Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis.

BACKGROUND: Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS: Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION: Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery, is the mainstay of managing locally advanced esophageal cancer. However, the optimal timing of surgery after neoadjuvant therapy is not defined clearly. METHODS: A systematic search of PubMed, Embase and Cochrane databases was conducted. 6-8 weeks were used as a cut-off to define early and delayed surgery groups. Overall Survival (OS) was the primary outcome, whereas pathological complete resolution (pCR), R0 resection, anastomotic leak, perioperative mortality, pulmonary complications, and major complication (> Clavien-Dindo grade 2) rates were secondary outcomes. Cohort studies and national registry bases studies were analysed separately. Survival data were pooled as Hazard Ratio (HR) and the rest as Odds Ratio (OR). According to heterogeneity, fixed-effect or random-effect models were used. RESULTS: Twelve retrospective studies, one RCT, and six registry-based studies (13,600 participants) were included. Pooled analysis of cohort studies showed no difference in OS (HR 1.03, CI 0.91-1.16), pCR (OR 0.98, CI 0.80-1.20), R0 resection (OR 0.90, CI 0.55-I.45), mortality (OR 1.03, CI 0.59-1.77), pulmonary complications (OR 1.26, CI 0.97-1.64) or major complication rates (OR 1.29, CI 0.96-1.73). Delayed surgery led to increased leak (OR 1.48, CI 1.11-1.97). Analysis of registry studies showed that the delayed group had a better pCR rate (OR 1.12, CI 1.01-1.24), with no improvement in survival (HR 1.01, CI 0.92-1.10). Delayed surgery was associated with increased mortality (OR 1.35, CI 1.07-1.69) and major complication rate (OR 1.55, CI 1.20-2.01). Available RCT reported surgical outcomes only. CONCLUSION: National registry-based studies' analysis shows that delay in surgery is riskier and leads to higher mortality and major complication rates. Further, well-designed RCTs are required.

Hybrid natural orifice transluminal endoscopic surgery splenectomy: A case report.

Laparoscopic splenectomy has become an established standard of care in managing surgical diseases of the normal-sized spleen. Natural orifice transluminal endoscopic surgery (NOTES) is a step forward in making laparoscopic surgery even less invasive. In addition, the spleen can be accessed easily with the hybrid transvaginal approach. We present the case of a 38-year-old woman with medical refractory immune thrombocytopenic purpura. Hybrid notes splenectomy was performed using three working 5-mm abdominal trocars and a 10-mm camera port through the posterior fornix of the vagina. The organ was retrieved intact transvaginally. The patient had minimal post-operative pain and was discharged on the 1st post-operative day. Transvaginal hybrid NOTES approach is feasible for operative visualisation, dissection, clipping and specimen extraction in patients requiring splenectomy. It may offer better cosmesis and faster recovery. Comparative studies with conventional laparoscopic approach are desirable.

Preduodenal portal vein: A recipe for disaster during laparoscopic cholecystectomy.

We had encountered a very rare congenital anomaly of a preduodenal portal vein while doing laparoscopic cholecystectomy. More significant in our case is that this preduodenal vein is hiding behind omental adhesions with the gallbladder. We want to raise awareness about this very rare anomaly. Recognition and knowledge of this anomaly will prevent the potential of a serious operative misadventure.

Case of Undifferentiated Carcinoma with Osteoclast-like Giant Cells Associated with a Mucinous Cystic Neoplasm of the Pancreas: A Diagnostic Conundrum.

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGC) is a rare histological subtype of pancreatic ductal adenocarcinoma according to the World Health Organization classification of digestive system tumors. This subtype is exceptionally uncommon, accounting for less than 1% of pancreatic malignant tumors. This paper presents a rare case of a 62-year-old female patient diagnosed with UC-OGC. The patient initially presented with symptoms, including epigastric pain and the presence of an abdominal mass, which led to further investigation and the eventual diagnosis of this unusual and challenging form of pancreatic cancer.

Reconstructive techniques following low anterior resection for carcinoma of the rectum.

INTRODUCTION: Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied. EVIDENCE ACQUISITION: PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023. EVIDENCE SYNTHESIS: Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown. CONCLUSIONS: In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.

An Observational Study Comparing Hybrid Transvaginal Notes and Four-Port Laparoscopic Cholecystectomy.

