Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases.

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.

Pyrexia of Unknown Origin: An Atypical Presentation of Hepatic Hemangioma.

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.

SURGICAL MANAGEMENT OF LARGE HEPATOCELLULAR CARCINOMA: THE FIRST SINGLE-CENTER STUDY FROM WESTERN INDIA.

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.

Multimodality Management of Ruptured Large Hepatocellular Carcinoma and Its Recurrence: Rupture at Presentation Should Not Rupture Hope of Long-Term Survival.

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.

Dilemmas in Diagnosis and Management of Gastroenteropancreatic Mixed Neuroendocrine Non-neuroendocrine Neoplasms: First Single-Centre Report from India.

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.

Surgical management of large hepatocellular carcinoma: the first single-center study from western india / Manejo cirúrgico de grandes carcinomas hepatocelulares: primeiro estudo de um único centro da índia ocidental

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.

Multimodality management, recurrence patterns, and long-term outcome of gastroenteropancreatic neuroendocrine neoplasms: Progress over 17 years.

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.

Late postcholecystectomy Mirizzi syndrome due to a sessile gall bladder remnant calculus managed by laparoscopic completion cholecystectomy: a feasible surgical option.

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.

Infrequent intrahepatic cystic neoplasm: dilemmas in diagnosis and management.

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.

Gastroduodenal artery: single key for many locks.

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.

Revision Roux-en-y hepaticojejunostomy for a post-cholecystectomy complex vasculobiliary injury with complete proper hepatic artery occlusion: A case report and literature review.

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.

Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: is it olde worlde?

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.

An outcome analysis of videoscopic assisted retroperitoneal debridement in infected pancreatic necrosis: a single centre experience.

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.

An outcome analysis of laparoscopic management of diverticulitis.

BACKGROUND: All operative procedures for simple or complicated diverticulitis, including primary resection and anastomosis (PRA) with or without a diverting stoma, Hartmann procedure (HP), or stoma reversal, whether done in an elective setting or as an emergency, can be performed laparoscopically. However, owing to low incidence of the disease and complexity of the procedure, there are very few studies on outcomes of laparoscopic surgery for sigmoid diverticulitis from India. AIM: The present study was undertaken to evaluate outcomes of laparoscopically treated patients of sigmoid diverticulitis. METHODS: Prospective observational study enrolled 37 patients with sigmoid diverticulitis managed laparoscopically from March 2015 to March 2017. Demographic, clinical, operative, postoperative, and complication data were entered into a patient proforma and analyzed. RESULTS: Eleven simple and 26 complicated diverticulitis patients were operated laparoscopically, 22 in emergency setting and 15 in elective setting. Only three patients required conversion to open surgery-two due to dense adhesions and one due to chronic obstructive pulmonary disease (COPD). No patients had ureteric or bowel injury. Eighteen patients underwent laparoscopic PRA without stoma, 11 patients had PRA with stoma, 6 had HP, and 2 had laparoscopic lavage. Results showed lesser blood loss, shorter hospital stay, and fewer complications in the elective group and simple diverticulitis patients. None of the patients had anastomosis-related complications. Two patients had stoma-related complications. CONCLUSION: Laparoscopic management of diverticulitis is feasible, safe, provides the benefits of less wound-related complications, and shorter hospital stay and should be the surgical procedure of choice in elective or emergency setting for simple/complicated diverticulitis.

Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: Is it olde worlde?

OBJECTIVE: This article aims to identify the patient selection criteria and approach in treating persistent external pancreatic fistulas surgically with Roux-en-Y fistulojejunostomy, and it evaluates 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 who were 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.

Autoimmune Pancreatitis Type II: First Report from India.

Autoimmune Pancreatitis (AIP) presents in two forms - Type I or lymphoplasmacytic sclerosing pancreatitis and Type II or idiopathic ducto-centric pancreatitis (IDCP). AIP II is rare in south Asia and, especially so, in India. Most patients have either Idiopathic Chronic Pancreatitis (ICP) or alcohol related chronic pancreatitis. AIP Type I has been described in India. We herein report a patient who had features of ICP on imaging, for whom surgery was performed to relieve chronic pancreatic pain. However, the pathologic features revealed AIP Type II or IDCP.