Pancreatic Duct-to-mucosa versus Invagination or Complete External Drainage Anastomosis in Case of Small Pancreatic Duct after Pancreaticoduodenectomy: Comparative Historical Review

After pancreaticoduodenectomy (PD), pancreatic duct-to-mucosa anastomosis (PDM) has been usually applied which may prevent risk of pancreatic fistula (PF). In cases with a small pancreatic duct, however, PDM is difficult to complete. Procedures involving the invagination (IV) or complete external tube drainage (CED) are supposed to be alternative options for anastomosis. We retrospectively compared clinical results between PDM and IV or CED in 104 patients with a tiny pancreatic duct who underwent PD. The 77 patients undergoing PDM (the control group) and 27 patients undergoing other procedures, including 19 for CED and 8 for IV, were comparatively examined. Fatty pancreas was commonly observed in CED group. Pancreaticojejunostomy was significantly more frequently applied in CED group, and the operating time in the IV group was significantly longer than in control group (p<0.05). The anastomotic time in CED group tended to be shorter than those in control and IV groups (18 versus 29 and 37 min). The incidences of PF were not significantly different among groups (31% in control, 47% inCED and 14% in IV, respectively); however, a grade B or C level of PF was not observed in the IV group. PDM is often difficult to achieve and inadequate suturing may injure the pancreatic parenchyma in cases of very small pancreatic duct. Re-evaluation of the CED or IV procedure as an alternative option was suggested to be warranted

Unanticipated adverse event of endoscopic submucosal dissection: Rectal perforation associated with injury of the cecum wall, Report of a case

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer, but it is not generally used for colorectal lesions because of its high risk of adverse events. An unanticipated adverse event of rectal ESD is reported. A 71-year-old man was found to have a laterally spreading tumor at the upper rectum. ESD was performed. During the ESD, rectal perforation occurred, and emergency laparoscopic surgery was performed. At the operation, rectal perforation with retroperitoneal emphysema was detected. Surprisingly, an 8-cm-long, lacerated wound was found at the cecum wall. It was thought to have been caused by heat injury due to ESD. The perforated site was resected, and the laceration of the cecum was repaired by extracorporeal suture. In patients with perforation during ESD, it is essential to keep in mind that other organs might have heat-induced injury, and the patient should be more carefully followed

A case of acinar cell carcinoma of the pancreas

Background Acinar cell carcinoma (ACC) is a very rare malignancy and represents only 1% to 2% of pancreatic exocrine carcinomas. At the time of diagnosis, 75% of ACC are resectable. Reliable data concerning effective adjuvant chemotherapy has not been established.Case presentation A 30-mm tumor in the pancreatic tail was incidentally discovered by computed tomography in a 71-yearold man. Several swollen lymph nodes were seen around the main tumor. Endoscopic retrograde cholangiopancreatography (ERCP) revealed disruption of the main pancreatic duct. The patient underwent curative resection (R0) with distal pancreatectomy and node dissection. Histopathological examination revealed ACC with lymph node metastases; adjuvant chemotherapy was performed with gemcitabine after surgery. Twelve months later, the patient showed no sign of recurrence.Conclusion The prognosis of ACC is dismal, although compared to ductal adenocarcinoma, the mean survival appears to be longer. Patients with advanced-stage ACC might benefit from gemcitabine-based adjuvant chemotherapy

Liver resection for metastases of tracheal adenoid cystic carcinoma: Report of two cases

Introduction: Tracheal adenoid cystic carcinoma (ACC) is rare and accounts for <1% of all lung cancers. Although ACC is classified as a low-grade tumor, metastases are frequently identified in the late period. Extrapulmonary metastases are rare, and their resection has rarely been reported. Presentation of case: Case 1: A 77-year-old man underwent tracheal resection for ACC with postoperative radiation (60 Gy) 14 years before (at the age of 63). He underwent two subsequent pulmonary resections for metastases. Fourteen years after the first operation, he underwent extended right posterior segmentectomy with resection of segment IV and radiofrequency ablation for metastases of ACC to the liver. He was diagnosed with metastases to the kidney with peritoneal dissemination 4 years after the liver resection and died of pneumonia 2 years later. Case 2: A 53-year-old woman underwent a two-stage operation involving tracheal resection for ACC and partial resection of liver segments II and V for metastases of ACC to the liver. The tracheal margin was histopathologically positive. Postoperative radiation was performed, and she was tumor-free for 10 months after the liver resection. Discussion: Complete resection of tracheal ACC provides better survival. Radiotherapy is also recommended. However, the optimal treatment for metastases of ACC is unclear, especially because liver resection for metastases of tracheal ACC is rarely reported. Our two cases of metastases of tracheal ACC were surgically managed with good outcomes. Conclusion: Liver resection for metastases of tracheal ACC may contribute to long survival

Predictive Parameters of Intraoperative Blood Loss in Patients who Underwent Pancreatectomy

Background/Aims: Despite recent advances in surgical techniques, blood loss is an important factor associated with postoperative outcomes in pancreatectomy. It is useful to identify risk factors of increased blood loss. Methodology: The clinical records of 161 patients who underwent an elective pancreatectomy for peripancreatic diseases between 1994 and March 2011 were retrospectively examined. Univariate and multivariate analysis of clinicopathological and surgical parameters influencing intraoperative blood loss were performed. We determined the cut-off value of the amount of blood loss based on the analyzed results. Results: The mean and median blood loss was 1346±901 and 1070 mL, respectively. Red cell blood transfusion was performed in 72 patients (45%). Based on ROC analysis, the predictive value of blood loss in patients who received red cell blood transfusion was 880 mL (p < 0.001); however, blood loss was not significantly associated with postoperative complications (p = 0.40). The cut-off level of estimated amount of blood loss in the present study was set at 880 mL. Male patients, fatty pancreas, higher serum alkaline phosphatase level, longer operating time, performance of pancreaticoduodenectomy (PD) and combined resections of adjacent major vessels were associated with significantly more increased blood loss (p < 0.05). Based on multivariate analysis, longer operation time over 480 minutes and performance of PD were significantly associated with increased blood loss (p < 0.05). Conclusions: Attempting to reduce operating time in cases of PD is necessary to reduce intraoperative blood loss