IPEG 2024 Round Table Discussion from East Asia - Dr. Wataru Mukai

So next presentation would be the Doctor Wataru Mukai, talking about uh So hi everyone. Uh, my name is Doctor Mukai from OAM Japan. First, I'd like to, uh, send my gratitude to the chair and all the commentators allowing the, uh, allowing me to be, uh, sharing this case. And my case, uh, is, uh, not in surgery, neither, uh, hepatobiliary case, but I hope you can enjoy. So let's start the case. I have nothing to disclose. The case is a 6-year-old boy. His chief complaint was abdominal pain, continuous for 3 consecutive days. He was operated by us for urinal stenosis 3 days after he was born. His abdomen was slightly rigid with the gastric tenderness. Alas was elevated to 1200 units per liter. Abdominal sononography showed uh dilation of pancreatic duct up to 5.6 millimeter and isoechoic mass, uh, suspecting pancreatic lift was found. So, um, I was talking about the, uh, abdominal US, right? And next slide is enhanced CT CT scan and also MR MR cholangiography, uh, uh, chorangiopancreatography, uh. Showing that multiple pancreat lifts. With an abnormal duct. And this is the diagram which I drew of this confusing pancreatic duct malformation. It's main and accessory that are shaping like barbecue fork with branch connecting posteriorly. We first treated him conservatively, conservatively, but defeated pancreatitis. Also asked gastroenterologists for an ERCP, but it didn't work because of dense pancrelith obstructing the orifice. So, uh, first discussion is what is the treatment option? I will show you the video, uh, this runs very quickly, so please don't blink. Um, We chose the lithotomy considering minimal damage comparing to other surgical options. So I opened the pancreatic ducts, opened the duodenum, pulled out the tube through the pancreatic duct. And removed all the pancreat live. Place a tube through both major and minor duodenal papillae into the hepatic ducts. Then they close the pancreatic duct and pancreas covered with omentum. Then closed the duodenum and ended the surgery. The pancreatis was just like uh what we say, protein plug, uh, when, when we use the CFP. Polydocal cysts. So, um, interoperative contrast study, uh, shows the, uh, pancreatalis was removed perfectly and MRCP after 6 months showing that there is no recurrence of pancreatitis. So, um, I would like to accept any comments throughout treatment, any surgical options that, uh, maybe anyone suggests, and I want to ask, um, any suggestions for preventing recurrent panylo. Thank you very much. Thank you, Doctor Mackay. Great presentations. OK, can we, this is the poll for this presentation. Treatment for the symptomatic pancreatis. Revision. So stone removal with a stent. Pancreato diorectomy. And the surgery or others. I think this is one of the toughest situation, toughest cases for us. I may personally do the same way as Dr. Mukai does. You know, stone removal or making the otomy for the. To remove the stone and leave the stent. But we haven't treated the malformation, so maybe the Calculus recurs, right? So is there any way of preventing the recalculating. Any comments from the commentators? The first operation of duodeno duodenal stenosis is duodenostomy, isn't it? Uh, yes, uh, what we say the a diamond shaped anastomosis, so, but in the, in the picture, in your picture, you, you didn't, uh, draw the udontanus Tommy, so it's a little bit different. Of course, uh, I forgot to mention about the, uh, theodemodule stomy, uh, in the, uh, my figure. That's correct. But um In the surgery, I uh we opened up the duodenum and we didn't see any strictures or any um I mean, I. Anastomotic sites in the past. We can con uh confirm that my question is the patient have a duo duodenal stomy over their annular pancreas, so. Do you have any difficulty to uh cut the find the uh pancreatic duct because the in front of the pancreas the duodenum is loc duodenoduum is duodenal duodenostom is located. OK. So, um, I checked the past record, um, medical record about the first surgery, but, um, It said that it was annual pancreas, but in the surgery, I couldn't see any annual pancreas, and both duct was just opening like normal. Um, the first one was just beside the bile duct, and the second one was just, uh, anal side to the first one. So we couldn't tell what was the um What the site, the major pilla and the minor pilla was. Separated, but we just done the contrast study and just checked how it runs. I have one. Yes, please. Yes, I, I have a more comment. I, I think it is presumed that there was a definite, uh, issue, uh, with the drainage of pancreatic juice leading to the pancreatitis. From my, uh, little experiences, there is a possibility of uh developing, uh, necrotizing pancreatitis due to recurrent pancreatoliissis, so. The, which ultimately leading uh necessary uh pseudocysto degenostomy. So, uh, and you need to close follow-up uh for the occurring of a necrotizing pancreatitis or uh developing of a recurrent pancreatitis. And next, the surgical option can be, uh, the pancreatico rjanostomy or other drainage surgery is my recommendation. Thank you. Yeah, I think this is a tough situation for everyone. OK, thank you, Doctor Makay. Quick question before, uh, I had, uh, somebody was complimenting you in the chat. Uh, what camera do you use to record the video? It looked really good. For an open procedure. Oh, it's, it's a, um, Sony made, uh, 4K camera. And you just put it on top of a yes, exactly. Pretty good. Thank you very much. Glad to hear that. OK. Thank you, Dr. Makay.