Daily Triglyceride Output Volume as an Early Predictor for Chyle Leak Following Pancreaticoduodenectomy.

BACKGROUND/AIM: Useful prophylaxes of chyle leak (CL) after pancreatic surgery have not been established. The aim of the study was to identify an early clinical predictor for CL. PATIENTS AND METHODS: Fifty-five patients who underwent subtotal stomach preserved pancreaticoduodenectomy (SSPPD) were included. Clinical factors associated with postoperative CL were evaluated. RESULTS: Eleven patients (20%) developed a CL after SSPPD. Shorter operative time, absent pancreatic fistula, and triglyceride output volume at postoperative day (POD) two were independent risk factors for CL. The receiver operating characteristics curve of the daily triglyceride output volume at POD two indicated a cut-off point of 177 mg (AUC=0.782; p=0.004; 95% CI=0.639-0.925). CL was significantly associated with prolonged postoperative hospital stay in patients who did not develop a pancreatic fistula (p=0.003). CONCLUSION: Daily triglyceride output volume of >177 mg at POD two may be a predictor of CL following pancreaticoduodenectomy.

Combination of Distance from Superior Mesenteric Artery and Serum CA19-9 as a Novel Prediction of Local Recurrence in Patients With Pancreatic Cancer Following Resection.

BACKGROUND/AIM: Prediction of local recurrence and distant metastasis is important for patients with pancreatic cancer following pancreatic resection. The aims of this study were to identify a novel prognostic score which combines distance from common hepatic artery (CHA) or superior mesenteric artery (SMA) and examine serum CA19-9 for predicting local recurrence in patients with pancreatic cancer following resection. PATIENTS AND METHODS: This retrospective study comprised 149 patients who went through elective pancreatic resection for pancreatic cancer between June 2007 and December, 2017. We established new scores (CHA score and SMA score) using the distance between CHA or SMA and the tumor measured by preoperative CT scan in combination with preoperative serum CA19-9 values. We evaluated the relationship between the scores and local recurrence of pancreatic cancer. Finally, we investigated the relationship between the scores and local recurrence-free survival as well as the overall survival. RESULTS: The optimal cut-off levels of the distance between CHA or SMA and the tumor, as determined by ROC analysis, were 20.55 and 10.9 mm, respectively. In a logistic progression model, demonstrated by multivariate analysis, lymphatic invasion (p=0.002), preoperative serum CA19-9 (p=0.007) and SMA score (p=0.004) were identified to be independent predictors of local recurrence in patients with pancreatic cancer following resection. In a Cox progression model, demonstrated by multivariate analysis, intraoperative blood loss (p=0.022), lymphatic invasion (p=0.001) and SMA score (p<0.001) were identified as independent factors of local recurrence. The independent predictors of poor overall survival by multivariate analysis consisted of intraoperative blood loss (p=0.045), intraoperative transfusion (p=0.026) and SMA score (p<0.001). CONCLUSION: The SMA score may be an independent preoperative predictor of local recurrence and prognosis in patients with pancreatic cancer.

Radical resection of T1 pancreatic adenocarcinoma with a pseudocyst of the tail due to acute obstructive pancreatitis: report of a case.

A 53-year-old male visited his primary physician for epigastric and back pain. Abdominal-enhanced computed tomography (CT) revealed a simple cyst of the pancreatic tail attached to the stomach. A distal main pancreatic duct (MPD) was clearly dilated, but no pancreatic tumor was identified around the stenosis of MPD by CT scan and magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde pancreatography (ERP) revealed stenosis and distal dilation of the MPD located between the body and tail of the pancreas. Endoscopic ultrasound (EUS) revealed a low density mass of 7 mm in size with distal dilation of the MPD. With the suspicion of a small pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy with lymph node dissection (D2). On histopathological evaluation, a small pancreatic adenocarcinoma of 6 mm in size was detected around the stenosis of MPD. Final pathological diagnosis was moderately differentiated invasive ductal adenocarcinoma of the pancreas with no lymph node metastasis (Japan Pancreatic Society (JPS) classification 7th edition; Pbt, TS1 (6 mm), tub2, intermediate type, INF ß, ly1, v1, ne1, mpd(-), pT1b, pN0, pM0, stage IA,PCM(-), DCM(-) and the Union International Control Cancer (UICC) classification of malignant tumors 6th edition; pT1, pN0, pM0, stage IA, R0). We herein reported a patient who underwent radical resection for T1 pancreatic adenocarcinoma of 6 mm in diameter which caused acute pancreatitis and a pseudocyst due to obstruction of the MPD.

