Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm.

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Current Utility of Transgastric Percutaneous Drainage for the Management of Pancreatitis-Related Retrogastric Walled-Off Necrotic Collections: A Prospective Observational Study.

Introduction Pancreatic fluid collection (PFC) is one of the most frequent complications associated with acute pancreatitis. The route of drainage is guided by the size and site of collection. The present study aims to assess the clinical and technical success of transgastric percutaneous drainage (PCD) for managing retrogastric walled-off pancreatic necrosis (WOPN). Materials and methods A total of 44 patients with acute pancreatitis diagnosed with WOPN who underwent transgastric PCD with ultrasound or CT guidance as part of standard clinical management were included in the study. Patients were observed for improvement in clinical parameters, and treatment outcomes were noted in terms of technical success, clinical success, adverse events, need for additional procedures, hospital stay, and duration of placement of all drains. Data for the internalization of transgastric PCD was also observed in the study. Results Technical success during the drain placement was observed in 93% (n=41) of patients.Internalization of the transgastric drain was attempted in 12 patients and successful in 11 (91%). The median duration of hospital stay from the time of placement of the first PCD until discharge and the median duration of all PCDs placed were higher in patients where the transgastric drain was not internalized as compared to patients where the transgastric drain was internalized. Conclusion In WOPN, transgastric drain placement and successful internalization in any form help in the early resolution of peripancreatic and abdominal collections. It also reduces the time to percutaneous catheter removal, which in turn reduces the morbidity and decreases the need for additional interventions or surgery.

PD-L1 Expression in Ampullary Adenocarcinoma.

INTRODUCTION: Ampullary adenocarcinoma is a rare neoplasm often treated by the complex Whipple's procedure. Several histological factors predict poor prognosis including pancreatobiliary morphology, presence of lymphovascular, perineural invasion and local or distant metastasis. Systemic therapy with gemcitabine, 5-fluorouracil regimens are given with variable benefits. Immunotherapy checkpoint inhibitors have shown beneficial anti-tumor effects in several carcinomas, the most remarkable being in non-small cell lung cancer. Administration of these novel drugs is based on immunohistochemical expression (which may or may not be indicative of response to therapy) along with meticulous decision making by the multidisciplinary team. Immunohistochemistry (IHC) is an effective means of immune marker demonstration and has been used in various tumor types for predictive and prognostic purposes. METHODS: PD-L1 IHC (clone E1L3N) was applied in 101 cases of ampullary adenocarcinoma. Tumor infiltrating lymphocytes were also evaluated. The immunoreactivity was assessed and categorized into following staining thresholds: <1%, <5%, <10% and ≥10% for tumor cells (membranous and/or cytoplasmic staining pattern), and 5% and 10% cut-offs for immune cells. RESULTS: We found that at a 10% cut-off, 73.3% (74/101) patients were men (P = .006) older than 50 years of age (P < .001) presenting with a tumor measuring <3 cm (P = .001). It was significantly associated with intestinal differentiation (P = .004) and grade 1 tumors (P = .001). Twelve patients presented with recurrence as well (P = .03). CONCLUSION: In the context of ampullary adenocarcinoma, this study highlights the positivity observed with the PD-L1 IHC clone E1L3N at different thresholds, with the particularly stronger associations being evident at a 10% cut-off.

Jaundice in a Child with Sickle Cell Anemia: A Case Based Approach.

