Distal Duct Research Articles

Multiple stents are not superior to single stent insertion for pain relief in patients with chronic pancreatitis: a retrospective comparative study.

Background and study aims Patients with painful chronic pancreatitis (CP) and distal main pancreatic duct (MPD) stricture are considered candidates for treatment using a single plastic stent insertion. Multiple side-by-side stents have been proposed as an alternative treatment but comparative studies are lacking. The aim of this retrospective study is to assess differences in characteristics and treatment outcomes in patients with CP and MPD strictures treated with a different number of stents during the stenting period. Patients and methods Patients with painful CP and distal MPD obstruction requiring endoscopic treatment (01.2004 – 12.2012) were considered. The study population was divided in three groups: Patients treated with (A) exclusively one stent; (B) one or two stents; and (C) exclusively two stents during the stenting period. Patient characteristics and treatment outcomes were retrospectively assessed. Results Among 284 patients, 85 were selected according to inclusion criteria (Group A: 18, Group B: 35, Group C: 32). Median follow-up duration was 84 months. The median number of endoscopic procedures needed was higher for group B [3 (A) vs. 3 (C) vs. 4 (B), P = 0.001]. Regarding outcome, successful endoscopic treatment was lower in Group C (50 % vs. 88.2 % and 74.2 % for groups A and B, respectively; P = 0.02). This difference was attributed to better clinical outcome in Group A compared to Group C patients [OR(95%CI): 7.50 (1.46 – 38.70); P = 0.04]. Moreover, group C patients experienced higher levels of pain at the end of follow-up period [median Izbicki Score 0 (group A) vs. 0 (group B) vs. 6 (group C), P = 0.03]. Conclusions In patients with painful CP and distal MPD obstruction, treatment with a single stent is associated with better clinical outcome compared to treatment with exclusively two stents during the stenting period.

PERCUTANEOUS FLUOROSCOPICALLY-GUIDED TRANSCERVICAL RETROGRADE ACCESS FACILITATES SUCCESSFUL THORACIC DUCT EMBOLIZATION AFTER FAILED ANTEGRADE TRANSABDOMINAL ACCESS

The purpose of this study was to demonstrate the feasibility of percutaneous fluoroscopically-guided transcervical retrograde access into the thoracic duct following unsuccessful transabdominal cisterna chyli cannulation to perform thoracic duct embolization for the treatment of chylothorax. Five patients, including three (60%) women and two (40%) men, with median age of 62 years, underwent percutaneous transcervical thoracic duct access and embolization after failed transabdominal cisterna chyli cannulation for the treatment of chylothorax. In all patients, fluoroscopically-guided percutaneous transcervical retrograde access into the distal thoracic duct was achieved using a 21-gauge needle and an 0.018-inch wire. Following advancement of a microcatheter, retrograde lymphangiography was performed to identify the location of thoracic duct injury. A combination of 2:1 ethiodized oil to cyanoacrylate mixtures, platinum microcoils, or stent-grafts were used to treat the chylous leaks. Technical successes, procedure durations, fluoroscopy times, blood losses, immediate adverse events, clinical successes, and follow-up durations were recorded. Technical success was defined as cannulation of the distal thoracic duct using a transcervical approach followed by treatment of the thoracic duct injury. Adverse events were classified according to the Society of Interventional Radiology guidelines. Clinical success was defined as resolution of the presenting chylothorax. Percutaneous transcervical retrograde thoracic duct access and treatment was technically successful in all patients (n=5). Median procedure duration was 173 minutes (range: 136-347 minutes) with a median fluoroscopy time of 94.7 minutes (range: 47-125 minutes). Median blood loss was 10 mL (range: 5-20 mL). No minor or major adverse occurred. Clinical success was achieved in all patients (n=5). Median follow-up was 372 days (range: 67-661 days). Percutaneous fluoroscopically- guided transcervical retrograde thoracic duct access is an effective and safe method to perform thoracic duct embolization following unsuccessful transabdominal cisterna chyli cannulation for the treatment of chylothorax.

