How-I-Do-ItIt has been shown that external pancreatic ductal stenting (EPDS) can reduce the incidence of clinically relevant postoperative pancreatic fistula. Although studies have described EPDS in open pancreaticoduodenectomy (PD), EPDS in minimally invasive PD has not been reported yet. Thus, the objective of this study was to describe the technique of EPDS in minimally invasive PD. The procedure was performed either laparoscopically or using a robot. Once PD was completed, key steps included triple enterotomy, threading of silk-suture through all enterotomies and exteriorization, completing posterior layer of pancreaticojejunostomy (PJ), railroading stent through preplaced silk-suture, intubation of stent into the pancreatic duct, completion of PJ, followed by hepaticojejunostomy and parietalization of jejunum at the stent exit site. EPDS in PD through a minimally invasive approach can be performed safely in selected cases with either a small-sized pancreatic duct or a soft pancreas.
BackgroundStoma site carcinomas are rare tumors, most of which are metachronous cancers of the colon. Due to the rarity of the condition, evidence-based guidelines are yet to be formulated. The patient and the enterostomal therapist must be aware of stomal tumors to facilitate early intervention, as most tumors are diagnosed at an advanced stage. Therefore, here we describe a case of stomal carcinoma post abdominoperineal resection and its successful management. We also review similar cases reported in the literature.Case A 72-year-old male presented with a nodule over the stoma site of two months duration. He had undergone abdominoperineal resection with end descending colostomy in 1970 for rectal cancer. Examination revealed multiple nodular ulceroproliferative lesions from 9 o'clock to 3 o'clock position. Colonoscopy and staging with whole-body positron emission tomography combined with a contrast-enhanced computed tomography (PET-CT) ruled out other lesions and lymph nodal or distant metastases. Wide local excision and refashioning of stoma were performed. Histopathological examination revealed stage I metachronous descending colon cancer. His postoperative course was uneventful, and there is no evidence of tumor recurrence at three years of follow-up. ConclusionA primary adenocarcinoma originating from a colostomy site is rare but can occur many years after the end of the recommended postoperative follow-up period. It is essential to train ostomates to monitor the stoma for possible tumors to facilitate early diagnosis and to recognize the impact of such a recurrence on survival and quality of life.
BackgroundColorectal schwannomas are rare tumors often detected incidentally and frequently misdiagnosed on preoperative evaluation. They can grow to a large size and create a significant mass effect. A rare case of large rectal Schwannomas mimicking tailgut cyst and managed by a laparoscopic approach is described in the present report.Case A 48- year-old gentleman presented with urinary retention and constipation. Examination revealed an ill-defined hard mass in the left iliac fossa extending to the pelvis. Imaging revealed an 18x12x 9 cm cystic lesion suggestive of a tailgut cyst. The patient underwent Hand-assisted laparoscopic excision of the lesion. The tumor showed spindle cells with myxoid degeneration on microscopic examination and S-100 positivity in immunohistochemistry suggestive of Schwannoma. His postoperative course was uneventful, and there is no evidence of tumor recurrence at eight months of follow-up.ConclusionRectal Schwannoma with myxoid degeneration can mimic tailgut cyst and pose a diagnostic challenge Hand-assisted laparoscopic approach is feasible for excision of large rectal schwannomas.
Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. Methods: A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. Results: During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Conclusions: Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.
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