Laparoscopic surgery for right colon cancer with intestinal malrotation: A case report and review of the literature.

Intestinal malrotation (IM) results from abnormal midgut rotation during embryogenesis and usually presents in early infancy. IM in adults is often an incidental radiological diagnosis. Right colon cancer with IM has been sparingly reported in the world literature. Only 44.7% of these documented cases underwent successful laparoscopic resection, all of which were reported from Japan. The presence of aberrant anatomy and altered vascular orientation in IM presents challenges for laparoscopic resection with adequate nodal clearance. We present the case of a 72-year-old female diagnosed with carcinoma of the ascending colon, with IM incidentally detected on pre-operative cross-sectional imaging. She underwent laparoscopic right hemicolectomy. We also reviewed the documented cases of successful laparoscopic surgery for right colon cancers with IM. Aided by accurate delineation of vascular anatomy on pre-operative cross-sectional imaging, laparoscopic colectomy in the setting of IM is safe and feasible, and should be favourably considered.

Diaphragmatic injury during laparoscopic cholecystectomy: An unusual complication during a routine case.

Laparoscopic cholecystectomy is one of the most common procedures performed in surgical practice worldwide. Diaphragmatic injury is an extremely rare complication that can occur intraoperatively and needs to be dealt with immediately. This article describes a case report of diaphragmatic injury, technical details of how to deal with this complication and preventive strategies along with a review of literature on the topic.

Variations in biliary ductal and hepatic vascular anatomy and their relevance to the surgical management of choledochal cysts.

PURPOSE: An aberrant biliary ductal and vascular anatomy presents a technical challenge for choledochal cyst (CDC) surgery. Mismanagement may have unfavourable implications. This study highlights the spectrum, approach to their identification and management. METHODS: Forty of 117 (34 %) cases were identified to have an aberrant biliary ductal (n = 17) or arterial (n = 26) anatomy; 3 had both. The pancreaticobiliary anatomy was defined by an intraoperative cholangiogram (IOC) before January 2005 and a preoperative magnetic resonance cholangiopancreatogram (MRCP) subsequently. RESULTS: IOC missed 3 of 4 aberrant biliary ducts, while an MRCP accurately delineated 10 of 13 aberrant bile ducts. The significant biliary anomalies were: an aberrant right sectoral/segmental duct joining the common hepatic duct (CHD) or the cyst itself (n = 14), cystic duct (n = 1) and cystic duct-CHD junction (n = 1). The aberrant duct was incorporated into the biliary-enteric anastomosis (B-EA) by: (i) double ostia B-EA (n = 1), (ii) ductoplasty with single ostium B-EA for aberrant duct and CHD (n = 2), and (iii) transection of the CHD/cyst distal to the aberrant duct orifice with a single ostium B-EA (n = 13). The arterial anomalies were (i) replaced or accessory right hepatic artery (RHA) (n = 11) and (ii) RHA crossing anterior to the cyst (n = 15), which was repositioned posterior to the B-EA. CONCLUSION: It is important to consciously look for, appropriately identify and manage aberrant biliovascular anatomy. MRCP facilitates accurate preoperative delineation of aberrant duct anatomy. All major aberrant ducts need to be incorporated into the B-EA and aberrant arteries should not be ligated.

Anatomical appraisal of safe cholecystectomy: a prospective study.