1428 Biliary Obstruction Due to Extrahepatic Biliary Mucinous Cystic Neoplasm: An Uncommon Case

INTRODUCTION: Biliary mucinous cystic neoplasms (BMCNs) are a rare form of premalignant biliary cystic tumors, much like their better-known counterpart, biliary intraductal papillary mucinous neoplasms (IPMNs). BMCNs most commonly occur in females during the 5th decade of life. They account for approximately 1-5% of all liver cysts. The lack of awareness of these lesions poses a challenge for proper and timely diagnosis. Here, we present an interesting case of extrahepatic BMCN. CASE DESCRIPTION/METHODS: A 30-year-old female presented with pruritis, dark urine, and light-colored stools. Labs revealed transaminitis and elevated bilirubin concerning for biliary obstruction. Abdominal ultrasound showed cholelithiasis and dilation of the distal common bile duct (CBD) concerning for choledocholithiasis. MRCP was performed and described a 2.2 × 2.4 cm cystic dilatation of the extrahepatic bile duct involving the distal common hepatic duct (CHD) concerning for either type 1B or type II choledochal cyst. Endoscopic ultrasound revealed a CHD cystic lesion with internal debris concerning for either sludge or biliary IPMN (Figure 1). ERCP with cholangioscopy revealed papillary projection in the CHD (Figure 2). Directed biopsies revealed mucinous epithelium with cytologic atypia. The patient was referred for complete resection of the CBD and CHD, cholecystectomy, and Roux-en-Y hepaticojejunostomy. Surgical pathology revealed a tumor consisting of a cystic structure lined by mucinous epithelium with estrogen receptor (ER) positive ovarian-type stroma, and mild to focal moderate dysplasia, consistent with noninvasive extrahepatic BMCN (Figure 3). DISCUSSION: BMCNs are often detected incidentally when investigating other common causes of biliary disease. The overall incidence of BMCNs is approximately 1:20,000 to 1:100,000. They are most commonly found within the liver (90%), are rarely extra-hepatic, and they seldom present with obstructive jaundice. The treatment of choice is surgical resection. Diagnosis is made via histological confirmation of ovarian-type stroma. The location of the lesion, in this case, is more common for IPMNs. Both IPMNs and BMCNs carry malignant potential requiring complete resection for diagnosis and treatment. With the risk of malignant transformation as high as 30%, an awareness of these rare neoplasms is very important.

2158 Successful Endoscopic Retrograde Cholangiopancreatography in a Patient With Situs Inversus and Choledocholithiasis

INTRODUCTION: Situs inversus is a congenital condition that causes left-right reversal of all organs. This results in unique challenges for the endoscopist when patients with situs inversus require ERCP. Several methods have been described in the literature to optimize the chances of successful cannulation in these unique patients. We describe the case of a 75 year old woman with situs inversus who developed choledocholithiasis requiring ERCP for stone extraction. We review the clinical features of situs inversus, as well as the methods needed to obtain successful cannulation. CASE DESCRIPTION/METHODS: A 75 year old woman with complete situs inversus was transferred to our facility. Eight days prior to this presentation, she developed epigastric pain and emesis. She had new liver test abnormalities with ALT 277, AST 110, alkaline phosphatase 221, and total bilirubin 5.5. A CT scan showed dilation of the common bile duct to 7 mm with a 6 mm stone noted in the distal duct. Upon arrival at our facility, ERCP was performed in the left lateral position. The procedure was notable for distortion of the stomach and duodenal bulb consistent with situs inversus. A precut sphincterotomy was necessary to achieve biliary cannulation. The bile duct was noted to come off the ampulla at 1 o’clock, in mirror image from normal anatomy. A 9 mm stone was identified and removed with a basket. DISCUSSION: Situs inversus is an autosomal recessive congenital condition with an incidence rate of approximately 1 in 5,000 to 10,000 live births. There is no evidence that situs inversus contributes to increased gallstone formation. Currently, there are 15 cases of ERCP performed for choledocholithiasis in situs inversus patients described in the literature. Besides the obvious differences in the orientation of the stomach and duodenum, the bile duct is often noted to come off the ampulla at “1 o’clock” instead of the typical “11 o’clock.” A variety of methods have been described to address these anatomical differences, including placing the patient in the prone position, changing the side of the bed that the endoscopist stands on, setting up the ERCP suite in mirror image, and rotating the duodenoscope 180 degrees clockwise in the stomach, and then either rotating an additional 180 degrees in the second portion of the duodenum or using a rotating sphincterotome. Endoscopists should be aware of the various techniques to optimize cannulation in patients with situs inversus to maximize chances of a successful intervention.

