Large cystic lympangioma of the pancreas: a case reportum.

Lymphangioma of the pancreas is rare and presents as a large cystic mass in the retroperitoneum. The pancreatic origin can be confirmed by careful evaluation of cross sectional imaging. Preoperative differentiation from other pancreatic cystic neoplasms is difficult but possible. Large symptomatic lesions warrant surgery. The diagnosis is confirmed by typical features on histopathology and immunohistochemistry. Presented here is a case report of a pancreatic lymphangioma, discussed in the context of available literature.

Aberrant right hepatic duct presenting as empyema of the gall bladder.

A 38-year-old male presented with recurrent right hypochondrial pain with history of acute cholecystitis. Ultrasonography of the abdomen showed distended gall bladder with dilated right hepatic duct with intrahepatic biliary dilatation in the right lobe of the liver. Endoscopic retrograde cholangiography showed non-visualization of the right ductal system and gall bladder with extrinsic compression of the common hepatic duct. Contrast-enhanced CT scan revealed a distended gall bladder with isolated dilatation of the intrahepatic biliary dilatation in the right lobe of the liver. Magnetic resonance cholangiography confirmed the same findings. At laparotomy, the right hepatic duct was seen directly inserted into the gall bladder body after a short extrahepatic course. The cystic duct provided the only route for biliary drainage through the gall bladder, but it was blocked. A cholecystectomy with a Roux-en-Y hepaticojejunostomy to the right hepatic duct was carried out. This case presents an extremely rare aberration affecting the extrahepatic biliary tree in which the right hepatic duct was directly inserted into the gall bladder.

Postcholecystectomy benign biliary strictures - long-term results.

BACKGROUND: Cholecystectomy is the most frequently performed general surgical procedure. Bile duct injury is a dreaded complication and is associated with serious long-term morbidity. PATIENTS AND METHODS: Three hundred patients with postcholecystectomy benign biliary strictures were managed from January 1989 to February 2004 at a tertiary care unit in northern India. Demographic data, clinical presentation, and immediate- and long-term results of surgical repair are analyzed from a prospective database. RESULTS: The time from cholecystectomy (open, n = 262; laparoscopic, n = 38) to stricture repair ranged from 0.2 to 360 (median 7) months. Thirty-six patients (12%) had prior stricture repair. Bismuth classification of the bile duct strictures was 32 type I, 113 type II, 126 type III, 18 type IV, and 11 type V. Two hundred and ninety-two patients (97%) underwent repair by a Roux-en-Y hepaticojejunostomy. One hundred patients (33.3%) had postoperative morbidity following stricture repair. Four patients (1.3%) died during the postoperative period. Of the 149 patients with a minimum available follow-up period of 5 years (mean 9.5, median 9.4 years; range 5-15.4 years), 134 (90%) had an excellent outcome (grade A, n = 122; grade B, n = 12); only 8 patients (5.4%) had a poor outcome. CONCLUSION: Excellent long-term outcomes with minimal morbidity and mortality can be achieved in the subgroup of benign biliary strictures managed in dedicated units with meticulous attention to the central tenets of biliary surgery.

An audit of postoperative radiotherapy after non-curative resection for cancer of the oesophagus.

AIMS: The role of postoperative radiotherapy (PORT) after non-curative resections for cancer oesophagus is not well defined. A policy of offering PORT after non-curative resections for cancer oesophagus has been followed at our institution, and we report an audit of our experience. MATERIAL AND METHODS: Between March 1990 and September 2002, 139 patients underwent resections for cancer oesophagus. Of these, 86 patients received PORT to a dose of 45-50.4 Gy/25-28 fractions. Eleven of these patients also received concurrent and adjuvant 5-fluorouracil (5-FU). Disease-free survival and overall survival were computed from the day of surgery using the Kaplan-Meier method. RESULTS: Seventy-six per cent (65/86) of patients had squamous cell carcinoma and 69% (59/86) of patients had tumours in the lower-third of the oesophagus. The median interval between surgery and PORT was 41 days, and 93% of patients received doses as planned. Strictures at the anastomotic site and ulcerations in the stomach mucosa were seen in 17% and 5% of patients, respectively. The median and 5-year disease-free survival was 12 months (95% CI 9.9-14.1) and 14%; whereas the median and 5-year overall survival was 17 months (95% CI 12.4-21.6) and 17%, respectively. Local and distant failures were seen in 29% and 45% of patients, respectively. CONCLUSIONS: PORT, after a non-curative resection of cancer oesophagus, is well tolerated with acceptable morbidity and survival.

Adjuvant chemo-radiotherapy in ampullary cancers.

