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1.
Cureus ; 16(7): e65140, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-39176340

RESUMO

Background An enhanced recovery approach in surgery helps early postoperative discharge. With the decreasing trend of morbidity and mortality in recent times in patients undergoing complex procedures such as pancreaticoduodenectomy, readmissions are the next major concern. The causes and outcomes of these readmissions should be investigated for their impact on patient care and prevention. Methodology A total of 997 patients discharged after pancreaticoduodenectomy from a tertiary care center in northern India, between 1989 and 2021, were studied retrospectively to assess the readmission rate for sequelae after pancreaticoduodenectomy. The causes, interventions, outcomes, and predictive factors were studied. Results A total of 103 (10.3%) patients required readmission for sequelae after pancreaticoduodenectomy, and 52 (50.4%) patients required interventions. The most common cause for readmission in our study was intra-abdominal collection (n = 23, 22.3%). Of these 103 patients, 63 (61.2%) had good outcomes, 36 (34.9%) had fair outcomes, and four (3.9%) had bad outcomes. Overall, 53 (51.5%) of 103 patients were readmitted within 30 days of discharge, most commonly with intra-abdominal collection (16 of 53, 30.1%). Of these 53 patients, 22 (41.5%) required interventions, 34 (64.1%) had good outcomes, and 27 (50.9%) were readmitted within seven days of discharge. Of these 27 patients, 12 (44.4%) required interventions, with 24 (88.8%) experiencing good outcomes. Of the 103 patients, 12 (11.6%) were readmitted between 31 and 90 days, mostly due to external stent, T-tube, or percutaneous transhepatic biliary drainage-related problems. Overall, 38 (36.9%) of 103 patients were readmitted after 90 days, mostly with incisional hernia and strictured hepaticojejunostomy. Of these 38 patients, 26 (68.4%) required intervention, and 23 (60.5%) had good outcomes. A previous history of cholangitis (odds ratio (OR) = 1.771, 95% confidence interval (CI) = 1.17-2.67, p = 0.007), postoperative fever (OR = 1.628, 95% CI = 1.081-2.452, p = 0.02), wound infection (OR = 2.011, 95% CI = 1.332-3.035, p = 0.001), and wound dehiscence (OR = 2.136, 95% CI = 1.333-3.423, p = 0.002) predicted readmission on univariate analysis. Multivariate analysis showed a previous history of cholangitis (OR = 1.755, CI = 1.158-2.659, p = 0.008) and wound infection (OR = 1.995, 95% CI = 1.320-2.690, p = 0.001) as factors independently predicting readmission. Conclusions Readmitted patients have high intervention rates and good recovery rates. Readmissions should not be considered a scale for poor healthcare. Patient education, proper management of postoperative complications, and a properly designed discharge care system can help tackle this problem.

2.
Ann Hepatobiliary Pancreat Surg ; 27(3): 258-263, 2023 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-37127398

RESUMO

Backgrounds/Aims: Hemangiomas are the most common benign liver lesions; however, they are usually asymptomatic and seldom require surgery. Enucleation and resection are the most commonly performed surgical procedures for symptomatic lesions. This study aims to compare the outcomes of these two surgical techniques. Methods: A retrospective analysis of symptomatic hepatic hemangiomas (HH) operated upon between 2000 and 2021. Patients were categorized into the enucleation and resection groups. Demographic profile, intraoperative bleeding, and morbidity (Clavien-Dindo Grade) were compared. Independent t-test and chi-square tests were used for continuous and categorical variables respectively. p-value of < 0.05 was considered significant. Results: Sixteen symptomatic HH patients aged 30 to 66 years underwent surgery (enucleation = 8, resection = 8) and majority were females (n = 10 [62.5%]). Fifteen patients presented with abdominal pain, and one patient had an interval increase in the size of the lesion from 9 to 12 cm. The size of hemangiomas varied from 6 to 23 cm. The median blood loss (enucleation: 350 vs. resection: 600 mL), operative time (enucleation: 5.8 vs. resection: 7.5 hours), and postoperative hospital stay (enucleation: 6.5 vs. resection: 11 days) were greater in the resection group (statistically insignificant). In the resection group, morbidity was significantly higher (62.6% vs. 12.5%, p = 0.05), including one mortality. All patients remained asymptomatic during the follow-up. Conclusions: Enucleation was simpler with less morbidity as compared to resection in our series. However, considering the small number of patients, further studies are needed with comparable groups to confirm the superiority of enucleation over resection.

