Ischemic gastropathy after distal pancreatectomy with en bloc celiac axis resection versus distal pancreatectomy for pancreatic body/tail cancer

Diffuse arterial atherosclerosis presenting with acute ischemic gastritis: A case report

BACKGROUND

Ischemic gastritis is a clinically rare disease with high mortality that infrequently reported in the medical literature and under-recognized clinically and histopathologically. Early diagnosis and treatment can only be achieved through upper gastrointestinal endoscopy after symptoms appear.

CASE SUMMARY

A 68-year-old woman with a history of intracranial aneurysm developed dizziness, chest tightness and unconsciousness for 2 d. Computed tomography angiography showed diffuse coronary atherosclerosis, moderate to severe stenosis in the proximal end of the left anterior descending branch, multiple calcified plaques in the proximal end of the circumflex branch and right coronary artery, and mild to moderate stenosis. The patient also developed diffuse atherosclerosis in the splenic and mesenteric arteries, with mild lumen stenosis and atherosclerosis in the abdominal aorta and its branches. Endoscopy showed submucosal congestion and damage of the entire gastric mucosa, of which the fundus and body of the stomach were most seriously affected. The mucosa was swollen, with a deep purple color, surface erosion and dark red oozing blood. Pathological examination showed bleeding and necrosis of the gastric mucosa, with residual contours of the gastric glands, consistent with ischemic gastritis.

CONCLUSION

Ischemic gastritis is a rare disease that may be difficult to diagnose as its symptoms may be similar to those of other gastrointestinal diseases. Diagnosis is usually based on endoscopic and pathological examinations, which show insufficient blood supply to the gastric mucosa leading to mucosal damage and necrosis.

Outcomes of Distal Pancreatectomy With Celiac Axis Resection for Pancreatic Cancer

OBJECTIVES

This study aimed to show the clinical and oncologic outcomes of distal pancreatectomy with celiac axis resection (DP-CAR) from a high-volume single center and analyze them from diverse perspectives.

METHODS

Forty-eight patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR were included in the study. The primary outcome was morbidity and 90-day mortality, and the secondary outcome was overall survival and disease-free survival.

RESULTS

Morbidity (Clavien-Dindo classification grade ≥3) occurred in 12 patients (25.0%). Thirteen patients (27.1%) had pancreatic fistula grade B and 3 patients (6.3%) had delayed gastric emptying. The 90-day mortality was 2.1% (n = 1). The median overall survival was 25.5 months (interquartile range, 12.3-37.5 months) and median disease-free survival was 7.5 months (interquartile range, 4.0-17.0 months). During the follow-up period, 29.2% of participants survived for up to 3 years and 6.3% survived for up to 5 years.

CONCLUSIONS

Despite its associated morbidity and mortality, DP-CAR should be considered as the only therapeutic option for pancreatic body and tail cancer with celiac axis involvement when carried out on carefully selected patients performed by a highly experienced group.

Clinical features and progress of ischemic gastritis with high fatalities: Seven case reports

BACKGROUND

Ischemic gastritis is a clinically rare and highly fatal disease that occurs when the hemodynamics of a patient with vascular risk is disrupted. Early diagnosis and treatment are possible only with upper endoscopy after symptom appearance. We report seven cases of ischemic gastritis and its clinical features, prognosis, and indicators that may help in early detection.

CASE SUMMARY

Of the seven patients, six had vascular risk and five died within 2 wk of diagnosis. Their symptoms included hematemesis and hypotension. Although surgery is a choice for radical treatment, not all patients were tolerant. For such patients, conservative treatment was selected, but all of them died. In contrast, patients who underwent repeat endoscopy showed improved mucosal findings, suggesting that this improvement may not affect prognosis. Some ischemic changes such as wall thickening, mural emphysema, and fluid retention in the stomach were observed before diagnosis through endoscopy and computed tomography (CT). The CT scan can be effective for early detection, and improvement in circulatory failure and aggressive treatment may save the lives of patients with this disease.

CONCLUSION

The characteristic CT findings enable early detection of ischemic gastritis. Early diagnosis increases the chance of survival if early therapeutic intervention and improvement of circulatory dynamics can be achieved in this highly fatal disease.