CRYPTOGENIC ORGANIZING PNEUMONIA: A RARE COMPLICATION OF THE QUADRIVALENT INFLUENZA VACCINE

SESSION TITLE: Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/20/2019 1:00 PM - 2:00 PM INTRODUCTION: Cryptogenic organizing pneumonia (COP) is an idiopathic form of organizing pneumonia that affects distal bronchioles, respiratory bronchioles, alveolar ducts and alveolar walls. We report a patient who developed cryptogenic organizing pneumonia (COP) twice- one month after receiving the quadrivalent influenza vaccine a year apart CASE PRESENTATION: A 65 year old Caucasian male received Flulaval influenza vaccine in 2016 with no immediate adverse effects. A month later, the patient was hospitalized with dyspnea and cough leading to acute hypoxemic respiratory failure. Patient was started on non-invasive ventilation and antibiotics. Patient’s clinical condition deteriorated with worsening of bilateral infiltrates (Figure 1.1). Bronchoalveolar lavage showed acute inflammatory cells with cultures being negative. Right upper lobe wedge biopsy showed COP. Patient was started on IV Solumedrol and transitioned to high dose oral prednisone (Figure 1.2). One week later patient was clinically better. Prednisone was continued 3 months more and discontinued. Repeat CT chest with contrast showed resolution of the infiltrates (Figure 1.3).A year later in 2017, patient received an inactivated quadrivalent vaccine (Fluzone) and had no immediate complications. One month later he presented with weakness, dyspnea, fever, hemoptysis and cough. Imaging showed patchy bilateral multifocal infiltrates (Figure 1.4) Infectious etiology was ruled out. Based on the similarities to his presentation a year ago COP secondary to the inactivated quadrivalent vaccine was felt likely and patient was started on steroids. Chest x-ray showed improved aeration bilaterally with eventual clearing of infiltrates. DISCUSSION: The patient had biopsy proven COP in the first instance. A year later, the temporal relationship to the influenza vaccination, the similar clinical picture, absence of infection and the response to steroids made this presumptively COP. Both instances were within 1 month of receiving an inactivated quadrivalent flu vaccine. There are no such reported cases in North America. Hibino et al reported two cases of COP after receiving an influenza vaccine1 who were diagnosed with lung biopsy and treated with high dose steroids. CONCLUSIONS: We present this rare complication of influenza vaccination to increase clinician awareness of this condition. COP due to influenza vaccination can be serious; however, early intervention and diagnosis can be key to preventing further complications. Despite this possible complication, Influenza vaccine is necessary to prevent morbidity and mortality in susceptible individuals. Reference #1: 1. Hibino, M., & Kondo, T. (2017). Interstitial Pneumonia Associated with the Influenza Vaccine: A Report of Two Cases. Internal Medicine,56(2), 197-201. https://doi.org/10.2169/internalmedicine.56.7239 DISCLOSURES: No relevant relationships by Raju Abraham, source=Web Response No relevant relationships by Thomas Betlej, source=Web Response No relevant relationships by Naina Chandan, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response

1318 Pancreaticopleural Fistula in a Patient With Recurrent Alcoholic Pancreatitis: Combined Endoscopic and Medical Management

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, resulting from disruption of the pancreatic duct. This injury may be secondary to acute/chronic pancreatitis, trauma, or surgery. Here we describe a patient with a PPF, and our workup and treatment for this rare condition. CASE DESCRIPTION/METHODS: A 61-year-old male with COPD, alcohol misuse, and history of recurrent acute alcoholic pancreatitis complicated by pseudocysts was admitted with one month of worsening shortness of breath from a large left pleural effusion, which reaccumulated within four days after a 1.6 L thoracentesis. On examination he had mild abdominal tenderness in the RUQ and epigastrium. Labs were notable for serum amylase 1105 U/L, lipase >1000 U/L, and WBC 10.8. He underwent another thoracentesis, removing 1.5 L of fluid which was an exudate with amylase greater than 2000 U/L. CT of the chest and abdomen showed a subdiaphragmatic LUQ fluid collection with communication to the pancreatic body and duct. A chest tube was then placed to prevent fluid re-accumulation. MRCP confirmed a PPF from the proximal pancreatic body duct to the left pleura. He was started on octreotide. ERCP confirmed a fistula originating from the distal pancreatic duct but attempts to pass a wire into the dorsal pancreatic duct were unsuccessful, and a ventral pancreatic sphincterotomy was performed. His chest tube was removed after one day, and he was discharged to continue octreotide at home. Unfortunately, he returned the following day with complaints of dyspnea. Pancrelipase was then added in an attempt to minimize pancreatic exocrine secretions. On follow-up 1 and 2 months later, the pleural fluid is much smaller, and the patient's dyspnea has resolved. DISCUSSION: Here we present a novel management of PPF without pancreatic duct stent placement and instead with pancreatic sphincterotomy to divert pancreatic secretions away from the fistula tract and medical therapy (octreotide and pancrelipase) to reduce the pancreatic secretion. The diagnosis was reached through a combination of clinical history, lab studies (particularly, the elevated amylase in the pleural fluid), and CT and MR imaging. This was further confirmed with ERCP, which is useful especially if a stent can be placed to divert secretions away from fistula tract. Ultimately, this diagnosis requires a high index of suspicion, particularly in patients who present with recurrent effusions in the setting of pancreatitis.

