Elastography for Evaluation of Regression in Liver Fibrosis After Surgical Biliary Drainage for Benign Biliary Strictures: A Practical Possibility?

BACKGROUND: Hepatic fibrosis and secondary biliary cirrhosis are consequences of long-standing benign biliary strictures. Evidence on the reversibility of fibrosis after the repair is incongruous. METHODOLOGY: A prospective observational study on patients who underwent Roux-en-Y hepaticojejunostomy for benign biliary stricture. A liver biopsy was performed during repair and correlated with preoperative elastography. The improvement in liver functions and regression of fibrosis was compared with preoperative liver function tests and elastography. RESULTS: A Total of 47 patients [mean age-38.9 y (Range: 21 to 66)] with iatrogenic benign biliary stricture were included. A strong female preponderance was noted. High strictures (type III and IV) comprised 72.7% of the study group. The median interval (injury to repair) was 7 months (2 to 72 mo). The median duration of jaundice was 3 months (1 to 20 mo). Both factors had a significant correlation with the stage of fibrosis ( P =0.001 and P =0.03, respectively). Liver biopsy revealed stage I, II, III, and IV fibrosis in 26 (55.3%), 11 (23.4%), 2 (4.3%), and 2(4.3%), respectively. The remaining 6 (12.8%) had no fibrosis. The severity of fibrosis had a good correlation with preoperative liver stiffness measurement-value on FibroScan. Significant improvement in liver function tests (bilirubin-3.55±3.48 vs. 0.59±0.52; Albumin-3.85±0.61 vs. 4.14±0.37; ALP-507.66±300.65 vs. 167±132.07; P value 0.00) and regression of fibrosis (liver stiffness measurement; 10.42±5.91 vs. 5.85±3.01, P value 0.00) was observed after repair of the strictures. CONCLUSION: Improved biliary function and regression of liver fibrosis can be achieved with timely repair of benign biliary stricture and it is feasible to be evaluated using elastography.

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center.

BACKGROUND/PURPOSE: Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period of six-years at our tertiary care center. METHODS: Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24 hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. RESULTS: Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5 g/dL vs. 1.5 g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged. CONCLUSION: Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.

Inhibitor development in mild haemophilia after a major surgery for periampullary cancer (Whipple's procedure) in an elderly man.

Around the world, with the availability of factor concentrates, patients with haemophilia have undergone major and minor surgeries. Inhibitor development in early postoperative period leading to inadequate factor recovery and ongoing bleeding is a nightmare for both operating surgeon as well as haematologists. We describe a case of an elderly man with mild haemophilia A, who was diagnosed with pancreatic carcinoma and underwent Whipple's procedure. After an uneventful procedure, he developed high-titre inhibitors and bleeding a week after surgery posing major challenges in his management. The case highlights the importance of experienced surgeons, trained haematologists, regular monitoring of factor assay/inhibitors, adequate factor and bypassing-agent support while performing such procedures.

Incidental peritoneal tuberculosis: surgeon's dilemma in endemic regions.

BACKGROUND: Peritoneal tuberculosis has varying clinical manifestations. The study was conducted to highlight the entity of incidental peritoneal tuberculosis. Diagnostic and therapeutic dilemma is likely to occur on detection of unexpected peritoneal nodules. MATERIALS AND METHODOLOGY: Incidental peritoneal tuberculosis was defined as peritoneal tuberculosis (peritoneal tubercles or ascites) detected intraoperatively in patients undergoing surgical exploration for other indications with no preoperative suspicion of abdominal tuberculosis or active tubercular lesions anywhere in the body. Retrospective analysis of patients operated in our department from June 2016 to November 2017 was performed. RESULTS: Of the 409 patients operated, 5 patients (1.2%) had incidental peritoneal tuberculosis. The primary indication of surgery was laparoscopic cholecystectomy in three, restoration of bowel continuity in one and laparoscopic appendectomy in one. Two patients had remote history of antitubercular therapy for pulmonary and nodal tuberculosis, respectively. The three patients planned for laparoscopic cholecystectomy had their procedures deferred on suspicion of peritoneal carcinomatosis. Subsequently, all the three underwent cholecystectomy after completion of antitubercular treatment. None of the resected specimen (gallbladder/appendix/colon) had evidence of tuberculosis (acid fast bacilli positive or caseating granuloma). Antitubercular treatment for 6 months was completed in all the patients with active peritoneal disease. CONCLUSION: Incidental peritoneal tuberculosis represents an uncommon form of peritoneal tuberculosis. Absence of prior tuberculosis does not preclude the diagnosis of peritoneal tuberculosis. In an endemic region of tuberculosis, surgeons must be aware of the entity on encountering such finding. Frozen section can help in guiding appropriate management.

