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.

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.

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.

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.

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.

Abernethy malformation: Single-center experience from India with review of literature.

Abernethy malformation is a rare congenital anomaly in which there is direct communication between the portal and systemic venous circulation. The clinical presentation ranges from asymptomatic with incidental detection on imaging to secondary complications of disease or related to associate anomalies. This is a retrospective analysis of data from nine patients with Abernethy malformation at a single center. This is a referral center for Pediatric Cardiology and for Hepatobiliary and Pancreatic Surgery. The patients presented to the Pulmonary Hypertension Clinic/the Hepatobiliary Surgery Clinic. Out of nine patients, four were male. Type II Abernethy malformation was present in five patients whereas three patients had type I malformation. One of the patients had communication between inferior mesenteric vein and internal iliac vein. Five out of nine patients were erroneously diagnosed as idiopathic primary pulmonary hypertension and were treated with vasodilators. One patient required living donor liver transplant. One patient was managed with surgical shunt closure whereas two patients required transcatheter shunt closure. The rest of the patients were managed conservatively. Abernethy malformation is more common than previously thought and the diagnosis is often missed. There are various management options for Abernethy malformation, which includes surgical or transcatheter shunt closure and liver transplant. Management of Abernethy malformation depends upon type, presentation, and size of shunt.

Peritoneo-cutaneous fistula from spilled gall bladder calculus following laparoscopic cholecystectomy.

Inadvertent spillage of gall stones is a rare yet important cause of delayed postcholecystectomy complications. Varied presentations and difficulty in diagnosis are the hallmarks, making it crucial to have a high index of suspicion to detect and intervene appropriately. Peritoneo-cutaneous fistulae from the retained stone can be completely excised in toto.

Isolated primary tuberculosis of spleen-A rare entity in the immuno-competent patient.

INTRODUCTION: Tuberculosis is a global public health concern, with 9.6 million affected individuals worldwide. Current screening and diagnostic regimes focus primarily on smear positivity, and hence, the rising numbers of Sputum negative and Extra-Pulmonary Tuberculosis has become a significant set-back to adequate diagnosis, disease notification and treatment, due to the large number of false negatives. PRESENTATION OF CASE: We hereby describe an intriguing presentation of tuberculosis - A 23 yr old lady with no comorbid illness, came to us with ten month history of on and off pyrexia, weakness and left hypochondriac pain. On evaluation, two isolated hypodense lesions in the spleen were detected. Diagnostic laparoscopy and Splenectomy were performed and histopathology revealed features of primary tubercular abscess. DISCUSSION: Commonly, abdominal visceral involvement is seen as a part of miliary tuberculosis in the immuno-compromised patient. However, in the absence of any co-morbidity and preserved immune function, this case depicts the rare possibility of primary isolated Tubercular splenic abscess in the normal healthy individual. CONCLUSION: We require a close eye and a keen sense of clinical acumen to accurately diagnose and treat smear negative and uncommon forms of Tuberculosis. Considering the growing prevalence and difficulty in disease control, there is need for greater knowledge and awareness to help mitigate the global burden of Tuberculosis.

Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD-First report from India.

Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m2 within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.