Diagnostic double strike in the emergency room

$\textbf {Background:}$ Pancreatic injuries are rare in cases of blunt abdominal trauma and therefore easily misdiagnosed at time of hospital admission. They are associated with a significantly elevated morbidity and lethality. Bicycle handlebar injuries are the most common cause of pancreatic trauma in children and adolescents. $\textbf {Case presentation:}$ We report two cases of a 23-year-old Caucasian woman and a 15-year-old Caucasian boy who presented to our clinic with a similar history of a bicycle accident on 2 consecutive days. Both suffered from a fall from a bicycle with bicycle handlebar injury 4 and 6 days prior to admission in our clinic. Emergency distal pancreatectomies were performed in both cases. $\textbf {Conclusions:}$ Pancreatic injuries must be highly suspected in bicycle handlebar injuries, even if amylase/lipase levels or ultrasound findings seem unremarkable. The best initial strategies are early computed tomography and a quick referral to a level 1 trauma center. Distal pancreatectomy is the treatment of choice in cases of complete rupture of the pancreatic body

Anti-tumorigenic effects of emodin and its’ homologue BTB14431 on vascularized colonic cancer in a rat model

Objective: New drugs for cancer treatment are being sought worldwide. Therapeutic agents derived from natural substances can provide cost-efficient options. We evaluated the effect of emodin, an active natural anthraquinone derivate, and it’s in-silico homologue the novel substance BTB14431 in vivo. Method: CC-531 colon cancer cells were implanted intraperitoneal (ip) and subcutaneous (sc) in 100 WAG/Rij rats. 28 days after tumor cell implantation, solid cancers were treated for 7 days by varying doses of BTB14431 (0.3 mg/kg body weight; 1.7 mg/kg) or emodin (2.5 mg/kg; 5 mg/kg). Treatment was applied either via an intravenous (iv) port catheter or by ip injection. Saline solution served as control. 21 days after final dose all animals were euthanized and ip tumor weight, sc tumor weight and animal body weight (bw) were determined by autopsy. Significant lower total tumor weight occurred after iv treatment with low dose BTB14431 (6.8 g; 90% confidence interval (CI) 5.3 - 8.2 g; p $\leq$ 0.01) and also low and high concentrations of emodin (9.4 g; CI 7.9 - 10.7 g; p $\leq$ 0.01 and 8.3 g; CI 7.6 - 9.3; p $\leq$ 0.01). Iv treatment by high dose BTB14431 did not lead to a decline in tumor weight. High dose ip treatment by emodin led to a lower overall (11.1 g; CI 10.1 – 13.8 g; p $\leq$ 0.01) and ip tumor weight (8.6 g; CI 6 – 10.4 g; p $\leq$ 0.01). Sc tumor weight was not affected. All other ip treatments did not result in changes of combined, ip or sc tumor weight. Bw decreased during iv treatment in all animals and increased after treatment was completed. Regain of bw was stronger in animals receiving low dose emodin. Conclusion: Our study shows promising anti-cancer properties of BTB14431 and supports the evidence regarding emodin as a natural antitumorigenic agent. Optimal dosing of iv emodin and especially BTB 14431 for maximal efficacy remains unclear and should be a subject of further research

Small bowel obstruction due to a giant Meckel's diverticulum

$\textbf {Background:}$ Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, with an average length of 3 cm. Complications occur in 6.4% and most commonly include inflammation and gastrointestinal bleeding. Preoperative diagnosis is demanding and achieved in 4%. $\textbf {Case Report:}$ A 34-year-old otherwise healthy patient presented with an acute abdomen due to small bowel obstruction. Computed tomography scan could not identify the underlying cause. Emergency laparotomy was performed, and a torqued giant Meckel’s diverticulum measuring 17 cm was found as the underlying cause for the small bowel obstruction. Resection of the affected ileum segment and ileo-ileal reconstruction were performed. The postoperative course was uneventful. $\textbf {Conclusion:}$ In extremely rare cases, small bowel obstruction in an otherwise healthy patient might be caused by torsion of a symptomatic giant Meckel’s diverticulum

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

Recurrence of pancreatic ductal adenocarcinoma after complete histopathological remission caused by FOLFIRINOX

