Splenic Artery Pseudoaneurysm Causing Massive Hematemesis 10 Years After Necrotizing Pancreatitis.

We report a case of a 54-year-old male presenting to a regional hospital with severe hematemesis and hemodynamic instability. His medical history was significant for a previous episode of alcoholic necrotizing pancreatitis and pseudocyst, requiring cystoenterostomy drainage and debridement 10 years prior. He underwent multiple gastroscopies and one emergency laparotomy which failed to definitively treat the bleeding. A splenic artery pseudoaneurysm was diagnosed with computed tomography angiography, adjacent to the previous cystoenterostomy site. The patient was transferred to a major tertiary center with access to interventional radiology and underwent successful embolization of the pseudoaneurysm.

Predicting the efficacy of surgery for pain relief in patients with alcoholic chronic pancreatitis.

BACKGROUND: Recurrent pain is the most disabling complication in patients with chronic pancreatitis. Pancreatic surgery is currently considered as last-resort therapeutic option. The aims of this study were to assess pancreatic surgery performance for chronic pain in patients with alcoholic chronic pancreatitis and to determine factors predictive of therapeutic response. METHODS: All patients with chronic pancreatitis who underwent pancreatic surgery for chronic pain were included and divided into 2 groups according to the cause of chronic pancreatitis: alcoholic and any other chronic pancreatitis causes as the control group. Alcohol, tobacco, and painkiller intake, quality of life data 6 months and 1 year after surgery, and morphological and pathological features were analyzed. RESULTS: Fifty patients were included in the alcoholic chronic pancreatitis group and 16 patients in the control group. Smoking cessation before pancreatic surgery was achieved in 40% of the alcoholic chronic pancreatitis group compared with 73% of the control group (P = .005). Histological analysis revealed a higher prevalence of hypertrophic nerves and perineural inflammation in the alcoholic chronic pancreatitis group than in the control group (P = .03 and P = .04 respectively). In multivariate analysis, in the alcoholic chronic pancreatitis group, factors predictive of 6-month narcotic use cessation were surgery performed within a maximum of 2 years after chronic pancreatitis diagnosis (odds ratio = 4.228 [1.04-17.17]) and postoperative smoking cessation (odds ratio = 3.561 [1.021-12.41]); at 1 year, only smoking cessation was predictive of narcotic use cessation (odds ratio = 11.33 [2.677-47.98]). CONCLUSION: In patients with alcoholic chronic pancreatitis undergoing surgery for chronic pain, narcotic use cessation and improved quality of life depend on early surgery and complete smoking cessation.

Mass forming chronic pancreatitis mimicking pancreatic cystic neoplasm: A case report.

Mass forming chronic pancreatitis is very rare. Diagnosis could be done by the pathologic findings of focal inflammatory fibrosis without evidence of tumor in pancreas. A 34-year-old man presented with right upper abdominal pain for a few weeks and slightly elevated bilirubin level on clinical findings. Radiological findings of multidetector-row computed tomography, magnetic resonance (MR) imaging with MR cholangiopancreatography and endoscopic ultrasonography revealed focal branch pancreatic duct dilatation with surrounding delayed enhancing solid component at uncinate process and head of pancreas, suggesting branch duct type intraductal papillary mucinous neoplasm. Surgery was done and pathology revealed the focal chronic inflammation, fibrosis, and branch duct dilatation. Herein, I would like to report the first case report of mass forming chronic pancreatitis mimicking pancreatic cystic neoplasm.

Pancreatoduodenectomy for groove pancreatitis Report of two cases.

Groove pancreatitis is a rare condition with patients having clinical characteristics similar to those of chronic pancreatitis. Differentiating on clinical and radiological basis between groove pancreatitis and paraduodenal head cancer can be extremely challenging. Due to diagnostic uncertainty and to poor response to medical treatment surgery may offer these patients the best chance of cure. As the main localization of the inflammatory process is at the groove between the duodenum and the head of the pancreas, pancreato-duodenectomy is proposed as the most reliable surgical procedure. We report about two patients presenting with clinical and radiological features suggesting a groove pancreatitis in which control of symptoms was achieved by pancreatoduodenectomy. KEY WORDS: Groove pancreatitis, Paraduodenal pancreatic cancer.

Laparoscopic Puestow: lateral pancreaticojejunostomy.

