Neuroendocrine Carcinoma of the Colon: Emergency Presentation of a Rare Disease With Poor Biology.

Neuroendocrine tumors (NETs) are rare entities. Most common among them are gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and pulmonary NETs. Most of them are indolent in nature. Colonic NETs are rare among GEP-NETs and mostly present with large size and with metastasis. Emergency presentation with hematochezia is rare in colonic NETs. This case report discusses a rare emergency presentation of colonic NETs and highlights their poor biological nature.

PD-L1 Expression in colorectal carcinoma and its correlation with clinicopathological parameters, microsatellite instability and BRAF mutation.

CONTEXT: : Programmed cell death ligand-1 (PD-L1) is the key inhibitor of the cytotoxic immune response thus causing progression of tumors and adverse prognosis in many malignancies. OBJECTIVE: The current study investigates PD-L1 expression in colorectal carcinoma and its correlation with clinicopathological parameters, microsatellite instability, and BRAF mutation. MATERIAL AND METHODS: 110 cases of colorectal carcinoma were evaluated for PD-L1 expression using SP263 clone in tissue microarray. Clinico-pathological characteristics and survival data were correlated with PD-L1 expression analyzed at different cut-offs of ≥1%, ≥10% and ≥50% in tumor cells and tumor infiltrating lymphocytes along with its correlation with BRAF expression and microsatellite instability status in these cases. RESULTS: Mean age was 49 years with male to female ratio of 1.5:1. 52.7% cases presented with stage 3/4 disease and 14.7% with >10 cm tumor size. Tumor cells expressed PD-L1 in 40% and TILs in 45.4% cases at a cut off of ≥1% was 17.3%, at ≥10% was 15.5% and at ≥50% was 7.3%. Significant association was seen between tumor proportion score (TPS) and increasing age, histological type, histological grade, tumor size, higher T stage (p = 0.03), TILs (p = 0.04), lymph vascular invasion, and perineural invasion. PDL-1 correlated with BRAF expression and microsatellite instability (MLH-1/PMS-2 expression loss). The overall survival was significantly higher (p < 0.001) with negative PDL1 expression in cases of colorectal carcinoma. CONCLUSIONS: Immunotherapy may be used as potential therapeutic option in colorectal carcinoma cases showing microsatellite instability and BRAF mutations which show poor response to conventional chemotherapy regimen and anti-EGFR therapy.

Microsatellite Instability in Sporadic Colorectal Malignancy: A Pilot Study from Northern India.

BACKGROUND: Three molecular pathways are described as the genetic basis of colorectal tumorigenesis. Among these, microsatellite instability (MSI) has shown greatest promise in serving as a biomarker to determine disease aggression by tumour biology, recurrence, and response to chemotherapy. METHODOLOGY: This prospective observational pilot study included patients of colorectal cancers, in a population subset coming to a tertiary care hospital in northern India, who were operated with curative or palliative intent over a period of one year and followed up for a maximum of 55 months. The post-operative pathological assessment was done for MSI status using PCR technique, and an attempt was made to evaluate its correlation with conventional clinical and histological parameters, early recurrences, disease-free survival and overall survival in comparison to MSS type tumours in sporadic cases of colorectal malignancies. RESULTS: Out of 38 patients of colorectal cancer, 26 were included in the study. Male to female ratio was 7:6 (n=14:12). Mean age of presentation was 48±14.2 years. Incidence of MSI was n=4 (15.4%). On subgroup analysis, age of presentation (p=0.044) and evidence of perineural invasion (p=0.017) was found to have significant statistical association with MSI tumour biology. Recurrence was seen in seven of the seventeen patients who previously had no synchronous or metastatic disease (41.2%). The mean disease-free survival for MSS was 21.32 months and was 25.25 months for MSI group which was statistically insignificant (p = 0.277). Out of four MSI tumour biology patients one was alive and without recurrence at 47 months. While the other two were alive and without recurrence till 27 months of follow-up.   Conclusion: Age and perineural invasion showed statistically significant association with MSI tumour biology. Due to the small sample size statistical significance was not established with site, recurrence rate, DFS and OS.

