Multifocal Desmoplastic Small Round Cell Tumor: A Case Report of a Rare Neoplasm.

Desmoplastic small round cell tumor (DSRCT) is a rare, highly aggressive malignancy predominantly affecting adolescents and young adults. We report a case of multifocal DSRCT in an 11-year-old male who presented with complaints of unilateral forehead swelling, proptosis, and ophthalmoplegia for four months along with abdominal pain and dysphagia for six months. A whole-body computed tomography revealed widespread lesions in the skull, orbit, thorax, and abdomen with local infiltration. Ultrasound-guided biopsy of the forehead lump was performed. Based on histopathological and immunohistochemical investigations, it was diagnosed to be a DSRCT with multifocal presentation. The patient underwent chemo-radiation but unfortunately succumbed to neutropenic sepsis and renal failure. DSRCT is a very rare, highly aggressive malignancy with an extremely poor prognosis. Orbital presentations are even rarer, with less than 10 such cases currently described in English medical literature.

Intraductal papillary neoplasm of the bile duct: A case report of a rare tumor with a brief review of literature.

INTRODUCTION AND IMPORTANCE: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare neoplasm, mostly found in patients from far Eastern areas where hepatolithiasis and clonorchiasis are endemic. Very few cases are reported from India. CASE PRESENTATION: We present a case of recurrent cholangitis in a 59-year-old male, initially suspected to have IPNB based on preoperative imaging. Confirmation occurred intraoperatively, with mucin-filled bile ducts and papillary lesions in the resected hepatic duct. Treatment included left hepatectomy, extrahepatic bile duct excision, and Roux-en-Y hepaticojejunostomy. Histopathology indicated invasive pancreatobiliary-type IPNB with clear margins. The patient experienced post-hepatectomy hepatic insufficiency and superficial incisional surgical site wound infection, managed conservatively. Discharge occurred on postoperative day 21, with satisfactory recovery at the 16-month follow-up. CLINICAL DISCUSSION: IPNB is recognized as the biliary equivalent of intraductal papillary mucinous neoplasm, as these two conditions exhibit multiple commonalities in terms of clinical and histopathological characteristics. The unique aspect of our case lies in the intricacies associated with its diagnosis. Initially, imaging modalities did not yield a definitive characterization of the lesion. Notably, the endoscopist misinterpreted mucin expression emanating from the papilla as purulent material, primarily due to the patient's concurrent cholangitis. Subsequent repetitions of both CT scan and MRI provided some valuable insights that contributed to the diagnostic clarity of the IPNB. CONCLUSION: In cases of symptoms like biliary obstruction with bile duct dilation, wall nodules, papillary/solid-cystic masses, and upstream-downstream dilation, IPNB should be considered. Striving for R0 resection is crucial for enhanced long-term patient survival.

Influence of polymorphisms in TNF-α and IL1ß on susceptibility to alcohol induced liver diseases and therapeutic potential of miR-124-3p impeding TNF-α/IL1ß mediated multi-cellular signaling in liver microenvironment.

