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.

Neutrophil Lymphocyte Ratio can Preempt Development of Sepsis After Adult Living Donor Liver Transplantation.

Background: Development of sepsis is a major contributor to poor outcomes after liver transplant. The neutrophil-lymphocyte ratio (NLR) is an easily calculable inflammatory biomarker. We aim to utilize NLR to diagnose and predict the onset of sepsis in patients undergoing living donor liver transplants (LDLT). Materials and methods: Analysis of the perioperative course of 314 consecutive adult patients who underwent elective ABO compatible LDLT was done. Patients were divided into two cohorts; those who developed sepsis and a control group. Sepsis was defined by the combination of SIRS and clinical/radiological suspicion of infection. NLR was calculated by dividing the percentage of neutrophils by the percentage of lymphocytes in peripheral blood. Results: ostoperatively, 127 out of 314 patients (40.5%) having at least one episode of sepsis were included in the septic cohort and were compared to the 187 (59.5%) patients in the control group. Demographic and baseline characteristics, including NLR (13.74 ± 0.99 vs. 12.65 ± 0.57, P = 0.294) were comparable preoperatively. The NLR of the septic cohort was significantly higher than the control cohort (15.01 ± 1.67 vs. 9.98 ± 0.63, P = 0.001) 3 days prior to sepsis and remained significantly higher till the day of sepsis. The area under the cover was maximum for NLR 1 day prior to the development of sepsis (r = 0.707) with a sensitivity, specificity, positive predictive value, and negative predictive value of 62.4%, 62.2%, 51.4%, and 72.0%, respectively, at a cutoff of 8.5. Conclusion: NLR is a useful tool in diagnosing and pre-empting development of sepsis in LDLT.

Pancreas-preserving limited duodenal resection: Minimizing morbidity without compromising oncological adequacy.

Backgrounds/Aims: Pancreaticoduodenectomy is the most common procedure for the management of duodenal pathologies. However, it is associated with substantial morbidity and a low risk of mortality. Pancreas-preserving limited duodenal resection (PPLDR) can be performed under specific scenarios. We share our experience with PPLDR and its outcome. Methods: We retrospectively analyzed a prospectively maintained database of patients undergoing limited duodenal resection in the form of wedge (sleeve) resection or segmental resection of one or more duodenal segments from March 2016 to March 2021 at a tertiary care center in North India. Results: During the study period, 10 patients (including 9 males) underwent PPLDR. Five of these 10 patients showed primary duodenal or proximal jejunal pathology, while the remaining five had duodenal pathology involving an adjacent organ tumor. Four patients underwent wedge (sleeve) resection, while the remaining six underwent segmental duodenal resection of one or more duodenal segments. Mean hospital stay was 6 days (range, 3-11 days) without 30-day mortality. Morbidity occurred in 4 patients (Grade I-II, n = 3; Grade III, n = 1). All patients were alive and disease-free at the time of last follow-up. The mean follow-up duration was 23 months (range, 2-48 months). Conclusions: PPLDR is a safe and effective alternative for pancreaticoduodenectomy when selected carefully for specific tumor types and location.

Impact of human leukocyte antigen compatibility on outcomes of living donor liver transplantation: Experience from a tertiary care center.

INTRODUCTION: The role of HLA compatibility in kidney, heart, and stem cell transplantation is well known, but with regard to living donor liver transplantation (LDLT), there is a different scenario. In the present study, we aim to examine the effects of donor-recipient HLA mismatches at A, B, and DR loci on various outcomes of LDLT-like graft survival, early allograft dysfunction (EAD), acute rejection, length of hospital (LOH) stay, sepsis, and cytomegalovirus (CMV) reactivation. METHODS: This is a retrospective single center study of a cohort of adult patients who underwent first time ABO-compatible (ABOc) LDLT between January 2010 and December 2018. Transplants with incomplete records or without HLA typing data were excluded. Donor-recipient HLA-A, B, and DR mismatches were assessed in the host versus graft (HVG) direction and were correlated with various post-transplant outcomes. RESULTS: Among 140 transplants being evaluated, approximately two third had total HLA mismatches between 2 and 3. HLA mismatches at each locus as well as cumulative HLA mismatches did not show any association with overall graft survival, EAD, acute rejection episodes, and LOH stay. However, the presence of minimum one mismatch at HLA-A and DR loci was associated with the development of CMV reactivation (P = .03) and sepsis (P = .02) post-LDLT respectively. CONCLUSION: HLA mismatch is not associated with acute rejection, early graft dysfunction, and overall survival in LDLT. Its impact on CMV reactivation and sepsis needs further evaluation.

Effects of preoperative statin on liver reperfusion injury in major hepatic resection: a pilot study.

UNLABELLED: During major liver resection, ischemia reperfusion injury occurs resulting in adverse outcome. Animal studies have demonstrated the beneficial effect of statins on hepatic ischemic injury, but no clinical studies have been performed. Twenty consecutive patients undergoing major hepatic resection were included and were randomized into two groups. The study group (n = 10) patients received oral atorvastatin 40 mg for 3 days prior to surgery, including the day of surgery, and the control group (n = 10) received a placebo. Outcomes were assessed at 4, 24, and 72 h by measurement of serum liver enzymes and cytokines-IL-1, IL-6, CRP, and TNF α. The two groups were evenly matched for demographic and perioperative variables. The AST levels were significantly higher in the control group compared with the study group at 4 h (909.60 ± 222 vs. 362.6 ± 129 U/L), 24 h (215.30 ± 86.9 vs. 605.30 ± 186.1 U/L) and 72 h (84.30 ± 32.7 vs. 204.70 ± 67.5) (p < 0.001). Plasma IL-1 values in the study group showed significantly lower values compared with the control group (p < 0.001) postoperatively. Plasma IL-6 values postoperatively showed significantly lower mean values as compared with the mean of the control population (p < 0.001). TNF α values at 4, 24, and 72 h postoperatively comparable in the two groups (p = 0.011) (p = 0.096) and (p = 0.237), respectively. Statins have the potential for pharmacological prevention of IRI. Further studies would be needed to substantiate the role of statins in prevention of IRI during liver resection. CLINICAL TRIAL REGISTRATION: PGIMER, Chandigarh-NK/1081/MS/12182-83.