Pancreatic heterotropia in gallbladder with adenocarcinoma: A rare incidental finding.

ABSTRACT: Heterotopic pancreas is defined as the presence of aberrant pancreatic tissue present outside the pancreas without connection to its neural, vascular, and anatomic location. The commonly seen locations are stomach, duodenum, jejunum, Meckel commonly seen locatio, and ampulla of Vater. The gallbladder is an extremely rare site for pancreatic heterotropia. Its association with adenocarcinoma has not been described yet. A case of 50-year-old male with pancreatic heterotropia along with carcinoma gallbladder is being presented here.

Primary Sclerosing Encapsulating Peritonitis (PSEP) With Meckel's Diverticulum: A Rare Case Report.

Sclerosing encapsulating peritonitis (SEP) is a rare disease. Preoperative diagnosis of SEP can be made with imaging, such as computed tomography (CT). SEP is characterized by a partial or complete encasement of the small intestine by a layer of a thick grayish-white fibro collagenous membrane similar to an abdominal cocoon. The most common symptoms of SEP are abdominal pain, nausea, and vomiting. This rare disease often leads to acute or sub-acute intestinal obstruction. We discuss, in this report, how we managed a case of primary sclerosing encapsulating peritonitis with Meckel's diverticulum at our institution.

Recurrent dermatofibrosarcoma protuberans: A report of two cases involving the trunk and abdominal wall.

In this paper, we report two cases of dermatofibrosarcoma protuberans (DFSP) who were treated with distinct surgical approaches. In the first case, a 50-year-old woman presented with a mass on her right shoulder and underwent local excision with subsequent reconstruction using a deltopectoral flap. The second case was of a young female who presented with a giant protuberant DFSP on the anterior abdominal wall who was treated with wide local excision along with inlay mesh repair of the defect. Early excision and adjuvant radiotherapy facilitates a low recurrence rate while also improving the prognosis of the patients.

Primary ALK-Positive Large B Cell Lymphoma of Pancreas.

INTRODUCTION: Primary pancreatic B-cell lymphoma is rare with most common type being Diffuse Large B-cell lymphoma (DLBCL). Anaplastic lymphoma kinase-positive large B-cell lymphoma (ALK+ LBCL) represents less than 1% of all DLBCL. Extra-nodal presentation is rare with presentation as a primary pancreatic mass being exceptional. CASE REPORT: A 42 years female presented with lump in central upper abdomen for one month with evidence of icterus. Lab Investigations showed deranged Total Bilirubin/Direct Bilirubin, AST, ALT, ALP, Amylase, Lipase, CEA, CA 19-9 and CA-125 levels. CECT scan showed large solid mass in pancreas with necrotic areas within. Biopsy revealed a lymphoma with strong expression of ALK (granular cytoplasmic), CD138, MUM1, kappa, moderate expression of CD45 and focal expression of CD20, CD79a and PAX5 and lack of expression of CD5, CD3, CD45RO, BCL6, CD10 and EMA. FNAC and Flow Cytometry was also performed. A final diagnosis of ALK positive LBCL was made with pancreas as primary. CONCLUSION: Present case is the first case of ALK positive LBCL reported in pancreas. Expression of mature B-cell markers such as CD20, CD79a and light chain restriction may be seen unlike previous claims.

Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice?

BACKGROUND: Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India. METHODS: A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS). RESULTS: With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%). CONCLUSIONS: Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Laparoscopically guided transversus abdominis plane block offers better pain relief after laparoscopic cholecystectomy: results of a triple blind randomized controlled trial.

BACKGROUND: Transversus abdominis plane (TAP) block is a regional anaesthetic technique providing analgesia to the parietal peritoneum, muscles and skin of the anterior abdominal wall innervated by somatic nerves T6 to L1. We present the results of our randomized triple blind study comparing laparoscopically guided TAP block with the commonly used port site local anaesthetic infiltration for pain relief after laparoscopic cholecystectomy. METHODS: A hundred patients with symptomatic gallstones planned for laparoscopic cholecystectomy were randomized into two groups of TAP block and port site infiltration. Group A received 4-quadrant TAP block with 10 ml of 0.25% bupivacaine at each of the four sites guided laparoscopically and port site infiltration with 10 ml of normal saline at each of the 4 ports for blinding the surgeon. Group B received port site infiltration with 0.25% bupivacaine, and infiltration with normal saline at TAP block sites for blinding the surgeon. Post-operative pain (at 3, 6, 24 h and 1-week post-operative) (VAS), time to return to activities of daily living and patient satisfaction (Capuzzo Score) were recorded by an observer blinded towards the groups of the patients. RESULTS: The median VAS at 3, 6, 24 h, at discharge, and 1-week post-operative were lesser in Group A compared to Group B (p ≤ 0.001 for all). The median duration of hospital stay was also lesser in Group A compared to Group B (p = 0.48, not significant) as was the time to return to activities (p < 0.05). The median Capuzzo score was higher in Group A compared to Group B (p < 0.001). CONCLUSION: This study shows that laparoscopically guided TAP block is a safe and easy-to-use technique. It reduces the severity of post-operative pain, helps in quick recovery, early discharge and improved patient satisfaction after laparoscopic cholecystectomy. Clinical Trials Registry of India 020227.

