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1.
Cureus ; 15(4): e37167, 2023 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-37168160

RESUMO

An inflammatory myofibroblastic tumor (IMT) is a very rare tumor of mesenchymal origin with unclear etiopathogenesis, no unique diagnostic features, and no specific management protocol. It is often confused with inflammatory pseudotumor in literature, and the distinction needs further study. The average size, recurrence risk, and metastatic potential differ as per the site of origin. The abdomen is a very rare site for IMTs. Hepatic IMTs (H-IMTs) are reported to be solid tumors with sizes ranging from 1 cm to 20 cm in literature, and gastric IMTs (G-IMTs) range from 3 cm to 10 cm in size and can be solid-cystic. We report here a case of a 36-year-old gentleman with a 34x27x17 cm solid-cystic lesion in the lesser sac with loss of fat planes with stomach and left hemi-liver. The patient was managed by complete surgical resection of the lesion with wedge gastrectomy and wedge hepatectomy and recovered uneventfully. To our knowledge and based on our literature review, this case presents the largest reported and solid-cystic G-IMT with the involvement of left hemi-liver in a young gentleman and discusses its management as well as the relevant literature on this rare entity. This clinical presentation of G-IMT should be kept in the differential diagnosis in a relevant case presenting in the future. Immunohistochemistry is a must to establish the diagnosis, and surgical resection to negative margins is the management option of choice in resectable cases.

2.
Langenbecks Arch Surg ; 408(1): 104, 2023 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-36826524

RESUMO

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.


Assuntos
Veias Mesentéricas , Neoplasias Pancreáticas , Humanos , Veias Mesentéricas/cirurgia , Pâncreas/cirurgia , Veia Porta/cirurgia , Neoplasias Pancreáticas/cirurgia , Jejuno/cirurgia , Pancreaticoduodenectomia/métodos
4.
Surg J (N Y) ; 7(4): e301-e306, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34926811

RESUMO

Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

5.
Surg J (N Y) ; 6(4): e180-e184, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33335986

RESUMO

Pyrexia of unknown origin (PUO) has been a diagnostic challenge for decades. Hepatic hemangioma (HH) is not a common differential diagnosis of PUO. It is the most common benign hepatic tumor, commonly asymptomatic and incidentally detected, or can present with vague abdominal pain. PUO is a rare presenting feature. We describe a case of 38-year-old lady presenting with PUO. With no other identifiable source of fever despite exhaustive investigations, a giant hemangioma in right lobe of liver detected on abdominal ultrasonography was deemed to be the cause of PUO. The patient had sudden decrease in hemoglobin while undergoing workup, which on imaging showed a bleeding hemangioma and right hepatectomy was performed. Patient had an uneventful recovery and her PUO also resolved after surgery. HH should be considered a rare diagnosis of exclusion for PUO after a standard algorithmic approach does not reveal any other cause.

6.
Arq Bras Cir Dig ; 33(2): e1505, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33237158

RESUMO

BACKGROUND: Majority of patients with large size HCC (>10 cm) are not offered surgery as per Barcelona Clinic Liver Cancer (BCLC) criteria and hence, their outcomes are not well studied, especially from India, owing to a lower incidence. AIM: To analyze outcomes of surgery for large HCCs. METHODS: This retrospective observational study included all patients who underwent surgery for large HCC from January 2007 to December 2017. The entire perioperative and follow up data was collected and analyzed. RESULTS: Nineteen patients were included. Ten were non-cirrhotic; 16 were BCLC grade A; one BCLC grade B; and two were BCLC C. Two cirrhotic and three non-cirrhotic underwent preoperative sequential trans-arterial chemoembolization and portal vein embolization. Right hepatectomy was the most commonly done procedure. The postoperative 30-day mortality rate was 5% (1/19). Wound infection and postoperative ascites was seen in seven patients each. Postoperative liver failure was seen in five. Two cirrhotic and two non-cirrhotic patients had postoperative bile leak. The hospital stay was 11.9±5.4 days (median 12 days). Vascular invasion was present in four cirrhotic and five non-cirrhotic patients. The median follow-up was 32 months. Five patients died in the follow-up period. Seven had recurrence and median recurrence free survival was 18 months. The cumulative recurrence free survival was 88% and 54%, whereas the cumulative overall survival was 94% and 73% at one and three years respectively. Both were better in non-cirrhotic; however, the difference was not statistically significant. The recurrence free survival was better in patients without vascular invasion and the difference was statistically significant (p=0.011). CONCLUSION: Large HCC is not a contraindication for surgery. Vascular invasion if present, adversely affects survival. Proper case selection can provide the most favorable survival with minimal morbidity.


Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Adulto , Idoso , Carcinoma Hepatocelular/cirurgia , Feminino , Hepatectomia , Humanos , Índia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Estudos Retrospectivos , Resultado do Tratamento
7.
Surg J (N Y) ; 6(2): e112-e117, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32566748

RESUMO

A 59-year-old gentleman with a history of aortic valve replacement presented with spontaneously ruptured hepatocellular carcinoma in right lobe of a hepatitis C virus (HCV)-related chronic liver disease with hemoperitoneum. This acute emergency was managed by transarterial embolization. Right trisectionectomy with preservation of segment IVB after augmentation of future liver remnant by transarterial chemoembolization followed by portal vein embolization was subsequently performed. Sustained virological response to HCV was attained after surgery using sofosbuvir-based regimen. He had a delayed operative bed recurrence 1.5 years later with pulmonary metastatic disease which was managed by operative bed metastasectomy with mesh reconstruction of diaphragm and sorafenib. He is on sorafenib since past 3 years and doing well at 4.5-years follow-up since the first presentation, with significant regression of pulmonary disease and no other disease elsewhere, which highlights that where there is hope, there is a way.

8.
Surg J (N Y) ; 6(1): e37-e41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32133413

RESUMO

Hepatic portal venous gas (HPVG), a rare radiological finding, is historically considered an ominous sign with 100% mortality rates. The dictum that HPVG warrants surgical intervention is challenged in the recent literature. This is because of the identification of various causes of HVPG other than bowel gangrene. Most of these newly identified causes can be managed conservatively. However, bowel gangrene, if missed, is fatal. Hence, sound clinical judgment and accurate diagnosis based on specific clinical parameters and imaging findings are important. We present a case of a young male with tumor lysis syndrome and neutropenic sepsis. He underwent treatment for a relapse of T-cell acute lymphocytic leukemia and presented with abdominal pain and distension. Computed tomography (CT) scan showed HPVG, and the differential diagnosis was neutropenic colitis or pseudomembranous colitis, with steroid use as the probable cause. The patient was managed conservatively. The case emphasizes that the evaluation for a specific cause of HPVG is important to reduce unnecessary surgery. A succinct literature review provides the reasons for the changing mortality rates.

9.
J Gastrointest Cancer ; 51(1): 102-108, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30784017

RESUMO

PURPOSE: Mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) is a rare neoplasm comprising of exocrine and neuroendocrine elements, each representing ≥ 30% lesion. It is commonly misdiagnosed as adenocarcinoma or grade-3 neuroendocrine neoplasm (NEN). Management is not well-defined. METHODS: Retrospective analysis of prospectively entered data at our centre from January 2011 to January 2018 revealed 16 MiNENs off 130 neuroendocrine neoplasms (NENs). These were analysed for demographics, clinicopathological characteristics, management strategies and prognosis. RESULTS: Four out of 16 patients, metastatic at presentation, were started on chemotherapy. Eleven of remaining 12 patients had pre-operative biopsy. Only two were diagnosed MiNEN. Four patients (33.34%) received 5-fluorouracil (5-FU)-based neoadjuvant chemotherapy and underwent curative surgery with adjuvant cisplatin+etoposide (Cis-Eto). Out of these, two patients (16.6%) developed metastasis and were shifted to capecitabine+temozolomide (Cap-Tem). Six patients (50%) with neuroendocrine-dominant MiNEN received adjuvant Cis-Eto after surgery. Two (16.6%) developed metastases for which Cap-Tem was started. One of them developed locoregional and liver metastasis. Three patients (25%) have succumbed to progressive disease, three (25%) are on treatment, and six (50%) are disease-free at 4-30 months. CONCLUSION: Preoperative diagnosis of MiNEN is challenging, and it needs quality histopathological examination and immunohistochemistry. The 30% criteria is therapeutically insignificant, and treatment based on most aggressive component is prognostically more relevant. Neoadjuvant 5-FU-based regimens may downstage adenocarcinoma-dominant tumours. There are no guidelines on adjuvant Cis-Eto. Cap-Tem can be considered second-line chemotherapy. Poor survival is reported irrespective of site of origin and adjuvant therapy.