BACKGROUND: Recently, a great interest has arisen in hybrid natural orifice transluminal endoscopic surgery-cholecystectomy (NOTES-C). It has the potential to cause less postoperative pain and may offer better cosmesis over conventional laparoscopic cholecystectomy (CLC). PATIENTS AND METHODS: A total of 112 females who underwent conventional cholecystectomy were compared with 108 patients of hybrid transvaginal NOTES-cholecystectomy (TV NOTES-C). We compared intraoperative factors, postoperative pain, the analgesic requirement at different intervals, duration of hospital stay, and time to return to normal activities. In addition, cosmesis and patient satisfaction were assessed at four weeks. RESULTS: Postoperative pain and analgesic requirement were less in the hybrid TV NOTES-C group (p<0.001 at 95% CI). Hybrid TV NOTES-C patients were discharged more frequently within 12 hours (27.5% versus 1.8%; p<0.001) and returned faster (2.22 versus 4.62 days; p<0.001) to normal activities. Cosmetic results and short-term quality of life as assessed by the patient and observer scar assessment scale (POSAS) and short form-36 (SF-36) scores, respectively, were better in the hybrid TV NOTES-C group (p<0.001 at 95% CI). CONCLUSIONS: Hybrid TV NOTES-C is associated with reduced postoperative analgesic requirements, faster return to normal activities, better cosmesis, and patient satisfaction compared to conventional four-port cholecystectomy.

The Practice of Pancreatoduodenectomy in India: A Nation-Wide Survey.

Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.

IgG4-Related Pancreato-Biliary Disease in the Disguise of Malignancy.

The Immunoglobulin G4-related disease (IgG4-RD) is a multisystem inflammatory condition. Pancreaticobiliary manifestations often present as mass lesions that mimic malignancies. The diagnosis is confirmed by histopathological examination, that shows lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and positive immunohistochemistry for IgG4. We encountered 3 such patients in a tertiary care hospital in India. Two patients presented with obstructive jaundice and the third with pain abdomen. They had resectable lesions involving the pancreatic head, the right hepatic duct, and gallbladder fundus, respectively, on imaging. Tumor markers were not significantly elevated in any of them. All 3 patients underwent radical surgeries, suspecting malignancy. Surgical specimens showed typical features of IgG4-RD on histomorphology. Serum IgG4 level was elevated in first 2 patients but was normal in sclerosing cholecystitis patient. To conclude, IgG4-RD is a malignant mimicker; hence, on clinical suspicion, liberal attempts for tissue diagnosis may avoid radical surgeries.

Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled.

Squamous cell carcinoma (SCC) involving the gastrointestinal tract is exceptionally rare, except in the esophagus and the anal canal. In the hindgut, a common site of involvement is the colo-rectum, commonly seen in the fifth decade of life. The presentation is usually in the advanced stages and carries a poor prognosis. Due to the rarity of the disease, before labeling it as a primary lesion, the possibility of metastasis from a distant primary should be entertained. Consensus guidelines regarding the management of such a rare condition are lacking. Here, we present the case of an elderly gentleman with a history of surgery for urinary bladder cancer 20 years back (the nature of which is not known). The patient presented with left lower abdominal pain and altered bowel habits. His pain had persisted for approximately two months along with a recent onset of overflow incontinence but no other associated constitutional symptoms. Examination revealed pallor and a vague abdominal mass in the left iliac fossa. On further evaluation with a colonoscopy, a growth was seen in the sigmoid colon. Computed tomography of the abdomen revealed a locally invasive growth arising from the sigmoid colon along with a space-occupying lesion in the left lobe of the liver enhancing on the portal phase. Biopsy from the sigmoid and the liver lesion was reported as SCC which was confirmed by immunohistochemistry. Given the metastatic nature of the lesion, treatment options were discussed in a multidisciplinary team setting, and the decision was made to proceed with diversion colostomy and palliative chemotherapy. SCC of the colon is a rare disease and is usually diagnosed at an advanced stage. Even in operable cases, the prognosis is dismal, and various treatment modalities have been attempted. Due to the rarity of the disease and paucity of data regarding definitive management, treatment varies from one patient to another.

Staple Line Dehiscence in Gastric Conduit Following Esophagectomy: A Complication Conspicuously Missing a Mention It Deserves.

