Retroperitoneal Peripancreatic Ganglioneuroma Encasing the Celiac Trunk and Superior Mesenteric Artery

A retroperitoneal ganglioneuroma is an exceptionally rare surgical entity, even more so in pancreaticoduodenal tumors. These well-differentiated neuroepithelial tumors originate in the neural crest, emerge in the sympathetic nervous system, and consist of ganglion cells and stromal Schwann cells. Generally, these tumors, despite being mostly benign, may be associated with venous or arterial vascular involvement. The symptomatology presented will depend on the mass effect due to tumor growth, and surgical excision is the only therapeutic option offered today to these patients. However, encapsulation of the main vessels represents a great surgical complexity. Various surgical approaches have been employed throughout history; however, the current preferred method is an open midline laparotomy, involving an extensive Kocher maneuver and an artery-first approach, aiming for an R0 resection of the tumor with total vascular preservation to the greatest extent possible. We present a case of an R2 resection involving a 95 mm x 85 mm retroperitoneal peripancreatic ganglioneuroma with double vascular involvement (celiac trunk and superior mesenteric artery). The procedure utilized an artery-first approach with total vascular preservation in a 17-year-old woman who had long-standing gastrointestinal symptoms due to the mass effect.

A CARE-compliant article: Unicentric Castleman disease presenting as a retroperitoneal mass of the upper edge of the pancreas: A case report

RATIONALE

Castleman disease (CD) is a rare lymphoproliferative disease with a poorly understood etiology. The occurrence of CD in the abdominal cavity is very rare, especially in the retroperitoneal peripancreatic region.

PATIENT CONCERNS

A 33-year-old woman was referred to our department on March 1, 2018 for a detailed physical examination due to retroperitoneal peripancreatic lymph node enlargement over 15 days.

DIAGNOSIS

Enhanced magnetic resonance imaging of the epigastrium showed the mass with abundant blood supply is located between the liver and the stomach in the upper margin of the pancreas. Postoperative pathological examination revealed CD, type of unicentric Castleman disease.

INTERVENTIONS

We performed an open surgery on this patient and completely removed the mass. There was no postoperative radiochemotherapy.

OUTCOMES

The patient was followed-up for more than 12 months after the operation and showed good recovery.

LESSONS

CD is a rare disorder that is hard to diagnose early and complete resection of the tumor is still the most effective treatment.

Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis?

OBJECTIVE

In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking.

METHODS

A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis.

RESULTS

315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16).

CONCLUSION

EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.