Incidentally Detected Gallbladder Carcinoma: Can F-18 FDG PET/CT Aid in Staging and Prognostication?

Purpose: Incidental gallbladder carcinoma (IGBC) is diagnosed in post-cholecystectomy specimens for benign indications, where the role of 2-fluro-2-deoxyglucose positron emission tomography/computed tomography(FDG-PET/CT) is not clearly defined. The present study aimed to assess the benefits of staging and prognosticating with FDG-PET/CT in IGBC. Materials and Methods: A retrospective observational study from a tertiary-care center from January 2010 to July 2020 was performed. The demographic, clinical, histopathological, and treatment-related histories were collected. FDG-PET/CT-image findings were compared with survival outcomes through telephonic follow-up. The chi-square test was used for comparing frequencies. The univariate and multivariate survival estimates were analyzed using the Kaplan-Meier analysis and the Cox-proportional hazard model, respectively. Log-rank test was used to compare the Kaplan-Meier curves. Results: The study included 280 postcholecystectomy participants (mean age: 52 ± 11 years; women: 227) of whom 52.1% had open surgery(146/280). Residual disease in the gallbladder fossa (54.8% vs. 36.6%, p = 0.002) and liver infiltration (32.9% vs. 22.4%, p = 0.05) were seen more frequently in open surgery compared to laparoscopic surgery, while anterior abdominal wall deposits were more common in laparoscopy(35.1% vs. 24%,p = 0.041). FDG-PET/CT changed the management in 10% (n = 28) of patients compared to contrast-enhanced CT. The median survival was 14 months (95%CI-10.3-17.7). A higher stage of the disease on the FDG-PET/CT (loco-regional disease-HR 4.86, p = 0.006; metastatic disease-HR 7.53, p < 0.001) and the presence of liver infiltration (HR-1.92, p = 0.003) were independent predictors of poor survival outcomes. Conclusion: FDG-PET/CT detects residual and metastatic disease in patients with IGBC, enabling the institution of appropriate management and acting as a tool for prognostication of survival.

Hepatic alveolar echinococcosis simulating metastatic malignancy.

Echinococcosis is a parasitic disease caused by infection with tiny tapeworms of the genus Echinococcus. Echinococcosis is classified as either cystic echinococcosis or alveolar echinococcosis. The common form is a zoonosis from goats and sheep that tends to cause liver lesions. The larval stage of Echinococcus multilocularis causes alveolar echinococcosis/alveolar hydatid disease. It is a zoonosis with field mice and tundra voles as intermediate and wild carnivores like foxes and wolves as definitive hosts. This zoonosis is highly uncommon compared to the other form known as cystic echinococcosis but poses a great human threat if untreated. We report the case of a young man who was working in the Kashmir Valley, North India, and presented with jaundice and right upper quadrant abdominal pain. Computed tomography revealed a large solid-cystic intrahepatic lesion measuring 125x118x123 mm, suggestive of a malignant tumor with central necrosis. A liver biopsy showed necrosis with PAS-positive membranes morphologically consistent with echinococcosis. Alveolar echinococcosis can present as a solid-cystic mass in the liver and can simulate metastatic malignancy.

Proposal for a new morphological "combined type" of gallbladder cancer: description of radiopathological characteristics and comparison with other morphological types.

OBJECTIVE: To describe the radiopathological characteristics of a new morphological "combined type" of gallbladder cancer (GBC) and compare it with the mass replacing gallbladder and thickening types of GBC. MATERIALS AND METHODS: The imaging and pathological details of consecutive patients with GBC between August 2020 and December 2022 were retrospectively reviewed. Two radiologists reviewed computed tomography/magnetic resonance imaging in consensus for the morphological type of GBC. The radiologists classified GBC as mass replacing gallbladder, wall thickening, and combined type. The combined type was defined as a mass arising from the thickened wall of an adequately distended gallbladder that extended exophytically into the adjacent liver parenchyma. The presence of calculi, site, and size of lesion, biliary/portal vein involvement, liver, lymph node, and omental metastases was compared among the various types. The pathological characteristics were also compared. RESULTS: Of the 481 patients (median age 55 years, 63.2% females) included in the study, mass replacing gallbladder, wall thickening, and combined-type GBC were seen in 42.8% (206/481), 40.5% (195/481), and 16.6% (80/481) of patients, respectively. In the combined type of GBC, biliary/portal vein involvement was seen in 63.7% (51/80) and 7.5% (6/80) of patients. Liver, lymph node, and omental metastases were seen in 67.5% (54/80), 40% (32/80), and 41.2% (33/80) patients, respectively. Liver metastases were significantly more common in the combined type (p = 0.002). There were no significant differences in pathological characteristics among the various types. CONCLUSION: Combined-type GBC is less common than the mass replacing gallbladder and thickening types and is associated with a higher risk of liver metastases.

