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Pancreaticoduodenectomy (PD) is recognized as one of the most intricate abdominal surgical procedures, often accompanied by high morbidity rates. The occurrence of an anastomotic ulcer at the gastrojejunal anastomosis post-pancreaticoduodenectomy surgery is a relatively uncommon complication, albeit potentially leading to severe, life-threatening consequences. The predominant symptomatology manifests as acute abdominal pain accompanied by peritonitis. Conventionally, diagnosis is achieved through computed tomography (CT) scans, facilitating subsequent management, and surgical management is recommended in the majority of instances. Herein, we present a rare case of a patient who experienced ulcer perforation at the gastrojejunal anastomosis site after undergoing pancreaticoduodenectomy with stomach preservation, and we reviewed the available literature to gain more comprehension of this rare complication of this type of surgical intervention.
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Anastomosis Quirúrgica , Pancreaticoduodenectomía , Tomografía Computarizada por Rayos X , Humanos , Pancreaticoduodenectomía/efectos adversos , Anastomosis Quirúrgica/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico , Dolor Abdominal/etiología , Masculino , Úlcera Péptica Perforada/cirugía , Úlcera Péptica Perforada/etiología , Peritonitis/etiología , Peritonitis/cirugía , Peritonitis/diagnóstico , Yeyuno/cirugía , Persona de Mediana Edad , Estómago/cirugíaRESUMEN
INTRODUCTION: Xanthogranulomatous pancreatitis (XGP) is a rare, benign, and idiopathic disease that often presents with non-specific symptoms and can mimic or coexist with other pancreatic diseases. Despite its infrequency, XGP is frequently misdiagnosed as a pancreatic neoplasm, with only 15 reported cases in the literature. The pathogenesis of XGP remains unclear. CASE REPORT: We present the case of a 34-year-old woman with no pathological history who experienced continuous abdominal pain and oral intolerance, without signs of cholestasis. An abdominal CT scan initially suggested a cystic neoplasm of the pancreas, leading to a laparotomic cephalic duodenopancreatectomy. The anatomopathological study and immunohistochemistry revealed XGP in association with a mucinous cystic neoplasm with mild to moderate atypia. The patient remained hospitalized for six days post-surgery without any complications. DISCUSSION: XGP may be induced by the inflammatory reaction secondary to the obstruction of the pancreatic duct by mucin. The etiology is unknown, but it is attributed to a combination of obstruction, hemorrhage, or ductal infection. Abdominal pain is the most common symptom. Differentiating XGP from malignant processes of the pancreatic gland is challenging. Surgical treatment typically involves the Whipple procedure; however, echoendoscopy with biopsy is now available for a more accurate and early differential diagnosis. CONCLUSION: XGP is a rare and challenging differential diagnosis for pancreatic neoplasms. Due to its potential to mimic malignant lesions, a high index of suspicion is necessary. Echoendoscopy with fine-needle aspiration biopsy should be considered a routine diagnostic tool before major surgery, such as the Whipple procedure.
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Objetivo: realizar una revisión bibliográfica y presentación de caso de colangiocarcinoma tubulopapilar. Material y Método: Se revisó la ficha médica y las características clínicas, radiológicas y patológicas del tumor, y la literatura científica respecto al carcinoma tubulopapilar. Caso Clínico: Paciente con ictericia progresiva asociado a baja de peso. El estudio imagenológico muestra amputación del tercio distal del colédoco por tejido de partes blandas, sugerente de colangiocarcinoma. Se realiza endosonografía, arrojando "fragmentos superficiales de adenocarcinoma tubulopapilar". Se realiza duodenopancreatectomía cefálica y, posteriormente, se inicia quimioterapia. Discusión: El colangiocarcinoma es una neoplasia de la vía biliar. Existen diferentes variantes histológicas, entre ellas el colangiocarcinoma tubulopapilar. Su diagnóstico se basa en estudios imagenológicos y anatomopatológicos. El principal hallazgo imagenológico va a depender del patrón de crecimiento tumoral; masiforme, periductal o intraductal. Dentro de los intraductales, se describe un carcinoma biliar con crecimiento tubulopapilar, con fenotipo pancreatobiliar epitelial. En los últimos años han sido de interés por tener mejor pronóstico. Conclusión: El colangiocarcinoma tubulopapilar es una variante histológica poco frecuente del colangiocarcinoma, que se asocia a un mejor pronóstico que otras variantes.