Following esophagectomy, anatomical reconstruction with a gastric tube is the most common practice. The construction of the gastric tube is done with staplers nowadays, be it a minimally invasive esophagectomy or a conventional open surgery. Even though anastomotic leak and conduit necrosis are reported widely in the literature, the number of studies on staple line dehiscence is meager in comparison. Management of conduit failure usually sacrifices conduit combined with a diverting cervical esophagostomy. We report a case of successful surgical management of a big staple line dehiscence and 'salvaging of the conduit'.

Harmonic Lingual Frenotomy for Ankyloglossia: A Newer Novel Technique.

The objective of this is to report a newer novel technique of harmonic scalpel frenotomy, a day care procedure under local infiltration anesthesia that could achieve quick bloodless adequate ankyloglossia release and excellent healing with subsequent improved articulation and speech. The procedure was performed, patient followed up for six months and excellent results noted. A 37-year-old male patient presented with type II ankyloglossia on Coryllos ankyloglossia grading scale and class III on Kotlow's assessment. A quick bloodless frenotomy with adequate release of ankyloglossia was achieved using harmonic scissors. Patient experienced no discomfort. Patient was observed for two hours and discharged the same day with chlorhexidine mouth gargles and analgesics. Postoperative healing was excellent with adequate tongue protrusion and improvement in articulation and speech. We report this newer novel technique of harmonic scissors frenotomy, a day care procedure under local infiltration anesthesia, that achieved quick bloodless adequate ankyloglossia release, excellent healing and evident improvement in articulation and speech.

Solitary Fibrous Tumor of the Liver: A Rare Tumor in a Rarer Location.

Solitary fibrous tumor is an uncommon mesenchymal neoplasm. Liver is a rare location of this tumor. We report a case of hepatic solitary fibrous tumor in a 56-year-old female, who presented with right upper abdominal pain. An extended right hepatectomy was performed. Histopathological and immunohistochemical examination revealed solitary fibrous tumor of the liver.

Pathogenesis and Management of Hepatolithiasis: A Report of Two Cases.

Hepatolithiasis or primary intrahepatic stones are prevalent in the Far-East countries such as Korea, Japan and Taiwan. It has been associated with helminthiasis, bacterial infections, environmental and dietary factors. Despite high prevalence of helminthiasis like ascariasis, poor environmental condition and low protein diet, India and Middle-East countries have a low incidence of hepatolithiasis. We report two cases of hepatolithiasis associated with bacterial infections and were surgically managed. The first case is a 45-year-old female presenting with upper abdominal pain and fever. She had multiple calculi in intrahepatic biliary radicles, common bile duct, common hepatic duct and gall bladder. She was managed by cholecystectomy, left lateral liver sectionectomy, choledochoscopy assisted stone clearance of the residual liver and Roux-en-Y hepatico-jejunostomy. The second case is a 60-year-old female presenting with epigastric pain and fever and past history of cholecystectomy for cholelithiasis. She had multiple right and left intrahepatic calculi and managed by left lateral liver sectionectomy with excision of CBD and Roux-en-Y hepatico-jejunostomy. Both the cases showed growth of bacteria in the culture of the intraoperatively collected bile.

Randomized controlled pilot trial of nifedipine as oral therapy vs. topical application in the treatment of fissure-in-ano.

BACKGROUND: Fissure-in-ano is a common condition that leads to pain and affects quality of life. Sphincterotomy remains the gold standard, but it may lead to troublesome incontinence in some patients. To overcome this problem, numerous pharmacologic therapies have been tested with varying outcomes. The investigators compared the effect of the addition of oral and topical nifedipine to conservative measures in the treatment of patients with fissure-in-ano. METHODS: Ninety patients with fissure-in-ano, randomized into 3 groups of 30 each, were included in the study. Group I received conventional treatment, group II received oral nifedipine and conventional treatment, and group III received topical nifedipine along with conventional treatment. Patients were followed for 8 weeks for pain relief (assessed using a visual analogue scale) and healing to evaluate the effect of treatment. RESULTS: Pain relief was significantly better in the group III at 3 weeks and 2 months compared with group I (P < .05). Groups II and III were comparable in terms of pain relief. Healing rates were significantly better in group II (P = .03) and group III (P = .00) compared with group I, but groups II and III were found to be comparable. Adverse effects were most commonly reported by group II patients, but these were not significantly higher than in other 2 groups. CONCLUSIONS: We recommend the addition of either oral or topical nifedipine to conservative measures to significantly improve pain relief and healing rates in patients with fissure-in-ano.