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Abudalou M, Malkowski M, Huh A, Ricklan D, Stallwood C. Ampullary Adenocarcinoma Causing Small Intestinal Obstruction. Cureus 2020; 12:e11575. [PMID: 33364100 PMCID: PMC7749798 DOI: 10.7759/cureus.11575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ampullary adenocarcinoma is a malignant tumor that arises from the ampullary complex, distal to the confluence of common bile duct and pancreatic duct. It is a rare tumor and pathologically differentiated into intestinal or pancreaticobiliary in origin. Management is surgical resection. We report a case of a 67-year-old male who presented with abdominal pain, vomiting, and constipation. Computed tomography scan showed a cystic mass compressing the duodenum and causing small intestinal obstruction. Pathologic evaluation was consistent with ampullary adenocarcinoma.
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Affiliation(s)
| | | | - Alex Huh
- Gastroenterology, Tufts Medical Center, Boston, USA
| | - David Ricklan
- Pathology, St. Elizabeth's Medical Center, Brighton, USA
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Salehi O, Vega EA, Kutlu OC, Alarcon Velasco SV, Krishnan S, Ricklan D, Kozyreva O, Conrad C. Combining Appleby with RAMPS - Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection. J Gastrointest Surg 2020; 24:2700-2701. [PMID: 32557017 DOI: 10.1007/s11605-020-04686-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PATIENT: A 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response. TECHNIQUE Prior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound. CONCLUSION L-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | | | - Sandeep Krishnan
- Department of Gastroenterology, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - David Ricklan
- Department of Pathology, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA.
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Vega EA, Nicolaescu DC, Salehi O, Kozyreva O, Vellayappan U, Ricklan D, McCarty J, Fontan F, Pomposelli F, Conrad C. Laparoscopic Segment 1 with Partial IVC Resection in Advanced Cirrhosis: How to Do It Safely. Ann Surg Oncol 2019; 27:1143-1144. [PMID: 31848810 DOI: 10.1245/s10434-019-08122-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic versus open hepatocellular carcinoma (HCC) resection reduces morbidity without a compromise in oncologic safety.1-4 Moreover, in the subgroup of cirrhotic patients, a decreased risk of prolonged postoperative ascites and liver decompensation has been reported.5-7 METHODS: A 54-year-old homeless, deaf male with chronic alcoholism, hepatitis C, and advanced cirrhosis was referred with a caudate tumor from a critical access hospital. Imaging showed a 3.6-cm HCC in the caudate lobe compressing the inferior vena cava (IVC). With the patient in reversed, modified French position, the liver was mobilized, and the hepatocaval space dissected. Portal and short hepatic vein branches were individually controlled, and the caudate lobe was dissected off the IVC. At the superior portion of the Spiegel process, the tumor was inseparable from the IVC, necessitating en bloc segment 1 with partial IVC resection. The IVC was reconstructed laparoscopically following a preplanned approach. The pathology report confirmed R0 resection of a moderately differentiated hepatocellular carcinoma without microvascular or perineural invasion (pT1bN0M0). CONCLUSION Laparoscopic caudate lobectomy for cirrhotic patients with partial IVC resection is technically demanding. It therefore requires a strategic and preplanned approach with dedicated instrumentation and laparoscopic skills available. Although the caudal view along the axis of the IVC facilitates dissection, a laparoscopic approach necessitates particular attention to central venous pressure management (intravenous fluid and respiratory tidal volume), meticulous control of portal and short hepatic vein branches, and availability of specialty laparoscopic instrumentation to ensure procedural safety.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Diana C Nicolaescu
- Medical Doctoral School, Tulcea Emergency Hospital, IOSUD Titu Maiorescu University of Bucharest, Bucharest, Romania
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Usha Vellayappan
- Department of Anesthesia, St. Elizabeth's Medical Center, Boston, MA, USA
| | - David Ricklan
- Department of Pathology, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Justin McCarty
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Fermin Fontan
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Frank Pomposelli
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA. .,General Surgery and Surgical Oncology, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins Street, Suite 201, Boston, MA, 02135, USA.
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