Recurrent giant retroperitoneal liposarcoma: Review of literature and a rare case report.

INTRODUCTION AND IMPORTANCE: Retroperitoneal liposarcomas (RPLS) are usually grow large with frequent recurrences. Complete surgical excision remains the gold standard treatment for primary and even recurrent tumours. Their prognosis depends on their histological type and grade. We report a recurrent giant de-differentiated RPLS weighing 18.55 kg which was completely excised. To the best of our knowledge, this is one of the largest liposarcoma reported in the literature. CASE PRESENTATION: A 40 year old female presented with a gradually progressing large abdominal lump for 1year. She had had a similar large lump twice in the past and undergone excision of the tumour elsewhere. Firm non-tender mass felt all over abdomen with edema noted over abdominal wall and bilateral lower limbs. PET CT showed large heterogeneously enhancing mass occupying almost the entire abdominopelvic cavity. 50 × 40 × 40cm tumour was completely excised and biopsy showed grade 2 dedifferentiated liposarcoma (DDLS). She is under close follow up with no recurrence at 12months. CLINICAL DISCUSSION: DDLS have lower risk of distant metastases but have a high risk of local recurrence. The most important favourable prognostic factor in these tumours is complete resection with negative margins. Because of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS. CONCLUSION: The dedifferentiated subtype should be suspected in locally aggressive RPLS. Close follow up with early detection of recurrences and prompt excision with negative margins lowers the risk of recurrences and improves survival.

Abdominal packing for surgically uncontrollable haemorrhage.

BACKGROUND: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82% due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. PATIENTS AND METHODS: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years). The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were: liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). RESULTS: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <34 degrees C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. CONCLUSION: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.

Post hepatectomy liver failure - A comprehensive review of current concepts and controversies.

Post hepatectomy liver failure (PHLF) comprises of a conundrum of symptoms and signs following major hepatic resections. The pathophysiology essentially revolves around disruption of the normal hepatocyte regeneration and disturbed liver homeostasis. Prompt identification of the pre-operative predictors of PHLF in the form of biochemical parameters and imaging features are of paramount importance for any hepatic surgeon and forms the cornerstone of its management. Treatment revolves around a goal-directed resuscitation of the systemic organ failure. Auxiliary support systems such as liver dialysis devices and stem cell therapy are still under investigational trials for treatment of the same. Orthotopic liver transplantation (OLT) is the last resort in most cases not responding to other measures.

Effect of informed consent on patients undergoing gastrointestinal surgery and living donor liver transplantation and on their relatives in a developing country.

BACKGROUND: Informed consent is a systematic process for obtaining permission before conducting a healthcare intervention. In a developing country, gaining informed consent is generally perceived to be a ritual only to comply with legal requirements. The present study examined this by assessing the process of informed consent in patients undergoing gastrointestinal surgery or living donor liver transplantation (LDLT) and their relatives, based on their comprehension and overall satisfaction, in India. METHODS: All patients undergoing any gastrointestinal surgery or LDLT procedure between August 2015 and July 2016 and their relatives were included, and were administered a structured questionnaire 5 days after the procedure. RESULTS: The majority of patients (94·2 per cent) could recall the nature of their disease, the surgery performed (81·6 per cent) and anticipated complications (55·6 per cent). Among their relatives, these proportions were 97·8, 87·3 and 58·5 per cent respectively. Recall was associated with age, occupation and education among both patients and relatives. Patients undergoing LDLT, their donors and their relatives had better recall than those who had other gastrointestinal procedures (P < 0·001). Many patients found the process of informed consent useful and reassuring. CONCLUSION: The details and risks of an operation were understood by most of the patients, especially those undergoing liver transplantation. Patients from developing countries can generally understand 'informed consent', and value it.

