Advanced thymic carcinoma with a hepatic metastasis treated with chemotherapy and staged resection.

Thymic carcinoma is rare, with resulting treatment of patients with extrathoracic metastasis being on a case-by-case basis. We describe the management of a woman in her 70s with an incidentally discovered cystic hepatic lesion with confirmation of a solitary extrathoracic metastasis from a synchronous primary thymic carcinoma. Following chemotherapy and staged resection of the metastasis and the primary tumour, the patient remained free of disease on radiological surveillance 6 months postoperatively.

Hepatic reactive lymphoid hyperplasia-associated primary biliary cholangitis masquerading as a neoplastic liver lesion.

Hepatic reactive lymphoid hyperplasia is an uncommon benign condition, often found incidentally as a solitary liver lesion. The chronic inflammatory reaction associated with autoimmune conditions and malignancies has been postulated as a possible aetiology. The diagnosis is challenging as it often mimics various malignancies radiologically and histologically, hence the diagnosis being made only after surgical resection. Lymphadenopathy is common with primary biliary cholangitis, though rarely reported with reactive lymphoid hyperplasia. We report a case of hepatic reactive lymphoid hyperplasia associated with portacaval lymphadenopathy in a patient with primary biliary cholangitis, diagnosed after surgical resection. We propose lesional biopsy be considered in patients with primary biliary cholangitis found to have a solitary lesion with supporting low-risk clinical and radiological features.

Triple synchronous malignancies of the stomach, bladder and thyroid in a previously treated prostate cancer patient: A Case Report.

Cancers that develop within six months of the first primary cancer are referred to as synchronous malignancies. These malignancies are difficult to diagnose and treat, with treatment primarily based on case reports.

Hepatic metastasis of anal squamous cell carcinoma.

A 50-year-old woman was diagnosed with anal squamous cell carcinoma following a colonoscopy performed for positive test from the National Bowel Screening Programme. During the staging imaging, it was discovered to have a liver lesion that was atypical for metastasis. She underwent a segmental liver resection, and histopathology showed the liver lesion as a metastatic squamous cell carcinoma. We aim to discuss the incidence, presentation and management strategies for this rare hepatic metastasis of anal squamous cell carcinoma.

Jejunal Diverticulitis: A Single-Center Experience and Proposed Management Algorithm.

Background: Jejunal diverticulitis is rare and usually an incidental diagnosis found on imaging. Its symptoms are non-specific. Hence, the diagnosis often is delayed, and a high mortality rate has been reported. The aim of this study was to review our experience in the management of jejunal diverticulitis and to propose a management algorithm. Methods: A retrospective review of all cases of jejunal diverticulitis seen from November 2015 to November 2018 was performed. Data collected included demographics, history of diverticulitis, risk factors, clinical presentation, biochemistry and imaging results, and management outcome. Results: Eight patients were identified during the study period, five females and three males with a median age of 71 years (range 61-85 years). One patient was on steroid treatment, and one patient had a history of jejunal diverticulitis. Abdominal pain was present in all patients, but other symptoms were variable. Two patients were initially believed to have constipation and were discharged home. All patients underwent a computed tomography (CT) scan for the diagnosis, showing that three had uncomplicated jejunal diverticulitis and five had localized perforation. Five patients were managed conservatively initially; two failed this treatment because of small bowel obstruction and persistent abdominal pain with rising inflammatory markers. Three underwent emergency laparotomy (two because of sepsis; one was thought to have a foreign body). There were no deaths. A proposed management algorithm is discussed. Conclusions: A CT scan is the mainstay for the accurate diagnosis of jejunal diverticulitis. The proposed algorithm can aid in selection of patients suitable for conservative management.

Safety, efficacy and compliance of extended thromboprophylaxis in hepatobiliary and upper gastrointestinal surgery.

BACKGROUND: Extended venothromboprophylaxis (eVTP) after abdominal surgery for hepatobiliary (HPB) and upper gastrointestinal (UGI) malignancies is recommended. Safety, efficacy and compliance within this group of surgical patients are not well described. The primary aim was to assess safety and compliance of post-operative administration of eVTP with low molecular weight heparin. Secondary aim was to assess barriers to treatment and monitor the rate of post-operative venous thromboembolism. METHODS: A prospective observational cohort study of patients undergoing abdominal surgery for HPB or UGI malignancies was undertaken from January 2014 to June 2016. All patients were assessed for eVTP. Demographics, clinical outcomes and clinical questionnaires on discharge and at follow-up 6 weeks post their initial surgery were used to assess the safety, compliance and efficacy of eVTP. RESULTS: A total of 100 patients were assessed for post-operative eVTP. Of these, 80 patients were prescribed 28 days of low molecular weight heparin. Of 80 patients, 65 (85%) patients completed the full eVTP, 11 (13%) missed 1-5 injections and only four (6%) missed 6-15 injections. In the 80 eVTP patients, there were no episodes of significant bleeding or venous thromboembolism. A total of nine (11%) patients would be unwilling to undertake eVTP again for a variety of reasons, including ease of disposal of syringes and needle phobias. CONCLUSION: The administration of eVTP in patients undergoing major HPB and UGI surgery is safe, with minimal morbidity and high compliance. The greatest barrier to administration is doctor prescription.

