Pseudocysts are a recognised complication following acute or chronic pancreatitis. Usually located in peripancreatic areas, they have also been reported to occur in atypical regions like liver, pelvis, spleen, and mediastinum. Mediastinal pseudocysts are a rare entity and present with myriad of symptoms due to their unique location. They are a clinical challenge to diagnose and manage. In this paper, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 7 of our patients, as well as our experience in managing these patients along with their clinical outcome.
Ectopic pancreas is typically asymptomatic anomaly that can present anywhere along the GI tract. It is often found incidentally and may become clinically evident when complicated by inflammation, bleeding, obstruction, or malignant transformation. Here, we present a case of ectopic pancreas who presented with gastrointestinal bleeding.
Aims: Management of hepatolithiasis is complicated by residual and recurrent disease, and endoscopic access to biliary tree in such patients enables therapeutic interventions thereby avoiding the morbidity associated with relaparotomy. In this study we assess a modified biliary reconstruction in the form of hepaticojejuno- duodenal access loop (HJDA) with regard to the feasibility of endoscopic access to intrahepatic ducts with follow-up.
Methods: From August 2011 till December 2016, all patients treated for hepatolithiasis with bilateral disease, nondilated extrahepatic biliary system or extensive intrahepatic strictures underwent HJDA. After completion of hepaticojejunostomy (HJ), the free end of the Roux loop was anastomosed to the first part of duodenum in a side to side fashion. In the fourth week postoperatively, endoscopy with conventional forward viewing endoscope was performed to explore the possibility of accessing the biliary system.
Results: Endoscopic access to the intrahepatic bile ducts through the HJDA was possible in all the patients and mean time taken to access the HJ was 3.5 minutes (2-7 minutes). There were no complications pertinent to construction of the HJDA. One patient had bile leak from HJ, which settled with conservative management and surgical site infection was seen in four. We did not have any mortality in our series. During the follow up, three of our patients (30%) subsequently presented with cholangitis at a mean period of 22 months and were successfully managed with endoscopic procedures alone. One patient required balloon dilatation of the HJ stricture, while the other two were managed by endoscopic removal of calculi. Overall, five endoscopic procedures were required in three patients with recurrent cholangitis in the follow up period with rate of 1.67 procedures per patient.
Conclusion: HJDA is a modified biliary reconstruction technique which facilitates endoscopic access to the biliary system for removal of recurrent/residual intrahepatic stones. It is therefore recommended in patients with complicated hepatolithiasis like bilateral disease, recurrence, multiple intrahepatic strictures and for those in whom future endoscopic access to biliary tree is deemed necessary.
This study aimed to determine if neutrophilto-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in pancreatic cystic neoplasms (PCN) and if these improved the performance of the international consensus guidelines (ICG) in the initial triage of these patients. Methods: 318 patients with surgically-treated suspected PCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma. The optimal cut-off for NLR and PLR were determined by plotting the receiver operating characteristics (ROC) curves of NLR/PLR in predicting malignant PCN and utilizing the Youden index. Results: The optimal NLR and PLR cut-offs were determined to be 3.33 and 205, respectively. Univariate analyses demonstrated that symptomatic PCNs, obstructive jaundice, presence of solid component, dilatation of main pancreatic duct 10 mm, high NLR and high PLR were predictive of a malignant PCN. Multivariate analyses demonstrated that obstructive jaundice, presence of solid component, MPD 10 mm and high PLR but not NLR were independent predictors of a malignant PCN. A high PLR significantly predicted invasive carcinoma in patients classified within the ICG HR group. Comparison between the ROC curves of the ICG versus ICG plus PLR in predicting malignant PCN demonstrated a significant improvement in the accuracy of the ICG when PLR was included [AUC 0.784 (95% CI: 0.740e0.829) vs AUC 0.822 (95% CI: 0.772e0.872) (p = 0.0032)]. Conclusions: High PLR is an independent predictor of malignancy in PCN. The addition of PLR as a criterion to the ICG improved the accuracy of these guidelines in detecting invasive neoplasms.
Background: Indications for total duodenopancreatectomy (TDPE) for pancreatic neuroendocrine neoplasms (pNENs) are not clear enough. Aim: To show incidence and typical indications for TDPE for pNENs. Method: Analysis of large surgical series and 5 own TDPE cases. Results: Literature review and our experience of 113 procedures (2001e2015) have shown that TDPEs were performed in 4e13% cases of pNENs. Indications were: Large tumors, occupying more than two anatomical regions with or without vascular involvement; Multiple pNENs > 2 cm in all the anatomical regions, usually in patients with MEN-1 or MEN-4; pNEN of the body and/or tail coexisting with malignant tumor of the pancreatoduodenal zone or vice versa; pNEN of the head and body and/ or tail with multiple serous cystadenomas in von Hippel-Lindau (VHL) disease. In one case TDPE with SMA resection, excision of common, propria hepatic and hepatic arteries resection and right adrenalectomy was performed. Reconstruction was performed by direct SMA anastomosis, and reversed splenic artery with newly-formed hepatic artery bifurcation. Zero lethality, one complication: unexplainable small bowel segmental necrosis, which was successfully treated by gasrtoenteroanastomosis resection with small bowel segment. Patient with VHL died 8 months after surgery due to dissemination of renal cancer. In one case liver mets developed 2,5 years after surgery which were successfully treated by TACE. Four patient are alive within time limits from 1 to 5,5 years with acceptable quality of life. Conclusion: When indicated TDPE, is efficient option for pNEN treatment. Short-and long-term results are acceptable and survival is mainly dependent on NEN or coexisting tumors behavior.
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