Laparoscopic surgery for right colon cancer with intestinal malrotation: A case report and review of the literature.

Intestinal malrotation (IM) results from abnormal midgut rotation during embryogenesis and usually presents in early infancy. IM in adults is often an incidental radiological diagnosis. Right colon cancer with IM has been sparingly reported in the world literature. Only 44.7% of these documented cases underwent successful laparoscopic resection, all of which were reported from Japan. The presence of aberrant anatomy and altered vascular orientation in IM presents challenges for laparoscopic resection with adequate nodal clearance. We present the case of a 72-year-old female diagnosed with carcinoma of the ascending colon, with IM incidentally detected on pre-operative cross-sectional imaging. She underwent laparoscopic right hemicolectomy. We also reviewed the documented cases of successful laparoscopic surgery for right colon cancers with IM. Aided by accurate delineation of vascular anatomy on pre-operative cross-sectional imaging, laparoscopic colectomy in the setting of IM is safe and feasible, and should be favourably considered.

Diaphragmatic injury during laparoscopic cholecystectomy: An unusual complication during a routine case.

Laparoscopic cholecystectomy is one of the most common procedures performed in surgical practice worldwide. Diaphragmatic injury is an extremely rare complication that can occur intraoperatively and needs to be dealt with immediately. This article describes a case report of diaphragmatic injury, technical details of how to deal with this complication and preventive strategies along with a review of literature on the topic.

Circumportal pancreas: a clinicoradiological and embryological review.

Circumportal pancreas is a congenital fusion anomaly of the pancreas where the pancreatic tissue from the uncinate process, anomalously encases the portal vein and/or the superior mesenteric vein. Depending upon the level of the pancreatic annulus the variant can be classified into three subtypes-suprasplenic, infrasplenic or mixed; and each subtype exhibits either an anteportal or retroportal main pancreatic duct. Limited literature is available on this intriguing anomaly primarily because of its relatively low prevalence in humans (published prevalence rates vary from 0.2 to 2.5 %), probable lack of awareness among medical professionals and its generally symptomless course. In an attempt to appraise the embryological basis, clinicoradiological manifestations and potential surgical implications of circumportal pancreas, literature published in English was searched using PubMed and information collated so as to provide up-to-date information on this relatively understudied entity. The anomaly by itself remains innocuous but its preoperative recognition in those undergoing pancreatic resection bears decisive influence on planning and selecting apposite surgical resection planes as inadvertent duct injury can lead to pancreatic fistula.

Kinetics of liver function tests after a hepatectomy for colorectal liver metastases predict post-operative liver failure as defined by the International Study Group for Liver Surgery.

BACKGROUND: Post-hepatectomy liver failure (PHLF) has been defined by the International Study Group for Liver Surgery (ISGLS). The purpose of the present study was to examine the kinetics of conventional liver function tests (LFT) after a major liver resection and is the first to examine their utility in predicting PHLF in groups defined by the ISGLS. METHODS: Consecutive patients undergoing a major liver resection for colorectal liver metastases were stratified into ISGLS groups and their LFT up to 1 year after surgery compared. Receiving-operating characteristic (ROC) analysis of LFT identified optimal thresholds in predicting category C liver failure. RESULTS: In total, 32, 22 and 19 patients belonged to ISGLS groups A, B and C, respectively. The median international normalized ratio (INR) and bilirubin values on post-operative days 1, 3, 5 and 7 were significantly different among the groups (all P-values <0.05). ROC analysis of day 1 INR (AUC 0.813) and day 5 bilirubin (AUC 0.798) revealed thresholds of 1.35 and 52 µmol/l to have sensitivities of 85% and 81% and specificities of 63% and 73%, respectively, to predict group C liver failure. DISCUSSION: Post-operative LFT after a major liver resection differs significantly among the three ISGLS groups. Thresholds of bilirubin and INR can be used to identify patients who are at a maximum risk of complications.

Ogilvie's Syndrome with Perforation Peritonitis after Caesarean Section.

Acute colonic pseudo-obstruction in the immediate post-partum period, following Caesarean section is rare, and requires a high index of suspicion for diagnosis. Sometimes, rapidly progressive dilatation of the caecum can lead to perforation peritonitis. There are only a few case reports describing this important entity. Presented herein is a young primigravida, who developed Ogilvie's syndrome and peritonitis 5 days following an uneventful elective Caesarean section. Clinical details, management strategy adopted and a brief review of literature is presented to draw attention to this condition.

Twelve-Year Survival After Resection of Hepatocellular Carcinoma with Right Atrial Tumor Thrombus.

INTRODUCTION: A large hepatocellular carcinoma (HCC) with macrovascular invasion is generally considered to have poor prognosis due to unfavorable tumor biology andsuch patients are relegated to palliative options. This report describes long term survival after surgery in a patient with HCC and tumor thrombus in the rightatrium. METHODS: Case records of the patient, details of follow up visits and surveillance computed tomography scans performed were reviewed. A brief discussion of thesurgical strategy adopted along with outcome of similar cases in literature is presented. RESULTS: A 60 year old man presented with a HCC in segments 4, 5 with extension of tumor into the middle, left hepatic veins, inferior vena cava and right atrium.Patient underwent extraction of the tumor thrombus from the right atrium under cardiopulmonary bypass along with extended left hepatectomy. He receivedthree cycles of adjuvant chemotherapy with Gemcitabine, Oxaliplatin and Interferon. There was a parietal wall recurrence after 1 year and 10 months whichwas excised. Since then he remains well and is on regular follow up for more than 12 years from his index surgery with no evidence of disease, making himthe longest known survivor with such an advanced presentation. CONCLUSION: This is an unusual instance where aggressive resection for HCC with right atrial tumor thrombus has resulted in an exceptionally long survival.

