Preoperative Immunonutrition and Postoperative Outcomes in Radical Pancreaticoduodenectomy Patients.

BACKGROUND/AIMS: This study aimed to compare the patient groups who received and did not receive immunonutrition in terms of mortality and morbidity in patients who underwent radical pancreaticoduodenectomy. MATERIALS AND METHODS: Two groups were formed from 40 patients who underwent radical pancreaticoduodenectomy in our clinic in 2021. The patients in study group were given enteral immunonutrition support for 5 days preoperatively. For this purpose, a standard enteral immunonutrition product containing arginine, omega-3 fatty acids, and RNA (dietary nucleotides) was used. Patients' data of demographical, laboratory, postoperative complications, and current clinical status were analyzed. RESULT: Mortality developed in 5 (25 %) patients in the treatment group and 4 (20 %) patients in the control group in the following months (P > .05). The estimated survival rate in the treatment group was 21.8 ± 2.8 months in the treatment group 19.1 ± 1.7 months in the control group (P > .05). The length of hospital stay was 12.89 ± 3.3 days in the treatment group, while it was 16.47 ± 6.83 days in the control group (P < .05). In the postoperative follow-ups, delayed gastric emptying symptoms developed in 3 patients in the treatment group, while the same complication was observed in 9 patients in the control group (P < .05). Surgical site infections occurred in 4 patients in the treatment group and 9 patients in the control group (P < .05). CONCLUSION: It was observed that preoperative oral immunonutrition before pancreaticoduodenectomy was effective in reducing the risk of delayed gastric emptying after surgery and the length of hospital stay.

Evaluation of the predictive effects of trauma scoring systems in colorectal injuries.

INTRODUCTION: Colorectal injuries following traumas are significant causes of morbidity and mortality. This study aimed to evaluate the predictive effect of trauma scoring systems on mortality and morbidity in patients with post-traumatic colon injury. METHODS: The records of 145 patients with colon trauma treated at Seyhan State Hospital between January 1, 2010, and January 1, 2020, were retrospectively analyzed. Injury Seriousness Score (ISS), Revised Trauma Score (RTS), Trauma Injury Severity Score (TRISS), and Colon Injury Score (CIS) scores were calculated for all patients. The predictive effects of scoring systems on primary outcomes of surgical treatment, complication rates, mortality, and anastomotic leaks were evaluated. RESULTS: The mean age of the patients was 36.1 (SD ± 16.6), and the female/male ratio was 37/108. Anastomotic leakage occurred in 12 (8.2%) patients, and complications were observed in 57 (39.3%) patients. Seven (4.7%) patients died. A statistically significant relationship was observed between the increase in CIS and anastomotic leakage, morbidity, and mortality. Increases in ISS and decreases in RTS and TRISS were associated with increased morbidity and mortality, but these relationships were not statistically significant. CONCLUSION: A significant relationship was observed between the increase in CIS and anastomotic leakage, morbidity, and mortality. The study suggests the need for a specific scoring system for evaluating the prognostic status in colon traumas, as ISS, RTS, and TRISS scores were not found to be significantly predictive of outcomes in this patient population.

Analysis of appendiceal neoplasms in 1,423 appendectomy specimens: a 10-year retrospective cohort study from a single institution.

OBJECTIVE: This study aimed to reveal the incidence, clinicopathological, and oncological outcomes of appendiceal neoplasms. METHODS: This is a retrospective cohort study from a single institution. Patients with a pathological diagnosis of malignancy who underwent appendectomy between January 2011 and 2021 were included in the study, and groups were formed according to pathological type. Clinical, pathological, and oncological results were compared in these groups. RESULTS: The incidence of neoplasia was 2.38% (n=34) in a cohort of 1,423 appendectomy cases. Of the cases, 56% (n=19) were female. The median age in the entire cohort was 55.5 (range: 13-106) years. In the cohort, the rate of neuroendocrine tumor mucinous cystadenoma adenocarcinoma, and low-grade appendiceal mucinous neoplasm, according to the American Joint Committee on Cancer classification of appendiceal neoplasms, was 32.3% (n=11), 26.4% (n=9), 26.4% (n=9), and 14.7% (n=5), respectively. Neuroendocrine tumor patients (median age: 35 years) were younger than the other groups (p=0.021). Secondary complementary surgery was performed in 66.7% (n=6) of adenocarcinoma patients and 27.3% (n=3) of neuroendocrine tumor patients. Right hemicolectomy was performed in all neuroendocrine tumor patients requiring secondary surgery, while right hemicolectomy was performed in three adenocarcinoma patients and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in three adenocarcinoma patients. After a median follow-up of 44.4 months (95% confidence interval: 18.6-70.1), the mean survival rate was 55% in appendiceal adenocarcinoma patients compared to 100% in neuroendocrine tumor patients. CONCLUSION: Appendiceal neoplasms are rare but remain an important cause of mortality. Appendiceal adenocarcinomas are associated with poorer oncological outcomes compared to other neoplasms.