Elastography for Evaluation of Regression in Liver Fibrosis After Surgical Biliary Drainage for Benign Biliary Strictures: A Practical Possibility?

BACKGROUND: Hepatic fibrosis and secondary biliary cirrhosis are consequences of long-standing benign biliary strictures. Evidence on the reversibility of fibrosis after the repair is incongruous. METHODOLOGY: A prospective observational study on patients who underwent Roux-en-Y hepaticojejunostomy for benign biliary stricture. A liver biopsy was performed during repair and correlated with preoperative elastography. The improvement in liver functions and regression of fibrosis was compared with preoperative liver function tests and elastography. RESULTS: A Total of 47 patients [mean age-38.9 y (Range: 21 to 66)] with iatrogenic benign biliary stricture were included. A strong female preponderance was noted. High strictures (type III and IV) comprised 72.7% of the study group. The median interval (injury to repair) was 7 months (2 to 72 mo). The median duration of jaundice was 3 months (1 to 20 mo). Both factors had a significant correlation with the stage of fibrosis ( P =0.001 and P =0.03, respectively). Liver biopsy revealed stage I, II, III, and IV fibrosis in 26 (55.3%), 11 (23.4%), 2 (4.3%), and 2(4.3%), respectively. The remaining 6 (12.8%) had no fibrosis. The severity of fibrosis had a good correlation with preoperative liver stiffness measurement-value on FibroScan. Significant improvement in liver function tests (bilirubin-3.55±3.48 vs. 0.59±0.52; Albumin-3.85±0.61 vs. 4.14±0.37; ALP-507.66±300.65 vs. 167±132.07; P value 0.00) and regression of fibrosis (liver stiffness measurement; 10.42±5.91 vs. 5.85±3.01, P value 0.00) was observed after repair of the strictures. CONCLUSION: Improved biliary function and regression of liver fibrosis can be achieved with timely repair of benign biliary stricture and it is feasible to be evaluated using elastography.

Hepatic alveolar echinococcosis simulating metastatic malignancy

ABSTRACT Echinococcosis is a parasitic disease caused by infection with tiny tapeworms of the genus Echinococcus. Echinococcosis is classified as either cystic echinococcosis or alveolar echinococcosis. The common form is a zoonosis from goats and sheep that tends to cause liver lesions. The larval stage of Echinococcus multilocularis causes alveolar echinococcosis/alveolar hydatid disease. It is a zoonosis with field mice and tundra voles as intermediate and wild carnivores like foxes and wolves as definitive hosts. This zoonosis is highly uncommon compared to the other form known as cystic echinococcosis but poses a great human threat if untreated. We report the case of a young man who was working in the Kashmir Valley, North India, and presented with jaundice and right upper quadrant abdominal pain. Computed tomography revealed a large solid-cystic intrahepatic lesion measuring 125x118x123 mm, suggestive of a malignant tumor with central necrosis. A liver biopsy showed necrosis with PAS-positive membranes morphologically consistent with echinococcosis. Alveolar echinococcosis can present as a solid-cystic mass in the liver and can simulate metastatic malignancy.

Deep-learning models for differentiation of xanthogranulomatous cholecystitis and gallbladder cancer on ultrasound.