Surgery for Abdominal Tuberculosis in the Present Era: Experience from a Tertiary-Care Center.

BACKGROUND: The role of surgery in abdominal tuberculosis is being redefined, as many patients will be candidates for endoscopic dilatation rather than open surgery. METHODS: A retrospective analysis was done of the surgical procedures performed in patients with abdominal tuberculosis in a large tertiary-care center in North India. Details such as clinical presentations, previous history of tuberculosis, any anti-tubercular therapy (ATT), Mantoux skin test results, and the surgical procedures and findings were recorded. Short-term outcomes also were analyzed. RESULTS: Thirty-five patients (26 male) were included, and the median age at presentation was 24 years (range 12-80 years). Sixteen patients had received prior ATT for abdominal tuberculosis. The indication for surgery was intestinal obstruction, perforation, and bleeding in 23 (66%), 10 (29%), and 2 (6%) respectively. Twenty-eight patients had intestinal strictures, with the ileum being the most common site (n = 21). Perforation was present in 10 patients, of which six had multiple perforations. Cocoon abdomen was present in four patients, two of whom had associated small-bowel stricture. Among 33 patients who underwent bowel resection, 14 had ileo-cecal resection/right hemicolectomy. The rest had small-bowel resection. Primary anastomosis and stoma creation was performed in 12 (36%) and 21 (64%), respectively. Post-operative intra-abdominal collections (p = 0.02) and incision dehiscence (p = 0.05) were more common in patients having stoma creation. CONCLUSION: Surgical intervention is warranted in a subset of patients with abdominal tuberculosis and may be required in patients with recurrent intestinal obstruction or pain, intestinal perforation, or gastrointestinal bleeding.

Tuberculosis of Gal-Blader Mimicking Malignancy - A Case Report.

A correct preoperative diagnosis of gall-bladder tuberculosis is exceptionally unusual in the absence of pathognomic features both on clinical presentation and on imaging. Herein we present a case of 50 year female who was operated with a provisional diagnosis of gall-bladder malignancy and was found to have tuberculosis of gall-bladder on histopathology.

Gallbladder tuberculosis camouflaging as gallbladder cancer - case series and review focussing on treatment.

INTRODUCTION: Gallbladder tuberculosis, in an endemic region, is a common infectious etiology affecting a rare organ. The high prevalence of carcinoma gallbladder in the endemic regions of tuberculosis, like India, poses diagnostic dilemma. CASE SERIES: We are reporting three cases of gallbladder tuberculosis mimicking carcinoma gallbladder of which the first two cases were operated with a presumptive diagnosis of malignancy. The third case presented to us after laparoscopic cholecystectomy elsewhere and on evaluation was found to have disseminated tuberculosis. DISCUSSION: The lack of pathognomonic clinical and radiological characters results in histological surprise of gallbladder tuberculosis following surgery performed for other indications like malignancy. In preoperatively diagnosed patients medical management plays pivotal role in management. Surgery is required in symptomatic patients. On the other hand, histologically proven cases following surgical resection require antitubercular therapy. CONCLUSION: Previous history of tuberculosis or concomitant tuberculosis at other sites may provide clue to the diagnosis of biliary tuberculosis. Antitubercular treatment after surgery plays an important role in preventing further dissemination.