Long-term outcomes of laparoscopic longitudinal pancreatojejunostomy and modified Frey's procedure for patients of chronic pancreatitis: A 10-year experience.

INTRODUCTION: To mitigate the morbidity associated with open procedures for chronic pancreatitis (CP), there is a paradigm shift towards the laparoscopic approach. However, since these procedures are technically demanding, literature is still limited. We present our experience and long-term outcomes in the management of CP with laparoscopic surgical procedures. PATIENTS AND METHODS: This is a retrospective observational study of patients who underwent a laparoscopic surgery for CP between 2009 and 2019. Pain scores using the Visual Analogue Scale (VAS) were compared pre- and postoperatively. In patients with diabetes, the pre- and post-operative insulin requirement was compared. RESULTS: Data of 62 patients were analysed. The mean duration of follow-up was 69 (±22) months. All patients had pain relief post-surgery. The relief of pain was sustained, with the median VAS scores being 1 at 3- and 5-year follow-up. There was a decrease in the median insulin requirement of diabetic patients, which was significant at 3-month and 1-year follow-up ( P < 0.05). CONCLUSION: Our study demonstrates that laparoscopic surgical procedures offer long-term pain control with low morbidity. Effective ductal decompression may result in a short-term improvement of the endocrine function of the gland.

Optimal timing of laparoscopic cholecystectomy post-endoscopic retrograde cholangiography and common bile duct clearance: A prospective observational study.

Background: The treatment of patients with cholelithiasis with common bile duct (CBD) stones is CBD clearance with cholecystectomy. While traditional teachings advocate waiting for 4-6-week post-endoscopic retrograde cholangiography (ERCP) with CBD clearance, recent studies favour an early laparoscopic cholecystectomy (LC). Hence, this study was conducted to evaluate the optimal timing of LC post-ERCP. Methods: We conducted a prospective observational study between March 2017 and October 2018. Patients diagnosed with cholelithiasis and CBS stones on ultrasonography or computed tomography were included. They were assigned to one of two groups (<2 weeks and >2 weeks) based on the time interval between ERCP and subsequent LC. Chi-square test was used to analyse the intraoperative and post-operative outcomes between the two study groups. Results: One hundred and forty patients were included in the study of which 69 underwent an early LC (<2 weeks). There was a significant decrease in the blood loss and incidence of bowel injury in the early group. Calots triangle was better defined and critical view of safety was achieved more in the patients who underwent an early LC. This resulted in a significantly lower incidence of drain placement and length of hospital stay in those patients who underwent an early LC. Conclusion: A delay of 2 weeks after ERCP makes the LC more difficult and is associated with a longer hospital stay. We advocate LC within 2 weeks of ERCP whenever feasible.

Role of Indocyanine Green to Mitigate Wound Complications in Component Separation Technique for Ventral Hernia Repair-Our Early Experience.

BACKGROUND: The ease of the anterior component separation technique (ACST) makes it an attractive surgical option for ventral hernia repairs (VHR). Incorporation of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion during open ACST is an effective way to minimize the wound complications. This study aims to evaluate the impact of adoption of ICG-FA on wound-related complications following open ACST in VHR. METHODS: We performed a retrospective review of patients who underwent VHR with the open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of open ACST with onlay meshplasty done before (March 2018-April 2019) and after (May 2019 to July 2020) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin. RESULTS: The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of surgical site occurrence's was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less patients of the post-ICG cohort (29% vs. 5%; p value 0.045). CONCLUSION: This study demonstrates the effectiveness of perfusion mapping by the use of ICG angiography to determine potential areas of decreased perfusion and thereby minimize wound complications. Using ICG-FA to guide removal of at-risk tissue to minimize wound complications may substantially improve the patients outcome.

The Impact of Donor Body Mass Index on Safety and Outcomes in Living Donor Liver Transplantation: An Analysis of the National United States Database.