Sickle cell anemia (SCA) is an autosomal recessive disorder caused by a mutation in beta globin gene. Hepatobiliary system is affected in 10-40% of patients with SCA and has a multifactorial etiology. The authors present a child with SCA and conjugated hyperbilirubinemia due to biliary obstruction. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting, had complications of post sphincterotomy bleed, retroperitoneal hematoma and post laparoscopic cholecystectomy sepsis with acute sickle hepatic crisis. He was managed successfully and is doing well on follow-up. Here authors discuss a stepwise approach in management of jaundice in a patient with SCA. Patients with SCA are prone to develop vaso-occlusive crisis (VOC) during periods of stress. VOC affects the liver as acute sickle hepatic crisis, acute hepatic sequestration or sickle cell intrahepatic cholestasis and is collectively termed as sickle cell hepatopathy. Hemolysis due to sickling results in cholelithiasis with its associated complications. These patients are vulnerable to viral hepatitis and hemochromatosis due to multiple blood transfusions. There may be a concomitant acute viral hepatitis, drug induced liver injury, Budd-Chiari syndrome or other chronic liver diseases. These conditions have considerable clinical overlap and may coexist, making the evaluation more challenging. Detailed history, examination and investigations are required for differentiation of etiology. Periods of stress must be tackled with proper hydration, oxygen supplementation, maintaining hemoglobin >10 g/dL, and a low hemoglobin S fraction. Patients with SCA and conjugated hyperbilirubinemia are "high-risk" and best managed by a multidisciplinary team. Preventive strategies like timely vaccinations, chelation, etc. must be practised.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey.

PURPOSE: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers. METHODS: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era. RESULTS: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase. CONCLUSION: Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

Does Timing of Completion Radical Cholecystectomy Determine the Survival Outcome in Incidental Carcinoma Gallbladder: A Single-Center Retrospective Analysis.

Introduction Incidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival. Methods All patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests. Results Ninety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival. Conclusion Early surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.

An unusual cause of obstructive jaundice in childhood: Intra-choledochal malignant neuroendocrine tumour.

The extrahepatic biliary apparatus is a rare site for neuroendocrine tumours. A 13-year-old child presented with cholestatic symptoms of jaundice and pruritus with soft hepatomegaly and mild ascites. Magnetic resonance imaging and endoscopic ultrasound revealed a mid-common bile duct mass, and dilated intrahepatic biliary system. An en-bloc resection of the extrahepatic biliary apparatus, showed malignant cells disposed in lobules in a desmoplastic stroma with intramural invasion, staining positive for cytokeratin, chromogranin, synaptophysin and negative for CD56. At 3 months post-resection, whole body positron emission tomography scan was normal with no recurrence at 24 months.

A Pilot Study of Perioperative Cisplatin-Capecitabine Chemotherapy With Preoperative Chemoradiation for Resectable Gastric Cancers.

OBJECTIVES: The standard of care for resectable gastric cancers (GCs) includes perioperative chemotherapy (CT) or postoperative chemo/chemoradiotherapy (CRT) strategies. Poor treatment compliance postsurgery suggests that intensified surgical adjuvant treatment is more likely deliverable preceding surgery and, therefore, the safety and efficacy of perioperative cisplatin-capecitabine (CX) with preoperative chemoradiation (preopCRT) were ascertained. MATERIALS AND METHODS: Between January 2017 and December 2018, 28 potentially resectable locally advanced GC patients were offered neoadjuvant CT-2 cycles of CX at 3-weekly intervals, followed by preopCRT 45 Gy/25 fractions/5 weeks and concurrent capecitabine, followed by surgical resection and 3 adjuvant cycles of CX. RESULTS: Neoadjuvant CT was commenced in 28 patients (100%), preopCRT in 18 patients (64%), and surgery performed in 13 patients (46%). At each treatment step, decreasing patient numbers were due mainly to disease progression (12 [43%]) or other reasons, including (3 [11%]) from treatment-related toxicity. The R0 resection rate was 92% (12/13); a median of 18 nodes was obtained after D2 nodal clearance in 92% (12/13). There were 20%/4%/4% grade 3/4/5 toxicities. The median radiotherapy dose/duration was 45 Gy/5.4 weeks. Adjuvant CT was started in 11 patients (39%) and the third cycle was received by 7 patients (25%). No tumor (ypT0N0) was noted in 23% of the operated patients (3/13), or 11% of the intention-to-treat population (3/28). The median, 1-year, and 2-year survivals were 12 months, 53%, and 32%, respectively. CONCLUSIONS: Intensified preoperative treatment is doable in relatively unselected advanced GC patients in real-world settings of a public-sector hospital from a low-middle-income country. Disease progression during preoperative therapy allows patients destined for early clinical evidence of disease dissemination to avoid futile surgery, as opposed to a surgery-first strategy, without an overt increase in surgical morbidity or mortality, with encouraging R0 resection rates.