BACKGROUND: The radiological differentiation of xanthogranulomatous cholecystitis (XGC) and gallbladder cancer (GBC) is challenging yet critical. We aimed at utilizing the deep learning (DL)-based approach for differentiating XGC and GBC on ultrasound (US). METHODS: This single-center study comprised consecutive patients with XGC and GBC from a prospectively acquired database who underwent pre-operative US evaluation of the gallbladder lesions. The performance of state-of-the-art (SOTA) DL models (GBCNet-convolutional neural network [CNN] and RadFormer, transformer) for XGC vs. GBC classification in US images was tested and compared with popular DL models and a radiologist. RESULTS: Twenty-five patients with XGC (mean age, 57 ± 12.3, 17 females) and 55 patients with GBC (mean age, 54.6 ± 11.9, 38 females) were included. The performance of GBCNet and RadFormer was comparable (sensitivity 89.1% vs. 87.3%, p = 0.738; specificity 72% vs. 84%, p = 0.563; and AUC 0.744 vs. 0.751, p = 0.514). The AUCs of DenseNet-121, vision transformer (ViT) and data-efficient image transformer (DeiT) were significantly smaller than of GBCNet (p = 0.015, 0.046, 0.013, respectively) and RadFormer (p = 0.012, 0.027, 0.007, respectively). The radiologist labeled US images of 24 (30%) patients non-diagnostic. In the remaining patients, the sensitivity, specificity and AUC for GBC detection were 92.7%, 35.7% and 0.642, respectively. The specificity of the radiologist was significantly lower than of GBCNet and RadFormer (p = 0.001). CONCLUSION: SOTA DL models have a better performance than radiologists in differentiating XGC and GBC on the US.

Gastrointestinal involvement in gallbladder cancer: Computed tomography findings and proposal of a classification system.

BACKGROUND: There is relatively scarce data on the computed tomography (CT) detection of gastrointestinal (GI) involvement in gallbladder cancer (GBC). We aim to assess the GI involvement in GBC on CT and propose a CT-based classification. METHODS: This retrospective study comprized consecutive patients with GBC who underwent contrast-enhanced computed tomography (CECT) for staging between January 2019 and April 2022. Two radiologists evaluated the CT images independently for the morphological type of GBC and the presence of GI involvement. GI involvement was classified into probable involvement, definite involvement and GI fistulization. The incidence of GI involvement and the association of GI involvement with the morphological type of GBC was evaluated. In addition, the inter-observer agreement for GI involvement was assessed. RESULTS: Over the study period, 260 patients with GBC were evaluated. Forty-three (16.5%) patients had GI involvement. Probable GI involvement, definite GI involvement and GI fistulization were seen in 18 (41.9%), 19 (44.2%) and six (13.9%) patients, respectively. Duodenum was the most common site of involvement (55.8%), followed by hepatic flexure (23.3%), antropyloric region (9.3%) and transverse colon (2.3%). There was no association between GI involvement and morphological type of GBC. There was substantial to near-perfect agreement between the two radiologists for the overall GI involvement (k = 0.790), definite GI involvement (k = 0.815) and GI fistulization (k = 0.943). There was moderate agreement (k = 0.567) for probable GI involvement. CONCLUSION: GBC frequently involves the GI tract and CT can be used to categorize the GI involvement. However, the proposed CT classification needs validation.

Emergency surgical intervention in acute corrosive ingestion: single-center experience from India.

BACKGROUND: Surgical intervention for acute corrosive injury is often required. It is associated with considerable morbidity and mortality. Sparce data is available on the types and timing of surgery after acute corrosive ingestion and complications associated with the same. METHODS: This is a retrospective single-center study from a tertiary care center in India. All patients who underwent surgical exploration after acute corrosive intake between January 2003 and June 2014 were enrolled in the study. Data on patients' presentation, their endoscopic findings, indications of surgery, type of surgery and post-operative follow-up was retrieved. RESULTS: Out of 170 patients who presented with acute corrosive ingestion, 24 patients (14.11%) required emergency surgery. The mean interval between ingestion and surgery was 9.92 ± 9.03 days. Presence of peritonitis was the most common indication for surgery (n = 10; 41.7%) followed by mediastinitis (n = 7; 29.2%). A total of 17 resectional and 7 non-resectional procedures were performed. Thirteen (54%) patients succumbed to their illness post-operatively due to multi-organ failure (n = 9), refractory shock (n = 3) or pulmonary thromboembolism (n = 1). Patients with early surgery (≤7 days) after corrosive ingestion had similar mortality compared to patients with late surgery (>7 days) (50% versus 67%; P = 0.30). Of the 11 surviving patients, eight patients (72%) underwent successful reconstructive surgery on follow-up. CONCLUSIONS: Emergency surgery after corrosive ingestion carries high morbidity and mortality. However, after the initial stormy acute phase, majority of patients can undergo successful reconstructive surgery on follow-up.

