Robotic monosegment donor hepatectomy for pediatric liver transplantation: First report.

BACKGROUND: LT for infants less than 5 kg remains a challenge with high technical complication rates, which is further compounded by large-for-size grafts requiring hyper-reduction. The benefits of MIDH especially for standard left lateral segment (LLS) resection have been unequivocally demonstrated. However, given the fine margins of error, the highly challenging technical aspects of anatomical graft reduction test the limits of safety and may not be routinely feasible with the conventional laparoscopic approach. CASE REPORT: A 14-month-old girl weighing 4.4 kg with extrahepatic biliary atresia was referred to our unit for an LT. Her mother volunteered to donate and the calculated volume of the LLS was 342 ml, with an estimated GRWR of 7.6. Given the extremely high GRWR, a segment II monosegment graft was planned. A RMDH was performed, with a final GRWR of 4. The donor and recipient were discharged on the 5th and 12th post-operative days, respectively. CONCLUSION: We present the first-ever report of an RMDH. Our report highlights the fact that robotic surgery can safely replicate a highly precise surgical operation, thereby safely pushing the limits of MIDH.

Estimation of liver volume in the western Indian population.

BACKGROUND: A number of formulae to estimate standard liver volume (SLV) exist. However, studies have shown that only certain formulae are applicable to a particular patient population, whereas the other formulae have not been accurate in estimating the SLV. Aim of this study was to assess which formula is most accurate in estimating SLV in the western Indian population. METHODS: Data for donors of living donor liver transplantation from September 2014 to July 2015 was analyzed. Liver volumes were measured using computed tomography volumetry (CTV). SLV was calculated using formulae by the currently existing formulae. The mean SLV and CTV, percentage error in the SLV, and the correlation between SLV and CTV were calculated. RESULTS: Fifty-nine healthy subjects underwent donor hepatectomy [28 (47.5 %) males]. The mean age, mean body mass index (BMI), and mean body surface area (BSA) were 31.8 ± 8.8 years, 23.8 ± 3.7 kg/m(2), and 1.6 ± 0.4, respectively. Mean CTV was 1178 ± 246.8 mL. Difference between mean SLV and mean CTV ranged from -133.5 (±189) mL to 632.2 (±190.2) mL. Mean SLV was significantly different from CTV by all the formulae except Urata. Percentage of population whose SLV was within 15 % of the mean CTV ranged from 1.7 % to 67.8 %, with the highest percentage obtained by using Fu-Gui's formula. However, there was wide inter-individual variation on scatter plots between SLV and CTV by both these formulae. CONCLUSION: Currently existing formulae were not accurate in estimating SLV in our population.

Post-operative abdominal drainage following major upper gastrointestinal surgery: single drain versus two drains.

BACKGROUND: Traditionally, surgeons have resorted to placing drains following major gastrointestinal surgery. In recent years, the value of routine drainage has been questioned, especially in the light of their role in post-operative pain, infection, and prolonged hospital stay. The aim of this study was to compare the peri-operative outcomes following the use of a single versus two drains for gastric and pancreatic resections. MATERIALS AND METHODS: Patients undergoing resections for gastric and pancreatic malignancies were included in the study. Patients were subdivided into two groups depending on the number of drains placed, viz. one drain (Group 1) or two drains (Group 2). Clinico-pathologic outcomes were recorded and compared. RESULTS: Of the 285 patients included in the analysis, group 1 consisted of 226 patients while group 2 included 59 patients. Overall, drains alerted the surgeon to existence of complications in 62% of patients - 70% in group 1 and 44.4% in group 2 (P < 0.19). The morbidity and mortality rates in groups 1 and 2 were 25.2% and 3.9%, and 23.7% and 0%, respectively (P < 0.61 and P < 0.12). There were no drain-related complications. Median hospital stay was significantly lower in group 1 (11 vs. 14 days) (P < 0.001). CONCLUSION: The insertion of drains did aid in the detection of complications following gastric and pancreatic surgery. Two drains offer no further advantage over one drain in terms of detection of complications. While the number of drains did not contribute to, or reduce, the morbidity and mortality in the two groups, the use of one drain significantly reduced hospital stay. Taken together, these findings support the prophylactic insertion of a single intra-abdominal drain following gastric and pancreatic resections.

Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration.

BACKGROUND: Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements. PURPOSE: To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India. METHODS: Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume). RESULTS: 500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C. CONCLUSION: Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations. SYNOPSIS: The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.

Synchronous hepatocellular carcinoma with renal cell carcinoma: a case report and review of literature of multiple synchronous primary malignancies.