Giant villous adenoma of rectum- what is the malignant potential and what is the optimal treatment? A case and review of literature.

INTRODUCTION: Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential. CASE REPORT: A 62-year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. DISCUSSION: Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose risk of malignancy is especially high up to 50% when greater than 2 cm in size. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas. Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases. CONCLUSION: Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. As per current data, the combined risk of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than 8 cm in size. Laparoscopic colorectal resection is safe and effective.

Gall bladder flip technique in laparoscopic cholecystectomy.

BACKGROUND: The precise steps for the removal of gall bladder from the gall bladder bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus creates a 'tug of war' like situation. MATERIALS AND METHODS: This is a description of a simple technique that aids in accurate dissection of the gallbladder from liver bed. As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, the medial and lateral peritoneal folds of gall bladder are further incised. The assistant is asked to leave the traction from the gallbladder fundus, while the surgeon holds the dissected surface of gall bladder around 2-3 cm away from its attachment with liver and flip it above the liver. Further dissection is carried out using a hook or a dissector till it is disconnected completely from the liver bed. RESULTS: We have employed 'Flip technique' in around 645 consecutive cases of laparoscopic cholecystectomy operated in the past 3 years. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in this study. Ease of dissection by surgeons was rated as 9.6 on a scale of 1-10. CONCLUSION: Gallbladder 'Flip technique' is a simple and easily reproducible technique employed for dissection of gall bladder from liver bed that reduces complications and makes dissection easier.

Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study.

BACKGROUND: Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia. METHODS: Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. RESULTS: There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. CONCLUSIONS: The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.

Early post-operative weight loss after laparoscopic sleeve gastrectomy correlates with the volume of the excised stomach and not with that of the sleeve! Preliminary data from a multi-detector computed tomography-based study.

BACKGROUND: Pre- and post-operative stomach volumes can be important determinants for effectiveness of laparoscopic sleeve gastrectomy (LSG) in causing weight loss. There is little existing data on the volumes of stomach preoperatively and that excised during LSG. This study was designed to evaluate the change in gastric volume after LSG using multi-detector CT and to correlate it with early post-operative weight loss. METHODS: Twenty consecutive patients with BMI ≥ 40 kg/m(2) and medical comorbidities underwent LSG between October 2011 and October 2013 and were analysed prospectively. The pre-operative stomach volume was measured by MDCT done 1-3 days before the surgery. LSG was performed in the standard manner using a 36F bougie. The volume of excised stomach was measured by distending the specimen with saline. MDCT of the upper abdomen was repeated 3 months postoperatively to calculate the gastric sleeve volume. Weight loss and resolution of comorbidities were documented. RESULTS: The mean pre-operative weight of patients was 123.90 kg, and the mean pre-operative stomach volume on MDCT was 1,067 ml. The stomach volume on pre-operative MDCT correlated with pre-operative weight and BMI. The mean volume of the excised stomach was 859 ml when measured by distension of the specimen and 850 ml on MDCT. After 3 months post surgery, the mean volume of gastric sleeve on MDCT was 217 ml, and the mean weight of the patients was 101.22 kg. The volume of the excised stomach calculated by MDCT correlated with the weight loss achieved 3 months postoperatively. However, no correlation was seen between the gastric sleeve volume 3 months postoperatively and weight loss during this period. CONCLUSIONS: MDCT is a good method to measure gastric volume before and after LSG. Early post-operative weight loss (3 months) correlates well with the volume of the excised stomach but not with that of the gastric sleeve.

A randomized trial comparing the use of endobiliary stent and T-tube for biliary decompression after laparoscopic common bile duct exploration.

PURPOSE: To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration. METHODS: Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded. RESULTS: There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001). CONCLUSIONS: Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.

Laparoscopic choledochoduodenostomy for biliary stone disease: a single-center 10-year experience.

BACKGROUND AND AIMS: Patients with a dilated common bile duct (CBD) and multiple, primary, or recurrent stones are candidates for choledochoduodenostomy. This article reviews our technique and results of laparoscopic choledochoduodenostomy (LCDD) in patients with CBD stones. SUBJECTS AND METHODS: Prospectively maintained data of patients with a dilated CBD and multiple, primary, or recurrent CBD stones who underwent LCDD after laparoscopic CBD exploration (LCBDE) at a tertiary-care teaching hospital in New Delhi, India, during a 10-year period from April 2001 to March 2011 were analyzed. RESULTS: During this period, of 195 patients who underwent LCBDE for CBD stones, 27 patients underwent LCDD. The mean age of patients was 45.7±13.5 years. There were 6 male and 21 female patients. Sixteen (59.2%) patients had jaundice at presentation. Average CBD diameter was 19.6±4.4 mm. On average, 11.5±15.7 stones were removed from the CBD. Mean operative time was 156.3±25.4 minutes. Mean operative blood loss was 143.3±85.5 mL. Average postoperative hospital stay was 6.4±3.8 days. CBD clearance was obtained in all cases. One patient had a bile leak that resolved with conservative treatment. There was no mortality. No patient has had recurrence of symptoms or cholangitis after a follow-up of up to 9 years. CONCLUSION: LCDD can be safely performed in patients with a large stone burden and recurrent or primary CBD stones. Although it requires advanced laparoscopic skills, the benefits of a single-stage laparoscopic procedure can be extended to these patients safely with good results.