Pancreatic Dysfunction and Reduction in Quality of Life Is Common After Pancreaticoduodenectomy.

BACKGROUND: Improvements in survival after pancreaticoduodenectomy has increased the number of patients potentially at risk of pancreatic insufficiency. AIMS: We studied long-term (> 1 year) pancreatic functions (endocrine and exocrine) after pancreaticoduodenectomy and aimed to recognize the impact of various clinicopathological factors and postoperative complications on pancreatic functions. METHODS: All patients who underwent pancreaticoduodenectomy at least 1 year prior were recruited from July 2020 to December 2021. Endocrine function was assessed using HbA1c, fasting blood sugar and postprandial blood sugar levels. Pancreatic exocrine function was assessed clinically with history of steatorrhea and objectively with quantitative estimation of fecal elastase-1 levels in stool samples. Volume of remnant pancreas, parenchymal thickness and duct diameter were assessed by computed tomography. Quality of life assessment was done using SF-36 questionnaire. RESULTS: Of the 106 patients assessed, 64 patients met the inclusion criteria. Endocrine insufficiency was noted in 51.6%, and 34.3% had new onset diabetes mellitus. The incidence of pancreatic exocrine insufficiency was 87.5% and severe insufficiency was found in 62.5% of patients. Twenty-nine (45.3%) patients had both exocrine and endocrine insufficiency. Patients with CRPOPF had higher risk of severe exocrine insufficiency (5 vs. 2, OR 1.57(0.28-8.81) p = 0.6). The SF-36 scores were lower than general population especially in role limitation due to physical health, role limitation due to emotional problems, energy/fatigue, general health perception and health change domains. CONCLUSION: Post-pancreaticoduodenectomy patients have a high frequency of pancreatic insufficiency and should be screened for same. The post-operative pancreatic fistula increases the risk of pancreatic exocrine insufficiency.

Negative pressure wound therapy versus standard care for incisional laparotomy subcutaneous wounds in gastrointestinal perforations: A randomized controlled study.

BACKGROUND: Surgical site infections after gastrointestinal perforation with peritonitis have significant morbidity, increased hospital stays, and cost of treatment. The appropriate management of these wounds is still debatable. METHODS: Patients undergoing surgery for gastrointestinal perforation with peritonitis via midline incision were screened for inclusion. After the closure of the midline fascia, patients were randomized into an open negative pressure wound therapy group (application of negative pressure wound therapy and attempted delayed closure at day 4) or a standard care group (no negative pressure wound therapy and attempted delayed closure at day 4). Postoperative outcomes, including surgical site infection till 30 days, were compared between the groups. This was assessed by an independent assessor not involved in the study for delayed closure. Although a priori sample size was calculated, an interim analysis was performed due to slow recruitment during the COVID pandemic. After interim analysis, a continuation of the trial was deemed unethical and terminated. RESULTS: Ninety-six patients were assessed, and 69 were randomized (34 in the negative pressure wound therapy group and 31 in the standard care group). The age, body mass index, comorbidities, blood loss, operative time, and stoma formation were comparable. The surgical site infection was significantly lower in the negative pressure wound therapy group compared to the standard care group (6 [18%] vs 19 [61%], P < .01). The number needed to prevent 1 surgical site infection was 2.3. In a subgroup analysis, the use of negative pressure wound therapy also significantly decreased the rate of surgical site infection in stoma patients (4 [30.7%] vs 9 [69.3%], P = .03). CONCLUSION: Open negative pressure wound therapy significantly decreases the incisional surgical site infection rate in patients with a dirty wound secondary to gastrointestinal perforation with peritonitis.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis.

