Konstantinos A. Boulas

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.

Surgically proved visually isoattenuating pancreatic adenocarcinoma undetected in both dynamic CT and MRI. Was blind pancreaticoduodenectomy justified

INTRODUCTION Visually isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on CT and recognizable only by secondary imaging signs. The frequency of isoattenuating pancreatic adenocarcinomas at dynamic-enhanced CT has been reported to range from 5.4% to 14%. Furthermore, 80% of the visually isoattenuating pancreatic adenocarcinomas are detectable in dynamic-enhanced MRI. Consequently, a pancreatic adenocarcinoma undetected in both the above imaging studies is an exceptionally rare event. PRESENTATION OF CASE The present report describes a case of a histologically proved 3.5cm pancreatic adenocarcinoma undetected in both dynamic-enhanced CT and MRI. The patient presented with progressive jaundice over the preceding 20 days. Initial abdominal CT showed a dilated pancreatic and common bile duct without demonstration of a lesion responsible for the clinical and imaging findings. Additional diagnostic work-up with dynamic CT and dynamic MRI failed to reveal a definitive mass. ERCP revealed an irregular interruption of the pancreatic and distal common bile duct with upstream dilation. Blind radical pancreaticoduodenectomy was performed. Histologic examination showed a pT3pN1MO pancreatic ductal adenocarcinoma of the head/neck. DISCUSSION Isoattenuating pancreatic adenocarcinoma patients represent a small but meaningful subset of patients with pancreatic cancer, as they have better survival. The more favorable postsurgical survival makes it even more imperative to correctly diagnose their cases at early stages by obtaining further diagnostic work-up with dynamic pancreatic CT, dynamic MRI and endoscopic ultrasound. CONCLUSION When the above studies fail to unmask the lesion, blind pancreaticoduodenectomy should be based on strong clinical suspicion and secondary imaging findings.

Early Rupture of an Ultralow Duodenal Stump after Extended Surgery for Gastric Cancer with Duodenal Invasion Managed by Tube Duodenostomy and Cholangiostomy

When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the whole first part of the duodenum, complete omentectomy, bursectomy, and D2+ lymphadenectomy performed for a pT3pN2pM1 (+ number 13 lymph nodes) adenocarcinoma of the antrum. Duodenal stump rupture was managed successfully by end tube duodenostomy, without omental patching, and tube cholangiostomy. Close assessment of clinical, physical, and radiological signs, output volume, and enzyme concentration of the tube duodenostomy, T-tube, and closed suction drain, which was placed near the tube duodenostomy site to drain the leak around the catheter, dictated postoperative management of the external duodenal fistula.

Ectopic spleen: An easily identifiable but commonly undiagnosed entity until manifestation of complications

INTRODUCTION Ectopic spleen is an uncommon clinical entity as splenectomy for treatment of ectopic spleens accounts for less than 0.25% of splenectomies. The most common age of presentation is childhood especially under 1 year of age followed by the third decade of life. PRESENTATION OF CASE The present report refers to a patient with torsion of a pelvic spleen treated with splenectomy. The patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days. On the first 65 days, vague pain was attributed to progressive torsion of the spleen which resulted in venous congestion. On the last 6 days, exacerbation of pain was attributed to irreducible torsion, infraction of the arterial supply, acute ischemia, strangulation and rupture of the gangrenous spleen. Diagnosis was made by CT which revealed absence of the spleen in its normal position, a homogeneous pelvic mass with no contrast enhancement, free blood in the peritoneal cavity, and confirmed by laparotomy. DISCUSSION Clinical manifestations of ectopic spleen vary from asymptomatic to abdominal emergency. Symptoms are most commonly attributed to complications related to torsion. Operative management, including splenopexy or splenectomy, is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic ectopic spleen is associated with a complication rate of 65%. CONCLUSION Although an ectopic spleen can be easily identified on clinical examination, it is commonly misdiagnosed until the manifestation of complications in adulthood.

