Pancreas-sparing duodenectomy for duodenal neoplasms including malignancies

BACKGROUND/AIMS: Pancreas-sparing duodenectomy (PSD) represents an attractive operation for benign or premalignant duodenal disease. However, use of PSD is controversial for indications that include malignancy. METHODOLOGY: The present study investigated 16 patients who underwent PSD for duodenal neoplasms including adenoma, cancer, carcinoid and non-epithelial tumor. Indications for PSD were divided into 3 categories: early stage neoplasms; isolated duodenal neoplasms in high-risk patients; and duodenal involvement from adjacent organ malignancies. This study classified PSD into 4 types based on the resected portion of the duodenum, as used in gastrectomy (total, subtotal, distal, and proximal) and we experienced pancreas-sparing proximal duodenectomy and pancreas-sparing distal duodenectomy. RESULTS: Pancreatic fistula or anastomotic leak occurred in 2 patients, and were closed with nonoperative management. Although 1 patient with gallbladder cancer died postoperatively due to the results of a concomitant operation, no postoperative deaths or re-operations related to PSD were encountered. Mean duration of follow-up was 65 months. Three patients died as a result of distant metastases from primary cancer without local recurrence, and 2 patients died from other causes. The remaining 10 patients are well, with no symptoms related to the hepatobiliary and pancreatic systems. CONCLUSIONS: Good results after long-term follow-up suggest that PSD represents an attractive option for duodenal neoplasms. Moreover, absence of local recurrence suggests that PSD may also be acceptable for selected duodenal malignancies.     

Pancreas-sparing duodenectomy: classification, indication and procedures.

BACKGROUND/AIMS: Recent advances in the surgical anatomy of the pancreatoduodenal region have permitted duodenum-preserving pancreatic head resection. However, pancreas-sparing duodenectomy (PSD) has not been systematically studied and various types of such procedures have been reported under the designation of PSD. METHODOLOGY: PSD was performed in 6 patients with extensive duodenal lesions including trauma, mucosa-associated lymphoid tissue (MALT) lymphoma, corrosive necrosis, bleeding, leiomyosarcoma and congenital stenosis. Three patients had the whole papilla Vateri and half of the duodenum preserved and anastomosed to the jejunum. One patient had the duodenal button including the papilla of Vater transplanted to the jejunum. Another patient had the intraduodenal portion of the major papilla excised and the terminal portion of the bile and pancreatic ducts anastomosed to the jejunum. RESULTS: Two patients with moribund conditions died of the underlying disorders 2 weeks and 3 months after surgery, respectively, but without leakage or other surgery-associated complications. The other 4 patients survived the surgery without anastomotic insufficiency. Three survivors, who had complete preservation of the major and minor papillae along with the half portion of the duodenum, had normal morphology and function of the biliopancreatic system post-operatively. The fourth survivor, that with excision of the intrapancreatic portion of the major papilla, had regurgitation of contrast material into the bile and pancreatic ducts 2 months after surgery on active insufflation of the intestinal lumen, but remained asymptomatic. No abnormality in liver and pancreatic function was detected as of 7 months post-operatively. CONCLUSIONS: PSD appears to be applicable in the clinical setting, although classification of the procedure seems mandatory in consideration of indications, techniques, and long-term consequences of biliopancreatic function.     

Perforated juxta-papillary duodenal diverticula: two cases

Perforation of juxta-ampullary duodenal diverticula, occurring spontaneously or after abdominal trauma, is a severe condition. Diagnosis is difficult to establish and is based on tomodensitometry, which is the most reliable diagnostic tool. Treatment consists in diverticulectomy that can be associated with drainage of the duodenum or anastomosis between digestive and biliary tract. We report two cases of perforated juxta-ampullary duodenal diverticula. Perforation was spontaneous in one case and complicated a blunt abdominal trauma in the other case.     

Post-traumatic pseudoaneurysm of the common hepatic artery with duodenal fistula

BackgroundPost-traumatic pseudoaneurysm of the hepatic artery is rare, especially after blunt abdominal trauma; an even more rare occurrence is enteric fistulisation.Case outlineA 29-year-old man was admitted with an acute episode of upper gastrointestinal bleeding three months after blunt abdominal trauma and was found to have an hepatic artery pseudoaneurysm with duodenal fistula. Surgical treatment was by ligature of the artery and duodenal closure with omental patch.DiscussionThere is one previous case report of hepatic artery pseudoaneurysm as a delayed complication of blunt abdominal trauma. The presence of a haematoma in the hepatoduodenal ligament after blunt trauma should raise the suspicion of hepatic artery injury, and surgical exploration may prevent the subsequent development of pseudoaneurysm. CT scan has become an important instrument both in diagnosis and in surgical planning.     

