Retroperitoneal-first dissection approach at the dorsal space for a huge serous cystic neoplasm of the pancreatic tail: a case report

BACKGROUND

Large tumors of serous cystic adenomas in the pancreatic body-to-tail severely compress the surrounding organs and retroperitoneal space.

CASE PRESENTATION

We present a unique surgical challenge for distal pancreatectomy (DP). We present the case of a patient who had a massive mass lesion measuring more than 20 cm in size that had been misdiagnosed as a retroperitoneal tumor by the previous hospital. However, an expert radiologist at our institute diagnosed serous cystadenoma of the pancreas based on imaging characteristics. We decided to perform retroperitoneal space first dissection using a small incision because we were concerned about tumor infiltration or compressive adhesions in important retroperitoneal vessels. We safely attempted distal pancreatectomy by limiting the laparotomy incision step-by-step while securing the main vascular injury of the retroperitoneum. In addition to the ordinary cooperation with urological surgeons, this technique is referred to by the concept of retroperitoneal procedures for minimally invasive surgery in urology.

CONCLUSIONS

This approach is useful for lifting resected specimens by prior and wide retroperitoneal dissection, which may lead to safety and the prevention of unexpected vascular injury.

Needle-based confocal endomicroscopy in the discrimination of mucinous from non-mucinous pancreatic cystic lesions

BACKGROUND

Pancreatic cystic lesions (PCLs) are considered a precursor of pancreatic cancer. Needle-based confocal endomicroscopy (nCLE) is an imaging technique that enables visualization of the mucosal layer to a micron resolution. Its application has demonstrated promising results in the distinction of PCLs. This study evaluated the utility of nCLE in patients with indeterminate PCLs undergoing endoscopic ultrasound fine-needle aspiration (EUS-FNA) to distinguish mucinous from non-mucinous lesions.

AIM

To evaluate the accuracy of nCLE in indeterminate PCLs undergoing EUS-FNA to distinguish mucinous from non-mucinous lesions.

METHODS

Patients who required EUS-FNA between 2015 and 2017 were enrolled prospectively. During EUS-FNA, confocal imaging, analyses of the tumor markers carcinoembryonic antigen and amylase, and cytologic examination were conducted. All patients were followed for at least 12 mo and underwent laboratory testing and computed tomography scanning or magnetic resonance imaging. nCLE videos were independently reviewed by 6 observers to reach a final diagnosis (mucinous vs non-mucinous) based on criteria derived from previous studies; if there was disagreement > 20%, a final diagnosis was discussed after consensus re-evaluation. The sensitivity, specificity, and accuracy of nCLE were calculated. Adverse events were recorded.

RESULTS

Fifty-nine patients were included in this study. Final diagnoses were derived from surgery in 10 patients, cytology in 13, and imaging and multidisciplinary team review in 36. Three patients were excluded from final diagnosis due to problems with nCLE acquisition. Fifty-six patients were included in the final analysis. The sensitivity, specificity, and accuracy of nCLE were 80% [95% confidence interval (CI): 65-90], 100% (95%CI: 72-100), and 84% (95%CI: 72-93), respectively. Post-procedure acute pancreatitis occurred in 5%.

CONCLUSION

EUS-nCLE performs better than standard EUS-FNA for the diagnosis of indeterminate PCL.

Largest Serous Cystadenoma in the first Trimester treated Laparoscopically: A Case Report

We report the first case of a giant serous cystadenoma approximately 7.5kg in weight in a 28-year old primigravida at 8 weeks of gestation which was successfully excised laparoscopically. Postoperatively, she had a quick recovery and she was discharged on post op day 3 with an intact pregnancy and no complications. This is the largest ovarian cyst in early pregnancy that has been ever reported from our hospital. We also believe this cyst to be the largest cyst in early pregnancy ever reported in the literature that has been managed by Laparoscopy.