Peri-operative outcomes of pancreaticoduodenectomy comparing an isolated Roux loop or single loop for reconstruction: An ambispective observational study.

BACKGROUND: A post-operative pancreatic fistula is a major cause of morbidity and mortality in patients undergoing pancreaticoduodenectomy. We compared two methods of reconstruction of pancreaticojejunal anastomosis, an isolated loop with a single loop, to assess their effects on the incidence and severity of fistula. METHODS: The data was collected in an ambispective manner. The drain fluid was sent for amylase measurement on post-operative day 3 and a fistula was defined and classified according to the 2016 modification of the International Study Group for Pancreatic Surgery definition. The patients were divided into the isolated (Group I) and single (Group II) loop groups and compared for the incidence and severity of clinically relevant fistula along with other parameters. RESULTS: A total of 349 (Group I: 201, Group II: 148) patients were included in the study. The incidence of clinically relevant fistula was comparable (p = 0.206). Grade C fistula was found to be lower in the group I (7 % vs 11.6 %, p = 0.137), in patients with a soft pancreas (8.5 % vs 18.3 %, p = 0.049) and pancreatic duct diameter less than 5 mm (9.8 % vs 17.2 %, p = 0.036). The operative time was lower in Group I than in Group II (438 min vs 478, p < 0.001). CONCLUSION: We found that the incidence of clinically relevant fistula was similar in both the groups but the isolated reconstruction method reduced the incidence of severe fistula. In patients with a smaller pancreatic duct, soft pancreas echotexture and obesity, it provides a safer alternative and can be performed in less time than a single loop reconstruction.

A Comparison Between the Comprehensive Complication Index and the Clavien-Dindo Grading as a Measure of Postoperative Outcome in Patients Undergoing Gastrointestinal Surgery-A Prospective Study.

BACKGROUND: The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD to assess which of the two was a better measure of postoperative outcomes. MATERIALS AND METHODS: Between June 2015 and December 2016, we recorded the complications using CD grading and CCI in 1000 consecutive patients in our gastrointestinal and hepatopancreaticobiliary surgery unit. The outcome variables studied were postoperative length of hospital stay (LOS), postoperative intensive care unit (ICU) stay, and time to normal activity. The results were expressed as strength of correlation and predictive accuracy of the outcome variables. RESULTS: There were 600 males and 400 female patients, with a mean age of 50.3 y. A total of 788 (78.8%) elective and 212(21.2%) emergency procedures were performed. The overall 90-day/in-hospital mortality was 7.9%. Both CD and CCI showed a good correlation with LOS (r = 0.58; P = 0.001, r = 0.57; P = 0.001), ICU stay (r = 0.62; P = 0.002, r = 0.62; P = 0.001), and time to normal activity (r = 0.48; P = 0.01; r = 0.49; P = 0.01). The accuracy of CCI to predict the LOS (area under the curve [AUC] = 0.89; P < 0.001), ICU stay (AUC = 0.85; P < 0.001), and time to normal activity (AUC = 0.76; P < 0.001) was comparable to that of CD (AUC = 0.90; P < 0.001, AUC = 0.87; P < 0.001, AUC = 0.77; P < 0.001). CONCLUSIONS: Both CD and CCI were equally accurate in measuring the postoperative outcomes and in their ability to predict the same in patients undergoing gastrointestinal and hepatopancreaticobiliary surgeries. Considering the relative ease of determination of CD, it remains a more commonly used measure for assessing the severity of complications and outcomes compared to CCI.

Effect of Remote Ischaemic Preconditioning on Liver Injury in Patients Undergoing Major Hepatectomy for Colorectal Liver Metastasis: A Pilot Randomised Controlled Feasibility Trial.

BACKGROUND: Liver resection produces excellent long-term survival for patients with colorectal liver metastases but is associated with significant morbidity and mortality from ischaemia reperfusion injury (IRI). Remote ischaemic preconditioning (RIPC) can reduce the effect of IRI. This pilot randomised controlled trial evaluated RIPC in patients undergoing major hepatectomy at the Royal Free Hospital, London. METHODS: Sixteen patients were randomised to RIPC or sham control. RIPC was induced through three 10-min cycles of alternate ischaemia and reperfusion to the leg. At baseline and immediately post-resection, transaminases and indocyanine green (ICG) clearance were measured. FINDINGS: The RIPC group had lower ALT and AST levels immediately post-resection (ALT: 43% lower 497 ± 165 vs 889 ± 170 IU/L; p = 0.019 AST: 54% lower 408 ± 166 vs 836 ± 167 IU/L; p = 0.001) and at 24 h (ALT: 41% lower 412 ± 144 vs 698 ± 137 IU/L; p = 0.026 AST: 50% lower 316 ± 116 vs 668 ± 115 IU/L; p = 0.02). ICG clearance was reduced in controls versus RIPC immediately after resection (ICG-PDR: 11.1 ± 1.1 vs 16.5 ± 1.4%/min; p = 0.035). CONCLUSIONS: This pilot study shows that RIPC has potential to reduce liver injury following hepatectomy justifying a prospective RCT powered to demonstrate clinical benefits.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations.