Identification of PI3K-AKT signaling as the dominant altered pathway in intestinal type ampullary cancers through whole-exome sequencing.

BACKGROUND: The genetic landscape of intestinal (INT) and pancreatobiliary (PB) type ampullary cancer (AC) has been evolving with distinct as well as overlapping molecular profiles. METHODS: We performed whole-exome sequencing in 37 cases of AC to identify the targetable molecular profiles of INT and PB tumors. Paired tumor-normal sequencing was performed on the HiSeq 2500 Illumina platform. RESULTS: There were 22 INT, 13 PB, and two cases of mixed differentiation of AC that exhibited a total of 1,263 somatic variants in 112 genes (2-257 variants/case) with 183 somatic deleterious variants. INT showed variations in 78 genes (1-31/case), while PB showed variations in 51 genes (1-29/case). Targetable mutations involving one or more major pathways were found in 86.5% of all ACs. Mutations in APC, CTNNB1, SMAD4, KMT2, EPHA, ERBB, and Notch genes were more frequent in INT tumors, while chromatin remodeling complex mutations were frequent in PB tumors. In the major signaling pathways, the phosphoinositide 3-kinase (PI3)/AKT and RAS/mitogen-activated protein kinase (MAPK) pathways were significantly mutated in 70% of cases (82% INT, 46% PB, p = .023), with PI3/AKT mutation being more frequent in INT and RAS/MAPK in PB tumors. Tumor mutation burden was low in both differentiation types, with 1.6/Mb in INT and 0.8/Mb in PB types (p =.217). CONCLUSIONS: The exome data suggest that INT types are genetically more unstable than PB and involve mutations in tumor suppressors, oncogenes, transcription factors, and chromatin remodeling genes. The spectra of the genetic profiles of INT and PB types suggested primary targeting of PI3/AKT in INT and RAS/RAF and PI3/AKT pathways in PB carcinomas.

Prevalence and spectrum of pathogenic germline variants in intestinal and pancreatobiliary type of ampullary cancer.

BACKGROUND: Ampullary cancer may occur as a component of hereditary cancer syndromes. Mutations in inherited cancer susceptibility genes play a therapeutic role and its knowledge in ampullary cancer is lacking. METHODS: Thirty-seven cases of ampullary carcinoma were subjected to tumor-normal whole exome sequencing with mean coverage of 100X (blood) and 200X (tumor). Data were analyzed and correlated with intestinal and pancreatobiliary differentiation. RESULTS: There were 22 intestinal, 13 pancreatobiliary and 2 cases of mixed differentiation. One hundred and forty-three germline variations with at least >1 pathogenic germline variants (PGVs) across 83 genes were found in 36 of 37 patients. Twelve genes (14.5 %) showed >3, 20 genes (24.1 %) showed two and 51 genes (61.4 %) showed one PGVs. Intestinal differentiation showed higher PGVs (117 variants, 73 genes) than pancreatobiliary differentiation (85 variants, 62 genes). PGVs in ERCC5, MEN1, MSH3, CHEK1, TP53, APC, FANCA, ERBB2, BRCA1, BRCA2, RTEL1, HNF1A and PTCH1 were seen in >50 % of cases. Nine genes harbored somatic second hits in 14 cases. PGVs in DNA damage-repair, homologous recombination repair, TP53 transcriptional regulation, DNA double stranded breaks, cell cycle and nucleotide excision repair genes were seen in all cases of intestinal and pancreatobiliary differentiation, while DNA mismatch repair genes were found in 81.8 % of intestinal and 84.6 % of pancreatobiliary cancers. Functional pathway analysis showed that DNA damage-repair, double stranded break repair, mismatch repair, homologous recombination repair and TP53 transcriptional regulation genes were altered in both while nucleotide-excision repair was significantly mutated in intestinal type and cell-cycle genes in pancreatobiliary type (p < 0.05). CONCLUSION: This study reports spectrum of PGVs in intestinal and pancreatobiliary differentiation of ampullary carcinoma at higher frequency through whole exome sequencing. PGVs were most frequently found in DNA repair genes. Detecting PGVs through tumor-normal sequencing may identify therapeutically actionable and double-hit mutations that can guide towards appropriate management.