Multiple synchronous primary malignancies have been reported since the 19th century. A number of proposed theories as to the predisposing factors have been discussed. The criteria to diagnose multiple primary malignancies have been revised by Warren and Gates. We hereby present a case of an asymptomatic individual detected with a synchronous hepatocellular carcinoma and a renal cell carcinoma, its presentation, diagnosis, and the management. The occurrence of synchronous hepatocellular carcinoma with renal cell carcinoma is very rare and only a few cases have been reported. Synchronous extrahepatic primary malignancies have been reported in a few studies across the world though with a varied incidence rate. The occurrence seems to be in the older age group without gender differentiation. The extrahepatic malignancies were more common in cirrhotic livers though the overall survival does not differ between patients with hepatocellular carcinoma alone and hepatocellular carcinoma with synchronous extrahepatic malignancies.

Gastrointestinal stromal tumors: case series of 29 patients defining the role of imatinib prior to surgery.

BACKGROUND: The aim of this study was to assess the role of neoadjuvant imatinib in redefining treatment for gastrointestinal stromal tumors (GISTs). METHODS: A total of 76 patients were reviewed. Among them, 29 patients who were administered neoadjuvant imatinib for borderline resectable and locally advanced GISTs followed by surgery were analyzed. Adjuvant imatinib was administered based on risk stratification. RESULTS: The median age of the neoadjuvant imatinib group was 51 years. The median duration of neoadjuvant imatinib administration was 8.5 months. The response rate with neoadjuvant imatinib was 79.3%. Five patients, initially considered to have locally unresectable lesions, ultimately underwent resection (three R0, two R2). Another three patients, who had M1 disease, underwent R2 resection (due to the presence of metastasis) with complete resection of the primary lesion. In 19 patients, who would have originally required extensive surgery, underwent conservative surgery (R0). In two patients, neoadjuvant imatinib did not influence the final procedure. The postoperative complication rate was 13.8%, and there were no postoperative deaths. There was one locoregional recurrence and two cases of distant metastasis. The 1-, 2-, and 3-year overall survivals were each 100%. CONCLUSIONS: Neoadjuvant imatinib for locally advanced GISTs is a safe concept for downsizing, improving resectability, and aiding organ-preserving surgery. It also improves the chance of long-term survival. Surgery, however, remains the cornerstone of curative treatment of GISTs even after neoadjuvant imatinib.

Complications as indicators of quality assurance after 401 consecutive colorectal cancer resections: the importance of surgeon volume in developing colorectal cancer units in India.

BACKGROUND: The low incidence of colorectal cancer in India, coupled with absence of specialized units, contribute to lack of relevant data arising from the subcontinent. We evaluated the data of the senior author to better define the requirements that would enable development of specialized units in a country where colorectal cancer burden is increasing. METHODS: We retrospectively analyzed data of 401 consecutive colorectal resections from a prospective database of the senior author. In addition to patient demographics and types of resections, perioperative data like intraoperative blood loss, duration of surgery, complications, re-operation rates and hospital stay were recorded and analyzed. RESULTS: The median age was 52 years (10-86 years). 279 were males and 122 were females. The average duration of surgery was 220.32 minutes (range 50-480 min). The overall complication rate was 12.2% (49/401) with a 1.2% (5/401) mortality rate. The patients having complications had an increase in their median hospital stay (from 10.5 days to 23.4 days) and the re-operation rate in them was 51%. The major complications were anastomotic leaks (2.5%) and stoma related complications (2.7%). CONCLUSIONS: This largest ever series from India compares favorably with global standards. In a nation where colorectal cancer is on the rise, it is imperative that high volume centers develop specialized units to train future specialist colorectal surgeons. This would ensure improved quality assurance and delivery of health care even to outreach, low volume centers.

Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocellular carcinoma.

BACKGROUND: Single-port laparoscopic surgery is slowly but steadily gaining popularity among surgeons performing minimally invasive abdominal surgeries. The aim of the present study is to assess our initial experience with single-port laparoscopic liver resection for hepatocellular carcinoma. METHODS: Between March 2009 and April 2011, 24 patients underwent single-port laparoscopic liver resection for hepatocellular carcinoma. Of these, 13 were laparoscopic segmentectomies, 4 were laparoscopic left lateral sectionectomies, 1 was a right hepatectomy, 1 was a left hepatectomy, and 4 were nonanatomical resections. RESULTS: Median operating time and blood loss were 205 min (95-545 min) and 500 ml (100-2,500 ml), respectively. Two procedures were converted to multiport laparoscopic hepatectomy due to instrument length limitations, and four were converted to open surgery. There were no serious intraoperative or postoperative complications in this series. Median postoperative stay was 8.5 days (5-16 days). CONCLUSIONS: Although the procedure requires a lot of technical expertise added to the skill of liver surgery, single-port laparoscopic liver resection for hepatocellular carcinoma seems a feasible approach in a variety of well-selected cases. In spite of the demanding nature of the procedure and the requirement of better instrumentation for single-port laparoscopic surgery, the results seem to compare favorably with conventional laparoscopic surgery and open surgery.

Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes.

PURPOSE: During pancreatoduodenectomy (PD), two techniques have been described to dissect the head of pancreas, viz. the superior mesenteric artery (SMA) approach by dissecting the uncinate process and the uncinate process first approach. METHODS: Forty-four consecutive patients, who underwent PD between June 2009 and April 2010, were analyzed. Thirty patients underwent the SMA first approach along with uncinate dissection (group 1), while 14 patients underwent the uncinate process first approach (group 2). RESULTS: There were 30 male and 14 female patients. The median age was 51 years (range 19-76 years). Median intraoperative blood loss in group 1 was 800 ml, while that in group 2 was 600 ml. A mean of 0.52 units of blood were transfused in group 1 (range 0-3) compared to 0.2 units in group 2 (range 0-1). The median operative time in group 1 was 457.5 min and the median operative time was 450 min in group 2. Complication rate was 40% and 14.3% in groups 1 and 2, respectively. Median duration of hospital stay was 14 days in group 1 and 12.5 days in group 2. Median nodes resected in group 1 were 8 (range 0-26), while in group 2 they were 9 (range 2-14). Resection margins were positive in two cases (one in each group). There were two mortalities in group 1 and no mortalities in group 2. None of the above differences were significant. CONCLUSIONS: SMA first is a safe technique. It compares well with the uncinate first approach in terms of operative time, blood loss, number of lymph nodes retrieved, margin positivity and operative morbidity. Both techniques may be useful in situations such as a large uncinate process tumor or when superior mesenteric vein/portal vein/superior mesenteric artery involvement is suspected or present. Further studies, evaluating data related to specific predefined uncinate tumors, would be the next logical step in further defining the precise role of these techniques.

Is early feeding after major gastrointestinal surgery a fashion or an advance? Evidence-based review of literature.

Early enteral nutrition (EN) after major digestive surgery has been receiving increasing attention. Supporting evidence has not been clear. This evidence-based review traces the development of early EN and analyses whether it is indeed an advance. We performed a PubMed search in October 2009 with the key words enteral nutrition, early feeding, and gastrointestinal surgery. Our emphasis was on earliest studies documenting the benefits or adverse effects of EN, comparative studies, documenting the benefits or adverse effects of EN, comparative studies, and randomized controlled trials. Thirty-one results were returned from which 17 were included for evaluation (1979-2009). Fifteen papers concluded that early EN was beneficial. In general, patients put on early EN and immunonutrition postoperatively seemed to have decreased hospital stay, decreased complication rates, decreased treatment and hospital costs, and even decreased morbidity and mortality; however, judicious use has been suggested. One study did not recommend early enteral feeding in well-nourished patients at low risk of nutrition-related complications and another suggested that immunonutrition is not beneficial and should not be used routinely. Early EN has been safely given after major digestive surgery since 1979. It benefits patients undergoing major gastrointestinal (GI) surgeries, with reduction in perioperative infection, better maintainance of nitrogen balance, and shorter hospital stay. Early EN may be superior to total parenteral nutrition (TPN). However, TPN is perhaps better tolerated in the immediate postoperative period. Early enteral immunonutrition should be used only in malnourished and in transfused patients. Early EN after major digestive surgery is an old advance that is now in fashion.

Ectopic pancreatic tissue mimicking ampullary tumor.

Ectopic pancreas is an anomaly in the fusion of the two pancreatic buds where an ectopic rest develops at a place away from the normal site. We report a 70-year-old lady who presented with obstructive jaundice; she was found to have an ampullary tumor highly suggestive of malignancy, for which she underwent pancreatico-duodenectomy. However, histology showed ectopic pancreatic tissue in the ampulla.

Gastric cancer presenting with acute disseminated intravascular coagulation.

Patients presenting with acute disseminated intravascular coagulation (DIC) as the first symptom of malignancy are rare. A 68-year-old man presented with DIC. On evaluation, he was found to have adenocarcinoma of the stomach. Resection of the growth controlled the DIC for a few days, after which the patient developed altered coagulation parameters and sepsis, and succumbed.