An Interesting Case of Pancreaticoduodenal Trauma

A case of severe duodenal trauma is described in which duodenal rupture occurred but relative integrity of the pancreas was maintained. Conservative surgical management with construction of a new papilla of Vater and with anastomotic protection by a gastrojejunostomy proved successful and obviated the need for pancreaticoduodenectomy.     

Intramural duodenal hematoma presenting as a complication of peptic ulcer disease.

We report the first case in the English literature of an intramural duodenal hematoma presenting as a complication of Helicobacter pylori-induced peptic ulcer disease. Intramural duodenal hematomas have been previously described in patients-usually in the setting of blunt trauma, postendoscopic biopsy, gastrostomy placement, and hemostatic therapy and in patients with a coagulopathy or bleeding diathesis-but not as a presentation of peptic ulcer disease. It is important to recognize this complication, as surgical management may benefit patients with a duodenal hematoma.     

Retrospective Analysis of Duodenal Injuries: A Comprehensive Overview

Background/Aim:

Duodenal injury is an uncommon finding, accounting for about about 3 – 5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6 - 25%) and morbidity (30 - 60%).

Patients and Methods:

Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College.

Results:

Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected.

Conclusion:

Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality.     

Intramural Duodenal Hematoma: An Unusual Complication of Endoscopic Small Bowel Biopsy

We report a case of intestinal obstruction secondary to intramural duodenal hematoma after endoscopic small bowel biopsy. Review of the literature indicates that intramural duodenal hematoma occurs mainly in infants and children after trauma to the abdomen. The diagnosis can be made by upper gastrointestinal series and confirmed by computerized axial tomography of the abdomen. Conservative management in the form of nasogastric suction and total parenteral nutrition resulted in amelioration of obstructive symptoms within 10 days. Physicians should be alerted to the possibility of developing intramural duodenal hematoma after small bowel biopsy. This is the first report of such an unusual complication after endoscopic small bowel biopsy in children.     

Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: A case report

Intramural duodenal hematoma (IDH) is a rare complication following endoscopic retrograde cholangiopancreatography (ERCP). Blunt damage caused by the endoscope or an accessory has been suggested as the main reason for IDH. Surgical treatment of isolated duodenal hematoma after blunt trauma is traditionally reserved for rare cases of perforation or persistent symptoms despite conservative management. Typical clinical symptoms of IDH include abdominal pain and vomiting. Diagnosis of IDH can be confirmed by imaging techniques, such as magnetic resonance imaging or computed tomography and upper gastrointestinal endoscopy. Duodenal hematoma is mainly treated by drainage, which includes open surgery drainage and percutaneous transhepatic cholangial drainage, both causing great trauma. Here we present a case of massive IDH following ERCP, which was successfully managed by minimally invasive management: intranasal hematoma aspiration combined with needle knife opening under a duodenoscope.     

Benign Duodenal Stenosis Caused by Huge Mesenteric Hematoma Conservatively Improved with Long-term Use of Double Elementary Diet Tube

Mesenteric hematoma is an uncommon condition caused by focal bleeding in the mesenteric vessels. Hematomas are related to trauma, pancreatitis, arteriopathy, and the use of antithrombotic agents. Although hematomas cause intestinal stenosis by compressing the adjacent small bowel, duodenal stenosis due to hematoma is rare. Therefore, the treatment indications for cases of hematoma with stenosis have not been established. We herein report a case with a large mesenteric hematoma that caused duodenal stenosis by compressing the third portion of the duodenum. Stenosis was successfully ameliorated after long-term use of a double elementary diet tube.     

