Challenging the limits in pancreatic surgery: A case report

Johannes Lemke; Stefan A Schmidt; Marko Kornmann; Karl-Heinz Orend; Doris Henne-Bruns

doi:10.1016/j.ijscr.2016.10.062

Challenging the limits in pancreatic surgery: A case report

Int J Surg Case Rep. 2016:29:151-154. doi: 10.1016/j.ijscr.2016.10.062. Epub 2016 Nov 15.

Authors

Johannes Lemke¹, Stefan A Schmidt², Marko Kornmann¹, Karl-Heinz Orend³, Doris Henne-Bruns⁴

Affiliations

¹ Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
² Department of Diagnostic and Interventional Radiology, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
³ Department of Cardiothoracic and Vascular Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
⁴ Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Electronic address: doris.henne-bruns@uniklinik-ulm.de.

Abstract

Introduction: Today, pancreatic surgery can be performed with low mortality and tolerable morbidity in specialized centers. Nevertheless, due to its anatomical localization and proximity to important vascular structures, surgical resection of the pancreas remains challenging in many cases.

Presentation of case: Here, we present the case of a young woman who presented in our department with abdominal pain and a tumor mass located at the pancreatic head. She had undergone explorative laparotomy elsewhere before, in which the pancreatic tumor mass was reported to be unresectable due to infiltration of the mesenteric root. However, biopsies obtained had not revealed malignancy. Moreover, postoperatively a stenting of the portal vein had been performed due to portal vein thrombosis and varices. Upon admission in our clinic, computed tomography revealed a tumor of the pancreatic head, occlusion of the portal vein stent and, more importantly, extravascular dislocation of the stent with perforation into the stomach. Upon explorative laparotomy we initially performed a mesenterico-caval shunt to release portal hypertension. Secondly, the dislocated stent was successfully removed upon gastrotomy, and finally, a partial pancreaticoduodencectomy was performed. Interestingly, the histopathological analysis revealed granulocytic epithelial lesions (GELs) confirming a type-2 autoimmune pancreatitis without evidence for malignancy. The postoperative course was uneventful and the patients was dismissed without any remaining symptoms.

Discussion & conclusion: This interesting and unique case underlines the complexity in diagnosis of pancreatic tumors with unsolved dignity and differential diagnosis of pancreatitis and pancreatic cancer. Furthermore, it demonstrated the challenges in pancreatic surgery for exceptional and uncommon conditions demanding complex surgical approaches.

Keywords: Autoimmune pancreatitis; Case report; Mesenterico-caval shunt; Pancreatic surgery; Pancreaticoduodenectomy.