PURPOSE: Patterns of failure following surgical treatment of ampullary cancers indicate that up to 45% of patients develop loco-regional recurrence. The effect of adjuvant chemo-radiotherapy on survival and loco-regional control is not yet established in this malignancy. PATIENTS AND METHODS: From January 1989 to December 2000, 113 patients underwent pancreatico-duodenectomy for ampullary cancer. One hundred and four patients who survived the operation were available for analysis to study the effect of adjuvant chemo-radiotherapy on survival and loco-regional control. Forty-nine patients received adjuvant chemo-radiotherapy (median dose 50.4 Gy with concurrent 5-Flurouracil) and long-term outcome in these patients was compared with those 55 who did not receive adjuvant therapy. RESULTS: The overall median survival was 30.1 (range 1.6-140.0) months with actuarial 1, 3 and 5-year survival rates of 79, 43 and 33%, respectively. No significant difference in median survival (34.6 vs 24.5 months; P=0.3) and actuarial 5-year survival rates (38 vs 28%) was seen between those who received and those who did not receive adjuvant therapy. Adjuvant chemo-radiotherapy did not influence the survival in high-risk patients (P=0.84), in various T and N stages and had no impact on loco-regional recurrence (P=0.6). CONCLUSIONS: Adjuvant chemo-radiotherapy did not improve the long-term survival or decrease recurrence rates in patients with ampullary cancers who had undergone pancreatico-duodenectomy.

Evaluation of bilioenteric anastomosis using quantitative hepatobiliary scintigraphy.

BACKGROUND/AIMS: The patterns of quantitative hepatobiliary scintigraphy for bilioenteric anastomoses have not been objectively defined. This study was undertaken to establish the patterns of quantitative hepatobiliary scintigraphy in the patients with bilioenteric anastomoses performed for repair of postcholecystectomy benign biliary strictures. METHODOLOGY: 37 patients with bilioenteric anastomosis (Study group) and 10 postcholecystectomy healthy subjects (Controls) underwent quantitative hepatobiliary scintigraphy. Study group patients were further categorized into: Group A (n=27) - normal clinical and biochemical parameters, and Group B (n=10) - abnormal clinical and/or biochemical parameters. On scintigraphy, time of maximal activity and time of clearance of half of the activity was calculated at the liver parenchyma and hepatic hilum. Time of appearance of activity in the intestine was also recorded. RESULTS: There was no significant difference in the scintigraphic parameters between Group A and Controls except for earlier appearance of activity in the intestines (p=0.036) in Group A. In Group B there was significant increase in the time of clearance of half of the activity at the liver parenchyma and hepatic hilum compared to Controls (p=0.003 and 0.036 respectively), and at the liver parenchyma compared to Group A (p=0.002). CONCLUSIONS: Quantitative hepatobiliary scintigraphic patterns in patients with bilioenteric anastomosis were similar to those of postcholecystectomy controls. Patients with abnormal biochemical parameters had significant delay in clearance of activity. Significance of these scintigraphic patterns in this subset of patients can be determined only on long-term follow-up.

Surgical management of complicated hydatid cysts of the liver.

AIMS: To review the clinical presentation and surgical management of complicated hydatid cysts of the liver. METHODS: Forty-three patients with hydatid disease of the liver were managed surgically between 1991 and 1998. There were 14 men and 29 women with a median age of 34 years. An abdominal ultrasound, computed tomography and serology established diagnosis. Preoperative endoscopic retrograde cholangiography was performed in patients with associated jaundice and high suspicion of intrabiliary rupture. Eleven (26%) patients had complicated cysts and formed the basis for our study. RESULTS: Infection (n = 5, 11%) and intrabiliary rupture (n = 4, 9%) were the common complications. Intrathoracic rupture and intraperitoneal rupture were encountered in one patient each. All patients with infected cysts presented with pain and fever (n = 5, 100%) while those with intrabiliary rupture had jaundice (n = 4, 100%), pain and fever (n = 3, 75%). Surgical procedures performed in complicated cysts were-infection: omentoplasty (n = 2) and external drainage (n = 3); intrabiliary rupture: omentoplasty (n = 2) and internal drainage (n = 2). Patient with intrathoracic and intraperitoneal rupture underwent external drainage. There was no mortality. Postoperative morbidity was encountered in 14 patients and was more in complicated cysts (n = 6/11; 55%) compared to uncomplicated cysts (n = 8/32; 25%). CONCLUSION: Hydatid disease in not an uncommon problem. Around a fourth of patients, present with complications such as infection or intrabiliary rupture. The site, size, number of cysts and presence of complications govern the choice of surgical procedure. Complicated cysts can be successfully managed surgically with good long-term results.

Bronchobiliary fistula: an anaesthetic point of view.

Bronchobiliary fistula is defined as the passage of bile in the bronchi and in the sputum (bilioptysis). This rare disorder is associated with significant morbidity. Authors review the anaesthetic management of bronchobiliary fistula and recommend the use of double lumen endotracheal tube even in cases with a closed/sealed bronchobiliary fistula.

Outcome following pancreaticoduodenectomy in patients undergoing preoperative biliary drainage.