3.
Surg J (N Y) ; 8(3): e169-e173, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35991490

RESUMO

Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.

4.
South Asian J Cancer ; 11(3): 195-200, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-36588607

RESUMO

Ashish SinghBackground Regarding gallbladder cancer (GBC) there is conflicting evidence in the literature whether retroperitoneal lymph nodal metastases (RLNM) should be considered as regional nodal metastasis or as distant metastasis (DM) and the jury is out on radical curative surgery in presence of RLNM. This is an analysis of GBC patients, to see the effect of RLNM on survival and to compare with that of patients with DMs. Methods A retrospective analysis of a prospective database of patients of GBC with RLNM (interaortocaval and paraaortic) or DM on frozen section biopsy at surgery, between January 2013 and December 2018. Data was analyzed using the Statistical Package for the Social Sciences software (version 22.0). Survival in these two groups (RLNM and DM) was compared with log-rank test. A p -value of < 0.05 was considered significant. Results A total of 235 patients with ostensibly resectable GBC underwent surgical exploration. The planned curative resection was abandoned in 91 (39%) patients because of RLNM ( n = 20, 9%) or DM ( n = 71, 30%) on frozen section biopsy. Demographic profile and blood parameters were similar. The median survival for RLNM and DM groups were 5 (range 2-26) and 6 (range 2-24) months, respectively, with no significant difference on log-rank test ( p = 0.64). There was no 3-year or longer survivor in either group. Conclusion Due to similar poor survival in presence of RLNM or DM, RLNM should be considered as the equivalent of DM. This study strengthens evidence to avoid curative surgery in patients with RLNM. These lymph nodes should be sampled preoperatively, if suspicious on imaging, for fine-needle aspiration cytology and at surgery, as a routine for frozen section histological examination before initiating curative resection to avert a futile exercise.

5.
Ann Hepatobiliary Pancreat Surg ; 25(4): 492-499, 2021 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-34845121

RESUMO

BACKGROUNDS/AIMS: Re-resection of incidental gallbladder carcinoma (IGBC) is possible in a select group of patients. However, the optimal timing for re-intervention lacks consensus. METHODS: A retrospective analysis was performed for a prospective database of 91 patients with IGBC managed from 2009 to 2018. Patients were divided into three groups based on the duration between the index cholecystectomy and re-operation or final staging: Early (E), < 4 weeks; Intermediate (I), > 4 weeks and < 12 weeks; and Late (L), > 12 weeks. Demographic data, tumor characteristics, and operative details of patients were analyzed to determine factors affecting the re-resectability of IGBC. RESULTS: Twenty-two patients in 'E', 48 in 'I', and 21 in 'L' groups were evenly matched. Nearly two thirds were asymptomatic. Curative resection was possible in 48 (52.7%) patients. Metastasis was detected during staging laparoscopy (SL)/laparotomy in 26 (28.6%) patients. The yield of SL was more in the 'L' group (30.8%) than in the 'I' (11.1%) or 'E' (nil) group, avoiding unnecessary laparotomy in 13.6%. Only 28.5% of patients in the 'L' group could undergo curative resection (R0/R1 resection), significantly less than that in the 'E' (50.0%) or 'I' group (64.6%) (both p < 0.001). On multivariate analysis, presentation in intermediate period and tumor differentiation increased the chance of curative resection (p < 0.05). CONCLUSIONS: Asymptomatic patients in the 'I' group with well differentiated IGBC have the best chance of obtaining a curative resection.