BACKGROUND: Principles of safe cholecystectomy include dissection of the hepatocystic triangle and identification of the bilio-vascular structures to achieve critical view of safety. The aim of the present study was to document the variations in anatomical landmarks and bilio-vascular structures exposed during laparoscopic cholecystectomy. METHODS: All consecutive patients who underwent laparoscopic cholecystectomy were included in the study. Recommended techniques of safe cholecystectomy were followed. Rouviere's sulcus was classified into four types. Cystic duct was assessed for its length and diameter. A new classification was suggested for cystic artery. RESULTS: Five hundred patients were included in the study. Critical view of safety was achieved in 463 (92.6%) patients. Type1 Rouviere's sulcus was the most common variant found in 263 (52.6%). Normal cystic duct was present in 339 (67.8%). Wide cystic duct of normal length was the most common variant found in 71 (14.2%). Single cystic artery supero-medial to cystic duct (type1-s) was the most common variant found in 384 (76.8%). Inferior cystic artery i.e. artery infero-lateral to cystic duct (type-2) was the second most common variant, found in 40 (8%). Multiple cystic arteries in the hepatocystic triangle were due either to early division of single cystic artery (type-1m) or double cystic artery (type-3). Aberrant right hepatic artery giving off a small cystic artery (type-4) was seen in 12 (2.4%). CONCLUSION: Wide variation in the anatomical structures is noted when principles of safe laparoscopic cholecystectomy is followed. Awareness is paramount to avoid bilio-vascular injury during surgery.

Ogilvie's Syndrome with Perforation Peritonitis after Caesarean Section.

Acute colonic pseudo-obstruction in the immediate post-partum period, following Caesarean section is rare, and requires a high index of suspicion for diagnosis. Sometimes, rapidly progressive dilatation of the caecum can lead to perforation peritonitis. There are only a few case reports describing this important entity. Presented herein is a young primigravida, who developed Ogilvie's syndrome and peritonitis 5 days following an uneventful elective Caesarean section. Clinical details, management strategy adopted and a brief review of literature is presented to draw attention to this condition.

Twelve-Year Survival After Resection of Hepatocellular Carcinoma with Right Atrial Tumor Thrombus.

INTRODUCTION: A large hepatocellular carcinoma (HCC) with macrovascular invasion is generally considered to have poor prognosis due to unfavorable tumor biology andsuch patients are relegated to palliative options. This report describes long term survival after surgery in a patient with HCC and tumor thrombus in the rightatrium. METHODS: Case records of the patient, details of follow up visits and surveillance computed tomography scans performed were reviewed. A brief discussion of thesurgical strategy adopted along with outcome of similar cases in literature is presented. RESULTS: A 60 year old man presented with a HCC in segments 4, 5 with extension of tumor into the middle, left hepatic veins, inferior vena cava and right atrium.Patient underwent extraction of the tumor thrombus from the right atrium under cardiopulmonary bypass along with extended left hepatectomy. He receivedthree cycles of adjuvant chemotherapy with Gemcitabine, Oxaliplatin and Interferon. There was a parietal wall recurrence after 1 year and 10 months whichwas excised. Since then he remains well and is on regular follow up for more than 12 years from his index surgery with no evidence of disease, making himthe longest known survivor with such an advanced presentation. CONCLUSION: This is an unusual instance where aggressive resection for HCC with right atrial tumor thrombus has resulted in an exceptionally long survival.

Median Arcuate Ligament Syndrome: an Important Consideration in Pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.

Penetrating injuries of the inferior vena cava.

Inferior vena cava (IVC) injuries occur in 0.5-5% of cases of penetrating abdominal injury. Uncommonly encountered in general surgical and trauma practice, they remain extremely lethal despite advances in resuscitation and critical care. Important factors determining treatment outcomes are the hemodynamic status of the patient at presentation, the level and extent of injury, and the presence of associated injuries. Operative approaches and techniques for definitive repair are to be tailored to the condition of the patient, type of injury, and available expertise. In a patient with severe hemodynamic compromise, damage control principles take priority to stop bleeding and save life. The most commonly employed strategies are venorrhaphy or ligation. Retro-hepatic and supra-hepatic caval injuries are particularly challenging in terms of exposure and repair, and are associated with high fatality. Endovascular approaches are being used in select cases with success. This paper reviews in detail the epidemiology, injury patterns, management protocols, and outcomes of IVC injuries due to penetrating abdominal trauma.

