Background and Clinical Significance: Ganglioneuromas are rare benign tumors of neural crest origin, with gastrointestinal involvement being uncommon and ampullary localization exceptionally rare. Pancreatic neuroendocrine tumors (NETs) are also uncommon neoplasms with variable biological behavior. The coexistence of these two entities is unusual, particularly in the absence of an identifiable hereditary syndrome. Case Presentation: A 38-year-old man presented with hematemesis and multiple episodes of melena over 18 h and was found to have significant anemia with borderline hemodynamic stability. Upper gastrointestinal endoscopy revealed an enlarged, actively bleeding papilla of Vater, and initial hemostasis was achieved with adrenaline injection and endoscopic clipping. However, recurrent massive bleeding developed within 36 h, accompanied by hemodynamic instability. Repeat endoscopy confirmed ongoing hemorrhage, and the patient subsequently underwent emergency pancreaticoduodenectomy. Histopathological examination demonstrated an ampullary ganglioneuroma and an incidental well-differentiated pancreatic neuroendocrine tumor (WHO Grade 2). Surgical margins were negative, and no lymph node metastases were identified. Further evaluation for hereditary endocrine syndromes was unremarkable. The patient remains asymptomatic, with no evidence of recurrence during a 10-year follow-up period. This case highlights the diagnostic and therapeutic challenges associated with rare periampullary tumors. Although ganglioneuromas are typically benign, their anatomical location may result in severe clinical manifestations such as life-threatening bleeding. The coexistence with a pancreatic NET raises questions regarding potential shared pathogenesis, although no genetic syndrome was identified. Limitations of endoscopic management in uncontrolled bleeding and the importance of definitive surgical intervention are emphasized. Conclusions: This case highlights an exceptionally rare coexistence of ampullary ganglioneuroma and pancreatic neuroendocrine tumor presenting with life-threatening gastrointestinal bleeding. Although ganglioneuromas are benign, their anatomical location may result in severe clinical manifestations. Early recognition and decisive surgical management are crucial when endoscopic control fails. Favorable long-term outcomes can be achieved following complete resection.

Background: Pancreaticopleural fistula is a rare complication of chronic pancreatitis resulting from pancreatic duct disruption, typically presenting with pleural effusion and predominant respiratory symptoms. Bilateral pleural involvement is exceptionally uncommon and poses significant diagnostic and therapeutic challenges. Case Presentation: A 56-year-old man with a history of chronic alcohol abuse presented with progressive dyspnea and mild epigastric pain. Imaging revealed bilateral pleural effusions, an atrophic pancreas with a markedly dilated main pancreatic duct containing calculi, and a fistulous tract extending from the pancreatic body through the esophageal hiatus into the mediastinum. Magnetic resonance cholangiopancreatography confirmed the diagnosis of chronic calculous pancreatitis complicated by a pancreaticopleural fistula. After unsuccessful conservative management, the patient underwent distal pancreatectomy, resection of the fistulous tract, and Roux-en-Y pancreatojejunostomy. The postoperative course was uneventful, with complete resolution of pleural effusions and sustained clinical improvement. Conclusions: This case highlights the importance of considering pancreaticopleural fistula in patients with unexplained pleural effusions and minimal abdominal symptoms, particularly in the context of chronic pancreatitis. Bilateral involvement, although rare, should not preclude timely diagnosis. Appropriate diagnostic studies by computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography are crucial for establishing the diagnosis. Surgical management offers definitive treatment in patients with ductal obstruction and calculous disease, resulting in excellent long- term outcomes.

