Solitary Fibrous Tumors of the Mesocolon: A Report of Two Cases and Review of Literature.

Solitary fibrous tumors (SFTs) are an uncommon group of neoplasms. The visceral pleura is the most common site of origin of these tumors. The colonic mesentery is an unusual site of origin of SFTs. A pre-operative diagnosis of SFT is challenging as there are no pathognomonic clinical or radiological signs. Most patients reported thus far were diagnosed post-operatively with the aid of immunohistochemical markers. Complete surgical excision is the treatment of choice for SFTs. Recurrences are uncommon. However, they can occasionally show aggressive behavior. In this report, we describe two cases of rare colonic mesentery SFTs.

An audit of Complicated Choledochal Cysts- 15-years' experience at a tertiary care center.

PURPOSE: Complicated choledochal cysts (CDC) have a variable presentation, and their management differs from an uncomplicated CDC. They are infrequently reported. We present our 15 years of experience in the management of complicated CDC. METHODOLOGY: We reviewed the data of patients with CDCs managed at a tertiary level center from 2005 to 2020 from a prospectively maintained database. RESULTS: Of 215 patients with CDC, 123 patients presented with complicated CDC. The median age of complicated CDC was 31 years with a female preponderance (62.6%). The most common type of CDC associated with complications was type I (69.1%), followed by type IVA (29.3%). The Complicated CDC was presented as cholangitis with or without cystolithiasis (n = 45), cystolithiasis and hepatolithiasis(n = 44), malignancy(n = 10), complications associated with incomplete cyst excision (n = 10), acute pancreatitis (n = 8), chronic pancreatitis(n = 8), portal hypertension (n = 6), spontaneous rupture (n = 4), gastric outlet obstruction (n = 1). These patients were managed as a one-stage approach (52.03%) and a two-stage approach (47.96%). On univariate and multivariate analysis, increasing age, prolonged duration of symptoms, and presence of abnormal pancreaticobiliary ductal junction (APBDJ) were significantly associated with complicated CDC. CONCLUSION: The management of complicated CDC varied depending on the associated pathology, many of them required a staged approach. Increasing age, prolonged duration of symptoms, and presence of APBDJ were significantly associated with complicated CDC.

Primary Hepatic Choriocarcinoma with Pregnancy: A Diagnostic and Therapeutic Challenge.

Choriocarcinoma occurs mainly in the gonads, but an extragonadal origin has been reported, albeit infrequently. Primary hepatic choriocarcinoma (PHC) is a rare malignancy, with only 11 cases reported. Most cases reported were in males, with none reported in pregnant females. A 23-year-old primigravida presented with a large liver lesion involving the right lobe of the liver at 28 weeks of pregnancy. Preoperative imaging was suggestive of hepatocellular carcinoma. She underwent a non-anatomical resection of the liver lesion. Surprisingly, her postoperative histopathology revealed a diagnosis of PHC. Her blood workup showed elevated beta human chorionic gonadotrophin. She underwent a termination of her pregnancy at 32 weeks. Before initiating adjuvant chemotherapy four weeks after surgery, a whole-body PET scan revealed multiple bi-lobar liver and pelvic deposits. After a multidisciplinary team discussion, she was started on adjuvant chemotherapy. She is currently under regular follow-up, seven months post-surgery. PHC, one of the vascular lesions of the liver, poses a diagnostic and therapeutic challenge, warranting a multidisciplinary approach.

Is central pancreatectomy an effective alternative to distal pancreatectomy for low-grade pancreatic neck and body tumors: A 20-year single-center propensity score-matched case-control study.

Backgrounds/Aims: Central pancreatectomy (CP) is associated with a higher rate of postoperative pancreatic fistula (POPF), and it is less preferred over distal pancreatectomy (DP). We compared the short- and long-term outcomes between CP and DP for low-grade pancreatic neck and body tumors. Methods: This was a propensity score-matched case-control study of patients who underwent either CP or DP for low-grade pancreatic neck and body tumors from 2003 to 2020 in a tertiary care unit in southern India. Patients with a tumor >10 cm or a distal residual stump length of < 4 cm were excluded. Demographics, clinical profile, intraoperative and postoperative parameters, and the long-term postoperative outcomes for exocrine and endocrine insufficiency, weight gain, and the 36-Item Short Form Survey (SF-36) quality of life questionnaire were compared. Results: Eighty-eight patients (CP: n=37 [cases], DP: n=51 [control]) were included in the unmatched group after excluding 21 patients (meeting exclusion criteria). After matching, both groups had 37 patients. The clinical and demographic profiles were comparable between the two groups. Blood loss and POPF rates were significantly higher in the CP group. However, Clavien-Dindo grades of complications were similar between the two groups (p = 0.27). At a median follow-up of 38 months (range = 187 months), exocrine sufficiency was similar between the two groups. Endocrine sufficiency, weight gain, SF-36 pain control score, and general health score were significantly better in the CP group. Conclusions: Despite equivalent clinically significant morbidities, long-term outcomes are better after CP compared to DP in low-grade pancreatic body tumors.