Minimizing Hepatic Artery Thrombosis and Establishing Safety of Grafts With Dual Arteries in Living Donor Liver Transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) is a dreaded complication following living donor liver transplantation (LDLT) and can lead to graft failure and biliary complications. We evaluated the results of our arterial anastomotic technique and outcomes in grafts with dual arterial supply. PATIENTS AND METHODS: Between July 2010 and June 2015, 225 patients underwent LDLT. The hepatic artery anastomosis was done using our "W technique". In grafts with a dual arterial supply, two anastomoses were performed unless there was significant pulsatile back-bleeding in the smaller artery after the larger anastomosis. RESULTS: The mean age of the recipients was 43±15.2 years (6 months to 66 years). There were 184 right liver, 30 left liver, 10 left lateral segment, and 1 dual lobe (right liver and left lateral segment) grafts. Twenty-three (10.2%) patients had 2 graft arteries, 10 of which required 2 separate anastomoses, and an interposition saphenous vein conduit was used in one. HAT occurred in 3 (1.3%) patients. The median intensive care unit and postoperative hospital stays were 5 and 14 days, respectively. Post-transplant operative mortality was 12.4%. There was no difference in mortality (8.7% vs 12.4%, P = >.99) and biliary complications (11.9% vs 21.7%, P = .19) between recipients of grafts with single or dual graft arteries, respectively. CONCLUSIONS: A careful surgical "W technique" and intraoperative confirmation of a good arterial flow helps in reducing the incidence of early HAT. The presence of two arteries in the graft was not associated with increased incidence of HAT, mortality, or biliary complications.

Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India.

BACKGROUND: Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures. METHODS: We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated. RESULTS: Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3%) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4-60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40%), asymptomatic elevation of liver enzymes in four (40%) and jaundice in two patients (20%). The median time from transplantation to the detection of the stricture was 12 months (2-42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2-5) endoscopic sessions and 3.4 (1-6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2-12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7-11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis. CONCLUSIONS: Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.

Do the progesterone receptors have a role to play in gallbladder cancer?

BACKGROUND: Gallstone disease as well as gallbladder cancer are more common in women and female sex hormones may be involved in their etiology. AIM AND METHODS: To determine whether female sex hormones have a role in the pathogenesis, of gallbladder carcinoma and in its prognosis, we estimated, by enzyme immunoassay, the estrogen and progesterone receptors (ER and PgR) in the gallbladders of 21 patients with gallbladder cancer, 19 patients with cholelithiasis, and 6 patients who underwent incidental removal of essentially normal gallbladder as a component of wider resection. RESULTS: ER were present in the gallbladder mucosa in all the three groups in proportions which were not significantly different (9/21 in carcinoma, 4/19 in gallstones, and 1/6 normal), whereas the expression of PgR was greater in carcinomas (13/18), less in cholelithiasis (4/12), and absent in normal gallbladders. PgR expression was higher in tumors of lower stage (7/7) and lower in advanced disease stage IV tumors (6/11). PgR expression was associated with better disease stage (p=0.05) and significantly longer overall survival (median survival of 301 d vs 54 d) as well as better survival within the same stage (269 d vs 54 d for stage IV disease, p=0.011). Cox's regression analysis showed that PgR was an independent risk factor (R=0.2283, p=0.0035). CONCLUSIONS: Our findings suggest that the female sex hormones may have a role in the pathogenesis of gallbladder cancer and that PgR expression has a prognostic significance. We believe that when this relationship is reaffirmed by larger studies, gallbladder cancer may be treated with appropriate sex hormonal manipulation.

Evaluation of Pringle maneuver during liver resection in a rat model of surgical obstructive jaundice.

Temporary portal triad clamping (Pringle maneuver) during liver resection reduces intraoperative blood loss. A normal liver can safely tolerate normothermic ischemia for up to 60 min. However, its safety in patients with surgical obstructive jaundice (SOJ) is not known. Therefore, we investigated the effect of hepatic ischemia in an experimental rat model of SOJ created by ligating the bile duct. Four groups of rats were created: Group I (sham operation, 10 days later, liver resection); Group II (sham operation, 10 days later, liver resection with 5 min of hepatic ischemia); Group III (bile duct ligation, 10 days later, liver resection); and Group IV (bile duct ligation, 10 days later, liver resection with 5 min of hepatic ischemia). The ischemic injury was assessed by the survival of rats, liver tissue malondialdehyde and total glutathione (markers of free radical injury), serum alanine aminotransferase, aspartate aminotransferase, and liver histology. The results showed decreased survival (47.6% vs. 90% [p = .046]), increased liver tissue malondialdehyde (161 +/- 35 vs. 129 +/- 33 microg/gm liver tissue [p = .05]), and decreased liver tissue total glutathione (565 +/- 169 vs. 1075 +/- 276 nmol/gm liver tissue [p = .05]) in rats with SOJ subjected to hepatic ischemia when compared to nonjaundiced rats. The changes in serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase showed an increasing trend in the SOJ group but were not statistically significant. Ischemic changes in liver histology were seen more often in the SOJ group but were not statistically significant. These data suggest that temporary portal triad clamping in an experimental model of SOJ is detrimental to the outcome of liver resection.