Background and aims: Alcoholic liver disease (ALD) is the leading cause of the liver cirrhosis related death worldwide. Excessive alcohol consumption resulting enhanced gut permeability which trigger sensitization of inflammatory cells to bacterial endotoxins and induces secretion of cytokines, chemokines leading to activation of stellate cells, neutrophil infiltration and hepatocyte injury followed by steatohepatitis, fibrosis and cirrhosis. But all chronic alcoholics are not susceptible to ALD. This study investigated the causes of differential immune responses among ALD patients and alcoholic controls (ALC) to identify genetic risk factors and assessed the therapeutic potential of a microRNA, miR-124-3p. Materials and methods: Bio-Plex Pro™ Human Chemokine analysis/qRT-PCR array was used for identification of deregulated immune genes. Sequencing/luciferase assay/ELISA detected and confirmed the polymorphisms. THP1 co-cultured with HepG2/LX2/HUVEC and apoptosis assay/qRT-PCR/neutrophil migration assay were employed as required. Results: The combined data analysis of the GSE143318/Bio-Plex Pro™ Human Chemokine array and qRT-PCR array revealed that six genes (TNFα/IL1ß/IL8/MCP1/IL6/TGFß) were commonly overexpressed in both serum/liver tissue of ALD-patients compared to ALC. The promoter sequence analysis of these 6 genes among ALD (n=322)/ALC (n=168) samples revealed that only two SNPs, rs361525(G/A) at -238 in TNF-α/rs1143627(C/T) at -31 in IL1ß were independently associated with ALD respectively. To evaluate the functional implication of these SNPs on ALD development, the serum level of TNF-α/IL1ß was verified and observed significantly higher in ALD patients with risk genotypes TNF-α-238GA/IL1ß-31CT+TT than TNF-α-238GG/IL1ß-31CC. The TNF-α/IL1ß promoter Luciferase-reporter assays showed significantly elevated level of luciferase activities with risk genotypes -238AA/-31TT than -238GG/-31CC respectively. Furthermore, treatment of conditioned medium of TNF-α/IL1ß over-expressed THP1 cells to HepG2/LX2/HUVEC cells independently showed enhanced level of ER stress and apoptosis in HepG2/increased TGFß and collagen-I production by LX2/huge neutrophil infiltration through endothelial layer. However, restoration of miR-124-3p in THP1 attenuated such inter-cellular communications and hepatocyte damage/collagen production/neutrophil infiltration were prohibited. Target analysis/luciferase-reporter assays revealed that both TNF-α/IL1ß were inhibited by miR-124-3p along with multiple genes from TLR4 signaling/apoptosis/fibrogenesis pathways including MYD88, TRAF3/TRADD, Caspase8/PDGFRA, TGFßR2/MCP1, and ICAM1 respectively. Conclusion: Thus, rs361525(G/A) in TNF-α and rs1143627(C/T) in IL1ß gene may be used as early predictors of ALD susceptibility among East Indian population. Impeding overexpressed TNF-α/IL1ß and various genes from associated immune response pathways, miR-124-3p exhibits robust therapeutic potential for ALD patients.

Surgical outcome of extrahepatic portal venous obstruction: Audit from a tertiary referral centre in Eastern India.

Backgrounds/Aims: Extra hepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in Indian children. While endoscopy is the primary modality of management, a subset of patients require surgery. This study aims to report the short- and long-term outcomes of EHPVO patients managed surgically. Methods: All the patients with EHPVO who underwent surgery between August 2007 and December 2021 were retrospectively reviewed. Postoperative complications were classified after Clavien-Dindo. Binary logistic regression in Wald methodology was used to determine the predictive factors responsible for unfavourable outcome. Results: Total of 202 patients with EHPVO were operated. Mean age of patients was 20.30 ± 9.96 years, and duration of illness, 90.05 ± 75.13 months. Most common indication for surgery was portal biliopathy (n = 59, 29.2%), followed by bleeding (n = 50, 24.8%). Total of 166 patients (82.2%) had shunt procedure. Splenectomy with esophagogastric devascularization was the second most common surgery (n = 20, 9.9%). Nine major postoperative complications (Clavien-Dindo > 3) were observed in 8 patients (4.0%), including 1 (0.5%) operative death. After a median follow-up of 56 months (15-156 months), 166 patients (82.2%) had favourable outcome. In multivariate analysis, associated splenic artery aneurysm (p = 0.007), isolated gastric varices (p = 0.004), preoperative endoscopic retrograde cholangiography and stenting (p = 0.015), and shunt occlusion (p < 0.001) were independent predictors of unfavourable long-term outcome. Conclusions: Surgery in EHPVO is safe, affords excellent short- and long-term outcome in patients with symptomatic EHPVO, and may be considered for secondary prophylaxis.

Challenges in managing anorectal melanoma, a rare malignancy.

INTRODUCTION AND IMPORTANCE: Anorectal melanoma is a rare and aggressive malignancy that can be difficult to diagnose due to its nonspecific presentation. CASE PRESENTATION: We present a case of a 69-year-old woman who presented with painful defecation, bleeding per rectum, and a mass coming out of her anal opening. The initial differential diagnosis included hemorrhoids, rectal polyp, or a malignant lesion of the rectum. However, histopathological evaluation following transanal excision of the rectal mass revealed mucosal melanoma in the anorectal region. Further investigation showed no evidence of locoregional or distant metastasis. CLINICAL DISCUSSION: Surgery remains the primary treatment option for anorectal melanoma, but complete resection is often not feasible, leading to high rates of local recurrence and distant metastasis. The incidence of metastatic disease at the time of presentation is high, and a multidisciplinary approach is necessary to manage these patients. Currently, standard systemic therapies used for cutaneous melanoma are the mainstay of treatment for metastatic anorectal melanoma, but there is a need for further research to develop tailored treatment strategies. CONCLUSION: Our case report highlights the importance of considering anorectal melanoma in the differential diagnosis of patients presenting with anorectal symptoms. It emphasizes the need for a multidisciplinary approach to managing this rare malignancy. Early diagnosis, a multidisciplinary approach, and ongoing research into more effective treatments are crucial for improving outcomes for patients with anorectal melanoma.