The role of C-reactive protein ratio in predicting mortality in patients with Fournier gangrene.

PURPOSE: This study aimed to determine the C-reactive protein (CRP) ratio for the survival of patients with Fournier gangrene (FG). METHODS: Fifty-two patients with FG between January 2011 and September 2018 were retrospectively analyzed. Data on clinical presentation, Fournier Gangrene Severity Index (FGSI), CRP ratio, management, and outcome were analyzed. The CRP ratio was calculated as preoperative CRP/postoperative CRP value that measured 48 hours after surgical intervention. Possible alternative cutoff points for the FGSI and CRP were determined by receiver operating characteristic (ROC) analyses. The risk factors related to the prognosis were evaluated by univariate and multivariable logistic regression analyses. RESULTS: The mean CRP ratios were 6.7±6.6 in the survivor group and 1.2±0.8 in the nonsurvivor group (P=0.001). FGSI was significantly higher in the non-survivor group compared to survivor group (8.5±2.5 vs. 3.5±2.2, P=0.001). There was a negative correlation between FGSI and CRP ratio (r=-0.51). ROC analysis determined the cutoff value as 1.78 for CRP (sensitivity, 86%; specificity, 82%; area under the ROC curve, 0.90) to predict death. The incidence of death for patients with CRP ratio of ≤1.78 increased 26.7 fold for those with CRP ratio of >1.78 (95% confidence interval [CI], 4.8-146.5; P=0.001). In the multivariable logistic regression model, CRP ratio (odds ratio [OR], 10.3; 95% CI, 1.5-72.2; P=0.019) and FGSI (OR, 17.8; 95% CI, 2.6-121.1; P=0.003) were independent risk factors for death. CONCLUSION: The CRP ratio is a simple method to use to predict mortality in FG.

Analysis of appendiceal neoplasms in 1,423 appendectomy specimens: a 10-year retrospective cohort study from a single institution

SUMMARY OBJECTIVE: This study aimed to reveal the incidence, clinicopathological, and oncological outcomes of appendiceal neoplasms. METHODS: This is a retrospective cohort study from a single institution. Patients with a pathological diagnosis of malignancy who underwent appendectomy between January 2011 and 2021 were included in the study, and groups were formed according to pathological type. Clinical, pathological, and oncological results were compared in these groups. RESULTS: The incidence of neoplasia was 2.38% (n=34) in a cohort of 1,423 appendectomy cases. Of the cases, 56% (n=19) were female. The median age in the entire cohort was 55.5 (range: 13-106) years. In the cohort, the rate of neuroendocrine tumor mucinous cystadenoma adenocarcinoma, and low-grade appendiceal mucinous neoplasm, according to the American Joint Committee on Cancer classification of appendiceal neoplasms, was 32.3% (n=11), 26.4% (n=9), 26.4% (n=9), and 14.7% (n=5), respectively. Neuroendocrine tumor patients (median age: 35 years) were younger than the other groups (p=0.021). Secondary complementary surgery was performed in 66.7% (n=6) of adenocarcinoma patients and 27.3% (n=3) of neuroendocrine tumor patients. Right hemicolectomy was performed in all neuroendocrine tumor patients requiring secondary surgery, while right hemicolectomy was performed in three adenocarcinoma patients and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in three adenocarcinoma patients. After a median follow-up of 44.4 months (95% confidence interval: 18.6-70.1), the mean survival rate was 55% in appendiceal adenocarcinoma patients compared to 100% in neuroendocrine tumor patients. CONCLUSION: Appendiceal neoplasms are rare but remain an important cause of mortality. Appendiceal adenocarcinomas are associated with poorer oncological outcomes compared to other neoplasms.