OBJECTIVE: To assess the role of preoperative biliary drainage (PBD) in the early outcome following pancreaticoduodenectomy (PD) for periampullary tumors. DESIGN: Retrospective analysis of prospective database. PATIENTS AND METHODS: 121 PDs were performed for periampullary tumors between 1989 and 1998. 54 patients were operated following a PBD (group A) while 67 patients were operated without PBD. 50 patients underwent internal biliary drainage while 4 patients underwent external biliary drainage. Of the 67 patients without PBD, serum bilirubin was >10 mg% in 41 patients (group B) while 26 patients had bilirubin level of <10 mg% (group C). RESULT: Patients were well matched for age, sex distribution, presence of medical risk factors, duration of surgery, operative blood loss and stage of disease. Group A patients had a higher incidence of wound infection (43 vs. 24%; p = 0.03), intra-abdominal abscess (28 vs. 15%; p = 0.06), pancreaticojejunal anastomotic leak (20 vs. 5%; p = 0.01) and overall infective complications (52 vs. 29%; p = 0.01) compared to group B patients, and a higher overall infective complication rate than group C patients (52 vs. 27%; p = 0.02). Group B patients had a higher incidence of intra-abdominal bleeding compared to group A (20 vs. 6%; p = 0.01) and group C patients (20 vs. 4%; p = 0.03). Reoperation rate was significantly higher in group B compared to group A patients (27 vs. 13%; p = 0.04). The mortality rates were not significantly different in the three groups. CONCLUSION: Patients with jaundice (>10 mg%) have a higher risk of bleeding complications while those with PBD have more infective complications. PBD should be judicially employed in selected patients.

Determinants of pancreaticoenteric anastomotic leak following pancreaticoduodenectomy.

BACKGROUND: The purpose of the present paper was to study the incidence, presentation and management of pancreaticoenteric anastomotic (PEA) leak following pancreaticoduodenectomy (PD) and to identify risk factors associated with PEA leak. METHODS: One hundred and twenty patients underwent PD for benign and malignant pancreatic and periampullary lesions from 1989 to 1998. Prospectively collected data were analysed for incidence and outcome of PEA leak. Four clinical, three laboratory parameters, preoperative biliary drainage (PBD), perioperative octreotide use, nine intraoperative parameters, site of tumour and stage of malignant tumours were analysed by univariate and multivariate logistic regression analysis to identify factors influencing PEA leak. RESULTS: Pancreatic leak developed in 15 (12.5%) patients. Nine patients (60%) had a PEA leak that manifested as controlled leak through the drain. All were managed conservatively and the leak stopped after a mean duration of 17 days (range: 6-32 days). Six (40%) patients had associated intra-abdominal complications, and three (50%) died in the postoperative period. Pancreatic fistula healed in the three remaining patients after a mean duration of 18 days (range: 15-25 days). Diabetes (P = 0.02; odds ratio (OR) = 4.60; 95% confidence interval (CI): 1.23-17.18), PBD (P = 0.03; OR = 4.82; 95% CI: 1.21-19.24), sequence of reconstruction (bilioenteric anastomosis as first anastomosis; P = 0.01; OR = 6.25; 95% CI: 1.45-26.83) and duration of surgery > 8 h (P = 0.01; OR: 5.61; 95% CI: 1.54-20.39) were associated with a significantly higher incidence of PEA leak. CONCLUSION: Pancreaticoenteric anastomotic leak occurred in 12% of patients undergoing PD for pancreatic and periampullary tumours. The majority of these were uncomplicated and healed with conservative treatment. Complicated leaks were associated with high mortality. Diabetes mellitus, PBD, prolonged surgery and the sequence of reconstruction were risk factors associated with an increased incidence of PEA leak.

Impacted denture causing tracheo-esophageal fistula.

We report a 35-year-old man with an impacted denture resulting in tracheo-esophageal fistula. In view of significant local fibrosis and esophageal stenosis distal to the fistula, he was managed by subtotal esophagectomy and cervical esophagogastric anastomosis.

Laparoscopic bile duct injuries: spectrum at a tertiary-care center.

BACKGROUND AND PURPOSE: Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries. PATIENTS AND METHODS: From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients. RESULTS: Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up. CONCLUSION: The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.

Pseudoaneurysm of gastroduodenal artery associated with mitral valve prolapse presenting as haemobilia.

Pseudoaneurysms of the hepatic or gastroduodenal arteries may cause Haemobilia. Mitral valve prolapse associated with mycotic pseudoaneurysm of cerebral and extracerebral arteries have been reported. We report a case of gastroduodenal artery pseudoaneurysm presenting as haemobilia. The patient was successfully treated with indigenously fabricated steel coil embolization followed by surgery.

Squamous cell carcinoma arising from a congenital duplication cyst of the esophagus in a young adult.

Squamous cell carcinomas arising from the congenital anomalies in the esophagus are rare. One such case of an 18-year-old man, with an associated history of ventricular septal defect, who developed an epithelial malignancy within the duplication cyst extending to involve the lower third of esophagus is presented here. He responded well to radical treatment using concurrent chemo-irradiation, and continues to be free of disease after a follow-up of 14 months.

Implantation metastasis following external biliary drainage in biliary tract cancers--cause for concern!

Three patients with periampullary cancer developed tumor seedings along the T-tube choledochostomy tract, thus precluding curative resection in two patients and an early recurrence at the choledochostomy exit site in the third patient. External biliary drainage and intraoperative bile spill should be avoided in patients with curable biliary tract neoplasms.