A case report on enormous haemangioma of liver.

Introduction: Hemangiomas are the most common benign liver tumour. These tumours arise from the proliferation of vascular endothelial cells and increase in size owing to dilation. If their diameter exceeds 5 cm, they are classified as giant hemangiomas, while those surpassing 15 cm are considered enormous hemangiomas. Case presentation: A 38-year-old female patient presented with complaints of abdominal fullness for 18 months. Contrast-enhanced computed tomography was performed and two hemangiomas were diagnosed; the , larger one was an enormous hemangioma of size 20 × 16 cm. Non-anatomical hepatic resection was performed to remove the hemangiomas. The patient recovered well, without any complications. Clinical discussion: Hepatic hemangiomas are common, but hemangiomas greater than 15 cm in size are rare. They usually require no treatment unless the patient is symptomatic. Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma. Conclusions: Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months. Often, surgical intervention is required.

Perioperative Outcomes of Systematic Mesopancreas Dissection for Pancreatic and Periampullary Carcinoma at a Tertiary Referral Center From a Low Middle-Income Country.

Introduction Systematic mesopancreas dissection (SMD) is an emerging surgical approach in pancreatic cancer surgery. There is still debate about early postoperative and pathological outcomes using SMD in pancreatic cancer surgery. This study has been conducted to compare the perioperative outcomes, the lymph node yield, and the margin status in patients who underwent standard pancreaticoduodenectomy (ST-PD) and SMD-PD for pancreatic and periampullary carcinoma. Methods A retrospective comparative study was conducted in patients who underwent PD for pancreatic and periampullary carcinoma in a single unit of gastrointestinal and hepatopancreatobiliary surgery at Tribhuvan University Teaching Hospital, Nepal. Early perioperative and pathological outcomes were compared between the SMD-PD and ST-PD. Results The demographic data of 30 patients who underwent SMD-PD was comparable with the historical data of 40 patients who underwent ST-PD. The intraoperative blood loss and postoperative complications were found to be comparable between ST-PD and SMD-PD. However, the median operative time for SMD-PD was longer than ST-PD (360 minutes [IQR: 90 minutes] vs. 360 minutes [IQR: 60 minutes]). The rate of margin negative resection was similar between both groups. The median lymph node yield was significantly high in patients who underwent SMD-PD (17.5 (IQR: 6.5) vs. 11 [IQR-10.75]; p < 0.05). Conclusion SMD is safe and feasible for treating periampullary carcinoma and is particularly helpful in increasing lymph node yield.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Predictive Factors Associated With Survival in Periampullary Cancers Following Pancreaticoduodenectomy: A Retrospective Analysis.

Background Periampullary cancers arise from four different anatomical sites and are in close proximity. But they have different survival outcomes. There are various clinicopathological factors associated with survival after pancreaticoduodenectomy done for periampullary cancers. So, we aimed to identify the predictive factors associated with poor survival in periampullary cancers at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Methods We analyzed the medical records of patients who underwent pancreaticoduodenectomy (PD) at Tribhuvan University Teaching Hospital, Kathmandu, from April 2004 to May 2014. Demography, clinicopathological features, and survival outcomes were analyzed retrospectively. Results This study included 61 patients. The mean age of patients was 56.2 ± 14.2 years, and there was a male preponderance (M:F = 1.4). The median survival of all patients was 24 months. Non-pancreatic periampullary cancer patients had better median survival as compared to pancreatic cancer patients (24 vs. 8 months, p = 0.03). The presence of lymphovascular invasion (LVI), peripheral invasion (PNI), nodal involvement, and a higher lymph node ratio (LNR) were associated with poor median survival. However, perineural invasion was the only factor associated with poor survival in multivariate analysis. Conclusion The presence of perineural invasion is associated with poor survival outcomes in patients with periampullary cancer following pancreaticoduodenectomy. Also, carcinoma of the head of the pancreas has poor survival as compared to other periampullary cancers.

Duodenal perforation due to migrated biliary stent: Case report.

