Complete enucleation of a complicated solid pseudopapillary neoplasm of pancreas: A case report

INTRODUCTION

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare pancreatic tumor, usually affecting young females. It is categorized as a low-grade malignant tumor without any specific epithelial differentiation, which can occur anywhere in the pancreas.

CASE PRESENTATION

Here, we present the case of a 35-year-old lady who presented to us with abdominal pain and a pancreatic mass. She had a prior laparotomy at a different center without any specific intervention for the lump. After presenting to our center, she was managed through proper evaluation and adequate preparation for surgery. The diagnosis was challenging, and so was the surgery. We had enucleated the lesion completely. Histopathology confirmed the diagnosis of SPN. There are no signs of recurrence after two years.

DISCUSSION

Patients are either asymptomatic or usually present with abdominal pain, a large abdominal lump, or some vague symptoms. A high index of suspicion is the key to diagnosis. Complete resection is the gold standard of treatment. Enucleation is also a good option in difficult cases. The prognosis after surgery is excellent.

CONCLUSION

Total enucleation of the SPN of the pancreas is a reasonable alternative in selected cases when performed by experienced hepatobiliary-pancreatic surgeons.

Biliary Embryonal Rhabdomyosarcoma: A Case Report

A 10 years old boy who was initially diagnosed as choledochal cyst underwent laparotomy. There was presence of necrotic and soft tissue growth within common bile duct (CBD). After extensive toileting of bile duct, a T-tube was placed. His histopathology followed by immunohistochemistry revealed Embryonal Rhabdomyosarcoma. Later the patient received VAC regime chemotherapy. On follow-up imaging, there was no tumour mass in CBD. So, T-tube removed and now the patient is doing well.

Primary Sclerosing Cholangitis- A Rare Cause of Obstructive Jaundice: A Case Report

Diagnosis of primary sclerosing cholangitis (PSC) is often very difficult and may have a suspicion with altered liver functions. PSC is known to be associated with inflammatory bowel disease. This article presents a case study of a 70 years old male patient who presented with obstructive jaundice with recurrent episode of cholangitis in June 2019 at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Evaluation revealed beaded appearance in MRCP with positive relevant markers which raised suspicion of PSC and it was confirmed by biopsy and histopathology of the affected segment in biliary tree. The importance of early detection of primary sclerosing cholangitis in an effort to decrease the morbidity and mortality from cholangiocarcinoma will also be emphasized and our management according to local protocol and outcome of this patient.

Management of Choledocholithiasis: Should We Remove the Bile Duct?

Retrieval of stone by endoscopic papillotomy, laparoscopic choledochotomy or open choledochotomy is the treatment of choice for choledocholithiasis. Published literature shows that the recurrence rate is 4% to 24% with existing method of treatment. We have treated 8 patients who admitted with recurrent choledocholithiasis in the department of Hepato-Biliary-Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh in the period of January 2016 to December 2019. None had intrahepatic duct abnormality or stones. All patients underwent either ERCP stenting, open choledocholithotomy or both 16 to 84 months back. Management policy is designed and outcome is observed on these patients. There were 3 males and 5 females; age ranges 18 to 60 years. The common bile duct (CBD) diameter of all patient ranges from 15 to 24mm. The shape of CBD is different from normal variant; S shaped, saculated, grossly dilated with terminal narrowing. Considering the anatomical abnormality and recurrence of disease we have removed the abnormal part of common bile duct along with stones and the operation was completed by Roux-en-Y hepaticojejunostomy. All patients were completely symptom free for 6 to 48 months after surgery. Removal of abnormal part of common bile duct with reconstruction in the form of Roux-en-Y hepatico-jejunostomy may be considered for treating choledocholithiasis with abnormal CBD (abnormally dilated, abnormally shaped, angulated or sacculated) however, long-term follow up is required for final comment.

Post-Operative Severe Hyperbilirubinemia: A Case Report

Hyperbilirubinemia is commonly seen in medical practice. But what could be the highest level of bilirubin in an individual that is still an unanswered question. We came across to a 37 years old lady in October 2018 with hepaticolithiasis who underwent extended choledocholithotomy. Her preoperative serum bilirubin was within normal range. Post-operatively she developed cholangitis and from 3rd post-operative day onwards she developed severe hyperbilirubinemia, which was high as 70.47 mg/dl on the 6th post-operative day. Other causes of post-operative hyperbilirubinemia were excluded. She was managed conservatively for this hyperbilirubinemia and bilirubin level gradually reduced.

A Rare Case of Insulinoma: A Case Report

Insulinoma is a rare variety of endocrine neoplasm and is usually benign, solitary, and small in size. The hallmark of this disorder is high endogenous insulin secretion resulting in development of symptoms of hypoglycemia. Insulinomas account for 60% of islet cell tumors (ICT) of the pancreas. Ninety percent (90%) of the insulinomas measure less than 2cm. Early localization of the disease is essential to prevent lethal hypoglycemia. Here we report a case of insulinoma in a 28 year old female who subsequently underwent distal pancreatectomy with splenectomy on February 2017 in Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

Single Sitting Surgery for Concomitant Hydatid Cyst of Lung and Liver: A Case Report

Hydatid disease is one of the diseases that have been discovered in the ancient times. Liver and lung are the most commonly affected organs, though it can involve any organs. Hydatid disease involving both the liver and the lung is reported about 10% of the cases. Here we report a case of 34 year old male presented with upper abdominal pain and intermittent fever for 3 months admitted in October 2016. His chest radiograph and computed tomography scan revealed large cystic lesion at right lung and another similar large lesion in the right lobe of liver. Echinococcus antibody was found positive. We treated him surgically. Histopathology reports confirmed concomitant hydatid cyst of both the lung and the liver.

