Periampullary Mass as an Unusual Manifestation of Coccidioidomycosis. Case Report and Literature Review

In Colombia, coccidioidomycosis is a rare entity, and the intestinal manifestation is infrequent, with around a dozen cases reported in the world literature. This article reports the case of a 29-year-old male Venezuelan immigrant with a 4-month history of abdominal pain, jaundice, nausea, and vomiting. The tomography and the endoscopic study revealed a circumferential exophytic mass in the second portion of the duodenum. The biopsy revealed multiple spherules filled with round fungal endospores with a final diagnosis of disseminated coccidioidomycosis. The patient was discharged before the final pathology report with fluconazole doses of 200 mg every other day and an order for outpatient magnetic resonance cholangiography for outpatient follow-up, which he has not attended.

La coccidioidomicosis en Colombia es una entidad infrecuente y la presentación intestinal es extremadamente rara, con alrededor de una docena de casos reportados en la literatura mundial. En el presente artículo se reporta el caso de un paciente inmigrante venezolano masculino de 29 años con historia de dolor abdominal, ictericia, náuseas y vómito de 4 meses de evolución. La tomografía y el estudio endoscópico evidenciaron una masa exofítica circunferencial en la segunda porción del duodeno. La biopsia reveló múltiples esférulas llenas de endosporas fúngicas redondas con diagnóstico final de coccidioidomicosis diseminada. El paciente fue dado de alta antes del reporte final anatomopatológico con dosis de fluconazol de 200 mg interdiario y orden de colangiorresonancia ambulatoria para control ambulatorio, mismo al cual no ha asistido.

Tratamiento quirúrgico paliativo de los tumores periampulares, una opción de paliación a largo plazo / Palliative surgical treatment of periampullary tumors, an option of long-term palliation

RESUMEN Introducción: los tumores de la encrucijada duodeno-bilio-pancreática o periampulares corresponden a un grupo heterogéneo de tumores. Se originan dentro de los 2 cm de la papila duodenal mayor. En los tumores irresecables, el tratamiento debe estar dirigido a la paliación más efectiva. El tratamiento quirúrgico paliativo va dirigido a resolver la obstrucción biliar, duodenal y el dolor, con el fin de optimizar la calidad de vida de los pacientes. Objetivo: describir el comportamiento del tratamiento quirúrgico paliativo de los tumores periampulares. Materiales y métodos: se realizó una investigación observacional, descriptiva y prospectiva con los pacientes con tumor periampular irresecable tributarios a tratamiento quirúrgico paliativo, en el Servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en la ciudad de Matanzas, desde enero del 2010 hasta diciembre del 2019. Resultados: el tumor de páncreas fue el más representado. Todos los pacientes fueron tributarios de derivación biliar quirúrgica paliativa, sin embargo, la derivación gástrica se realizó solo con confirmación endoscópica de infiltración tumoral u obstrucción duodenal y la esplacnicectomía química, siempre que fue factible técnicamente o las condiciones del paciente lo permitieron. La hepaticoyeyunostomía en Y de ROUX fue la derivación biliar de elección. La principal complicación quirúrgica fue la sepsis provocando las muertes. Conclusiones: la paliación quirúrgica es la alternativa de elección con mejores resultados a largo plazo, en los tumores periampulares irresecables con buen estado general, lo que contribuye a una mejor calidad de vida (AU).

ABSTRACT Introduction: the tumors of the duodenal-biliary-pancreatic junction or periampullary tumors correspond to a heterogeneous group of tumor. They originate inside the 2 cm of the major duodenal papilla. In unresectable tumors, the treatment should be intended for the most effective palliation. The surgical palliative treatment is intended for solving biliary, duodenal obstruction, and pain, with the aim of optimizing patients' life quality. Objective: to describe the behavior of the periampullary tumors palliative surgical treatment. Materials and methods: a prospective, descriptive, observational research was carried out in patients with unresectable periampullary tumor tributary to palliative surgical treatment, in the Service of General Surgery of the University Hospital "Comandante Faustino Perez Hernandez", of Matanzas, from January 2010 to December 2019. Results: pancreas tumor was the most represented one. All patients were tributary to biliary palliative surgical derivation, however, gastric derivation was performed only with endoscopic confirmation of tumor infiltration or duodenal obstruction, and chemical splanchnicectomy whenever it was technically feasible and the patient's conditions allowed it. Roux's Y-shaped hepaticojejunostomy was the elective biliary derivation. The main surgical complication was sepsis provoking deaths. Conclusions: surgical palliation is the election alternative with long- term better outcomes, in unresectable periampullary tumors with a good general status, contributing to better life quality (AU).

