Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study.

Background: Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC). Methods: The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity. Findings: On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used. Interpretation: In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit. Funding: Cambridge Hepatopancreatobiliary Department Research Fund.

Demographic Patterns, Risk Factors, and Outcomes of Abdominal Aortic Aneurysms in Young Adults ≤55 Years: An Experience in a Tertiary Care Centre of India.

Introduction Abdominal aortic aneurysms (AAA) are uncommon in young adults ≤55 years of age. There is a lack of literature on clinical characteristics, risk factors, and therapeutic outcomes so we present a case series of 11 patients of AAA aged ≤55 years. Methods We included single-center retrospective case series between 2013 to 2020. We reviewed 44 patients who were operated for AAA in a tertiary care center in India. We identified 13 patients who were ≤55 years; two patients with incomplete records were excluded. A patient information sheet was used to retrieve demographic data, clinical presentation, outcomes, and follow-up. Results Out of 11 patients, 10 were men. Nine patients (81.8%) had symptomatic AAA. The majority (45.4%) exhibited an infrarenal aneurysm and the median size of the aneurysm was 5.8 cm (IQR: 5.5-6.4 cm). Eight patients (72.7%) had a history of smoking. Hypertension was observed in six patients and one patient had associated coronary artery disease. Clamping time was > 45 minutes among three patients; all smokers. Blood loss was > 500 ml in five patients. The median length of hospital stay was 10 days (7-40); more among patients with metabolic equivalents (METS) score < 4, 14.5 (8-19) days. No grade III-IV complications and mortality were noted with a median follow-up of 15 months, with all patients living. Conclusion The aneurysm was symptomatic in the majority of participants. An association of smoking in increasing both the median clamping time and length of hospital stay was seen. No mortality and good disease-free follow-up suggested good outcomes.

Ectopic breast tissue lesion in axilla: Cytology report of two cases.

Ectopic breast tissue (EBT) predominantly seen along the primitive embryonic milk lines that extend from axilla to groin. Axillary breast tissue is one of the common variant of EBT seen in 2% to 6% of women. Phyllodes tumour in EBT is uncommon. The various cystic, inflammatory and neoplastic lesions may occur in EBT similar to breast counterpart. Therefore, EBT should be carefully investigated as it may affect the management of the patient. We report two cases (axillary phyllodes tumour and axillary fibroadenoma) of axillary EBT diagnosed on cytology.

Giant mediastinal parathyroid adenoma presenting as bilateral brown tumour of mandible: a rare presentation of primary hyperparathyroidism.

Hyperparathyroidism (HPT) is becoming increasingly common endocrinopathy in clinical practice. Nowadays, it is mostly diagnosed in subclinical or early clinical stage. Bony involvement in HPT has seen significant fall in incidence. Brown tumour of bone is exceptionally rare as a first manifestation of primary HPT (PHPT). Its radiological and histopathological features may be mistaken for other bony pathologies. If possibility of underlying HPT is overlooked the disease is bound to recur after surgery adding to morbidity of the patient. Here we present a case of bilateral brown tumour of mandible which was mistakenly treated as giant cell granuloma by surgical curettage. That the patient was harbouring an ectopic parathyroid adenoma with hypercalcemia causing non-specific symptoms was missed by the referring physician. This led to recurrence of the lesion. On subsequent evaluation, a giant mediastinal parathyroid adenoma causing PHPT was detected at our centre and was removed via mini sternotomy approach.

Fistulating Richter's Hernia of Groin with Necrotizing Soft Tissue Infection: A Lethal Combination.

Strangulation of groin hernia can result in significant morbidity and mortality. Spontaneous external fistulation following strangulation is rare and typically occurs with Richter's hernia. Spreading Necrotizing Soft Tissue Infection (NSTI) secondary to Enterocutaneous Fistula (ECF) is an ominous sign, further worsening its prognosis. Early diagnosis and prompt surgical treatment is crucial to improve outcome. Herewith the authors are presenting a case of neglected inguinal hernia. It was complicated with ECF formation and rapidly spreading NSTI of flank. He underwent resection and anastomosis of the gangrenous bowel, anatomical repair of the hernia along with soft tissue debridement of flank region. This patient however succumbed to sepsis with multi organ dysfunction. Significant delay in seeking medical care led to dismal outcome.

Isolated implant metastasis in chest wall due to seeding of transpleurally placed PTBD catheter tract in a case of hilar cholangiocarcinoma.

Percutaneous transhepatic biliary drainage (PTBD) catheter site metastasis in cases of cholangiocarcinoma is reported sporadically. But it is unusual to see left-sided tumour metastasising to the right PTBD catheter site. Metastasis, in general, has a poor prognosis, but recurrence along the catheter tract in the absence of other systemic diseases can be a different scenario altogether. To date, there is no consensus on the management of this form of metastasis. But carefully selected patients can benefit from aggressive surgical resection. We report a case of a young patient with isolated chest wall metastasis 1 year after resection of left-sided hilar cholangiocarcinoma. The metastasis was resected and, on pathological analysis, was confirmed to be due to implantation of malignant cells along the tract of the PTBD catheter placed via a transpleural route.

A new technique of closing a gastroatmospheric fistula with a rectus abdominis muscle flap.

Proximal enteroatmospheric fistulae are difficult to manage and carry high mortality from sepsis and electrolyte imbalances. Conservative management with total parenteral nutrition, exclusion of fistula, resection and anastomosis are conventional methods of treatment with low success rate. Providing muscle cover to manage an enteroatmospheric fistula is a noble concept. A postoperative high-output gastroatmospheric fistula (GAF) was repaired by superior epigastric artery-based rectus abdominis muscle flap (RAMF). Postoperative recovery was uneventful. This technique may be useful for closure of proximal enteroatmospheric fistulae that fail to heal through medical and conventional surgical management.