Migration of Tenckhoff Catheter to Sigmoid Colon: A Rare Delayed Complication.

Bowel perforation associated with inserted peritoneal dialysis (PD) catheter mainly occurs during the perioperative period. Delayed bowel perforation is difficult to diagnose because of its different clinical signs and rarity. A 53-year-old woman developed acute abdomen after her PD catheter was changed. It was found that the changed catheter perforated the sigmoid colon. Primary repair of the perforated area of the sigmoid colon was performed, and the last inserted PD catheter was removed. The postoperative period and recovery were uneventful. Perforations due to the PD catheter may remain silent until the catheter is replaced. In patients with frequent episodes of peritonitis, a perforation area due to PD catheter which limited itself should be considered as the etiology.

Modified techniques versus Hadfield's procedure in patients with periductal mastitis.

BACKGROUND: Periductal mastitis (PM) is a rare disease characterized by chronic inflammation of the terminal mammary ducts. Complete removal of terminal lactiferous ducts with Hadfield procedure is a previously defined technique in treatment but carries various complications risks. This study aims to evaluate the effectiveness of modified techniques in the treatment of PM. METHODS: Twenty women who underwent surgery due to PM between January 2012 and December 2019 were retrospectively analyzed. Types of PM were determined. All patients were operated on with three different incisions [Hadfield's operation with periareolar incision (n:11), periareolar combined radial incision (n:7), and round block incision (n:2)]. RESULTS: The mean age was 37.5 ± 6.5 years (range: 24-49). Sixty percent of patients had type 3 PM. In Hadfield's procedure, NAC retraction (n:2), seroma (n:1), and hematoma (n:1) were seen. In the periareolar incision combined radial incision group only one patient had complications (seroma) and none in the round block method. Follow-up was 12 ± 1.5 months and disease relapse occurred in two patients in the Hadfield group. Patients who underwent round block were more satisfied with the appearance of the nipple. CONCLUSIONS: In the treatment of PM, the main principle of surgical treatment is the excision of the affected canal with a clear margin. Apart from the classical Hadfield procedure, the round block method and periareolar combined radial incision techniques can be performed in the treatment of PM.

Extrapelvic intravenous uterine leiomyomatosis mimicing cardiac myxoma and deep vein thrombosis.

Extrapelvic intravenous uterine leiomyomatosis is a rare smooth muscle neoplasm. Uterine leiomyomatosis is a histologically benign pathology. Rarely, it can be confused with a cardiac mass. A 44-year-old female patient was admitted with increasing severity of pain and swelling in both legs for the past week. The patient was initially diagnosed with bilateral deep vein thrombosis. After further evaluation, we decided that the patient had cardiac myxoma. However, we intraoperatively observed that the lesion in the right atrium was arising from the inferior vena cava. In the final postoperative histopathological evaluation, the definite diagnosis was extrapelvic intravenous leiomyomatosis. The patient was discharged uneventfully following her second operation.

Risk Factors in the Development of Rectus Sheath Hematoma and Treatment Modalities.

Background: In this study,we aim to present the clinical features of patients with rectus sheath hematoma(RSH), as well as the condition's therapeutic management and results. Methods: The study included patients who were diagnosed with and received treatment for spontaneous RSH between the years 2010 and 2020. The demographic and clinical features of the patients, as well as follow-up parameters, were analyzed retrospectively. Results: Our study included 53 patients. The number of female patients was twice as many as the number of male patients. The median age was 65.7 +-14.68 years, and 63.3% of the patients were over the age of 65. The most frequently used anticoagulant was warfarin (30.1%), and it was most often used for heart diseases (54.7%). The international normalized ratio value at the time of admission to the hospital was 1.93+1.18, and the hemoglobin value was 11.2 gr/dl. The average hematoma diameter was 74 mm, and the most common stage was typeI (75.6%). Of the patients, 90.6% were followed up conservatively. The average duration of hospital stay was 15.1 days, and mortality occurred in eight patients during their hospital stay. Conclusion: Spontaneous RSH should be consideredfor elderly female patients who have used anticoagulants. Most patients are followed up medically, but mortality is still high.

