Camila Cristina S. Torres

THE OBITUARY OF THE PYLORUS-PRESERVING PANCREATODUODENECTOMY

Pancreatoduodenectomy is the treatment of choice for patients with benign and malignant disease of pancreatic head. Classic pancreatoduodenectomy was described by Whipple originally and included distal hemigastrectomy. Pylorus-preserving pancreatoduodenectomy (pylorus-preserving) was popularized in the late 1970s for benign disease and it included full preservation of the pylorus. However, delayed gastric emptying after pylorus-preserving is a frustrating complication. Its incidence varying from 19% to 61% in previous series and it results in discomfort, prolonged length of stay and increases the risk of respiratory complications. Delayed gastric emptying contributes to increased hospital costs and decreased quality of life. There has been no evidence from prospective studies and meta-analyses to indicate the superiority of pylorus preserving in terms of quality of life or delayed gastric emptying2,4,5,7. More recently, and mostly in Japan since the late 1990s, subtotal stomach-preserving pancreatoduodenectomy (stomachpreserving) in which the pyloric ring and 2 cm of the distal stomach only is removed with preservation of about 90% of the stomach has been performed for pancreatic head disease. This surgical procedure was associated with fewer postoperative complications. After stomach-preserving, many recent studies have been carried out comparing the two techniques2,6,8. Subtotal stomach-preserving pancreatoduodenectomy was adopted in 2011 at the Department of Hepato-pancreatobiliary Surgery, Federal University of Maranhão, Brazil. Delayed gastric emptying is a very important complication and needs to be minimized in patients who undergo pancreatoduodenectomy for malignant disease. Many factors were reported in the pathophysiology of this complication after pylorus-preserving. Pylorospasm caused by operative disruption of the vagal nervous system and vascular supply with antropyloric ischemia may play a main role2,7,9. As for prophylactic management of pylorospasm due to denervation after pylorus-preserving, some operative technique has been described. The most common are: a) mechanical dilatation of the pylorus ring, b) pyloromyotomy, c) preservation of the right gastric artery, gastroduodenal artery and all innervation along the lesser curvature of the stomach and proximal duodenum, and d) low doses of erythromycin in the unfed period with preservation of the right gastric artery2,7. Kawai et al. in a prospective, randomized, controlled trial, reported that the overall incidence of delayed gastric emptying was 4.5% in stomach-preserving and 17.2% in pylorus preserving, a significant difference (p=0.024). Time of passage from esophagogastric junction to gastrojejunostomy or duodenojejunostomy on postoperative day 7 was significantly delayed in pylorus-preserving compared with stomach-preserving (p<0.0001)6. Hayashibe et al. revealed that the incidence of delayed gastric emptying in pylorus preserving was significantly higher than that in stomach-preserving (p=0.02). Days of nasogastric intubation and days until liquid diet in pylorus-preserving were significantly longer than that in stomach-preserving (p=0.002 and p=0.004, respectively)4. Zhou et al. reported that both overall delayed gastric emptying and clinically relevant delayed gastric emptying occurred significantly less often in the stomach-preserving group than in the pylorus-preserving (p=0.006 and p=0.013 respectively). Primary delayed gastric emptying was recorded in two patients in the stomach-preserving group and in eight in the pylorus-preserving group (p=0.041). Length of stay was significantly shorter after stomach-preserving than after pylorus-preserving (p=0.017)9. Fujii et al. reported that the incidence of delayed gastric emptying was significantly higher in the pylorus-preserving group than in stomach-preserving (p=0.0012). The duration of nasogastric intubation and the fasting period were significantly longer in the pylorus-preserving (p=0.0006 and p<0.0001, respectively)1. The gastric emptying requires coordination of the antrum, pylorus and duodenum. The antropyloric region is innervated by the gastric branches of the vagus nerve and by the hepatic vagal plexus. After surgery involving radical lymph node dissection in the hepatoduodenal ligament area, the motility of the antropyloric region is compromised2,4,5,7. Pylorus-preserving pancreatoduodenectomy was described for benign disease6. In pancreas head carcinoma, peripyloric lymph nodes metastasis was reported to be 6% to 12%. Therefore, peripyloric lymph nodes dissection is the standard procedure in order to perform R0 resection. A D2 lymph node dissection includes the area along the hepatoduodenal ligament, the common hepatic artery, the superior mesenteric artery, and peripylorus8. Consequently, the vagal innervation around the pyloric ring is destroyed causing dysfunction of the pylorus in pylorus-preserving. Preservation of the vagal nerve is not compatible with radical lymph node dissection of the hepatoduodenal ligament6,8. Kurahara et al. reported that in patients with D2 regional lymph node dissection, the pylorus-preserving group had significantly higher incidence of delayed gastric emptying (p=0.0326) and longer length of stay compared with the stomach-preserving group (p= 0.0476). On the other hand, the incidence of delayed gastric emptying and the length of stay in the two groups were comparable in patients with D1 regional lymph node dissection (p=0.3348 and p=0.1383 respectively). In this context, stomach-preserving is the most appropriate surgery involving D2 regional lymphadenectomy in order to decrease this postoperative complication7. Poor nutritional status could result in an adverse prognosis. After pancreatoduodenectomy, approximately 12% of the body weight was lost at six months and started to recover by one year after the surgery. During this period, Fujii et al. revealed that serum total protein and albumin levels showed better recovery in the stomach-preserving group than in pylorus-preserving group, when the difference in the serum albumin levels reached statistical significance (p=0.0303)1. The serum total lymphocyte

Laparoscopic treatment of Dunbar syndrome: A case report

Highlights • An uncommon syndrome of gastrointestinal obstruction due to vascular compression is presented.• Treatment of Dunbar syndrome by laparoscopy is proposal.• Better results with laparoscopic treatment are discussed.• Others forms of treatment are discussed.

