Preserving a rare type of variant right hepatic artery combines surgical radicality and intact liver perfusion during pancreatectomy

An anomalous anatomy of the celiac trunk, and particularly of the right hepatic artery, may have a significant impact on major hepatobiliary and pancreatic surgery. According to some authors, every third patient has an aberrant right hepatic artery. We present a very rare case of replaced right hepatic artery (RRHA) arising from the gastroduodenal artery associated with an accessory left hepatic artery originating from the left gastric artery in a 54-year-old woman with a pancreatic head carcinoma. The patient underwent total pancreatectomy on account of a soft lipomatous pancreas with heterogeneous changes of the pancreatic body and tail. We preserved the RRHA and achieved R0 resection margins. Preoperative evaluation of CT angiograms, an awareness of any anomalous arterial anatomy of the upper abdomen, and a meticulous surgical technique are the key to performing oncologically radical surgery without threatening the arterial liver supply

Criteria for determining malignancy in pancreatic intraductal papillary mucinous neoplasm based on computed tomography

$\textit {Introduction:}$ Determining the dignity of intraductal papillary mucinous neoplasms (IPMNs) by imaging procedures is challenging. Various CT-based criteria were evaluated. $\textit {Patients and Methods:}$ Preoperative CT scans from 47 patients with IPMN were analyzed. Predefined criteria of malignancy were compared between patients with benign (bIPMN; $\it n$ = 28) and malignant (mIPMN; $\it n$ = 19) tumors, and a summation score was determined. $\textit {Results:}$ Preoperative carbohydrate-antigen 19-9 levels were higher in patients with mIPMN ($\it p$ = 0.013). The diameter of the main pancreatic duct was greater in patients with mIPMN (($\it p$ < 0.0001). More patients with mIPMN showed bile duct obstruction (($\it p$ = 0.0076), solid tumor components (($\it p$ = 0.0076), contrast enhancement in cystic walls (($\it p$ = 0.0086), peripancreatic lymph nodes (($\it p$ = 0.0076), and abrupt diameter changes of the main pancreatic duct (($\it p$ = 0.0008). The CT density of the cysts was higher in mIPMN (($\it p$ = 0.0063). The diagnostic accuracy of the summation score (sensitivity: 0.84, specificity: 0.96) was greater when compared to each individual CT parameter. $\textit {Conclusions:}$ The prevalence and extent of various CT-based abnormalities are greater in patients with mIPMN, but the wide overlap limits the diagnostic value of each individual parameter. A simple summation score largely enhances the diagnostic accuracy

Facing the surgeon's nightmare

$\bf Background$ Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality. $\bf Methods$ We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). $\bf Results$ A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors ($\it P$ < .05). Reoperation was necessary in all affected patients on postoperative day 12 $\pm$ 9 on average. Mortality was significantly associated with POPF grade C ($\it P$ < .05) being present in 39.1% (9/23). $\bf Conclusions$ POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice

A double metachronous ureter metastasis following curative resection of rectal cancer

A malignant ureteral obstruction is most often due to primary tumors of the ureter. However, it can occur secondary due to external tumor compression or metastatic infiltration. Distant metastases to the ureter are extremely rare. We present a case of a rare double distant metachronic metastasis to the right ureter as well as to the right renal pelvis in a 58-year-old female with a history of anterior resection for rectal cancer 2 years earlier. She presented with recurrent urinary tract infection and right hydronephrosis caused by an ureteral mass. The patient underwent a right nephroureterectomy via laparotomy. Two metastases of the rectal cancer in the ureteral mucosa were verified at histology. On account of the infiltration of the right ureteral orifice, a completion transurethral resection of the tumor was performed. A follow-up 3 and 6 months later showed no signs of tumor relapse and the patient was doing well. The differential diagnosis of malignant ureteral obstruction in patients with history of colorectal cancer should include the rare possibility of distant metastasis from the primary tumor