BACKGROUND:The main complications of hepatic hydatid disease are infection and rupture into the biliary tree or into the peritoneal cavity. Fungal infections within the biliary tract and the liver are very rare, whereas cases of hepatic echinococcal cysts infected by fungi have not been previously reported. CASE PRESENTATION:We report on a 63-year-old male patient with a 3-day history of dull, non-radiating pain in the right hypochondrium, low-grade fever, and malaise. His past medical history included a Roux-en-Y hepatico-jejunostomy and gastro-enteroanastomosis for locally extended adenocarcinoma of the intra-pancreatic common bile duct. Laboratory analyses showed elevated WBC and C-reactive protein levels. The computed tomography scan showed an infected hydatid cyst grade CE5 according to Gharbi's and WHO classifications. Catheterization was performed, and cultures revealed Candida glabrata. Anidulafungin was initiated with a loading dose of 200 mg, followed by a daily dose of 100 mg. After 23 days, cultures of the draining fluid showed no fungi or other bacteria. Two days later the catheter was removed, the patient was discharged, and at the time of follow-up at 1 and 2 months, remained well. CONCLUSION:Fungal infections should be considered in patients with an infected echinococcal cyst of the liver. Understanding of the etiology and epidemiology, along with early and rapid detection of C. glabrata, is necessary for prompt treatment.

BACKGROUND:Actinomycosis is a chronic inflammatory condition caused by Actinomyces israelii or other Actinomycetes species, with primary abdominopelvic involvement being the most important form of the disease, especially when there is splanchnic infiltration. In cases of colonic involvement, the disease is often misdiagnosed as a neoplasm by imaging studies, and surgery is undertaken. CASE PRESENTATION:We report the case of a 48-year-old male living in a rural area in whom a computed tomography (CT) scan showed a large, irregular abdominopelvic mass infiltrating the urinary bladder, the left ureter, and the sigmoid colon with luminal obstruction. He was referred with the presumptive diagnosis of abdominal sarcoma for surgical evaluation and treatment. He underwent a Hartmann's procedure with resection of the sigmoid colon and formation of an end colostomy. Multiple tissue samples were taken from the mass for histopathological examination. The correct diagnosis was made after pathological examination by detection of actinomycetes colonies. Penicillin-based therapy was commenced and continued for six months, when a CT revealed complete resolution of the pre-operative findings without any evidence of a mass. CONCLUSION:Although rare, actinomycosis should be considered in the differential diagnosis of colonic neoplastic lesions. Proper long-term antibiotic treatment is necessary for complete eradication of the infection and resolution of tissue alterations.

Objective: Impairment of the Fas/FasL apoptotic pathway is a mechanism contributing to the malignant transformation of multiple cell types. This study aimed to investigate the clinical and prognostic relevance of serum soluble Fas (sFas) and soluble Fas ligand (sFasL) levels in patients with pancreatic and papilla of Vater adenocarcinomas. Methods: An ELISA was used to determine sFas and sFasL levels. Serum samples were obtained from 53 healthy controls, 82 pancreatic and 14 papilla of Vater carcinoma patients. Sera from carcinoma patients were obtained before surgery and 30 days after surgery. The relationships of preoperative levels with clinicopathological features and patient survival were evaluated. Changes in serum sFas and sFasL levels after surgery were also evaluated. Results: Higher sFas and lower sFasL levels were found in the serum of carcinoma patients in comparison to healthy controls. Serum sFas and sFasL levels correlated significantly with both lymph node and distant metastases and an advanced stage of disease. Elevated sFas and decreased sFasL levels correlated significantly with poor overall survival when the entire study population was considered with sFas being an independent prognostic factor. After patient stratification, their prognostic value was evident in pancreatic carcinoma patients only. Preoperative sFas levels decreased and sFasL levels increased after radical resection of the tumor but remained unchanged in cases of unresectable disease. Conclusions: These findings suggest that serum levels of sFas and sFasL could be useful tumor markers with prognostic value in pancreatic adenocarcinomas. Increased sFas secretion may reflect a mechanism for apoptotic escape of cancer cells.