Background: The prevalence of obesity is rising in the general population. Donor obesity (body mass index ≥30 kg/m2) may potentially reduce the donor pool and impact outcomes in living donor liver transplantation (LDLT). Methods: We utilized the national transplant database to investigate the impact of donor obesity on donor and recipient outcomes. This was a retrospective cohort study of all LDLTs performed in the United States between January 2010 and June 2023. Outcomes of interest were analyzed by univariable and multivariable logistic regression. Patient and graft survival was evaluated using Kaplan-Meier and Cox proportional analysis. Results: Six hundred seventy-four donors with obesity and 3498 donors without obesity were analyzed. Donors with obesity had higher rates of readmission within 1 y of donation (15.9% versus 11.6%; P = 0.003). The risk of readmission was significantly different between 6 wk and 6 mo of donation (8.8% versus 5.9%; P = 0.036). Donor body mass index (odds ratio [OR], 1.460; 95% confidence interval [CI], 1.129-1.999; P = 0.004) and preoperative alkaline phosphatase levels (OR, 1.005; 95% CI, 1.000-1.011; P = 0.038) were independent predictors of donor readmission. High LDLT center volume was associated with reduced odds of donor readmission (OR, 0.509; 95% CI, 0.373-0.694; P < 0.001). Graft and recipient survival was comparable. Conclusions: Selection of living donors with obesity may be a potential avenue to increase the available donor pool without compromising recipient outcomes; however, they are at an increased risk for readmission between 6 wk and 6 mo of donation. The reason for readmission requires further study.

The Potential Utilization of Machine Perfusion to Increase Transplantation of Macrosteatotic Livers.

BACKGROUND: The demand for liver transplantation has led to the utilization of marginal grafts including moderately macrosteatotic livers (macrosteatosis ≥30% [Mas30]), which are associated with an elevated risk of graft failure. Machine perfusion (MP) has emerged as a technique for organ preservation and viability testing; however, little is known about MP in Mas30 livers. This study evaluates the utilization and outcomes of Mas30 livers in the era of MP. METHODS: The Organ Procurement and Transplantation Network database was queried to identify biopsy-proven Mas30 deceased donor liver grafts between June 1, 2016, and June 23, 2023. Univariable and multivariable models were constructed to study the association between MP and graft utilization and survival. RESULTS: The final cohort with 3317 Mas30 livers was identified, of which 72 underwent MP and were compared with 3245 non-MP livers. Among Mas30 livers, 62 (MP) and 1832 (non-MP) were transplanted (utilization of 86.1% versus 56.4%, P < 0.001). Donor and recipient characteristics were comparable between MP and non-MP groups. In adjusted analyses, MP was associated with significantly increased Mas30 graft utilization (odds ratio, 7.89; 95% confidence interval [CI], 3.76-16.58; P < 0.001). In log-rank tests, MP was not associated with 1- and 3-y graft failure (hazard ratio, 0.49; 95% CI, 0.12-1.99; P = 0.319 and hazard ratio 0.43; 95% CI, 0.11-1.73; P = 0.235, respectively). CONCLUSIONS: The utilization rate of Mas30 grafts increases with MP without detriment to graft survival. This early experience may have implications for increasing the available donor pool of Mas30 livers.

Fulminant amoebic colitis co-infection in a patient with COVID-19.

A woman in her 80s who presented with sudden abdominal pain and bloody stool associated with fever, dry cough and malaise, was found to be COVID-19 RT-PCR positive with fulminating necrotising amoebic colitis. She underwent right extended hemicolectomy with ileostomy and survived despite an unpredictable post-operative course, the need for aggressive intensive care and other major risk factors, and was discharged home after the twentieth day of her presentation.This case summarises the survival of a geriatric patient diagnosed with two lethal complications - amoebic colitis and COVID-19 respiratory infection with the aid of prompt surgical intervention and appropriate critical care.

A Review of Machine Perfusion Strategies in Liver Transplantation.

The acceptance of liver transplantation as the standard of care for end-stage liver diseases has led to a critical shortage of donor allografts. To expand the donor organ pool, many countries have liberalized the donor criteria including extended criteria donors and donation after circulatory death. These marginal livers are at a higher risk of injury when they are preserved using the standard static cold storage (SCS) preservation techniques. In recent years, research has focused on optimizing organ preservation techniques to protect these marginal livers. Machine perfusion (MP) of the expanded donor liver has witnessed considerable advancements in the last decade. Research has showed MP strategies to confer significant advantages over the SCS techniques, such as longer preservation times, viability assessment and the potential to recondition high risk allografts prior to implantation. In this review article, we address the topic of MP in liver allograft preservation, with emphasis on current trends in clinical application. We discuss the relevant clinical trials related to the techniques of hypothermic MP, normothermic MP, hypothermic oxygenated MP, and controlled oxygenated rewarming. We also discuss the potential applications of ex vivo therapeutics which may be relevant in the future to further optimize the allograft prior to transplantation.