Should tall cell thyroid cancers be evaluated differently from well-differentiated thyroid cancers?

OBJECTIVE: In this study, we aimed to investigate the clinical features of Papillary thyroid carcinoma(PTC) Tall cell variant(TCV), long-term outcomes and surgical experience in papillary thyroid carcinoma. MATERIAL-METHOD: 33 patients who were operated in our clinic between August 2012 and March 2018 and diagnosed as TCV in their pathology evaluation were included in the study. The demographic and clinical features of the patients, pathological features of the tumor and long-term results were examined. RESULTS: A total of 33 patients were included in our study. The mean age was 55.2(18-85) years. The female sex was more dominant (75.8%). The most common presenting complaint was swelling in the neck (75.7%).Total thyroidectomy was performed in 84.8% and completion thyroidectomy after lobectomy was performed in 15.2%. Neck dissection was performed in 33% of the patients. The mean tumor diameter was 3.6 (1-10) cm. The tumor was multifocal in 36.3% of the patients. The capsule invasion rate of the tumors was present in 69.7% of the patients, extrathyroidal rate was 39.4%, Metastatic lymph nodes were detected in 30.3% of the cases. The mean follow-up duration was 39.3+22.4(5.25-78.63) months. 39.4% of patients had distant metastasis during follow-up. Disease free survival rate was 57.6%, total survival was 42.4 + 3.8 (34.7-50.0) months. CONCLUSION: TCV is closely associated with larger tumor diameter, multifocal location, extrathyroidal spread and lymph node involvement, We believe that more aggressive surgery should be performed in the treatment of TCV cases and it is important to follow up the patients more closely. KEY WORD: Esophagus cancer, Neutrophil/lymphocyte ratio, Preoperative lymphocyte /neutrophil ratio, Prognosis.

Intraabdominal Schwannomas Single-center experience.

OBJECTIVE: Intraabdominal schwannomas are rare benign tumors. In this study, we aimed to present our clinical experience in patients with intrabdominally located Schwannoma. MATERIAL-METHOD: Patients who received the diagnosis of intrabdominal schwannoma between 2011-2019 were retrospectively examined. Demographic and clinical characteristics, treatment methods, short- and long-term results and immunohistochemical characteristics of the patients were analyzed. RESULTS: A total of 7 patients were included in the study. Four patients were female and three were male. The mean age was 51.5 (31-63) years. The most common clinical presentation was abdominal pain (57.1%). Tumor location was stomach (n=2), pelvic region (n=2), rectum (n=1), retropancreas (n=1), and left juxtadrenal space (n=1). Postoperative wound infection developed in one patient and pancreatic fistula complication was seen in one patient. Re-admissions to the hospital were due to anemia and pleural effusion in two patients. The mean tumor diameter was 6 cm (0.3-13 cm). All patients were S 100 strongly positive Mitoses / 50 HPFs (high power field), <2 Ki67 <3%. The mean follow- up period was 60 months. Currently, 5 patients are being followed without disease, 1 patient survives despite recurrence and 1 patient has died due to non-cancer reasons. CONCLUSION: Intrabdominal schwannomas are rare tumors which most commonly exhibit gastrointestinal involvement. Since these tumors are mostly benign, the long-term prognosis of patients is good. Schwannoma should be kept in mind in the differential diagnosis of intrabdominal masses. Radical resections with high morbidity and mortality should be avoided if preoperative diagnosis is made. KEY WORDS: Abdominal tumor, Mesenchymal tumor, Nerve sheath tumor, Schwannoma.

The usefulness of drainage-internal capitonnage with/without selective bile duct repair technique for liver hydatid cyst.

