Acinar cell cystadenoma

$\bf Background:$ Von Hippel-Lindau (VHL) disease may occur at various localisations which can be both intraand extrapancreatic as well as challenging to diagnose by medical imaging. $\bf Case$ $\bf Report:$ A positron emission tomography/magnetic resonance imaging in a 40-year old woman was performed to monitor a haemangioblastoma. Additionally, it showed findings which were considered to be a pancreatic neuroendocrine tumour (pNET) and retroumbilical metastasis. The suspected metastasis was laparoscopically resected; however, pathological evaluation did not lead to a clear categorisation. Consequently, the pancreatic head was resected in which a pNET and various acinar cell cystadenomas were found. $\bf Conclusion:$ Diagnostic and therapy of advanced VHL disease can be difficult; if in doubt, a surgical approach may establish clarity

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

Exploring pain, quality of life, and emotional well-being in patients with advanced pancreatic cancer practicing spiritual meditation

$\bf Introduction:$ Studies on mind-body approaches in patients with advanced pancreatic ductal adenocarcinoma (PDAC) are rare. We performed a pilot study with follow-up until 1 year to explore changes in pain, quality of life (QoL), stress, and negative emotions in patients with advanced PDAC, who regularly practiced a standardized form of spiritual meditation in addition to standard medical care. $\bf Methods:$ At baseline and every 2 months for a maximum of 1 year, global pain, QoL (global, SEIQoL, FACT-G), spiritual well-being (FACIT-Sp), perceived stress (PSQ-20), anxiety and depression (HADS), and diurnal cortisol secretion (cortisol slope) were assessed. Changes from baseline were explored by pairwise comparisons of available cases. $\bf Results:$ Twenty participants (11 women, 62 $\pm$ 9.9 SD years) participated in the study, of whom 9 patients survived the study year. Pairwise comparisons revealed transient improvements of pain after 4 and 6 months (both $\it p$ values < 0.05), of global QoL after 4, 6, 8, 10 months (all $\it p$ values < 0.05), of SeiQoL scores after 4 months ($\it p$ < 0.05), of FACT-G scores after 6 months ($\it p$ < 0.05), and of FACIT-Sp scores after 2 and 6 months (both $\it p$ values < 0.05). Furthermore, overall stress levels (PSQ-20) decreased from baseline to 2, 6, and 8 months (all $\it p$ values < 0.05), and anxiety declined from baseline to 6 months ($\it p$ < 0.05). Depression scores and the cortisol slope did not change. $\bf Conclusion:$ This pilot study demonstrated the acceptability and feasibility of studies on spiritual meditation in patients with advanced PDAC. Randomized controlled trials are warranted to study the effects of spiritual meditation and other mind-body interventions on pain, QoL, and emotional well-being in this patient population.$\bf Einleitung:$ Bislang gibt es kaum Studien zu Mind-Body-Ansätzen bei Patienten mit fortgeschrittenem duktalem Adenokarzinom der Bauchspeicheldrüse (PDAC). Wir führten eine explorative Pilotstudie mit einer einjährigen Nachbe- obachtungszeit durch, um Veränderungen von Schmerzen, Lebensqualität, Stress und negativen Emotionen bei Patienten mit fortgeschrittenem PDAC zu untersuchen, die zusätzlich zur medizinischen Standardversorgung regelmäßig eine standardisierte Form der spirituellen Meditation praktizierten. $\bf Methoden:$ Zu Beginn der Studie und alle zwei Monate wurden über einen Zeitraum von maximal einem Jahr die globalen Schmerzen, die Lebensqualität (global, SEIQoL, FACT-G), das psychologische Wohlbefinden (FACIT-Sp), Stress (PSQ-20), Angst und Depression (HADS) sowie die circadiane Cortisolausschüttung (Cortisolabfall) untersucht. Die Änderungen gegenüber dem Ausgangswert wurden mit paarweisen Vergleichen der jeweils verfügbaren Fälle auf Signifikanz getestet. $\bf Ergebnisse:$ 20 Patienten (11 Frauen, 62 $pm$ 9.9 SD Jahre) nahmen an der Studie teil, von denen 9 das Studienjahr überlebten. Paarweise Vergleiche zeigten vorübergehende Verbesserungen der Schmerzen nach 4 und 6 Monaten (beide $\it p$-Werte < 0.05), der globalen Lebensqualität nach 4, 6, 8 und 10 Monaten (alle $\it p$-Werte < 0.05), der SeiQoL-Werte nach 4 Monaten ($\it p$ < 0.05), der FACT-G-Werte nach 6 Monaten ($\it p$ < 0.05) und der FACIT-Sp-Werte nach 2 und 6 Monaten (beide $\it p$-Werte < 0.05). Außerdem war der Gesamtstress (PSQ-20) nach 2, 6 und 8 Monaten (alle $\it p$-Werte < 0.05) sowie die Ängstlichkeit nach 6 Monaten ($\it p$ < 0.05) signifikant gesunken. Die Depressionswerte und der circadiane Cortisolabfall änderten sich nicht. $\bf Schlussfolgerung:$ Diese Pilotstudie weist auf die Akzeptanz und Durchführbarkeit von Studien zu spiritueller Meditation bei Patienten mit fortgeschrittenem PDAC hin. Randomisierte kontrollierte Studie sollten folgen, um die Effekte von spiritueller Meditation und anderen Mind-Body-Interventionen auf Schmerzen, Lebensqualität und emotionales Wohlbefinden in dieser Patientengruppe zu untersuchen

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

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

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

Waiving subsequent complete lymph node dissection in melanoma patients with positive sentinel lymph node does not result in worse outcome on 20-year analysis

The aim of the present study was to investigate long-term outcomes of melanoma patients who had micrometastasis on sentinel lymph node (SLN) biopsy. We focused on the comparison between melanoma patients with and without complete lymph node dissection (CLND) following a positive SLN biopsy result. Patients without CLND did not significantly differ from patients with CLND in regard to age, gender, tumor thickness, tumor ulceration, capsule infiltration of SLN, and invasion level of SLN. On 10-year analysis, we did not observe a significantly increased risk for melanoma relapse or melanoma-specific death in patients who did not undergo CLND after the detection of micrometastases on SLN biopsy. On 20-year analysis, again, the patients without CLND had no significantly increased risk of melanoma relapse and worse melanoma-specific survival. Hence, our 10-year survival data confirm the current notion that waiving CLND in SLN-positive patients does not result in clinical disadvantages with respect to melanoma-specific survival. For the first time, we demonstrate on 20-year survival analysis that relapse rates and melanoma-specific survival does not significantly differ between patients with or without CLND on long-term follow-up

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