Pancreas divisum: analysis and therapeutic alternatives with a case report.

INTRODUCTION: Pancreas divisum is a relatively common pancreatic duct anatomic variant, firstly described in the 17th century. CASE REPORT: We reported a 2-year-old child admitted to the Pediatric Clinic with breathing difficulties and abdominal pains. Examination and X-ray image, showed a vast right hydrothorax containing rusty coloured solution with a high degree of amylase. Ultrasound and computed tomography examination revealed pancreatic polycyclic pseudocysts; following magnetic resonance cholangiopancreatography (MRCP), the diagnosis of pancreas divisum was confirmed. The general condition of the patient worsened, requiring an urgent operation. External drainage of the perforated pancreatic pseudocyst was performed. Following external fistula maturation, a change from external to internal drainage was performed using Roux-en-Y fistulojejunostomy. A 3-year postoperative period was uneventful. CONCLUSION: Pancreas divisum cases are unique requiring clinical experience, rational approach, and complex multimodal management. MRCP is a valuable diagnostic method. Amongst therapeutic options, outer and internal drainage can be seen as reliable methods. Further investigations are absolutely required to determine practical and appropriate conclusions.

The analysis of the connection between plaque morphology of asymptomatic carotid stenosis and ischemic brain lesions.

BACKGROUND/AIM: A certain percentage of patients with asymptomatic carotid stenosis have an unstable carotid plaque. For these patients it is possible to register the existence of lesions of the brain parenchyma - the silent brain infarction. These patients have a greater risk of ischemic stroke by modern imaging methods. The aim of this study was to analyze the connection between the morphology of atherosclerotic carotid plaque in patients with asymptomatic carotid stenosis and the manifestation of silent brain infarction, and to analyze the influence of risk factors for cardiovascular diseases on the occurrence of silent brain infarction and the morphology of carotid plaque. METHODS: This retrospective study included patients who had been operated for high grade (> 70%) extracranial atherosclerotic carotid stenosis at the Clinic for Vascular and Transplantation Surgery of the Clinical Center of Vojvodina over a period of 5 tears. The patients analyzed had no clinical manifestation of cerebrovascular insufficiency of the carotid artery territory up to the time of operation. The classification of carotid plaque morphology was carried out according to the Gray-Weale classification, after which all the types were subcategorized into two groups: stable and unstable. Brain lesions were verified using preoperative imaging of the brain parenchyma by magnetic resonance. We analyzed ipsilateral lesions of the size > or = 3 mm. RESULTS: Out of 201 patients 78% had stable plaque and 22% unstable one. Unstable plaque was prevalent in the male patients (male/female ratio = 24.8% : 17.8%), but without a statistically significant difference (p > 0.05). The risk factors (hypertension, nicotinism, hyperlipoproteinemia, and diabetes mellitus) showed no statistically significant impact on carotid plaque morphology and the occurrence of silent brain infarction. Silent brain infarction was detected in 30.8% of the patients. Unstable carotid plaque was found in a larger percentage of patients with silent brain infarction (36.4% : 29.3%) but without a significant statistical difference (p > 0.05). CONCLUSIONS: Even though silent brain infarction is more frequent in patients with unstable plaque of carotid bifurication, the difference is of no statistical significance. The effects of the number and type of risk factors bear no statistical significance on the incidence of morphological asymptomatic carotid plaque.

Origin and pathological characteristics of Klatskin tumor: a case report and literature review.

Hilar cholangiocarcinomas involving the bifurcation of the hepatic duct are called Klatskin tumors. A resected specimen of the hilar hepatic region with Klatskin tumor was analyzed. The lining epithelium of major biliary ducts was regular, while the majority of epithelial cells lining the excretory ducts of peribiliary glands (PBGs) exhibited malignant features. The connective tissue surrounding the PBGs was infiltrated by mucinous malignant epithelial cells, sometimes in a signet-ring cell form, with perineural invasion. The tumor epithelial cells showed distinct CK 7 and CA 19-9 positivity. The described cholangiocarcinoma was classified as the Bismuth-Corlette type IIIb and originated from the excretory ducts and acinar cells of PBGs.

[Acute pancreatitis in children].