Complicated colonic diverticulosis: surgical perspective from an Indian Centre.

INTRODUCTION: Colonic diverticulosis was previously uncommon in India but its incidence seems to have increased recently. Patients with the disease in developing countries are also underdiagnosed and are therefore more likely to present with complications needing operation. However there is a paucity of surgical data on the condition. METHOD: Between August 1996 and February 2005 we operated on 32 patients (28 males, 4 females mean age 60 years) with colonic diverticulosis and analysed their characteristics from a prospective database. We here with describe our experience. RESULTS: Operations for diverticular disease constituted 3% of all the colorectal operations we performed. The diverticula were in the sigmoid colon in 28 (88%) and also in the descending colon in 4 (12%). Twenty-four patients were symptomatic. Twenty-two patients were diagnosed before surgery, 8 at operation and the rest from resected specimens. Emergency operations were performed in 23 and elective procedures in 9 patients. Ten patients were operated on for perforation and abscess, 8 for obstruction, 8 for colovesical fistula, 3 for peritonitis and 3 for haemorrhage. Emergency procedures were performed in 2 stages (resection plus a proximal diversion) in 20; unless done for bleeding in a stable patient where a primary anastomosis was done. One patient who had had an emergency procedure died of sepsis and ketoacidosis in the post-operative period. The 8 patients with colovesical fistulae were all males, had only sigmoid involvement and had had symptoms for a longer duration than the 24 without fistulae. CONCLUSIONS: Although operations for colonic diverticulosis still form a small proportion of the total number of colorectal operations, the diagnosis is often delayed till complications ensue and thus patients usually require emergency procedures. Males with long standing symptoms and sigmoid diverticula may develop colovesical fistulae.

A Single Centre Analysis of Clinical Characteristics and Treatment of Endocrine Pancreatic Tumours.

Background. Endocrine Pancreatic Tumours (PENs) are rare and can be nonfunctioning or functioning. They carry a good prognosis overall though high grade lesions show a relatively shorter survival. The aim of the current study is to describe a single centre analysis of the clinical characteristics and surgical treatment of PENs. Patients and Methods. This is a cohort analysis of 40 patients of PENs who underwent surgery at Sir Ganga Ram Hospital, New Delhi, India, from 1995 to 2013. Patient particulars, clinical features, surgical interventions, postoperative outcome, and followup were done and reviewed. The study group was divided based on grade (G1, G2, and G3) and functionality (nonfunctioning versus functioning) for comparison. Results. PENs comprised 6.3% of all pancreatic neoplasms (40 of 634). Twenty-eight patients (70%) had nonfunctioning tumours. Eighteen PENs (45%) were carcinomas (G3), all of which were nonfunctioning. 14 (78%) of these were located in the pancreatic head and uncinate process (P = 0.09). The high grade (G3) lesions were significantly larger in size than the lower grade (G1 + G2) tumours (7.0 ± 3.5 cms versus 3.1 ± 1.6 cms, P = 0.007). Pancreatoduodenectomy was performed in 18 (45%), distal pancreatectomy in 10 (25%), and local resection in 8 (20%) and nonresective procedures were performed in 4 patients (10%). Fourteen patients (35%) had postoperative complications. All G3 grade tumours which were resected had positive lymph nodes (100%) and 10 had angioinvasion (71%). Eight neoplasms (20%) were cystic, all being grade G3 carcinomas, while the rest were solid. The overall disease related mortality attributable to PEN was 14.3% (4 of 28) and for malignant PENs was 33.3% (4 of 12) after a mean follow-up period of 49.6 months (range: 2-137 months). Conclusion. Majority of PENs are nonfunctioning. They are more likely malignant if they are nonfunctioning and large in size, show cystic appearance, and are situated in the pancreatic head. Early surgery leads to good long term survival with acceptable postoperative morbidity.

