Staged Interventional and Surgical Treatment of Patient with Chronic Pancreatitis Complicated by Pancreaticopleural Fistula with Lung Abscesses.

BACKGROUND Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Its formation is associated with local disruption of the pancreatic duct or pseudocyst communicating with the ductal system. Rarely, other intrathoracic complications may develop such as mediastinitis, pericarditis, hemothorax, and pleural empyema. The combination of pancreaticopleural fistula with lung abscesses is extremely rare. CASE REPORT A 37-year-old male patient, a long-term alcohol abuser, was admitted with complaints on left thoracic and upper abdominal pain, fever with a body temperature of 39.1°C, and a severe cough with purulent sputum. Left-sided pneumonia with pleural effusion was diagnosed. Thoracentesis and then a pleural drainage were performed. However, the symptoms persisted. Pleural effusion amylase was very high - more than 60 000 IU/L. Computed tomography and magnetic resonance imaging revealed cystic changes in the pancreatic head, pseudocyst in the pancreatic body, dilation of the Wirsung duct, and pancreaticopleural fistula with several left lung abscesses. Step by step, the patient underwent drainage of lung abscesses, external drainage of the pancreatic pseudocyst, and external-internal stenting of the pancreatic duct under ultrasound guidance. After fistula resolution, the patient was readmitted and successfully underwent the Bern variant of the Beger procedure. Six months later, he had no complaints and returned to work. In a follow-up examination, there was no fistula, no ductal hypertension, and only small pulmonary residual changes. CONCLUSIONS A very rare case of chronic pancreatitis complicated by pancreaticopleural fistula with lung abscesses is presented. The clinical outcome was good due to the staged character of treatment and participation of a multidisciplinary specialist team.

Appendectomy and resection of the terminal ileum with secondary severe necrotic changes in acute perforated appendicitis.

BACKGROUND: Resectional procedures for advanced and complicated appendicitis are performed infrequently. Their extent can vary: cecal resection, ileocecectomy, and even right hemicolectomy. We present a very rare case of appendectomy that was combined with partial ileal resection for severe necrotic changes and small perforation of the ileum. CASE REPORT: A 19-year-old female patient was hospitalized with right iliac fossa pain and fever 10 days after the onset of symptoms. On laparoscopy, a large mass in a right iliac fossa was found. The ultrasound-guided drainage of the suspected appendiceal abscess was unavailable. After conversion using McBurney's incision, acute perforated appendicitis was diagnosed. It was characterized by extension of severe necrotic changes onto the ileal wall and complicated by right iliac fossa abscess. A mass was bluntly divided, and a large amount of pus with fecaliths was discharged and evacuated. Removal of necrotic tissues from the ileal wall led to the appearance of a small defect in the bowel. A standard closure of this defect was considered as very unsafe due to a high risk of suture leakage or bowel stenosis. We perform a resection of the involved ileum combined with appendectomy and drainage/tamponade of an abscess cavity. Postoperative recovery was uneventful. The patient was discharged on the 15th day. CONCLUSIONS: In advanced appendicitis, the involved bowel resection can prevent possible complications (e.g., ileus, intestinal fistula, peritonitis, and intra-abdominal abscess). Our case may be the first report of an appendectomy combined with an ileal resection for advanced and complicated appendicitis.

Esophagectomy and pancreatoduodenectomy in the same patient: tactical and technical considerations.

Esophagectomy (EE) and pancreatoduodenectomy (PDE) are considered the most invasive and technically demanding surgical procedures performed on the digestive organs. These surgical interventions significantly change the normal anatomic relationships in the upper abdomen. Any additional digestive surgeries, especially resectional procedures, performed after a prior EE or PDE can be extremely difficult. The cases of simultaneous or metachronous EE and PDE in the same patient are very interesting from both a scientific and a practical viewpoint. We collected and analyzed the existing literature data on EE and PDE in the same patient. There were 60 cases: 3 cases of EE after PDE, 22 cases of PDE after EE, and 35 cases of simultaneous EE and PDE. The technical and tactical features of the surgery in a different sequence of stages or in a simultaneous procedure are discussed in a review.