A rare case of pseudoaneurysmal hemorrhage, necrotizing fasciitis, and costochondritis after pancreaticoduodenectomy.

BACKGROUND: Necrotizing fasciitis after pancreaticoduodenectomy (PD) has never been reported. We experienced a case of necrotizing fasciitis caused by pseudoaneurysmal hemorrhage after PD. CASE PRESENTATION: A 72-year-old male was diagnosed with cholangiocarcinoma and underwent PD. Bile leakage was detected postoperatively, conservatively resolved, and the patient was discharged on the 36th day after surgery. On the 42nd day after surgery, a pseudoaneurysm of the gastroduodenal artery ruptured. Transcatheter arterial embolization was performed for hemostasis: however, a large intra-abdominal abscess caused by an infected hematoma was recognized. On the 57th day after surgery, the patient developed necrotizing fasciitis. He underwent debridement with skin reconstruction using a latissimus dorsi flap and skin transplantation. Costochondritis and liver metastasis were detected on the 267th day after surgery. Infection was controlled by rib cartilage resection, debridement, and negative pressure wound therapy. Chemotherapy involving gemcitabine and cisplatin was initiated on the 460th day after the initial surgery with a partial response (PR) and was continued for more than one year. CONCLUSIONS: We herein reported a rare case of necrotizing fasciitis following hematoma infection after PD that was treated using multidisciplinary therapy with PR following chemotherapy.

Development of recognised position-guided navigation system.

BACKGROUND: Previously, we developed an image-guided navigation system (IG-NS) incorporating augmented reality technology. Nevertheless, the system could still only aid the operator by presenting imagery and was short of achieving the goal of developing a real navigation system. Therefore, we developed a recognised position-guided navigation system (RP-NS) and herein reported the functionality and usefulness of this system in a phantom model for clinical applications. METHODS: We developed RP-NS which was reconstructed by adding the positional recognition and instruction functions with the cautions by displaying the images on the monitor with a voice to the IG-NS. We evaluated accuracy of positional recognition and instruction functions using phantom model. By utilising the chronological recording of the tip position of the surgical apparatus, the surgical precision of the operators was assessed. Finally, the feasibility of improvements in surgical precision using this system was evaluated. RESULTS: The RP-NS indicated an accuracy of the position recognition functions with an error of 2.7 mm. The surgeons could perform partial hepatectomies within mean value of 7.5% error as compared with calculated volume according to the instruction. Improvements in surgical precision using this system were obtained on the surgeons with different levels. CONCLUSIONS: The RP-NS was highly effective as a navigation system owing to precise positional recognition and adequate instruction functions. Therefore, these results indicate that the use of this system may complement differences in proficiency, and numerically evaluate surgical skills and analyse tendencies of surgeons.

Retroperitoneal lymphangioma mimicking malignant tumor treated by pancreaticoduodenectomy.

Lymphangiomas are classified as lymphatic malformations, which are more common in children and rare in adults. It frequently occurs in the cervical and axillary regions and uncommonly in the retroperitoneum. A 39-year-old woman presented to our department for the investigation for a 55 mm asymptomatic mass in the right anterior adrenal cavity. Abdominal ultrasound showed a tumor containing cysts in the right anterior adrenal cavity. Contrast-enhanced computed tomography showed that the tumor was poorly contrasted and ill-defined. Magnetic resonance imaging suggested that the tumor contained a small amount of fat. The tumor tended to grow, and the possibility of malignant diseases such as liposarcoma could not be excluded. Therefore, surgical resection was performed. Since intraoperative findings showed that the tumor tightly invaded to the duodenum and pancreatic head, a pancreaticoduodenectomy was selected. The entire tumor was removed without exposing the tumor. Macroscopic findings indicated that the specimen was 55 mm in size, indistinctly demarcated, yellow-white in color, and polycystic. Histologically, lymphovascular proliferation was observed with infiltration of the pancreatic head and the duodenal muscle layer. The diagnosis of lymphangioma was finally made. There was no recurrence 2 years after surgery.

Study on the Validity of Pancreaticoduodenectomy in the Elderly.