6.
Cancer Genet ; 258-259: 41-48, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34455261

RESUMO

Ampulla is a complex region located at the confluence of pancreatic and common bile duct and intestinal epithelium. Tumors arising in this region are anatomically and morphologically heterogenous, however they show unique as well as overlapping molecular features. Cancers of both these anatomic sites share morphological as well as genetic profile despite having few unique differences. Targeted therapies are currently emerging as one of the demanding approaches for treatment in most cancer types especially for malignant epithelial tumors and therefore genetic profiling of cancers is the key for identification of potentially therapeutic targetable mutations to know their prevalence and prognostic impact. We studied 97 resected cases of formalin fixed paraffin-embedded AC by deep targeted sequencing using Ampliseq cancer hotspot panel comprising of 50 oncogenes and tumor suppressor genes. Potentially therapeutic targetable mutations were observed in 58/83 (70%) cases. Fourteen patients did not show any pathogenic mutation. TP53 (48.1%), KRAS (37.3%), APC (25.3%), SMAD4 (22.8%), MET (16.8%), CTNNB1 (15.6%) and PIK3CA (10.8%) were the major mutated potential therapeutic targets. KRAS mutation (43.2 Vs. 32.6%) was more prevalent in pancreatobiliary subtype, while TP53 (58.6 Vs 35.1), APC (36.9 Vs 10.8), SMAD4 (28.2 Vs 16.2), MET (21.7 Vs 10.8) and CTNNB1 (19.5 Vs 10.8) were more prevalent in intestinal subtype. WNT signaling pathway was the major altered pathway in intestinal subtype. These mutated genes and pathways may be targeted with currently available drugs and may be explored for future development of targetable agents to improve the disease course in patients of AC.


Assuntos
Ampola Hepatopancreática/patologia , Biomarcadores Tumorais/genética , Neoplasias do Ducto Colédoco/epidemiologia , Predisposição Genética para Doença , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Mutação , Adulto , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/metabolismo , Neoplasias do Ducto Colédoco/genética , Neoplasias do Ducto Colédoco/patologia , Feminino , Seguimentos , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico
7.
Ann Hepatobiliary Pancreat Surg ; 22(1): 36-41, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29536054

RESUMO

BACKGROUNDS/AIMS: A residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period. METHODS: This study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015. RESULTS: A RGB was observed in 93 patients, who had a median age of 45 (25-70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi's syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3-108) in 65 patients and the outcome was excellent and good in 97% of the patients. CONCLUSIONS: Post-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

9.
Chin Clin Oncol ; 5(1): 8, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26932432

RESUMO

BACKGROUND: Gall stones (GS) cause inflammation of the gall bladder (GB) i.e., chronic cholecystitis (CC) and xantho-granulomatous cholecystitis (XGC) which can result in a thick walled GB (TWGB). Gall bladder cancer (GBC) may also present as TWGB. While CC and XGC can be treated with simple cholecystectomy (SC), GBC merits extended cholecystectomy (EC). We propose a new surgical approach, anticipatory extended cholecystectomy (AEC), for doubtful TWGB in the belief that AEC would not violate the sacrosanct cholecysto-hepatic plane in doubtful cases and thereby not ruin the chances of cure for a patient whose GB demonstrates malignancy on frozen section histopathology. The addition of lymphadenectomy in cases which turn out to be malignant completes the procedure for GB cancer, but spares all problems related to lymphadenectomy in an undeserving patient. METHODS: AEC involves removal of GB with a 2-cm wedge of liver, which is then subjected to frozen section histological examination. Lymphadenectomy is performed if GBC is confirmed. AEC was performed in 13 patients between January 2011 and June 2014. During the same period, 1,673 SC for CC/XGC and 116 EC for GBC were performed. RESULTS: All patients were symptomatic for GS (3 with acute cholecystitis). Ultrasonography (US) raised suspicion of GBC in 11 patients. CT raised suspicion of GBC in 9 patients. Preoperative FNAC was done in 2 patients; in 1 it was negative and in 1 it was suspicious for malignancy. Preoperative diagnosis was GBC in 8, TWGB in 2, XGC, porcelain GB and GB perforation in 1 each. AEC and frozen section was done in all 13 patients. It was reported as GBC in 2 patients and as suspicious of GBC in 1 patient; lymphadenectomy was performed in these 3 patients. Final histopathology revealed XGC in 9, CC in 2 and GBC in 2 patients. CONCLUSIONS: In patients with TWGB on US/ CT with low suspicion of cancer, AEC serves as a triage-if frozen section biopsy turns out to be positive for GBC, AEC can be completed to EC by performing lymphadenectomy. We wish to name this approach as the 'Lucknow' approach for TWGB.


