of fractures, community-acquired pneumonia, bacterial Ruptured with like Salmonella, renal failure, dementia and increased risk of and spontaneous in the setting of bacterial peritonitis in patients with liver .5 Disconnected Pancreatic Duct: A It is also interesting to note that acid-suppressive Surgical Challenge therapy may interfere with the activity of antifungal drugs, a relevant aspect when treating these patients.6 Dhruv Jain1 To conclude, it is likely that there was a synergistic Rajesh Panwar1 increase in the risk of with PPI Kumble Seetharama Madhusudhan2 and antibiotics in our patient. Since the use of both PPI Sujoy Pal1 and antibiotics is common in both out-patient and in- Pramod Kumar Garg3 patient settings, it is essential to recognize and suspect this potential adverse effect, in otherwise immunocompetent 1Department of GI Surgery & Liver Transplantation, 2 3 patients, and also to use the drugs judiciously. Department of Radiodiagnosis, Department of , All India Institute of Medical Sciences, New Delhi, India. References Corresponding Author: Dr Rajesh Panwar 1. Mimidis K, Papadopoulos V, Margaritis V, Thomopoulos K, Email: [email protected] Gatopoulou A, Nikolopoulou V, Kartalis G. Predisposing factors and clinical symptoms in HIV-negative patients with Candida oesophagitis: are they always present? Int J Clin Pract. 2005 Feb;59(2):210-3. The surgical treatment for disconnected pancreatic duct 2. Kim KY, Jang JY, Kim JW, Shim JJ, Lee CK, Dong is difficult, even in the elective setting. Here we describe et al. Acid suppression therapy as a risk factor for Candida a case of DPDS wherein emergency surgery was required. . Dig Dis Sci. 2013 May;58(5):1282-6. This report aims to highlight the clinical and technical 3. Daniell HW Acid suppressing therapy as a risk factor nuances of this tricky situation. for Candida esophagitis. Dis . 2016 Jul;29(5): 479-83. Case Report 4. Vermeersch B, Rysselaere M, Dekeyser K, Rasquin K, De Vos M, Elewaut A, Barbier F. Fungal colonization of the An 18 year-old male was referred to our hospital after esophagus. Am J Gastroenterol. 1989 Sep;84(9):1079-83. having undergone an emergency laparotomy for blunt 5. Vaezi MF, Yang YX, Howden CW. Complications of abdominal trauma two months prior, at another hospital, Proton Pump Inhibitor Therapy. Gastroenterology. 2017 Jul;153(1):35-48. with the details of the procedure and operative findings 6. Ning-Ning Liu and Julia R. Köhler. Antagonism of being unavailable. He was emaciated (Weight:35 Kg, 2 Fluconazole and a Proton Pump Inhibitor against Candida BMI:14.4kg/m ) and had a high output fistula (600 ml/day) albicans. Antimicrob Agents Chemother. 2016 Feb; 60(2): from the midline wound. The patient was evaluated under 1145–1147. the department of gastroenterology, where he was found to be having disconnected pancreatic duct syndrome (DPDS). An Endoscopic Retrograde Pancreatography (ERP) with trans-papillary pancreatic duct stenting was performed. ERP showed leakage of contrast at the level of the neck of , and the distal duct was not opacified (Figure 1). The fistula output remained high even after transpapillary stenting. As the patient was malnourished

Tropical Gastroenterology 37 Vol.40, No.1, January-March 2019 and was in poor general condition, he was started on nasojejunal feeds and was given injection octreotide for 10 days. Following this, the fistula output decreased to less than 200 ml/day, and the patient was discharged on oral feeds. The fistula output further decreased to around 10 ml/day over the next 2 weeks. Around 4 weeks later, the patient presented with a gradually increasing lump in the upper . On further evaluation with Magnetic resonance imaging (MRI), the lump was found to be a pancreatic pseudocyst (Figure 1) for which an endoscopic ultrasound (EUS) guided transmural drainage was done Figure 1: Contrast-Enhanced Computed tomography (at 4 months after the and 2 months after the trans- (CECT) Axial scan (a) and coronal curved reformat papillary stenting). However, soon after the procedure, (b) of pancreas showing laceration in the pancreas the patient worsened with severe pain, tachycardia, and (arrow) with the prominent main pancreatic duct in hypotension. On abdominal examination, the epigastric body and tail regions (arrow heads in b). Endoscopic lump had disappeared, and there was diffuse tenderness. He Retrograde Pancreatography (ERP) image (c) was diagnosed with ruptured pseudocyst with peritonitis showing leakage of contrast and non-opacification of and taken for emergency surgery after resuscitation. the distal duct. Axial balanced spin-echo MR image (d) and MRCP (e) showing collection (C) in the neck At laparotomy, there was around 300 ml of region of pancreas (arrow) communicating (arrow) serosanguinous fluid in the peritoneal cavity with moderate with the prominent main pancreatic duct in body and adhesions. Anterior wall of the pseudocyst, between the tail regions (arrowhead). Labeled D – ; G – stomach and the colon, was thin and flimsy and had a gall bladder. defect through which the contents had escaped into the peritoneal cavity. The stent was seen entering into the cyst through the posterior wall of the stomach. (Figure 2a) After opening the lesser sac, the pancreas was found to be entirely transected with a gap of 2 cm between the proximal and the distal parts. The thin anterior wall of the pseudocyst was excised, and the cyst wall dissected off from the posterior wall of the stomach superiorly and the transverse mesocolon inferiorly. The stent protruding through the posterior wall of the stomach was removed and the gastric opening repaired in two layers. The ductal opening in the distal pancreas was not visible and could be identified only after excavating the parenchyma, analogous Figure 2: Intraoperative photograph (a) and schematic to the technique1 used to locate the duct during surgery for representations (b & c) of the procedure. chronic in patients with small ducts. The duct was then opened longitudinally for 3 cm and a Roux-en Y stenting had already been done. A single drain was placed cysto-pancreatico-jejunostomy performed incorporating near the anastomosis. the remaining cyst cavity into the anastomosis as shown in Figures 2b & 2c. As the transected end of the pancreas Post-operative recovery was uneventful. The was unhealthy, longitudinally opening the duct allowed nasogastric tube was removed on post-operative day us to anastomose to the healthy distal part of the pancreas. (POD) 3, and oral feeding resumed on POD 4. Drain Ductal opening in the proximal pancreas was not sought output was only 50 ml/day but the drain fluid was as the normal passage was intact and papillotomy and high (1477 IU/ml). The patient was discharged on POD7

