A young man in his 40s was evaluated in the emergency department for abdominal and right flank pain. A CT scan of the abdomen and pelvis showed a solid, well-circumscribed lesion measuring 7.1×8.1×5.4 cm, which was arising from the retroperitoneum and extending from the third portion of the duodenum towards the right kidney. A percutaneous core biopsy was obtained, demonstrating an atypical smooth muscle neoplasm suggestive of a low-grade leiomyosarcoma. The patient underwent surgery for an en-block resection of the mass and the final pathology confirmed a perivascular epithelioid cell neoplasm without significant pleomorphism, mitosis or necrosis. Our case adds to the small number of perivascular epithelioid cell tumour cases reported in the literature and we present it in order to increase our understanding of this tumour and to assist in its appropriate diagnosis and management.

Patient: Male, 62-year-old Final Diagnosis: Lymphangioma Symptoms: Asymptomatic • incidental finding Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: Lymphangiomas are rare and benign malformations of the lymphatic system. The presentation of intra-abdominal lymphangiomas, especially from within the hepatoduodenal ligament, is rare in the adult population. In this report, we examine a lymphangioma within the hepatoduodenal ligament resulting in biliary obstruction. Case Report: A 62-year-old man with surgical history of cholecystectomy presented to the hepatobiliary clinic for a peri-hilar cystic lesion identified on surveillance magnetic resonance imaging (MRI). The patient’s MRI revealed a 5.5-cm cystic lesion at the peri-hilar region, likely arising from the biliary tree, which had been increasing in size and causing biliary dilatation. The patient underwent an endoscopic ultrasound, showing a 4.3×2.2 cm cystic structure likley arising from the cystic duct stump with internal septation. An endoscopic retrograde cholangiopancreatography (ERCP) was performed and demonstrated no communication between the biliary tree and the cystic lesion. Given the uncertain etiology of the lesion and its obstructive nature, the patient was moved to the operating room for a complete excision. A well-encapsulated cystic lesion was identified between the cystic duct and the common hepatic duct, which did not communicate with the biliary tree. Pathology confirmed the diagnosis of lymphangioma with features of vascular channel proliferation in the background of fibrotic stroma and lymphoid aggregates. The vascular channel proliferation demonstrated positive immunohistochemical staining for D2-40. At 3-year follow-up, there was no evidence of post-resection recurrence. Conclusions: This case represents an acquired lymphangioma occurring as a sequela of cholecystectomy, likely caused by interruption of the lymphatic drainage system secondary to surgical manipulation.

No abstract

Objective: Describe the surgical technique used in our hospital. Methods: Surgical technique.The patient is positioned in reverse Trendelenburg. Pneumoperitoneum 15 mmHg, 10 mm optical 30 , three 5 mm trocars and two trocars 12 mm. Harmonic Scalpel is used as an energy device, clips to vessels and section between clips. Extended Kocher maneuver releasing the entire duodenum to the angle of Treitz, to expose vena cava. Gastrocolic ligament section. Dissection through hepatoduodenal ligament and hepatic pedicle, dissection and distal bile duct section. Transection of stomach at antrum level. Transection of jejunum, 10 cm from the Treitz. Section of the gastroduodenal artery. Blunt dissection below the pancreatic neck and the superior mesenteric vein, creating a retropancreatic tunnel, pancreatic section with harmonic scalpel. Child Reconstruction (modified technique). Hepaticojejunostomy and pancreatojejunostomy anastomosis with continuous suture plane, gastrojejunostomy using stapler. The surgical specimen is removed through a suprapubic incision. Results: This is our inicial seri with good results. Conclusion: Laparoscopic pancreaticoduodenectomy should be performed in centers with training in advanced laparoscopic surgery. The advantage of this approach includes less operative bleeding and early recovery, with morbidity and mortality equivalent to the open technique.