Role of retrograde dilatation in the management of pharyngo-esophageal corrosive strictures

Pharyngo-esophageal corrosive stricture is a complex clinical scenario. If an esophageal opening cannot be found orally through endoscopy, a retrograde approach with a mini-laparotomy and gastrostomy should be attempted. This study primarily aimed at defining the role of preoperative retrograde dilatation of pharyngo-esophageal corrosive strictures. A retrospective analysis of 51 cases of pharyngo-esophageal corrosive strictures identified between 1997-2005 was performed. The demographic details were analyzed. The details of the injury to the pharynx either in isolation or in combination were noted and the management details were recorded. In 21 patients preoperative retrograde dilatation was considered and the technique was successful in 14 (Group I). In seven the technique failed (Group II) and these patients underwent transhiatal resection and gastric pull-through and/or retrosternal pharyngocoloplasty. In Group I patients the postoperative stay was significantly less than in Group II (12 +/- 2.03 days vs. 18 +/- 4.32 days; p = 0.001) Recurrent aspiration, respiratory tract infections, choking sensation and the need for tracheostomy were less frequent in Group I. The overall functional assessment was good in Group I. For treatment of pharyngo-esophageal obstruction, if antegrade dilatation is not possible due to technical reasons, retrograde dilatation is a viable option before opting for organ replacement/bypass procedures. There is no best replacement of the native organ to maintain quality of life.     

An unusual presentation of primary pelvic hydatid cyst

Aim-Background

Human echinococcosis is a zoonotic infection. Musculoskeletal involvement presents in just 1–4% of cases. Primary pelvic hydatid cyst is a rare entity.

Method

We report the case of an unusual presentation of primary pelvic hydatid cyst in a 38-year-old male.

Results

The patient presented to our hospital complaining of a pain in the lower abdomen for the past month and difficulty in passing urine for a week. MRI of pelvis and both hips showed a multiloculated cystic lesion in the pelvis that suggested a hydatid cyst with daughter cyst, 9.4 × 6.7 cm, with bony and soft tissue involvement. The patient underwent a cystopericycstectomy, which revealed an infected hydatid cyst in the rectovesical pouch; excision of the cyst was performed.

Conclusion

Primary pelvic hydatid cyst is a rare entity. Surgery is recommended to remove macroscopic cystic lesions and protect functions.     

CENTRAL PANCREATECTOMY FOR BENIGN PANCREATIC PATHOLOGY/TRAUMA: IS IT A REASONABLE PANCREAS‐PRESERVING CONSERVATIVE SURGICAL STRATEGY ALTERNATIVE TO STANDARD MAJOR PANCREATIC RESECTION?

BACKGROUND: The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation. METHODS: Between January 2000 and December 2005, eight central pancreatectomies were carried out. There were six women and two men with a mean age of 35.7 years. The cephalic pancreatic stump is oversewn and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop in two and with the stomach in six patients. The indications for CP were: non-functional islet cell tumours in two patients, traumatic pancreatic neck transection in two and one each for insulinoma, solid pseudopapillary tumour, splenic artery pseudoaneurysm and pseudocyst. Pancreatic exocrine function was evaluated by a questionnaire method. Endocrine function was evaluated by blood glucose level. RESULTS: Morbidity rate was 37.5% with no operative mortality. Mean postoperative hospital stay was 10.5 days. Neither of the patients developed pancreatic fistula nor required reoperations or interventional radiological procedures. At a mean follow up of 26.4 months, no patient had evidence of endocrine or exocrine pancreatic insufficiency, all the patients were alive and well without clinical and imaging evidence of disease recurrence. CONCLUSION: When technically feasible, CP is a safe, pancreas-preserving pancreatectomy for non-enucleable benign pancreatic pathology/trauma confined to pancreatic isthmus that allows for cure of the disease without loss of substantial amount of normal pancreatic parenchyma with preservation of exocrine/endocrine function and without interruption of enteric continuity.     