Choices of methods in dividing the neck of pancreas in laparoscopic pancreaticoduodenectomy / 中华外科杂志

Objective@#To discuss the methods, skills and experiences of dividing the neck of pancreas in laparoscopic pancreaticoduodenectomy(LPD).@*Methods@#The clinical data of 58 patients with periampullary tumors who received LPD at the Union Hospital of Fujian Medical University from December 2014 to January 2017 were retrospectively analyzed.There were 26 males and 32 females, ranged from 18 to 65 years, with a mean age of (46±12)years.@*Results@#All of the 58 patients underwent operation smoothly.Three cases underwent open anastomosis via an auxiliary incision after the total resection of specimen laparoscopically, due to the early learning curve of LPD.Two cases transformed into open operation as a result of tumor vascular invasion to portal vein(PV) or superior mesenteric vein(SMV). Fifty-three cases underwent laparoscopic or laparoscopic combined with robotic pancreaticoduodenectomy completely.Forty-two cases ligated gastroduodenal artery(GDA), fully penetrated the interspace between rear of pancreatic neck and SMV, suspended the pancreas and then divided the neck of pancreas from inferior to superior. Thirteen cases fully dissected the interspace between rear of pancreatic neck and SMV, divided the neck of pancreas from inferior to superior and then ligated GDA.Three cases ligated GDA, dissected PV and SMV at the superior and inferior margin of the neck of pancreas separately, and then divided pancreas from anterior to posterior.Mean time of dividing pancreas was (34.9±9.7)minutes, mean volume of blood loss while dividing pancreas was (30.1±8.2)ml.The main postoperative complications included pancreatic fistula(7 cases, Biochemical leak 2 cases, B grade 3 cases, C grade 2 cases), biliary fistula(3 cases), gastric fistula(1 case), delayed gastric emptying(1 case, C grade), abdominal infection(5 cases), hepatic failure (1 case), intra-abdominal hemorrhage(2 cases), reoperation(2 cases). One case died at the perioperative period while others recovered.The mean duration of postoperative stay was (14.2±5.1)days.@*Conclusions@#Dividing the neck of pancreas is one of the most important steps in LPD, which deserved sufficient attention.At the meantime, a suitable method of dividing the neck of pancreas should be chosen according to intraoperative exploration and preoperative imageological examinations.

Clinical analysis of nine patients with laparoscopic pancreaticoduodenectomy / 中国医师进修杂志

Objective To investigate the safety and feasibility of laparoscopic pancreaticoduodenectomy (LPD). Methods Clinical data of 9 patients who underwent LPD operation from September 2014 to February 2017 in the first hospital of Shanxi Medical University were analyzed retrospectively. Results 9 patients attempted LPD, while one required conversation to open procedure. Two cases underwent hand assisted laparoscopic surgery .The average operative time was (553 ± 86.1) minutes, the average amount of bleeding was (333.3 ± 304.1) ml, and the average hospitalization time after operation was (25.3 ± 8.9) d. Postoperative bowel sound recovery time was (3.5 ± 1) d. Postoperative complications included pancreatic leakage in 4 cases (A grade pancreatic leakage in 1 cases, B grade in 3 case), lymph leakage in 1 case, abdominal hemorrhage in 1 case , gastric emptying in 2 cases , and bile leakage in 1 case. All patients with postoperative complications were cured by non operative treatment. Postoperative pathological examination showed that 5 cases had duodenal papillary adenocarcinoma, 1 case had pancreatic ductal carcinoma, 2 cases had common bile duct disruption differentiation of carcinoma, and 1 case had pancreatic head retention cyst. Patients were followed up 3 to 24 months after operation. 1 case of pancreatic duct died 17 months after operation. One case of middle bile duct carcinoma 12 months after surgery had liver and retroperitoneal lymph node metastasis. The remaining 7 cases had no complications. Conclusions laparoscopic pancreaticoduodenectomy is minimally invasive, safe and feasible.

Resultados perioperatorios y sobrevida alejada de la pancreatoduodenectomía con resección vascular / Pancreaticoduodenectomy with vascular resection: perioperative results and long-term survival

Background: Pancreaticoduodenectomy (PDD) with vascular resection (VR) of the portal and superior mesenteric vein for locally advanced periampullary tumors is controversial. Aim: To evaluate the perioperative results and long-term survival of PDD with VR. Patients and Methods: Retrospective study. We included patients with periampullary tumors who underwent a PDD with VR between 1990 and 2008. We compared perioperative results and long-term survival with PDD without VR during the same period. We compared survival with non resected patients. Results: One hundred and eighty eight patients underwent a PDD, a VR was performed in 8 (4 percent) patients (Age: 58 +/- 14 years, Male: 4). Morbidity for PDD with and without VR was 75 percent and 59 percent (p = ns). Surgical mortality for PDD with and without VR was 0 percent and 8 percent (p = ns). In 6 of 8 patients the diagnosis was pancreatic cancer and histopathologic confirmation of vascular invasion was present in 4 patients. Long-term survival for patients with PDD with and without VR was similar (median 25 and 16 months; p = ns). Survival for patients with PDD with VR was superior to non resected patients (median 25 and 3 months; p = 0.0001). Conclusions: PDD with VR has similar perioperative results and long-term survival to PDD without VR. The survival reached with this type of surgery is far superior to non resected patients.