Assessing failure patterns of radical intent radiation strategies in patients with locally advanced carcinoma of the esophagus.

BACKGROUND: Patterns of failure following definitive CRT (dCRT) are different as compared to neoadjuvant chemoradiotherapy (NACRT) with increased locoregional failures documented with dCRT. AIM: To document failure patterns in patients with esophageal carcinoma treated with neoadjuvant and definitive intent radiation strategies. METHODS: Subjects were 123 patients treated with two chemoradiotherapy strategies. Group 1 (n = 99) underwent dose escalated definitive chemoradiotherapy (dCRT), Group 2 (n = 24) received neoadjuvant chemoradiotherapy (NACRT) followed by surgery. Cumulative incidence of locoregional failure (LRF), local failure (LF), regional lymph node failure (RLNF), and distant metastasis (DM) were computed; differences between the groups was evaluated using log rank test. Univariable and multivariable predictors of failure were identified using Cox regression analysis. RESULTS: Cumulative LRF: 64% in Group 1 vs 35% in Group 2 (P = .050). Cumulative LF: 59% in Group 1 vs 12% in Group 2 (P = .000). Cumulative RLNF: 30% in Group 1 vs 24% in Group 2 (P = .592). Most common RLNF: mediastinum for both groups (6% vs 12.5%, respectively). Distant metastasis: 40.4% Group 1 vs 17% Group 2 (P = .129), predominantly lung (Group 1, 5%), and nonregional nodes (Group 2, 8.3%). Univariate analysis identified age ≤50, absence of concurrent chemotherapy, dose ≤50 Gy, and incomplete radiotherapy to predict higher odds of LRF and DM for Group 1; absence of comorbidities predicted for lower odds of LRF for Group 2. Age ≤50 predicted for higher odds of RNLR for Group 1, while absence of comorbidities predicted for lower odds of RNLR in Group 2. Multivariate analysis identified age ≤50, incomplete radiotherapy, and absence of concurrent chemotherapy to predict higher odds of LRF for Group 1. Age ≤50, absence of concurrent chemotherapy predicted higher odds of DM for Group 1. Absence of comorbidity predicted lower odds of LRF in Group 2. CONCLUSION: LRF is common in both groups, with LF being predominant in dCRT as opposed to RNLF in NACRT. Age ≤50, absence of concurrent chemotherapy is a predictor of LRF and DM in dCRT.

Focal liver tuberculosis: a case report.

Abdominal tuberculosis is protean in its manifestations. Studies have shown that miliary tuberculosis of the liver is quite common but isolated or focal liver tuberculosis is still a rare condition. Though hepatic tuberculomas are a known entity in endemic regions of Southeast Asia, it is less likely seen in immunocompetent hosts. We present a case of focal liver tuberculosis, the difficulty in preoperative diagnosis, and its subsequent management.

Minimally invasive esophagectomy provides equivalent oncologic outcomes to open esophagectomy for locally advanced (stage II or III) esophageal carcinoma.