Polymeric locking clips [Hem-o-lok] versus Metallic clips in elective Laparoscopic Cholecystectomy: A Retrospective study of 1496 patients.

Background Laparoscopic cholecystectomy is one of the most commonly performed operation. Various methods for securing the cystic artery and cystic duct are described in literature. We aim to compare intra-operative and early post-operative outcomes of laparoscopic cholecystectomy using polymeric locking Hem-o-lok clips versus metallic ligaclips . Patients and Methods Retrospective study of prospectively maintained single institutional data including all consecutive patients who underwent elective laparoscopic cholecystectomy from 2013 to 2018. Patients in whom metallic ligaclips were used were grouped as Group I and those with Hem-o-Lok were grouped as Group II. The early post-operative outcomes of the two groups were compared. Results Total 1496 patients were included in the study; 836 patients in Group I and 660 in Group II. Study included 29.1% males and 70.9% females with mean age of 43.6 years. Hem-o-lok clip was better in securing wide cystic duct compared to metallic clips. Metallic clip failed to secure 8 out of 44 wide cystic duct compared to 0 out 70 with Hem-o-lok clips (p=0.002). The post-operative outcomes of both groups were comparable. There were no cystic duct leak, post- operative bleeding or major bile duct injuries in either group. Conclusion Use of Hem-o-lok clip is safe in laparoscopic cholecystectomy due to ease of application and security. Hem-o-lok is more useful in patients with thick and wide cystic duct which are difficult to secure with metallic clips with low risk of leak. Key words: Laparoscopic Cholecystectomy, Hem-o-lok clip, Metallic clip, Wide cystic duct.

Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience.

Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.

Incidental Gallbladder Carcinoma in Gallbladder Polyps: Challenges of Gallbladder Malignancy for an Endemic Population.

BACKGROUND: Gallbladder polyps are considered pre-malignant lesions of gallbladder carcinoma. This study aims to highlight the role of early cholecystectomy in the management of gallbladder polyps in an endemic population. METHODS: A retrospective analysis of 2,076 lap cholecystectomy procedures performed at the Department of Surgical Gastroenterology at a tertiary referral centre in Northern India was conducted and incidental malignancy in gallbladder polyps analysed. The 8th edition of the American Joint Committee on Cancer for tumour-node-metastasis (TNM) staging of gallbladder carcinoma was used. RESULTS: Of 54 patients with gallbladder polyps, 53 had benign histology and one had malignant cells in the lamina propria suggestive of T1a adenocarcinoma. The patient with the malignant polyp was older (57 years old) than the patients in the non-cancer group, which had a mean age of 45 (P = 0.039). The size of the malignant polyp was approximately 4 mm, significantly smaller than the average 7.9 mm size of the benign polys (P = 0.031). CONCLUSION: Cholecystectomy needs to be considered early in the management of small-sized gallbladder polyps, particularly in areas endemic for gallbladder carcinoma.

Factors predicting recovery of liver function after percutaneous drainage in malignant biliary obstruction: the role of hospital-acquired biliary sepsis.

