Is Revision Surgery Justified for Symptomatic Pancreatico-enteric Anastomotic Stenosis in Long-term Survivors Following Pancreaticoduodenectomy for Malignancy?

BACKGROUND: Pancreatico-enteric anastomotic (PEA) stenosis is one of the late complications following pancreaticoduodenectomy (PD) and reported for benign diseases. Literature for PEA stenosis following PD for malignancy is very limited due to low survival. MATERIAL AND METHODS: Patients undergoing surgery for symptomatic, recurrent, obstructive pancreatitis due to PEA stenosis following PD for malignancy were retrospectively identified from the authors' prospective database between January 1997 and December 2014. RESULTS: Six patients with median age 56.5 years underwent revision surgery for PEA stenosis during this time period. At primary PD, all were node negative with T1/T2 disease. The primary PEA were pancreatico-jejunostomy (PJ) (n = 5) and pancreatico-gastrostomy (n = 1). Median time to develop symptoms was 62 months. At revision surgery, a Roux-en-Y longitudinal PJ (n = 5) and an end-to-side PJ (n = 1) were done. With a median follow-up of 36 months, pain relief was excellent (n = 5) to average (n = 1). CONCLUSION: With improving long-term survival in patients undergoing PD for malignancy more such patients will be identified in future. Patients with symptomatic PEA stenosis following PD for malignancy can be managed surgically, with excellent outcomes in centers of expertise in pancreatic surgery.

IgG4-associated sclerosing cholangitis masquerading as hilar cholangiocarcinoma.

IgG4-sclerosing cholangitis (IgG4-SC) commonly presents with type 1 autoimmune pancreatitis. Isolated IgG4-SC is rare. Differentiating IgG4-SC from cholangiocarcinoma preoperatively is challenging due to overlapping radio-clinical manifestations and difficult preoperative histology. We present three cases preoperatively diagnosed and surgically treated as hilar cholangiocarcinoma. First and second cases presented with cholangiocarcinoma with portal vein involvement and third with a malignant-appearing hilar stricture. On histopathology, IgG4-SC was diagnosed in the first two cases. Third patient had raised serum IgG4, and histopathology was inconclusive for IgG4-SC and negative for malignancy. However, she responded to steroid therapy.

A rare case of lacrimal adenoid cystic carcinoma with large hepatic and multiple pulmonary metastases with successful surgical treatment.

INTRODUCTION: Adenoid cystic carcinoma (ACC) of the lacrimal gland is rare but with high recurrence rates and late metastases. They occasionally metastasise via haematogenous spread to lungs, brain and bone. Liver is a rare site of metastasis and is usually present with disseminated disease. PRESENTATION OF CASE: A 42 year old lady, a known case of adenoid cystic carcinoma of the lacrimal gland who had been operated 4 years ago for the same followed by chemotherapy and radiotherapy. She was detected with large hepatic and bilateral multiple pulmonary metastases. A right hepatectomy was done. After six months when her general condition improved we did a staged pulmonary metastatectomy. Histology confirmed the diagnosis. She is presently doing well with no recurrence since 18 months. DISCUSSION: Usually asymptomatic, the commonest symptom is pain. It is a locally invasive disease with a poor prognosis if detected late. Surgery is the only proven therapy. Isolated hepatic metastases being managed surgically has been reported. However, extensive, staged, surgical resection of hepatic and pulmonary metastases has not been reported. CONCLUSION: Lacrimal ACC is an aggressive tumour with known late metastases with the liver being affected seldomly. Our case highlights that even disseminated metastases to the liver and the lungs from lacrimal ACC can be managed surgically with a good outcome. To our knowledge, no such report with distant metastases to the liver and the lung along with their successful surgical management has been reported.

Total colectomy in a gangrenous large bowel due to a rare double closed loop obstruction.

INTRODUCTION: Closed loop obstruction is commonly encountered in sigmoid volvulus. When such obstruction becomes fulminant, it is called acute necrotizing colitis. Gangrene of the entire large bowel from the caecum till the distal end of the sigmoid is a rare entity. PRESENTATION OF THE CASE: We present here one such case of necrotizing colitis in a 27 years old gentleman who presented with large bowel obstruction and septic shock. Computed tomography (CT) revealed sigmoid volvulus with ischaemic changes. The rest of the colon was dilated. On laparotomy, a gangrenous sigmoid due to the volvulus was found along with complete gangrene of the proximal bowel from the ileocaecal junction till the volvulus. This was probably due to a double closed loop obstruction, one at the sigmoid volvulus and the second being between a probable competent ileocaecal valve and the proximal end of the volvulus. A total colectomy with an end ileostomy was performed. DISCUSSION: Necrotising colitis involving the entire colon is seldom seen. Large bowel obstruction is a known surgical emergency due to a probable closed loop obstruction due to a competent ileocaecal valve. CONCLUSION: To our knowledge, such gangrene of the entire large bowel due to a sigmoid volvulus and a competent ileocaecal valve has not been reported in literature so far. We also highlight here, the rapid ischaemic changes that follow a closed loop obstruction. In our case the CT has shown ischaemic changes only in the sigmoid. Hence, timely diagnosis and intervention is imperative.