Spontaneous intramural duodenal hematoma in type 2B von Willebrand disease

Intramural duodenal hematoma is a rare cause of a proximal gastrointestinal tract obstruction.Presentation of intramural duodenal hematoma most often occurs following blunt abdominal trauma in children,but spontaneous non-traumatic cases have been linked to anticoagulant therapy,pancreatitis,malignancy,vasculitis and endoscopy.We report an unusual case of spontaneous intramural duodenal hematoma presenting as an intestinal obstruction associated with acute pancreatitis in a patient with established von Willebrand disease,type 2B.The patient presented with abrupt onset of abdominal pain,nausea,and vomiting.Computed tomography imaging identified an intramural duodenal mass consistent with blood measuring 4.7 cm×8.7 cm in the second portion of the duodenum abutting on the head of the pancreas.Serum lipase was 3828 units/L.Patient was managed conservatively with bowel rest,continuous nasogastric decompression,total parenteral nutrition,recombinant factorⅧ(humateP)and transfusion.Symptoms resolved over the course of the hospitalization.This case highlights an important complication of an inherited coagulopathy.     

Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation

Endoscopic retrograde cholangiopancreatography(ERCP)is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases.The most common ERCP-induced complication is pancreatitis,whereas hemorrhage,cholangitis,and perforation occur less frequently.Early recognition and prompt treatment of these complications may minimize the morbidity and mortality.One of the most serious complications is perforation.Although the incidence of duodenal perforation after ERCP has decreased to1.0%,severe cases still require prolonged hospitalization and urgent surgical intervention,potentially leading to permanent disability or mortality.Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract.However,evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects.Duodenal fistulas are usually a result of sphincterotomies,perforated duodenal ulcers,or gastrectomy.Other causative factors include Crohn's disease,trauma,pancreatitis,and cancer.The majority of duodenal fistulas heal with nonoperative management.Those that fail to heal are best treated with gastrojejunostomy.Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips.Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop.The fistula was successfully repaired by additional clipping and fibrin glue injection.     

Laparoscopic drainage of an intramural duodenal hematoma

A 21-year-old man was admitted with vomiting and abdominal pain 3 days after sustaining blunt abdominal trauma by being tackled in a game of American football. A diagnosis of intramural hematoma of the duodenum was made using computed tomography and upper gastrointestinal tract contrast radiography. The hematoma caused obstructive jaundice by compressing the common bile duct. The contents of the hematoma were laparoscopically drained. A small perforation was then found in the duodenal wall. The patient underwent laparotomy and repair of the injury. Laparoscopic surgery can be used as definitive therapy in this type of abdominal trauma. (Received Nov. 12, 1997; accepted Aug. 21, 1998)     

Occult Duodenal Perforation Complicating Cerebral Infarction: New Problems in Diagnosis of Cushing's Ulcer

Cushing's ulcers of the duodenum are well known complications of neurosurgery, head trauma, and other causes of increased intracranial pressure. Perforation of Cushing's ulcer of the duodenum is infrequently described. That the use of high-dose corticosteroids for cerebrovascular infarct in an aphasic patient may obscure the symptomatology and physical findings of a perforated Cushing's ulcer has not been described to our knowledge. We report a patient with a large left hemispherical infarct and resultant aphasia who developed a perforated duodenal ulcer and extensive chemical peritonitis while receiving high dose corticosteroids for increased intracranial pressure. She was unable to register any compliants and the typical physical findings of perforated duodenal ulcer with chemical peritonitis were virtually absent. A high index of suspicion must be maintained for a perforated Cushing's duodenal ulcer in the patient receiving high dose dexamethasone despite the presence of nonspecific symptomatology and abdominal findings. Elevated serum gastrin levels, as in this patient, may also indicate the patients with increased intracranial pressure who are at greater risk for developing Cushing's ulcer.     

Hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation

Here, we present the case of a 53-year-old man with a hepatothorax due to a right diaphragmatic rupture related to duodenal ulcer perforation. On admission, the patient complained of severe acute abdominal pain, with physical examination findings suspicious for a perforated peptic ulcer. Of note, the patient had no history of other medical conditions or recent trauma, and the initial chest radiography and laboratory findings were not specific. A subsequent abdominal computed tomography revealed intrathoracic displacement of the liver, gallbladder, transverse colon and omentum through a right diaphragmatic defect. The patient then underwent an explorative laparotomy that confirmed duodenal ulcer perforation. A primary repair of the duodenal perforation was performed, and the diaphragmatic defect was repaired using a polytetrafluoroethylene patch after the organs were reduced and the cavity irrigated. This particular case proves interesting as right-sided spontaneous diaphragmatic ruptures are very rare and difficult to diagnose. Additionally, the best treatment for such large diaphragmatic defects is still controversial, especially in cases of intrathoracic or intra-abdominal contamination.     