We previously reported 2 cases of pathologic complete response (pCR) of a pancreatic cancer (PC) following neoadjuvant FOLFIRINOX treatment. We now complete our report by a follow-up on both patients. Patient 1 achieved a disease-free survival of 12 months after initial resection until she developed a singular hepatic metastasis. Treatment by FOLFIRINOX and complete removal of the metastasis by atypical liver resection after 6 months allowed for another 12 months of disease control. After intra-abdominal tumor recurrence and development of intracerebral metastases, the patient died 34 months after primary diagnosis. Patient 2 developed hepatic tumor recurrence only 3 months after initial resection. However, treatment by FOLFIRINOX led to a stable disease for 27 months after resection and was followed by atypical liver resection of multiple segments. Six months later, another hepatic recurrence was suspected. Via next-generation sequencing (NGS) of the tumor genome, a deleterious mutation in the ataxia telangiectasia-mutated ($\it ATM$) gene, causing a $\it BRCA$ness, was detected. After initial treatment by FOLFOX, maintenance therapy with the poly-ADP-ribose-polymerase (PARP) inhibitor olaparib was initiated. The patient is now alive for 54 months after initial diagnosis of metastasized pancreatic adenocarcinoma. Tumor recurrence is possible even after pCR of PC and remains challenging. In case of multifocal tumor recurrence, chemotherapy remains the standard treatment. Recently, genetic sequencing allows individualized treatments. In selected cases, highly specialized teams can offer a variety of therapeutic options leading to previously unseen clinical courses

Pathologic complete response of pancreatic cancer following neoadjuvant FOLFIRINOX treatment in hepatic metastasized pancreatic cancer

$\textit {Introduction:}$ Pancreatic cancer is a lethal disease and often asymptomatic. Therefore, it is most often diagnosed at an advanced stage. The standard approach in a metastasized tumor stage is palliative chemotherapy. However, the prognosis remains extremely poor. $\textit {Case Report:}$ We present the case of a patient who was diagnosed with a cancer of the head of the pancreas with hepatic metastases. After receiving palliative intended chemotherapy with the FOLFIRINOX regimen, staging computed tomography revealed the disappearance of the liver metastases and local resectability of the pancreatic head tumor. The patient underwent an uneventful Whipple's procedure. Surprisingly, pathohistological investigation revealed a complete pathological response. $\textit {Conclusion:}$ Pathological complete response after FOLFIRINOX treatment in hepatic metastasized pancreatic cancer is extremely rare. It enables surgical resection and increases the survival rate significantly

Long term follow-up of a simplified and less burdened pancreatic duct ligation model of exocrine pancreatic insufficiency in Goettingen Minipigs

$\bf Background$ Pancreatic duct ligation in a minipig model leads to exocrine pancreatic insufficiency (EPI). This allows the study of digestive processes and pancreatic enzyme replacement therapies. However, detailed descriptions of the surgical procedure, perioperative management, a determination of exocrine pancreatic insufficiency are scarce in the literature. Data of the long-term health status of minipigs upon EPI induction are still not available. Therefore, the present study describes in detail an experimental approach to the induction of exocrine pancreatic insufficiency via pancreatic duct ligation in minipigs and the long term follow up of the animal’s health state. $\bf Methods$ 14 Goettingen minipigs underwent pancreatic duct ligation via midline laparotomy for the induction of exocrine pancreatic insufficiency. Fecal fat content, fat absorption, chymotrypsin levels, body weight and blood vitamin and glucose levels were determined. $\bf Results$ Exocrine pancreatic insufficiency was successfully induced in 12 Goettingen minipigs. Two minipigs failed to develop exocrine insufficiency most likely due to undetected accessory pancreatic ducts. All animals tolerated the procedure very well and gained weight within 8 weeks after surgery without requiring pancreatic enzyme replacement therapy. The follow up for approx. 180 weeks showed a stable body weight and health state of the animals with normal blood glucose levels (Table 1). From approx. 130 weeks post pancreatic duct ligation, all animals were supplemented with pancreatic enzymes and vitamins resulting in blood concentrations almost within the reference range. $\bf Conclusions$ Pancreatic duct ligation in minipigs is an excellent method of inducing exocrine pancreatic insufficiency. It is important to identify and ligate accessory pancreatic ducts since persistence of accessory ducts will lead to maintenance of exocrine pancreatic function. The EPI model caused no persistent side effects in the animals and has the potential to be used in long-term EPI studies with up to 100 weeks post-OP without supplementation with enzymes and vitamins