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Highlights • Duodenal diverticulum is present in 5–22% of population. • Complicated diverticulum can lead to perforation, bleeding, obstruction, pancreatitis. • Pancreatoduodenectomy is an option when all other surgical approaches are not usable., Introduction Duodenal diverticula are quite prevalent in general population, seen on up to 5% of radiology studies and up to 22% of autopsy examinations. Presentation of the case 70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of perforated duodenal diverticulitis which failed to improve with IV antibiotics. Emergent pancreatoduodenectomy was performed with full recovery and uncomplicated hospital stay. Discussions Conservative therapy with antibiotics and bowel rest is successful in majority cases of perforation. Failure of conservative therapy demands surgical management. Variety of surgical approaches ranging from simple diverticulectomy to segmental resection, duodenal exclusion/bypass to pancreatoduodenectomy are available. Conclusion Pancreatoduodenectomy is an option when complicated duodenal diverticulum is not resolved with conservative or interventional therapy.Pancreatoduodenectomy is an option when complicated duodenal diverticulum is not resolved with conservative or interventional therapy. This report has been written in concordance with the SCARE criteria Agha et al. [1].

In this retrospective review, we evaluate a standardized care plan (SCP) for patients undergoing pancreaticoduodenectomy, which included selective placement of feeding jejunostomy tubes (FJTs) and a perioperative fast-track recovery pathway (FTRP).A review of 242 patients undergoing pancreaticoduodenectomy was completed. Patients treated pre- and post-SCP implementation were compared. Univariate comparison followed by multivariable linear regression were performed to identify predictors of hospital length of stay (HLOS).SCP patients (n = 100) were slightly older but otherwise similar to pre-SCP patients (n = 142). FJT placement occurred less frequently in SCP patients (38 versus 94%, P 0.001). All SCP patients were initiated on the FTRP. Among SCP patients, an oral diet was introduced earlier (5 versus 8.5 d, P 0.001) and HLOS was shorter (11 versus 13 d, P = 0.015). Readmission rates were similar. Following adjustment with linear regression, we confirmed SCP status as a predictor of HLOS. To assess SCP components, HLOS was evaluated separately based on FTRP status and FJT placement. Although both were highly associated with HLOS, neither was independently predictive in multivariable analysis.Implementation of an SCP resulted in shorter HLOS without an increase in readmissions. Future studies are necessary to identify specific components of SCPs that most influence outcomes.

Background Elevated levels of norepinephrine (NE) have been reported in recipients of small-for-size liver (SFS) grafts in the perioperative period. The aim of the study is to test the hypothesis that although circulating catecholamines are elevated in recipients of SFS grafts, they are not the primary agents responsible for the hepatic artery (HA) vasospasm. Methods Female porcine recipients receiving a 20% ( n = 10) partial liver graft were compared with a control group, using 60% partial liver transplanted grafts ( n = 9). Hepatic blood flow (PVF, HAF) and levels of plasma catecholamines (epinephrine and NE) were measured at designated time points through postoperative day (POD) 7. Phentolamine (PA), an α-adrenergic blocker, was administered at doses of 1 to 112.5 ug/kg/min through an indwelling HA to the recipients of 20% group on POD1 ( n = 5). Results In the 20% group following reperfusion, HA vasospasm was found at 10, 60, and 90 min, and persisted on POD 3 and POD 7. Plasma NE levels increased after reperfusion in 20% and 60% groups and peaked at 6 h with 10- to 13-fold increased levels compared with baseline. In the 20% group, NE levels remained elevated up to POD 7. PA infusion at low (1–10 ug/kg/min) and high (12.5–112.5 ug/kg/min) doses did not reverse the reduced HAF observed in 20% group recipients. Conclusion Elevated serum NE does not appear to be the primary factor mediating HA vasospasm in the porcine SFS graft.

Fig 1. Pre-operative 3-dimensional CT reconstruction. The mass (black arrow) abuts the celiac axis and encases the left gastric artery (white arrow). A 48-YEAR-OLD MAN underwent upper endoscopy for epigastric pain and nausea. Because of endoscopic findings of gastritis and positive biopsy for Helicobacter pylori, he was started on standard triple drug therapy, but failed to respond. His symptoms became more severe and he reported a 10-pound weight loss. Abdominal computed tomography (CT) and magnetic resonance imaging revealed a 3 3 4 cm mass in the gastrohepatic omentum abuting the celiac axis and encasing the left gastric artery (Fig 1). A pre-operative biochemical workup was normal. During exploratory laparotomy, a 5 3 8 cm mass was found to involve the left gastric artery and the celiac axis. Therefore, celiac axis resection was needed to accomplish complete tumor removal (Figs 2 and 3). To test the sufficiency of the collateral blood supply to the liver, a clamp was applied to the common hepatic artery proximal to gastroduodenal artery and proper hepatic artery pulse was verified by Doppler. The tumor was completely mobilized and resected en bloc with the celiac axis. The patient had an uneventful postoperative course with slight elevation of aspartate and alanine aminotransferase levels. Pathologic examination of the specimen demonstrated a mass arranged in solid sheets with myxoid changes and plexiform patterns containing spindle cells with uniform nuclei and ill-defined cytoplasmatic borders. There was no necrosis or lymphovascular invasion. Operative margins were clear of tumor. Immunoperoxidase stains demonstrated positivity for C-kit (CD117), CD34, S-100, and actin. Immunostaining for desmin was negative. The pathologic diagnosis was consistent with extragastrointestinal stromal

The authors report a case of hepatic intraductal oncocytic papillary carcinoma, a very rare subtype of hepatic papillary cholangiocarcinoma with only 8 cases reported so far in the English literature.

Primary vein leiomyosarcoma is rare type of a vascular sarcoma and arises from the spindle cells of the venous wall. The tumor may present difficulty of vascular reconstruction after en block resection. We present a case of internal iliac vein transposition for vascular reconstruction after resection of an external iliac vein leiomyosarcoma.To our knowledge, this is first report of the external iliac vein replacement with the ipsilaterally transposed internal iliac vein.

Le leiomyosarcome primaire veineux est un type rare de sarcome vasculaire et a pour origine les cellules de la paroi veineuse. La tumeur peut induire une difficile reconstruction vasculaire apres sa resection en monobloc. Nous presentons un cas de transposition de la veine iliaque interne pour reconstruction vasculaire apres la resection d’un leiomyosarcome de la veine iliaque externe. A notre connaissance, c’est le premier cas rapporte de remplacement de la veine iliaque externe avec la veine iliaque interne homolaterale transposee.