INTRODUCTION: Acute pancreatitis in children is mostly due to abdominal trauma, diseases or congenital anomalies of the biliary-pancreatic tree. Both exogenous and endogenous functions of the gland could be disturbed by various levels of damage. CLINICAL FINDING AND DIAGNOSTICS: Acute abdominal pain, gastrointestinal signs and general deterioration are the main clinical findings. The examination can be completed by blood and urine tests of amylase, electrolytes level, and the C-reactive protein. In addition to these tests, ultrasound, computed tomography and endoscopy are required as well. THERAPEUTIC METHODS: The therapy of choice is non-operative treatment using medicaments to control the pain, decrease the pancreatic activity and prevent further complications. If the conservative treatment fails, the surgical approach is necessary: drainage, resections, by-pass procedures, etc. CONCLUSION: Acute pancreatitis is a very serious disease in childhood. Clinical experience and rational approach are very important in the diagnostic and therapeutic methods.

[Role of surgical resection in treatment of pancreatic adenocarcinoma].

INTRODUCTION: Pancreatic adenocarcinoma is the fifth leading cause of death from malignant diseases. The total five-year rate is bellow 5%, but in patients who underwent pancreatic resection, the five-year rate may be up to 20%. Surgical resection is still the only therapeutic option that offers the possibility of cure. In recent decades, the perioperative mortality rate has been significantly reduced in the institutions performing a number of these operations per year and has become less than 5%. Postoperative morbidity remains high. MATERIAL AND METHODS: The results of surgical resection in the treatment of pancreatic adenocarcinoma have been analyzed. A retrospective study included the patients operated at the Department for Abdominal, Endocrine and Transplantation surgery, Clinical Center of Vojvodina. RESULTS: In the period from February 1st 1998 to February 1st 2007 a total of 67 patients with pancreatic adenocarcinoma underwent resection. The average age of patients was 58.81 +/- 1.42 years. There were 44 (65.7%) male and 23 (34.3%) female patients. The most common locations of cancer were the head, then the body and the tail of the pancreas and they were found in 57 (85.1%) cases, 7 (10,4%) cases and 3 (4,47%) cases, respectively. The postoperative mortality appeared in 3 (4.47%) cases and postoperative morbidity in 21 (31.3%) cases. The average survival was 22.89 +/- 3.87 months, the median being 9.0 +/- 2.18 months. The five-year survival rate was 13.5%. CONCLUSION: For patients with pancreatic cancer, surgical resection still remains the only chance of cure. These procedures are performed with acceptable postoperative mortality and morbidity rate. The percentage of cured patients is still unsatisfactorily low.

Primary closure of the common bile duct in the treatment of choledocholithiasis.

Surgical institutions equipped to apply endoscopic retrograde cholangiopancreatography with papillotomy do not treat non-complicated choledocholithiasis in a surgical way any more. However, those institutions which have not yet started to perform cholangiopancreatography apply surgical treatment of choledocholithiasis, and therefore, choledochography is still an option to end the exploration of choledochus with or without the concrement removal. Since cholangiopancreatography has not become a routine treatment in our institution, we have tried to determine the role of the primary closure of the choledochus in the treatment of choledocholithiasis as well as the indications and contraindications for its application.

[Von Meyenburg complex associated with adult polycystic liver disease].

INTRODUCTION: The von Meyenburg complex (bile duct hamartoma) is a rare developmental disorder, manifested by multiple bile ducts. The polycystic liver disease is a rare congenital anomaly which may remain undiscovered until adult life, occurring more frequently in women. It is mostly asymptomatic, but sometimes surgical intervention is necessary. In the majority of cases, it is combined with cysts in the kidney and, rarely, in other organs as well. The cysts may vary in diameter from 1 mm to 20 cm, or even more. CASE REPORT: A 55-year-old woman underwent surgery based on clinical diagnosis: suspected Echinococcus liver cyst. Liver biopsy was performed, and a parenchymal tissue of 6.5x4x3 cm, with a cyst with a diameter of 2.5 cm, was resected. Within the cyst lumen there was a necrotic, mushy, yellow contents. Microscopically examined, it showed plenty of cholesterol crystals. The wall of the cyst consisted of hypocellular connective tissue. In the surrounding liver parenchyma, there were cystical formations of the same structure, measuring 1-2 mm. Also, there were some multiple bile duct hamartomas. The ducts were encircled by a delicate connective tissue. DISCUSSION AND CONCLUSION: These changes correspond to von Meyenburg complex, i.e. biliary microhamartoma combined with adult polycystic disease. In our case, in the wall of the cyst there were numerous cholesterol crystals, pointing to its retention character and, probably, to the mechanism of its origin. After degeneration of biliary epithelium, the cyst wall grew very thick, due to proliferation of the connective tissue evoked by the aggressive chemical contents of the bile. Frequent development of cholangiocarcinoma within the cyst wall also points to long-term chemical irritation.