3002 Several Endoscopies Later, Hemosuccus Pancreaticus Comes to Light

INTRODUCTION: Hemosuccus pancreaticus (HP) is an extremely rare cause of upper gastrointestinal bleeding occurring in an estimated one in 1,500 cases. HP is believed to occur through a vascular malformation within the splenic artery leading to intermittent bleeding within the pancreatic duct. The most common causes of HP are due to chronic inflammatory changes from pancreatitis, pseudocysts, or pancreatic malignancy. HP is a challenging diagnosis due to intermittent bleeding, difficulty in localizing anatomical structures, and vague clinical symptoms. Clinically, patients present with vague abdominal pain and intermittent gastrointestinal bleeding not often visualized on EGD, which make diagnosis extremely challenging. Upper GI bleeding can have different etiologies, including but not limited to, peptic ulcer disease, varices, Mallory-Weiss tears, and angioectasis. A rare form of upper GI bleeding can be caused by HP, which is described as bleeding from the pancreatic duct via the Ampulla of Vater. Here we present a case of Hemosuccus Pancreaticus after ruling out common causes. CASE DESCRIPTION/METHODS: 45-year-old male with medical history significant for chronic pancreatitis complicated by enlarging pancreatic cysts and alcoholic cirrhosis, who presented with melena, left upper quadrant pain, and significant acute blood loss anemia. Patient had several admissions to our facility and underwent several endoscopic procedures without an obvious etiology. During endoscopy on his most recent admission, blood was seen oozing from the ampulla concerning for HP. Patient then had diagnostic angiography by IR notable for distal aneurysm formation communicating with the distal pancreatic duct. Once patient had been discharged, patient had another episode of syncope and was transferred to another facility where he had ultrasound-guided right common femoral artery arteriogram with subsequent coiling of a large pseudoaneurysm arising from the inferior pancreatic artery. DISCUSSION: Hemosuccus Pancreaticus is a rare entity but can be seen in patients with chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. HP occurs when a direct communication is formed between the pancreatic duct and a vessel after a pancreatic cyst or malignancy erodes into an arterial pseudoaneurysm. Given the fact that this diagnosis is rare and can be potential life-threatening with the rupture of the pseudoaneurysm, it is imperative for physicians to be familiar with the pathology, presentation, and appropriate management of HP.

Incidental abdominal lymph node metastases from a known breast cancer in resected specimen of invasive pancreatic ductal adenocarcinoma: report of a case.

Breast cancer is known to metastasize to all organs of the body. However, abdominal lymph node metastases from breast cancer are extremely rare. We herein report a resected case of an invasive pancreatic ductal adenocarcinoma (PDAC) in which abdominal lymph node metastases from breast cancer were diagnosed. A 54-year-old woman was pointed out to have a tumor in the pancreatic tail with dilatation of the distal pancreatic duct. She had undergone partial mastectomy for left breast cancer at the age of 51years and had undergone partial liver resection for liver metastasis in the segment 3/4 6months earlier. Computed tomography revealed a low-density tumor in the pancreatic tail with dilated distal main pancreatic duct. Magnetic resonance imaging (MRI) exhibited a high-intensity tumor in the pancreatic tail in diffusion-weighted images. With a diagnosis of pancreatic cancer, distal pancreatectomy and splenectomy with lymph nodes dissection was performed. Lymph node metastases along the splenic artery were pathologically similar to PDAC. However, lymph node metastases along the left gastric artery, common hepatic artery, celiac axis, and superior mesenteric artery were pathologically similar to breast cancer. Immunohistochemistry staining of abdominal lymph nodes with GATA-3 was positive, which strongly suggested metastatic breast cancer. Although she received chemotherapy with S-1 for breast cancer and PDAC for 4months, MRI showed multiple liver metastases derived from breast cancer. Finally, she died 12months after operation.