Stent graft placement and balloon dilation for pseudoaneurysm complicated by distal arterial stenosis of the hepatic artery after pancreaticoduodenectomy.

Hemorrhage from ruptured pseudoaneurysm is a rapidly progressing and potentially fatal complication after pancreaticoduodenectomy (PD). Stent graft placement for hepatic artery pseudoaneurysm has recently been reported as a valid alternative to transcatheter arterial embolization (TAE). We report a case of pseudoaneurysm of the common hepatic artery (CHA) with distal arterial stenosis treated by stent graft placement for pseudoaneurysm and balloon dilation for arterial stenosis due to pancreatic fistula after PD. A 67-year-old man underwent PD for intraductal papillary mucinous neoplasm with concomitant early gastric cancer. After the operation, pancreatic fistula developed, for which conservative management by drainage was continued. On the postoperative day 30, melena started. Emergency abdominal angiography revealed a pseudoaneurysm in the CHA, as well as distal arterial stenosis extending from the proper hepatic artery (PHA) to bilateral hepatic arteries. The portal vein was also stenotic due to pancreatic fistula, for which TAE was not judged suitable because of the risk of liver failure. Therefore, stent graft placement and balloon dilation were chosen. Three pieces of coronary covered stent were placed in a coaxial overlapping manner followed by balloon dilation of the proper and left hepatic arteries. Balloon dilation of the right hepatic artery failed by technical reasons. Completion arteriography confirmed the patency from the CHA to the left hepatic artery as well as the exclusion of the pseudoaneurysm. A liver abscess that developed in the right hepatic lobe after intervention was successfully treated by percutaneous drainage, and the patient discharged on day 27 after stent graft placement. Non-embolic management with preservation of the liver arterial flow may be an option for complicated pseudoaneurysm after PD.

Pancreatic Follicular Lymphoma Presenting as Acute Pancreatitis: Report of a Case.

Pancreatic B-cell lymphoma is rare; it accounts for 0.2% to 2.0% of extranodal non-Hodgkin lymphoma, and constitutes less than 0.5% of all pancreatic malignancies. Most histologic types of the pancreatic lymphoma are diffuse large B-cell lymphoma, and follicular lymphoma is quite rare. We report here a case of pancreatic follicular lymphoma that was initially detected by acute pancreatitis. This is the first reported case of pancreatic follicular lymphoma presenting with acute pancreatitis. A 71-year-old woman had epigastric and left upper quadrant abdominal pain. Computed tomography (CT) revealed features of acute pancreatitis. After standard therapy for pancreatitis, enhanced CT showed a pancreatic tumor (50 × 35 mm) in the body of the pancreas with gradual enhancement. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed a complete interruption of the pancreatic duct in the body, with mild dilation of the duct in the tail of the pancreas. Endoscopic ultrasonography revealed hypervascularity of the pancreatic tumor. The patient underwent distal pancreatectomy to remove the cause of pancreatitis and to disclose the diagnosis. Histologic examination revealed follicular lymphoma of pancreas. Despite recent improvement in clinical strategies, differential diagnosis between pancreatic lymphoma and pancreatic cancer is still difficult without histologic information. Pancreatic lymphoma should be considered as a differential diagnosis in a patient who initially presents with acute pancreatitis.

Identification of inferior pancreaticoduodenal artery during pancreaticoduodenectomy using augmented reality-based navigation system.