INTRODUCTION: Chronic pancreatitis is a painful inflammatory disease that leads to progressive and irreversible destruction of pancreatic parenchyma [1]. A lateral pancreaticojejunostomy, also known as the Puestow procedure, is performed for symptomatic chronic pancreatitis associated with a dilated pancreatic duct secondary to calcifications or strictures [4]. An open approach is used traditionally due to the complexity of the case, and there have only been a handful of laparoscopic case reports [2]. This video depicts a laparoscopic lateral pancreaticojejunostomy for chronic pancreatitis. METHODS: A 45-year-old gentleman with a 20-year history of chronic alcohol abuse presented with diffuse abdominal pain. His pain was worse postprandially and associated with loose stools. A computed tomography scan revealed multiple calcified deposits within the body and tail of the pancreas, and a dilated pancreatic duct measuring 1.4 cm with a proximal obstructing calcified stone. A 5-port foregut technique was used, and a 15-cm pancreatic ductotomy was performed with an ultrasonic scalpel. Calcified stones were cleared from the duct, and a roux-en-y pancreaticojejunostomy was performed using a hand-sewn technique. RESULTS: The patient had a relatively uncomplicated hospital course with return of bowel function on postoperative day 4. His patient-controlled analgesic device was discontinued on post operative day 3. He was ambulating, tolerating a regular diet and discharged home on postoperative day 5. At 12- and 26-month follow-up, he remains off narcotics, but still requires 1-2 tabs of pancreatic enzyme replacement per meal. Most importantly, he has not had any alcohol for over 2 years. CONCLUSION: The two primary goals in treating chronic pancreatitis include long-term pain relief and improvements in quality of life [3]. For patients with chronic pancreatitis and a dilated pancreatic duct, a laparoscopic lateral pancreaticojejunostomy may be an effective approach to decrease pain and improve quality of life.

[Scrotal Mass as a Rare Initial Manifestation of Necrotising Pancreatitis]. / Skrotale Raumforderung als seltene Erstmanifestation einer nekrotisierenden Pankreatitis.

A scrotal mass as initial manifestation of necrotising pancreatitis is very rare. In addition, the diagnosis is very difficult because diseases that occur more frequently produce similar symptoms. Therefore, it is very important to think about rare entities in the differential diagnosis for testicular pain.

Short- and long-term results of modified Frey's procedure in patients with chronic pancreatitis: a retrospective Japanese single-center study.

BACKGROUND: The study aim was to determine the short- and long-term results of surgical drainage procedure for chronic pancreatitis at a single center in Japan. METHODS: The records of 28 consecutive patients were retrospectively reviewed. All patients underwent surgery at Kobe University Hospital between June 1999 and April 2013. Long-term follow-up was performed in all patients for a median period of 77 months. RESULTS: The 26 men (93%) and 2 women (7%) had a mean age of 47 years. The etiology of pancreatitis was chronic alcohol abuse in 24 patients (86%). The major indication for surgery was persistent symptoms (97%). Modified Frey's procedure in 21 patients, lateral pancreaticojejunostomy (LPJ) in 6 patients, LPJ and distal pancreatectomy in one patient, were performed. There was no postoperative mortality. Postoperative morbidity occurred in 6 patients (21%). The percentage of pain-free patients after surgery was 97%, and further acute exacerbation was prevented in 97%. Two patients (6%) required subsequent surgery for infectious pancreatic cyst and intraabdominal abscess. Of the patients that completed follow-up, 13 (46%) had diabetes mellitus, including 5 patients (19%) with new-onset diabetes, and 6 patients (19%) developed pancreatic exocrine insufficiency. CONCLUSIONS: Modified Frey's procedure is safe, feasible, and effective to manage chronic pancreatitis. The technique prevents further exacerbations and maintains appropriate pancreatic endocrine and exocrine function.

Frey's pancreaticojejunostomy in tropical pancreatitis: assessment of quality of life. A prospective study.

INTRODUCTION: Tropical pancreatitis is a form of chronic pancreatitis originally described in the tropics. Prospective studies in Western countries have shown improved quality of life (QOL) following surgery in alcoholic chronic pancreatitis. In studies on Frey's pancreaticojejunostomy for tropical pancreatitis, improvement in pain was considered the endpoint, and there is a paucity of data in the literature with regard to QOL with tropical pancreatitis following surgery. OBJECTIVE: Our objective was to prospectively analyze the outcome of Frey's pancreaticojejunostomy in tropical pancreatitis and health-related QOL following surgery by administering the Short Form 36-item health survey (SF-36). MATERIALS AND METHODS: A total of 25 patients underwent Frey's pancreaticojejunostomy between 2010 and 2012 and were included in the study; data were collected prospectively. The visual analog scale (VAS) for pain and the SF-36 form were used to record health-related QOL preoperatively, and at 3 and 12 months post-surgery, comparing the same with the general population. RESULTS: Patients with tropical pancreatitis experience poor QOL (26.71 ± 15.95) compared with the general population (84.54 ± 12.42). Post-operative QOL scores (78.54 ± 15.84) were better than the pre-operative scores (26.71 ± 15.95) at 12-month post-surgery follow-up. The VAS score for pain improved at 12 months post-surgery (1.58 ± 1.41 vs. 8.21 ± 1.64). Two of the three patients (12.5 %) who had diabetes were free from anti-diabetes medication at 12 months post-surgery. Steatorrhea was seen in five patients (20.8 %) before surgery and increased to eight (33.3 %) at 12 months post-surgery. Mean body weight increased from 45.75 kg pre-operatively to 49.25 kg at 12 months post-operatively. CONCLUSIONS: Frey's pancreaticojejunostomy effectively reduces pain in tropical pancreatitis, with significant improvement in health-related QOL, which is comparable with the general population in most aspects.

