Solid Pseudopapillary Tumor of Pancreas with Sinistral Portal Hypertension: A Rare Presentation.

An elderly male presented with complaint of dull aching pain in left upper abdomen of 2 months' duration. He was well built, and on abdominal examination, a large lump was palpable in left lumbar region. His biochemical, hematological parameters and tumor markers including CA 19.9 were within prescribed normal limits. Contrast enhanced computed tomography (CT) of the abdomen revealed large, well-defined, mixed solid, and cystic lesion arising from distal body-tail of the pancreas extending up to splenic hilum. Chronic thrombosis involving retro pancreatic splenic vein with multiple perisplenic, peripancreatic, and perigastric collaterals were noted. Based on characteristic CT abdomen findings, a diagnosis of solid pseudopapillary tumor (SPT) of the pancreas with sinistral portal hypertension (SPH) was made. The patient was planned for open distal pancreatectomy with splenectomy. At surgery, splenic flexure of colon was densely adhered to the tumor, and hence en bloc resection of colon was also performed. Postoperative period was uneventful, and he was discharged from the hospital on postoperative day 6. Histopathology reported solid pseudopapillary tumor of the pancreas, 22 cm in the largest dimension. SPT of the pancreas rarely present with SPH. At 22-cm size, this may be one of the largest SPTs reported in the English literature to date.

Evaluation of ACS-NSQIP and CR-POSSUM risk calculators for the prediction of mortality after colorectal surgery: A retrospective cohort study.

Background: Several risk calculating tools have been introduced into clinical practice to provide patients and clinicians with objective, individualised estimates of procedure-related unfavourable outcomes. The currently available risk calculators (RCs) have been developed by well-endowed health systems in Europe and the USA. Applicability of these RCs in low-middle income country (LMIC) settings with wide disparities in patient population, surgical practice and healthcare infrastructure has not been adequately examined. Patients and Methods: Through this single tertiary care, LMIC-centre, retrospective cohort study, we investigated the accuracy of the two most widely validated RCs - American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) RC and ColoRectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) - for the prediction of mortality in patients undergoing elective and emergency colorectal surgery (CRS) from March 2013 to March 2020. Online RCs were used to predict mortality and other outcomes. Accuracy was assessed by Brier score and C statistic. Results: Of 105 patients, 69 (65.71%) underwent elective and 36 (34.28%) underwent emergency CRS. The 30-day overall mortality was 12 - elective 1 (1.4%) and emergency 11 (30.5%). ACS-NSQIP RC performed better for the prediction of overall (C statistic 0.939, Brier score 0.065) and emergency (C statistic 0.840, Brier score 0.152) mortality. However, for elective CRS mortality, Brier scores were similar for both models (0.014), whereas C statistic (0.934 vs. 0.890) value was better for ACS-NSQIP. Conclusions: Both ACS-NSQIP and CR-POSSUM were accurate for the prediction of CRS mortality. However, compared to CR-POSSUM, ACS-NSQIP performed better. The overall performance of both models is indicative of their wider applicability in LMIC centres also.

Current Oncologic Standards for Surgery of Small Bowel Cancers.

PURPOSE: The last 2 decades has witnessed efforts towards standardization of surgery for small bowel cancers. The proposed recent guidelines/recommendations pertaining to choice of procedure and extent of lymphadenectomy are based on analysis of data from high volume centres of excellence. We evaluated whether these recently proposed oncologic recommendations can be replicated in the setting of single centre/team. METHODS: This was a retrospective analysis of consecutive adult patients (age ≥ 18 years) who underwent surgery for tumours of small intestine (duodenum, jejunum, and ileum) by the same team of surgeons from 01/01/2010 to 12/31/2019. The procedure performed and lymph nodes harvested during pathologic examination were compared with recent recommendations. RESULTS: Of the 32 patients (20 males and 12 females), mean age was 52.4 (range 31-77) years. Twenty-nine (90.6%) patients underwent surgery for small bowel cancers. Duodenum was the most common site, while NET was the commonest cancer. Whipple's procedure was performed for tumours of II part of duodenum, while for the rest, segmental resection was performed. The median number of lymph nodes examined for duodenal adenocarcinoma and NET was 14 and 9, respectively. For jejunal/ileal adenocarcinoma, median lymph node number examined was 11. CONCLUSION: Our study shows that these recently proposed standards for surgery of small bowel cancers are achievable if basic principles of oncologic surgery are followed.

Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low-Middle-Income Country (LMIC).

BACKGROUND: Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of 'EL care protocol' aimed at cost-effective optimal utilization of best available local expertise and infrastructure. METHODS: One hundred and two consecutive adult patients (≥16 years) who underwent EL from December 2012-December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien-Dindo classification), readmissions and costs. RESULTS: Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16-93) years. There were no complications in 22 (21.6%) patients, while Clavien-Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien-Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590). CONCLUSIONS: LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.

Management of Giant Gastric Ulcer Perforation: Report of a Case and Review of the Literature.

Giant gastric ulcer (GGU) is defined as an ulcer more than 3 cm in diameter. Now infrequent in clinical practice, in the pre-H2 receptor antagonist (H2RA) era, the incidence of GGU varied between 12 and 24% of all gastric ulcers. Proton pump inhibitors reportedly achieve better healing rates and symptom relief in comparison to H2RA. The GGU is associated with high incidence of serious complications such as hemorrhage. A perforated GGU though rare (<2%) offers serious challenges in management. We report one such case wherein the role of multidetector CT scan (MDCT) for diagnosis and treatment planning, surgical options for GGU perforations, and factors affecting outcome are discussed.

Duplication of vas deferens-A rare anomaly with review of literature.

INTRODUCTION: Isolated duplication of vas deferens is a rare anomaly with only eleven cases reported in medical literature. Unawareness regarding this rare anomaly can lead to inadvertent injury to the vas during inguinal hernia surgery or failure of vasectomy procedure. PRESENTATION OF CASE: A 27-year-old gentleman was diagnosed with isolated duplication of vas during left sided open inguinal hernia surgery. He had no other genito-urinary anomaly. Patient had an uneventful recovery from surgery. CONCLUSION: It is a rare anomaly and unawareness regarding this condition can lead to catastrophic consequences during inguinal hernia and vasectomy surgeries.