Utility of X-ray and indocyanine green fluorescence imaging in detecting hepatocellular carcinoma dissemination on laparoscopic surgery: A case report

Indocyanine green (ICG) fluorescence imaging is useful for the intraoperative detection of the peritoneal dissemination of hepatocellular carcinoma (HCC). However, in laparoscopic surgery, disseminations cannot be accurately identified unless the camera lens is positioned close to the lesion. The present study describes a case of HCC dissemination in which the lesions were accurately identified by combining intraoperative fluoroscopy with ICG fluorescence imaging. A 76-year-old male was diagnosed with HCC dissemination. Computed tomography revealed a 9-mm disseminated nodule near the gallbladder. Although transarterial chemoembolization had also been used to treat this lesion, chemoembolization was technically difficult to perform. Therefore, a coil was placed around the lesion to serve as an intraoperative landmark for later laparoscopic resection. Given the potential difficulty of detecting the lesion during laparoscopic surgery, ICG fluorescence imaging was used to determine the approximate location of the dissemination. The lesion exhibited strong fluorescence, which facilitated its complete resection.

Surgery for pancreatic cancer: current controversies and challenges

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Successful intragastric suture repair using endoscopy for refractory ischemic stomach perforation: A case report

INTRODUCTION

Ischemic stomach perforation and bleeding are major complications after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for locally advanced pancreatic cancer. Although there are some treatment options for ischemic gastric events, we need to discuss the optimal treatment based on the patient's general condition and history.

CASE PRESENTATION

A 76-year-old woman with advanced pancreatic cancer underwent DP-CAR with the reconstruction of the common hepatic artery-celiac artery. She presented with a high fever and melena at 13 days and twenty-nine days after the operation, respectively. Contrast-enhanced computed tomography (CECT) demonstrated ischemic stomach perforation, which was localized. Although nonsurgical treatments, including endoscopic clipping and proton-pump inhibitor administration, were attempted, her symptoms were not relieved. Therefore, we performed intragastric suture repair using oral endoscopy (ISE) for gastric perforation. Although she presented with surgical site infection and a catheter-related blood stream infection after ISE, she was discharged 140 days after the first operation.

CLINICAL DISCUSSION

Ischemic gastric events following DP-CAR can be treated with non-surgical and surgical approaches. In this case, non-surgical management could not improve the patient's gastric complications, and she had to undergo surgery. Given the patient's condition, ISE was an indication for this complication and was, thus, performed among surgical procedures, resulting in the alleviation of the complication. Using ISE may provide safe and less invasive surgery.

CONCLUSION

This is the first case of ISE for use in refractory ischemic stomach perforation following DP-CAR. ISE can be a useful and minimally invasive surgical procedure.

Extended right surgical margin in distal pancreatectomy with celiac axis resection for pancreatic body cancer under the presence of replaced right hepatic artery; A case report

BACKGROUND

While distal pancreatectomy with celiac axis resection (DP-CAR) contributes to R0 resection for pancreatic body cancer, arterial blood flow to the liver from gastroduodenal artery is essential. However, in the presence of replaced right hepatic artery (r-RHA), extended DP-CAR (Ex-DP-CAR) in which the right edge of pancreatic resection includes the confluence of gastroduodenal artery (GDA) and proper hepatic artery (PHA) may be feasible. Herein, we report a patient with r-RHA and perform Ex-DP-CAR without reconstruction of PHA.

CASE PRESENTATION

A 39-year-old man with pancreatic cancer, cT4N0M0 (UICC 8th), underwent DP-CAR after neoadjuvant chemotherapy (NAC). After laparotomy, unlike the evaluation in preoperative imaging, the tumor was found to invade the confluence of GDA and PHA. After confirmation of arterial blood flow to the liver, GDA and PHA was ligated and Ex-DP-CAR was completed with R0 margin status. The postoperative course was uneventful, with no recurrence 18 months after the surgery.

CONCLUSION

We performed Ex-DP-CAR with resection of the confluence of GDA and PHA in the presence of r-RHA, which has a potential role in expanding the surgical indications for R0 resection by reducing the risk of ischemic complications without reconstruction of arterial blood supply to the liver.