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Cystic lesions of the adrenal gland.

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively.

Obstructing primary squamous cell carcinoma of caecum: A case report.

Squamous cell carcinoma (SCC) of the colon is a rare malignancy and usually a pathological surprise. Clinical presentation is usually very similar to adeno carcinoma variety. We report a case of a 56 year old male with primary SCC of caecum presenting as small bowel obstruction and managed with surgery and adjuvant chemotherapy. It was labelled as primary SCC after extensive search for other primary malignant SCC in body with possible metastasis to caecum. Due to rarity of the disease and lack of literature standardized protocols for neo-adjuvant and adjuvant therapy are not available.

Liver Transplant Society of India Guidelines for Liver Transplant During COVID-19 times.

Coronavirus disease-2019 (COVID-19) pandemic has affected liver transplantation in many ways. There is risk of infection to the transplant recipients; and COVID-19 is associated with significant risk of mortality in patients on wait list. The Liver Transplant Society of India (LTSI) has prepared guidelines regarding selection of adult and pediatric patients for liver transplantation, transplant for acute liver failure, use of deceased donor organs, transplant techniques and minimally invasive donor hepatectomy, pre- and postsurgery testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related coronavirus disease 2019 in donors and recipients, role of COVID-19 antibody testing, shifting of recipients from COVID-19 to non-COVID-19 areas after recovery, isolation policy of team members exposed to COVID-19 patients, drug therapy of proven or suspected COVID-19 infection early posttransplant, care of SARS-CoV-2 positive donors and recipients and a separate COVID-19 consent for surgery.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience.

INTRODUCTION: The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. METHOD: We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. RESULTS: Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2-15 cm). The tumour extent was defined as 'borderline resectable' in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. CONCLUSION: SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

Whipple's Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience.

INTRODUCTION: Whipple's pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple's PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child's A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child's B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. CONCLUSION: Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple's PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report.

INTRODUCTION AND IMPORTANCE: Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. CASE PRESENTATION: A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. CLINICAL DISCUSSION: The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. CONCLUSION: The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

BACKGROUND: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. PATIENTS AND METHODS: We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. RESULTS: A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) - the proportion increased significantly from 23% in 1996-2004 to 51.6% in 2013-2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). CONCLUSION: The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome.

BACKGROUND: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. METHODS: We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. RESULTS: Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. CONCLUSION: PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.

Successful Resection in a Case of Hepatocellular Carcinoma Masquerading as Hilar Cholangiocarcinoma: A Case Report.

Obstructive jaundice in the setting of a hilar mass raises strong suspicion of a cholangiocarcinoma, with diagnosis usually made on imaging. Jaundice, when present in patients with hepatocellular carcinoma, is mostly related to underlying liver disease (i.e. cirrhosis) and only rarely to diffuse tumor infiltration of liver parenchyma or hilar invasion. We report here the good outcome of a 67 year-old patient who presented with obstructive jaundice, underwent surgery and was given a diagnosis of hepatocellular carcinoma, which was made only at histopathological examination of resected specimen.

Living donor intestinal transplant using a standardized technique: first report from India.

AIM: We describe the first living donor intestinal transplant (LDIT) in India and discuss the indications and problems of this complex procedure. METHODS: A 43-year-old male patient required massive bowel resection for gangrene due to thrombosis of the superior mesenteric artery. He was maintained on parenteral nutrition but developed cholestasis and well as repeated catheter related infections with progressive loss of venous access due to thrombosis of central veins. A LDIT was performed using 200 cm of small intestine from the patient's son. The graft was based on the continuation of the superior mesenteric vessels beyond the ileocolic branch. The artery was anastomosed directly to the aorta and the vein to the venacava. RESULTS: The graft functioned well and he was weaned off parenteral nutrition. However, he later developed complications (wound dehiscence and enterocutaneous fistula) and developed sepsis. He succumbed to sepsis with a functioning graft 6 weeks after the transplant. The donor recovered uneventfully and was discharged on the 4th postoperative day. CONCLUSIONS: LDIT can be life saving in patients with intestinal failure and failure of parenteral nutrition. There is a need to introduce this modality in India. In a setting of scarcity of deceased donor organs the living donor option has advantages.