Does exchanging comments of Indian and non-Indian reviewers improve the quality of manuscript reviews?

BACKGROUND: The quality of peer reviewing in developing countries is thought to be poor. To examine whether this was so, we compared the performance of Indian and non-Indian reviewers who were sent original and review articles submitted to The National Medical Journal of India. We also tested whether informing reviewers that their comments would be exchanged improved the quality of their reviews. METHODS: In a prospective, randomized, blinded study, we sent 100 manuscripts to pairs of peer reviewers (Indian and non-Indian) of which 78 pairs of completed replies were available for analysis. Thirty-eight pairs of reviews were exchanged and 40 were not. The quality of the reviews was assessed by two editors who were unaware of the reviewers' nationality and whether they had been told that their reviews would be exchanged. The quality of the reviews was scored out of 100 (based on a predesigned evaluation proforma). We also measured the time taken to return a manuscript. RESULTS: Overall, non-Indian reviewers scored higher than Indians (mean scores non-Indians first, 56.7 v. 48.6, p < 0.001), especially those in the non-exchanged group (58.4 v. 47.3, p < 0.001) but not the exchanged group (54.8 v. 50.0, p < 0.06). Being informed that reviews would be exchanged did not affect the quality of reviews by non-Indians (54.8 exchanged v. 58.4 non-exchanged) or of reviews by Indians (50.0 exchanged v. 47.3 non-exchanged). The editors' assessment of the reviewers matched well (r = 0.59, p < 0.001). Non-Indians took the same amount of time as Indians to return their reviews, although the postage time was at least eight days longer. CONCLUSIONS: We found that non-Indian peer reviewers were better than Indians and informing them that their views would be exchanged did not seem to affect the quality of their reviews. We suggest that Indian editors should also use non-Indian reviewers and start training programmes to improve the quality of peer reviews in India.

Research in Indian medical institutes.

BACKGROUND AND METHODS: The research output of medical institutions in India is thought to vary considerably, although no studies have been done since 1965. We consulted the Corporate Index of the Science Citation Index to count the number of publications included from each of the 128 medical institutions in India between 1981 and 1988. We also compared these results to the number of publications from leading international institutions in 1988. RESULTS: Only 6 (4.7%) institutions had over 50 articles per year included, 33 (26%) had 5 to 50 articles included, 43 (38%) had 1 to 5 articles and 41 (32%) had less than one article included. Seven medical colleges had none. Only the All India Institute of Medical Sciences, New Delhi and the Post-graduate Institute of Medical Education and Research, Chandigarh could be compared with the world leaders. CONCLUSIONS: The quality of research from Indian medical colleges is low. To improve it we suggest teaching institutions should forbid their faculty to undertake private practice. research grants should be disbursed more evenly and research achievement should be considered an important criterion for selection and promotion.

The place of antibiotics in preventing wound infection after clean operations in an Indian hospital: a prospective, randomised, controlled clinical trial.

Two hundred patients in a major Indian hospital who were undergoing clean operations participated in a prospective, randomised, controlled clinical trial of the effectiveness of systemic antibiotics in preventing wound infectious. Of the patients on antibiotics 12.6% developed wound infections and of those not on antibiotics 13.3% did--a difference of no significance. Other factors analysed which included age, duration of operation, place on the operating list and length of the incision did not appear to effect the incidence of infection. Wound infection delayed the discharge of the patient from hospital by seven days. Avoiding antibiotic prophylaxis in these operations would have saved our hospital 12,500 pounds a year. We suggest that prophylactic antibiotics are ineffective in preventing wound infection after clean operations in India. Their use is wasteful and should be discouraged.

Balloon tamponade in the management of bleeding oesophageal varices.

