deployment. A total of 14 patients developed complications of which 10(14.2%) patients developed bleeding during the procedure for which standard of care followed and 2 developed mild post ERCPpancreatitis which was duly managed. Conclusion:Although ERCPhas been established as standard of care for relieving jaundice with obstruction, technical difculties pertaining to the growth location and access for the same restrict the outcomes in many cases. Hence the availability of other modes including palliative surgery could also be offered in such subset of patients.

Primary pancreatic lymphoma: diagnostic pitfall of an uncommon medical entity mimicking operable pancreatic carcinoma: case report and review of literature

Almost all pancreatic neoplasms, including the commonest pancreatic ductal adenocarcinoma (PDAC) are derived from pancreatic epithelial components. Primary pancreatic lymphoma (PPL) is rare, accounting for less than 0.5% of all primary pancreatic tumours and presents a diagnostic and therapeutic challenge owing to their rarity, difficult access, and clinical and imaging features, which can mimic PDAC. A 26-year-old man presented with pain abdomen, jaundice, anorexia and weight loss for two months, along with two episodes of hematemesis and melena. Examination revealed an icteric patient with no palpable abdominal lump. His had a serum bilirubin of 13.6 mg/dl. His ultrasound abdomen, CT scan and MRCP showed a mass in the head and uncinate process of the pancreas with circumferential nodular thickening in second part of duodenum. Side viewing endoscopy was suggestive of carcinoma head of pancreas with duodenal infiltration, for which endoscopic biopsy was taken which revealed non-Hodgkin's lymphoma B cell type. A PET CT showed a metabolically active mass lesion in the head of pancreas, with no other focus of disease anywhere else, suggestive of primary pancreatic lymphoma. This patient was referred to Medical oncology and started on chemotherapy. Lymphoma should be considered when a large, homogeneous, hypoenhancing mass is encountered in the pancreatic head, and with bulky lymphadenopathy. Preoperative tissue diagnosis such as fine needle aspiration cytology with or without flow cytometry and/or laparoscopy/endoscopy guided tissue biopsy may be necessary. It is crucial to differentiate PPL from pancreatic adenocarcinoma since their treatment is primarily medical and prognosis differs considerably.

PERIAMPULLARY ADENOCARCINOMA: A RARE REPORT FROM SOUTH INDIA

Periampullary malignancy is the term utilized for neoplasms emerging from the head of pancreas, ampulla of Vater, distal bile pipe and periampullary distinct of duodenum. Of these, the pancreatic adenocarcinoma conveys the most noticeably awful anticipation with greater part of mortalities.Studies have shown that pancreatic carcinoma has the most limited middle endurance of 17.1 months of all periampullary carcinomas. Herein, we present a case of a 63-year-old male patient without any history of trauma or important previous symptoms presented to the tertiary care hospital with compliance of sudden weight loss and abdominal pain over the preceding 3 months. On examination he was deeply jaundice. His laboratory and radiological examination revealed periampullary adenocarcinoma. This individual had successfully underwent Whipple procedure and followed by Chemotherapy. This case is being presented not only the cancer is rare but also to understand and improve better clinical insight on this rare disease

Clinical Effects of Stereotactic Body Radiation Therapy Targeting the Primary Tumor of Liver-Only Oligometastatic Pancreatic Cancer

AimTo investigate the efficacy and safety of stereotactic body radiotherapy (SBRT) targeting the primary tumor for liver-only oligometastatic pancreatic cancer.MethodsWe compared the efficacy and safety of SBRT plus chemotherapy with chemotherapy alone in patients with liver-only oligometastatic pancreatic cancer. The populations were balanced by propensity score-weighted and propensity score-matched analyses based on baseline variables. The primary outcome was overall survival (OS). The secondary outcomes included progression free survival (PFS), local progression, metastatic progression and symptomatic local control.ResultsThis is a retrospective study of 89 pancreatic cancer patients with liver-only oligometastasis. Overall, 34 (38.2%) and 55 (61.8%) patients received SBRT plus chemotherapy and chemotherapy alone, respectively. After propensity score matching, 1-year OS rate was 34.0% (95%CI, 17.8-65.1%) in the SBRT plus chemotherapy group and 16.5% (95%CI, 5.9-46.1%) in chemotherapy alone group (P=0.115). The 6-month PFS rate was 29.4% (95%CI, 15.4-56.1) in SBRT plus chemotherapy and 20.6% (95%CI, 8.8-48.6) in chemotherapy alone group (P=0.468), respectively. Further subgroup analysis indicated that the addition of SBRT improved OS in patients with primary tumor located in the head of pancreas (stratified HR, 0.28; 95% CI, 0.09 to 0.90) or good performance status (stratified HR, 0.24; 95% CI, 0.07 to 0.86). In terms of disease control, SBRT delayed local progression of pancreas (P=0.008), but not distant metastatic progression (P=0.56). Besides, SBRT offered significant abdominal/back pain relief (P=0.016) with acceptable toxicities.ConclusionsThe addition of SBRT to chemotherapy in patients with liver-only oligometastatic pancreatic cancer improves the OS of those with primary tumor located in the head of pancreas or good performance status. In addition, it is a safe and effective method for local progression control and local symptomatic palliation in patients with metastatic pancreatic cancer.

A case report of portal vein thrombosis and common bile duct compression in the patient having pseudocyst of pancreas and its management by percutaneous trans-hepatic biliary drainage

Pancreatitis is a systemic disease owing to release of inflammatory mediators and digestive enzymes. Acute pancreatitis is sudden inflammation of the pancreas. Alcohol and gallstones are main cause of acute pancreatitis. Chronic pancreatitis is the persistent inflammation and irreversible fibrosis associated with atrophy of pancreatic parenchyma. There are various complications associated with pancreatitis such as strictures, pancreatic necrosis, pseudo-cyst of pancreas, pancreato-cutaneous fistulas, venous thrombosis, arterial aneurysm in various arteries around pancreas etc. Common bile duct (CBD) strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. CBD strictures occur as a consequence of recurrent acute inflammatory episodes which may ultimately result in a periductal fibrotic stricture. CBD can be compressed as a result of extrinsic compression by large pseudocyst or aneurysm. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. Vascular complications in chronic pancreatitis are rare. Venous thrombosis is the most common complication of pancreatitis affecting venous system. It occurs as consequences of an inflammatory mass in head of pancreas, and splenic vein thrombosis occurs in association with chronic pancreatitis in 4-8% cases. Present case is a case of acute pancreatic collection in head of pancreas with aneurysmal small bleeding causing complete CBD compression and extensive venous thrombosis involving superior mesenteric vein, portal vein, splenic.