PURPOSE: It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2 weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC). MATERIALS AND METHODS: This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7 days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups. RESULTS: One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031). CONCLUSION: Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

Multiparametric MR imaging with diffusion-weighted, intravoxel incoherent motion, diffusion tensor, and dynamic contrast-enhanced perfusion sequences to assess gallbladder wall thickening: a prospective study based on surgical histopathology.

OBJECTIVE: To investigate the diagnostic performance of a multiparametric magnetic resonance imaging (MRI) protocol comprising quantitative MRI (diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), diffusion tensor imaging (DTI), and dynamic contrast-enhanced (DCE) perfusion MRI) and conventional MRI in the characterization of gallbladder wall thickening (GWT). METHODS: This prospective study comprised consecutive adults with GWT who underwent multiparametric MRI between July 2020 and April 2022. Two radiologists evaluated the MRI independently. The final diagnosis was based on surgical histopathology. The association of MRI parameters with malignant GWT was evaluated. The area under the curve (AUC) for the quantitative MRI parameters and diagnostic performance of conventional, and multiparametric MRI were compared. The interobserver agreement between two radiologists was calculated. RESULTS: Thirty-five patients (mean age, 56 years, 23 females) with GWT (25 benign and ten malignant) were evaluated. The quantitative MRI parameters significantly associated with malignant GWT were apparent diffusion coefficient on DWI (p = 0.007) and mean diffusivity (MD) on DTI (p = 0.013), perfusion fraction (f) on IVIM (p = 0.033), time to peak enhancement (TTP, p = 0.008), and wash in rate (p = 0.049) on DCE-MRI. TTP had the highest AUC of 0.790, followed by MD (0.782) and f (0.742) (p = 0.213) for predicting malignant GWT. Multiparametric MRI had significantly higher sensitivity (90% vs. 80%, p = 0.045) than conventional MRI for diagnosing malignant GWT. The two radiologists' reading had substantial to near-perfect agreement (kappa = 0.639-1) and moderate to strong correlation (interclass correlation coefficient = 0.5-0.88). CONCLUSION: Multiparametric protocol incorporating advanced sequences improved the diagnostic performance of MRI for differentiating benign and malignant GWT. KEY POINTS: • Multiparametric MRI had 90% sensitivity and 88% specificity for diagnosing malignant GWT, compared to 80% sensitivity and 88% specificity for conventional CE-MRI. • Among the quantitative MRI parameters, TTP (perfusion-MRI) had the highest AUC of 0.790, followed by MD (0.782) and IVIM-f (0.742). • For most quantitative MRI parameters, there was moderate to strong agreement (ICC = 0.5-0.88).

Dynamics of Serum Procalcitonin Can Predict Outcome in Patients of Infected Pancreatic Necrosis: A Prospective Analysis.

BACKGROUND: Timely intervention can alter outcome in patients of infected pancreatic necrosis (IPN) but lacks adequate biomarker. Role of serum procalcitonin (PCT) in the management of IPN is understudied, and hence, this study was planned. METHODOLOGY: All patients of acute pancreatitis with IPN without prior intervention were included. Baseline demographic, radiological and laboratory parameters were documented. PCT was measured at baseline, prior to intervention, and thereafter every 72 h. Patients were grouped into those having baseline PCT < 1.0 ng/mL and those with PCT ≥ 1.0 ng/mL and various outcome measures were compared. RESULTS: Of the 242 patients screened, 103 cases (66 males; 64.1%) with IPN were grouped into 2: PCT < 1.0 ng/mL (n = 29) and PCT ≥ 1.0 ng/mL (n = 74). Patients with baseline PCT ≥ 1.0 ng/mL had significantly more severe disease scores. 16 out of 19 patients with rise in PCT on day-7 post-intervention expired. PCT ≥ 1.0 ng/mL group had higher need for ICU (p = 0.001) and mortality (p = 0.044). PCT > 2.25 ng/mL (aOR 22.56; p = 0.013) at baseline and failure in reduction of PCT levels to < 60% of baseline at day-7 post-intervention (aOR 53.76; p = 0.001) were significant mortality predictors. CONCLUSION: Baseline PCT > 1.0 ng/mL is associated with poor outcome. PCT > 2.25 ng/mL and failure in reduction of PCT levels to < 60% of its baseline at day-7 post-intervention can identify high-mortality risk patients.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India.