AIM OF THE STUDY: Prolonged cholestasis adversely affects liver function. Hepatic functional recovery is mandatory prior to any surgical or medical intervention. Serum bilirubin levels correlate well with, and are a surrogate marker for, hepatocyte function. We aimed to ascertain factors responsible for slow decline of bilirubin and delayed recovery of liver function following percutaneous drainage in malignant biliary obstruction. MATERIAL AND METHODS: Sixty-seven patients with malignant jaundice who underwent percutaneous biliary drainage (PTBD) were followed until they achieved target bilirubin ≤ 3 mg/dl. According to duration, patients were divided into early (≤ 6 weeks, n = 43) and late (> 6 weeks, n = 24) groups. Various clinical, tumour-related and procedure-related factors were analysed for their contribution to delayed recovery with the χ2 or t-test. Multi-variate logistic regression analysis was used to predict independent associations. RESULTS: Gallbladder cancer presenting with type I block was the commonest pathology. Overall demographic, clinical, tumour characteristics and procedural details were comparable between groups. Duration of jaundice (p = 0.026), liver involvement (p = 0.041), baseline total (p = 0.001) and direct bilirubin levels (p < 0.001), positive bile cultures with hospital-acquired bacteria (p = 0.031) were significant factors on univariate analysis. Bacterial growth was significantly greater following repeated biliary manipulations. The commonest organisms were Pseudomonas and Citrobacter spp. Number of re-instrumentations, post-procedural biliary sepsis and native biliary organisms were non-contributory. No factor was significant on multivariate analysis. CONCLUSIONS: Factors directly linked to extent and duration of disease are validated as significant contributors to functional recovery after biliary drainage. Biliary sepsis with hospital-acquired organisms, especially following re-interventions is a significant modifiable risk-factor affecting bilirubin decline.

Is Final Histopathological Examination the Only Diagnostic Criteria for Xanthogranulomatous Cholecystitis?

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an uncommon inflammatory disease of gallbladder (GB) and can mimic GB cancer in extensive form. This study aims to assess the predictability of XGC on the basis of clinical presentation, laboratory tests, and radiological or intraoperative findings on frozen section analysis. MATERIALS AND METHODS: This is a retrospective study, conducted over a period of 4 years from October 2013 to November 2017. In this study, all patients with histopathological reports of XGC, who underwent cholecystectomy or a radical cholecystectomy, were included. Clinical records of these patients were reviewed for clinical features, laboratory tests, and findings on radiological imaging. RESULTS: Out of 700 consecutive cholecystectomies reviewed, 34 had histologically proven XGC (4.85%). Two patients had simultaneous presence of GB carcinoma with XGC. The most common presenting symptoms were right upper quadrant pain in 32 (94%) patients, jaundice in 9 (36%) patients, and fever in 5 (14%) patients. The most common radiological finding was cholelithiasis in 85.2% of cases. Thick-walled GB was present in 79.4% of patients; irregular wall thickening was present in 20.5% of patients. Intramural nodule was present in two patients, whereas hepatic invasion was observed in 11% and pericholecystic infiltration was present in 8.8% of patients. Regional lymphadenopathy was present in 9 (26.4%) patients. CONCLUSION: Clinical presentation and laboratory parameters were unequivocal due to considerable overlap. Despite recent advances in radiology, none have significant sensitivity and specificity to accurately diagnose XGC preoperatively. Intraoperative frozen section can add to the diagnosis with limited accuracy. The diagnosis of XGC can be confirmed only on histopathological examination.

Paraneoplastic Hypoglycaemia: A Rare Manifestation of Pelvic Gastrointestinal Stromal Tumour.

Non-Islet Cell Tumour Induced Hypoglycaemia (NICTH), presenting with recurrent fasting hypoglycaemia is a very rare paraneoplastic syndrome. It usually presents with large metastatic mesenchymal tumours. NICTH secondary to Gastrointestinal Stromal Tumour (GIST) is even rarer. Diagnosis of NICTH is based on the low serum insulin level, low serum concentrations of Insulin Like Growth Factor (IGF-I) and IGF binding protein- III (IGFBP-III) in combination with elevated concentrations of pro-IGF-II. Various Immunohistochemical (IHC) markers are integral to diagnosis of GIST namely 2-deoxyglucose-6-phosphate phosphatase -1(DOG-1), Cluster Differentiation 34 (CD 34), Cluster Differentiation 117 (CD117). The management requires prompt intravenous hydration and glucose infusions followed by surgical resection. We hereby, report a rare case of a 65-year-old female with intractable fasting hypoglycaemia due to overproduction of "big" insulin-like growth factor II diagnosed to have pelvic GIST and managed by Steroids and Imatinib.

