Accessory right hepatic artery and its significance for a surgeon: A case report

Right hepatic artery (RHA) is a branch of the common hepatic artery; however, there are cases documented in the literature showing anatomical variations. Accessory RHA is an incidental finding during hepatobiliary and pancreatic surgery. This artery should be identified, carefully separated, and preserved during these surgeries. We encounter the variation while doing Whipple’s procedure in a 61-year-old patient diagnosed with carcinoma of the head of the pancreas. Intra-operatively, accessory RHA was present which was arising from the superior mesenteric artery. It was identified, carefully separated, and preserved. Variations in the origin of the artery may make it vulnerable to injuries during surgical procedures if due care is not taken

Multiple Biliary Stones: a Rare Long-term Complication after Whipple Procedure / Múltiplos cálculos biliares: uma complicação rara a longo prazo após o procedimento de Whipple

A hypertensive, diabetic woman underwent a successful Whipple procedure at the age of 84 due to carcinoma of the ampulla of Vater. She presented an extremely rare complication 24 months after the surgery, consisting of acute cholangitis due to multiple biliary lithiases associated with a bilioenteric anastomotic stricture. The diagnosis was confirmed with computed tomography, magnetic resonance cholangiopancreatography, and cholangiography. The patient was successfully treated with multiple percutaneous transhepatic cholangioplasties (AU)

Uma mulher hipertensa e diabética foi submetida a um procedimento bem-sucedido de Whipple aos 84 anos devido a um carcinoma da ampola de Vater e apresentou uma complicação extremamente rara 24 meses após da cirurgia, consistindo em colangite aguda devido à presença de litíase biliar múltipla associada com estenose da anastomose bilio-entérica. O diagnóstico foi confirmado com tomografia computadorizada, colangiopancreatografia por ressonância mag-nética e colangiografia.O paciente foi tratado com sucesso com múltiplas colangioplastias transhepáticas percutâneas (AU)

Pancreatic Reconstruction With Modified Technique Using A “Double U Stitch Pancreatogastrostomy” Following A Laparoscopic Whipple’s Pancreaticoduodenectomy

Background: Pancreaticoduodenectomy is a standard procedure for periampullary tumours. Pancreatic anastomosis is the Achilles heel of the procedure with a significant leak rate and the associated high morbidity. We adopted a modified pancreatic stump drainage with pancreato-gastrostomy - pancreatic stump mobilization with invagination into the lumen of the stomach via posterior gastrotomy and fixation with two U shaped sutures to the posterior wall of the stomach traversing across the pancreatic parenchyma. Materials and Methods: We did a retrospective analysis of a prospectively maintained database of patients who underwent Laparoscopic Whipple’s pancreaticoduodenectomy (WPD) from November 2017 to March 2019 in our department, a tertiary referral centre of Northern India. A total of 34 patients underwent totally laparoscopic Whipple’s pancreatoduodenectomy with the modified Pancreatogastrostomy. Results: A total of 34 patients underwent totally laparoscopic WPD during this study period. The median age was 50 years (27 to 70 years) with 17 male and 17 female patients. Of these patients, 23 patients had their tumours arising from the ampulla, 6 from the duodenum, 3 from the pancreas, 1 SCN head of pancreas and 1 from the distal common bile duct. All patients had R0 resection with a median lymph node yield of 13 (6-19). 9 patients had stage 1 disease, 10 patients had stage 2 disease and 14 patients had stage 3 disease. 31 patients had moderately differentiated adenocarcinoma while 2 patients had well-differentiated tumour morphology. 14 patients had pancreato-biliary differentiation with the remaining 19 patients having intestinal differentiation. The overall number of significant complications according to Clavien-Dindo classification was 17.6% (Grade 3 and higher) . Conclusion: Laparoscopic WPD is a feasible procedure in the hands of a well-trained laparoscopic surgeon. Modified P-G as described, simplifies the pancreatic drainage with a low incidence of post-operative pancreatic fistula and its attendant complications.