Advanced gastric neuroendocrine tumor with hepatic metastasis - A case report.

INTRODUCTION AND IMPORTANCE: Gastric neuroendocrine tumors (NETs) are rare neoplasms that originate from enterochromaffin cells in the gastric mucosa and pose a diagnostic dilemma due to their non-specific presentation. CASE PRESENTATION: We present a 79-year-old woman, who came with complaints of abdominal pain associated with loss of pain and appetite. Although on the first look multiple differentials could be listed, upon complete evaluation she was diagnosed to have type III Gastric NET. Histopathology and immunohistochemistry allowed diagnostic confirmation of the disease along with strong clinical suspicion. The patient however succumbed to the illness due to advanced disease and lack of established protocol for its management. CLINICAL DISCUSSION: The treatment of Gastric NETs primarily involves surgical resection of the tumor and is especially helpful in type I and II cases. For advanced metastatic type III NETs, lines of therapy have not been established although surgical resection can be done if the majority (∼90 %) of the tumor is resectable. Patients should be given a choice in decision making and newer drug therapies should always be considered. CONCLUSION: Since gastric NETs are a rarer cause of abdominal pain, it can often be overlooked in favor of other, more common differentials. One should be aware of this disease and the newer diagnostic methods to have any sort of clinical suspicion when presented with such a scenario. The management of the condition although not been established, novel therapies should be considered if the tumor is not resectable.

Surgical outcomes after re-operation for excision of choledochal cyst with delayed biliary complications: A retrospective study on 40 patients.

PURPOSE: The purpose of this study is to review our experience in patients who underwent re-operation for delayed biliary complications after choledochal cyst (CDC) excision. METHODS: All the patients who underwent re-operation. for delayed biliary complications after CDC excision between August 2007 and July 2020 were included in this retrospective study. The outcomes of these patients were compared with those who underwent primary surgery (CDC excision) at our institution. RESULTS: Of the total 40 patients with delayed biliary complications, 25 (62.5%) were female. Thirty-seven (92.5%) patients had a history of cholangitis. The median interval between CDC excision and the reoperation was 70 (4-216) months. The median duration of symptoms before reoperation was 12 (2.5-84) months. Re-do hepaticojejunostomy and direct hepaticojejunostomy were performed in 34 and in 6 patients respectively. Median operative time and blood losses were 219 min and 150 ml respectively. The median postoperative stay was 9 days. Postoperative complications developed in 10 (25%) patients. There was no operative mortality. Over a median follow-up of 71 months, a satisfactory outcome was achieved in 86% of patients. Restricture and intrahepatic stones developed in three and two patients respectively. Incidence of type IV cyst, cholangitis before operation, and operative blood loss were significantly more in the re-operative group. Clinical outcomes like the incidence of recurrent cholangitis, re-stricture, and postoperative hospital stay were comparable between the two groups. CONCLUSION: Surgery affords excellent results for majority of the patients with delayed biliary complications after CDC excision. Type IV cysts are more commonly associated with the development of delayed biliary complications.

Giant choledochal cyst: The largest reported!

Choledochal cyst (CC) is an atypical congenital abnormality of the biliary system. CC more than 10 cm is rare and only a few cases are reported. Herein, we reported a 25 × 18 cm CC and highlighted how definitive treatment after a timely diagnosis provides good prognosis irrespective of the size.

An Open-Label Randomized Controlled Trial Comparing Effectiveness of Aggressive Hydration Versus High-dose Rectal Indomethacin in the Prevention of Postendoscopic Retrograde Cholangiopancreatographic Pancreatitis (AHRI-PEP).