Safety of open technique for first-trocar placement in laparoscopic surgery: a series of 6,000 cases.

BACKGROUND: The open technique for the placement of the first trocar in laparoscopic surgery has become the preferred method due to the reduced number of complications associated with it. In 2002 we reported our technique, which has been widely accepted at many centers, including all the units of our hospital. We now report on a series of 6,000 cases in which this technique was used. METHOD: The method is the same as that reported by us previously (Surg Endosc 16:1366-1370, [10]) except for the minor modification of using a Mayo towel clip instead of the Allis forceps for holding the cicatrix pillar, as the pillar tends not to slip out of the former. During closure, Allis forceps is used to lift the divided rectus sheath on each side to take the suture bite and ensure complete secure closure. A total of 6,000 consecutive cases have been performed using this technique in two tertiary care hospitals over the last 11 years. RESULTS: A total of 6,000 cases (5,350 females and 650 males) were operated on over an 11-year period. There were no visceral or vascular complications. Four hundred seventy-five patients (7.9%) had had previous abdominal surgery. The supraumbilical route was used in 348 patients and lateral entry in 90 patients. Port-site hernias were seen in 25 cases (0.4%) and wound infections in 56 cases (0.9%). The average time for trocar placement was 2 min (range = 1-12 min) and the average port size was 15 mm (range = 12-22 mm). The average time for port closure at the end of the procedure was 3 min (range = 1-7 min). CONCLUSIONS: The technique of open-trocar placement in laparoscopic surgery has now become standardized, with its safety having been well established. Our experience has shown that this technique is safe, effective, reproducible, easy to learn, can be performed quickly, and has excellent results.

Laparoscopic management of CBD stones: an Indian experience.

BACKGROUND: Common bile duct stones (CBDS) that are seen in the Asian population are very different from those seen in the west. It is not infrequent to see multiple, large, and impacted stones and a hugely dilated CBD. Many of these patients have been managed by open CBD exploration (OCBDE), even after the advent of laparoscopic cholecystectomy (LC), because these large stones pose significant challenges for extraction by endoscopic retrograde cholangiopancreatography. This series presents the largest experience of managing CBDS using a laparoscopic approach from Indian subcontinent. METHODS: Between 2003 and 2009, 150 patients with documented CBDS were treated laparoscopically at a tertiary care hospital in New Delhi. Of these, 4 patients were managed through transcystic route and 140 through the transcholedochal route. RESULTS: There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7%), and 23 patients (15%) had nonfatal postoperative complications. Three patients had retained stones (2%) and one developed recurrent stone (0.7%). CONCLUSIONS: Even in patients with multiple, large, and impacted CBDS, there is scope for a minimally invasive procedure with its attendant benefits in the form of laparoscopic CBD exploration (LCBDE).

Evaluation of the role of preoperative Double-J ureteral stenting in retroperitoneal laparoscopic pyelolithotomy.

BACKGROUND: Since the first retroperitoneal laparoscopic pyelolithotomy (RPPL) was reported by Gaur and associates in 1994, its technique has improved considerably. The applicability and indications of the procedure are expanding with advances in technology, expertise, and experience. To date, there has been no prospective study in the literature about the role of preoperative Double-J (D-J) ureteral stenting in patients who undergo RPPL. This study is an endeavor to evaluate the role of preoperative D-J stenting in RPPL. METHODS: The study included 184 patients, who were randomized into 2 groups. Group A included 95 patients, who underwent RPPL with D-J stenting. Group B included 89 patients, who underwent RPPL without D-J stenting. In group A, D-J stents were inserted under local anesthesia preoperatively, on the side of surgery. Complications during surgery and during the postoperative period were carefully recorded. RESULTS: The duration of drainage and volume in group A was significantly lower than in group B. The duration of postoperative stay was significantly reduced in group A (mean 3.3 vs. 5.74 days). The analgesic requirement in group A also was significantly lower than in group B (mean 378.95 vs. 558.99 mg). No statistically significant difference existed between the two groups, in terms of minor intraoperative and postoperative complications (25.3% vs. 29.2%; p < or = 0.547). CONCLUSIONS: D-J stenting and type of renal pelvis influenced the results, i.e., duration of drainage, analgesic requirement, and duration of stay, in patients undergoing RPPL. However, there was no significant difference in operative time, intraoperative blood loss, and postoperative complications. D-J stent group had significant increase in the rate of urinary tract infection postoperatively.