Cystic microfilarial infestation of the liver: a rare presentation.

Cystic liver lesions in an adult may occur for a variety of reasons, most of which are benign in nature. Infiltrating benign lesions in the liver parenchyma may pose a clinical challenge in diagnosis and management. In the case presented herein, a cystic lesion adjacent to the gall bladder and involving the liver parenchyma had to be differentiated from gall bladder carcinoma, which is quite common in India. Parasitic infestation of the liver is an extremely rare presentation and may pose a significant challenge in its diagnosis and management. This case highlights an infrequent presentation and the challenges in the clinical approach and subsequent management.

Richter's hernia after an intraperitoneal mesh repair.

For ventral hernia repair, laparoscopic surgery offers various advantages, including the application of a large mesh using the intraperitoneal approach. However, improper closure of the port site may lead to serious complications. Port-site hernia is a rare outcome of inadequate repair of the fascial or peritoneal layer, and Richter's hernia in a high risk patient, in the presence of an intraperitoneal mesh, is a particularly challenging scenario. Herein, we present a 58-year-old woman who, after a ventral hernia repair, was diagnosed with a small bowel hernia through a 10-mm port site. The patient complained of pain and mild swelling at the port site in the postoperative period, and her symptoms indicated intestinal obstruction. Clinical evaluation and abdominal X-ray confirmed the diagnosis, and early laparoscopic re-exploration and management were the key to a favorable outcome.

Abdominal echinococcosis: outcomes of conservative surgery.

BACKGROUND: Hydatid disease, infection with the larval stage of the cestode Echinococcus spp., represents a substantial disease burden worldwide. We report here the outcomes of conservative surgery in patients with abdominal echinococcosis. METHODS: We carried out a retrospective review of patients who underwent conservative surgery for abdominal hydatid disease during the period January 2008 to December 2011. Perioperative outcomes were analysed after a mean follow-up of 24 months (range 6-36 months). RESULTS: Thirty patients (mean age 40.4 years; male:female=7:3) underwent surgery. Most (29 patients) had a hepatic hydatid cyst and underwent partial cystectomy with omentoplasty; surgery was open in 22 cases (73%), laparoscopic in six cases (20%) and laparoscopic converted to open in one case (3%); one patient with a splenic cyst underwent open splenectomy. Cystobiliary communication was present in 10 cases (3%). Postoperative complications included transient biliary leak in two cases (7%), grade 1 surgical site infection in five cases (17%) and respiratory tract infection in three cases (10%), with no mortality. Mean hospital stay was 17 ± 9.2 days. None of the patients had recurrence of disease on follow-up imaging. CONCLUSION: Conservative surgery offers an effective approach for abdominal echinococcosis, with minimal morbidity or recurrence, and is an alternative to radical procedures.

Complications after Frey's procedure for chronic pancreatitis.

BACKGROUND: Frey's operation is indicated on patients with chronic pancreatitis who have "head dominant" disease and involves resection of the head of pancreas and lateral pancreaticojejunostomy (LRLPJ). There is little information about the postoperative complications after this procedure and the factors likely to be responsible for them. This paper addresses this aspect of LRLPJ. METHODS: A retrospective review was made of records of 41 patients undergoing LRLPJ for chronic pancreatitis between January 1990 to June 2003. RESULTS: Sixteen (39%) patients had 19 complications in the early postoperative period; septic complications were the commonest. One patient died. Regression analysis showed preoperative endoscopic pancreatic stenting to be the factor responsible for majority of these complications (P = 0.0041). Patients with a history of pancreatic stenting had a prolonged hospital stay (P = 0.022). CONCLUSIONS: Postoperative complications after LRLPJ are usually septic in nature and are likely to occur more often in patients in whom endoscopic pancreatic stenting has been performed before surgical intervention.