Advanced Endoscopic Rescue of a Complication (Duodenojejunostomy Leak) After a Pylorus-Preserving Pancreaticoduodenectomy in a Post-Esophagectomy Patient with Pancreatic Adenocarcinoma: A Case Report and Review of the Literature.

Background: Approximately 4% of patients develop a second upper gastrointestinal cancer after esophagectomy, and nearly 60,000 people are diagnosed with pancreatic cancer in the United States each year. The need for a Whipple procedure after esophagectomy is rarely reported. Post-esophagectomy anatomy, particularly the vascular supply, makes this a complex operation. Herein, we describe the advanced endoscopic rescue of a duodenojejunostomy (DJ) leak after pylorus-preserving pancreaticoduodenectomy (PPPD) in a post-esophagectomy patient. Presentation: A 72-year-old male with a remote history of esophageal cancer treated with minimally invasive three-hole esophagectomy and chemoradiation presented to our institution for evaluation and management of newly diagnosed pancreatic cancer. The patient had undergone common bile duct (CBD) stent placement by his gastroenterologist 2 weeks earlier after experiencing jaundice, weight loss, and steatorrhea. Endoscopic ultrasound confirmed the presence of a pancreatic head and neck mass, obstructing and dilating the main pancreatic duct and CBD. Fine-needle biopsy revealed a poorly differentiated adenocarcinoma. A PPPD was performed without intraoperative complications. The patient was subsequently readmitted with a DJ leak requiring interventional radiology and advanced endoscopic intervention. Conclusions: PPPD in patients with pancreatic cancer can be performed after previous esophagectomy. Careful dissection is crucial to avoid injury to the remaining right gastric and right gastroepiploic arteries that supply the gastric conduit after esophagectomy. The DJ is at risk after this operation, and access to tertiary care inclusive of interventional radiology and advanced endoscopic teams is critical to the correction and healing of a leak of this anastomosis.

Pylorus-Preserving Total Pancreatectomy for Intraductal Papillary Mucinous Neoplasm in the Setting of Previous Roux-en-Y Cystjejunostomy for Pancreatic Pseudocyst.

Background: Intraductal papillary mucinous neoplasms (IPMNs) are cystic lesions of the pancreas with malignant potential. The Sendai and Fukuoka criteria offer guidelines for surgical management of an IPMN. Presentation: A 69-year-old patient with a history of recurrent pancreatitis presented with steatorrhea and unintentional weight loss. Upon workup, he was found to have an IPMN, for which he met Sendai and Fukuoka criteria for surgical management. At the time of surgery, the patient's reported operative history was remarkable only for cholecystectomy; however, during the procedure, he was found to have a Roux-en-Y limb of jejunum attached to the head of the pancreas. Postoperative discussion with the patient and family revealed that this was likely the result of a past cystjejunostomy procedure used to drain what may have been a pancreatic pseudocyst that had developed after a bout of severe acute pancreatitis. Ultimately, the previously created Roux-en-Y limb was used in the reconstruction after specimen excision by total pancreatectomy. Conclusions: Main duct IPMNs have a high incidence of carcinoma. Those that meet Sendai and Fukuoka criteria should be surgically managed. In this study we present a case of IPMN management by total pancreatectomy with unique reconstruction using a previously created Roux-en-Y limb.

Early Clinical Outcomes of a Novel Antibiotic-Coated, Non-Crosslinked Porcine Acellular Dermal Graft after Complex Abdominal Wall Reconstruction.

BACKGROUND: Non-crosslinked porcine acellular dermal grafts (NCPADG) are currently the mainstay biomaterial for abdominal wall reconstruction (AWR) in complex hernia patients. We report early clinical outcomes using a novel rifampin/minocycline-coated NCPADG for AWR. STUDY DESIGN: A multi-institutional retrospective review was performed of patients who underwent ventral hernia repair using XenMatrix AB Surgical Graft (CR Bard, Inc [Davol]). Patient demographics, hernia and procedure characteristics, and surgical site occurrences/postoperative complications were reviewed up to 6 months after AWR. RESULTS: Seventy-four patients underwent AWR using XenMatrix AB Surgical Graft. Open AWR was performed in 52 patients (70.3%), and 22 patients (29.7%) underwent laparoscopic VHR. Median hernia size/area was 66.0 cm(2) (range 9.4 to 294.5 cm(2)). Sixteen patients (21.6%) had previous wound infections, and 16 patients (21.6%) had violation of the gastrointestinal tract during hernia repair. The most common locations of NCPADG placement were within the intraperitoneal (32.4%) and onlay (21.6%) positions, respectively. Median hospital length of stay was 4 days. Within 30 days after AWR, 6 (8.1%) patients were readmitted, postoperative seroma formation developed in 4 (5.4%) patients, 1 patient required percutaneous drainage, and surgical site infections developed in 5 (6.8%) patients. At 6 months follow-up, hernia recurrence had developed in 4 (5.4%) patients. CONCLUSIONS: Data suggest that use of a novel rifampin/minocycline-coated NCPADG was associated with a low rate of postoperative surgical site occurrences/postoperative complications during the first 30 days of follow-up in complex AWR patients. In addition, data suggest a low rate of hernia recurrence at 6-month follow-up. Additional study is warranted to determine whether early antimicrobial protection of the device translates into longer-term protection of the repair.