Assuntos
Colecistectomia/métodos , Colecistite/cirurgia , Neoplasias da Vesícula Biliar/cirurgia , Adulto , Idoso , Colecistite/diagnóstico por imagem , Colecistite/patologia , Feminino , Seguimentos , Neoplasias da Vesícula Biliar/diagnóstico por imagem , Neoplasias da Vesícula Biliar/patologia , Humanos , Excisão de Linfonodo/métodos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Ultrassonografia , Adulto Jovem
10.
Korean J Hepatobiliary Pancreat Surg ; 20(1): 17-22, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26925146

RESUMO

BACKGROUNDS/AIMS: Mirizzi's syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome. METHODS: Prospectively maintained data of all surgically treated MS patients were analyzed. RESULTS: A total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669). CONCLUSIONS: Preoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.

11.
Indian J Pathol Microbiol ; 58(3): 274-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26275245

RESUMO

BACKGROUND: Matrix metalloproteinase 7 (MMP7) has largely been studied in pancreatic cancer which is the most common component of periampullary cancer in the western population. In India, the ampullary carcinoma is seen as the most common periampullary cancer in resected pancreaticoduodenectomies. We aimed to study the expression of MMP7 and its correlation with clinicopathological features in ampullary cancer. MATERIALS AND METHODS: Consecutive cases of all ampullary cancer in a 3-year period were reviewed for histological differentiation (intestinal and pancreatobiliary) by morphology and immunohistochemistry (CDX2, MUC2, cytokeratin 20 [CK20], MUC1, cytokeratin 7 [CK7], and cytokeratin 17 [CK17]). All cases were stained for MMP7 and expression was correlated with histological variables, differentiation, and overall survival. RESULTS: There were a total of 91 ampullary carcinomas (36 intestinal, 44 pancreatobiliary and 6 other types). Ampullary carcinoma showed MMP7 expression in 63.7% cases. Two-third of intestinal type and half of the pancreatobiliary type cancers showed MMP7 expression. MMP7 expression was significantly higher in low pathological T-stage of total ampullary carcinomas; however, it was seen more commonly in higher overall stage of the pancreatobiliary type compared to intestinal type of ampullary carcinoma. Overall survival in patients with MMP7 expression was lower compared to MMP7 negative patients. CONCLUSIONS: This is the first study on MMP7 expression in ampullary cancer. MMP7 expression was seen in nearly 64 % of ampullary cancer and showed a significant correlation with low pathological (T-) stage and high overall stage with a shorter survival. MMP7 can be explored as a target for MMP inhibitor therapy in the future.


Assuntos
Ampola Hepatopancreática/patologia , Carcinoma/patologia , Metaloproteinase 7 da Matriz/análise , Neoplasias Pancreáticas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/análise , Carcinoma/mortalidade , Feminino , Histocitoquímica , Humanos , Imuno-Histoquímica , Índia , Masculino , Microscopia , Pessoa de Meia-Idade , Neoplasias Pancreáticas/mortalidade , Análise de Sobrevida
12.
Hum Pathol ; 44(10): 2213-9, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23834763