Iatrogenic vas deferens injury due to inguinal hernia repair

Aim-BackgroundOne of the most common operations performed by general and paediatric surgeons is that of inguinal hernia repair. A rare complication of this surgery is injury to the vas deferens (vas), regardless of the surgical technique used. The aim of this article is to review current data regarding the consequences following vas injury and to provide surgeons, who operate in the inguinal canal, with all the current knowledge regarding appropriate treatment of the injured vas.MethodsA systematic search was conducted through Pubmed, Embase, OVID, Medline, Cinahl and Google search engines to identify relevant reports.ResultsVas injury can be the result of intraoperative manipulations or can be related to the mesh used for hernioplasty. A 0.1–0.53 % incidence of vas injury is reported in open inguinal hernia repairs. The most common consequences are spermatic granuloma formation, vas and epididymal epithelium dysfunction and testicular atrophy, unilateral or bilateral. The mechanism of bilateral testicular damage is mediated through the formation of sperm autoantibodies and sympathetic orchiopathia. The optical loupe-assisted modified one-layer anastomosis technique yields overall similar patency rates when compared with microsurgical techniques, and also has positive outcomes in terms of shorter operative time, less infrastructure and lower cost.ConclusionsImmediate management of the injured vas requires a broad understanding of the consequences, advanced surgical skills, and liaison with specialists in this field. A therapeutic algorithm is proposed by the authors of this article.

Metastasis in lymph nodes on the anterior pancreatic surface of the body and tail: an extremely rare finding during bursectomy in extended surgery for gastric cancer.

The anterior surface of the pancreatic body and tail is a vast area which is not dissected as a standard practice in extended surgery for gastric cancer. The aim of this study was to evaluate metastatic involvement of lymph nodes (LNs) on the anterior surface of the pancreatic body and tail which were dissected en block with the posterior leaf of the bursa omentalis during bursectomy in extended surgery for gastric cancer (see Fig. 1a). Between October 2007 and November 2013, a total of 91 patients were submitted to extended surgery for primary pT3-4, pN0-3b, pM0 or pM1 (LYM? or CY?) gastric adenocarcinoma. Extended surgery was consisted of D2? No. 13, 14v, 15, 16a2, 16b1, 17, 18 lymphadenectomy and bursectomy [1]. Bursectomy was performed to achieve: (1) complete clearance of the high-risk infrapyloric LNs; (2) complete resection of disease from the head of the pancreas; (3) complete clearance of LNs along the superior mesenteric vein; (4) an aesthetic celiac-based node dissection; and (5) minorly, elimination of microscopic tumor deposits in the lesser sac [2]. After gross inspection of the surgical specimen, the lesser sac was opened along the posterior surface of the greater omentum and the posterior leaf of the bursa omentalis was resected. LNs along the posterior leaf of the bursa omentalis were retrieved by manual dissection following formalin fixation. These resected LNs were evaluated using serially sectioning at 25-lm intervals of 4-lm thickness and Hematoxylin-Eosin staining. Tumor deposits within LNs were classified and staged according to the revised guidelines set by the International Union Against Cancer 6th Edition [3]. A median number of three LNs along the posterior leaf of the bursa omentalis were harvested (see Fig. 1b, c). Metastasis in the above LNs was found in two patients (2.2 %). All these metastases were micrometastases. These two patients had a scirrhous type (abundant stroma), INFa (tumors displayed expanding growth with a distinct border from the surrounding tissues), moderate and marked lymphatic invasion, no and minimal venous invasion, solid type poorly differentiated adenocarcinoma of the middle and lower third posterior gastric wall classified as stage IV (T4a, N2, M1: LYM? No. 15 and 18 LNs, CY? and -, H0, P0). The perigastric metastatic pattern of these two patients included macrometastasis in the No. 4, 8, 9 and 11 LNs. Metastasis in the No. 11 LNs was found in both of them. Regarding the extraperigastric metastatic pattern, one patient had macrometastasis in the No. 18, and the other patient had macrometastasis in the No. 15 LNs. The present report was the first to evaluate LNs on the anterior pancreatic surface of the body and tail in surgery for gastric cancer. These LNs are not described as a separate LN station in the Japanese Classification of Gastric Carcinoma [4]. This study showed that: (1) when bursectomy is performed, LNs on the anterior pancreatic surface of the body and tail can be documented as a separate LN station; and (2) metastasis in the above LNs has low incidence. However, conclusions cannot be withdrawn as our study cohort was limited. The present study also raised some questions: (1) what are the risk factors that can K. Blouhos K. A. Boulas (&) A. Hatzigeorgiadis Department of General Surgery, General Hospital of Drama, End of Hippokratous Street, 66100 Drama, Greece e-mail: katerinantwna@hotmail.com

The isoattenuating pancreatic adenocarcinoma: Review of the literature and critical analysis.