Transoral Ultrasound in the Diagnosis of Obstructive Salivary Gland Pathologies

Transcutaneous ultrasound (TCUS) is an accepted diagnostic method in salivary gland diseases. However, sparse data are available on the use of transoral ultrasound (TOUS) in sialadenopathies. One hundred five patients presenting with various obstructive sialadenopathies were examined using TOUS and TCUS. Ultrasound findings were validated by direct visualization in subsequent sialendoscopy examinations. By TOUS, but not by TCUS, all patients with sialolithiasis (70/105) could be identified and virtually all concrements, even very small ones, were detected and distinguished from artifacts. Ductal stenoses (16/105) could be correctly differentiated from sialoliths, and exceptional insights into the delicate anatomy of parotid duct stenoses were gained. TOUS provided detailed information on other space-occupying lesions (14/105) and circumvented the method-related diagnostic weaknesses of TCUS. As a valuable tool in the diagnosis of obstructive sialadenopathies, TOUS seems superior to TCUS in pathologies involving the distal parotid duct, the submandibular duct system and the floor of the mouth.

Transurethral Resection of Ejaculatory Duct in Primary Infertile Men with Distal Ejaculatory Duct Obstruction

Transurethral Resection of Ejaculatory Duct in Primary Infertile Men with Distal Ejaculatory Duct Obstruction

867 Contraction of myoepithelial cells in human eccrine sweat glands, revealed by 3D live imaging

Sweat glands are single tubular organs subdivided into two parts: excretory and secretory ducts, both of which form a complicated coiled structure in the deep dermis. Secretory ducts are surrounded by contractile myoepithelial cells. Contraction of these myoepithelial cells is thought to contribute to the secretion of sweat. However, it remains unknown whether sweat gland myoepithelial cells contract. We previously revealed that myoepithelial cells were aligned in a well-oriented manner, enabling efficient contraction of secretory ducts, which likely facilitates sweat excretion. Human sweat gland dynamics were captured using a live-imaging system with actin, nuclear, and cell membrane markers. The contraction of myoepithelial cells was induced by pilocarpine, an acetylcholine analogue. Live-imaging data revealed that a portion of the secretory duct began to contract in the direction of narrowing tube diameter, immediately after pilocarpine addition; this was followed by gradual distention of two distal excretory ducts. The contractile motion of the coiled tubular components of the sweat gland showed sequential contraction, enabling transportation of sweat. Moreover, this contraction was inhibited by the sweating antagonist, atropine. These results suggest that myoepithelial cell contraction may be necessary to generate the driving force for transporting the sweat. We plan to further analyze the kinetics of myoepithelial contracting motion, in combination with pharmacological intervention, to identify the specific regulatory mechanisms involved.

Endoluminal radiofrequency ablation of the main pancreatic duct is a secure and effective method to produce pancreatic atrophy and to achieve stump closure

Radiofrequency energy has been used both experimentally and clinically to manage the pancreatic remnant after distal pancreatectomies. Our goal was to determine whether endoluminal radiofrequency (RF) ablation of the main pancreatic duct in large animals would be more efficient than glue occlusion as an exocrine pancreatic atrophy-inducing procedure. Thirty-four Landrace pigs were assigned to either the transpapilar (n = 16) or transection (n = 18) groups. The transection implied the pancreas neck was severed. In each of these groups the remaining distal pancreatic duct was occluded either by RF or by glue. In the transpapilar group complete atrophy was observed in all the RF cases, while atrophy was incomplete in all the members of the glue subgroup. The failure rate of the main pancreatic duct (usually expressed by a pseudocyst) in the transection groups was dramatically higher in the glue subgroup than the RF subgroups (9 out of 9 and 1 out of 9, respectively) and postoperative mortality occurred only in the glue subgroup (3 out of 9). These results show the superiority of endoluminal RF ablation over glue for main pancreatic duct occlusion, as seen by the degree of atrophy and fewer postoperative pancreatic fistulas.