Assuntos
Tumores Neuroendócrinos/diagnóstico , Tumores Neuroendócrinos/terapia , Adulto , Idoso , Feminino , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/patologia , Estudos Prospectivos , Estudos Retrospectivos , Adulto Jovem
10.
ABCD (São Paulo, Impr.) ; 33(2): e1505, 2020. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1130524

RESUMO

ABSTRACT Background: Majority of patients with large size HCC (>10 cm) are not offered surgery as per Barcelona Clinic Liver Cancer (BCLC) criteria and hence, their outcomes are not well studied, especially from India, owing to a lower incidence. Aim: To analyze outcomes of surgery for large HCCs. Methods: This retrospective observational study included all patients who underwent surgery for large HCC from January 2007 to December 2017. The entire perioperative and follow up data was collected and analyzed. Results: Nineteen patients were included. Ten were non-cirrhotic; 16 were BCLC grade A; one BCLC grade B; and two were BCLC C. Two cirrhotic and three non-cirrhotic underwent preoperative sequential trans-arterial chemoembolization and portal vein embolization. Right hepatectomy was the most commonly done procedure. The postoperative 30-day mortality rate was 5% (1/19). Wound infection and postoperative ascites was seen in seven patients each. Postoperative liver failure was seen in five. Two cirrhotic and two non-cirrhotic patients had postoperative bile leak. The hospital stay was 11.9±5.4 days (median 12 days). Vascular invasion was present in four cirrhotic and five non-cirrhotic patients. The median follow-up was 32 months. Five patients died in the follow-up period. Seven had recurrence and median recurrence free survival was 18 months. The cumulative recurrence free survival was 88% and 54%, whereas the cumulative overall survival was 94% and 73% at one and three years respectively. Both were better in non-cirrhotic; however, the difference was not statistically significant. The recurrence free survival was better in patients without vascular invasion and the difference was statistically significant (p=0.011). Conclusion: Large HCC is not a contraindication for surgery. Vascular invasion if present, adversely affects survival. Proper case selection can provide the most favorable survival with minimal morbidity.


RESUMO Racional: A maioria dos pacientes com CHC de grande porte (>10 cm) não tem indicação cirúrgica conforme os critérios do Barcelona Clinic Liver Cancer (BCLC) e, portanto, seus resultados não são bem estudados, principalmente na Índia, devido a uma menor incidência. Objetivo: Analisar os resultados da cirurgia para HCCs de grande porte. Métodos: Este estudo observacional retrospectivo incluiu todos os pacientes submetidos à cirurgia para grandes CHC de janeiro de 2007 a dezembro de 2017. Todos os dados perioperatórios e de acompanhamento foram coletados e analisados. Resultados: Dezenove pacientes foram incluídos. Dez não eram cirróticos; 16 eram BCLC grau A; um BCLC grau B; e dois eram BCLC C. Dois cirróticos e três não-cirróticos foram submetidos à quimioembolização transarterial sequencial pré-operatória e embolização da veia porta. Hepatectomia direita foi o procedimento mais comumente realizado. A taxa de mortalidade pós-operatória em 30 dias foi de 5% (1/19). Infecção da ferida e ascite pós-operatória foram observadas em sete pacientes cada. Insuficiência hepática pós-operatória foi observada em cinco. Dois pacientes cirróticos e dois não cirróticos apresentaram vazamento de bile no pós-operatório. O tempo de internação foi de 11,9±5,4 dias (mediana de 12 dias). A invasão vascular estava presente em quatro pacientes cirróticos e cinco não cirróticos. O acompanhamento médio foi de 32 meses. Cinco pacientes morreram no período de acompanhamento. Sete tiveram recorrência e sobrevida mediana livre de recorrência foi de 18 meses. A sobrevida livre de recorrência cumulativa foi de 88% e 54%, enquanto a sobrevida global cumulativa foi de 94% e 73% em um e três anos, respectivamente. Ambos eram melhores em não-cirróticos; no entanto, a diferença não foi estatisticamente significante. A sobrevida livre de recidiva foi melhor nos pacientes sem invasão vascular e a diferença foi estatisticamente significante (p=0,011). Conclusão: CHC grande não é contraindicação para cirurgia. Invasão vascular, se presente, afeta adversamente a sobrevida. Seleção adequada de casos pode fornecer sobrevida mais favorável com morbidade mínima.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Hepatectomia , Índia , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias
11.
Indian J Gastroenterol ; 38(5): 399-410, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31802438