BACKGROUND: Although rectal administration of nonsteroidal anti-inflammatory drugs is recommended as the standard pharmacologic modality to prevent postendoscopic retrograde cholangiopancreatography (ERCP) post-ERCP pancreatitis (PEP), vigorous periprocedural hydration (vHR) with lactated Ringer's solution (LR) is emerging as an effective prophylaxis modality for PEP. There has been no head-to-head comparison between these 2. STUDY: This was a single-center, randomized, open-label, noninferiority, parallel-assigned, equal allocation, controlled clinical trial in a tertiary care hospital. Consecutive adults referred for ERCP, satisfying predefined inclusion criteria, underwent simple randomization and blinded allocation into 2 groups. Those allocated to vHR received intravenous LR at 3 mL/kg/h during procedure, 20 ml/kg bolus immediately afterward, and then at 3 mL/kg/h for another 8 hours. Those randomized to rectal Indomethacin received only per-rectal 100 mg suppository immediately post-ERCP. Assuming PEP of 9% in Indomethacin arm and noninferiority margin of 4%, we calculated sample size of 171 patients in each arm for 80% power and α-error 5%. Primary outcome was incidence of PEP, within 1 week, as defined by Cotton's criteria. All analysis were done by intention-to-treat. RESULTS: Between October, 2017 to February, 2018, 521 patients were assessed. In all, 352 were enrolled, 178 randomized to vHR, and 174 to per-rectal Indomethacin. Baseline details and ERCP outcomes were not different between 2 groups. PEP occurred in 6 (1.7%) overall, with 1 (0.6%) in hydration arm, and 5 (2.9%) in indomethacin arm; an absolute risk reduction of 2.3% (95% confidence interval: 0.9%-3.5%) and odds ratio of 0.19 (95% confidence interval: 0.02-1.65). Three patients developed severe PEP, all receiving indomethacin. CONCLUSIONS: vHR with LR is noninferior to postprocedure per-rectal Indomethacin for PEP prevention (ClinicalTrials.govID:NCT03629600).

Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis.

BACKGROUND: The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications. METHODS: All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality. RESULTS: Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP. CONCLUSIONS: Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes.

Primary hepatic leiomyosarcoma masquerading as focal nodular hyperplasia of liver: A wolf in sheep's clothing.

ABSTRACT: Primary hepatic leiomyosarcoma is a rare hepatic malignancy which requires exclusion of other primary site of origin. Clinical presentation and imaging of this tumor is nonspecific and mimics many other hepatic neoplasms. A 62-year-old female patient presents here with right hepatic mass with insidious onset and radiological features favoring a benign solid lesion suggestive of focal nodular hyperplasia. On right hepatectomy, an encapsulated mass identified about 11 cm in maximum dimension with pushing margin and central scar-like area. Histopathological examination reveals a spindle cell tumor and panel of immunohistochemical markers is required to distinguish it from other morphological mimickers. Diagnosis of primary hepatic leiomyosarcoma requires histopathology along with immunohistochemical examination. It is thus advisable to do preoperative biopsy with immunohistochemistry in all patients having atypical imaging and clinical features.

Hilar tuberculosis versus Klatskin tumour: a diagnostic challenge.

Hepatobiliary tuberculosis is a rare condition causing obstructive jaundice either by enlarged lymph nodes around the bile ducts or involvement of biliary epithelium by the tuberculous process. Since a tissue diagnosis is not mandatory to proceed with the resection or initiation of a liver transplant protocol, benign lesions are occasionally misdiagnosed as hilar cholangiocarcinoma. Here, we present a case of hepatobiliary tuberculosis which presented as obstructive jaundice due to hilar obstruction. The mass causing the obstruction was then later found to be a pseudotumour, typical of tuberculosis. This diagnosis meant that extensive surgical resection as a protocol for cholangiocarcinoma was avoided. The patient recovered completely after a course of antitubercular therapy.

Frey procedure for chronic pancreatitis: A narrative review.

Chronic pancreatitis is (CP) is a progressive inflammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inflammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia.

Clinical Profile of Hepatoblastoma: Experience From a Tertiary Care Centre in a Resource-Limited Setting.