Arteriovenous malformation is a rare disease characterized by abnormal vascular connections between arteries and veins. The condition may remain asymptomatic until complicated by hemorrhage. We present a case of arteriovenous malformation in the pancreatic head complicated by upper gastrointestinal bleeding, which was successfully treated by selective transarterial embolization. A 62-year-old man presented with mild epigastric pain and several episodes of melena. Colonoscopy and upper gastrointestinal endoscopy were not diagnostic. Contrast-enhanced computed tomography revealed abnormal enhancement with multiple vascular branches in the pancreatic head, with early enhancement of the portal venous system in the arterial phase, suggesting the presence of an arteriovenous malformation. Selective angiography revealed an enlarged gastroduodenal artery feeding the malformation and subsequently draining into the portal venous circulation. Embolization of the gastroduodenal artery and of other small branches from the superior mesenteric artery resulted in complete obliteration of the feeding arteries and drainage veins. There was no bleeding recurrence, and the epigastric pain resolved. This case report demonstrates that selective transarterial embolization is a feasible and effective procedure for the treatment of a bleeding pancreatic head arteriovenous malformation.

Pneumatosis intestinalis (PI) is a rare condition characterized by gas-filled cysts within the wall of the gastrointestinal tract with variable presentation. We present two patients with pneumatosis intestinalis different in their clinical presentation, clinical course, and treatment. A 79-year-old male with a history of chronic obstructive pulmonary disease presented with an acute abdomen. Clinical findings and abdominal radiography suggested perforation of the digestive tract. During emergency laparotomy, multiple cystic bubbles and perforation were found in the terminal ileum, and the affected part of the ileum was resected. The second patient was a 64-year-old female under adjuvant chemotherapy with cisplatin and paclitaxel for ovarian adenocarcinoma. She presented with signs of bowel obstruction. Abdominal computed tomography was diagnostic for intestinal pneumatosis. She was successfully treated conservatively. These two cases highlight the varied clinical presentation of pneumatosis intestinalis and differences in its treatment. High clinical suspicion, cautious judgment of clinical and laboratory findings, and careful assessment of the imaging findings are necessary for accurate diagnosis and appropriate management.

This study describes a case of an 80-year-old patient admitted to our hospital with mid-epigastric pain, nausea, vomiting, and persistent fever for the last two days, after an episode of acute gallstone pancreatitis six weeks earlier. On admission, the patient was clinically stable with leukocytosis, high serum amylase levels, and high CRP levels. An abdominal CT scan showed a well-circumscribed, thick-walled fluid collection with air-fluid levels suggestive of an infected pancreatic pseudocyst. The patient underwent exploratory laparotomy in which fluid aspiration, removal of necrotic tissue, placement of drainage tube, and cholecystectomy were performed. Cultures from the pseudocyst revealed Candida glabrata. Antibiotics were discontinued, and intravenous antifungal therapy with anidulafungin was initiated at a loading dose of 200 mg, followed by a maintenance dose of 100 mg daily. The patient's condition improved shortly thereafter, with resolution of fever and normalization of laboratory tests. After three weeks of antifungal therapy, with no positive cultures from the drainage tube and no pathological findings on repeat CT, the patient was discharged from the hospital. He was doing well at six- and 12-month follow-ups.

The mechanism by which laparoscopic operations induce lower post-operative inflammatory response compared to open surgery was investigated with regard to the effect of the type of gas environment. Rats were subjected to midline laparotomy at either CO2 (group CO2) or room-air environment (group Air) or to anesthesia only (group Control) under atmospheric pressure conditions. At various timepoints after surgery (1, 3, 6, 24, or 48 h), the expression of inflammation biomarkers interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and nuclear factor-κΒ (NFκΒ) were assessed immunohistochemically in tissue samples excised from the liver, intestine, and kidneys, accompanied by histopathologic analysis, and their levels were measured by ELISA in blood samples. Tissue expression of IL-6, TNFα, and NFκΒ was downregulated in the liver and intestine in group CO2 compared to group Air and in the kidneys in group Air compared to group CO2. However, no differences were noted among groups regarding the histopathologic score of organ tissues and the blood serum levels of inflammation biomarkers. Post-operative local inflammatory response was lower in intra-peritoneal organs of rats subjected to laparotomy at CO2 rather than room-air environment under atmospheric pressure conditions.