Morbidity And Mortality Of Whipple Procedure

Background:To ascertain the rate and factors affecting morbidity and mortality in patients undergoing Whipple Procedure. KEY WORDS:Morbidity,Whipple procedure, post operative complications INTRODUCTION: Pancreaticoduodenectomy, also called the Whipple operation, is a common operation in major centers worldwide. It is done mostly for periampullary cancers and very rarely for benign diseases. Over the years the operation and its morbidity and mortality have been subject to much research. Starting from the initial days postoperative mortality rate has come down but morbidity rate still remains high. Material & Methods:A study of 12 cases of whipple procedure carried out in dept of general surgery, VS AND SVP hospital from January 2019 to June 2020 OBSERVATION AND Results:There were 12 patients and half of them developed morbidity. Surgical site infection was the most common complication (33.33%) followed by pulmonary complications (16.67%) and bile leak (8.33%). Half of the Mortality rate was due to pulmonary complication. Conclusion:Pancreatoduodenectomy was studied with regards to morbidity and mortality in our hospital. The morbidity rate is comparable to that of other centres. Pulmonary complications were the most common cause of mortality. Preoperative Hypoalbuminemia is a significant predictor of postoperative morbidity. Surgical site infection was the most common morbidity. Whipple procedure is a complex procedure with comparatively less mortality, but more morbidity in our hospital.

Adenocarcinoma de papila duodenal maior - Um relato de caso / Adenocarcinoma of the major duodenal papilla - A case report

Tumores periampulares (TP) são originados a partir de estruturas próximas a Ampola de Vater e correspondem a um grupo heterogêneo de neoplasias. O adenocarcinoma da papila duodenal maior faz parte desse grupo de neoplasias. As principais manifestações são a icterícia do tipo obstrutiva, prurido, colúria, acolia fecal, além de perda ponderal e dor abdominal, associado a elevação dos níveis séricos de bilirrubina e enzimas hepáticas. O prognóstico é obscuro, sendo os carcinomas do tipo pancreaticobiliar aqueles com pior prognóstico. A ecografia endoscópica é o método mais sensível para diagnóstico e estadiamento e o tratamento de escolha é pancreaticoduodenectomia, conhecida como cirurgia de Whipple, frequentemente associada à quimioterapia adjuvante ou terapia de quimiorradiação. O presente trabalho propõe descrever um caso de adenocarcinoma da ampola de Vater em paciente de 38 anos atendida no Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF), abrangendo desde a sintomatologia inicial, processo diagnóstico até a conduta terapêutica. Sua relevância está em alertar os profissionais da saúde sobre a importância de elencar os tumores periampulares entre os possíveis diagnósticos diferenciais para pacientes com síndrome colestática, dado que o diagnóstico e a ressecção cirúrgica precoce são os fatores decisivos para um melhor prognóstico. (AU)

Periampular tumors (PT) originate from structures close to Vater's Ampulla and correspond to a heterogeneous group of cancers. The adenocarcinoma of the major duodenal papilla is part of this group of cancers. The main manifestations are obstructive jaundice, pruritus, choluria, fecal acholia, weight loss and abdominal pain, associated with elevated serum levels of bilirubin and liver enzymes. The prognosis is poor, with pancreaticobiliar type carcinomas having the worst prognosis. Endoscopic ultrasound is the most sensitive method for diagnosis and staging, and the best treatment is pancreaticoduodenectomy, known as Whipple surgery, often associated with adjuvant chemotherapy or chemoradiation therapy. The article proposes to describe a case of adenocarcinoma of the Vater's ampulla in a 38-year-old patient treated at the University Hospital of the Federal University of Juiz de Fora (HU-UFJF), covering from the initial symptoms, the diagnostic process and the therapeutic conduct. Its relevance is to alert health professionals about the importance of listing periampular tumors among the possible differential diagnoses for patients with cholestatic syndrome, considering that the diagnosis and early surgical resection are decisive factors for a better prognosis. (AU)

Postoperative morbidity following Whipple’s procedure for periampullary carcinoma: a retrospective study spanning 5 years