BACKGROUND: In pancreaticoduodenectomy (PD), early ligation of the inferior pancreaticoduodenal artery (IPDA) before efferent veins has been advocated to decrease blood loss by congestion of the pancreatic head to be resected. In this study, we herein report the utility of early identification of the IPDA using an augmented reality (AR)-based navigation system (NS). METHODS: Seven nonconsecutive patients underwent PD using AR-based NS. After paired-point matching registration, the reconstructed image obtained by preoperative computed tomography (CT) was fused with a real-time operative field image and displayed on 3D monitors. The vascular reconstructed images, including the superior mesenteric artery, jejunal artery, and IPDA were visualized to facilitate image-guided surgical procedures. We compared operating time and intraoperative blood loss of six patients who successfully underwent identification of IPDA using AR-based NS (group A) with nine patients who underwent early ligation of IPDA without using AR (group B) and 18 patients who underwent a conventional PD (group C). RESULTS: The IPDA or the jejunal artery was rapidly identified and ligated in six patients. The mean operating time and intraoperative blood loss in group A was 415 min and 901 ml, respectively. There was no significant difference in operating time and intraoperative blood loss among the groups. CONCLUSIONS: The AR-based NS provided precise anatomical information, which allowed the surgeons to rapidly identify and perform early ligation of IPDA in PD.

Single-incision laparoscopic surgery for giant hepatic cyst.

INTRODUCTION: The aim of this study was to assess the feasibility and safety of single-incision laparoscopic fenestration and to introduce a new surgical technique. Laparoscopic fenestration has become a standard approach for symptomatic hepatic cysts because of the low recurrence rate and minimal postoperative pain. The single-incision laparoscopic surgery (SILS) technique has increasingly gained acceptance and is now applied to a variety of organs and operations. MATERIALS AND SURGICAL TECHNIQUE: Between February 2010 and March 2011, we consecutively performed six cases of single-incision laparoscopic fenestration. A SILS Port was placed through a single intraumbilical skin incision. In addition to standard laparoscopic instruments, a flexible 5-mm laparoscope and an articulating grasper were used. The cyst wall was dissected with a 5-mm bipolar vessel sealer. SILS was successfully performed in all patients, and none required conversion to conventional multiport laparoscopic surgery or open surgery. Intraoperative blood loss was minimal in all cases. Median operative time was 144 min (range, 100-210 min). All patients were discharged uneventfully on 3 day postoperative. Median postoperative follow-up at 15.5 months (range, 8-20 months) did not reveal any complications or recurrence. The umbilical incisions were almost unnoticeable. DISCUSSION: Our findings suggest that SILS for fenestration of a giant hepatic cyst is a safe and feasible. It is reproducible technique that is comparable to conventional laparoscopic surgery.

Comparison of hepatocellular carcinoma with cirrhosis patients undergoing hepatic resection between hepatitis B and C infection.

BACKGROUND/AIMS: Type B and C hepatic cirrhosis are main causes of hepatocellular carcinoma (HCC). In resected cases of HCC, residual liver function of type B cirrhotic patients tend to be better compared to type C cirrhotic patients. We compared clinical data of patients with type B hepatic cirrhosis with type C hepatic cirrhosis who underwent hepatic resection for HCC. METHODOLOGY: Subjects were 16 patients with type B hepatic cirrhosis and 20 patients with type C hepatic cirrhosis who underwent hepatic resection for HCC at Jikei University Hospital. Perioperative findings including age, gender, preoperative laboratory data including ICGR15, Child's classification, model for end-stage liver disease (MELD) score, tumor factor, type of resection, duration of operation, blood loss and incidence of post-operative complications, as well as disease-free and overall survival were analyzed. RESULTS: In type B cirrhotic patients, the age was younger (p<0.001), pre-operative ICGR15 (p=0.004), hemoglobin (p=0.032), albumin (p=0.006), Child's classification (p=0.008), and MELD score (p=0.011) were better, and incidence of postoperative pulmonary complications were fewer (p=0.039) than type C cirrhotic patients. Preoperative ICG, in 11 of 16 type B cirrhotic patients were normal (<10%). CONCLUSIONS: Residual liver function of type B cirrhotic patients were better than type C cirrhotic patients.