Haemosuccus pancreaticus: diagnostic and therapeutic challenges

Background:

Haemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. The objective of our study was to highlight the challenges in the diagnosis and management of HP.

Methods:

The records of 31 patients with HP diagnosed between January 1997 and June 2008 were reviewed retrospectively.

Results:

Mean patient age was 34 years (11–55 years). Twelve patients had chronic alcoholic pancreatitis, 16 had tropical pancreatitis, two had acute pancreatitis and one had idiopathic pancreatitis. Selective arterial embolization was attempted in 22 of 26 (84%) patients and was successful in 11 of the 22 (50%). Twenty of 31 (64%) patients required surgery to control bleeding after the failure of arterial embolization in 11 and in an emergent setting in nine patients. Procedures included distal pancreatectomy and splenectomy, central pancreatectomy, intracystic ligation of the blood vessel, and aneurysmal ligation and bypass graft in 11, two, six and one patients, respectively. There were no deaths. Length of follow-up ranged from 6 months to 10 years.

Conclusions:

Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. Diagnosis is based on investigations that should be performed in all patients, preferably during a period of active bleeding. These include upper digestive endoscopy, contrast-enhanced computed tomography (CECT) and selective arteriography of the coeliac trunk and superior mesenteric artery. Contrast-enhanced CT had a high positive yield comparable with that of selective angiography in our series. Therapeutic options consist of selective embolization and surgery. Endovascular treatment can control unstable haemodynamics and can be sufficient in some cases. However, in patients with persistent unstable haemodynamics, recurrent bleeding or failed embolization, surgery is required.     

Pancreaticogastrostomy for pancreatic ascites

BACKGROUND/AIMS: Management of pancreatic ascites is challenging. The aim of the present study was to study the role of pancreaticogastrostomy in management of pancreatic ascites. METHODOLOGY: Retrospective analysis of twelve operated cases with pancreatic ascites following failed conservative and endoscopic treatment was done for its outcome in terms of morbidity and a successful outcome. Patient data, imaging information and surgical procedure were noted. RESULTS: Four of the 12 patients with leak from the dilated main pancreatic duct had longitudinal pancreaticogastrostomy. The gross edematous jejunum and a shortened mesentery due to sub-acute peritonitis necessitated this surgery. None had recurrence of ascites. Steatorrhea was distinctly absent. None had deterioration of endocrine function. CONCLUSIONS: Longitudinal pancreaticogastrostomy is a viable option in patients with pancreatic ascites and dilated main pancreatic duct especially in those with a shortened mesentery and an edematous small bowel.     

Retention mucocele of distal viable remnant tip of appendix： An unusually rare late surgical complication following incomplete appendectomy

A 67-year old man was presented with a 6-mo historyof recurrent right lower quadrant abdominal pain.Onphysical examination,a vague mass was palpable inthe right lumbar region.His routine laboratory testswere normal.Ultrasonography showed a hypoechoiclesion in the right lumbar region anterior to the rightkidney with internal echoes and fluid components.Abdominal contrast-enhanced computed tomography(CECT)showed a well-defined hypodense cystic masslesion lateral to the ascending colon/caecum,notcommunicating with the lumen of colon/caecum.Aftercomplete open excision of the cystic mass lesion,grosspathologic examination revealed a turgid cystic dilatationof appendiceal remnant filled with the mucinousmaterial.On histopathological examination,mucinouscyst adenoma of appendix was confirmed.We report thisrare unusual late complication of mucocele formation inthe distal viable appendiceal remnant,which was leftoverfollowing incomplete retrograde appendectomy.Thisunusual complication is not described in the literatureand we report it in order to highlight the fact that a highindex of clinical and radiological suspicion is essentialfor the diagnosis of mucocele arising from a distal viableappendiceal remnant in a patient who has alreadyundergone appendectomy presenting with recurrentabdominal pain.