A case series of choledochal cyst with pancreatic divisum: A rare association.

Choledochal cysts (CC) are congenital cystic dilations of the biliary tree usually associated with abnormal pancreaticobiliary ductal junction (APBDJ), but its association with pancreatic divisum has been rarely described. We encountered four cases of CC associated with pancreatic divisum (PD). Three had Type 3 PD and one had Type 1 PD. Two cases presented with pancreatic complications, with one case requiring preoperative minor papilla sphincterotomy for recurrent pancreatitis. The association of CC with PD is infrequent, and the variable presentation alters management strategy. PD may be one of the factors responsible for complications associated with CC.

Bacteriological profile of intra-abdominal infections in a tertiary care hospital.

BACKGROUND AND OBJECTIVES: Intra-abdominal infections (IAIs) include a wide spectrum of pathological conditions, ranging from uncomplicated appendicitis to fecal peritonitis .The resulting infections should be diagnosed early and treated based on the organism isolated and its susceptibility. In this study the bacteriological profile and antimicrobial resistance pattern of intra-abdominal infections was analyzed. MATERIALS AND METHODS: A retrospective analysis of samples received from 119 cases of intra-abdominal infections in our Institute from January 2015 to December 2017 was analyzed. Patients with primary peritonitis from cirrhosis or ascites were not included in the study. The specimens were primarily processed, as per standard methods. Identification and antimicrobial susceptibility testing was done by the Vitek-2 system. Anaerobic culture was performed on 5% sheep blood agar plates and incubated in GEN bag anaerobic pouches. RESULTS: In our study perforative peritonitis 43/119 (36.1%) was predominant IAI followed by acute pancreatitis 14/119 (11.7%) and pancreatic necrosis 12/119 (10%). Microbial growth was observed in 66.3% (79/119) of the cases and combined infections were observed in14/119 (11.7%) of the cases. Escherichia coli was the predominant organism isolated in 58/119 (40.8%), out of which 41/58 (70.6%) were ESBL producers and 16/58 (27.5%) were multi drug resistant isolates. Klebsiella pneumoniae was isolated from 11/119 (9.2%) cases out of which 8/11 (72.7%) were ESBL and 3/11 (27.2%) were multidrug resistant isolates. Post-operative complications was observed in 12/119 (10%) patients with mortality in 15/119 (12.6%) patients. CONCLUSION: Early diagnosis and appropriate management of the infections will help to prevent the morbidity and mortality associated with these infections.

Mesenchymal Hamartoma of the Liver: Complete Excision Always Necessary.

Mesenchymal hamartoma (MH) is not an uncommon tumor of the liver in the age group of 2-10 years. It is the second most common benign liver tumor in children. Previously considered a developmental anomaly, newer insights into other theories of origin including toxic-metabolic, ischemic, and a true neoplastic process are in progress. Previous understanding of a purely benign nature of the tumor is being overridden by a real malignant transformation. Complete excision of the tumor with clear margins is recommended to achieve a long term cure. A thorough understanding of the natural history of these tumors and skillful surgical treatment are indispensable elements of care.

Positive Peritoneal Lavage Cytology -Implications for Staging and Management of Gastric Cancer.