PURPOSE: The aim of the present study is to describe the cavity-reducing internal capitonnage technique that we used for the surgical therapy of liver hydatid cyst, and contribute to the literature by presenting the short- and long-term outcomes of the patients who were operated on with this technique. METHODS: A drainage and internal capitonnage technique was performed on 12 cases due to liver hydatid cyst in our clinic between January 2016 and December 2019. RESULTS: The mean age of cases was 36.25 ± 12.5 years, with 7 females and 5 males. All cases had pain in the right upper quadrant, and a sense of fullness in 5 cases. None of the cases had ruptured cysts, jaundice, or other clinical manifestations. The preoperative laboratory findings were normal in 8 cases. Intraoperative biliary-cyst communication was demonstrated in 8 cases (66.7%). Cases were followed up for a mean duration of 38.1 months (range, 24-88 months). CONCLUSION: The drainage/internal capitonnage with/without selective bile duct repair is a technique that can be performed with very low morbidity and mortality rates in experienced hands, especially for centrally located hydatid cysts.

Early and late-term follow-up results of patients diagnosed with aortic aneurysm or aortic dissection with aortic regurgitation undergoing aortic valve repair or valve-sparing aortic surgery

Abstract Introduction: Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. Methods: Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. Results: In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. Conclusion: For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery.

INTRODUCTION: Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. METHODS: Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. RESULTS: In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. CONCLUSION: For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Xanthogranulomatous cholecystitis: a rare gallbladder pathology from a single-center perspective.

PURPOSE: The aim of this study was to review patients with xanthogranulomatous cholecystitis (XGC). METHODS: A total of 79 patients diagnosed with XGC were included in the study. The criteria for XGC in the pathology specimens were the presence of histiocytes, cholesterol deposits, lipids, and focal or widespread wall enlargement. RESULTS: Patients were diagnosed with XGC, of which 52 (65.8%) were male and 27 (34.2%) were female, creating a male-to-female ratio of 2:1. The mean age was 65.8 ± 14.3 years (range, 36-97 years). The most common presenting symptom was abdominal pain (63.3%), and the least common presenting symptom was jaundice (8.9%). Of the total, 25 patients were found to have pathological conditions with the potential to obstruct the bile duct or to slow bile flow. A frozen section examination was performed on 20 patients due to suspicion of a tumor by intraoperative macroscopic examination. However, no malignancy was detected in the cases who underwent a frozen section examination. An increase in wall thickness of the gallbladder was observed in 81.6% (n = 31) of the patients on computed tomography scans and in 81.8% (n = 18) of the patients on magnetic resonance imaging scans in which possible tumor lesions were reported, but no tumor was detected. CONCLUSION: It is difficult to diagnose XGC either preoperatively or intraoperatively, and further imaging methods are needed in the preoperative period other than ultrasonography. However, a definitive diagnosis depends exclusively on pathologic examination.

Bilateral breast lesions mimicking metastases of hepatocellular carcinoma in a male patient.

Hepatocellular carcinoma metastases to the breast have been reported only rarely. A 63-year-old male patient with metastatic hepatocellular carcinoma presented with a lump in his left breast. On physical examination, there was a hard, well-circumscribed, and partially mobile mass of 2 cm in diameter in the lower middle quadrant of the left breast. Breast ultrasound revealed a hypoechoic solid lesion of 1.8 cm × 1.9 cm in diameter in the lower middle quadrant of the left breast. F-18 FDG PET/CT imaging revealed bilateral subcutaneous nodular lesions of anterior chest wall that were adjacent but not invasive to the glandular tissues of the breasts, with high SUVmax values. Tru-cut biopsy result of the mass in the left breast region was reported as hepatocellular carcinoma metastasis. Positive immunohistochemical staining for Hep Par 1 and glypican-3 were detected. While the patient was on sorafenib therapy, he died 6 months later. Hepatocellular carcinoma is a common malignancy for which chronic hepatitis B infection has been defined as the most common etiologic factor. The most frequent metastatic sites are the lung, bone, lymphatics, and brain, respectively, and metastases to the breast have been reported extremely rarely. Breast metastasis from non-mammary malignant neoplasm is rare, accounting for approximately 2% of breast tumors. Metastasis to the breast from an extramam mary neoplasm usually indicates disseminated metastatic disease and a poor prognosis. It should be borne in mind that a mass lesion detected in the breast region by physical examination and imaging methods may be a hepatocellular carcinoma metastasis in male or female patients with hepatocellular carcinoma. KEY WORDS: Breast, Hepatocellular carcinoma, Metastasis.

