Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

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Though rare, jejunal diverticulosis can present with several life-threatening complications that mandates immediate surgery. While the surgical procedure may be technically simple, achieving the accurate preoperative diagnosis is often fraught with challenges. CT scan could prove invaluable in the management if the situation permits.

A 30-year-old lady was referred for the evaluation of a cystic pancreatic mass. The initial ultrasound scan showed a cystic mass measuring 6 ¥ 3 ¥ 3 cm adjacent to the tail of the pancreas. Clinical examination was unremarkable. Subsequently, a computed tomography (CT) scan was performed and showed a 5.1 ¥ 3.6 ¥ 4.6 cm well-circumscribed cystic lesion arising from the body of the pancreas (Fig. 1). The lesion was exophytic in nature and extended superiorly to just below the left hemidiaphragm. No calcification or septation was seen. Her serum carbohydrate antigen 19-9 (CA 19-9) was also found to be elevated at 86 U/mL (0-35 U/mL).An endoscopic ultrasound (EUS), together with fine needle aspiration (FNA) of the cyst, was performed. It showed that the cyst was arising from the body/tail region of the pancreas, and it was also thin-walled and septated. The rest of the pancreas appeared normal. FNA of the pancreatic cyst yielded only a minimal amount of thick mucoid fluid and was sent for both cytological examination and analysed for tumour markers. Cytological examination revealed ciliated columnar epithelial cells with mucoid material and no malignant cells. Unfortunately, our laboratory rejected the specimen for analysis of tumour markers as the contents were deemed too gelatinous and unsuitable.In view of the size and the predisposition for malignant change, she agreed for a laparoscopic spleen preserving distal pancreatectomy. During the diagnostic laparoscopy, the cyst was actually found to be an exophytic mass arising from the posterior wall of the stomach that was resting on the anterior surface of the pancreas (Fig. 2). An on-table gastroscopy was performed to exclude any mucosal involvement and to ensure an adequate gastric capacity after laparoscopic wedge resection.Post-operatively, she recovered well and was discharged on the third post-operative day. A repeat CA 19-9 performed several months later showed that it had normalized to 32 U/mL (0-35 U/mL).Final histology found the lesion to be arising from the posterior aspect of the stomach with the cyst confined in the serosa layer of the stomach and extending into the muscularis propria. It was lined by pseudostratified ciliated columnar epithelium, consistent with respiratory epithelium and surrounded by smooth muscle, reminiscent of a respiratory bronchiole. Scattered seromucinous glands were also seen. There was also focal ulceration of the lining epithelium with Fig. 1. CT scan showing the lesion, which seemed to be arising from the pancreas.Fig. 2. Gross pathological picture showing the cyst arising from the stomach. The cyst lies inferior to the resected stomach in this picture.

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