George Younan

Techniques of Vascular Resection and Reconstruction in Pancreatic Cancer.

Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care.

Replaced gastroduodenal artery: Added benefit of the “artery first” approach during pancreaticoduodenectomy—A case report

Highlights • A “replaced” artery is a totally replaced variant artery in the absence of the normal artery that has the same name.• The gastroduodenal artery supplies arterial perfusion to the head of the pancreas.• Arterial anomalies need to be identified and managed appropriately during surgery to prevent end organ ischemia.

Splenosis: A Rare Etiology for Bowel Obstruction—A Case Report and Review of the Literature

Splenosis is a historically uncommon etiology for bowel obstruction. Autotransplanted splenic tissues following surgery or trauma of the spleen are known to occur in multiple locations of the abdominal cavity and pelvis. The small bowel mesentery is a blood vessel-rich environment for growth of splenic fragments. We present a case of a 36-year-old male patient who sustained a gunshot wound to his left abdomen requiring a splenectomy and bowel resection fifteen years prior to his presentation with small bowel obstruction requiring exploration, adhesiolysis, and resection of the mesenteric splenic deposit. Our aim in this report is to provide awareness of splenosis as an etiology for bowel obstruction, especially with increased incidence and survival following abdominal traumas requiring splenectomies. We also stress on the importance of history and physical examination to include splenosis on the list of differential diagnoses for bowel obstruction.

A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It

The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.

Resection Versus Chemotherapy for Metastatic Neuroendocrine Tumors of the Pancreas

Pancreatic neuroendocrine tumors (PNET) represent a broad spectrum of disease with behavior ranging from benign to highly malignant. Treatment strategies are quite variable and frequently lack consensus. This chapter focuses on the debate between surgery and chemotherapy for metastatic PNET. We summarize the evidence for both strategies including which treatment is appropriate in each clinical setting.

Intrahepatic Reactive Lymphoid Hyperplasia: A Case Report and Review of the Literature

Introduction Reactive lymphoid hyperplasia (RLH) is a rare and benign lesion found in organs of the gastrointestinal tract, skin, lung, orbit, and more rarely in the liver. Due to its similar appearance on imaging, it is hard to differentiate from primary liver malignancies. The following is a case report of a patient presenting with a suspicious liver lesion found to be RLH associated with primary biliary cirrhosis (PBC), after surgical resection. Presentation of Case A 54-year-old woman presented with nonspecific abdominal pain, and her workup included axial imaging of the abdomen that showed a suspicious lesion in her liver. After an extensive workup, which included a percutaneous biopsy, failed to confirm a diagnosis, a laparoscopic surgical resection was recommended. Discussion RLH is a rare condition of the liver, presenting in a suspicious fashion and raising concerns for a primary liver malignancy. RLH should be considered in the differential diagnosis of small hepatic lesions in middle-age females in the absence of any significant risk factors for hepatocellular carcinoma (HCC). RLH tends to be associated with PBC of the liver. Conclusion RLH of the liver is a rare, hard to diagnose, benign lesion. When intrahepatic, it cannot be easily differentiated from primary liver tumors and frequently requires surgical resection for pathological diagnostic confirmation.

Duodenal Gangliocytic Paraganglioma Requiring a Pancreaticoduodenectomy: A Case Report and Review of the Literature

Introduction Duodenal gangliocytic paragangliomas (GPs) are a subclass of duodenal neuroendocrine neoplasms and are exceedingly rare. They have been associated with an indolent behavior; however, they can rarely metastasize. Radical resection like a pancreaticoduodenectomy is sometimes indicated. We hereby present a case requiring major surgery and perform a literature search about this disease. Presentation of Case A 49-year-old Caucasian female, who presented with an upper gastrointestinal bleed, was found to have a hypodense mass in the second/third portion of the duodenum. A biopsy of the mass during upper endoscopy was inconclusive. A pancreaticoduodenectomy was recommended based on the high suspicion for a duodenal adenocarcinoma and was performed successfully. Her final pathology revealed a duodenal gangliocytic paraganglioma. Discussion The majority of duodenal GPs present as gastrointestinal bleeds while others less commonly present with anemia, abdominal pain, duodenal obstructive symptoms, pancreatitis, or abnormal incidental findings on axial abdominal imaging. Duodenal GPs were initially viewed as benign tumors of the duodenum; however, there have been increasing incidence reports of hematogenous and lymphatic metastasis. Appropriate treatment of duodenal GPs is still controversial and ranges from local endoscopic submucosal resection to major radical surgery. Conclusion Duodenal GPs are very rare tumors of the second portion of the duodenum presenting with upper gastrointestinal bleeding and local symptoms of surrounding organs. Local or radical resection is usually recommended to prevent bleeding and the minor risk of metastatic spread.