The ALPPS procedure for hepatocellular carcinoma larger than 10 centimeters

Highlights • The options of treatment for hepatocellular carcinoma are presented.• Treatment of huge hepatocellular carcinoma by ALPPS is proposal.• Better results with ALPPS for hepatocellular carcinoma than other palliative procedures are discussed.• Selection of patients with huge hepatocellular for ALPPS to achieve good results is important.

Performance of Laparoscopic Pancreatoduodenectomy for Solid Pseudopapillary Tumor of Pancreas

Case series Patients: Female, 19 • Female, 18 Final Diagnosis: Solid pseudopapillary tumor of pancreas Symptoms: Abdominal discomfort Medication: — Clinical Procedure: Surgery Specialty: Oncology Objective: Unusual setting of medical care Background: Solid pseudopapillary tumor of the pancreas (Frantz tumor) is a rare, low-grade malignant neoplasm. Laparoscopic pancreatoduodenectomy is a good approach for tumors located in the pancreatic head. We present two successful cases in young women. Case Report: A 19-year-old woman was admitted to Department of Digestive Surgery due to epigastric pain, nausea, and vomiting. Computed tomography scan of the abdomen was performed, and a 3.0×2.2 cm solid tumor localized in the head of the pancreas was observed. After the diagnosis of Frantz tumor of the pancreas, the patient underwent laparoscopic pancreatoduodenectomy. Histopathology confirmed solid and cystic pseudopapillary tumor. The postoperative course was uneventful, and after 8 months the patient remained disease-free. An 18-year-old woman was admitted at the emergency room with abdominal pain, vomiting, and diarrhea. Computed tomography scans revealed a mass of 4.1×3.3 cm in size in the head of the pancreas consistent with a solid pseudopapillary tumor. Laparoscopic pancreatoduodenectomy was performed by two expert surgeons who divided the work: one did resection and the other did reconstruction. The patient was discharged at postoperative day 6 without complications, and during five months of follow-up the patient has been well and without disease. Conclusions: Laparoscopic pancreatoduodenectomy can be performed safely in patients with Frantz tumor by surgeons with expertise in laparoscopic surgery, technical skill, and adequate equipment.

Right hepatectomy due to hepatolithiasis caused by endoclip migration after laparoscopic cholecystectomy: a case report

Abstract Complications related to cholecystectomy occur in <3% of patients. Endoclip migration after laparoscopic cholecystectomy with hepatolithiasis is an extremely rare complication. We report a case of hepatolithiasis secondary to endoclip migration after laparoscopic cholecystectomy treated successfully via right hepatectomy. A 35-year-old female presented with upper abdominal pain, fever and vomiting 9 years after laparoscopic cholecystectomy for chronic calculus cholecystitis. Laboratory investigation revealed gamma-glutamyl transpeptidase of 550 U/L and alkaline phosphatase of 350 U/L. Magnetic resonance cholangiopancreatography revealed a dilated intrahepatic bile duct in segment 6 filled with stones. After preoperative evaluation, a right hepatectomy was performed using the intermittent Pringle maneuver. The postoperative recovery was uneventful and the patient was well after 4 months of follow-up. Although rare, endoclip migration should be considered in patients presenting with intrahepatic lithiasis even many years after laparoscopic cholecystectomy. Liver resection may be necessary in cases of failure of endoscopic extraction.

Isolated caudate lobectomy: Left-sided approach. Case reports

Highlights • The options of treatment for caudate tumors are presented.• Treatment of caudate tumors by left-sided approach is proposal.• Better results with left-sided approach are discussed.• Selection of patients with tumors in caudate lobe for left-sided approach is important.

Acute pancreatitis due to intragastric balloon

Introduction: Intragastric balloon therapy is an option for treatment of obesity. Some complications have been reported but acute pancreatitis due to compression of the pancreas is a rare event. The aim of this study is report a case of acute pancreatitis due to intragastric balloon insertion. Case Report: In a 33-year-old male with BMI of 43.4 kg/m2, intragastric balloon was inserted in the gastric fundus, the follow-up was uneventful. After four months, the patient had acute abdominal pain, nausea, vomiting and abdominal distension. Laboratory tests showed serum amylase 618 U/l and serum lipase 906 U/l. A CT scan showed that the tail of the pancreas was heterogeneous, minimal fluid and inflammation of peripancreatic fat. The intragastric balloon was observed causing compression at the transition from the body to the pancreatic tail. The intragastric balloon was removed and the patient underwent laparoscopic cholecystectomy. The inspection of the gallbladder was normal and the histology showed no signs of microlithiasis. The patient was discharged asymptomatic. Conclusion: Intragastric balloon is a common procedure in obese patients and pancreas compression due to the balloon should be included as cause of acute pancreatitis in these patients. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 8, August 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(8):499–502. www.ijcasereportsandimages.com Torres et al. 499 CASE REPORT OPEN ACCESS Acute pancreatitis due to intragastric balloon Orlando Jorge Martins Torres, Jose Maria Assunção Moraes-Junior, Camila Cristina S. Torres, Everardo de Almeida Nunes