Necrotizing pancreatitis complicated by oesophageal haemorrhage.

Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management.

Endoscopic transpapillary pancreatic stenting for internal pancreatic fistula with the disruption of the pancreatic ductal system.

BACKGROUND: Internal pancreatic fistula (IPF) is a well-recognized complication of pancreatic diseases. Although there have been many reports concerning IPF, the therapy for IPF still remains controversial. We herein report our experiences with endoscopic transpapillary pancreatic stent therapy for IPF and evaluate its validity. METHOD: Six patients with IPF who presented at our department and received endoscopic transpapillary pancreatic stent therapy were investigated, focusing on the clinical and imaging features as well as treatment strategies, the response to therapy and the outcome. RESULTS: All patients were complicated with stenosis or obstruction of the main pancreatic duct, and in these cases the pancreatic ductal disruption developed distal to the areas of pancreatic stricture. The sites of pancreatic ductal disruption were the pancreatic body in five patients and the pancreatic tail in one patient. All patients received endoscopic stent placement over the stenosis site of the pancreatic duct. Three patients improved completely and one patient improved temporarily. Finally, three patients underwent surgical treatment for IPF. All patients have maintained a good course without a recurrence of IPF. CONCLUSION: Endoscopic transpapillary pancreatic stent therapy may be an appropriate first-line treatment to be considered before surgical treatment. The point of stenting for IPF is to place a stent over the stenosis site of the pancreatic duct to reduce the pancreatic ductal pressure and the pseudocyst's pressure.

The Frey procedure with the use of 2 types of ultrasonically activated scalpels for chronic pancreatitis: report of a case.

A surgical procedure is the only way to relieve intractable pain in patients with chronic pancreatitis and an inflammatory mass in the pancreas head. Although the Frey procedure is safer and more effective for pain relief than is standard pancreaticodudenectomy, it is often associated with such complications as pancreatic fistula and postoperative hemorrhage. A 64-year-old man was admitted to our hospital because of increasingly frequent episodes of epigastralgia. This patient had continued to abuse alcohol until recently and was regularly using painkillers to relieve severe pain due to chronic pancreatitis. The patient underwent the Frey procedure with the use of 2 types of ultrasonically activated scalpel. There were no surgery-related complications. The patient was discharged 18 days after the operation. Neither recurrence of pain nor locoregional complications have been observed for 2 years after the procedure. Herein we report the use of the Frey procedure to treat an enlarged mass of the pancreatic head and discuss the efficacy of the ultrasonically activated scalpel for excavation of the pancreatic head and long dichotomy of the pancreatic duct.

Prospective evaluation of pain control and quality of life in patients with chronic pancreatitis following bilateral thoracoscopic splanchnicectomy.

BACKGROUND: Abdominal pain in chronic pancreatitis (CP) is the most common symptom with a highly unfavorable impact on the quality of life. It has been shown that bilateral thoracoscopic splanchnicectomy (BTS) may produce marked pain relief for the majority of patients. The aim of this study was to evaluate the effectiveness of BTS in pain control and quality-of-life improvement in patients with a severe form of CP. METHODS: Between April 2000 and April 2009, a total of 30 patients qualified for BTS due to CP-related pain. Their age ranged from 28 to 60 years. A 12-month follow-up period was planned for all the patients enrolled. To evaluate effectiveness of BTS, an 11-point Numeric Rating Scale (NRS) and the Quality of Life Questionnaire C-30 (QLQ-C30) in its basic form, developed by European Organization for Research and Treatment of Cancer, were used. An NRS value between 0 and 3 was considered a positive postoperative pain control result. RESULTS: The bilateral splanchnicectomy procedure was performed successfully in 27 of 30 qualified patients. A positive effect based on decreased pain (p < 0.05) at 12 months was achieved in 24 patients (80 %). The initial change in quality of life was not significant but it gradually improved with time (preop vs. 12 months QLQ-C30 score, p < 0.001). CONCLUSIONS: This study showed that BTS is safe and efficacious for pain alleviation in patients with severe CP. It may significantly increase the chances of a long-lasting, life-changing improvement in the quality of life.