Hepatocellular carcinoma: A clinicopathological and immunohistochemical study of 116 cases from a tertiary care hospital in Southern India.

Background: Diagnosis of hepatocellular carcinoma (HCC) is difficult on morphology alone in poorly differentiated tumors and metastatic carcinomas. Appropriate immunohistochemical markers are required for definite diagnosis. In this article, we have analyzed the histopathological and immunohistochemical features of HCC and elucidate the best possible immunohistochemistry (IHC) marker combination by comparing the sensitivity of various markers in different grades of tumor. Methods: A total of 116 consecutive cases were analyzed retrospectively. The hematoxylin and eosin stained sections were reviewed in all the cases. IHC was done using hepatocellular specific antigen (HSA), arginase-1, glypican-3, and polyclonal carcinoembryonic antigen (pCEA). The sensitivity of various immunohistochemical markers individually as well as in combination for different tumor grades was determined. Results: Histologically, the predominant subtype comprised of classic variant (109,93.9%) followed by combined hepatocellular and cholangiocarcinoma (4,3.4%) and fibrolamellar variant (3,2.6%). Trabecular pattern was the most common histological pattern. On grading, 65,56.03% were moderately differentiated, 34,29.31% well differentiated, and17, 14.65% poorly differentiated. HSA and polyclonal-CEA showed higher sensitivity than arginase-1 and glypican-3 in well and moderately differentiated tumors. In contrast arginase-1 and glypican-3 showed better sensitivity in poorly differentiated HCC. The overall sensitivity increased to greater than 90% if HSA/polyclonal-CEA is combined with either arginase-1/glypican-3 irrespective of tumor grade. Conclusion: Majority of the tumors were classic variants and moderately differentiated. HSA along with either arginase-1 or glypican-3 is the best combination of immunomarker for identification of hepatocellular differentiation irrespective of tumor grade.

The role of image guided percutaneous drainage in multidisciplinary management of necrotizing pancreatitis.

BACKGROUND: Percutaneous catheter drainage (PCD) has become popular as a minimally invasive technique in the treatment armamentarium of patients with necrotizing pancreatitis requiring intervention. It obviates surgery and its attendant morbidity in a considerable number of patients in this setting. AIM: The aim of the study was to examine whether PCD upfront avoids surgery in a cohort of patients with necrotizing pancreatitis requiring intervention, and to identify factors predicting its failure. METHODS: We retrospectively reviewed demographic, clinical, and perioperative details of patients with severe acute pancreatitis from January 2009 to December 2011. Of 40 patients with necrotizing pancreatitis admitted to the surgical gastroenterology unit at our institute, 23 patients requiring PCD or surgical intervention were included in this study. Patients with successful and failed PCD were compared to identify factors predictive of failure of PCD. We also compared patients undergoing open necroseotomy with those undergoing PCD upfront, and open necrosectomy in terms of major complications including death. RESULTS: . Surgery was avoided in 7/23 (30%) patients with necrotizing pancreatitis who underwent PCD upfront. Higher APACHE II score (p=0.003) and extent of intrapancreatic necrosis (> 50%, p=0.03) were statistically significant predictors of failure of PCD. Although the complications were not different in patients undergoing PCD upfront followed by surgery, they had lower APACHE II and SOFA scores after PCD and had resolution of organ failures. CONCLUSIONS: PCD obviates surgery or acts as a temporizing measure in a significant number of patients with necrotizing pancreatitis. APACHE II scores and extent of intrapancreatic necrosis are principle factors determining success of PCD.

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.

Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus aureus - a case report.

Methicillin resistant Stephylococcus aureus (MRSA) infection has now become a major problem in hospitals. We present a case of postoperative infection MRSA where the primary source of the infection was found to be an abdominal mesh that was used to reinforce the abdominal wall. After one year of surgery, the patient developed wound dehiscence and discharge. MRSA was isolated from the wound, mesh, external nares, throat and axilla. Initially she was started on clindamycin and discharged from the hospital. After 5 months, patient came back to the hospital with infection at the same site. The patient was then treated with vancomycin and MRSA clearance. She responded to the treatment with complete healing of the wound and clearance of MRSA.

Isolated splenic tuberculosis.

The authors report two cases of isolated splenic tuberculosis treated since 1989 in Nizam's Institute of Medical Sciences. One case presented as pyrexia of unknown origin (PUO) and another with idiopathic thrombocytopenic purpura (ITP). Both were found to have splenic tuberculosis after splenectomy. Pre operative diagnosis could not be made in these cases. Splenectomy followed by antituberculous chemotherapy cured the condition in both the cases. The authors underline the diagnostic difficulties, essentially related to the rarity of this condition inspite of the progress in modern imaging.

Pancreatico-biliary ductal union.

A long common channel distal to the pancreaticobiliary junction is the commonest anomalous arrangement of the pancreaticobiliary ductal system and is mostly observed in patients with congenital choledochal cysts. APBDU without choledochal cyst is a high-risk condition for the development of gallbladder carcinomas. Prophylactic excision of the extrahepatic biliary system and reconstruction of the biliary tract with hepatico-jejunostomy are recommended. APBDU should always be kept in mind when a patient with a long history of abdominal pain is found to have gall bladder wall thickness even without gallstones on imaging by a CT Scan or Ultra Sound. ERCP should be performed in these patients in order to detect APBDU. This may allow early detection of carcinoma of the biliary tract. Presence of common channel may be associated with a lower incidence of gallstones. However it requires corroboration by other studies. On the other hand carcinoma of the gall bladder appears to have a close association with abnormally long common channel.

Primary small intestinal adenocarcinoma.

Seven patients with adeno-carcinoma of the small intestine were seen over a period of five years. Four were localized to the duodenum, the jejunum was involved in two and the ileum in one. Abdominal pain, weight loss, anemia and obstruction were the most common presenting complaints. Endoscopy was the primary diagnostic modality for the duodenal tumours. Diagnostic accuracy of barium contrast examination was 83%. Curative resections were performed in two patients and palliative surgery in the rest.