Background Hepatoblastoma (HB) is a rare neoplasm of the liver, accounting for about 1% of all pediatric cancers. The aim of the present study is to report our experience with HBs over a period of five years from a tertiary center in Eastern India. Methodology This is a retrospective observational study. The data of all patients who were diagnosed with HB between August 2015 and December 2020 was reviewed. Results Twenty-three patients who were diagnosed and treated for HB at our center were included in the study. Sixteen (69.5%) of them were male. The median age of presentation was 14 (range, 3-58) months. An abdominal lump (n=23, 100%) and abdominal pain (n=11, 47.8%) were the most common presenting symptoms. The median level of serum alpha-fetoprotein at the time of initial evaluation was 8000 (878-1,280,000) ng/dL. The mean size of the largest focus in its largest dimension was 12.03±3.77 cm. The epithelial variant (n=22, 95.7%) was the most common histological subtype. One (4.3%), 10 (43.4%), 11 (47.8%), and one (4.3%) patient were found to have pre-treatment extent of tumor (PRETEXT) stages 1, 2, 3, and 4, respectively. Fifteen (65.2%) children were classified as standard risk and seven (34.7%) children as high risk. All the patients received neoadjuvant chemotherapy (NACT). The most commonly performed surgery was right hepatectomy (n=12, 52.1%). There were three (13%) cases of perioperative mortality. Four postoperative complications developed in three (13%) patients. Four (17.3%) patients developed chemotherapy-related complications. The median duration of follow-up was 31 (range, 0-58) months. Three (13%) patients developed relapses of the disease. Overall, five-year survival in our series was 73.9%. Conclusion This study shows that the overall outcomes of HB in a resource-limited setting such as ours are good with the adoption of multi-modality treatment. Managing chemotherapy-induced complications and making liver transplantation more feasible will improve the results further.

Outcome of Whipple's procedure for Groove pancreatitis: A retrospective cross-sectional study.

Background: Groove pancreatitis (GP) is a rare form of chronic pancreatitis primarily affecting the pancreatoduodenal groove. Very few studies have been published from India. The aim of the present study is to report our experience with Whipple's procedure for GP. Methodology: In this cross-sectional study, data of all patients who underwent Whipple's procedure for GP between August 2007 and July 2021 were retrospectively reviewed. Results: Of the total 504 Whipple's procedures, histopathologically proven GP was identified in 9 patients. All of them were male. Mean age at presentation was 42.66 ± 4.35 years. All of them had history of alcohol abuse. Eight (88.8%) of them had history of smoking. Postprandial abdominal discomfort and pain (n = 9, 100%) was the most common presenting symptom. Three (33.3%) patients had solid variety and six (66.6%) patients had cystic dystrophy of the duodenal wall. Two (22.2%) patients had mass in the head of the pancreas which was thought to be malignant. None of the patients underwent prior endoscopic management (stenting). Duration of surgery and blood loss was 330 (range, 300-379) minutes, and 250 (range, 200-750) ml respectively. There was no postoperative mortality. Postoperative complications developed in 5 (55.5%) patients. All the complications were managed conservatively. Median postoperative hospital stay was 10 (range, 9-16) days. Over a median follow-up of 41 (range, 12-120) months, complete remission of symptoms was achieved in 7 (78%) patients. Conclusion: Whipple's procedure is safe with acceptable perioperative outcomes and good long-term symptom control.

Outcome of reoperative surgery for late failure of postcholecystectomy bile duct injury repair.

The aim of the study is to report the outcomes of reoperative surgery for late failure of postcholecystectomy bile duct injury (BDI) repair. All the patients, who underwent a reoperative surgery for late failure of postcholecystectomy BDI repair at our institution between August 2007 and July 2020, were retrospectively reviewed. Of the total 262 patients of BDI repair, 66 underwent reoperative surgery for late failure. Median duration between last attempt repair and the onset of recurrent symptoms was 18 months. Eighty-five percent of patients with failed repair became symptomatic within 5 years of attempt repair. The most common type of BDI was E3. All the patients underwent Roux-en-Y hepaticojejunostomy. Twenty-nine postoperative complications developed in 23 (35%) patients. Postoperative mortality was 1.5%. Median postoperative hospital stay was 9 (5-61) days. Over a median follow-up of 80 (12-150) months, 5.2% (3/58) of patients developed clinically relevant anastomotic stricture. Three patients with secondary biliary cirrhosis died in the follow-up period due to decompensated liver disease. Overall, excellent or good long-term outcome was achieved in 83% (48/58) of patients which was significantly less satisfactory than primary repair patients (82.8% vs 92.7%, p = 0.039). Reoperative surgery is safe in patients with failed repair after postcholecystectomy BDI and good long-term clinical success can be achieved in most of the patients. The long-term results were less satisfactory in failed-repair group than those who underwent primary repair at our institution. Early referral to a specialized unit for BDI repair may improve long-term outcome.