RESUMO

BACKGROUND: Many advances in the management of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) happened in the last two decades. This study highlights the progress in its management over 17 years, outcomes, recurrence patterns, and follow up protocols. METHODS: This retrospective analysis of prospectively maintained database at a single tertiary center included GEP-NEN patients from January 2001 to August 2017. Management protocols were based on European Neuroendocrine Tumor Society guidelines. Recurrences were categorized as follows: localized nodal, regional, distant hepatic, or combined. Patients were divided into cohorts: cohort 1 (2001-2006), cohort 2 (2007-2011), and cohort 3 (2012-2017). Survival patterns were analyzed. RESULTS: One hundred and ninety-two patients were included with 98 (51.04%) grade (G) 1, 64 (33.34%) G2, and 30 (15.63%) G3. One hundred and four (54.16%) underwent curative surgery (58 G1, 27 G2, and 19 G3). Overall follow up ranged from 3 to 276 months; 39 were lost to follow up. Ninety-six patients had recurrences: 44 regional + distant and 40 liver-limited recurrences. One-, 3-, and 5-year survivals show significant differences among different treatment groups (p < 0.05). Significant increase in curative resections, chemotherapy utilization, and reduced recurrences were noted in cohort 3. Curative (R0) resection offered 1- and 3-year overall survival of 93.3% and 66.7% in cohort 1; 95.8% and 83.1% in cohort 2; and 100% and 92.9% in cohort 3. CONCLUSION: Curative resection is the most significant factor for improved survival. Debulking surgerical procedure have a role whereas upfront peptide receptor radionuclide therapy is questionable. Chemotherapy improves overall survival in inoperable/metastatic setting. Recurrence patterns indicate that a long-term follow up greater than 10 years is necessary.


Assuntos
Protocolos Antineoplásicos , Neoplasias Intestinais/mortalidade , Tumores Neuroendócrinos/mortalidade , Neoplasias Pancreáticas/mortalidade , Neoplasias Gástricas/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Humanos , Neoplasias Intestinais/patologia , Neoplasias Intestinais/terapia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/terapia , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/terapia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Gástricas/patologia , Neoplasias Gástricas/terapia , Tempo , Resultado do Tratamento , Adulto Jovem
12.
Int J Surg ; 71: 182-189, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31610284