How to prevent uncontrolled abdominal desufflation during laparoscopy in times of the coronavirus pandemic.

Aerosolization during laparoscopy poses a theoretical risk of infection to healthcare providers by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A simple, low-cost method of controlled abdominal desufflation during laparoscopy is described.

Post-cholecystectomy biliary strictures: not always benign.

BACKGROUND: Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge. METHODS: Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study. RESULTS: Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008). CONCLUSIONS: Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy.

Liver histology in benign biliary stricture: fibrosis to cirrhosis . . . and reversal?

BACKGROUND: Secondary biliary cirrhosis is a potential complication of post-cholecystectomy bile duct stricture (PCBDS). This study addresses the factors that determine the severity of pathological changes on liver biopsy and the correlation with long-term outcome following repair. METHODS: Liver biopsies obtained at surgery for repair of PCBDS in 71 patients were reviewed and pathological changes were scored from 0 to 3. Patients with fibrosis score 0-2 were categorized as the non-cirrhotic group and those with score 3 (secondary biliary cirrhosis) were categorized as the cirrhotic group. Clinical and biochemical parameters, stricture type and outcome were analyzed by univariate and multivariate analysis for correlation with degree of fibrosis. Follow-up liver biopsies (3-60 months) after stricture repair were obtained in five patients. RESULTS: There were 58 patients in the non-cirrhotic group and 13 in the cirrhotic group. On univariate analysis, portal hypertension and prolonged injury-repair duration correlated with secondary biliary cirrhosis. Patients with a fair outcome in the cirrhotic group (4/13) had derangements in liver function tests but had patent biliary enteric anastomosis on evaluation. Of the five patients in whom liver biopsies were obtained at follow up, two had regression, two were static, and one had progression. CONCLUSION: All patients with PCBDS had varying degrees of fibrosis. Prolonged injury-repair interval and portal hypertension were the important parameters correlating with secondary biliary cirrhosis. Early repair of biliary stricture is recommended to prevent liver fibrosis. A successful relief of biliary obstruction may halt and/or reverse pathological changes in the liver.

Keratin 8 sequence variants in patients with pancreatitis and pancreatic cancer.

Keratin 8 (KRT8) is one of the major intermediate filament proteins expressed in single-layered epithelia of the gastrointestinal tract. Transgenic mice over-expressing human KRT8 display pancreatic mononuclear infiltration, interstitial fibrosis and dysplasia of acinar cells resulting in exocrine pancreatic insufficiency. These experimental data are in accordance with a recent report describing an association between KRT8 variations and chronic pancreatitis. This prompted us to investigate KRT8 polymorphisms in patients with pancreatic disorders. The KRT8 Y54H and G62C polymorphisms were assessed in a cohort of patients with acute and chronic pancreatitis of various aetiologies or pancreatic cancer originating from Austria (n=16), the Czech Republic (n=90), Germany (n=1698), Great Britain (n=36), India (n=60), Italy (n=143), the Netherlands (n=128), Romania (n=3), Spain (n=133), and Switzerland (n=129). We also studied 4,234 control subjects from these countries and 1,492 control subjects originating from Benin, Cameroon, Ethiopia, Ecuador, and Turkey. Polymorphisms were analysed by melting curve analysis with fluorescence resonance energy transfer probes. The frequency of G62C did not differ between patients with acute or chronic pancreatitis, pancreatic adenocarcinoma and control individuals. The frequency of G62C varied in European populations from 0.4 to 3.8%, showing a northwest to southeast decline. The Y54H alteration was not detected in any of the 2,436 patients. Only 3/4,580 (0.07%) European, Turkish and Indian control subjects were heterozygous for Y54H in contrast to 34/951 (3.6%) control subjects of African descent. Our data suggest that the KRT8 alterations, Y54H and G62C, do not predispose patients to the development of pancreatitis or pancreatic cancer.

Management of complicated choledochal cysts.