The survival rates of gastric cancer patients with cytology-positive peritoneal lavage fluid without macroscopic dissemination (CY+/P-) is the same as that of patients with overt peritoneal metastasis.The 5-year survival rate of such patients is only 2%. The current study aims to highlight its significance in the staging of gastrointestinal malignancies and its implications for patient care. Prospective nonrandom analysis of peritoneal wash cytology in patients with gastrointestinal malignancies was conducted in the department of Surgical Gastroenterology, Nizams Institute of Medical Sciences, Hyderabad from January 2012 to June 2013. Descriptive statistics and ANOVA variance analysis was performed to estimate incidence, risk factors and the effect of surgery in causing peritoneal dissemination of malignancy. A total of 60 patients with operable gastric cancer underwent peritoneal lavage for evaluation of malignant cells. The incidence of Positive peritoneal lavage cytology was 8.3% (5/60).Four patients with positive lavage fluid belong to T3 stage (11.7%, p-0.309).Poorly differentiating and mucinous tumors had a higher incidence of positive cytology (18.1% and 25%).None of the patients with positive cytology had positive resection margin. Tumors with advanced T stage, lymph nodal involvement, lympho-vascular and perineural invasion have higher incidence of positive peritoneal cytology. Surgical handling has a negligible effect in peritoneal dissemination of tumor. Large scale studies are warranted to validate the findings and define it's role in management of gastric cancer.

Predictors of successful non-operative management of grade III & IV blunt pancreatic trauma.

INTRODUCTION: Although surgery is the preferred treatment for grade III&IV pancreatic trauma, there is a growing movement for non-operative management. in blunt pancreatic trauma. Very few studies compare operative versus non-operative management in adult patients. METHODS: Retrospective analysis of a prospectively maintained database was performed from 2004 to 2013 in the department of gastrointestinal surgery, NIMS, Hyderabad. Comparative analysis was performed between patients who failed versus those who were successfully managed with non-operative management. RESULTS: 34 patients had grade III/IV trauma out of which 8 were operated early with the remaining 26 initially under a NOM strategy, 10 of them could be successfully managed without any operation. Post-traumatic pancreatitis, Necrotizing pancreatitis, Ileus, contusion on CT, surrounding organ injuries are independently associated with failure of NOM on a univariate analysis. On multivariate logistic regression presence of necrosis& associated organ injury are factors that predict failure of NOM independently. Development of a pseudocyst is the only significant factor that is associated with a success of NOM. CONCLUSIONS: Non-operative measures should be attempted in a select group of grade III&IV blunt pancreatic trauma. In hemodynamically stable patients with a controlled leak walled off as a pseudocyst without associated organ injuries and pancreatic necrosis, NOM has a higher success rate.

Efficacy and safety of tigecycline monotherapy compared with vancomycin-aztreonam in the treatment of complicated skin and skin structure infections in patients from India and Taiwan.

BACKGROUND: To compare the monotherapy of tigecycline with vancomycin-aztreonam in hospitalized patients from India and Taiwan with complicated skin and skin structure infections (cSSSIs). METHODS: Safety and efficacy data were analyzed for Indian (n = 86) and Taiwanese (n = 41) patients hospitalized with cSSSIs who participated in two international Phase 3, randomized, double-blind studies. RESULTS: Patients were treated for 5-14 days. Cure rates at the test-of-cure assessment (12-92 days post-therapy) were generally similar between tigecycline and vancomycin-aztreonam in the clinically evaluable populations (India, 83.3% vs. 75.8%; Taiwan, 78.6% vs. 90%) and in the clinical modified intent-to-treat populations (India, 78.6% vs. 66.7%; Taiwan, 73.3% vs. 75.0%). Nausea and vomiting occurred more frequently with tigecycline, but overall safety and tolerability were comparable between the two treatments. CONCLUSIONS: Tigecycline monotherapy is a safe and effective therapy for cSSSIs in geographically distinct populations in Asia.

Extragastrointestinal stromal tumor arising in the pancreas: a case report with a review of the literature.

CONTEXT: Extragastrointestinal stromal tumors arising in the pancreas are extremely rare. To date, only eight cases have been reported in the literature. CASE REPORT: A 42-year-old female patient presented with gradually increasing abdominal pain of 6-month duration. Computerized tomography scan of the abdomen demonstrated a solid cystic mass in the body and tail of the pancreas. En-block R0 resection of the mass with distal pancreatectomy, splenectomy and left hemicolectomy was carried out following a radiological diagnosis of a malignant cystic neoplasm of the pancreas. Histopathological and immunohistochemical findings of the lesion were consistent with a gastrointestinal stromal tumor. CONCLUSION: Extragastrointestinal stromal tumor of the pancreas, though rare, should be considered in the differential diagnosis of the more common cystic lesions at this site.