Sixty-three patients with acute variceal haemorrhage were treated with the Sengstaken-Blakemore tube (SBT). Bleeding was initially controlled with the gastric balloon in 37 patients (60%) and with both gastric and oesophageal balloons in another 17 (27%), giving overall primary success in 54 patients (87%). Sixteen (26%) patients re-bled within 24 hours of deflation of the tube. Repeat balloon tamponade helped in controlling bleeding in 9 of these. Thus, a total of 47 (75%) patients stopped bleeding with SBT. There was no mortality. The only major complication was pulmonary infection (15%), which improved with antibiotics. Use of the SBT was found to be simple, quick, low cost and attended with few complications. Its use is recommended in patients with acute variceal bleeding, especially in developing countries with limited resources.

Informed consent in Indian patients.

It is commonly believed that patients in India do not need to be told about their operations as they are unable to understand the complexities and forget the salient facts soon afterwards. Obtaining informed consent is therefore considered to be an unnecessary ritual. We studied 100 consecutive patients undergoing elective major abdominal operations and asked them 5 days after their operations to recall certain details about the procedure which had been explained to them preoperatively. Seventy per cent of the patients recalled the relevant data. The ability was the same in males and females (67% and 69%) but the older, less educated and poorer patients performed worse than the others. Ninety-eight per cent of the patients appreciated being given the information as it reduced their anxiety about the operation. Indian patients are able to comprehend and should be informed about the details of their operation. Particular care should be taken during explanation to the old, poor and illiterate. In these informed consent should be a continuous process rather than a single event and the information should also be given to a younger and more educated relative.

Encephalomyelopathy following portocaval shunt in noncirrhotic portal fibrosis: a case report.

A 30 year old male patient presented with the clinical picture of progressive encephalomyelopathy eleven years after a portacaval shunt for non-cirrhotic portal fibrosis (NCPF). The spinal cord involvement in this patient was restricted to the corticospinal and the spinocerebellar pathways. The clinical picture and neuropathology of encephalopathy and of myelopathy have been described in patients with cirrhosis. Cases of encephalopathy and myelopathy have also been reported following shunt surgery in NCPF. We report the first case of encephalomyelopathy developing eleven years after portacaval shunt in a patient with noncirrhotic portal fibrosis.

Multiple large pyogenic liver abscesses of the tropics: a new entity.

BACKGROUND: Pyogenic liver abscesses most commonly occur in males in -he sixth decade, are usually associated with biliary tract disease, malignancy and immunosuppression and the mortality rate is high. We describe another form of pyogenic abscess occurring in females which, if treated aggressively, carries a much better prognosis. METHODS: Between 1986 and 1993 we treated 8 patients with multiple pyogenic liver abscesses. Diagnosis was established by ultrasound and CT scan followed by needle aspiration to confirm pus. Amoebic aetiology was excluded by a serology, poor response to metronidazole and biopsy of the abscess wall. RESULTS: The mean age of our patients was 30 +/- 7 years and there were 2 males and 6 females. They presented with fever and abdominal pain for more than 2 months, tender hepatomegaly, a raised ESR and alkaline phosphatase. US and CT scans showed multiple large abscesses in the right lobe. Histology suggested chronic inflammation and with no definite organism isolated except for visceral larva migrans in one case. All patients underwent surgery--deroofing with drainage was done in four, segmental hepatic resection in three and right hepatectomy in one. One patient had a recurrence and underwent repeated resection. Only one patient died and 7 did well with no recurrence at a mean followup of 24 +/- 27 months. CONCLUSIONS: Large multiple cryptogenic pyogenic abscesses of the liver occurring mostly in young females, which respond well to aggressive excisional surgery may constitute a distinct clinical entity.

Noradrenaline in upper gastrointestinal haemorrhage. A prospective, randomized, double blind controlled clinical trial.

The effect of noradrenaline (8 mg in 100 ml cold saline) gastric lavage was compared with that of cold saline alone in 42 patients with upper gastrointestinal haemorrhage in a prospective, randomized, double blind study. Fifty three per cent (11/21) of the patients given noradrenaline stopped bleeding within two hours of treatment compared with 14% (3/21) of those given saline alone. We suggest that noradrenaline gastric lavage is a simple, safe and effective method for controlling upper gastrointestinal haemorrhage and could be used with advantage in peripheral hospitals in tropical countries.