RESUMO

Periampullary carcinoma (PC) is classified into intestinal and pancreatobiliary subtypes using morphology and immunohistochemistry (IHC). Different combinations of markers have been used in the literature. One hundred eight PCs were classified using morphology and IHC (CDX2, mucin [MUC] 2, cytokeratin [CK] 20, CK7, CK17, and MUC1). The expression of these markers was compared with different histologic subtypes, histopathologic prognostic parameters, and patients' survival. There were 38 intestinal and 53 pancreatobiliary subtypes classified on morphology alone. CDX2 showed high sensitivity (89.5%) and specificity (100%) for intestinal type. CK20 and MUC2 showed low sensitivity (50% and 39.5%) but high specificity (86.8% and 96.2%) for intestinal type. CK7 and CK17 showed a sensitivity of 90.5% and 32% and a specificity of 21% and 89.4%, respectively, for pancreatobiliary subtype. MUC1 was 100% sensitive but 0% specific in pancreatobiliary subtype. The overall median survival in morphologic and IHC intestinal type was 45 months versus 20 months in pancreatobiliary type (P = 0.01). Intestinal and pancreatobiliary types of PC were differentiated in 84.2% of cases by morphology alone and in 87.9% cases with IHC. CDX2-positive tumors had a median survival of 44 months versus 22 months in CDX2-negative tumors (P = .03). IHC helped in reclassifying an additional 4 cases of mixed and other types. Among the panel used, CDX2 showed a high sensitivity and specificity for intestinal subtype and was an independent prognostic marker for longer survival. Thus, CDX2 may be used routinely with morphology in subtyping of PC, and a panel of markers may be used in morphologically difficult cases.


Assuntos
Adenocarcinoma/patologia , Ampola Hepatopancreática/patologia , Transformação Celular Neoplásica , Neoplasias do Ducto Colédoco/patologia , Intestinos/patologia , Pâncreas/patologia , Adenocarcinoma/metabolismo , Adenocarcinoma/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/metabolismo , Biomarcadores Tumorais/metabolismo , Fator de Transcrição CDX2 , Neoplasias do Ducto Colédoco/metabolismo , Neoplasias do Ducto Colédoco/mortalidade , Feminino , Proteínas de Homeodomínio/metabolismo , Humanos , Imuno-Histoquímica/métodos , Mucosa Intestinal/metabolismo , Masculino , Pessoa de Meia-Idade , Pâncreas/metabolismo , Sensibilidade e Especificidade , Taxa de Sobrevida
13.
J Gastrointest Cancer ; 44(1): 33-40, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22987147

RESUMO

INTRODUCTION: Radical resection to achieve R0 status remains the only potential curative option in patients with gall bladder cancer (GBC). This study was aimed to evaluate the efficacy of an extended criterion of radical resection to achieve R0 status in GBC. METHODS: A triple-phase CT with 3D reconstruction was done in all patients. A standard resectability criterion was followed in all patients. A minimum of liver segment 4B + 5 resection and radical lymphadenectomy including the para-aortic areas were undertaken in all patients. Adjacent organectomy was added as required. RESULTS: Between November 2008 and April 2011, 59 patients with GBC underwent operation and 40 (resectability, 68 %) underwent resection. The resectional procedures performed were segmentectomy 4B + 5 in 31 (78 %), median sectorectomy in 2 (5 %), extended right hepatectomy in 3 (8 %), and hepatopancreaticoduodenectomy in 4 (10 %) patients. Postoperative complications occurred in 24 (60 %) patients. Two patients died postoperatively. A total of 829 lymph nodes were harvested and the median lymph node count was 18 (4-77). Twenty-three (58 %) patients had lymph node metastases. Twenty-eight of 40 (70 %) had disease limited till N1 nodes. Metastases up to N2 lymph nodes were seen in 12 (30 %). American Joint Committee on Cancer seventh edition stages were I-2 (5 %) patients, II-5 (13 %), III-19 (48 %), and IV-14 (35 %). R0 resection was achieved in 33 (83 %) patients. Four patients had recurrence and one died of recurrence. All other patients are alive till the last follow-up. CONCLUSIONS: Assessment with triple-phase CT with 3D reconstruction can produce high resectability rate in GBC. Extended criterion of radical resection results in R0 status in more than 80 % of patients with GBC.