Gastroduodenal Artery Psuedoaneurysm Bleed through a Spontaneous Pancreaticoduodenal Fistula as a Result of Acute Necrotizing Pancreatitis.

Spontaneous pancreaticoduodenal fistulization and arterial psuedoaneurysm formation are both complications of acute pancreatitis. We present a 27-year-old man with hematemesis who was found to be bleeding from a gastroduodenal artery psuedoaneurysm through a spontaneous pancreaticoduodenal fistula as a result of severe alcohol-related necrotizing pancreatitis. This is the first reported case in the literature to describe this occurrence.

Systematic review and meta-analysis of outcomes after liver resection in patients with hepatocellular carcinoma (HCC) with and without bile duct thrombus.

INTRODUCTION: This meta-analysis aimed to compare perioperative and survival outcomes in patients who underwent hepatectomy with and without Bile Duct Tumour Thrombus (BDTT). METHODS: A comprehensive search of Cochrane Library, PubMed, MEDLINE and EMBASE was performed to identify relevant articles. The perioperative, postoperative and long term outcomes were compared. RESULTS: Eleven studies including 6051 patients met the inclusion criteria. The perioperative outcomes were comparable between the 2 groups. The BDTT group had higher proportion poorly differentiated tumours (OR = 1.87, X(2) = 10.00, df = 6, p = 0.002, I(2) = 40%), Lymphovascular invasion (LVI) (OR = 4.85, X(2) = 28.21, df = 9, p = <0.001, I(2) = 68%) and Macrovascular invasion (MVI) (OR = 5.41, X(2) = 8.73, df = 9, p = <0.001, I(2) = 0%). There was no difference in 1 and 3 year survival, however 5-yr survival was poorer in the BDTT group (OR = 0.37, X(2) = 37.04, df = 7, p = <0.001, I(2) = 81%). The mean difference (MD) in overall survival in the BDTT group was -20 months [-32.31, -7.06], p = 0.002, I(2) = 95%. CONCLUSION: Patients with HCC with BDTT had more advanced stage HCC with adverse histological features including higher rates of MVI, LVI and poor differentiation. Hepatectomy in this group of patients offers similar survival at 3 years but inferior long-term survival and should be considered when feasible.

Surgery for Acute Pancreatitis.

Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.

Narrow-band imaging with dual focus magnification in differentiating colorectal neoplasia.

BACKGROUND: Real-time optical diagnosis of colorectal polyps may lead to substantial time and cost savings and could potentially reduce complications associated with polypectomy. We prospectively assessed the utility of a novel narrow-band imaging (NBI) system with dual focus magnification (DF) in differentiating colorectal polyps in consecutive patients undergoing colonoscopy. PATIENTS AND METHODS: All procedures were carried out with a prototype 190 series Exera III NBI system with Dual Focus capability. Histology of each polyp was predicted in real time with NBI-DF based on the modified Sano's classification with a confidence level (low/high). NBI-DF diagnosis was then compared to the final (blinded) histopathology results. Primary endpoint was the accuracy of endoscopic prediction with the modified Sano's classification of all polyps when they were diagnosed with high confidence. Secondary endpoints were the accuracy of post-polypectomy surveillance intervals for diminutive polyps(≤ 5 mm). A total of 164 polyps in 87 patients (53 males) with a mean age of 63 (range 28-86) years were evaluated. RESULTS: 149 polyps were diagnosed with high confidence on endoscopic prediction, out of which 80 were diminutive, 31 small (6-9 mm) and 38 large (>10 mm). Overall accuracy of NBI-DF compared to final histopathology was 97%. The accuracy for post-polypectomy surveillance interval based on the endoscopic prediction was 97%. The NPV for diminutive rectosigmoid polyps for adenomatous histology was 100%. CONCLUSION: In this preliminary feasibility study, NBI-DF permitted prediction of histology of colorectal polyps with high accuracy. In addition, both of the secondary endpoints exceeded the ASGE PIVI thresholds for the management of diminutive polyps.

Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases.

We present a series of reconstruction of 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. All patients were reconstructed primarily by bipaddle pectoralis major myocutaneous (PMMC) flap. The age of patients ranged from 25 to 85 years (mean 49.5 years). All patients were male. The size of the paddle used for mucosal defect repair ranged from 5 x 3 to 9 x 7 cm and the size of the paddle used for skin cover ranged from 4 x 4 to 9 x 8 cm. The total flap size ranged from 10 x 5 to 17 x 7 cm. One patient had complete loss of flap (2.12%). Sixteen patients had minor complications all of which settled with conservative management. The follow up period varied from 1 month to 4 years. The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. We found the technique to be anatomically sound, technically easy and reliable. Precautions taken included proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising. We conclude that this technique is a useful alternative where microsurgical free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions. However, the disadvantages of this method include loss of nipple and areola and technical difficulty in obese patients and females.