INTRODUCTION: Biliary stents are frequently associated with various complications; however biliary stent migration causing duodenal perforation is rare and has only been reported in few cases. PRESENTATION OF CASE: We present a case of 33 years old male with pain abdomen and fever for 2 days came to Emergency department. He had undergone open common bile duct exploration (CBD), clearance of stone and placement of CBD stent. In X-ray abdomen, biliary stent migration was suspected. CECT abdomen was done for the confirmation of diagnosis which showed migrated stent with duodenal perforation. Patient underwent exploratory laparotomy and Thal patch repair, pyloric exclusion, retrograde duodenostomy and feeding jejunostomy. Post-operative period was uneventful. DISCUSSION: Biliary stents are used to relieve biliary obstruction. There is increasing use of endoscopic retrograde drainage via plastic endoprosthesis and so the related morbidities. One of the rare but serious complications is intestinal perforation and duodenal perforation is seen in most of the cases, explanation being the relative fixed position of the duodenum. CONCLUSION: Although intestinal perforation is an uncommon complication following CBD stenting, we should suspect it in patients presenting with pain and fever.

Colocolic intussusception secondary to colonic adenocarcinoma with impending caecal perforation in an elderly patient: A rare case report.

INTRODUCTION: Intussusception is a surgical emergency in which a part of the intestine slides into the distal adjacent part. Adult colocolic intussusception secondary to a tumoral process is a rare but serious clinical condition requiring immediate surgical intervention. CASE PRESENTATION: We report a case of a 65-year-old male patient presenting with abdominal pain and distention, subsequently diagnosed with colocolic intussusception in the descending colon with closed-loop bowel obstruction with impending caecal perforation. An exophytic mass on the descending colon was discovered intra-operatively, prompting a subtotal colectomy with ileosigmoidal anastomosis and loop ileostomy with the suspicion of malignancy. The histopathological examination of the surgical specimen concluded a moderately-differentiated colonic adenocarcinoma with 40% mucinous component. CLINICAL DISCUSSION: Adult intestinal intussusception is a rare but serious condition differing greatly in etiology from its pediatric counterpart. Its preoperative diagnosis is challenging in adults, which appears to be due to its imprecise presenting signs and symptoms; thus, the condition can be mistaken for other causes of intestinal obstruction. Adenocarcinomas remain the most common cause of malignant tumors in the colon, which also makes them one of the causes for colocolic intussusception. CONCLUSION: Intussusception can appear as a surgical emergency even in the elderly, necessitating prompt surgical intervention to avoid intestinal ischemia and gangrene. Its diagnosis can be aided to a great degree by CT imaging.

Morgagni hernia in adult: A case report.

INTRODUCTION AND IMPORTANCE: Morgagni Hernia is a congenital diaphragmatic hernia but can rarely present in adults. It occurs due to a congenital defect in the development of the diaphragm. Here we present a case of symptomatic Morgagni hernia diagnosed in a 53 years' female. CASE PRESENTATION: A 53 years' female presented with recurrent chest symptoms and was found to have bowel contents herniated into the right hemithorax on chest X-ray and CECT. Reduction of hernia was done laparoscopically and the hernia was repaired with non-absorbable suture in an interrupted manner. CLINICAL DISCUSSION: Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CECT of chest and repair of hernia without the use mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration. CONCLUSION: The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases.

Common hepatic artery pseudoaneurysm: A rare complication following total gastrectomy: A case report.

INTRODUCTION AND IMPORTANCE: Common Hepatic Artery (CHA) Pseudoaneurysm is a rare entity, attributed to infections, trauma, and upper abdominal surgery. Most cases occur after biliary and pancreatic surgery. CHA pseudoaneurysm after total gastrectomy is uncommon and can be devastating. CASE PRESENTATION: A 58-years male who underwent D2 total gastrectomy for gastric carcinoma ten days ago, presented with hematemesis, epigastric pain, and a history of melaena. After admission, upper gastrointestinal endoscopy showed a clot at the jejunojejunostomy site. Computed tomography with angiography was diagnostic of pseudoaneurysm of CHA located inferiorly. Coil embolization of CHA was done and the patient improved. CLINICAL DISCUSSION: Pseudoaneurysm of the common hepatic artery is a serious complication after abdominal surgery. Only a few cases have been reported with similar symptoms related to gastrointestinal bleeding following various upper abdominal surgeries. Coil embolization is a gold standard technique with a high success rate. CONCLUSION: CHA pseudoaneurysm is a dreadful potential complication of abdominal surgery including gastrectomy. Early recognition and emergency management of CHA pseudoaneurysm are crucial for a favorable outcome for patients with bleeding from CHA aneurysm.