Assuntos
Neoplasias da Vesícula Biliar/cirurgia , Hepatectomia/mortalidade , Neoplasias Hepáticas/cirurgia , Excisão de Linfonodo/mortalidade , Recidiva Local de Neoplasia/cirurgia , Neoplasias Peritoneais/cirurgia , Adulto , Idoso , Estudos de Viabilidade , Feminino , Neoplasias da Vesícula Biliar/mortalidade , Neoplasias da Vesícula Biliar/patologia , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Neoplasias Peritoneais/mortalidade , Neoplasias Peritoneais/secundário , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida
15.
Surg Today ; 41(5): 660-6, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21533938

RESUMO

PURPOSE: Post-endoscopic retrograde cholangiopancreatography (ERCP) perforation usually resolves conservatively; however, intervention is sometimes needed, and there is a paucity of literature regarding the best management approach. We evaluated our experience of managing post-ERCP perforations to help define the role of surgery with percutaneous drainage (PCD). METHODS: A retrospective chart review revealed 14 cases of post-ERCP perforation with intra-abdominal sepsis referred for intervention. We analyzed data pertaining to clinical details, management, and outcome. RESULTS: There were 12 patients with duodenal perforation and 2 with biliary perforation. Most (10/14; 72%) had symptom onset within 48 h, but delayed diagnosis or referral resulted in a mean delay until intervention of 6.6 days (range 1-18 days). Computed tomography revealed localized collections in 9 (64%) patients. Seven patients with localized collections and no or minimal contrast leak underwent PCD and rest, and 7 underwent surgery. The indications for surgery were free perforation, generalized peritonitis, and major contrast leak. Overall morbidity was 50% and there was one early postoperative death, caused by severe sepsis. CONCLUSION: There should be a high index of suspicion of perforation when abdominal signs and symptoms develop after ERCP. Computed tomography is the investigation of choice for diagnosis and guiding therapy. With judicious selection of surgery or PCD based on clinical and imaging features, patients can be managed with acceptable morbidity and low mortality.


Assuntos
Sistema Biliar/lesões , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Drenagem/métodos , Duodeno/lesões , Ferimentos Penetrantes/terapia , Adolescente , Adulto , Idoso , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Ferimentos Penetrantes/cirurgia , Adulto Jovem
16.
World J Gastroenterol ; 17(11): 1475-9, 2011 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-21472107

RESUMO

AIM: To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection (AR) and its subsequent management. METHODS: Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection (LAR) to identify the various preoperative, operative, and post operative factors that might have influence on anastomotic leaks and strictures. RESULTS: There were 68 males and 40 females with an average of 47 years (range 21-75 years). The median distance of the tumor from the anal verge was 8 cm (range 3-15 cm). Sixty (55.6%) patients underwent handsewn anastomosis and 48 (44.4%) were stapled. The median operating time was 3.5 h (range 2.0-7.5 h). Sixteen (14.6%) patients had an anastomotic leak. Among these, 11 patients required re-exploration and five were managed expectantly. The anastomotic leak rate was similar in patients with and without diverting stoma (8/60, 13.4% with stoma and 8/48; 16.7% without stoma). In 15 (13.9%) patients, resection margins were positive for malignancy. Nineteen (17.6%) patients developed anastomotic strictures at a median duration of 8 mo (range 3-20 mo). Among these, 15 patients were successfully managed with per-anal dilatation. On multivariate analysis, advance age (> 60 years) was the only risk factor for anastomotic leak (P = 0.004). On the other hand, anastomotic leak (P = 0.00), mucin positive tumor (P = 0.021), and lower rectal growth (P = 0.011) were found as risk factors for the development of an anastomotic stricture. CONCLUSION: Advance age is a risk factor for an anastomotic leak. An anastomotic leak, a mucin-secreting tumor, and lower rectal growth predispose patients to develop anastomotic strictures.


Assuntos
Adenocarcinoma/cirurgia , Adenoma/cirurgia , Fístula Anastomótica/etiologia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Neoplasias Retais/cirurgia , Grampeamento Cirúrgico/efeitos adversos , Técnicas de Sutura/efeitos adversos , Adenocarcinoma/patologia , Adenoma/patologia , Adulto , Fatores Etários , Idoso , Fístula Anastomótica/cirurgia , Distribuição de Qui-Quadrado , Constrição Patológica , Feminino , Humanos , Índia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Dig Surg ; 27(5): 375-9, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-20948214