Background: The morbidity rates for Whipple’s procedure has remained high even as mortality rates were coming down. This study was intended to assess postoperative morbidity rates in  a tertiary care centre and to compare it with other centres.Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated.Results: There were 48 patients and half of them developed morbidity. Surgical site infection was the most common complication (18.8%) followed by pulmonary complications (12.5%) and bile leak (6.25%). Half of the patients having pulmonary complications died while nobody with surgical site infection or bile leak died.Conclusions: In this study the morbidity rates were comparable to other centres. Hypoalbuminemia is a significant predictor of morbidity. Surgical site infection was the most common morbidity. Pulmonary complications were the most common cause for death. Morbidity rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where the study was conducted.

Postoperative Mortality Rate Following Whipple’s Procedure for Periampullary Carcinoma: A 5 Year Cohort Study

The mortality rates for Whipple’s procedure has come down during the last few years. This study was intended to assess perioperative mortality rates in a tertiary care centre and to compare it with other centres. Methods: Data was collected from various registers and medical records for this retrospective cohort study. All Whipple’s procedures for 5 years were included in the study. Statistical analysis was done using R statistical software and the results were tabulated. Results: There were 48 patients and 8 of them died. A median serum bilirubin level of 16.9 mg% was found statistically significant with respect to mortality. Similarly placed was median serum albumin levels of 2.71 gm% and poor differentiation of tumour. Conclusion: In this study the mortality rates were comparable to other centres. Hypoalbuminaemia is a significant predictor of mortality. Tumour size of more than 3 cm is associated with high mortality. High serum bilirubin levels is an independent predictor of mortality. Several studies also show similar predictors of death in Whipple’s procedure. Pulmonary complications were the most common cause for death. Mortality rate is comparable to other centres and Whipple’s procedure is a safe surgery in the tertiary centre where it was studied.

Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure

An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted deeply into this segment due to the small size of the intrahepatic bile duct. Next, we substituted the endoscope with an upper gastrointestinal endoscope. After positioning the endoscope, the SpyGlass digital system (SPY-DS) was successfully inserted deep into the B2 segment. Upon visualizing the residual stones, we conducted SPY-DS-guided electrohydraulic lithotripsy. The stones were disintegrated and completely removed. In cases of PDCS failure, a treatment strategy using the SPY-DS can be considered for patients with hepatolithiasis after a Whipple procedure.

Manejo anestésico en cirugía hepática, vía biliar y de páncreas

RESUMEN El paciente oncológico representa un reto intelectual y físico para el médico anestesiólogo. Dentro de la complejidad del tratamiento de cáncer, la cirugía hepática, de vía biliar y páncreas requieren consideraciones especiales. La epidemiología y el tipo de neoplasias específicas de esta zona del cuerpo hacen que los tratamientos quirúrgicos sean extensos y radicales para lograr ampliar la sobrevida de los pacientes. El manejo anestésico va encaminado a corregir y optimizar las comorbilidades del paciente previo a la cirugía. El transanestésico involucra un monitoreo invasivo para estabilizar hemodinámicamente al paciente y lograr mantener en adecuado plano anestésico a lo largo del procedimiento. La revisión que a continuación se expone es una actualización sobre la epidemiología y tipo de neoplasias que se involucran en esta zona. Se recuerdan los puntos importantes del manejo anestésico desde la valoración preoperatoria hasta el postoperatorio inmediato. Por último se sugiere un manejo anestésico óptimo basado en la literatura y en consensos de expertos en pacientes con estas condiciones.

