Choledochal cyst of the proximal cystic duct: a taxonomical and therapeutic conundrum.

Isolated choledochal cysts involving the cystic duct are rare. We present a case of a choledochal cyst involving only the proximal cystic duct, and discuss the taxonomic and therapeutic challenges. There is a need for a clearly defined classification system for these cysts as they may be categorised as either type II or type VI cysts. The optimal treatment remains debatable, with some authors recommending a bilioenteric reconstruction owing to the wide cystic duct-bile duct junction. However, we suggest that a cholecystectomy should be performed with examination of the specimen and frozen section in case of any abnormality rather than upfront bile duct excision. In addition, given the rarity of this condition and the paucity of long-term data, we recommend meticulous follow-up for development of any malignancy.

Primary giant aggressive amelanotic duodenal melanoma.

Primary malignant melanoma of the gastrointestinal tract is extremely rare. A 35-year-old man presented with complaints of abdominal pain and weight loss. Contrast enhanced computed tomography showed a large mass involving the duodenum and the superior mesenteric vessels. Upper gastrointestinal endoscopy demonstrated a large, friable mass along the duodenal wall and biopsy was suggestive of malignant melanoma. A detailed physical examination and whole body imaging (positron emission tomography and computed tomography) did not reveal any other lesion. The patient underwent a pancreaticoduodenectomy with segmental resection and anastomosis of the superior mesenteric vein as well as a segmental colectomy. His postoperative recovery was uneventful. The histopathology of the operative specimen showed a malignant amelanotic melanoma arising from the duodenum with lymph nodal involvement. He received oral temozolomide. However, he developed liver metastasis at six months and again at ten months, which was managed with radiofrequency ablation both times. He is doing well at 32 months of follow-up review. Multimodality treatment including surgery, adjuvant chemotherapy and salvage therapy appears to be a promising tool for achieving long-term survival in such patients.

Radiation induced liver disease: A clinical update.

Radiation-induced liver disease (RILD) or radiation hepatitis is a sub-acute form of liver injury due to radiation. It is one of the most dreaded complications of radiation which prevents radiation dose escalation and re-irradiation for hepatobiliary or upper gastrointestinal malignancies. This complication should be kept in mind whenever a patient is planned for irradiation of these malignancies. Although, incidence of RILD is decreasing due to better knowledge of liver tolerance, improved investigation modalities and modern radiation delivery techniques, treatment options are still limited. In this review article, we have focussed on patho-physiology, risk factors, prevention and management of RILD.