Primary squamous cell carcinoma of the ampulla of Vater is a very rare entity and there are only 11 reported cases to date. We describe a case of primary SCC of the ampulla of Vater with microsatellite instability (MSI) and response to pembrolizumab immunotherapy. To the best of our knowledge, this is the first reported case of SCC of the ampulla of Vater with MSI. Our patient is a 40-year-old male who presented with direct bilirubinemia (total bilirubin: 10.7, direct bilirubin: 7.1) and was noted to have a pancreatic head mass that measured 6.6 x 5.5 x 5.5 cm. The patient underwent a pylorus-preserving pancreatoduodenectomy with lymph node dissection. Pathology showed 5.5 x 3.5 x 3.5 cm squamous cell carcinoma of the ampulla of Vater based on positive p40 and CK5 on immunohistochemistry. It was noted to be invading the pancreatic head and duodenal mucosal. Surgical margins were negative. Adjuvant chemotherapy with mFOLFIRINOX (irinotecan, 5-fluorouracil, oxaliplatin) was not performed because of active Hepatitis C infection. Chemoradiotherapy with capecitabine and radiation therapy was initiated however patient had progression of disease despite that. The patient was transitioned to Pembrolizumab in the context of MSI high tumor with palliative intent. He had an excellent response to immunotherapy. The therapy was stopped after 18 cycles at patient's request because of persistent symptoms of dizziness and lethargy. At the eight-month follow-up after the last cycle of immunotherapy (2.5 years after surgical resection), the patient had no evidence of relapse on the CT scan.
Background. An aortoenteric fistula (AEF) describes a communication of the aorta or aortic graft with an adjacent loop of the bowel. Aortic graft erosion is a rare complication of abdominal aortic aneurysm repair. We describe a case of a patient presenting with sepsis from Candida glabrata fungemia secondary to aortoenteric erosion without any symptoms or signs of gastrointestinal bleeding. This is a unique case of Candida glabrata fungemia from aortoenteric graft erosion. Case Summary. This patient is a 75-year-old male with a history of a prior aortobifemoral bypass graft in 2005. He presented with complaints of right paraspinal pain and chills. He had no symptoms of gastrointestinal bleeding or abdominal pain. His white blood cell count was 25,600/mcl (4,000–11,000/mcL) with left shift. The erythrocyte sedimentation rate was 11 mm/hr (0-38 mm/hr), and C-reactive protein was 95.5 mg/L (<=10.0 mg/L). Blood cultures were obtained and eventually grew Candida glabrata. A computed tomography angiogram (CTA) of abdomen and pelvis demonstrated inflammation surrounding the graft concerning for graft infection with additional inflammatory changes tracking down both femoral limbs. He underwent staged bilateral femoralaxillary bypass followed by the excision of aortobifemoral bypass. Conclusion. Patients with aortoenteric erosion can present with sepsis in absence of gastrointestinal bleeding. Emergent computed tomography angiogram (CTA) of abdomen and pelvis should be performed to assess for aortic graft erosion or fistula. Empiric treatment with antibiotics should include antifungal agent like micafungin until the final culture is reported. The definite management is an extra anatomic bypass, followed by graft excision.
Background Recurrent laryngeal nerve injury is a feared complication of thyroid surgery, carrying significant morbidity including hoarseness, dysphagia, and respiratory distress. Direct visualization of the nerve during surgery is the standard of care for preventing injury. Intra-operative nerve monitoring (IONM) is an adjunct utilized to decrease the risk of nerve injury, with rising popularity over the past two decades. At present, its exact role is controversial. Some studies advocate routine use, while others suggest that it only adds benefit to select complex cases. The present study is a single-center, retrospective analysis to determine whether the use of IONM significantly prevents injury to the recurrent laryngeal nerve during first-time thyroid surgery, as compared to the current practice of direct nerve visualization. Methods All patients undergoing thyroid surgery at Wellspan York Hospital and its affiliated outpatient surgical center from July 2018 until March 2021 were included in the study. For nine months of the study, IONM was routinely used for first-time thyroid surgery. For the remaining period, direct visualization alone was used for first-time surgery, and IONM was used only selectively for ipsilateral re-operative thyroid surgery. All data was acquired from The Collaborative Endocrine Surgery Quality Improvement Program, a national endocrine surgical database. We compared nerve injury rates across the three groups of patients. Results 377 patients who had thyroid surgery were identified with a total of 591 nerves at risk for injury. Six patients suffered inadvertent nerve injury, for an injury rate of 1.02%. In the group undergoing first-time thyroid surgery with direct visualization alone, four nerves out of 450 (0.89%) were injured. In the group with IONM routinely used for first-time surgery, there was one nerve injury out of 120 (0.83%). For patients with history of previous ipsilateral endocrine surgery with selective nerve monitoring, one injury occurred in a total of 13 at-risk nerves (7.69%). Conclusions The use of IONM as compared to direct identification and photo documentation of the recurrent laryngeal nerve offered no significant advantage in preventing injury. Additionally, re-operative cases have higher incidence of nerve injury, and IONM may be helpful in improving safety in these cases.
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