1. Duodenum preserving pancreatic head resection
Department of Surgery
Yonsei University College of Medicine

2. 박 O 선 (F/26) Chief Complain Present illness Family history
Known pancreatic mass
Present illness
상기 26세 여환 2011년 1월 Acute pyelonephritis로 타병원 evaluation중 abdominal ultrasonography상 mass 관찰되어 further evaluation 위해 시행한 CT에서 pancreatic head mass 관찰되어 치료위해 내원함
Family history
작은아버지 – HCC

3. Review of System Generalized weakness(-) Fever/chill (-/-)
Headache/dizziness (-/-)
Cough/sputum (-/-)
Dyspnea/chest pain (-/-)
Anorexia/nausea/vomiting (-/-/-)
Constipation/diarrhea (-/-)
Abdominal pain/abdominal discomfort (-/-)
Dysuria/oliguira/hematuria (-/-/-)
Poor oral intake(-)
Weight loss/weight gain (-/-)

4. Physical examinations
General appearance :
Not so ill-looking appearance
Skin : warm & dry
Skin turgor : good
HEENT
Not icteric sclear
Not pale conjunctiva
Neck
Supple
No palpable cervical LNs
Chest/lung
Clear breath sound
No wheezing/ronchi
Heart
RHB without murmur
Abdomen
Soft/slight distended
Palpable mass ; 6cm sized, round, smooth surface(RUQ)
Tenderness (-)

5. Laboratory study CBC 8108(70%) > 13.6 < 371k T.bil 0.4
OT/PT 14 / 8
Albumin 4.7
CEA 0.83 CA

6. CT abd + pel
10.0 x 7.7cm septated cystic and solid mass in pancreas head portion. Septal calcifications and internal hemorrhage. The mass abuts duodenum. No pancreatic duct or bile duct dilatation. IMP) R/O SPT or MCN in pancreas head portion.

7. PET-CT ( )
Large cystic mass with solid portions, calcification, and multifocal intense FDG uptake around the pancreas head, suggestive of periampullary cancer. No significant LNE No other abnormal FDG uptake in the rest of imaged body

8. MRCP ( )
About  10cm  multilocular  cystic  mass  with  solid  component 
and  wall  calcification  at  the  head  of  the  pancreas No  node,  no  other  focal  lesion,  no  duct  dilatation
DDx> MCN,  probably  malignant ,  SPN
Mass에  의해  duodenum이  밀려있으며  fat  plane이  소실됨

9. Operation Preop diagnosis Postop diagnosis Operation name
R/O Mucinous cystic neoplasm
R/O Solid pseudopapillary neoplasm
Postop diagnosis
Solid pseudopapillary neoplasm
Operation name
Duodenum preserving pancreatic head resection

10. Operation Duodenum 이나 인접장기에 invasion 소견 보이지 않았으며 주변에 Lymph node들도
Reactive benign 양상
Mesenteric LN, right colic LN : Free from tumor
Portal vein과 pancreas의 superior/inferior border 를 dissection 하고 gastroduodenal artery, right gastroepiploic artery isolation & ligation 함
Treitz ligament에서 distal 10cm부위 jejunum에 서 Roux-en-Y pancreaticojejunostomy
(End to side anastomosis)

11. Pathologic finding
Pathologic diagnosis : Solid pseudopapillary neoplasm of
the pancreas with cystic change and calcification
Size : 10 X 9 X 6 cm
Resection margin : Free from tumor
Lymph node : total (0/23) Free from tumor

12. Progress POD#1~2 POD#3 POD#4~6 v/s stable H/V drain : serous Lab : wnl
Amylase/lipase: 6627/>6000
Lab : wnl
POD#3
H/V drain : serous 100cc
Amylase/lipase: 1976/>6000
L-tube removal
POD#4~6
v/s stable
H/V drain : serous 200cc
Amylase/lipase: 38 / 60
Diet build up
Nausea/vomiting (-/-)

13. Progress POD#7 POD#10 v/s stable Diet tolerable CT f/u
H/V drain removal
POD#10
Small amount of loculated fluid collection
No significant complication