Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

Isolated duodenal ischemia of unknown etiology: a case report

Background Acute abdomen is among the most common presentations observed in clinical practice. The present study describes a patient with isolated duodenal ischemia as an extremely rare etiology of acute abdomen. Case presentation A 79-year-old male with acute abdominal pain, nausea, and vomiting presented to the emergency department of our hospital. He was diagnosed with myelodysplastic syndrome 7 years ago, for which he took thalidomide and erythropoietin as the main medications. The prominent findings of the physical examination were hypotension, tachycardia, fever, mild hypoxemia, and epigastric and right upper quadrant tenderness of the abdomen. Except for mildly increased creatinine and lipase, other laboratory findings were in concordance with myelodysplastic syndrome. Due to the patient’s oliguria, the computed tomography (CT) scan was performed without contrast, which, together with the ultrasonography, raised the clinical impression of acute pancreatitis. The patient’s hypotension was refractive to supportive treatment, resulting in progressive deterioration of the clinical condition. A later contrast-enhanced CT scan suggested microvascular ischemia of the duodenum. An emergent Whipple’s procedure was planned initially, which was later switched to a damage control surgery due to the patient’s cardiac arrest during the surgery. Despite all the supportive therapy provided at the intensive care unit, the patient expired of a cardiac arrest which occurred two hours after the termination of the surgery. Conclusions The high rate of mortality in duodenal necrosis necessitates emergent diagnosis and proper management. When other common etiologies are ruled out, clinicians should consider duodenal pathology as a potential cause of acute abdomen.

P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention

Background Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure. Methods Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021. Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L). Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care. Results A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone. Conclusions Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.

IgG4-related disease as a rare cause of gastric outlet obstruction: a case report and literature review

Background IgG4-related disease involvement of the digestive tract is very rare. In few reported cases of isolated gastric/duodenal IgG4-related disease, none of which resulted in luminal obstruction. Case presentation A 59 years old female presented with longstanding gastrointestinal symptoms. CT showed mural thickening of the proximal duodenum. Gastroscopy showed antral ulcer extending into the duodenum with outlet obstruction and biopsy showed acute on chronic duodenitis. Whipple’s procedure was performed and IgG4-related disease was diagnosed on final pathology. Symptoms were revolved on mycophenolate mofetil and prednisone with no recurrence. Conclusions Our case is the only reported case with gastric outlet obstruction secondary to gastroduodenal IgG4-related disease. The diagnosis should be considered in the differential diagnosis of unexplained duodenal stricture, gastric outlet obstruction or gastrointestinal ulceration. IgG4-related disease usually responds to steroids but long-term response rates to steroid-sparing agents, especially in the subset of patients with luminal IgG4-related disease remains to be determined.

A systematic review of the perforated duodenal diverticula: lessons learned from the last decade

Background The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment. Methods A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008–2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included. Results Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required. Conclusion Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple’s procedure may be required depending on tissue friability and diverticular collar size.

Solid Pseudopapillary Neoplasm of Pancreas – A Case Series from Bangalore, India

BACKGROUND Solid pseudopapillary neoplasm (SPN) of pancreas is a rare epithelial tumour of low malignant potential. SPN accounts for less than 1 to 2 % of exocrine pancreatic tumours. It mainly affects women between the second and third decade of life, and its management is not well defined. The aim of this study was to report clinicopathological characteristics of SPN and its outcome. METHODS A retrospective study was conducted in a tertiary care centre from January 2015 to December 2019. All patients who were diagnosed and treated as SPN of pancreas in our institute were retrospectively reviewed. A data of the characteristics of these patients was developed, including age, gender, size, location of tumour, treatment, histopathological and immunohistochemical features. RESULTS Six patients were diagnosed as having SPN of pancreas, during the 5-year period. All 6 patients were female. Youngest age of occurrence was 15 years. Maximum age was 41 years. Average age was 25 years. All patients were symptomatic and the most common symptom was dull aching upper abdominal pain. Contrast enhanced computed tomography (CECT) was done for all patients. 3 patients had typical features of SPN. Endoscopic ultrasound (EUS) was done for 4 patients and EUS fine needle aspiration cytology (FNAC) was done for 3 patients. Patients were provided with procedure details and informed consent was taken. All patients were subjected to surgical treatment. Out of six patients, two underwent laparoscopic spleen preserving distal pancreatectomy, two patients underwent classical Whipple’s procedure and two patients had undergone median pancreatectomy. CONCLUSIONS SPN are rare neoplasms, typically affecting young females without clear histogenesis and with a malignant potential. Appearance from imaging studies can be adequate to guide surgical resection without pre-operative pathological assessment. But in unclear cases, EUS-FNAC with immunohistochemistry helps in establishing a pre-operative diagnosis. Surgical resection should be offered when feasible. Prognosis of SPN of the pancreas is good due to its favourable biological features, even in the presence of distal metastasis. KEYWORDS Solid Pseudopapillary Neoplasm (SPN)

Treatment of Polyostotic Fibrous Dysplasia With Intravenous Ibandronate

Introduction: Fibrous Dysplasia (FD) is proliferation of fibrous tissue within the bone marrow causing osteolytic lesions and pathologic fractures. Polyostotic FD in combination with a thigh myxoma is consistent with Mazabraud syndrome (MS). Bisphosphonates have shown promise in treatment and prevention of progression of FD. Clinical Case: A 34-year-old male with an unremarkable family history developed left thigh pain shortly after Whipple’s procedure for pancreatic cancer in 2017. Imaging revealed a 9cm left thigh mass and multiple femoral and pelvic intramedullary lesions compatible with FD. The thigh mass was removed and final pathology revealed an intramuscular myxoma with +GNAS mutation. Given clinical picture, genetics raised concern for MS and recommended endocrinology consultation. Patient reported chronic pain in chest, abdomen, back and multiple joints requiring spinal stimulator placement. Labs displayed subclinical hyperthyroidism and thyroid uptake scan revealed a right toxic MNG. Hence ablation was performed. Labs also displayed elevated alkaline phosphatase (ALP) bone isoenzyme of 103 IU/L (RR 0–72). Thoracic X-ray revealed chronic endplate vertebral compression fracture with no history of trauma and normal DEXA scan. NM bone scan was consistent with FD in skull, humerus, scapula, ribs, pelvis, femur and tibia. Given chronic pain at multiple sites and compression fractures, therapy with IV Zoledronic acid was given after Vitamin D was repleted. Within several hours, patient developed acute phase reaction (APR) with severe bone pain requiring hospitalization. ALP levels normalized within 1 year of therapy. 1.5 years post therapy, patient experienced a grand mal seizure. MRI brain revealed multifocal abnormal bone marrow within the calvarium, facial bones and skull base. Labs again displayed elevated ALP but new hypophosphatemia and an elevated serum FGF23. Given progression of skeletal disease as indicated by elevated FGF23, additional off-label injectable treatment options were reviewed and patient agreed to Ibandronate. Discussion: Majority of evidence for bisphosphanate treatment in FD is derived from observational studies, which report variable symptomatic improvement despite improvement of bone turnover markers. Oral anti-resorptives are commonly used but were not an option for our patient given history of Barrett’s esophagus and Whipple’s surgery. Pamidronate was first used in the treatment of FD with variable success rates. Denosumab is also being considered as a therapeutic option in FD however there are insufficient case reports to outline safety profile. Zoledronic acid is commonly used however our patient developed APR to the first dose and refused retrial. Given progression of disease, treatment was recommended. Therefore a milder anti-resorptive such as Ibandronate was considered which warrants further investigation in the treatment of FD.