Objective: To conduct a literature review and present a case study of tubulopapillary cholangiocarcinoma. Material and Method: The clinical record and the clinical, radiological, and pathological characteristics of the tumor were reviewed, along with the scientific literature regarding tubulopapillary carcinoma. Case Report: Patient with progressive jaundice associated with weight loss. Imaging studies show amputation of the distal third of the common bile duct by soft tissue, suggestive of cholangiocarcinoma. Endosonography was performed, yielding "superficial fragments of tubulopapillary adenocarcinoma." Subsequently, a cephalic duodenopancreatectomy is performed, followed by chemotherapy. Discussion: Cholangiocarcinoma is a neoplasm of the biliary tract. There are different histological variants, including tubulopapillary cholangiocarcinoma. Its diagnosis is based on imaging and pathological studies. The main imaging finding will depend on the pattern of tumor growth: mass-forming, periductal, or intraductal. Among the intraductal types, a biliary carcinoma with tubulopapillary growth and an epithelial pancreatobiliary phenotype has been described. In recent years, they have been of interest due to their better prognosis. Conclusion: Tubulopapillary cholangiocarcinoma is a rare histological variant of cholangiocarcinoma that is associated with a better prognosis than other variants.
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Introduction and importance: Inflammatory myofibroblastic tumors constitute a group of mesenchymal tumors associated with inflammatory infiltration. They occur mainly in young patients. It is classified by the World Health Organization as a borderline neoplasm. They are observed in many organs, particularly the lungs. Digestive localization is rare, and localization into the ampulla of Vater has been reported once. Case presentation: We report the case of a 39-year-old patient who was admitted for cholestatic jaundice with right hypochondrium pain. Computed tomography and magnetic resonance imaging revealed a tumor at the biliopancreatic junction. A cephalic duodenopancreatectomy was performed, and a histological examination of the surgical specimen revealed an inflammatory myofibroblastic tumor of the ampulla of Vater. The postoperative evolution was without any complications. Clinical discussion: This is the second case of localization of an inflammatory myofibroblastic tumor in Vater's ampulla. The therapeutic approach is the complete excision of these inflammatory tumors, thus reducing the risk of local recurrence. In the literature, all cases of incomplete excision have resulted in recurrences. Conclusion: Inflammatory myofibroblastic tumors are rare. The diagnosis was based on histopathological findings and confirmed using immunohistochemical techniques.
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Key Clinical Message: The differential diagnoses of solid pseudopapillary neoplasm of the pancreas include cystic pancreatic neuroendocrine tumor, acinar cell carcinoma, and pancreatoblastoma. Abstract: Solid pseudopapillary neoplasm (SPN) is a low-grade malignant pancreatic tumor which accounts for 0.9%-2.7% of all exocrine pancreatic neoplasms. It predominantly affects young females (90%) and less frequently occurs in male patients. Its prognosis after surgical resection remains excellent. Herein, we report a case of SPN in a male patient.
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Introducción: La duodenopancreatectomía cefálica es una operación cada vez más frecuente en pacientes seleccionados. Objetivo: Identificar la morbilidad y la mortalidad concerniente a la duodenopancreatectomía cefálica convencional. Métodos: Se realizó un estudio observacional, descriptivo de una serie de 15 casos operados de duodenopancreatectomía cefálica. Se investigaron las variables: estadificación según clasificación tumor, linfonódulo, metástasis (TNM), diagnóstico anatomopatológico, complicaciones, tiempo quirúrgico y estado al egreso. Se utilizaron el número absoluto y el porcentaje como medidas de resumen para las variables estadificación y diagnóstico; la media, la mediana y el rango para el tiempo quirúrgico y el intervalo de confianza para el estado al egreso. Resultados: El diagnóstico anatomopatológico principal fue adenocarcinoma de páncreas con 9 pacientes (60,1 %) y de duodeno con 2 (13,3 %). El estadio posoperatorio IIA fue el que prevaleció con 5 (45,5 %). El retraso del vaciamiento gástrico fue la complicación quirúrgica que prevaleció, con 7 (46,7 %) enfermos, seguida de la fístula biliar con 3 (20,0 %). La fístula pancreática, la lesión de la vena mesentérica superior y la hemorragia posoperatoria se presentaron una sola vez (6,7 %), respectivamente. Estas 2 últimas, provocaron la muerte del enfermo en las primeras 48 horas del posoperatorio. Fallecieron 4 (26,7 %) pacientes de la serie. Conclusiones: Las complicaciones posquirúrgicas se observan principalmente a expensas del retardo del vaciamiento gástrico, la fístula biliar y pancreática. La mortalidad puede estar relacionada con la prolongación del tiempo quirúrgico igual o mayor de 5 horas, con el consiguiente aumento de las pérdidas hemáticas.
