Andreas Minh Luu

Circumportal Pancreas—a Must Know Pancreatic Anomaly for the Pancreatic Surgeon

PurposeCircumportal pancreas is a rare congenital pancreatic anomaly with encasement of the portal vein and/or the superior mesenteric vein by pancreatic tissue. It is often overlooked on cross-sectional imaging studies and can be encountered during pancreatic surgery. Pancreatic head resection with circumportal pancreas is technically difficult and bears an increased risk of postoperative pancreatic fistula.Materials and MethodsA retrospective chart review of our data base for all patients who had undergone pancreatic head resection between 2004 and 2015 was performed.ResultsWe identified six patients out of 1102 patients who had undergone pancreatic head surgery in the study period. CT-scan and MRI were never able to identify circumportal pancreas prior to surgery. The right hepatic an artery derived from the superior mesenteric artery in four cases (67%). Additional resection of the pancreatic body was always performed. Postoperative course was uneventful in all cases without occurrence of pancreatic fistula.ConclusionsCircumportal pancreas is a rare entity every pancreatic surgeon should be aware of. It is difficult to identify on cross-sectional imaging studies. A right hepatic artery arising from the superior mesenteric artery should raise suspicion of circumportal pancreas. Additional pancreatic tissue resection should be performed during pancreatic head resections to avoid pancreatic fistula.

FOLFIRINOX treatment leading to pathologic complete response of a locally advanced pancreatic cancer

Pancreatic cancer (PC) is a lethal disease with a poor prognosis. It is typically asymptomatic and therefore most often diagnosed at an advanced stage. A primary unresectable PC can become resectable in case of tumor regression turning palliative into neoadjuvant therapy. We present a 67-year old female patient who was diagnosed with a locally advanced adenocarcinoma of the pancreatic head. After receiving palliative intended chemotherapy with the FOLFIRINOX regimen, staging computed tomography revealed local resectability of the pancreatic head tumor. The patient underwent an uneventful total pancreatectomy. Pathohistological investigation revealed a pathologic complete response (pCR). pCR after FOLFIRINOX treatment in primary unresectable PC is extremely rare. It might enable surgical resection and can increase the survival rate.

Diagnostic double strike in the emergency room - two cases of complete pancreatic ruptures due to bicycle handlebar injuries on two consecutive days

BackgroundPancreatic injuries are rare in cases of blunt abdominal trauma and therefore easily misdiagnosed at time of hospital admission. They are associated with a significantly elevated morbidity and lethality. Bicycle handlebar injuries are the most common cause of pancreatic trauma in children and adolescents.Case presentationWe report two cases of a 23-year-old Caucasian woman and a 15-year-old Caucasian boy who presented to our clinic with a similar history of a bicycle accident on 2 consecutive days. Both suffered from a fall from a bicycle with bicycle handlebar injury 4 and 6 days prior to admission in our clinic. Emergency distal pancreatectomies were performed in both cases.ConclusionsPancreatic injuries must be highly suspected in bicycle handlebar injuries, even if amylase/lipase levels or ultrasound findings seem unremarkable. The best initial strategies are early computed tomography and a quick referral to a level 1 trauma center. Distal pancreatectomy is the treatment of choice in cases of complete rupture of the pancreatic body.

Surprising Twist in the Plot – Sister Mary Joseph’s Nodule of Pancreatic Cancer Mimicking Wound Infection after Umbilical Hernia Repair

Umbilical hernia repair is the second most common type of hernia surgery after inguinal hernia repair. Depending on the surgical technique, complications occur in 5–25% and include wound infections and abscesses [1]. Pancreatic cancer is a fatal disease most commonly diagnosed at an advanced stage. It is typically asymptomatic or causes unspecific symptoms. Over 80% of the patients do not qualify for curative surgical resection due to locally advanced or metastasized disease. Common sites of metastasis include liver, lungs, peritoneum, and lymph nodes [2]. Umbilical metastasis originating from pancreatic cancer, also known as Sister Mary Joseph’s nodule (SMJN), is an extremely rare occurrence [3]. We report the cases of two patients who presented to our department with ulcerated umbilical lesions and had a history of umbilical hernia repair.

Small Bowel Obstruction due to a Giant Meckel's Diverticulum

Background: Meckels diverticulum is the most common congenital anomaly of the gastrointestinal tract, with an average length of 3 cm. Complications occur in 6.4% and most commonly include inflammation and gastrointestinal bleeding. Preoperative diagnosis is demanding and achieved in 4%. Case Report: A 34-year-old otherwise healthy patient presented with an acute abdomen due to small bowel obstruction. Computed tomography scan could not identify the underlying cause. Emergency laparotomy was performed, and a torqued giant Meckels diverticulum measuring 17 cm was found as the underlying cause for the small bowel obstruction. Resection of the affected ileum segment and ileo-ileal reconstruction were performed. The postoperative course was uneventful. Conclusion: In extremely rare cases, small bowel obstruction in an otherwise healthy patient might be caused by torsion of a symptomatic giant Meckels diverticulum.