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Role of inflammatory and nutritional markers in predicting complications after pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy is associated with considerable morbidity and mortality rates. Early recognition of patients likely to develop severe postoperative complications will allow the timely commencement of a tailored approach. This study aimed to predict postoperative complications using inflammatory and nutritional markers measured early in the postoperative period. METHODS: Patients who underwent pancreaticoduodenectomy between June 2019 and November 2020 were included in the study. Postoperative pancreatic fistula, delayed gastric emptying, and postoperative pancreatic hemorrhage were graded according to the International Study Group of Pancreatic Fistula and the International Study Group of Pancreatic Surgery. We also documented other complications such as wound infection, intra-abdominal collection, and nonsurgical complications. Nutritional and inflammatory markers were analyzed on postoperative days 1 and 3. Patients were followed up for 30 days or until discharge, depending on which was longer. RESULTS: Of the 58 enrolled patients, 51 were included in the study. The incidence of postoperative pancreatic fistula was 51% (clinically relevant postoperative pancreatic fistula 27.4%), delayed gastric emptying was 80.4% (clinically relevant delayed gastric emptying 43%), postoperative pancreatic hemorrhage was 3.9%, intra-abdominal collection was 23.5%, and wound infection was 29.4%. The median drain fluid interlukin-6 levels on postoperative day 1 and postoperative day 3 were significantly higher in patients developing clinically relevant postoperative pancreatic fistula than in those who did not develop clinically relevant postoperative pancreatic fistula on postoperative day 1 (211 [125, 425] fg/dL vs 99 [15, 170] fg/dL, [P = .045]) and on postoperative day 3 (110 [22, 28] fg/dL vs 10 [1.8, 45] fg/dL [P = .002]). Patients who tested negative for urine trypsinogen-2 on postoperative day 3 had a significantly lower probability of developing clinically relevant postoperative pancreatic fistula than those who tested positive (1 vs 24 [P < .001]). A model comprising both drain fluid interlukin-6 and urine trypsinogen-2 on postoperative day 3 definitively ruled out the occurrence of clinically relevant postoperative pancreatic fistula. CONCLUSION: Drain fluid interlukin-6 and urine trypsinogen-2 on postoperative day 3 ruled out the occurrence of clinically relevant postoperative pancreatic fistula.

Contrast-enhanced ultrasound of solid pancreatic head lesions: a prospective study.

OBJECTIVE: To evaluate the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of solid pancreatic head lesions (SPHL). METHODS: This prospective study comprised consecutive patients with SPHL who underwent CEUS evaluation of the pancreas. Findings recorded at CEUS were enhancement patterns (degree, completeness, centripetal enhancement, and percentage enhancement) and presence of central vessels. In addition, time to peak (TTP) and washout time (WT) were recorded. The final diagnosis was based on histopathology or cytology. Multivariate analysis was performed to identify parameters that were significantly associated with pancreatic ductal adenocarcinoma (PDAC). RESULTS: Ninety-eight patients (median age 53.8 years, 59 males) were evaluated. The final diagnosis was PDAC (n = 64, 65.3%), inflammatory mass (n = 16, 16.3%), neuroendocrine tumor (NET, n = 14, 14.3%), and other tumors (n = 4, 4.1%). Hypoenhancement, incomplete enhancement, and centripetal enhancement were significantly more common in PDAC than non-PDAC lesions (p = 0.001, p = 0.031, and p = 0.002, respectively). Central vessels were present in a significantly greater number of non-PDAC lesions (p = 0.0001). Hypoenhancement with < 30% enhancement at CEUS had sensitivity and specificity of 80.6% and 67.7%, respectively, for PDAC. There was no significant difference in the TTP and WT between PDAC and non - PDAC lesions. However, the WT was significantly shorter in PDAC compared to NET (p = 0.011). In multivariate analysis, lack of central vessels was significantly associated with a PDAC diagnosis. CONCLUSION: CEUS is a useful tool for the evaluation of SPHL. CEUS can be incorporated into the diagnostic algorithm to differentiate PDAC from non-PDAC lesions. KEY POINTS: • Hypoenhancement and incomplete enhancement at CEUS were significantly more common in PDAC than in non-PDAC. • Central vessels at CEUS were significantly associated with PDAC. • There was no difference in TTP and WT between PDAC and non-PDAC lesions.

Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy.

Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.

Value of neutrophil-lymphocyte ratio in evaluating response to percutaneous catheter drainage in patients with acute pancreatitis.

BACKGROUND: Early prediction of response to percutaneous catheter drainage (PCD) of necrotic collections in acute pancreatitis (AP) using simple and objective tests is critical as it may determine patient prognosis. The role of white blood cell (WBC) count and neutrophil-lymphocyte ratio (NLR) has not been assessed as a tool of early prediction of PCD success and is the focus of this study. AIM: To assess the value of WBC and NLR in predicting response to PCD in AP. METHODS: This retrospective study comprised consecutive patients with AP who underwent PCD between June 2018 and December 2019. Severity and fluid collections were classified according to the revised Atlanta classification and organ failure was defined according to the modified Marshall Score. WBC and NLR were monitored 24 h prior PCD (WBC-0/NLR-0) and 24 h (WBC-1/NLR-1), 48 h (WBC-2/NLR-2) and 72 h (WBC-3/NLR-3) after PCD. NLR was calculated by dividing the number of neutrophils by the number of lymphocytes. The association of success of PCD (defined as survival without the need for surgery) with WBC and NLR was assessed. The trend of WBC and NLR was also assessed post PCD. RESULTS: One hundred fifty-five patients [median age 40 ± 13.6 (SD), 64.5% males, 53.5% severe AP] were included in the final analysis. PCD was done for acute necrotic collection in 99 (63.8%) patients and walled-off necrosis in 56 (36.1%) patients. Median pain to PCD interval was 24 ± 69.89 d. PCD was successful in 109 patients (group 1) and 46 patients (group 2) who failed to respond. There was no significant difference in the baseline characteristics between the two groups except the severity of AP and frequency of organ failure. Both WBC and NLR showed an overall decreasing trend. There was a significant difference between WBC-0 and WBC-1 (P = 0.0001). WBC-1 and NLR-1 were significantly different between the two groups (P = 0.048 and 0.003, respectively). The area under the curve of WBC-1 and NLR-1 for predicting the success of PCD was 0.602 and 0.682, respectively. At a cut-off value of 9.87 for NLR-1, the sensitivity and specificity for predicting the success of PCD were calculated to be 75% and 65.4% respectively. CONCLUSION: WBC and NLR can be used as simple tests for predicting response to PCD in patients with acute necrotizing pancreatitis.

Outcome Following Percutaneous Transhepatic Biliary Drainage (PTBD) in Carcinoma Gallbladder: a Prospective Observational Study.

INTRODUCTION: Percutaneous biliary drainage (PTBD) is required as palliation and optimization for surgery or chemotherapy in carcinoma gallbladder (GBC) but may be associated with complications. We aimed to study the outcomes, complications, and changes in quality of life in patients with GBC undergoing PTBD. METHODS: A prospective study from July 2018 to December 2019 in patients of GBC presenting with obstructive jaundice was done. Patients planned for PTBD were included in the study. The progression of the disease, complications of PTBD, reinterventions, effects on initiation or completion of chemotherapy, surgical resection or intervention, and overall survival were recorded. Quality of life (QoL) was assessed using the SF-36 questionnaire before and after 4-6 weeks of intervention. RESULTS: Of 160 patients assessed for inclusion, 60 (mean age 53.7 ± 10.95 years, 27 (45%) males) were eventually included. Eleven patients (18.3%) had metastatic disease at presentation. Of 60 patients undergoing PTBD, none had immediate procedure-related complications, 41 (68%) patients had at least one, and 18 (30%) patients had more than one complication. The most common complication was peri-catheter bile leak (41.6%), followed by catheter dislodgement (30%), blockage (23.3%), and bleeding (10%). Reintervention was required in 32 (53%) patients. There was a significant decrease in QoL after PTBD (P < 0.0001). Median survival after PTBD was 12 weeks. CONCLUSION: The high technical success of PTBD does not translate into the improvement of QoL.