Introduction: Cephalic duodenopancreatectomy is an increasingly frequent operation in selected patients. Objective: To identify the morbidity and mortality related to conventional cephalic duodenopancreatectomy. Methods: An observational, descriptive study of a series of 15 cases operated on cephalic duodenopancreatectomy. The variables were investigated: staging according to the Tumor, Linphonod, Metastasis (TNM) classification, pathological diagnosis, complications, surgical time and discharge status. Absolute number and percentage were used as summary measures for the variables staging and diagnosis; mean, median and range for surgical time and confidence interval for discharge status. Results: The main pathological diagnosis was adenocarcinoma of the pancreas with 9 patients (60.1%) and of the duodenum with 2 (13.3%). Postoperative stage IIA was the one that prevailed with 5 (45.5%) patients. Delayed gastric emptying was the prevailing surgical complication, with 7 (46.7%) patients, followed by biliary fistula with 3 (20.0%). Pancreatic fistula, superior mesenteric vein injury, and postoperative hemorrhage occurred only once (6.7%), respectively. These last 2, caused the death of the patient in the first 48 hours of the postoperative period. Four (26.7%) patients in the series died. Conclusions: Postoperative complications are mainly observed at the expense of delayed gastric emptying and biliary and pancreatic fistula. Mortality may be related to the prolongation of surgical time equal to or greater than 5 hours with the consequent increase of blood loss.
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PURPOSE: The aim of the present study was to estimate the incidence of very early hepatic metastases (HMs) (<6 months) and their imaging patterns after cephalic duodenopancreatectomy (CDP) for periampullary carcinoma (excluding duodenal carcinoma) and to identify their associated risk factors. METHODS: From January 2003 to June 2016, all patients who underwent surgical treatment for periampullary carcinoma by CDP at our institution and with adequate pre- and postoperative CT scans were included. Univariate and multivariate logistic regressions were performed to determine factors associated with very early HM and recurrence. RESULTS: Of the 132 patients included retrospectively, 27 (20.5%) patients developed HMs. The mean time to diagnosis of HM was 103.9±55.2days. HMs were multiple in 81.4% of cases and bilobar in 59.3% of cases; their mean maximum size was 16.7±12.7mm. In univariate logistic analysis, lymphovascular emboli were significantly associated with HM (p=0.02). No independent risk factors for HM were found in multivariate analysis. In multivariate logistic analysis, two independent risk factors were identified for the occurrence of early recurrence: tumor size >23mm on preoperative CT scan (OR: 3.3; 95% CI: [1.2-9.3]; p=0.02) and tumor differentiation (poor vs. good: OR 15.5; 95 CI [1.5-158.3]; moderate vs. good: OR: 17.1; 95% CI: [1.9-154.4]; p=0.04). CONCLUSIONS: Nearly one in five patients developed HM after CDP within 6 months with a highly consistent pattern. A thorough preoperative assessment, combining CT scan and MRI with a delay of less than three weeks before surgery, appears essential. A routine systematic postoperative CT scan at 8 weeks is also required prior to initiating adjuvant chemotherapy. The type of surgical intervention does not seem to be a risk factor, although the risk of HM occurrence appears to be related to the lymphovascular invasion of the tumor and maybe its degree of differentiation, elements not assessable by imaging.
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Adenocarcinoma/secundario , Neoplasias Duodenales/cirugía , Neoplasias Hepáticas/secundario , Neoplasias Pancreáticas/cirugía , Adenocarcinoma/cirugía , Adulto , Anciano , Quimioterapia Adyuvante , Femenino , Humanos , Incidencia , Modelos Logísticos , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Neoplasias Peritoneales/secundario , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Intramural duodenal haematoma is a rare entity that usually occurs in the context of patients with coagulation disorders. A minimum percentage is related to processes such as pancreatitis and pancreatic tumours. CLINICAL CASE: The case is presented of a 45 year-old male with a history of chronic pancreatitis secondary to alcoholism. He was seen in the emergency room due to abdominal pain, accompanied by toxic syndrome. The abdominal computed tomography reported increased concentric duodenal wall thickness, in the second and third portion. After oesophageal-gastro-duodenoscopy, he presented with haemorrhagic shock. He had emergency surgery, finding a hemoperitoneum, duodenopancreatic tumour with intense inflammatory component, as well a small bowel perforation of third duodenal portion. A cephalic duodenopancreatectomy was performed with pyloric preservation and reconstruction with Roux-Y. DISCUSSION: Treatment of a duodenal haematoma is nasogastric decompression, blood transfusion and correction of coagulation abnormalities. Surgery is indicated in the cases in which there is no improvement after 2 weeks of treatment, or there is suspicion of malignancy or major complications arise. CONCLUSIONS: Duodenal intramural haematoma secondary to chronic pancreatitis is rare, although the diagnosis should be made with imaging and, if suspected, start conservative treatment and surgery only in complicated cases.