Dynamic CT has a reported sensitivity of as high as 97% in the detection of pancreatic cancer. Consequently, a substantial number of pancreatic tumors can still escape detection. The isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on dynamic CT as its attenuation is indistinguishable from the attenuation of the pancreatic parenchyma. 88% and 100% of the isoattenuating adenocarcinomas <20 mm and >20 mm respectively are recognized only by the presence of secondary imaging findings highly suggestive of malignancy. Dynamic MRI can unmask 80% of the isoattenuating pancreatic adenocarcinomas. If MRI fails to unmask the mass, EUS-biopsy is not mandatory to be performed as biopsy proof is not required for solid pancreatic masses suspicious for malignancy before proceeding to surgery. The isoattenuating adenocarcinomas should not be regarded as early cancers as less than one-third of them are stage T1 tumors. After curative intent surgery, isoattenuating pancreatic adenocarcinoma patients have a significantly longer median survival than usual pancreatic adenocarcinoma patients associated with the higher rate of well differentiated tumors among isoattenuating tumors. The more favorable postsurgical survival of the isoattenuating pancreatic adenocarcinoma patients makes it even more imperative to correctly diagnose their cases at a resectable stage.

Tube Pancreatico-Duodenostomy for Management of a Severe Penetrating Pancreaticoduodenal Injury

CONTEXT Optimal management of penetrating pancreaticoduodenal injuries and better outcomes are associated with simple, fast damage control surgery and shorter operative time. The performance of pyloric exclusion and tube duodenostomy has markedly decreased. However, there is still a trend toward their performance in cases of delay duodenal repair or severe pancreaticoduodenal injury. CASE REPORT The present report describes a case of a hemodynamically stable patient with a single penetrating gunshot trauma causing an AAST-OIS grade III pancreatic head injury and grade IV injury of the second portion of the duodenum. The patient was treated in our Level IV rural trauma center and submitted to primary closure of the posterolateral duodenal wall (the laceration of the contralateral inner medial duodenal wall could not be repaired), external duodenal and pancreatic drainage, and duodenal decompression by tube pancreatico-duodenostomy (insertion of a 18 Fr Foley catheter through the laceration of the pancreatic head toward the duodenal lumen), tube cholangiostomy, and pyloric exclusion accompanied with a feeding jejunostomy. CONCLUSIONS Tube pancreatico-duodenostomy, which is described for the first time in the literature, turned out to be effective and can be considered as an option in pancreaticoduodenal trauma when the inner medial duodenal wall cannot be repaired.

Making omental bursectomy, a routine in extended gastrectomy; a step-by-step guide

Total resection of the bursa omentalis has developed as an essential step of gastrectomy with extended lymphadenectomy for treatment of advanced gastric cancer. Experienced surgeons can safely perform bursectomy during extended gastrectomy without a significant increase in major surgical complications, especially pancreatic fistulas and adhesion formation. This article provides a detailed description of the technique of bursectomy as practiced by the authors. Points of technical interest are emphasized to describe an aesthetic dissection in the correct surgical plane, a D2+ lymphadenectomy and to reduce, and possibly prevent, the development of a pancreatic fistula.

Spontaneous Hemocholecyst in an End-Stage Renal Failure Patient on Low Molecular Weight Heparin Hemodialysis

The present paper describes a case of spontaneous hemocholecyst in a patient with end-stage renal failure on low molecular weight heparin hemodialysis. The patient presented with acute right upper quadrant pain. An initial ultrasound scan demonstrated a distended gallbladder containing echogenic bile without stones. During hospitalization the patient became febrile, and jaundiced, developed leukocytosis, and had an elevation in serum bilirubin, transaminases, and alkaline phosphatase. A new ultrasound demonstrated a thick-walled gallbladder containing echogenic bile and pericholecystic fluid. MRI depicted a distended gallbladder containing material of mixed signal intensity and a normal biliary tract. Open cholecystectomy revealed a gallbladder filled with blood and clots, and transcystic common bile duct exploration flushed blood clots out of the bile duct. To our knowledge this is the second case of spontaneous hemocholecyst reported in the literature as a consequence of uremic bleeding and LMWH hemodialysis in the absence of other pathology.