OBJECTIVES: The presentation of choledochal cysts (CDCs) is altered by complications such as acute severe cholangitis, hepatolithiasis, spontaneous perforation, portal hypertension, pancreatitis, malignancy of the biliary tract and previous surgery in the form of internal drainage of the cyst. The management and the outcome of such complicated cysts differ from that of an uncomplicated CDC. This presentation is an analysis of our experience with complicated CDCs. PATIENTS AND METHODS: One hundred and forty-four patients with CDCs were managed at a tertiary level referral hospital in North India, between January 1989 and June 2004. Thirty-three (23%) CDCs were associated with complicating factors: severe cholangitis requiring a biliary drainage procedure prior to definitive operative procedure (n = 11), spontaneous perforation (n = 3), hepatolithiasis (n = 6), acute cholecystitis (n = 1), recurrent acute pancreatitis (n = 1), chronic pancreatitis (n = 1), gastric outlet obstruction (n = 1), portal hypertension (n = 6), biliary tract malignancy (n = 4) and previous internal drainage of the cyst (n = 5). Five patients had more than one complication. The management outcome of complicated CDCs was compared with that of uncomplicated CDCs. RESULTS: Complicated CDCs were significantly more common with type IV-A anatomy. Endoscopic, percutaneous or external surgical biliary drainage procedure was performed in 14 complicated CDCs prior to cyst excision. Desired definitive surgical procedure could be performed in 26/33 (79%) patients with complicated CDCs as compared to 107/111 (96%) patients with uncomplicated CDCs. Four (12%) patients with complicated CDCs had early postoperative complications as compared to 9/111 (8%) patients with uncomplicated CDCs. During a median follow-up of 13 months (2 months to 8 years), 2 patients with complicated CDCs died due to advanced secondary biliary cirrhosis and advanced gall bladder cancer, respectively. Six patients reported complications. Of the 6 patients, 3 required reoperation for a strictured hepaticojejunostomy (n = 2) and hepatolithiasis (n = 1). In contrast, there was no disease-related mortality and only 1 out of 111 patients with uncomplicated cysts had a complication during follow-up. CONCLUSION: Complicated CDCs merit a carefully planned management strategy including percutaneous, endoscopic and surgical procedures. The management may have to be staged. The outcome depends on the nature of complication and the management strategy adopted.

Salvage surgery in variceal bleeding due to portal hypertension.

BACKGROUND: A proportion (10%-15%) of patients with variceal bleeding do not respond to medical management and require surgical intervention. METHODS: Retrospective analysis of 82 consecutive patients (median age 31 years, range 3-71; 60 male) who underwent salvage surgery for variceal bleeding between 1989 and 2005. RESULTS: Immediate control of variceal bleeding was achieved in 78 (95%) patients. Four patients (cirrhosis 3, portal vein block 1) continued to bleed in the postoperative period following gastro-esophageal devascularization (3) or portacaval shunt (1). Twelve (15%) patients died in hospital; the commonest cause of death (n=7) was liver failure and sepsis leading to multi-system organ failure. The mortality rate was higher among patients who had undergone emergency surgery for active bleeding than among those who had been adequately resuscitated and evaluated prior to surgery (12/45 vs. 0/37; p< 0.001). Mortality rate tended to be higher in patients with cirrhosis (overall 10/45 [22%]; Child A 1/9 [11%], Child B 4/20 [20%], Child C 5/16 [31%]) than in those with non-cirrhotic portal hypertension (3/37 [8%]; p=ns). CONCLUSIONS: Our data suggest that salvage surgery is justified in patients with variceal bleed in whom non-surgical measures fail.

Predictors of long-term survival in patients with gallbladder cancer.