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Abdomen Agudo/etiología , Enfermedades Duodenales/complicaciones , Hematoma/complicaciones , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIM: To determine predictors of clinically relevant pancreatic fistulas (CRPF) by measuring drain fluid amylase (DFA) in the early postoperative period. METHODS: This prospective clinical study included 382 patients with periampullary tumors that were surgically resected at our department between March 2005 and October 2012. A cephalic duodenopancreatectomy (DP) was performed on all patients. Two closed suction drains were placed at the end of the surgery. The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer. Pancreatic fistula (PF) was classified according to the International Study Group of Pancreatic Fistula (ISGPF) criteria. Postoperative complications were defined according to the Dindo-Clavien classification. All data were statistically analyzed. The optimal thresholds of DFA levels on the first, second and third postoperative days were estimated by constructing receiver operating curves, generated by calculating the sensitivities and specificities of the DFA levels. The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula (BPF) and CRPF. RESULTS: Pylorus-preserving duodenopancreatectomy was performed on 289 (75.6%) patients, while the remaining patients underwent a classic Whipple procedure (CW). The total incidence of PF was 37.7% (grade A 22.8%, grade B 11.0% and grade C 3.9%). Soft pancreatic texture (SPT) was present in 58.3% of patients who developed PF. Mortality was 4.2%. The median DFA value on the first postoperative day (DFA1) in patients who developed PF was 4520 U/L (range 350-99000 U/L) for grade A fistula (BPF) with a SPT and a diameter of the main pancreatic duct (MPD) of ≤ 3 mm. For grade B/C (CRPF), the median DFA1 value was 8501 U/L (range 377-92060 U/L) with a SPT and MPD of ≤ 3 mm. These values were significantly higher when compared to the patients who did not have PF (122; range 5-37875 U/L). The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were: DFA1 1200 U/L for the BPF and CRPF; DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF. The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF. CONCLUSION: DFA1 ≥ 1200 U/L is an important predictive factor for PF of any degree. The trend of DFA3 (decrease of < 50%) compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.
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Amilasas/metabolismo , Drenaje , Fístula Pancreática/enzimología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Biomarcadores/metabolismo , Drenaje/efectos adversos , Drenaje/mortalidad , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fístula Pancreática/diagnóstico , Fístula Pancreática/etiología , Fístula Pancreática/mortalidad , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/patología , Pancreaticoduodenectomía/mortalidad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Factores de Tiempo , Resultado del TratamientoRESUMEN
Upper gastrointestinal (GI) tract involvement in adult Crohn's disease (CD) is rare and severe complications unusual. Stenosis has been reported, but gastroduodenal fistulae are seldom detected during surgery and most of the fistulae are cologastric or ileogastric. In complicated gastroduodenal CD, medical treatments are often effective and surgery is only considered in exceptional cases. We here report the unusual case of a 23-year-old patient with upper GI CD presenting a hyperalgic giant ulcer of the bulb fistulized in the pancreatic gland. The failure of steroids and two lines of combined treatment led us to a salvage surgical option. Abdominal exploration showed a plate stomach with an inflammatory bulboduodenal block. Cephalic duodenopancreatectomy and cholecystectomy were performed; histological analysis reported large fissuring pylorus ulceration with micro abscesses reaching the pancreas and the presence of non-caseating granulomas. Six months after the surgery, the patient had stopped antalgic treatment and did not have residual abdominal pain. He had gained 11 kg in weight and had no diarrhea with pancreatic enzymes. To our knowledge, we report the first case of an upper GI and fistulizing CD patient heavily treated with steroids and combined immunosuppressant agents requiring salvage cephalic duodenopancreatectomy.