RESUMO

BACKGROUND: The incidence and pattern of bile duct injury (BDI) may be underreported because of the heterogeneous referral from multiple institutions. METHODS: Retrospective analysis of data from 5,782 cholecystectomies performed between 1989 and 2007 was done. BDI were categorized into Strasberg types. RESULTS: Fifty-seven (1%) patients sustained BDI. Ten of 57 (18%) patients had minor BDI (type A-10), 25/57 (44%) had major BDI (type C-3, type D-14, type E-8) and BDI could not be classified in the remaining 22/57 (39%) patients. Twenty-one of 25 (84%) major BDI were detected at operation - 21/57 (37%) injuries were detected and repaired intra-operatively. The other 36/57 (63%) injuries were detected after operation - 11 were managed expectantly, 5 had endoscopic stenting, 3 underwent percutaneous drainage of bilioma, 1 had a laparoscopic clipping of the subvesical duct, 4 underwent laparotomy and 12 required a combination of interventions. Five of the 57 (9%) patients died. At follow-up, 1 patient developed bile duct stricture which was managed endoscopically. All other patients were doing well at the last follow-up. CONCLUSIONS: In experienced centers, most of the major BDI can be detected and managed during cholecystectomy. Good results can be achieved by judicious selection of a combination of interventions in the majority of patients.


Assuntos
Ductos Biliares/lesões , Ductos Biliares/cirurgia , Colecistectomia Laparoscópica/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Incidência , Complicações Intraoperatórias/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Stents , Resultado do Tratamento , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/cirurgia , Adulto Jovem
18.
J Med Case Rep ; 4: 257, 2010 Aug 10.
Artigo em Inglês | MEDLINE | ID: mdl-20698946

RESUMO

INTRODUCTION: Varices of the colon are a rare cause of lower gastrointestinal bleeding, usually associated with portal hypertension due to liver cirrhosis or other causes of portal venous obstruction. Idiopathic colonic varices are extremely rare. Recognition of this condition is important as idiopathic colonic varices may be a cause of recurrent lower gastrointestinal bleeding. CASE PRESENTATION: We report the case of a 21-year-old Asian man from north India who presented with recurrent episodes of lower gastrointestinal bleeding. Colonoscopy revealed varices involving the terminal ileum and colon to the sigmoid. Thorough evaluation was undertaken to rule out any underlying portal hypertension. Our patient underwent subtotal colectomy including resection of involved terminal ileum and an ileorectal anastomosis. CONCLUSION: Colonic varices are an uncommon cause of lower gastrointestinal bleeding. Idiopathic colonic varices are diagnosed after excluding underlying liver disease and portal hypertension. Recognition of this condition is important as prognosis is good in the absence of liver disease and is curable by resection of the involved bowel.

19.
Int J Surg ; 7(2): 155-8, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19264566

RESUMO

To assess the outcome of esophageal resection in a patient with achalasia cardia. Retrospective analysis of 20 cases who underwent single or two stage esophageal resection for achalasia cardia. Total of 33 patients were treated surgically for achalasia cardia between 1989 and 2006. Twenty of these patients underwent esophageal resection. There were 13 males and seven females with a median age of 41 years (range 27-73 years). Patients were divided into two groups for description, one who underwent esophageal resection for end stage achalasia and another who underwent esophageal resection for iatrogenic esophageal perforations following pneumatic balloon dilatation.


Assuntos
Acalasia Esofágica/cirurgia , Adulto , Idoso , Perfuração Esofágica/cirurgia , Esofagectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
20.
J Gastrointest Surg ; 12(5): 836-41, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18266047

RESUMO

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures. METHODS: A review of a prospectively maintained database for XGC was performed. RESULTS: Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection-CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy. CONCLUSION: Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.


Assuntos
Colangite/diagnóstico , Doenças do Ducto Colédoco/diagnóstico , Granuloma/diagnóstico , Xantomatose/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangite/cirurgia , Colecistite/diagnóstico , Colecistite/cirurgia , Doenças do Ducto Colédoco/cirurgia , Diagnóstico Diferencial , Feminino , Granuloma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Xantomatose/cirurgia
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