Arterial stimulation and venous sampling (ASVS) is useful for recurrent lesions of insulinoma: a case report.

We encountered a recurrent case of benign solitary insulinoma in the pancreatic tail, which may have been caused by an inadequate surgical margin in the use of an ultrasonic dissector. A 45-year-old man was referred with hypoglycemia and diagnosed solitary insulinoma in the pancreas. Laparoscopic pancreatic enucleation was performed using an ultrasonic dissector. The tumor was extracted and the surgical margins were microscopically negative. Six years later, he presented with hypoglycemia again. Multiple small well-enhanced lesions were detected by computed tomography distant from the resection stump of the first operation. He underwent resection of all visible lesions with omentum and wide excision of the soft tissue surrounding the pancreas after preoperative arterial stimulation and venous sampling test. The postoperative course of the second operation was uncomplicated and the patient presents no sign of hypoglycemia after 12 months.

Clinical significance of portal venous metallic stent placement in recurrent periampullary cancers.

BACKGROUND/AIMS: We evaluate the clinical significance of portal venous expandable metallic stent (EMS) placement for patients who have malignant portal hypertension caused by recurrent periampullary cancer. METHODOLOGY: Four post-pancreatoduodenectomy patients underwent percutaneous transhepatic portal venous EMS placement because of symptoms of malignant portal hypertension: intractable ascites (2/4), growth of abnormal collateral vein (3/4), melena (2/4), gastroesophageal varix (3/4) and thrombocytopenia (2/4). They were diagnosed with having a recurrence by cytology of ascitis, computed tomography and/or tumor markers in serum. The stenosis segment was measured by percutaneous-transhepatic portography and was dilated with a balloon prestent placement. The patency of stent was confirmed using Doppler ultrasonography and enhanced computed tomography at least once a month. RESULTS: The portal venous pressure was significantly decreased from (24.5 +/- 3.92 mmH2O) to (19.5 +/- 3.87 mmH2O) and the symptoms related to portal hypertension were reduced in all patients. There were no complications related to EMS placement. All patients were alive more than a year later and two of four patients were alive more than two years without morbidity. CONCLUSIONS: Percutaneous-transhepatic portal EMS placement is a minimally invasive procedure and is a useful treatment against malignant portal hypertension caused by recurrent periampullary cancer.

A minimally invasive approach for postoperative pancreatic fistula.

Pancreas fistula is a well-known and severe complication of pancreaticoduodenectomy. It is difficult to control with conservative therapy, inducing further complications and severe morbidity. Until now, re-operation has been the only way to resolve pancreatic fistula causing complete dehiscence of the pancreatic-enteric anastomosis (complete pancreatic fistula). Percutaneous transgastric fistula drainage is one of the treatments for pancreatic fistula. This procedure allows both pancreas juice drainage and anastomosis re-construction at the same time. This is effective and minimally invasive but difficult to adapt to a long or complicated fistula. In particular, dilatation of the main pancreatic duct is indispensable. This paper reports the successful resolution of a postoperative pancreatic fistula by a two-way-approach percutaneous transgastric fistula drainage procedure. Using a snare catheter from the fistula and a flexible guidewire from the transgastric puncture needle, it can be performed either with or without main pancreatic duct dilatation.