Laparsopcic removal of an intraductal ERCP stone retrieval basket following guide wire fracture

Background: Gallstones within the common bile duct are a common cause of biliary obstruction. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and stone retrieval using either balloon catheters or wire basket devices is the gold standard treatment. Methods: We present the case of an 85 year old lady who presented with obstructive jaundice and deranged LFTs. Ultrasound confirmed choledocholithiasis and common bile duct (CBD) dilation. She proceeded to ERCP and sphincterotomy where multiple CBD stones were noted, the largest measuring 12 mm. Prior to removal using a wire basket device an attempt was made to crush the largest stone. In doing so the guidewire fractured with the basket and stone still within the common bile duct. A rescue mechanical lithotriptor was used in an attempt to clear the duct unsuccessfully. Further attempts to remove the stone and basket through the sphincterotomy were also unsuccessful and the patient proceeded to laparoscopy. Results: A four port laparoscopic approach was used with x1 12 mm umbilical port and x3 5 mm epigastric and right subcostal ports. A longitudinal choledochotomy revealed several stones and the wire basket. The wires were cut using scissors and the basket was retrieved along with the large impacted stone. Proximal and distal ducts were cleared using a fogarty balloon catheter. The CBD was closed using interrupted intracorporeal vicryl sutures and a T-Tube was inserted. A cholecystectomy was then performed and the specimen along with the wire basket and stones were removed using an endobag through the umbilical port. The T-Tube was brought out though one of the right subcostal ports. The patient returned to the ward and had an uncomplicated post op recovery. The T-Tube was removed several weeks later following a satisfactory tube cholangiogram. Discussion ERCP is the gold standard of treatment for the removal of common bile duct stones, with a success rate of over 95%.(1) Wire basket retention as a result of stone impaction within the basket and less commonly as a result of guide wire fracture occurs in 0.6% of cases. (2). Management of these complications can involve the use of balloon catheters, further mechanical lithotripsy techniques and in the setting of an impacted stone, extracorporeal shockwave lithotripsy (ESWL). However if these endoscopic methods fail then surgical intervention is indicated. Conclusion: Intraductal ERCP wire basket retention following wire fracture can be safely and effectively managed laparoscopically when traditional endoscopic methods have failed. This is associated with a significantly reduced level of morbidity when compared to traditional laparotomy and in specialist centres it should be considered as a first line treatment in such cases. (we have excellent video for this case that was not available at the time of this submission but will be accessible in the coming days)

Two new species of land planarians (Platyhelminthes, Tricladida, Geoplanidae) from protected areas in the southern extreme of the Paranaense Rainforest, Argentina

Here, we describe two new flatworm species of the genera Obama Carbayo et al., 2013 and Notogynaphallia Ogren & Kawakatsu, 1990 (Geoplaninae) found in riverine forests of central-eastern Argentina. Obama maculatentis sp. nov., which is about 50 mm in length, is characterized by black olive pigmentation on the dorsum, with two irregular rows of black spots, and light grey ventral surface. The eyes, with clear halos, extend to the dorsal surface. The foremost features of the copulatory apparatus include dorsal testes anterior to ovaries, extrabulbar prostatic vesicle with forked proximal portion, protrusible penis, male atrium with a large dorsal fold separating it from the female atrium, ovovitelline ducts ascending at the level of the gonopore, common ovovitelline duct dorsal to the distal portion of the female atrium, female canal ventro-anteriorly flexed, and female atrium with narrow lumen. Notogynaphallia fortuita sp. nov., which is about 30 mm in length, is characterized by beige ground pigmentation with tiny darker spots, cephalic region saffron yellow, and ventral surface light grey. The eyes, with small clear halos, extend to the dorsal surface. Regarding the internal anatomy, this new species shows parenchymatic musculature not organized in discrete layers, testes arising near the anterior end of the body, distal sperm ducts traversing the common muscle coat and joining in a short common sperm duct. The areas in which the land planarians were found represent the southernmost latitudes with representatives of the Interior Atlantic Forest (Paranaense Rainforest) biota, hence their biogeographical and conservation significance.

Vascular reconstruction in patients with perihilar and intrahepatic cholangicarcinoma.

Background: The aim of this study was to describe safety and possibility of vascular reconstruction in patients with perihilar and intrahepatic cholangiocarcinoma in single hepatopancreatobiliary(HPB) clinic. Methods: 52 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2013 to 2016 were radically operated in HPB department of Moscow Clinical Scientific Center. 16 of those had vascular resection and reconstruction, including vena cava resection in 3 patients, portal vein resection alone in 9 patients, combined hepatic artery and portal vein resection in 3 and hepatic artery resection alone in 1. Results: No significant difference was found in postoperative complications (type III-IV by Clavien-Dindo) between the vascular resection and non-vascular resection group(p > 0,05). R0 resection was achieved in 70% that was significantly higher than in previous years. Mortality was 9,2%. Conclusion: New strategy as implementation of vascular resection and reconstruction for treatment of hilar and intrahepatic cholangicarcinoma are safe and can improve resection rate.

