Alessio Carloni

Acute pancreatitis associated with a pancreatic hydatid cyst: understanding the mechanism by EUS

The liver and lungs are the most frequent localizations f hydatid disease, whereas pancreatic hydatid cysts are are, accounting for less than 1% of cases.1 Acute pancretitis is associated with hydatid parasitosis in 2% of cases in ndemic areas.2 Like liver cysts,3,4 pancreatic hydatid cysts may cause cute pancreatitis.5-9 Whereas parasite migration into he common bile duct is advocated as the etiological echanism to explain acute pancreatitis caused by liver ydatidosis,3,4 it is unclear why some patients affected y pancreatic cysts develop this complication. Two hyotheses are advocated: main pancreatic duct (MPD) ompression caused by the cyst itself6,10,11 and MPD bstruction by hydatid scolices’ migration from the hyatid cyst.5,9,12 Unfortunately, neither of these hypothees has been confirmed at imaging/surgery. Preoperative diagnosis of a pancreatic hydatid cyst may be ifficult. Symptoms are often aspecific: pain,7,12-14 an epigasric mass,12,15 or weight loss.7 At imaging, hydatid cysts ay be mistaken for cystic pancreatic tumors or intrauctal papillary mucinous neoplasia, especially when ingle.11 The onset of acute pancreatitis may prompt rgent pancreas imaging, although, in these cases, a ydatid cyst may be misdiagnosed as a pseudocyst,6,7 hich is a common complication of acute/recurrent ancreatitis.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation.

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.

Management of Common Bile Duct Stones in the Era of Laparoscopic Surgery

In the era of laparoscopic surgery, the best approach for common bile duct (CBD) stones remains a matter of debate. When CBD exploration was performed by laparotomy, prospective randomized trials did not show the superiority of preoperative endoscopic sphincterotomy (ES) over CBD surgery for stones.1,2 The advent of laparoscopic surgery led to a dramatic change in the approach of CBD stones treatment. Indeed, because of an obvious lack of expertise in laparoscopic surgery, surgeons elected to detect and treat preoperatively CBD stones by ES since they considered laparoscopic CBD exploration as an unduly, complex, and demanding procedure. It is worth mentioning that this approach requires several sessions of anesthesia and cumulates the risk of ES and laparoscopic cholecystectomy. In addition, it increases the cost.3,4 About 15 years after the introduction of laparoscopic cholecystectomy, one has to wonder whether or not this policy should be still applied. Indeed, in patients fit for surgery, laparoscopic CBD stones extraction seems to be superior to the association of ES and laparoscopic cholecystectomy.5 The reported incidence of CBD stones found during laparoscopic cholecystectomy ranges from 3 to 10%.6−8 It is unclear whether an asymptomatic choledocholithiasis requires treatment. Furthermore, it is well established that small stonesmay pass through the ampulla of Vater.9 Moreover, it is not clear what stone size precludes transpapillary migration into the duodenum nor which criteria will predict complications of pancreatitis or cholangitis if CBD stones are not treated. Therefore, it is generally recommended to treat CBD stones whenever detected. Theoretically, CBD stones can be treated with or without cholecystectomy. Moreover, if cholecystectomy is performed this could be done before, during or after CBD stones extraction. The purpose of this chapter is to try to clarify these different points.