A Comparative Study of Desarda's Versus Lichtenstein's Technique for Uncomplicated Inguinal Hernia Repair.

Purpose Since mesh-related long-term morbidity like chronic groin pain and vas entrapment in patients with an inguinal hernia is a concern, tissue-based repairs should be revaluated. There have been few prospective studies comparing the outcomes of Lichtenstein's technique and Desarda's technique for the repair of uncomplicated inguinal hernias. So, we conducted this prospective study comparing the two techniques. Methods This is a single-center prospective observational study conducted for a period of one year (2019). The patients who underwent surgery for uncomplicated inguinal hernia either by Lichtenstein's technique or Desarda's technique were included in the study. The two techniques were compared with respect to recurrence rates, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to activities of daily living (ADL). Results There was no significant difference in the recurrence rates, chronic groin pain, wound infection, or return to ADL between Lichtenstein's technique and Desarda's technique of inguinal hernia repair. The mean duration to return to ADL was lesser when patients underwent Desarda's repair though this difference was not significant. Conclusion Desarda's tissue repair was found comparable to Lichtenstein's mesh repair in terms of recurrence and postoperative morbidity, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to ADL. Desarda's technique may be considered as an alternative to mesh-based repairs to avoid long-term mesh-related morbidity for uncomplicated indirect hernias in the younger population.

Initial experience of radiofrequency ablation for the treatment of advanced haemorrhoidal disease.

Introduction: The ideal approach to the management of haemorrhoidal disease (HD) remains to be elucidated. A procedure that returns the anal cushions to their normal size without destroying them or damaging the surrounding tissues is sought. Radiofrequency ablation (RFA) overcomes many of the disadvantages of the previously described repairs and may be a valuable alternative in the management of advanced HD. Aim: To evaluate the efficacy and outcomes of the Rafaelo® technique for treatment of HD. Material and methods: A retrospective observational study was carried out between June 2019 and October 2020. The haemorrhoidal severity score (HSS), the Cleveland Incontinence Score (CIS), and the visual analogue scale (VAS) for pain were compared prior to and post procedure using a paired t-test. Results: Forty-seven patients were included in the study, with a mean age of 43 years. All individual symptom scores of HSS showed statistically significant improvement post RFA (p < 0.05). Minor complications like urinary retention (6.3%) and bleeding (12%) were noted. There were 2 instances of recurrence at 2 months. No major complications like anal stenosis or infections were observed. Conclusions: The RFA technique is a safe and effective treatment alternative for advanced HD. It results in a statistically significant improvement in the symptoms of HD and is associated with minimal discomfort to the patient with early return to normal activity.

Management of pancreatic trauma in urban India: A multicenter study.

Background: Pancreatic trauma occurs in 0.2-2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. The mortality and morbidity rates range from 9 to 34% and 30-60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India. Methods: We analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study 'Towards Improved Trauma Care Outcomes (TITCO)'. Results: Of the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma, 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries. Conclusion: Conservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidence: III.

Hepaticocystic Duct in an Era of Laparoscopic Cholecystectomy.

The biliary tract is notorious for its variable anatomy. A persistent hepaticocystic duct with agenesis of common bile duct is a rare biliary anomaly that creates a diagnostic dilemma and can add to the operative difficulties. It is important to diagnose this anomaly preoperatively since the gallbladder forms an integral part of bilioenteric continuity and an inadvertent cholecystectomy can lead to a surgical catastrophe. If diagnosed, surgeons can plan definitive treatment in the form of biliary diversion. We present a case of a 22-year-old man, who presented to us with obstructive jaundice and cholangitis. The biliary system was decompressed initially with a percutaneous transhepatic biliary drainage and an endoscopic retrograde cholangiogram established the diagnosis of a type IV hepaticocystic duct preoperatively in our case. Since diagnosis was made prior to operative intervention, we were able to perform a cholecystojejunostomy to maintain biliary continuity. The patient was discharged with an uneventful postoperative course. To our knowledge, this is the first report of such a variation being diagnosed preoperatively. We are also presenting a brief review of literature about persistent hepaticocystic ducts and the embryological basis of their origin.