AIM: Pancreaticoduodenectomy (PD) is still the only curative treatment for periampullary cancer. Confirming the outcomes of PD in elderly patients is important as the aging population continues to grow. PATIENTS AND METHODS: We analyzed 340 patients with periampullary cancer who underwent PD, dividing them into three groups by age: group A: aged 64 years or younger, n=115; group B: 65-74 years, n=144; and group C: 75 years or older, n=81. RESULTS: Group C had a significantly higher 60-day mortality of 6.3% (p=0.04), the lowest 5-year overall survival rate of 9.9% (p=0.02), and there was no impact of staging of the Union for International Cancer Control classification on overall survival of patients with pancreatic cancer. Independent prognostic factors of group C in the multivariate analysis were pancreatic cancer and reoperation. CONCLUSION: For elderly patients aged 75 years or over, caution should be exercised in selecting PD for patients with pancreatic cancer.

Impact of delayed gastric emptying after pancreaticoduodenectomy on survival.

BACKGROUND: Delayed gastric emptying (DGE), a common postoperative complication of pancreaticoduodenectomy, is not considered a life-threatening complication. In the present study, we analyzed the risk factors for DGE and its impact on long-term prognosis. METHODS: We analyzed 383 patients who underwent pancreaticoduodenectomy between 2003 and 2010, dividing them into two groups according to DGE grade as defined by the International Study Group of Pancreatic Surgery: 243 without DGE (non-DGE group) and 140 with DGE of any grade (DGE group). RESULTS: The 5-year overall survival was 32.7% in the DGE group, and 41% in the non-DGE group (P = 0.02). Cox proportional hazards analyses showed that pancreatic cancer (compared with ampulla of Vater cancer: hazard ratio [HR] 3.4, 95% confidence interval [CI] 1.82-6.34, P < 0.001), bile duct cancer (HR 2.1, 95% CI 1.08-4.06, P = 0.03), the Union for International Cancer Control stage (compared with stages I and II: HR 2.98, 95% CI 1.66-5.35, P < 0.001; compared with stage III: HR 4.71, 95% CI 2.51-8.86, P < 0.001), and DGE grade (grade C; HR 1.6, 95% CI 1.04-2.46, P = 0.03) were independent risk factors for cancer-specific survival. CONCLUSIONS: DGE, especially grade C, negatively affects cancer-specific survival.

Comparison of Outcomes with Hand-sewn Versus Stapler Closure of Pancreatic Stump in Distal Pancreatectomy.

AIM: The optimal method for pancreatic stump closure to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP), remains controversial though DP is still the only curative treatment for pancreatic cancer and other malignancies located on pancreatic body or tail. PATIENTS AND METHODS: A total of 44 patients who consecutively underwent open DP were retrospectively analyzed, dividing them into two groups: group H (hand-sewn; n=24) and group S (stapler closure; n=20). RESULTS: POPFs were encountered in 5 (21%) and 11 (55%) patients in groups H and S, respectively (p=0.02). POPFs of Clavien-Dindo grade IIIa or above were observed in two (8%) and seven (35%) patients in groups H and S, respectively (p=0.03). CONCLUSION: When indicating stapler closure, caution should be exercised for pancreatic consistency and thickness, device and cartridge type, and pancreatic duct ligation to more effectively control POPF rates.

Radical resection of a primary unresectable duodenal cancer after chemotherapy using S-1 and cisplatin: report of a case.

BACKGROUND: Therapeutic outcomes and prognosis of primary unresectable duodenal cancer remains unsatisfactory, because effective chemotherapy is not established. CASE PRESENTATION: A 71-year-old male diagnosed with unresectable duodenal carcinoma with distant lymph node metastases was judged inoperable (cT3N2M1 cStage in UICC7th). Duodenal obstruction developed due to tumor growth, and the patient underwent laparoscopic gastro-jejunostomy and then combined chemotherapy using S-1 and cisplatin. Abdominal CT revealed reduction of the tumor, and lymph node swelling almost disappeared after chemotherapy. He underwent subtotal stomach-preserving pancreaticoduodenectomy and lymph node dissection including the para-aortic region. The final stage was fT3N1M0, StageIIIA in UICC7th. He developed pancreatic fistula (ISGPF grade B), which subsided, and he was discharged 29 days after operation. He underwent adjuvant chemotherapy using S-1 for 1 year, and he remains well without recurrence. CONCLUSIONS: S-1/cisplatin combination chemotherapy allowed R0 resection for advanced duodenal cancer.