Intestinal obstruction after ingestion of foreign bodies is a rare condition. A wide variety of ingested foreign bodies has been reported as a cause of mechanical small bowel obstruction, with ingested fruit pits being rarely reported as causes of intestinal obstruction. Here, we report the case of a 70-year-old female diagnosed with intestinal obstruction due to swallowed olive pits tightly impacted in the distal ileum. A conclusive diagnosis was made preoperatively by computed tomography of the abdomen. After initial conservative treatment, the patient underwent laparotomy because of persistent obstruction. The ingested pits were removed through an enterotomy and the obstruction was successfully resolved.

Clear cell pancreatic carcinoma, as a primary lesion, represents a rare malignant entity with very few references. As for the incidence, the clinical characteristics and the prognosis are still to be defined. Here, we present the case of a 73-year-old female who presented with epigastric pain radiating to the back, anorexia, and dyspepsia. Abdominal computed tomography (CT) showed a well-circumscribed, low-attenuating tumor with peripheral enhancement, arising from the upper border of the pancreatic head. There were no metastases or other primary tumors. Radical resection of the tumor was undertaken. Histopathology showed round-to-oval neoplastic cells with a well-defined cell membrane, prominent cell borders, abundant clear cytoplasm, and centrally located nuclei. The periodic acid-Schiff reaction was positive and a diagnosis of primary clear cell pancreatic carcinoma was made. No adjuvant treatment was given. She remained under regular follow-ups with abdominal and thoracic CT scans for seven years without evidence of recurrence of other primary tumors. She was deceased 87 months after tumor resection because of conditions unrelated to the disease. This is the first case to the best of our knowledge, of long-term survival after radical resection of a primary pancreatic clear cell carcinoma, suggesting surgery as a treatment option for this rare tumor and review of the relevant literature.

Introduction: Pancreatic cancer is the most fatal cancer type in the world. Its high mortality is mostly correlated to the absence of symptoms and the difficulty in early diagnosis, which in the majority of the cases occurs when the disease has already spread metastasis. Nowadays, tests that could predict early diagnosis are not available yet and the number of prognostic tests is limited. Hence, there is an urgent need for biomarkers capable of detecting early development or the rapid progression of the disease. Patients and Methods: DNA methylation represents the most frequent epigenetic event among tumor suppressor genes that are involved in various carcinogenic pathways. In the recent study we have tried to evaluate, for the first time, the prognostic value of BRCA1 and BRCA2 methylation in the cell-free DNA of pancreatic cancer patients. Using methylation-specific real-time PCR we examined the methylation status of BRCA1 and BRCA2 in 55 patients with operable and 50 patients with metastatic pancreatic cancer. In the operable disease setting, BRCA1 was found to be methylated in 33/55 (63.5%) patients examined while BRCA2 was also highly methylated in 31/55 (56.3%). In the metastatic disease, BRCA1 was found to be methylated in 26/50 (52%) while BRCA2 was found methylated in 23/50 (46%). Results: All control samples were negative for BRCA1 orBRCA2 promoter methylation. Patients with operable pancreatic cancer and a methylated BRCA1 and BRCA2 promoter status had a statistically significant poorer outcome as compared with patients with a non-methylated one (p=0.012 and p=0.001, respectively). Conclusion: In this study plasma methylation of BRCA1 and BRCA2 represents a frequent event in both the operable as well as in the metastatic setting. BRCA1 and BRCA2 methylation was significant and correlated with decreased survival in patients with operable pancreatic cancer. A larger cohort of patients is required to further explore the potential of these findings as well as to investigate whether BRCA1/2 methylation in plasma could serve as a potential prognostic biomarker in pancreatic cancer.