RESUMO

BACKGROUND: Diverticulitis is one of the most common gastrointestinal diseases in western population. Colonic resection is recommended by international guidelines as a routinely used technique for purulent diverticulitis. Laparoscopic lavage was introduced as a non-resection alternative. The studies available so far have shown contradictory results. This meta-analysis aims to compare laparoscopic lavage versus colonic resection in patients with Hinchey Ⅲ-Ⅳ diverticulitis. METHODS: We did a systematic review of articles published before March 20, 2019, with no language restriction by searching PubMed, Cochrane library, EMBASE databases, clinicaltrials.gov, and Google Scholar databases. We included all RCTs and cohort studies comparing outcomes between patients with Hinchey Ⅲ-Ⅳ diverticulitis undergoing laparoscopic lavage versus colonic resection. Important outcomes were mortality, complications, length of stay, readmission and reoperation rates. We combined data to assess the outcomes using DerSimonian and Laird random-effects model. RESULTS: A total of 569 patients with diverticulitis of which more than 80% were Hinchey Ⅲ were enrolled from 3 RCTs and 5 cohort studies. Laparoscopic lavage was associated with shorter operative time (WMD -78.9, 95%CI -100.58 to -57.11, P < 0.0001) and total postoperative hospital stay (WMD -7.62, 95%CI -11.60 to -3.63, P = 0.0002) but a higher rate of intra-abdominal abscess (OR 2.69, 95%CI 1.39 to 5.21, P = 0.0032) and secondary peritonitis (OR 5.30, 95%CI 1.91 to 14.73, P = 0.0014). CONCLUSION: Laparoscopic lavage for patients with Hinchey Ⅲ to Ⅳ diverticulitis does provide similar mortality, shorter operative time and hospital stay. However, the evidence so far suggests that it might be inadequate for sepsis control and may result in more unplanned reoperations. Further studies are needed to standardize the formal indication for laparoscopic lavage.


Assuntos
Colectomia/efeitos adversos , Doença Diverticular do Colo/cirurgia , Laparoscopia/efeitos adversos , Lavagem Peritoneal/efeitos adversos , Complicações Pós-Operatórias/etiologia , Abscesso Abdominal/etiologia , Adulto , Idoso , Colectomia/métodos , Feminino , Humanos , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Lavagem Peritoneal/métodos , Peritonite/etiologia , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Reoperação/estatística & dados numéricos , Resultado do Tratamento
13.
BMJ Case Rep ; 12(8)2019 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-31387861

RESUMO

Postcholecystectomy Mirizzi syndrome (PCMS) is an uncommon entity that can occur due to cystic duct stump calculus, gall bladder remnant calculus or migrated surgical clip. It can be classified into early PCMS or late PCMS. It is often misdiagnosed and the management depends on the site of impaction of stone or clip. Endoscopy can be performed for cystic duct stump calculus. However, surgery is the treatment for remnant gall bladder calculus. Role of laparoscopic management is controversial. We present here a case of a 48-year-old woman with late PCMS due to an impacted calculus in a sessile gall bladder remnant following a subtotal cholecystectomy, managed with laparoscopic completion cholecystectomy, review the literature, provide tips for safe laparoscopy for PCMS and summarise our algorithmic approach to the management of the postcholecystectomy syndrome.


Assuntos
Colecistectomia Laparoscópica/métodos , Síndrome de Mirizzi/cirurgia , Síndrome Pós-Colecistectomia/cirurgia , Cálculos/diagnóstico por imagem , Cálculos/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Síndrome de Mirizzi/complicações , Síndrome de Mirizzi/diagnóstico por imagem , Síndrome Pós-Colecistectomia/etiologia , Reoperação
14.
BMJ Case Rep ; 12(5)2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31151975

RESUMO

Biliary mucinous cystic neoplasm (BMCN) is a rare intrahepatic neoplasm comprising approximately 5% of cystic liver lesions. It can cause diagnostic dilemmas with most common differentials being complex hepatic cyst, hydatid cyst and intraductal papillary neoplasm of the bile duct. Affecting middle-aged female population, BMCN presents variedly ranging from vague abdominal symptoms to obstructive jaundice. Preoperative diagnosis is difficult. Preoperative CT scan with intravenous contrast and carbohydrate antigen 19.9 levels may give a clue towards the diagnosis. Intraoperative frozen section or cyst fluid aspiration cytology might help confirm the diagnosis. Fine needle aspirations should not be performed if BMCN is suspected, and intraoperative cyst spillage should be avoided to prevent tumour dissemination. We present here a case with a very atypical presentation of BMCN and review its present literature in brief.


