[A Case of Choledochoduodenal Fistula and Ruptured Gastroduodenal Arterial Pseudoaneurysm with Penetration to the Duodenum in Invasive Pancreatic Cancer].

The patient was a 76-year-old woman who was referred to our department for jaundice. From further evaluation, resectable cancer of the pancreas head was diagnosed. The patient did not want to undergo surgery, although it had been planned. Thus, we performed biliary stenting and subsequently applied chemoradiotherapy. Then, the patient underwent the best supportive care(BSC). Eleven months after the diagnosis of the pancreatic cancer, she presented with hematemesis while in the hospital for a lumbar compression fracture, and her vital signs showed that she was in shock. Emergency endoscopic examination of the upper gastrointestinal tract revealed bleeding from the duodenal bulb. Endoscopic hemostasis was difficult; therefore, emergency interventional radiology(IVR)was conducted. Owing to the ruptured gastrointestinal pseudoaneurysm in the duodenum, embolization was performed. The 2nd-look endoscopic examination of the upper gastrointestinal tract showed that the biliary stent was exposed to the duodenal bulb, which led to the formation of a choledochoduodenal fistula. As the subsequent course, the patient received conservative treatment and had no onset of retrograde choledochitis; however, the patient died due to the original cancer 15 months after the diagnosis and 4 months after the bleeding.

Needle tract seeding following endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer: a report of two cases.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a useful tool in pancreatic cancer diagnosis. However, the procedure itself may cause peritoneal dissemination and needle tract seeding at the puncture site. We herein report two cases of gastric wall metastasis due to needle tract seeding after EUS-FNA. CASE PRESENTATION: Case 1: A 68-year-old woman was admitted to our hospital for persistent cough. Computed tomography (CT) scan revealed inflammatory changes in the left lung field, and incidentally, a 15-mm hypovascular mass was detected in the pancreatic body. She underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. She underwent distal pancreatectomy with splenectomy; however, a small hard mass was observed in the posterior gastric wall during surgery. We performed partial gastrectomy, and the resected specimen was diagnosed as a needle tract seeding following EUS-FNA. She then underwent adjuvant chemotherapy with TS-1, but the pancreatic cancer showed recurrence 6 months after surgery. She died due to peritoneal dissemination 18 months after surgery. Case 2: A 70-year-old man was incidentally detected with a pancreatic body mass on a CT scan as part of his follow-up for recurrence of basal cell carcinoma. He underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. He had nodules in both lungs, and it was difficult to differentiate them from lung metastasis of pancreatic cancer. Therefore, he underwent neoadjuvant chemoradiotherapy, and thereafter, the lung nodules showed no changes; hence, he underwent distal pancreatectomy with splenectomy. During surgery, we observed a hard mass in the posterior gastric wall. We performed partial gastrectomy, and the resected specimen was diagnosed as needle tract seeding due to EUS-FNA. He underwent chemotherapy with TS-1, and he is still alive 18 months after surgery at the time of writing. CONCLUSION: For resectable pancreatic body or tail tumors, EUS-FNA should be carefully performed to prevent needle tract seeding and intraoperative as well as postoperative assessment for gastric wall metastasis is mandatory.