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Background: Synchronous cystic lesions of the pancreas with different pathophysiology in the same patient are a rare occurrence.. Case Presentation: We report the incidental finding of a multicystic lesion within the pancreatic head in a morbidly obese woman during workup for bariatric surgery. The lesion contained an intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia within an acinar cell cystadenoma (ACA). ACAs are rare tumors first described in 2002. Conclusion: To date, there have been no published reports of synchronous IPMN within an ACA. This case report intends to increase provider awareness of these lesions as well as highlight the importance of surveillance and careful histological examination of heterogeneous cystic lesions of the pancreas., Competing Interests: No competing financial interests exist.

Background: Pancreatic neuroendocrine tumors (PNETs) are relatively rare, and data guiding management of metastatic lesions are scarce. Hepatic metastases are most common; here we describe a case of metastatic PNET implanted into the posterior gastric cardia. Case Presentation: This case study describes the progression of a 44-year-old man with a history of pancreatic neuroendocrine tumor (PNET) resected through distal pancreatectomy and splenectomy who developed recurrent disease in his stomach with extension into the left adrenal fossa 17 months after initial resection. He subsequently underwent a total gastrectomy and left adrenalectomy with en bloc resection of this recurrence without complication. Final pathology revealed a morphologically similar PNET with positivity for CAM5.2, chromogranin A, and synaptophysin. Conclusion: The unusual location of his recurrence could suggest that his preoperative endoscopic ultrasound and fine-needle aspiration may have had a role in seeding the posterior gastric wall, highlighting the risk of performing this diagnostic procedure in the setting of suspected pancreatic malignancy., Competing Interests: No competing financial interests exist.

Background: In the literature, pancreatic cancer is not frequently acknowledged among the tumors that are considered a part of Lynch Syndrome. Case Presentation: Our case is one of a young man who was found, very early in life, to have pancreatic cancer. His tumor demonstrated germline microsatellite instability, and hence by definition the patient has Lynch syndrome. He responded well to treatment, which included surgery and adjuvant chemotherapy. To date he remains in remission from pancreatic cancer. Conclusion: The rare instances in this case report include: (a) The patient had pancreatic cancer that fulfilled the histopathological and clinical criteria for Lynch syndrome. (b) Pancreatic cancer was diagnosed earlier in our patient than is expected in patients who suffer from pancreatic cancer as a part of Lynch syndrome. (c) Our patient had an excellent response to chemotherapy. He remains in remission to date from pancreatic cancer and is 5 years since his last treatment for this disease., Competing Interests: No competing financial interests exist.

Background: Duodenal masses are rare entities and symptomatic presentation generally is due to abdominal pain or the presence of gastrointestinal bleeding. A number of published case reports in the literature have detailed various neoplasms that have caused an intussusception isolated to the duodenum. This is a particularly unusual phenomenon due to the location and fixation of this portion of the proximal small bowel to the retroperitoneum. We present here a case of duodeno-duodenal intussusception secondary to a leiomyoma. Case: A 65-year-old Caucasian male presented with intermittent bloody stools and syncope over a 9-month period secondary to a duodenal leiomyoma causing intussusception, which was treated through a pancreaticoduodenectomy. Conclusion: Intussusception of the duodenum is an uncommon entity and the diagnosis of a leiomyoma should be considered in the setting of a potential mass in the small intestine., Competing Interests: No competing financial interests exist.

Background: Gastrointestinal malrotation arises from intrauterine events that occur early in the first trimester of gestation, and can result in a midgut volvulus that classically presents in the neonatal period with bilious emesis. Gastrointestinal malrotation can present clinically with symptoms such as chronic abdominal pain or bowel obstruction, or remain completely asymptomatic only to be discovered as an incidental finding much later in life during surgical exploration for other diseases. We sought to identify the prevalence of gastrointestinal malrotation in patients undergoing surgical exploration for hepatopancreatobiliary (HPB) malignancy and describe the operative considerations of these cases. Case Presentation: We performed a retrospective review of our prospectively acquired HPB surgery database from January 1, 2006, to December 1, 2013. We identified three cases of gastrointestinal malrotation out of a total of 1220 HPB cases reviewed, which represents 0.2%. We found two cases of gastrointestinal malrotation in the setting of pancreatic ductal adenocarcinoma and one case in the setting of cholangiocarcinoma. All three patients underwent exploratory laparotomy with resection of their respective primary tumors. We searched the English literature for cases of HPB malignancy in the setting of gastrointestinal malrotation. Conclusion: Our case series and review of the literature underscore the rarity and complexity of these cases., Competing Interests: No competing financial interests exist.

Background: Correct preoperative diagnosis of hepatobiliary disease can be challenging-even with current advances in radiographical imaging, laboratory testing, and endoscopic evaluation. Case presentation 1: A 65-year-old female with painless jaundice and weight loss was found to have cholelithiasis complicated by the Mirizzi syndrome. Case presentation 2: A 71-year-old female with new-onset painless jaundice and impacted stone in the gallbladder neck was found to have a cholangiocarcinoma. Case presentation 3: A 70-year-old male with progressive painless jaundice and weight loss was found to have a pancreatic adenocarcinoma. Conclusion: Proper diagnosis and management of patients with painless jaundice can be difficult in the preoperative setting and may require surgical exploration to obtain a definitive diagnosis., Competing Interests: No competing financial interests exist.