Assuntos
Neoplasias dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares Intra-Hepáticos , Neoplasias Císticas, Mucinosas e Serosas/diagnóstico por imagem , Neoplasias dos Ductos Biliares/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Císticas, Mucinosas e Serosas/cirurgia , Doenças Raras , Tomografia Computadorizada por Raios X , Resultado do Tratamento
15.
J Hepatobiliary Pancreat Sci ; 26(7): 281-291, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31099488

RESUMO

Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.


Assuntos
Artérias/anatomia & histologia , Procedimentos Cirúrgicos do Sistema Digestório , Duodeno/irrigação sanguínea , Estômago/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Humanos , Planejamento de Assistência ao Paciente
16.
Int J Surg Case Rep ; 58: 6-10, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30986642

RESUMO

INTRODUCTION: Complete proper hepatic arterial [PHA] occlusion due to accidental coil migration during embolization of cystic artery stump pseudoaneurysm resulting from a complex vasculobiliary injurie [CVBI] post laparoscopic cholecystectomy [LC] is an extremely rare complication with less than 15 cases reported. We present a case depicting our strategy to tackle this obstacle in management of CVBI and review the relevant literature. PRESENTATION OF CASE: A 35 year old lady presented on sixth postoperative day with an external biliary fistula following Roux-en-y hepaticojejunostomy [RYHJ] for biliary injury during LC. She developed a leaking cystic artery pseudoaneurysm, during angioembolisation of which, one coil accidentally migrated into left hepatic artery resulting in complete PHA occlusion. Fourteen months later, cholangiogram revealed a worsening RYHJ stricture despite repeated percutaneous balloon dilatations. Multiple collaterals had developed. Revision RYHJ was fashioned to the anterior wall of biliary confluence with an extension into left duct. Minimum hilar dissection ensured preservation of collateral supply to the biliary enteric anastomosis. Postoperative recovery was uneventful. The patient is doing well at 1 year follow up. DISCUSSION: Definitive biliary enteric repair should be delayed till collateral circulation is established within the hilar plate, hepatoduodenal ligament and perihepatic/peribiliary collaterals to provide an adequate arterial blood supply to biliary confluence and extrahepatic portion of the bile duct. CONCLUSION: Assessment of hepatic arteries should be part of investigation of all complex biliary injuries. Delayed definitive biliary enteric repair ensures a well-perfused anastomosis. Minimum hilar dissection is the key to preserve biliary and hepatic neovasculature.

17.
BMJ Case Rep ; 12(3)2019 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-30898942

RESUMO

Solitary hypervascular lesion in the distal body/tail of pancreas in a patient with non-specific abdominal symptoms is a diagnostic challenge. Neuroendocrine neoplasm (NEN) and metastasis from renal cell carcinoma are the most common differentials and intrapancreatic accessory spleen (IPAS) is the rarest of its differential diagnosis. We present, here, a case of a 56-year-old man with a space-occupying lesion in body/tail of pancreas that was preoperatively diagnosed as a NEN based on elevated chromogranin levels and hyperenhancing lesion on contrast-enhanced CT scan. He underwent a spleen-preserving distal pancreatectomy. The final histopathology revealed an IPAS.


Assuntos
Coristoma/diagnóstico por imagem , Pancreatopatias/diagnóstico por imagem , Baço , Coristoma/patologia , Coristoma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatectomia , Pancreatopatias/patologia , Pancreatopatias/cirurgia , Tomografia Computadorizada por Raios X
18.
Dig Dis ; 37(4): 315-324, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30699408

RESUMO

BACKGROUND: The incidence of pancreatic adenocarcinoma (PDAC) in patients with chronic pancreatitis (CP) is as high as 5%. It is a commonly encountered diagnostic challenge in patients with CP on long-term follow-up. SUMMARY: This review consolidates the existing literature on assessment of PDAC in background of CP, its evaluation through the available investigations, surgical management, and prognostication. Recent change in symptomatology of an otherwise stable CP should raise a suspicion of malignancy. Endoscopic ultrasound (EUS) is more specific and sensitive in establishing the diagnosis of PDAC compared to cross-sectional imaging (computed tomography/magnetic resonance imaging). Intraoperative assessment with careful palpation coupled with careful clinical judgment helps in differentiating between an inflammatory mass and pancreatic cancer. Confirmation can be obtained with either preoperative EUS-guided fine needle cytology/core biopsy or intraoperative core biopsy under ultrasound guidance. However, despite complete evaluation with above options, 1-6% patients often show malignancy on final histopathological examination. Key Messages: Diagnosis of PDAC in CP needs a high index of suspicion. Cross-sectional imaging has poor negative predictive value. CA 19-9 with MUC5AC combination may become an ideal investigation. EUS with core biopsy/frozen section has a good sensitivity and specificity and low false negative results. Complete radical resection should be the aim to get long-term survival.