Solid Pseudopapillary Tumor of the Pancreas: A Case Report

Solid pseudopapillary tumors (SPT) of the pancreas are rare neoplasms of the pancreas accounting for only 1-2% of all pancreatic neoplasms, often detected initially on imaging. Its histogenesis is still uncertain and it has a low-grade malignant potential but excellent post-surgical curative rates and rare metastasis. Pathological and/or cytological evaluation still remains the gold standard in reaching a definitive diagnosis. It occurs most commonly in young females. We report a case of solid pseudopapillary tumor in the head of the pancreas in a 20 years old female admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh on 5th December 2015. Whipple's operation was done as a definitive treatment.

Complete Annular Pancreas with Concurrent Entero-Pancreatico-Biliary Symptoms in Adult: A Case Report

Complete Annular pancreas (AP) is a rare congenital anomaly, often presented and operated at the early age of life. Adult presentation group usually presents with either biliary or duodenal or pancreatic symptoms. We report a case of 43 years old female presenting with concurrent enteric, biliary and pancreatic symptoms admitted on April 2016 in Hepatobiliary and Pancreatic Surgery Department of BSMMU, Dhaka, Bangladesh. A complete type of annular pancreas with partial duodenal stenosis and dilated common bile duct was observed during laparotomy. We performed gastrojejunostomy as well as hepaticojejunostomy (Roux-en-Y anastomosis). Patient was discharged in a good symptom free condition. Complete Annular Pancreas can present at any age, with any one or all of the biliary, pancreatic or duodenal symptoms. Surgery is the treatment of choice and has a good outcome.

A Rare Case of Polycystic Disease of the Pancreas

Polycystic disease of the pancreas is very rare and only few cases have been reported in the literature. We report a case of 27 year old female presented with recurrent upper abdominal pain associated with nausea and vomiting. Her ultrasonography of whole abdomen and computed tomography (CT) scan revealed polycystic pancreas associated with hepatic cysts. She underwent distal pancreatectomy with splenectomy. Histological examination revealed typical features of polycystic pancreatic disease in the resected specimen. Previously two of her sisters and her mother were also diagnosed as cases of polycystic pancreatic disease and they all underwent operative treatments. Among them one of those sisters and her mother received treatment under our department in 2009 and 2014 accordingly.

Acinar Cell Carcinoma of the Pancreas: A Case Report

Acinar cell carcinoma (ACC) of the pancreas is a very rare neoplasm. We report a case of pancreatic acinar cell carcinoma involving the uncinate process of the pancreas. A 45 year old man presented with a painful upper abdominal mass without any jaundice or weight loss. Computed Tomography (CT) and Magnetic Resonance Cholangio-Pancreatography (MRCP) indicated a mass lesion in the uncinate process of the pancreas. He underwent Whipple's procedure (Pancreaticoduodenectomy). Histological slides revealed features of Acinar cell carcinoma (ACC) in the uncinate process of the pancreas and a lymph node.

Distal Common Bile Duct Tuberculosis with Obstructive Jaundice: A Case Report

Tuberculosis (TB) isolated in Common Bile Duct (CBD) is very rare and its treatment is somewhat controversial. We report a case of distal CBD tuberculosis diagnosed as cholangiocarcinoma. A 40 year old man presented with obstructive jaundice without abdominal pain, fever or weight loss. Ultrasonography and Magnetic Resonance Cholangio-Pancreatography (MRCP) indicated a mass lesion in the Distal CBD, which caused structure of the distal common bile duct. As Cholangiocarcinoma was suspected, he underwent Whipple procedure (pancreaticoduodenectomy). Histological examination of resected specimen revealed typical features of tuberculosis in the distal CBD, pancreatic head and lymph nodes. The rest of the abdominal cavity was unremarkable. Anti-microbial therapy for tuberculosis is started for 12 month course and he is well.

Delayed primary suture prevents wound infection in patients with obstructive jaundice and septic abdomen

This study was undertaken to assess the efficacy of delayed primary closure in prevention of postoperative wound infection in patients with obstructive jaundice and septic abdomen. Here analyzed 93 patients retrospectively who underwent surgery in hepato-biliary-pancreatic unit of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2011 to June 2011. Primary closure of the abdominal wound was applied in all patients. There was no mortality, but 21 patients had postoperative morbidity (wound infection in 17, intra-abdominal abscess in 1, melaena in 1, biliary leakage in 1, burst abdomen in 1). Seventy-two patients had uneventful postoperative recovery were included in Group 1. Patients who developed postoperative wound infection (n=17) were included in Group 2. Rest 4 patients who developed other complications were excluded from the study. Pre-, per and postoperative parameters were compared between two groups for identifying the risk factors for SSI. Delayed primary closure of the wound was applied prospectively in 21 patients (Group 3) on the basis of retrospective results and the outcome was assessed. Retrospective analysis revealed that the patient who developed wound infections (Group 2) after primary closure; significantly greater number of patients had obstructive jaundice or intra-abdominal septic condition preoperatively. Prospective results revealed that there was no wound infection in 21 patients with in obstructive jaundice or intra-abdominal sepsis in which delayed primary closure was applied. Hospital stay was significantly reduced in Group 3 in compare to Group 2. In subsequent follow up, it has been found that 2 patients developed incisional hernia in Group 2 patients but none in Group 3 patients. Delayed primary closure of the wound is a good option in patient with obstructive jaundice and intra-abdominal septic condition for preventing postoperative wound infection.