BACKGROUND:Radiofrequency-assisted liver resection (RF-LR) techniques minimize intraoperative blood loss, while avoiding the Pringle maneuver. Both surgical excision and radiofrequency ablation of liver parenchyma compromise gut barrier function with subsequent bacterial translocation. The present study sought to investigate in a porcine model the impact of two RF-LR techniques on the integrity and inflammatory response of the gut barrier.METHODS:Twenty-four pigs were subjected to either (a) partial hepatectomy (PH) employing the "sequential coagulate-cut" technique using a monopolar electrode (SCC group), the one using the bipolar Habib-4X device (group H), or the "crush-clamp" technique (group CC) or (b) sham operation (group Sham). At 48-h post-operation, ileal tissue was excised to be subjected to histopathologic examination, histomorphometric analysis, and immunohistochemical assessment of the mitotic and apoptotic activities and the expression of interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and nuclear factor-κB (NFκΒ).RESULTS:Histopathologic score increased in all PH groups, being higher in group SCC, while lower in group H. Villous height decreased in group SCC only. Mitotic index decreased, while apoptotic index increased in all PH groups. An increase in tissue expression score was noted for IL-6 in group CC, for TNFα in all PH groups, being lower in group H compared to group CC, and for NFκB in all PH groups.CONCLUSIONS:The Habib-4X technique for liver resection proved to preserve the integrity of gut barrier, being less injurious in the intestinal mucosa compared to the SCC and CC techniques.

Epigenetic modification of several genes is a key component in the development of gastric cancer. The methylation status of RASSF1A , SOX17 and Wif-1 genes was evaluated in the cell free circulating DNA of 70 patients with advanced gastric cancer, using methylation-specific PCR. Patients with higher cell-free DNA concentration seem to have lower PFS, than patients with lower cell-free DNA concentration (p = 0.001). RASSF1A was the tumor suppressor gene, most frequently methylated in metastatic gastric cancer patients, followed by SOX17 and Wif-1 (74.3%, 60.0% and 47.1%, respectively). Patients having the SOX17 promoter methylated, had lower progression free survival and overall survival, than unmethylated ones (p < 0.001). Patients having the Wif-1 promoter methylated, had lower progression free survival and overall survival, than unmethylated ones (p = 0.001). Patients having the RASSF1A promoter methylated, had lower progression free survival and overall survival, than unmethylated ones (p = 0.004). Promoter methylation of the examined genes was significantly associated with a decrease in progression free survival and overall survival, comparing to that of patients without methylation. Simultaneous methylation of the above genes was associated with even worse progression free survival and overall survival. The methylation of RASSF1A , SOX-17 and Wif-1 and genes, is a frequent epigenetic event in patients with advanced gastric cancer.

Introduction. Common hepatic artery is one of the three branches of Haller tripod and gives rise to the left and right hepatic arteries. We describe the case of a 62-year-old woman with the right hepatic artery rising from abdominal aorta, diagnosed incidentally during an abdominal computed tomography angiography. Case report. The common hepatic artery was absent. In its place, the left hepatic artery originated from the celiac trunk, while the right replaced hepatic artery was observed arising directly from the abdominal aorta. Conclusions. The uncommon abnormal vascular pattern presented has not been yet classified as an anatomic variation. Such arterial aberrations should be considered by surgeons during cholecystectomy, liver transplantation and pancreatectomy, to avoid complications.

In pancreatic cancer resection, when primary portal vein reconstruction (PVR) fails, small bowel oedema will increase until a new, successful PVR is performed. To decrease venous occlusion time, a quick interposition grafting procedure is proposed. The picture shows a bifurcated prosthesis bridging the gap between the distal vein inflow (superior mesenteric vein [SMV], first jejunal branch [JB1], and inferior mesenteric vein [IMV]) and the proximal portal vein (PV) outflow. SMV to right (R) Dacron limb and PV to Dacron body end to end anastomoses are performed initially, partially restoring the venous circulation (left limb clamped), while the common JB1 and IMV trunk to left (L) Dacron limb end to end anastomosis is performed last.Image 1