Decalogue of Transversus Abdominis Release Repair- Technical Details and Lessons Learnt.

Background Posterior component separation (PCS) via transversus abdominis release (TAR) technique overcomes the pitfalls of traditionally described repairs. We evaluate the safety and efficacy of this approach and present the lessons we have learnt in our experience with a large series of complex ventral hernias. We also evaluate the importance of pre-operative optimisation and the value of a dedicated abdominal wall reconstruction (AWR) team in improving the surgical outcomes. Study Design A retrospective review of all patients undergoing TAR at a specialised hernia centre in the 2016-2019 period was performed. Pertinent data collected included patient demographics, peri-operative details and post-operative complications. Primary outcome variables were surgical site occurrences (SSO) and hernia recurrence. A multivariate regression model was developed to determine significant predictors of SSO. Results In 92 consecutive patients, the mean age was 52 years with a mean body mass index of 27.9%. Major comorbidities included diabetes (41%), hypertension (23%), and chronic obstructive pulmonary disease (15%). The mean hernia defect was 13.2 cm and the average operative time was 232 minutes. Complete posterior sheath closure was achieved in 95.6% cases. There were 18 (19.5%) cases of SSO which were managed conservatively and no cases required mesh explanation. There were 2 (2.1%) recurrences which required a redo surgery. On multivariate analysis operative time (p value 0.047) was a significant predictor of SSO. Conclusions AWR using the TAR approach offers a robust repair with low overall morbidity. A holistic pre-operative optimisation strategy and a dedicated AWR team can further improve surgical outcomes.

Enhanced Drainage Protocol in Large Amoebic Liver Abscess.

Background Amebic liver abscess (ALA) contributes significantly to morbidity and mortality in patients of the developing world. Even though medical management is the primary modality of treatment, 15% of the cases are refractory and require intervention for drainage. Pigtail catheterization is inefficient and results in a long duration of hospital stay. So, we conducted a prospective observational study to determine the efficacy and safety of drainage of large ALA using a wide bore 24 French (Fr) drain compared with a conventionally used 10 Fr pigtail catheter. Materials and Methods A single center prospective observational study was conducted over a period of 5 years and data of 122 patients was collected. After starting empirical medical therapy, patients underwent drainage of ALA with either a 10 French pigtail or a 24 Fr drain. The primary outcome variables were resolution of clinical symptoms such as fever and pain in abdomen, length of hospital stay, and resolution of abscess on imaging at day 3. Secondary outcome was complications related to the procedures. Results Data of 122 patients was collected. Males constituted a vast majority (96%) of the study population and the fifth decade was the most common age group involved. Alcoholics had a higher chance of developing a large ALA. Sixty-eight patients underwent drainage of the ALA using a 24 Fr drain which resulted in faster resolution of symptoms (2.4 vs. 5.1 days, p -value 0.033), a shorter duration of catheter in situ (6.4 vs. 13.2, p -value 0.011), and a faster drainage of ALA (residual volume at day 3; 177 vs. 212 mL, p -value 0.021). Twenty-eight patients had a biliary communication of which 26 required therapeutic endoscopic retrograde cholangiopancreatography. Conclusion In patients with a large ALA, placement of a wide bore 24 Fr catheter hastens recovery of the patients when compared with drainage with a standard 10 Fr pigtail catheter. Placement of a biliary stent serves as a useful adjunct for their management and it may obliviate the need for a major biliary diversion surgery.

Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy.

Background Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD. Methods A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct. Results The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment. Conclusion This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Congenital Transmesenteric Hernia-Importance of a Timely Intervention.

Transmesenteric hernia is a rare cause of small bowel strangulation in adults. Our patient was a 61-year-old previously healthy male, who presented with vomiting and abdominal pain with no surgical history and no trauma in the past. Computed tomography with contrast enhancement was suggestive of superior mesenteric vein (SMV) compression without any obvious cause. The emergency exploratory laparotomy revealed venous congestion of small bowel caused by a transmesenteric hernia with the herniated loop compressing the SMV. On reducing the hernia, complete reversal of the bowel congestion was noted and small bowel resection was averted. A high index of suspicion for a transmesenteric hernia in small bowel obstruction of unknown etiology and a timely surgical intervention are must for a good clinical outcome.