Assuntos
Adenocarcinoma/complicações , Adenocarcinoma/diagnóstico , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/diagnóstico , Pancreatite Crônica/complicações , Detecção Precoce de Câncer , Humanos , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/prevenção & controle , Pancreatite Crônica/epidemiologia , Pancreatite Crônica/prevenção & controle , Pancreatite Crônica/cirurgia , Prognóstico
19.
Turk J Surg ; 35(1): 62-69, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32550305

RESUMO

OBJECTIVES: This article aimed to identify patient selection criteria and approach in treating persistent external pancreatic fistulas surgically with Roux-en-Y fistulojejunostomy, and the study evaluated the outcomes of Roux-en-Y fistulojejunostomy with a review of the relevant literature. MATERIAL AND METHODS: A retrospective data analysis from January 2010 to May 2017 revealed 6 patients managed with Roux-en-Y fistulojejunostomy for persistent external pancreatic fistulas, and their details were entered in a proforma. Standard surgical steps were performed in all patients, and the patients were followed up postoperatively for 1 year. Data were analyzed for outcomes, and the literature was reviewed. RESULTS: Four of 6 patients had persistent external pancreatic fistulas following pancreatic necrosectomy, 1 had surgery for pancreatic pseudocyst, and 1 after pancreaticoduodenectomy for pancreatic head mass. An average duration of conservative management was 14 weeks, and Roux-en-Y fistulojejunostomy was performed at a median distance of 6 cm from pancreas via a midline laparotomy. All patients recovered without major complications. Only 1 patient developed diabetes at a 1-year follow-up. CONCLUSION: Fistulojejunostomy is a safe and effective treatment for persistent pancreatic fistula having the benefit of avoiding a difficult major pancreatic resectional surgery in an already debilitated patient with frozen tissue planes, along with low postoperative morbidity and mortality. The short- and mid-term outcomes in the literature for this procedure are good, as it has also been seen in our study on diverse indications.

20.
Turk J Surg ; 35(3): 214-222, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32550331

RESUMO

OBJECTIVES: Infected pancreatic necrosis (IPN) is a dreadful complication of moderately severe and severe acute necrotising pancreatitis (ANP). Videoscopic assisted retroperitoneal debridement (VARD) is a minimally invasive surgical option for predominantly left sided, posterior and laterally located disease in patients not responding to conservative and percutaneous options. This study aimed to present an outcome analysis of VARD in the management of IPN at our tertiary care centre. MATERIAL AND METHODS: The present retrospective analysis of prospectively entered data included 22 patients diagnosed as ANP with IPN from January 2015 to December 2017. These patients were admitted in the surgical gastroenterology unit of our tertiary care centre. The outcome of these patients managed with VARD was evaluated. RESULTS: The aetiology of ANP was idiopathic, and gallstones were found in 7 patients each and alcohol in 8. Twelve patients were managed with a single VARD procedure; whereas, 10 required a re-debridement due to suboptimal improvement. Eighteen out of 22 patients survived whereas 4 succumbed to major postoperative bleeding/severe sepsis and multiorgan failure (Mortality 18.2%). Hospital stay after the index procedure was between 6 to 11 weeks. CONCLUSION: VARD is a safe and effective surgical option for the management of IPN that worsens or fails to respond to conservative and percutaneous drainage options after a minimum of 4 weeks of moderately severe and severe ANP. It decreases postoperative morbidity and mortality and avoids major laparotomy, and hence, it can be considered in a selected group of patients.

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