SUMMARY Cancer patients are an intellectual and physical challenge for the anesthesiologist. Within the complexity of cancer treatment, surgery of liver, bile duct and pancreas requiere special attention. The specific types of neoplasmas in this area of the body along with their unique epidemiology, make surgical treatments to be radical with the objective of achieving a longer expectation of life. The anesthetic management is aimed to correct and optimize the patient´s comorbidities prior and during surgery. This involves invasive hemodynamic monitoring to keep the patient in an adequate level of anesthesia and stable in their neurologic, renal and cardiovascular variables. The review that is set out below is an update of the types of tumoral diseases that involve this area. Key points are being highlighted regarding the anesthetic management from the preoperative assessment until the inmmediate postoperative period.Finally we suggest an optimal anesthetic procedure based on literature and expert consensus in patients with these conditions.http://jaf.com.uy/2012/07/16/parador-al-aire-libre-en-pueblo-centenario/.

RESUMO O paciente oncológico apresenta um desafio intelectual e físico para o médico anestesiologista. Dentro da complexidade do tratamento, a cirurgia hepática, de via biliar, e pâncreas, requer considerações especiais. A epidemiologia, e o tipo de neoplasia especifica desta região do corpo, fazem com que os tratamentos cirúrgicos sejam extensos e radicais para conseguir uma maior sobrevida. O manejo anestésico visa a corrigir e diminuir as co-morbilidades do paciente previamente à cirurgia. O trans-anestésico obriga a um monitoramento invasivo para estabilizar hemodinamicamente o paciente e conseguir manter um adequado plano anestésico durante o procedimento. Nesta revisão continuada se expõe, uma atualizaçao da epidemiologia e o tipo de neoplasias que se envolvem nesta região. Recordam-se os pontos importantes do manejo anestésico desde a avaliação pré-operatório até o pós-operatório imediato. Por último se sugere um manejo anestésico ótimo fundamentado na literatura e no consenso de expertos em pacientes com estas condições.

Arteriovenous malformation of the pancreatic head – difficulties in diagnosis and treatment.

A patient with pancreatic arteriovenous malformation who presented diagnostic and therapeutic difficulties is presented. The initial tests appeared to suggest inflammatory bowel disease, but the diagnosis was clinched by the finding of blood issuing from the ampulla of Vater. Repeated angiographic embolization did not obliterate the vascular malformation, and the symptoms eventually resolved after Whipple’s pancreaticoduodenectomy.

Clinical experiences of Duct-to-Mucosa Pancreaticojejunostomy and PTBD in Pancreaticoduodenectomy(personal experiences of 93 cases) / 한국간담췌외과학회지

BACKGROUND: Pancreaticoduodenectomy is well established in the armamentarium of the surgeon treating periampullary carcinoma and benign lesion. With refinement of operative technique and more enlighting management during the postoperative period, the morbidity and mortality of this procedure have reduced significantly. Leakage of the pancreaticojejunal anastomosis has been a major complication after this procedure, frequently reported in an incidence of 5 percent to 15 percent. Therefore, authors retrospectivly reviewed about clinical experience of duct-to-mucosa anastomosis and PTBD in pancreaticoduodenectomy. OBJECTS & METHODS: The authors retrospectively reviewed the medical records of 93 patients who had undergone a pancreaticoduodenectomy with the duct-to-mucosa method between 1994 and 2000 by one surgeon. RESULTS: The male-to female ratio was 2.1:1(63:30) and mean age was 57 years old(range from 26 to 77). Thirty patients(32.6%) of 93 patients were distal common bile duct cancer, 22 patients(24%) were pancreatic head cancer, 21 patients(23%) were Ampulla of Vater cancer, 5 patients(5.4%) were chronic pancreatitis, 3 patient(3.3%) were duodenal cancer. The operative morbidity was 35.8%, and there was three perioperative mortality(3.2%). The mean operative time was 8.8 hours. A pancreatic fistula was diagnosed in 6 of the 93 patients(6.5%) and surgical intervention was done in 1 of the 6 patients. A PTBD for preoperatively biliary drainage was done 64 cases and complication related PTBD was 3 cases(4.7%, hemobilia). CONCLUSIONS: Even if this anastomotic technique requires a little more time and attention by the surgeon, we experienced that the low incidence of pancreatico-jejunal anastomosis related complication represents a validation of the method, and a motivation to adapt this anastomotic technique. But, this method is not absolute because surgeon's preference is most important factor in operation.