Purpose: Although pancreatic cancer is a common malignancy, signet ring cell carcinoma of the pancreas is a very rare histologic type with only 6 cases reported so far. We present a patient with primary signet ring cell carcinoma of the pancreas and a good response to neoadjuvant chemotherapy. Case report: A 67-year-old woman presented at a regional hospital with a 2-week history of painless progressive jaundice. Abdominal computed tomography showed a tumor in the head of the pancreas, 4.5 cm in largest diameter. Since endoscopic biopsy and biliary stenting were not available, the patient had undergone palliative choledochoduodenostomy and tru-cut needle biopsy of the lesion. Histopathology revealed primary signet ring cell carcinoma of the pancreas. The tumor was considered borderline resectable and 3-month neoadjuvant chemotherapy with gemcitabine alone was administered due to the low creatinine clearance rates. Follow-up abdominal scan demonstrated very good response to chemotherapy and significant tumor regression to 1.5 cm in largest diameter. Radical cephalic duodenopancreatectomy was performed. Conclusion: Significant tumor downsizing in our patient clearly demonstrates good response to neoadjuvant gemcitabine monotherapy. The optimal preoperative chemotherapy leading to tumor reduction and disease control in patients with borderline resectable and locally advanced pancreatic carcinoma is controversial, necessitating further randomized studies including combined chemoradiotherapy and multidrug combination regimens.

Schwannomas are tumours that arise from Schwann cells of the peripheral nerve sheath and rarely occur in the retroperitoneum. We report a 45-year-old woman who presented with a 2-year history of continuous progressive right-sided lower back and dull flank pain radiating into her posterolateral thigh. Abdominal magnetic resonance imaging showed a homogenous soft-tissue tumour with thick capsular lining, which lay in the right retroperitoneum. The tumour was removed at surgery. A histological examination confirmed the diagnosis of benign encapsulated cellular schwannoma. Complete tumour excision should be regarded as the treatment of choice for benign retroperitoneal schwannomas. Successful treatment of these tumours requires thorough preoperative planning and a multidisciplinary approach.

Ischemia/reperfusion injury is still a major cause of morbidity and mortality during liver surgery and transplantation. A variety of surgical and pharmacological therapeutic strategies have been investigated to minimize the effects of ischemia/reperfusion. The aim of our study was to analyze and compare preventive influences of ischemic preconditioning, adenosine and prostaglandin E1 in the experimental model of hepatic ischemia/reperfusion injury. Adult chinchilla rabbits were divided into four groups: 10 rabbits subjected to liver ischemic preconditioning (3-min period of inflow occlusion followed by a 5-min period of reperfusion) followed by 45 min of Pringle maneuver; 10 rabbits subjected to pre-treatment with intraportal injection of adenosine followed by 45 min of Pringle maneuver; 10 rabbits subjected to pre-treatment with intraportal injection of prostaglandin E1 followed by 45 min of Pringle maneuver; and control group of 10 rabbits subjected to 45 min of inflow liver ischemia without any preconditioning. On the second postoperative day, blood samples were obtained and biochemical parameters of liver function were measured and compared. Liver tissue samples were also obtained and histopathological changes were compared. Based on biochemical and histopathological parameters, it was demonstrated that ischemic preconditioning provided the best protection against hepatic ischemia/reperfusion injury. This was probably due to a wider range of mechanisms of action of this method oriented to reduce oxidative stress and inflammation, and restore liver microcirculation and hepatocyte energy compared to the examined pharmacological strategies.

Pancreatic fistula occurs as a result of pancreatic duct disruption during acute pancreatitis. An external or pancreatico-cutaneous fistula is defined as a leakage of pancreatic secretion through an abdominal wound or previously inserted drain. If the extravasated pancreatic juice is walled-off by the fibrous or granulation tissue, a pseudocyst is formed. Fistulization of the pancreatic pseudocyst into the different surrounding hollow viscera is reported. However, we present a patient with spontaneous cutaneous fistulization of the pancreatic pseudocyst into the lumbar region successfully treated conservatively. Such an extremely rare presentation is only reported twice and thus highly unexpected during the follow-up of patients after recovery from acute pancreatitis. The patient presented with 5-days intermittent fever and a tender, fluctuant, and erythematous swelling of the left lumbar paravertebral region with black necrotic skin spot on the top of it. Abdominal computed tomography scan revealed retroperitoneal pseudocyst originating from the pancreatic body and tail and extending to the left flank. Incision of the swelling evacuated dark amylase rich fluid. Colostomy disc and bag were applied to collect further spontaneous outflow of pseudocyst content. Symptoms instantly resolved and the patient was managed conservatively with ambulatory follow-up of the daily volume of fistula discharge. Over the next 37 days daily fistula output gradually reduced to nil with the spontaneous closure of the external skin fistula opening. Frequent follow-ups of patients after severe acute pancreatitis are necessary for early detection and timely successful treatment of pancreatic pseudocysts with such unusual and rare presentation.

Objective: Periampullary carcinomas are a group of neoplasms with variable histopathology that originate from the anatomical junction of different epithelial types including the bile duct, pancreatic duct, and duodenal mucosa. This study was performed to determine whether the histopathologic type of these tumors should be considered an independent prognostic factor. Methods: We analyzed the specimen histopathology of 37 patients who underwent radical cephalic pancreatoduodenectomy for carcinoma of the ampulla of Vater during a 5-year period. We excluded patients with other tumors with an indication for Whipple’s procedure and those in whom R0 resection was not achieved. Results: The carcinomas of the hepatopancreatic ampulla were intestinal in 23 (62%) patients, pancreatobiliary in 13 (35%), and mixed type in 1 (3%). The analysis demonstrated significantly more advanced local tumor spread, a more aggressive lymph node metastasizing pattern, and more frequent lymphatic and perineural invasion in patients with pancreatobiliary than intestinal and mixed type tumors. Conclusion: Pancreatobiliary type of ampullary carcinoma is associated with a poorer prognosis than intestinal and mixed types because of its more aggressive behavior. Histopathology should be regarded as an independent predictor of survival and may have therapeutic and prognostic implications for patients.

We present a patient with blunt abdominal trauma with severe acute right limb ischemia and clinical signs of diffuse peritonitis. Computed tomography angiography showed circumferential dissection of the infrarenal aorta with occlusion of the right common iliac artery. We opted for simultaneous abdomen exploration and open repair of injured aorta. Critical weakening of the aortic wall with imminent rupture was identified intraoperatively. Aortotomy cranially from bifurcation showed circumferential intimomedial dissection. The fixation of fragile intimomedial flap of aortic dissection was achieved with reinforcement using an anterior longitudinal ligament. The long aortoiliac arteriotomy was repaired using a great saphenous vein patch. Patient had uneventful postoperative course and was discharged after 7 days. In patients with abdominal polytrauma with peritonitis, and no available endovascular tools, open surgery for circumferential aortic dissection is possible and successful. Described reinforcement of the posterior aortic wall to the anterior longitudinal ligament should be added to the armamentarium of aortic injury treatment.