Vascular reconstruction in patients with perihilar and intrahepatic cholangicarcinoma.

Background: The aim of this study was to describe safety and possibility of vascular reconstruction in patients with perihilar and intrahepatic cholangiocarcinoma in single hepatopancreatobiliary(HPB) clinic. Methods: 52 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2013 to 2016 were radically operated in HPB department of Moscow Clinical Scientific Center. 16 of those had vascular resection and reconstruction, including vena cava resection in 3 patients, portal vein resection alone in 9 patients, combined hepatic artery and portal vein resection in 3 and hepatic artery resection alone in 1. Results: No significant difference was found in postoperative complications (type III-IV by Clavien-Dindo) between the vascular resection and non-vascular resection group(p>0,05). R0 resection was achieved in 70% that was significantly higher than in previous years. Mortality was 9,2%. Conclusion: New strategy as implementation of vascular resection and reconstruction for treatment of hilar and intrahepatic cholangicarcinoma are safe and can improve resection rate.

Utilization of end to side Inverted Mattress Pancreaticojejunostomy after three different type of pancreatectomy

Introduction: The continuity of pancreatic duct should be established after partial pancreatectomy such as pancreaticoduodenectomy and central pancreatectomy. It is also required after distal pancreatectomy if the drainage of pancreatic juice is impaired like Duval procedure. However pancreaticojejunostomy after any type of partial pancreatectomy accompany considerable risk of seriously life threatening complication such as grade B and C POPF despite various techniques of pancreaticojejunostomy (PJ) were devised to minimize the rate of POPF. Method: We presented a modification of Mattress PJ named “Inverted Mattress PJ” and published improved outcome after pancreaticoduodenectomy and central pancreatectomy in the aspects of POPF. Additionally, we present the utilization of Inverted Mattress PJ to establish the continuity of pancreatic duct after distal pancreatectomy. Result: Usually, PJ is not required after distal pancreatectomy because pancreatic juice can be drained through ampulla of Vater. However in particular condition in which the drainage of pancreatic juice through proximal duct is impaired by stricture, or stone etc, the distal pancreatic duct need to be drained. In such a case of IPMN of distal pancreas with proximal pancreatic duct obstruction, we performed distal pancreatectomy and pancreaticojejunostomy utilizing Inverted Mattress PJ. The patient was discharged 1 week after surgery without complications. Conclusion: In conclusion, the inverted mattress end-to-side pancreaticojejunostomy is a safe technique after pancreaticoduodenectomy and volume sparing central pancreatectomy and also can be utilized in particular condition after distal pancreatectomy safely.

CURRENT ASPECTS OF DIAGNOSTICS AND TREATMENT OF ACUTE BILLARIAN PANCREATITIS

Relevance. The article is devoted to the problem of diagnosis and treatment of acute biliary pancreatitis, which remains one of the most common surgical diseases of the abdominal cavity and accounts for 33.2% of the total number of patients with acute pancreatitis.
 Objective of the work is to improve the diagnosis and results of surgical treatment of patients with acute pancreatitis of biliary etiology.
 Materials and methods. The results of treatment of 264 patients with acute pancreatitis of biliary etiology are analyzed. Operative treatment was applied in 92 (34,8 %) patients: endoscopic operations were performed in 44 patients (16,7 %). Thus, in 10 (3,8 %) patients, endoscopic papilloprotectomy was performed with the auditory of the duct system and the extraction of concrements. In other cases, organo-preserving intervention was performed without disturbing the morphofunctional integrity of the sphincter apparatus of the duct system: the cannulation in 6 (2,3%) patients, mechanical (balloon) in 5 (1,9 %) cases, pharmacological (myogenic antispasmodic) dilatation of distal duct and a large duodenal papilla in 11 (4,2 %) patients. In residual choledocholithiasis, a technique of papillotomy under the control of choledochoscopy was proposed – 12 (4,54 %) patients. A comparative analysis of the effectiveness of the treatment of patients who used the "open" (comparative group) and noninvasive endoscopic interventions in the early disease (the main group) was performed.
 Results. So in the main group the length of stay in the hospital was 12±3,2 days, respectively, in the comparison group – 26±4,3 days. In 42 (95,4 %) patients who had undergone endoscopic surgery, a positive clinical effect, a rapid regress of the symptoms of acute pancreatitis was achieved. In two (4,5 %) patients in the main group, the course was complicated by the development of the abscess of the stuffing box, and puncture under ultrasound control was performed. In patients of the comparison group complications arose in 5 (41,6 %) patients, it is noteworthy that all of them had undergone operative interventions, which were limited only to the rehabilitation and drainage of the abdominal cavity, a stuffing box bag. The mortality rate among unopposed was 1,2 % (2 patients), and among the operated – 11,9 % (11 patients). Among prooperated patients who died, 81,8 % (9 people) were elderly patients.
 Conclusions. The use of minimally invasive endoscopic interventions in the early phase of the disease reduces the length of stay of patients in the hospital from 26±4,3 days (comparison group) to 12 3,2 days (main group) and the number of complications occurring by 37,1 % (P <0, 05). Application of the proposed method of papillotomy under the control of choledochoscopy makes it possible to reduce the risk of perforation of the wall of the duodenum with the development of peritonitis or retroperitoneal phlegmon by 1,2 % (P <0,05).