老年卒中后抑郁与非抑郁患者人格特征分析

目的调查卒中后抑郁的影响因素、临床结局及采用明尼苏达多相人格测验研究老年卒中后抑郁患者的心理特征。方法对160例老年卒中患者进行回顾性病例对照研究,根据有无卒中后抑郁分为2组,采用logistic回归分析卒中后抑郁的影响因素,并统计分析卒中后抑郁患者的人格特征。结果抑郁人格、疑病人格、精神衰弱人格量表分值差异显著(P0.05);疑病分值、抑郁分值与老年卒中后抑郁呈正相关;配偶支持、卒中部位、简易智能评分量表分值和美国国立卫生研究院卒中评分量表分值与老年卒中后抑郁发生相关。老年卒中后抑郁组卒中后30 d Bathel生活能力评分比对照组显著降低(P0.05),30 dRankin评分0-1级抑郁组人数显著减少(P0.001)。结论老年卒中后抑郁患者人格以抑郁人格、疑病人格、精神衰弱人格为主;缺乏配偶支持、前循环病变、认知障碍和卒中严重的患者更易发生老年卒中后抑郁;老年卒中后抑郁的发生延长平均住院时间、影响卒中的临床康复。     

Intramural duodenal hematoma of pancreatic origin.

Non-traumatic intramural hematoma of the duodenum is an unusual clinical entity. Indeed, in a majority of 70% of patients intramural hematoma of the duodenum is caused by a blunt, frequently minor abdominal trauma. The main etiology of non-traumatic intramural hematoma of the duodenum in the adult is overdose anticoagulant therapy. Rarer causes include pancreatic disease, blood dyscrasia or vascular collagen disease. In this presentation a case of pancreatitis-induced intramural duodenal hematoma is discussed and compared with corresponding data in the literature.     

Chronic duodenal obstruction: A mechano-vascular etiology of pancreatitis

Conclusions 1. Six cases are presented that indicate that chronic duodenal obstruction from a variety of causes, such as superior mesenteric compression, proximal loop obstruction, inflammatory stricture, annular pancreatic stenosis, and malignant constriction, is an etiologic factor in the induction of pancreatic inflammatory disease.2. Postgastrectomy pancreatitis results not only from direct trauma to the pancreas, its ducts, or its blood supply, but also may follow obstruction of the proximal loop. It is of importance that proximal loop distention does not occur. Prevention of such a complication can best be assured by positioning the nasogastric tube beyond the gastroenteric stoma in the proximal loop.3. The occurrence of attacks of acute pancreatitis in patients with annular pancreas may be related more to the duodenal narrowing than to the anatomic abnormality, per se. Therefore, it is advised that these patients and others with duodenal strictures be kept on a low-residue diet to prevent occlusion of the stenotic bowel.4. Whether the physiologic mechanism that induces pancreatitis in patients with chronic duodenal obstruction is mechanical or vascular remains to be determined by further experimental study.The Secretion used in this study was furnished by the Eli Lilly Company, Indianapolis, Ind.Permission to report Cases 2–5 in this paper was granted by Dr. Ralph Colp (Cases 2 and 3), Dr. Richard Marshak (Case 4), and Dr. A. I. Friedman (Case 5).     

Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endosco...     

脑卒中后抑郁患者血清β-内啡肽水平变化的研究

目的探讨脑卒中后抑郁（poststroke depression，PSD）患者血清β-内啡肽（beta-endorphin，β-EP）水平变化，探讨PSD患者神经肽变化。方法采用放射免疫法检测51例PSD患者、32例非PSD患者及38例正常人的血清β-EP水平，并观察25例PSD患者抗抑郁治疗后血清β-EP水平变化。结果治疗前，PSD组血清β-EP水平显著高于非PSD组（P〈0．01）和正常对照组（P〈0．01）；治疗后，PSD抗抑郁治疗组与PSD未抗抑郁治疗组相比，汉密尔顿抑郁量表（HAMD）评分和β-EP水平均显著降低（P〈0．01）。PSD组治疗前、PSD抗抑郁治疗组治疗后及PSD未抗抑郁治疗组治疗后的HAMD评分均与血清β-EP水平呈显著性正相关。结论PSD患者血清β-EP水平明显升高并且与抑郁程度相关，提示PSD可能引起了患者脑内啡肽功能的变化。