Cavernous Transformation of the Portal Vein Requiring Temporary Mesocaval Shunt and Internal Jugular Vein Interposition Graft

The current treatment of pancreatic cancer involves a multidisciplinary team providing multimodal therapies, which include chemotherapy, radiation, and surgery. With improvements in tumor response to contemporary systemic agents, surgical resection is now being considered for tumors that were previously believed to be technically unresectable. This chapter illustrates a complex situation where the pancreatic tumor caused segmental occlusion of the superior mesenteric portal vein confluence, resulting in cavernous transformation of the portal vein in the setting of proximal arterial abutment. We describe diversion of mesenteric flow through mesocaval shunting prior to portal dissection, which then allowed for a safe pancreatectomy enhanced by improved visualization of the superior mesenteric artery.

Robotic-Assisted Distal Pancreatectomy for a Pancreatic Desmoid Tumor: A Case Report and Review of the Literature

Introduction: Desmoid tumors are rare, indolent tumors of mesenchymal origin, with a potential for local invasion and adjacent organ involvement, without a metastatic potential. Pancreatic desmoid tumors are defined as tumors involving the pancreas parenchyma, sparing adjacent organs, and requiring a pancreatectomy for adequate surgical resection. Case presentation: We report a case of a lesser sac heterogeneous solid tumor involving the pancreatic tail in a 69-year-old man without a known genetic predisposition. Treatment consisted of a robotic-assisted distal pancreatectomy and splenectomy due to the intimate anatomical association of the mass to the pancreatic parenchyma and splenic vessels. The mass was found to be a desmoid-type fibromatosis on pathological assessment. Discussion: Surgical resection with adequate margins remains the gold curative standard for desmoid-type fibromatosis tumors of the abdomen and retroperitoneum. Pancreatic desmoid tumors tend to be sporadic, occur equally among genders, most commonly involving the distal body and tail of the pancreas, requiring a distal pancreatectomy for adequate surgical margins. Conclusion: We report in this article the twenty first case of a pancreatic desmoid tumor in the literature and the first report of a robotic-assisted resection of this tumor.

Cholecystectomy of an Intrahepatic Gallbladder in an Ectopic Pelvic Liver: A Case Report and Review of the Literature

Introduction Ectopic pelvic liver is an exceedingly rare condition usually resulting after repair of congenital abdominal wall defects. Intrahepatic gallbladder is another rare condition predisposing patients to cholelithiasis and its sequelae. We describe a cholecystectomy in a patient with an intrahepatic gallbladder in a pelvic ectopic liver. Presentation of Case A 33-year-old woman with a history of omphalocele repair as an infant presented with signs and symptoms of symptomatic cholelithiasis and chronic cholecystitis, however, in an unusual location. After extensive workup and symptomatic treatment, cholecystectomy was recommended and performed via laparotomy and hepatotomy using microwave technology for parenchymal hepatic transection. Discussion Given the rare combination of an intrahepatic gallbladder and an ectopic pelvic liver, advanced surgical techniques must be employed for cholecystectomies, in addition to involvement of hepatobiliary experienced surgeons due to the distortion of the biliary and hepatic vascular anatomy. Conclusion Cholecystectomy by experienced hepatobiliary surgeons is a safe and effective treatment for cholecystitis in patients with intrahepatic gallbladders in ectopic pelvic livers.