Tropical Gastroenterology 38 Vol.40, No.1, January-March 2019 with drain in-situ that was subsequently removed 4 weeks References after the surgery since the output was nil for 3 consecutive 1 Izbicki JR, Bloechle C, Broering DC, Kuechler T, Broelsch days. The patient was doing well (weight: 40 Kg, BMI: CE. Longitudinal V-shaped excision of the ventral pancreas 16.4) and had no exocrine or endocrine insufficiency at 6 for small duct disease in severe : months after surgery. prospective evaluation of a new surgical procedure. Ann Surg. 1998; 227: 213–219. 2 Nadkarni NA, Kotwal V, Sarr MG, Swaroop Vege S. Discussion Disconnected Pancreatic Duct Syndrome: Endoscopic Stent or Surgeon’s Knife? Pancreas. 2015; 44: 16–22. DPDS typically occurs as a result of severe acute 3 Devière J, Bueso H, Baize M, Azar C, Love J, Moreno necrotizing pancreatitis or abdominal trauma.2 Most cases E, et al. Complete disruption of the main pancreatic duct: endoscopic management. GastrointestEndosc. 1995; 42: (around 75%) are managed with endoscopic therapy, but 445–451. 3,4 surgical intervention may be required. Surgical options 4 Varadarajulu S, Wilcox CM. Endoscopic placement of include resection of the distal pancreatic segment or permanent indwelling transmural stents in disconnected internal drainage.2 Resection may be the best option for pancreatic duct syndrome: does benefit outweigh the risks? GastrointestEndosc. 2011; 74:1408–1412. transection at the level of the distal body that results in a 5 Howard TJ, Rhodes GJ, Selzer DJ, Sherman S, Fogel small unhealthy distal segment, which may be sacrificed E, Lehman GA. Roux-en-Y internal drainage is the best without consequences. Internal drainage is an attractive surgical option to treat patients with disconnected duct option in patients with a sizeable distal segment and has syndrome after severe . Surgery. 2001; 130: 714-719-721. been shown to be associated with lesser operative time, loss, transfusion requirement, and hospital stay compared with resection.5 A few small series have reported a success rate of 2 up to 90%. Groove Pancreatitis in a Patient It needs to be emphasized that most of the patients in the series mentioned above were operated in with Agenesis of Dorsal Pancreas: the elective setting. Our patient had to be operated in an A one of its kind emergency setting for peritonitis. There was uncontrolled rupture of the cyst into the peritoneal cavity, and the Neha Nischal posterior gastric wall had been breached. Resection was avoided as the transection at the neck of pancreas resulted Sakshi Arya in a sizeable distal segment. Internal drainage is a risky Nayna Goyal option in the emergency and should be considered only Neeraj Wadhwa after careful clinical assessment of the intra-abdominal Sunil Kumar Puri milieu. Creating a pancreatico-enteric anastomosis in Department of Radiology, GB Pant Institute of the setting of inflammation and friable tissues can be Postgraduate Medical Education and Research disastrous as the leakage of enteric contents may result in (GIPMER), New Delhi, India. severe septic complications. In such situations, external drainage may be the best option to tide over the initial Corresponding Author: Dr Neha Nischal crisis, and pancreatic leakage may be dealt with at a later Email: [email protected] date electively when the local inflammation has settled. We chose to do internal drainage as our patient was stable, and the surgery was performed within 6 hours of cyst Developmental anomalies of the pancreas are well rupture due to which there was minimal contamination, known. However, complete agenesis of the dorsal and the tissues were not inflamed or friable. pancreas is an extremely rare malformation. These

Tropical Gastroenterology 39 Vol.40, No.1, January-March 2019