Curative Resection for Metastatic Solid Pseudopapillary Neoplasm of Pancreas-a Case Series.

Solid pseudopapillary neoplasm (SPN) is an unusual tumor of the pancreas. Unlike ductal adenocarcinoma, SPN is commoner in young women and is indolent with better prognosis. Fifteen percent of patients, however, develop metastases, often synchronous and involving the liver or peritoneum. Owing to the paucity of cases, management of the metastatic disease is not clearly defined. Retrospective review of case notes of patients treated between 2006 and 2019. There were 53 patients with SPN of which 4 had hepatic metastases-3 synchronous and 1 metachronous. Two patients underwent simultaneous distal pancreatectomy and splenectomy with liver resection (right posterior sectionectomy and metastasectomy). One required right hepatectomy with metastasectomy for metachronous liver metastases. The other underwent a staged operation-remnant tumor excision with metastasectomy followed by right hepatectomy after portal vein embolization. All four patients are recurrence free on median follow-up of 38.5 months. In view of the excellent prognosis, we recommend radical resection of both the primary lesion and metastases for SPN.

US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery.

Importance: Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective: To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants: This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures: cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures: The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results: A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance: There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

Intracholecystic papillary-tubular neoplasms of the gallbladder - A clinicopathological study of 36 cases.

Intracholecystic papillary-tubular neoplasms (ICPNs) account for <0.5% of all cholecystectomies. There is a lack of significant published data from the Indian subcontinent on ICPN to the best of our knowledge. The objective of the current study was to describe the clinicopathological features of ICPN of gallbladder from the departmental archives during a 5.5-year period. We also aimed to classify them into various histological subtypes and to correlate the clinicopathological parameters of ICPN with invasive adenocarcinoma. This study included 36 cases diagnosed over a period of 5.5 years (2013-2018). Clinical, radiological and histopathological data were analyzed in detail. The incidence of ICPN was 0.8%. The mean age of patients was 45.7 years with a female to male ratio of 1.3:1. Biliary phenotype was associated with invasion (p ≤0.001). Papillary pattern was present in 15 cases (41.6%) and was associated with invasion (p ≤0.001). High grade dysplasia was seen in 34 cases (94.4%), of which invasion was seen in 18 cases (50%). One case in our study also had synchronous common bile duct carcinoma. Majority (92%) of the patients were alive and well at the end of available follow-up (mean of 7 months and 25 days). ICPNs are mass forming neoplasms of the gallbladder with a slight female predominance. Biliary phenotype has an aggressive course, often associated with an invasive adenocarcinoma component. Papillary configuration of the lesion is significantly associated with an invasive component. Diligent follow-up of these lesions is warranted as they can be associated with other malignancies of the biliary system.

Intraductal Hepatocellular Carcinoma without Parenchymal Tumor: A Case Report.

INTRODUCTION: Obstructive jaundice due to hepatocellular carcinoma is rare. We present a case of hepatocellular carcinoma presenting as an intraductal tumor, which was clinically and radiologically diagnosed as cholangiocarcinoma. CLINICAL PRESENTATION: A 59-year-old male was admitted with recurrent episodes of jaundice. He was found to have a tumor in the right hepatic duct extending into intrahepatic ducts, which was clinically and radiologically diagnosed as cholangiocarcinoma. RESULTS: The patient underwent right hepatectomy with excision of the bile duct and left hepaticojejunostomy. Histological examination revealed an intraductal moderately differentiated hepatocellular carcinoma. The rest of the liver parenchyma showed features secondary to biliary obstruction but no tumor. CONCLUSION: A case of hepatocellular carcinoma presenting as an intraductal tumor with obstructive jaundice and no evidence of parenchymal tumor is presented.

Portal annular pancreas. A rare variant and a new classification.

CONTEXT: Portal annular pancreas is a rare congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein/superior mesenteric vein. It is asymptomatic, but could have serious consequences during pancreatic surgery, if unrecognized. We describe a variant of this anomaly encountered during pancreaticoduodenectomy and propose a new classification. CASE REPORT: We report a 51-year-old male who underwent a pancreaticoduodenectomy for periampullary carcinoma. After division of the pancreatic neck, a sheath of tissue was found posterior and extending to the left of the portal vein. When we divided this tissue, a large duct was encountered; this duct communicated with the main pancreatic duct. On review of the CT images, the main pancreatic duct was seen to be passing posterior to the portal vein and a smaller accessory pancreatic duct was present anterior to the portal vein. We describe the surgical implications. CONCLUSION: This variant of portal annular pancreas has not yet been reported during pancreaticoduodenectomy and we propose a new classification for this fusion anomaly.