BACKGROUND: Minimally invasive esophagectomy (MIE) has been performed at specialized centers for 15 years, but few studies have looked at outcomes in patients with locally advanced cancers, and few studies have provided long-term survival comparison with Ivor Lewis esophagectomy (ILE) to determine oncologic benefit or equivalence of MIE. HYPOTHESIS: Minimally invasive esophagectomy for locally advanced esophageal carcinoma has similar oncologic outcomes to traditional open ILE with less associated short-term morbidity and mortality. DESIGN: Retrospective comparison of patients with stage II or III esophageal carcinoma undergoing 3-field MIE compared with open ILE. SETTING: University medical center. PATIENTS: From 1995 to 2009, 64 patients who underwent MIE (33 patients) or ILE (31 patients) with clinical stage II or III esophageal cancer were compared. MAIN OUTCOME MEASURES: Primary end points included operative performance, morbidity, mortality, hospital stay, and survival. RESULTS: No differences were noted between the groups in demographics, neoadjuvant therapy use (P = .22), resection completeness (R0:R1) (P = .57), length of stay (P = .59), intensive care unit stay (P = .36), anastomotic leak (P = 1.0), pulmonary morbidity (P = .26), and mortality (P = 1.0). Median follow-up was 19 months for MIE and 17 months for ILE. Survival at 2 years was 55% for MIE (18 of 33 patients) and 32% for ILE (10 of 31 patients) while disease-free survival was 55% for MIE (18) and 26% for ILE (8). CONCLUSIONS: Our survival analysis shows divergent curves that favor MIE but have not yet reached statistical significance. The oncologic outcomes of MIE are comparable to that of ILE 2 years after resection.

High prevalence of low bone mineral density in patients with tropical calcific pancreatitis.

OBJECTIVES: Patients with tropical calcific pancreatitis (TCP) have multiple risk factors for developing low bone mineral density (BMD). We studied BMD and serum 25-hydroxyvitamin D (25[OH]D) in north Indian TCP patients. METHODS: In a cross-sectional study, 72 TCP patients (mean age, 31 ± 10 years) and 100 controls were studied. Serum 25(OH)D was measured in all subjects; BMD was measured by dual-energy x-ray absorptiometry in 56 adult patients and 4 children and compared with a reference Indian population. RESULTS: Mean BMD and BMD Z-scores at the lumbar spine and total hip were significantly lower in all age groups. The BMD Z-scores at the lumbar spine and total hip were -1.0 ± 1.0 and -1.2 ± 1.2, respectively. Low bone density (Z-score ≤ -2 at ≥ 1 sites) was present in 22 (39%) adult patients and 3 of the 4 children studied. On multivariate analysis, BMD Z-scores were positively associated with body mass index and inversely with pancreatitis. Vitamin D deficiency (25[OH]D < 50 nmol/L) was equally prevalent in patients (86%) and controls (85%). CONCLUSIONS: Despite their young age, patients with TCP have significantly low BMD. Measures to improve nutrition should be instituted in all TCP patients from an early age.

Surgical management of patients with post-cholecystectomy benign biliary stricture complicated by atrophy-hypertrophy complex of the liver.

BACKGROUND: Atrophy-hypertrophy complex (AHC) of the liver rarely complicates post-cholecystectomy benign biliary strictures (BBS). This study aimed to analyse the effect of AHC on the surgical management of patients with BBS. METHODS: Between 1989 and 2005, 362 patients underwent surgical repair for BBS at a tertiary referral centre in northern India. A total of 36 (10%) patients had AHC. Patients with AHC (n= 36) were compared with those without (n= 336) to define the factors associated with the development of AHC. RESULTS: Overall, 35 patients with AHC underwent Roux-en-Y hepaticojejunostomy; right hepatectomy was performed in one patient. The interval between bile duct injury and stricture repair did not influence the development of AHC (mean 24 months in AHC patients vs. 19 months in non-AHC patients; P= 0.522). Of the 36 patients with AHC, 26 (72%) had hilar strictures (Bismuth's types III, IV, V), as did 163 of the 326 (50%) patients without AHC (P= 0.012). Patients with AHC had more blood loss at surgery (mean blood loss 340 ml in the AHC group vs. 190 ml in the non-AHC group; P= 0.004) and required more blood transfusion (mean blood transfused 300 ml vs. 120 ml; P= 0.001). Surgery was prolonged in AHC patients (mean duration of operation 4.2 hours in the AHC group vs. 2.8 hours in the non-AHC group; P= 0.001). Over a mean follow-up of 43 months (range 6-163 months), three of 36 (8%) AHC patients required re-intervention for recurrent strictures, compared with nine of 326 (3%) non-AHC patients (P= 0.006). CONCLUSIONS: Iatrogenic injury at the hepatic hilum predisposes for the development of AHC. Surgery is more difficult and blood transfusion requirements are higher in patients with AHC during surgical repair of BBS. Atrophy-hypertrophy complex is a risk factor for recurrent stricture formation after hepaticojejunostomy.

