Background: One of the critical steps during pancreatoduodenectomy (PD) procedure lies in identifying the complicated vascular anatomy of the resected area. The blood supply usually stems from branches of the celiac and the superior mesenteric arteries. However, only in 55-79% of surgeries, the anatomy of the blood vessels encountered by the surgeon is considered normal, while in the remaining cases, there are vascular variations that make these surgeries even more challenging. Any change or deviation from the known surgical course of PD makes surgery difficult and can result in an increase in intra/postoperative complications. In order to reduce difficulties encountered during PD, as well as reducing complication rates and improving surgical outcomes, a preliminary design, which includes preoperative identification of anatomical variations, is needed. The most accurate and accessible tool for identifying such variations is computed tomographic angiography (CTA). The aim of this retrospective study is to assess the prevalence of vascular anomalies encountered during PD, and examine whether there is an association between these anomalies and intra/postoperative morbidity and mortality.
Ewing sarcoma (ES), a malignant tumor of small round blue cells, arises usually in skeletal tissues and lacks neuroectodermal differentiation [1]. It was reported firstly by James Ewing in 1921. Although previously regarded as a separate entity from primitive neuroectodermal tumor (PNET), which exhibits neuroectodermal features, nowadays, they are treated as the same tumor due to the similarity in chromosomal translocation and immunohistochemical characteristics [1]. These tumors belong to the ES family of tumors which include skeletal ES/ PNET, extraskeletal ES/PNET and Askin tumor (thoracopulmonary PNET). These tumors originate from distinctive mesenchymal progenitor cells due to their similar histologic and immunohistochemical characteristics. ES is a highly metastatic type of sarcoma and represents almost 10-15% of bone sarcomas, and is regarded as the second most common primary malignant bone tumor [2]. Although 5-year survival and overall survival have been improved significantly recently, the recurrence rate of such tumors remains high.
Introduction: Gastrointestinal (GI) bleeding is a very common surgical emergency, with an incidence of 150 cases/100000 adults. The small bowel accounts for almost 2-10% of all causes of GI hemorrhage, with vascular abnormalities being the most common cause of small bowel bleeding, while small bowel tumors account for only 5-10%. Gastrointestinal Stromal Tumor (GIST) is the most common mesenchymal tumor of the GI tract, and represent less than 1% of all GI tumors. GIST may present as an incidental radiological/operative finding, or may even present as a surgical emergency in the form of intestinal obstruction, perforation or massive obscure GI bleeding. Methods: A retrospective study over a period of 7 years, between January 1st, 2011 and December 31st ,2017 was performed at the general surgery department at Rambam Health Care Campus, Haifa, Israel. All patients 18 years old and older with a diagnosis of GIST were included in the study. Results: During the aforementioned period, data on 66 patients (n=66) with a diagnosis of GIST were reported. 53% (n=35) patients had gastric GIST, 33.3% patients (n=22) involving the small bowel, 6% (n=4) affected the peritoneum, 3% (n=2) had rectal GIST, 3% (n=2) colon GIST and 1.5% (n=1) had retroperitoneal GIST. Of patients with small bowel GIST, 50% (n=11) presented with GI hemorrhage, with 9 patients (41%) presenting with massive obscure GI bleeding. Most of these patients (7/9) presented initially with melena which evolved into cherry red rectal bleeding later. Average packed cells transfusion was 11.6 units (range 3 units-23 units). There was no association between tumor size and risk for blood transfusion, as the smallest tumor diameter reported was 0.7 cm in a patient receiving 23 packed cells units. On the contrary, a clear correlation was observed between time from admission to diagnosis and the number of packed cells transfused, indicating the importance of high index of suspicion for such entity. 9 out of the 11 patients were diagnosed by Computed Tomographic Angiography (CTA), one was diagnosed during laparotomy and one by push enteroscopy, reflecting the important rule for CTA in diagnosing such rare entity. Conclusion: Small bowel GIST is a rare, yet underestimated entity as a cause of massive GI bleeding, and High index of suspicion is mandatory. Abdomino-pelvic CTA is highly recommended as a first line investigation for patients with massive GI bleeding. Due to lack of studies in the English literature, multi-centric high volume studies are encouraged.
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