Delayed jejunal perforation following blunt abdominal trauma.

Jejunal perforation is a known complication of abdominal trauma. We report two cases of jejunal perforation presenting nearly 2 months following blunt injury to the abdomen and discuss possible mechanisms for delayed small bowel perforation.

Inadvertent central venous infusion of enteral feed: a case report.

Inadvertent administration of enteral feed into an intravenous line is preventable usually by design of incompatible connectors, but these may not be available universally. We discuss a case report where this occurred and the subsequent management strategy.

The pancreas and tuberculosis: a diagnostic challenge.

Pancreatic tuberculosis is often mistaken for malignancy and can pose a diagnostic challenge. A high degree of suspicion is necessary to diagnose this condition which responds well to anti-tuberculosis treatment (ATT). Fine-needle aspiration cytology helps to differentiate malignancy from treatable conditions like tuberculosis. Records of four patients treated for pancreatic tuberculosis between 1997 and 2006 were studied. All patients had a pancreatic mass which was suspected to be malignant at imaging. The diagnosis of tuberculosis was established by FNAC in one case and after laparotomy in one; two had tuberculosis of other systems. All showed good response to ATT which included resolution of the pancreatic mass over mean follow up of 2 years. We suggest that all inoperable masses of the pancreas should be subjected to FNAC to rule out treatable conditions like pancreatic tuberculosis.

Spontaneous perforation of choledochal cyst and hyperemesis gravidarum.

A 28-year-old primigravida at seven weeks gestation presented to the Accident & Emergency Department complaining of vomiting for five days. She was admitted and managed as a case of hyperemesis gravidarum. Two days later she developed abdominal distension. Ultrasound scan revealed ascites and common bile duct dilatation. The ascitic fluid was bile stained. At emergency laparotomy spontaneous perforation of the supraduodenal part of the common bile duct was seen. This was closed around a T-tube. She then underwent medical termination of pregnancy. The post-operative T-tube cholangiogram was suggestive of a type I choledochal cyst. Three months later this was excised and biliary enteric continuity restored by performing a hepaticojejunostomy. To the best of our knowledge, spontaneous rupture of a choledochal cyst in a patient of hyperemesis gravidarum has not been reported before. In this article, we discuss treatment options for choledochal cyst during pregnancy.

Left gastric artery pseudoaneurysm following traumatic pancreatic transection.

A 24-year-old man presented to us 10 days after suffering blunt trauma to the abdomen. He was diagnosed with pancreatic transection and underwent distal pancreatectomy and splenectomy. Two weeks after the operation, he developed intra-abdominal haemorrhage. Selective visceral angiogram revealed left gastric artery pseudoaneurysm, which had embolised. His recovery was uneventful. To our knowledge, ruptured left gastric artery pseudoaneurysm following pancreatic trauma, has not been reported before. In this article, we discuss some vascular complications of pancreatic trauma.

Schwannoma of bile duct--a case report.

This is a case report of a 29 year old woman who presented with painless and progressive obstructive jaundice. Imaging investigations of the abdomen revealed a tumour of the common bile duct. She was treated by complete excision of the bile duct and hepaticojejunostomy. The histopathology report of the tumour read as benign schwannoma.

Management of adult choledochal cysts--a 15-year experience.

BACKGROUND: Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. METHODS: The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. RESULTS: The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. CONCLUSIONS: Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Pancreatic metastasis from renal cell carcinoma 16 years after nephrectomy: a case report and review of the literature.

Two percent of all malignant pancreatic tumors are metastases from other primaries, with small cell lung cancer, colorectal cancer, breast cancer and hematological neoplasms being the commonest. Renal cell carcinoma (RCC) metastasizing to the pancreas is rare and occurs in 2.8% of patients with metastatic RCC. However, RCC is the most common primary leading to solitary pancreatic metastasis. Metastases often present many years after nephrectomy for primary RCC (median time of 8 years) and should therefore be looked for on surveillance or when patients present with upper abdominal symptoms. Complete surgical resection when possible offers the best chance for cure.