Category Archives: Hepato-Biliary-Pancreatic

What is the classification of choledochal cysts?

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Choledochal Cyst. In: Doherty GM. eds. Quick Answers Surgery. McGraw-Hill; Accessed April 02, 2021. 

  • Type I cysts (fusiform dilation of common bile duct [CBD]) account for 85-90%
  • Type II (true diverticula of CBD) 1-2% of cases
  • Type III (choledochocele—dilation of distal/intramural portion of CBD) < 2% of cases
  • Type IV (multiple cysts involving intrahepatic and extrahepatic ducts) as high as 15% of cases in some series
  • Type V (cystic malformation of intrahepatic ducts) rare
  • 3-5% incidence of carcinoma
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Solid pseudopapillary neoplasms (SPN) of the pancreas

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Gandhi D, et al. Solid pseudopapillary Tumor of the Pancreas: Radiological and surgical review. Clin Imaging. 2020 Nov;67:101-107.

Full-text for Emory users.

Highlights:

  • Solid Pseudopapillary Neoplasms of the pancreas are rare pancreatic tumors with low grade malignant potential, typically affecting young females.
  • Small SPNs (< 3cm in diameter) usually appear as completely solid tumors with sharp margins and gradually enhancing, well encapsulated masses in the pancreas and may demonstrate varying amounts of hemorrhage.
  • Large lesions have mixed solid – cystic components showing early weak enhancement with gradual increase in enhancement in the hepatic venous phase.
  • Atypical features including extracapsular, as well as parenchymal invasion, simulation of islet cell tumors, calcifications, ductal obstruction, and metastasis are suspicious for malignant degradation.
  • The tumor is considered unresectable in the event that it invades or encases the aorta, encases >180 degree of the SMA regardless of tumor location in the pancreas, abuts the celiac artery (when the tumor is located in the pancreatic head) or encases >180 degree of the celiac artery (when the tumor is located in the body/tail of the pancreas).
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Article of interest: Bleeding complications after pancreatic surgery: interventional radiology management

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Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg. 2019 Apr;8(2):150-163. doi: 10.21037/gs.2019.01.06.

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

The anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades

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Kumar KH, et al. Anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades in the human pancreas: a cadaveric study. Surg Radiol Anat. 2021 Mar;43(3):367-375.

Full-text for Emory users.

Results: The gastroduodenal (GDA), anterior superior pancreaticoduodenal (ASPD), and anterior inferior pancreaticoduodenal (AIPD) artery was found in all the cases, whereas the posterior superior pancreaticoduodenal (PSPD) and posterior inferior pancreaticoduodenal (PIPD) artery was present in 93.34% cases. The ASPD artery originated from GDA in all the cases. Two types of variations were observed in the origin of PSPD artery and four types each in the origin of AIPD and PIPD artery. Anatomical and numerical variations were observed in both anterior and posterior arches, posterior arch being absent in 20% cases.

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T-Tubes

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Dageforde LA, Lillemoe KD. (2020). Management of Acute Cholangitis. In: Cameron JL, Cameron AM (Eds), Current Surgical Therapy, 13th ed. Elsevier: Philadelphia.

“Recent literature advocates for primary closure of the common bile duct after elective CBDE because of complications from T-tube placement. But in patients with cholangitis, placement of a T-tube is necessary for biliary decompression and allows easy access for future cholangiogram if the obstruction does not resolve. T-tube drainage has been associated with bile leak and requires externalization of the tube for several days until postoperative cholangiography demonstrates resolution of obstruction. Primary closure can lead to stricture and bile leak and result in no direct access to the biliary tree for future investigations.”

Fig. 2. Insertion of a T-tube in the common bile duct with subsequent closure using absorbable monofilament suture (4-0 or 5-0). The T-tube is prepared in one of the ways shown. From: Zollinger RM, Jr, Zollinger RM. Atlas of Surgical Operations. 7th ed. New York: McGraw-Hill; 1993.

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Article of interest: Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective RCT.

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Igami T, et al. Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective randomized controlled trial. J Hepatobiliary Pancreat Sci. 2011 Mar; 18(2):176-83.

Full-text for Emory users.

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Pancreatic cystic neoplasms

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Scholten L, et al. Pancreatic Cystic Neoplasms: Different Types, Different Management, New Guidelines. Visc Med. 2018 Jul;34(3):173-177.

Pancreatic cystic neoplasms (PCN) include different types of cysts with various biological behavior. The most prevalent PCN are intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystic neoplasm (SCN). Management of PCN should focus on the prevention of malignant progression, while avoiding unnecessary morbidity of surgery. This requires specialized centers with dedicated multidisciplinary PCN teams. The malignant potential of PCN varies enormously between the various types of PCN. A combination of computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography, and endoscopic ultrasound with or without fine needle aspiration is typically needed before a reliable diagnosis can be made. Several guidelines discuss the management of PCN; however, most of these are non-evidence-based without clear consensus on the optimal treatment and follow-up strategy. The 2018 European guidelines on PCN are the first evidence-based guidelines to include IPMN, MCN, SCN, and all other PCN. This guideline advises a more conservative approach to side-branch IPMN and MCN smaller than 40 mm and more often a surgical approach in IPMN with a main duct dilatation beyond 5 mm. The goal of this review is to summarize the different types and management of the most common PCN based on the current literature and guidelines.

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