Distribution of abalone egg-laying hormone-like peptide in the central nervous system and reproductive tract of the male mud crab, Scylla olivacea

The mud crab, Scylla olivacea, is a high value economic marine animal in Thailand. However, collection of these crabs from natural habitat for local consumption and export has caused rapid population decline. Hence, aquaculture of this species is required and to this measure understanding of endocrine control of their reproduction must be understood. Egg laying hormone (ELH) is a neuropeptide synthesized by the bag cells (neurons) in the abdominal ganglia of Aplysia gastropods. It plays a critical role in controlling egg production and laying in gastropods, and its possible homolog (ELH-like peptide) was reported in the neural and ovarian tissues of prawns and recently in female reproductive tract of the blue swimming crab, Portunus pelagicus. In this study, we have studied the histology of the male reproductive tract in Scylla olivacea which are comprised of anterior testis, posterior testis, early proximal spermatic duct (ePSD), proximal spermatic duct (PSD), middle spermatic duct (MSD) and distal spermatic duct (DSD), by immunohistochemistry, detected an abalone ELH- immunoreactivity (aELH-ir) in epithelium of ducts in posterior testis and epithelium of all parts of spermatic duct. Furthermore, we could detect aELH-ir in neurons of cluster 9, 11, olfactory neuropil (ON) in the brain and in the small neurons located between the third and the fourth thoracic neuropils (T3-T4) and between the fourth and the fifth thoracic neuropils (T4-T5) of thoracic ganglia. Thus, the presence of aELH in male S. olivacea was designated the role of female egg laying behavior in the male mud crab.

Endoscopicretrograde cholangio-pancreatography management of long-term complications after pancreaticoduodenectomy

Objective: To investigate the feasibility and effectiveness of endoscopicretrograde cholangio-pancreatography(ERCP)in the management of long-term complications after pancreaticoduodenectomy. Methods: From January 2009 to July 2018, the clinical data of 62 patients with biliary or pancreatic long-term complications after pancreatoduodenectomy were reviewed at Department of General Surgery, and the corresponding ERCP were carried out in the multi-disciplinary cooperation.There were 39 males and 24 females.The age was 56.5 years(aging from 13 to 76 years). The time of treatment was 3 months to 20 years after pancreatoduodenectomy.The long-term biliopancreatic complications after pancreatoduodenectomy included 51 cases of biliary calculi, 42 cases of bilioenteric anastomotic stenosis with proximal bile duct dilatation, and 11 cases of pancreaticointestinal anastomosis stenosis with distal pancreatic duct dilatation.All patients received conventional duodenoscopy or single-balloon enteroscopy assisted ERCP under general anesthesia. Results: A total of 95 ERCP were performed in 62 patients, averaging 1.5 times per case.The long-term complications of cholangiopancreatic after pancreatoduodenectomy(ERCP indications) included 56 times of bile duct stones(58.9%), 45 times of bilioenteric anastomatic stricture(47.4%), 11 times of recurrent pancreatitis(11.6%), 6 cases(6.3%) of bilioenteric anastomatic foreign body, 3 times of intrahepatic bile duct stenosis(3.2%). Among the 95 times, 82 times(86.3%) achieved endoscopic endoscopy, 76 times(80.0%) were diagnosed successfully, and 72 times(75.8%) were successfully treated with ERCP.Small intestinal perforation occurred in 1 patient undergoing duodenoscopy, and then healed by surgical repair. Conclusion: Multi-disciplinary collaboration of ERCP is safe and effective in the treatment of long-term complications after pancreaticoduodenectomy, but the long-term effect still needs further clinical follow-up.