Insulinoma-Accurate Preoperative Localization Is the Key to Management: An Initial Experience.

Insulinoma is the commonest functioning pancreatic neuroendocrine tumor. The only curative treatment is surgical excision after preoperative localization. A retrospective analysis of nine patients (February 2017-June 2020), 2 males and 7 females, was done for clinical presentation, biochemistry, localization methods, intraoperative findings, postoperative outcome, histopathology reports, and follow-up. Techniques for localization of the tumor were pancreatic protocol triple-phase multi-detector computed tomography (MDCT), endoscopic ultrasound (EUS), Ga 68 DOTANOC PET-CT, and Ga 68 NOTA-exendin-4 PET-CT (GLP1R scan). The mean age was 38 (range 20-68) years and mean duration of symptoms 34 (range 8-120) months, and symptoms of Whipple's triad were present in all cases after a supervised 72-h fast. MDCT localized tumor in 8/9 cases. EUS before MDCT in one patient had also localized tumors. Ga 68 DOTANOC PET-CT detected tumor in 2/4 patients. In one patient, MDCT or DOTANOC PET scan could not localize tumor; GLP1R scan localized tumor accurately. Two patients had associated MEN1 syndrome. All 9 patients underwent surgical resection (four open and five laparoscopic) of tumor-enucleation (3), distal pancreatectomy with splenectomy (3), and pancreatoduodenectomy (PD) (3). The last four procedures and all three enucleations were laparoscopic. Five patients developed postoperative pancreatic fistula (POPF), only one grade B which required percutaneous drain placement. One patient, who had initial open enucleation, developed hypoglycemia after 48 h; PD was performed. All patients were cured and all, except one (who died of upper GI bleed), were alive and disease-free during a mean follow-up of 26 (range 2-41) months. Preoperative localization of insulinoma is important and decides the outcome of surgery in terms of cure. MDCT can localize tumors in most patients; the last resort for localization is the GLP1R scan. Laparoscopic procedures are equally effective compared to open surgery. Considering the benign nature of the disease, enucleation is the procedure of choice.

HARTMANN'S PROCEDURE REVISITED.

Between July 1991 and June 1999 out of 176 patients undergoing colonic surgery (elective and emergency), Hartmann's procedure was performed in 63. There were 39 males and 24 females. Mean age was 43 years (range 12 to 81). To assess the utility of Hartmann's procedure the documents of all these 63 patients were retrospectively analysed. In 47 bowel continuity was reestablished. The over all mortality in first stage operation (Hartmann's procedure) was 12.7% and mortality in the second stage procedure (reestablishing bowel continuity) was nil. Complication rate was drastically less in second operation. The authors conclude that Hartmann's procedure is safe and effective while dealing with colorectal pathologies as resection and primary anastomosis is fraught with danger.

Mini-lap cholecystectomy: a viable alternative to laparoscopic cholecystectomy for the Third World?

BACKGROUND: Laparoscopic cholecystectomy (LC) requires expensive equipment and special training. Mini-lap cholecystectomy (MLC) has no start-up costs but no large series from a single centre has been reported as the procedure is considered hazardous because of inadequate exposure of the surgical field. METHODS: We retrospectively reviewed the outcome of 737 cholecystectomies performed through a 3-5-cm transverse subcostal incision and compared the results to published series of laparoscopic cholecystectomy. RESULTS: The operating time (61.6 min; range 35-130), conversion rate (4%), rate of postoperative complications (3.6%), bile duct injuries (0.3%), number of analgesic doses required (3.4; range 3-8), duration of postoperative hospital stay (1.4; range 1-15 days), and the time off work (13.3 days; range 8-61) compare well with the reported results of laparoscopic and MLC. Ninety-three per cent of the patients were followed up for a median period of 28.4 months and none developed biliary stricture. CONCLUSIONS: Mini-lap cholecystectomy is considered a safe, viable alternative to LC in the Third World.

Pitfalls in the management of Mirizzi's syndrome.

Pressure on the common hepatic duct due to a gallstone impacted in Hartmann's pouch or cystic duct results in jaundice and cholangitis. Repeated episodes of inflammation and pressure necrosis lead to the formation of a cholecysto-choledochal fistula (Mirizzi's syndrome Type I & II). Preoperative diagnosis is difficult and a formal cholecystectomy may lead to bile duct injury. Of the 792 patients operated upon for symptomatic gallstone disease from June 1992 to June 1997 at our centre, 18 patients (2%) had Mirizzi's syndrome. There were 11 females and 5 males, with a mean age of 48 (SD 20; range 20-74) years. Thirteen patients (81%) presented with cholangitis. Ultrasound scan suggested the diagnosis of carcinoma gallbladder in 9 (56%). Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed the diagnosis in 16. Cholecystectomy was done by the fundus first technique. A complete cholecystectomy was done only if there was no cholecysto-choledochal fistula (n = 5), otherwise a cuff of gallbladder was used to repair the bile duct (n = 10). Hepatico-jejunostomy was done to drain the fistula in one patient. A T-tube drain was placed in the common bile duct (CBD) and a cholangiogram done, before closing the abdomen in all. Histology revealed carcinoma in fundus of gallbladder in one patient (6%). One patient died of haemobilia 3 weeks after operation. Wound infection developed in 5 (30%) patients and 12 (75%) have been followed up for a median period of 28 months. One patient developed a biliary stricture with intrahepatic stones and later underwent a hepatico-jejunostomy. Two have undergone repair of incisional hernia. High index of clinical suspicion, ERCP to clinch the diagnosis, NBD to drain the infected bile, a fundus first partial cholecystectomy and primary repair of CBD, followed by a peroperative T-tube cholangiogram, usually leads to a satisfactory outcome.

OUR FIRST HUNDRED LAPAROSCOPIC CHOLECYSTECTOMIES.

Hundred patients with symptomatic gallstone disease underwent laparosopic cholecystectomy between June 1996 and August 1997. There were 78 females and 22 males, with a mean age of 46.2 (SD 17.8; range 21 to 85) years. The common presentations were right upper abdominal pain (n=66), acute cholecystitis (n=8) and history of jaundice (n=11). Sixteen patients underwent ERCP for suspected CBD stones. Endoscopic papillotomy and basketing cleared the CBD of all calculi in 12. Three patients required conversion to open cholecystectomy because of dense adhesions (n=2) and to control intraoperative haemorrhage (n=1). Mean operating time was 67.2 (SD 39.2; range 22 to 186) minutes. The mean requirement of analgesics was 2.8 (SD 1.3; range 2 to 5) doses and post-operative hospital stay was 1.6 (SD 1.4; range 1 to 7) days. All patients resumed normal activity within 14 days of operation and are well and satisfied with their operation at a median follow up of 8.6 months.

Synchronous oesophageal carcinoma with non Hodgkin's lymphoma, problems with management.

A case of synchronous malignancy of oesophagus with Non Hodgkin's lymphoma is presented and the rarity of such an association is discussed. The inherent difficulties encountered were initial planning of therapy keeping in view of the general condition of the patient. The patient received three cycles (every 21 days) of CHOP regimen for Non Hodgkin's lymphoma and to maintain a static state of oesophageal cancer. The patient showed more than 75 percent response to NHL counterpart, and for carcinoma oesophagus counterpart short course high dose loco-regional radiation therapy was given and the tumor was found to be resectable.