Successful resection of a solitary metastatic liver tumor from prostate cancer 15 years after radical prostatectomy: a case report.

BACKGROUND: A solitary metastatic liver tumor of prostate cancer is extremely rare because liver metastasis occurs as a part of systemic dissemination of prostate cancer. We herein report a successfully resected case of a solitary metastatic liver tumor from prostate cancer almost 15 years after radical prostatectomy. CASE PRESENTATION: A 70-year-old male who had undergone radical prostatectomy for prostate cancer 15 years previously presented to our hospital for treatment of a liver tumor. Serum prostate-specific antigen was elevated at 13.77 ng/ml. Abdominal computed tomography revealed a solitary tumor with a diameter of 54 mm in segment 4 of the liver. No metastatic lesions were found in other organs. The patient was given a diagnosis of a metastatic liver tumor from prostate cancer, and he underwent medial segmentectomy. Microscopically, the resected specimen was composed of eosinophilic tumor cells with oval nuclei and prominent nucleoli, which exhibited a cribriform pattern and a fused glands pattern with positive prostate-specific antigen and prostatic acid phosphatase staining; these findings were compatible with metastatic prostate cancer. Other than portal thrombosis that required anticoagulation, the patient made a satisfactory recovery and was discharged on postoperative day 15. CONCLUSION: To the best of our knowledge, this is the first report describing successful resection of a solitary metastatic liver tumor from prostate cancer in the medical literature. In such a rare circumstance, hepatic resection for liver metastasis of prostate cancer seems justified.

Radical resection of T1 pancreatic adenocarcinoma with a pseudocyst of the tail due to acute obstructive pancreatitis: report of a case.

A 53-year-old male visited his primary physician for epigastric and back pain. Abdominal-enhanced computed tomography (CT) revealed a simple cyst of the pancreatic tail attached to the stomach. A distal main pancreatic duct (MPD) was clearly dilated, but no pancreatic tumor was identified around the stenosis of MPD by CT scan and magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde pancreatography (ERP) revealed stenosis and distal dilation of the MPD located between the body and tail of the pancreas. Endoscopic ultrasound (EUS) revealed a low density mass of 7 mm in size with distal dilation of the MPD. With the suspicion of a small pancreatic cancer, the patient underwent distal pancreatectomy and splenectomy with lymph node dissection (D2). On histopathological evaluation, a small pancreatic adenocarcinoma of 6 mm in size was detected around the stenosis of MPD. Final pathological diagnosis was moderately differentiated invasive ductal adenocarcinoma of the pancreas with no lymph node metastasis (Japan Pancreatic Society (JPS) classification 7th edition; Pbt, TS1 (6 mm), tub2, intermediate type, INF ß, ly1, v1, ne1, mpd(-), pT1b, pN0, pM0, stage IA,PCM(-), DCM(-) and the Union International Control Cancer (UICC) classification of malignant tumors 6th edition; pT1, pN0, pM0, stage IA, R0). We herein reported a patient who underwent radical resection for T1 pancreatic adenocarcinoma of 6 mm in diameter which caused acute pancreatitis and a pseudocyst due to obstruction of the MPD.

Pancreatic Follicular Lymphoma Presenting as Acute Pancreatitis: Report of a Case.

Pancreatic B-cell lymphoma is rare; it accounts for 0.2% to 2.0% of extranodal non-Hodgkin lymphoma, and constitutes less than 0.5% of all pancreatic malignancies. Most histologic types of the pancreatic lymphoma are diffuse large B-cell lymphoma, and follicular lymphoma is quite rare. We report here a case of pancreatic follicular lymphoma that was initially detected by acute pancreatitis. This is the first reported case of pancreatic follicular lymphoma presenting with acute pancreatitis. A 71-year-old woman had epigastric and left upper quadrant abdominal pain. Computed tomography (CT) revealed features of acute pancreatitis. After standard therapy for pancreatitis, enhanced CT showed a pancreatic tumor (50 × 35 mm) in the body of the pancreas with gradual enhancement. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed a complete interruption of the pancreatic duct in the body, with mild dilation of the duct in the tail of the pancreas. Endoscopic ultrasonography revealed hypervascularity of the pancreatic tumor. The patient underwent distal pancreatectomy to remove the cause of pancreatitis and to disclose the diagnosis. Histologic examination revealed follicular lymphoma of pancreas. Despite recent improvement in clinical strategies, differential diagnosis between pancreatic lymphoma and pancreatic cancer is still difficult without histologic information. Pancreatic lymphoma should be considered as a differential diagnosis in a patient who initially presents with acute pancreatitis.

