Patient Cases


The following is a description of the clinical course and recovery of patients with gastrointestinal (GI), pancreatic, liver and gallbladder cancer who underwent surgery.

WHIPPLE SURGERY


WHIPPLE SURGERY (Pancreatic cancer)


A 45 year-old male patient presented with yellow discoloration of eyes and laboratory investigations consistent with obstructive jaundice. CT scan demonstrated a periampullary mass with a classic double duct sign (Figure 1). Upper GI endoscopy confirmed an ampullary tumor and biopsy was positive for adenocarcinoma or cancer (Figure 2). A Whipple surgery (pancreaticoduodenectomy) was performed. The patient had an uncomplicated postoperative recovery and was discharged home on postoperative day six on a normal diet. His final pathology demonstrated a pT1N1M0 adenocarcinoma of the ampulla with vascular invasion and adjuvant (postoperative) chemotherapy was recommended.

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DISTAL PANCREATECTOMY


DISTAL PANCREATECTOMY (Pancreatic cyst)


A 67 year-old female presented with upper abdominal pain since six months. An upper GI endoscopy was unremarkable and a 1.2 cm cyst in the body of the pancreas was seen on ultrasound and CT scan (Figure 1). On endoscopic ultrasound the cyst was abutting the main pancreatic duct and the aspirated cyst fluid demonstrated a markedly elevated CEA level at 28,000 suggestive of a mucinous cyst. A distal pancreatectomy was performed. Postoperative recovery was uncomplicated and the patient was discharged home on postoperative day five on a normal diet. The final pathology demonstrated a mucinous cystadenoma (a premalignant tumor) as shown in Figure 2 and 21 benign lymph nodes.

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BILIARY BYPASS


BILIARY BYPASS / ROUX-EN-Y HEPATICO-JEJUNOSTOMY (Chronic pancreatitis)


A 47 year-old deeply jaundiced female presented with long-standing diabetes mellitus, right upper abdominal pain and a weight loss of 10 kg. Blood tests demonstrated a total bilirubin of 20.4 mg% and CA 19-9 tumor marker level of 890 U/ml. An outside CT scan was reported as suspected pancreatic head cancer. A dedicated pancreatic CT scan demonstrated chronic atrophic calcific pancreatitis, distal biliary stricture and no evidence of pancreatic cancer. A Roux-en-Y hepaticojejunostomy (biliary bypass) was performed. Her postoperative recovery was unremarkable and she was discharged home on postoperative day four on a normal diet with progressive normalization of serum bilirubin and CA 19-9.

TOTAL GASTRECTOMY


TOTAL GASTRECTOMY (Stomach cancer)


A 26 year-old female underwent an upper GI endoscopy for hematemesis (vomiting of blood) which demonstrated a 2.5 cm gastric ulcer. Biopsy was positive for a signet-ring adenocarcinoma. CT scan demonstrated a thickened stomach wall (Figure 1) and endoscopic ultrasound staging of the tumor was uT3N1. She received 3 cycles of preoperative chemotherapy followed by total gastrectomy and D2 lymphadenectomy. Her postoperative recovery was uncomplicated and she was discharged home on postoperative day ten on a normal diet without need for nutritional supplementation via the jejunostomy tube. CT scan on the day of discharge was unremarkable (Figure 2). Final pathology demonstrated poorly differentiated adenocarcinoma, 36 lymph nodes negative for metastases and tumor stage ypT1aN0M0. She subsequently received adjuvant chemotherapy.

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LEFT ADRENALECTOMY


LEFT ADRENALECTOMY (Adrenal tumor)


A 46 year-old female was referred with complaints of left backache and increase in the size of a left adrenal mass on CT scan (Figure 1). She underwent a left adrenalectomy with an uneventful postoperative course. She was discharged home on postoperative day three and a CT scan performed on postoperative day ten was unremarkable (Figure 2). Final pathology demonstrated a 2.2 cm adrenocortical tumor with capsular invasion and negative margins (Figure 3).

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RIGHT HEMICOLECTOMY


RIGHT HEMICOLECTOMY (Colon Cancer)


Figure 1

A 46 year-old female was admitted with abdominal pain and emesis. CT scan demonstrated a tumor of the mid-transverse colon and colonoscopy confirmed adenocarcinoma on biopsy (Figure 1). An extended right hemicolectomy was performed. Postoperative recovery was uncomplicated and the patient was discharged home on a normal diet on postoperative day four. Final pathology demonstrated moderately differentiated adenocarcinoma of the colon, no lymphovascular invasion, 38 lymph nodes negative for metastases, pT3N0M0, Stage II colon cancer. She successfully completed adjuvant (postoperative) chemotherapy and remains tumor-free two years since surgery.

RADICAL CHOLECYSTECTOMY


RADICAL CHOLECYSTECTOMY (Suspected gall bladder cancer)


A 56 year-old male with gallbladder adenomyomatosis was referred with progressive increase in size of a gallbladder mass on abdominal ultrasound. CT scan and MRI were unable to definitively rule out the presence of gallbladder cancer (Figure 1). Duplex ultrasound also demonstrated hypervascularity of the gallbladder nodule (Figure 2). A radical cholecystectomy including the gallbladder with en bloc resection of liver segments 4b, 5 and a regional lymph node dissection was performed. His postoperative recovery was uncomplicated and he was discharged home on postoperative day five. Final pathology demonstrated gallbladder adenomyomatosis (Figure 3).

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PARTIAL HEPATECTOMY


PARTIAL HEPATECTOMY (Liver cyst)


A 50 year-old male presented with complaints of right upper abdominal pain since six months. A CT scan and MRI were consistent with a simple cyst of the left liver complicated by intracystic hemorrhage (Figure 1-2). Given the symptomatic nature of the cyst and presence of hemorrhage a partial hepatectomy (left lateral sectionectomy) was performed. Postoperative recovery was uncomplicated and he was discharged home on postoperative day three on a normal diet. Final pathology confirmed hemorrhage in a simple benign cyst of the liver (Figure 3).

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