The aim of this study was to examine the predictors of long-term survival (> 24 months) in patients with gall bladder cancer. A retrospective review of 117 cases of gall bladder cancer resected between 1989 and 2000. The resections included 80 simple cholecystectomies and 37 extended procedures. Patients with survival > 24 months (n = 44) were compared with those having survival < 24 months (n = 73) for 17 prognostic factors. Overall median survival was 16 months with a 5-year survival of 27%. T status (P = .000) and adjuvant chemoradiotherapy (P = .001) were independent predictors of long-term survival. Survival advantage was seen in T3N+ve disease (P = .007) with extended procedures. Complete (R0) resection was attained in 30 patients with a 5-year survival advantage of 30% as compared with incomplete (R1) resection (P = .0002). Adjuvant chemoradiotherapy improved survival in simple cholecystectomy group (P = .0008) but no advantage was seen after extended procedures. Stage III (P = .001) and node-positive disease (P = .0005) had significant benefit with adjuvant therapy. Poor differentiation and vascular invasion were associated with poor long-term survival. R0 resection was associated with prolonged survival. Extended procedures improved survival in patients with T3N+ve disease. Addition of chemoradiotherapy made significant improvement in long-term survival in stage III and node-positive lesions and in patients undergoing simple cholecystectomy. R0 resection predicted long-term survival in gall bladder cancer. T3 N+ve disease had better survival after extended procedures. Adjuvant chemoradiotherapy improved survival in stage III and node-positive disease. Poor differentiation and vascular invasion were adverse predictors of survival.

Redefining the role of splenectomy in patients with idiopathic splenomegaly.

BACKGROUND: Despite extensive work-up to establish the cause of splenomegaly, splenectomy may be required for diagnosis in certain situations. The aim of this study was to find out the role of diagnostic splenectomy in the current era. METHODS: Between January 1989 and June 2004, 211 patients underwent splenectomy for indications other than trauma. In 41 (19%) patients, splenectomy was carried out for diagnostic purposes. Retrospective analysis of these patients was done for the purpose of the study. RESULTS: All patients who underwent diagnostic splenectomy had a complete haemogram, biochemical tests for liver and renal function, bone marrow biopsy and abdominal ultrasonography before splenectomy. There were 28 (68%) men and 13 (32%) women with median age of 37 years (range, 6-62 years). The median duration of symptoms was 12 months (range, 1-180 months). Common presentations were fever (n = 27; 66%), malaise (n = 26; 63%), pallor (n = 33; 80%) and gross splenomegaly (n = 27; 66%). Thirty-two (78%) patients had hypersplenism. Splenic lesions were shown in 14 (34%) patients on ultrasonogram and in 16 (39%) patients on contrast-enhanced computed tomography scan of the abdomen. Open splenectomy was carried out in all patients. Seventeen (41%) patients had postoperative complications. Among these, three (7%) patients had postoperative bleeding. One patient died because of acute respiratory distress syndrome. Final histopathology of the spleen showed lymphoma in 15 (37%), tuberculosis in five (12%) and other lesions in five (12%) patients. Sixteen (39%) patients had only congestive splenomegaly. CONCLUSION: A high proportion of patients presenting with idiopathic splenomegaly will have underlying haematological malignancies even in tropical countries. The clinical presentation, laboratory profile and imaging findings were not helpful in differentiating between patients with haematological malignancies and non-malignant conditions. Splenectomy still has an important role in establishing the pathology in patients presenting with idiopathic splenomegaly.

Ampullary carcinosarcoma with osteosarcomatous, small cell neuroendocrine carcinoma and conventional adenocarcinoma components; First report.

Caracinosarcomas are tumours with diverse epithelial and mesenchymal differentiation. They most commonly occur in the female reproductive organs and upper aero digestive tract. They are relatively rare in the gastrointestinal tract and affect the oesophagus most commonly. Ampullary carcinosarcomas are exceptionally rare. We report a case of ampullary carcinosarcoma in a 67-year-old male, with osteosarcomatous, small cell carcinoma and conventional adenocarcinoma components. To the best of our knowledge, this is the first reported case of its kind.