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study.

BACKGROUND: There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres. MATERIALS AND METHODS: Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India. RESULTS: Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days). CONCLUSIONS: This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.

Omental flaps in pancreaticoduodenectomy.

CONTEXT: Pancreaticoduodenectomy continues to have a high morbidity (40-50%). Major complications of pancreaticoduodenectomy include leaks from the pancreaticojejunostomy and an intra-abdominal bleed from the gastroduodenal artery stump. The omentum has been used for the prevention of anastomotic leaks. OBJECTIVES: The use of omental flaps to prevent a pancreaticojejunostomy leak and bleeding complications from a pancreaticojejunostomy leak after pancreaticoduodenectomy. PATIENTS: Seventy-seven patients who underwent a pancreaticoduodenectomy. INTERVENTIONS: Pedicled flaps were made from the greater omentum. One omental flap was wrapped over the pancreaticojejunostomy (separating it from gastroduodenal artery stump) and the second omental flap was wrapped over the duodenojejunostomy. RESULTS: Omental flaps were used in 25 patients (Group 1) and a pancreaticoduodenectomy was done without an omental flap in 52 patients (Group 2). None of the 25 patients had any complications related to the omental flap. A pancreaticojejunostomy leak occurred in 4/25 (16%) patients in Group 1 and in 11/52 (21%) patients in Group 2 (P=0.762). None of the pancreaticojejunostomy leaks in Group 1 was clinically significant. The pancreaticojejunostomy leaks in Group 2 were responsible for intra-abdominal bleeding in 2 patients (1 died) and for intra-abdominal abscess in 5 patients (1 died). Neither of the 2 (8%) deaths in Group 1 was related to a complication from pancreaticojejunostomy. There were 5 (10%) deaths in Group 2 (three following an intra-abdominal bleed, one due to bleeding from the gastrojejunostomy, and one due to sepsis following a pancreaticojejunostomy leak). Thus, there were four patients in Group 2 who died from a pancreaticojejunostomy leak and/or a major vascular bleed vs. none in Group 1 (P=0.298). CONCLUSION: The use of omental flaps is a simple technique for decreasing the risk of major vascular complications related to pancreaticojejunostomy leak following pancreaticoduodenectomy.

Surgical strategies in patients with gallbladder cancer: nihilism to optimism.

INTRODUCTION: Gallbladder cancer is an aggressive disease with dismal results of surgical treatment and a poor prognosis. However, over the last few decades selected groups have reported improved results with aggressive surgery for gallbladder cancer. METHODS: Review of recent world literature was done to provide an update on the current concepts of surgical treatment of this disease. RESULTS: Long-term survival is possible in early stage gallbladder carcinoma. Tis and T1a gallbladder carcinoma can be treated with simple cholecystectomy only. However, in T1b and beyond cancers, aggressive surgery (extended cholecystectomy) is important in improving the long-term prognosis. Laparoscopic cholecystectomy should not be performed where there is a high index of suspicion of malignancy due to the frequent association with factors (such as gallbladder perforation and bile spill) which may lead to implantation of cancer cells and dissemination. Surgical resection for advanced carcinoma gallbladder is recommended only if a potentially curative R0 resection is possible. Aggressive surgery with vascular and multivisceral resection has been shown to be feasible albeit with an increase in mortality and morbidity. However, the true benefit of these radical resections is yet to be realized, as the actual number of long-term survivors of advanced gallbladder carcinoma is few. CONCLUSIONS: Surgery for gallbladder carcinoma, like other malignancies, has the potential to be curative only in local or regional disease. Pattern of loco-regional spread of disease dictates the surgical procedure. Radical surgery improves survival in early gallbladder carcinoma. The long-term benefit of aggressive surgery for advanced disease is unclear and may be offset by the high mortality and morbidity.