Central Pancreatectomy: Significance of Vascularity on Anastomotic Integrity and a Note on Reconstructive Technique.

Central pancreatectomy is a pancreatic parenchymal sparing surgery usually indicated for benign and borderline malignant tumors of the neck and proximal body of the pancreas. Due to the presence of extensive intra-pancreatic spread, pancreatic parenchyma sparing procedures such as central pancreatectomy are invariably deferred in pancreatic malignancy. The need for management of two pancreatic stumps with a usually soft texture and non-dilated ducts, given the indications, increases the risk of pancreatic fistula and therefore morbidity. Proximal stump management is usually a closure either by suture or stapler with reinforcements; the technique preferred depends on the experience of the surgeon and is mostly extrapolated from distal pancreatectomy. Distal stump management is the Achilles' heel owing to the texture of the pancreas and pancreatic duct size. Need for additional mobilization may have a bearing on the perfusion of the pancreatic stump and hence may lead to clinically relevant leaks. The use of octreotide accentuating the said vascular insufficiency may not be an overstatement. Here we present a case of solid pseudopapillary tumor (SPT) of the neck and proximal body of the pancreas in which a central pancreatectomy with falciform patch closure of the proximal stump and binding pancreaticogastrostomy (PG) was contemplated and further we discuss the types of reconstruction with special reference to the vascular pattern of distal pancreas.

Aberrant Left Colic Artery and Its Surgical Implications.

Arterial anomalies of the viscera are not unusual. Of the arterial anomalies, the celiac and the superior mesenteric anomalies are well studied and reviewed in the literature. These variations are due to changes occurring during the development of vessels. Also, the variations in the colonic blood supply have been detailed in the context of conduit surgery in esophageal replacement and oncological resections. Of these, the rarer anomaly is the aberrant left colic artery (ab LCA). Previously described in various anatomic descriptions; it has never been reported in a clinical situation. A middle-aged female presented with abdominal pain and lower gastrointestinal (GI) bleed. On further evaluation, she was diagnosed to have transverse colon malignancy. She underwent extended right hemicolectomy with complete mesocolic excision and D3 lymphadenectomy as classically described. During the dissection, she was found to have an LCA arising from the superior mesenteric artery (SMA) just below the inferior border of the pancreas two centimeters higher to the origin of the middle colic artery. This artery was carefully dissected and preserved. Injury of the ab LCA is possible given the unusual course of the artery. Implications of iatrogenic injury in colonic and pancreatic surgeries may result in additional morbidity which is discussed in detail.

Mediastinal Pseudocyst: Varied Presentations and Management-Experience from a Tertiary Referral Care Centre in India.

Pseudocysts are a recognised complication following acute or chronic pancreatitis. Usually located in peripancreatic areas, they have also been reported to occur in atypical regions like liver, pelvis, spleen, and mediastinum. Mediastinal pseudocysts are a rare entity and present with myriad of symptoms due to their unique location. They are a clinical challenge to diagnose and manage. In this paper, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 7 of our patients, as well as our experience in managing these patients along with their clinical outcome.