Clinical profile and outcome of solid pseudopapillary neoplasm of the pancreas: A retrospective study on 28 patients.

BACKGROUND: Solid pseudopapillary neoplasms (SPN) of the pancreas are rare tumors accounting for 0.9-2.7% of all exocrine pancreatic tumors. Very few studies comprising of more than 10 patients have been published. The aim of the present study is to report on our experience with SPNs over a period of 14 years from a tertiary center of Eastern India. METHODOLOGY: Data of all patients whose histopathology reports of surgically resected specimen confirmed SPN were retrospectively reviewed in the present study. RESULTS: Twenty-eight patients had a pathologically confirmed diagnosis of SPN. Twenty-five (89.3%) patients were females with a median age of 26 (15-45) years. Abdominal pain (89.2%) was the most common presenting symptom. Abdominal mass was palpable in 12 (42.8%) patients. The mean size of the tumor was 9.03 cm (range, 4-25 cm). The most common location of the tumor was in the body and tail of pancreas (35.7%). The most commonly performed operation was distal pancreaticosplenectomy (n = 17, 60.7%), followed by Whipple's procedure (n = 8, 28.5%). Thirty postoperative complications developed in 23 (82.1%) patients. The operative mortality was 3.5% (n = 1). The median hospital stay was 10 (5-25) days. Over a median follow-up period of 36 months (range), no patient developed recurrence. CONCLUSION: Although the size of tumor was quite large at the time of initial presentation, complete surgical resection was possible in all the patients. In experienced hand, surgery can be performed with acceptable perioperative mortality and excellent long-term outcomes.

Duodenal Adenocarcinoma Versus Foreign Body Granuloma in the Background of Postcholecystectomy Migration of Endoclip Into Duodenum: A Histopathological Surprise.

A surgical endoclip in the cystic pedicle rarely migrates to the duodenum and is considered a rare complication of laparoscopic cholecystectomy. Duodenal adenocarcinoma endoscopically mimicking a foreign body granuloma in the background of postcholecystectomy endoclip migration has never been reported before. A 53-year-old Indian male presented with progressive weakness and melena for the last three months. He underwent laparoscopic cholecystectomy a year ago with an uneventful clinical course and post-operative recovery. A complete hemogram revealed hemoglobin of 4.5g/dL. Upper gastrointestinal endoscopy revealed a large necrotic polypoidal mass arising from the lateral wall of the first part of the duodenum. Contrast-enhanced computed tomography (CT) of the abdomen showed an impacted surgical clip into the lateral wall of the first part of the duodenum. Intraluminal extension of the surgical clip was not appreciated in the imaging. We suspected the diagnosis to be foreign body granuloma in the duodenal wall. He underwent open duodenal wedge resection. Microscopic evaluation of resected specimens revealed poorly differentiated adenocarcinoma. All the resection margins were free. He had an uneventful recovery and was discharged on the seventh post-op day. He was symptom-free and doing well on follow-up at 12 months. The purpose of reporting the case was to make the readers aware of the delayed massive upper gastrointestinal hemorrhage as a rare complication of endoclip migration (ECM) post laparoscopic cholecystectomy. In our case, the duodenal adenocarcinoma mimicked a foreign body granuloma endoscopically, and hence a possibility of duodenal adenocarcinoma as a potential delayed complication of ECM cannot be ruled out. Although rare, in case of upper gastrointestinal hemorrhage in the background of the previous history of laparoscopic cholecystectomy, endoclip migration should be kept as a differential diagnosis.

Extrahepatic mucinous biliary cystadenoma: A rare cause of gastric outlet obstruction.

Extrahepatic mucinous biliary cystadenoma is an extremely rare clinical entity that can present with varieties of vague clinical signs and symptoms. Gastric outlet obstruction caused due to this has never been reported before. We highlighted the diagnostic dilemma we faced when radiological investigations could not suggest the accurate organ of origin.