The efficacy of 18F-FDG PET/CT in the preoperative evaluation of pancreatic lesions.

PURPOSE: Since the treatment strategy for benign and malignant pancreatic lesions differ, we aimed to evaluate the clinical value of PET/CT in the diagnosis and management of pancreatic lesions. METHODS: Ninety patients who had a histologically confirmed pancreatic lesion were studied. Receiver operating characteristic (ROC) curve analysis was used to investigate the ability of PET/CT to differentiate malignant lesions from benign tumors. RESULTS: The malignant and benign groups comprised 64 and 26 patients, respectively. Despite the similarity in the size of primary tumors (P = 0.588), the mean maximum standardized uptake values (SUVmax) obtained from PET/CT imaging were significantly higher in malignant lesions (9.36 ± 5.9) than those of benign tumors (1.04 ± 2.6, P < 0.001). ROC analysis showed that the optimal SUVmax cutoff value for differentiating malignant lesions (to an accuracy of 91%; 95% confidence interval, 83%-98%) from benign tumors was 3.9 (sensitivity, 92.2%; specificity, 84.6%). CONCLUSION: PET/CT evaluation of pancreatic lesions confers advantages including fine assessment of malignant potential with high sensitivity and accuracy using a threshold SUVmax value of 3.9.

Hemosuccus pancreaticus A case report and review of the literature.

Hemosuccus pancreaticus is a rare clinical condition, defined as a bleeding from an artery around the pancreas or a lesion on the pancreas, to the pancreatic duct. The intensity of bleeding can vary from occult bleeding to life threatening massive acute bleeding. In this article, we aimed to present a 68-year-old man who presented to our clinic with recurrent upper gastrointestinal bleeding and abdominal pain. Endoscopy revealed hemorrhage from ampulla vateri, CT angiographic examination showed an aneurysm of the splenic artery and that the splenic artery was connected to the pancreatic duct.Splenectomy and subtotal pancreatectomy was performed on the patient. The patient was discharged with healing. Hemosuccus pancreaticus should be kept in mind in patients with a history of pancreatitis and peripancreatic aneurysm and upper gastrointestinal bleeding.The early diagnosis and treatment of HP is life-saving. In this study, we aimed to review the basic symptoms and clinical findings, along with the diagnosis and treatment methods of HP. KEY WORDS: Gastrointestinal bleeding, Pancreas, Splenic Artery.

Intractable external pancreatic fistula post-necrosectomy treated successfully with a fistulojejunostomy.

Pancreatic fistula formation is a known complication of pancreatic surgery, pancreatitis, and pancreatic injury. We here report a case of a 65-year-old man who was diagnosed with gallstone-induced acute pancreatitis with walledoff pancreatic necrosis. The patient initially underwent medical treatment and percutaneous drainage at 4 weeks. After a four-week period, a formal laparotomy with necrosectomy, and the catheter drainage of the cavity were performed. Having postoperatively developed a pancreatic fistula, the patient was managed conservatively. After 6 weeks of medical treatment, patient underwent an endoscopic retrograde pancreatography and was diagnosed with disconnected duct syndrome. The conservative management was continued for 3 more months. Pancreatic duct stenting was attempted but was not successful in cannulating the disconnected duct, and he was finally planned for a Roux-en-Y fistulojejnuostomy. The fistulojejunostomy was performed on an average of 6 months after placement of peri-pancreatic drain. The patient recovered uneventfully and is doing well at a 12-month follow-up. Refractory external pancreatic fistula is defined as an external pancreatic fistula not resolving with these measures for longer than 6 weeks. Most fistulas developing after acute pancreatitis are related directly to the need for necrosectomy to treat infected necrosis. Patients are initially approached conservatively. When patients fail to respond to either percutaneous drainage, endoscopic interventions, or novel techniques, operative intervention is the most viable approach to treat the fistula. Fistulojejunostomy is a safe and effective treatment for intractable pancreatic fistula having the benefit of avoiding a difficult major pancreatic resectional surgery, along with low postoperative morbidity and mortality. KEY WORDS: Acute pancreatitis, Pancreatic necrosis, Pancreatic fistula, Fistulojejunostomy.