Identification of inferior pancreaticoduodenal artery during pancreaticoduodenectomy using augmented reality-based navigation system.

BACKGROUND: In pancreaticoduodenectomy (PD), early ligation of the inferior pancreaticoduodenal artery (IPDA) before efferent veins has been advocated to decrease blood loss by congestion of the pancreatic head to be resected. In this study, we herein report the utility of early identification of the IPDA using an augmented reality (AR)-based navigation system (NS). METHODS: Seven nonconsecutive patients underwent PD using AR-based NS. After paired-point matching registration, the reconstructed image obtained by preoperative computed tomography (CT) was fused with a real-time operative field image and displayed on 3D monitors. The vascular reconstructed images, including the superior mesenteric artery, jejunal artery, and IPDA were visualized to facilitate image-guided surgical procedures. We compared operating time and intraoperative blood loss of six patients who successfully underwent identification of IPDA using AR-based NS (group A) with nine patients who underwent early ligation of IPDA without using AR (group B) and 18 patients who underwent a conventional PD (group C). RESULTS: The IPDA or the jejunal artery was rapidly identified and ligated in six patients. The mean operating time and intraoperative blood loss in group A was 415 min and 901 ml, respectively. There was no significant difference in operating time and intraoperative blood loss among the groups. CONCLUSIONS: The AR-based NS provided precise anatomical information, which allowed the surgeons to rapidly identify and perform early ligation of IPDA in PD.

Short rigid scope and stereo-scope designed specifically for open abdominal navigation surgery: clinical application for hepatobiliary and pancreatic surgery.

BACKGROUND: We have reported the utility of an image display system using augmented reality (AR) technology in hepatobiliary surgery under laparotomy. Among several procedures, we herein report a system using a novel short rigid scope and stereo-scope, both designed specifically for open abdominal navigation surgery, and their clinical application for hepatobiliary and pancreatic surgery. METHODS: The 3D reconstructed images were obtained from preoperative computed tomography data. In our specialized operating room, after paired-point matching registration, the reconstructed images are overlaid onto the operative field images captured by the short rigid scopes. The scopes, which are compact and sterilizable, can be used in the operative field. The stereo-scope provides depth information. Eight patients underwent operations using this system, including hepatectomy in two, distal pancreatectomy in three, and pancreaticoduodenectomy in three patients. The stereo-scope was used in five patients. RESULTS: All eight operations were performed safely using the novel short rigid scopes, and stereo images were acquired in all five patients for whom the stereo-scope was used. The scopes were user friendly, and the intraoperative time requirement for our system was reduced compared with the conventional method. CONCLUSIONS: The novel short rigid scope and stereo-scope seem to be suitable for clinical use in open abdominal navigation surgery. In hepatobiliary and pancreatic surgery, our novel system may improve the safety, accuracy and efficiency of operations.

Histopathologically proven autoimmune pancreatitis mimicking neuroendocrine tumor or pancreatic cancer.

Autoimmune pancreatitis (AIP) can be difficult to distinguish from pancreatic cancer. We report a case of histopathologically proven AIP mimicking neuroendocrine tumor (NET) or pancreatic cancer in a 53-year-old man. He was referred to our hospital for further evaluation of a pancreatic mass detected on ultrasonography at a medical check-up. Abdominal ultrasonography showed a 15-mm hypoechoic mass located in the pancreatic body. Computed tomography revealed a tumor without any contrast enhancement, and magnetic resonance imaging demonstrated the mass to be hyperintense on diffusion-weighted image. Endoscopic retrograde cholangiopancreatography revealed slight dilatation of a branch of the pancreatic duct without stricture of the main pancreatic duct. The common bile duct seemed intact. Under suspicion of a non-functioning NET or malignant neoplasm, laparotomy was performed. At laparotomy, an elastic firm and well-circumscribed mass was found suggestive of a non-functioning NET, thus enucleation was performed. Histopathologically, the lesion corresponded to AIP.