Preduodenal Portal Vein And Polysplenia: A Case Report and Review Of Literature

Preduodenal portal vein (PDPV) is a rare anomaly in which the portal vein courses anterior to the second part of the duodenum. PDPV is often associated with other congenital anomalies such as polysplenia, malrotation and pancreatic anomalies. We report an elderly male with Stage IIB esophageal adenocarcinoma. Incidental findings on staging computed tomography (CT) included an anomalous preduodenal and presplenic portal vein and polysplenia, though the patient did not present with any symptoms related to these findings. Post-neoadjuvant chemoradiation, the patient underwent an Ivor Lewis esophagectomy. Appreciating the anomalous tract of the portal vein anterior to the pancreas and duodenum from the preoperative images, we were able to perform duodenal mobilization (Kocher manuever) without vessel injury. Since, PDPV is often an asymptomatic and incidental finding in adults, serious surgical complications may occur if not appreciated on preoperative imaging or intraoperatively. Heightened awareness of PDPV and other associated anomalies remains vital to a safe procedure in all ages

The Impact of Preoperative Frailty on Endoscopic Cerebrospinal Fluid Leak Repair Outcomes in the Anterior Skull Base

Background: Measurements of surgical frailty estimate a patient\u27s ability to withstand the physiologic stress of a procedure. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Methods: Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. Results: A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average BMI was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). The average duration of leak was 9.31 ± 22.14 months. 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and definitively diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes (myocardial infarction, cerebrovascular accident, pneumonia, pulmonary embolism/deep vein thrombosis, and meningitis), surgical outcomes (bleeding requiring transfusion, postoperative CSF leak), or readmission (all p \u3e 0.05). Discussion: Endoscopic CSF leak repair in a frail population, including lumbar drain placement and postoperative bedrest, did not have an increased rate of complications. Previous data suggests there are increased complications in open craniotomy procedures in patients with significant comorbidities. Our preliminary data suggests that the endoscopic approach to CSF leak repair may be better tolerated in the frail population