Delayed postpancreatectomy hemorrhage as the role of endovascular approach:Four case reports

BACKGROUND Pancreatic resection is still associated with high morbidity rates and delayed postpancreatectomy hemorrhage(PPH)is the most feared complication as it may lead to hemorrhagic shock or serious septic complications.Today,endovascular approach represent safe and efficient method for minimally invasive management of extraluminal PPH.CASE SUMMARY We describe four patients whose postoperative recovery after pancreatic resection was complicated by postoperative pancreatic fistula(POPF)and visceral artery hemorrhage.In all cases endovascular approach was utilized and it resulted in satisfactory outcomes.We discuss modern diagnostic and therapeutic approach in this clinical scenario.CONCLUSION PPH is relatively uncommon,but it is a leading cause of surgical mortality after pancreatic surgery.Careful monitoring and meticulous follow-up are required for all patients post-operatively,especially in the case of confirmed POPF,which is the most significant risk factor for the development of a PPH.Angiography as a diagnostic and therapeutic method may be an optimal first-line treatment for the management of delayed PPHs.In our experience,endovascular treatment for hemorrhagic complications of pancreatic resections has shown satisfactory results.

Reversible lesions in the brain parenchyma in Wilson's disease confirmed by magnetic resonance imaging:earlier administration of chelating therapy can reduce the damage to the brain

The aim of this study was to evaluate the resolution of brain lesions in patients with Wilson’s disease during the long-term chelating therapy using magnetic resonance imaging and a possible signiifcance of the time latency between the initial symptoms of the disease and the introduction of this therapy. Initial magnetic resonance examination was performed in 37 patients with proven neurological form of Wilson’s disease with cerebellar, parkinsonian and dystonic presentation. Magnetic resonance reexamination was done 5.7 ± 1.3 years later in 14 patients. Patients were divided into： group A, where chelating therapy was initiated 〈 24 months from the ifrst symp-toms and group B, where the therapy started≥ 24 months after the initial symptoms. Symmetry of the lesions was seen in 100% of patients. There was a signiifcant difference between groups A and B regarding complete resolution of brain stem and putaminal lesions （P= 0.005 andP=0.024, respectively）. If the correct diagnosis and adequate treatment are not established less than 24 months after onset of the symptoms, irreversible lesions in the brain parenchyma could be ex-pected. Signal abnormalities on magnetic resonance imaging might therefore, at least in the early stages, represent reversible myelinolisis or cytotoxic edema associated with copper toxicity.

Approach to persistent ascites after liver transplantation

Persistent ascites(PA)after liver transplantation(LT),commonly defined as ascites lasting more than 4 wk after LT,can be expected in up to 7%of patients.Despite being relatively rare,it is associated with worse clinical outcomes,including higher 1-year mortality.The cause of PA can be divided into vascular,hepatic,or extrahepatic.Vascular causes of PA include hepatic outflow and inflow obstructions,which are usually successfully treated.Regarding modifiable hepatic causes,recurrent hepatitis C and acute cellular rejection are the leading ones.Considering predictors for PA,the presence of ascites,refractory ascites,hepatorenal syndrome type 1,spontaneous bacterial peritonitis,hepatic encephalopathy,and prolonged ischemic time significantly influence the development of PA after LT.The initial approach to patients with PA should be to diagnose the treatable cause of PA.The stepwise approach in evaluating PA includes diagnostic paracentesis,ultrasound with Doppler,and an echocardiogram when a cardiac cause is suspected.Finally,a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear.PA of unknown cause should be treated with diuretics and paracentesis,while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.