Introducción: La pancreatoduodenectomía (PDD) con resección vascular (RV) cuando existe invasión de la vena porta o mesentérica superior (VP-VMS) es controversial. Objetivo: Evaluar los resultados del perioperatorio y la sobrevida alejada de los pacientes sometidos a esta técnica. Material y Método: Estudio retrospectivo que incluyó a los pacientes con un tumor periampular en quienes se realizó una PDD con RV entre 1990 y 2008. Se compararon los resultados del perioperatorio y de sobrevida alejada con el grupo sometido a una PDD sin RV durante el mismo período. Se comparó también la sobrevida con los pacientes no resecados. Resultados: Se realizaron 188 PDD, en 8 (4 por ciento) de estos pacientes se realizó PDD con RV (Edad: 58 +/- 14 años, Hombres: 4). La morbilidad postoperatoria para la PDD con y sin RV fue de 75 por ciento y 59 por ciento (p = ns). La mortalidad postoperatoria para los grupos con y sin RV fue de 0 por ciento y 8 por ciento (p = ns). En 6 de los 8 pacientes el diagnóstico fue cáncer de páncreas y en 4 se confirmó histopatológicamente la invasión de VP-VMS. La sobrevida del grupo con y sin RV no tuvo diferencia significativa (medianas 25 y 16 meses; p = ns). La sobrevida de los pacientes sometidos a una PDD con RV fue superior a los pacientes no resecados (medianas 25 y 3 meses; p = 0,0001). Conclusiones: La PDD con RV obtiene resultados perioperatorios y de sobrevida alejada comparables a una PDD sin RV. La sobrevida alcanzada con esta técnica es ampliamente superior a la de los pacientes no resecados.

Analysis on Missed Diagnosis of Periampullary Tumor in Five Cases of Cholecystolithiasis / 中国微创外科杂志

Objective To explore the diagnosis and treatment of cholecystolithiasis accompanying periampullary tumor.Methods A retrospective analysis was performed with clinical data of 5 patients with cholecystolithiasis complicated with periampullary tumor among the 2680 patients receiving laparoscopic cholecystectomy(LC)in our hospital from May 1994 to March 2006.Results Pain in epigastrium,icteric sclera and skin were found in all 5 patients 0.5-17 months after LC.Neoplasms in ampulla were found in re-hospitalization,and periampullary tumor was diagnosed,which were missed in the first operation.Conclusions Improving the knowledge of cholecystolithiasis complicated with periampullary tumor,performing various auxiliary investigations,and reinforcing postoperative follow-up are beneficial for avoidance of missed diagnosis of periampullary tumor,and for early diagnosis and treatment.

Postoperative Complications Following 122 Pancreaticoduodenectomies

BACKGROUND: A pancreaticoduodenectomy is the procedure of choice in patients with periampullary cancer. Because of the improvement in the postoperative mortality and morbidity over the past several decades, the indications for pancreaticoduodenectomy are becoming more extended. The aim of this study was to determine the incidence, the origin, and the present management strategy for early and late complications following this operation. METHODS: In one hundred twenty-two patients who had undergone a pancreaticoduodenectomy for periampullary cancer, mid bile-duct cancer, and other benign or malignant diseases during the period from Oct. 1994 to Dec. 1997 postoperative complications and operative mortality were analyzed retrospectively. RESULTS: Thirty-nine patients were treated for common bile-duct cancer, 37 patients for cancer, 22 patients for ampulla of Vater cancer, 5 patients for duodenal cancer, 4 patients for advanced gastric cancer, 2 patients for gall bladder cancer, and 13 patients for benign diseases or traumatic injury of the pancreas. A standard pancreaticoduodenectomy was performed in 92 patients, a pylorus-preserving pancreaticoduodenectomy in 12 patients, a total pancreatectomy in 11 patients, and a hepatopancreaticoduodenectomy in 7 patients. Of all the patients, 6 patients were treated with a pancreticoduodenectomy with combined portal vein resection. There was one hospital death. Postoperative complications occurred in 66 patients, and 24 patients had more than one. In 10 patients with complications, reoperative treatment was performed. The remaining 56 patients underwent the conservative treatments. CONCLUSIONS: The pancreaticoduodenectomy remains a formidable procedure despite the low mortality rate reported recently. Postoperative complications following a pancreaticoduodenectomy are common and their prompt recognition and appropriate management are of great importance in contributing to a successful outcome for the majority of patients.