Median Arcuate Ligament Syndrome: an Important Consideration in Pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.

Penetrating injuries of the inferior vena cava.

Inferior vena cava (IVC) injuries occur in 0.5-5% of cases of penetrating abdominal injury. Uncommonly encountered in general surgical and trauma practice, they remain extremely lethal despite advances in resuscitation and critical care. Important factors determining treatment outcomes are the hemodynamic status of the patient at presentation, the level and extent of injury, and the presence of associated injuries. Operative approaches and techniques for definitive repair are to be tailored to the condition of the patient, type of injury, and available expertise. In a patient with severe hemodynamic compromise, damage control principles take priority to stop bleeding and save life. The most commonly employed strategies are venorrhaphy or ligation. Retro-hepatic and supra-hepatic caval injuries are particularly challenging in terms of exposure and repair, and are associated with high fatality. Endovascular approaches are being used in select cases with success. This paper reviews in detail the epidemiology, injury patterns, management protocols, and outcomes of IVC injuries due to penetrating abdominal trauma.

How to prevent uncontrolled abdominal desufflation during laparoscopy in times of the coronavirus pandemic.

Aerosolization during laparoscopy poses a theoretical risk of infection to healthcare providers by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A simple, low-cost method of controlled abdominal desufflation during laparoscopy is described.

Predictors of Successful Kasai Portoenterostomy and Survival with Native Liver at 2 Years in Infants with Biliary Atresia.

OBJECTIVES: Kasai portoenterostomy (KPE) is the primary treatment for biliary atresia (BA) with subsequent liver transplantation in failed cases. The aim of this work was to study the outcome of KPE in children with BA and identify the factors predicting a successful KPE. METHODS: Children diagnosed with BA and undergoing KPE between January 2010 and January 2018 were included in the study. A successful KPE was defined as decrease in bilirubin to less than 2 mg/dL at 6 months after KPE. Factors affecting the outcome (successful KPE and survival with native liver [SNL] at 2 years) were evaluated by logistic regression. RESULTS: A total of 79 children with post-KPE BA were included. Successful KPE was achieved in 29 (36.7%) of 79 children undergoing KPE. The data for survival with native liver at 2 years were available for 61 children as 9 were lost to follow up before 2 years and another 9 were aged less than 2 years at the time of analysis. Twenty-seven (44.3%) of these 61 survived with their native liver at 2 years. On logistic regression analysis, lower age at KPE, use of postoperative steroids and absence of cholangitis were significant predictors of a successful KPE. A successful KPE at 6 months was the lone independent predictor of SNL at 2 years in these children. CONCLUSION: Early age at KPE, use of postoperative steroid and prevention of cholangitis can result in successful KPE. Those with successful KPE are likely to survive with their native liver at 2 years.

"No go" donor hepatectomy in living-donor liver transplantation.

BACKGROUND: Selection of appropriate donors after rigorous evaluation is of paramount importance in living-donor liver transplantation. Despite this, donor surgery may not proceed due to unforeseen reasons. The aim of this paper is to study reasons for "no go" donor hepatectomy in living liver donors. PATIENTS AND METHODS: Donor operations stopped after surgical start, directly due to donor safety-related reasons, qualified for inclusion as "no go" donor hepatectomy. Living-donor evaluation was performed as per standard protocol. Data for consecutive living liver donors operated between April 2012 and November 2016 were analyzed to evaluate reasons for "no go" donor hepatectomy in a liver transplantation unit at a tertiary care teaching hospital. RESULTS: In 307 donors, the operation was aborted in 7 (2.3 %). One patient had unexpected biliary pathology with fibrosis found intraoperatively. Operations in five donors were abandoned in view of liver parenchymal abnormalities (fibrosis/steatohepatitis). One donor had hemodynamically significant bradycardia after handling the round ligament. All these donors recovered uneventfully and remained well on follow-up. CONCLUSIONS: "No go" donor hepatectomy remains a real possibility despite rigorous assessment. Although thresholds for on-table rejection of the donor after complete evaluation vary, "no go" hepatectomy is a calculated risk-avoidance approach.

Imaging in ductal plate malformations.

Ductal plate malformations are a heterogenous group of congenital fibrocystic liver diseases resulting from insult to the ductal plate at various stages of embryogenesis. As a result various biliary malformations, cysts, hamartomas and congenital hepatic fibrosis may be seen. We present a radiological pictorial of ductal plate malformations, accurate diagnosis of which is important for clinical management.

Major Liver Resection for Large and Locally Advanced Hepatocellular Carcinoma.

Optimal management of large and locally advanced hepatocellular carcinoma (HCC) remains a clinical challenge especially in patients with chronic liver disease (CLD). We present our experience of major liver resection for large and locally advanced HCC. Prospectively collected data of patients with large and locally advanced HCC who underwent major liver resection between March 2011 and May 2015. The outcome measures of interest were the characteristics of tumor, surgical outcome, and overall as well as disease-free survival. Eighteen patients (14 male) with median age of 59 years (20 to 73 years) with good performance status underwent resection. Fifteen patients were in Child Pugh class A and three in class B. On contrast-enhanced computed tomography (CECT) scan, four patients had lobar/segmental portal vein involvement, two patients had bilobar disease, and one had biliary obstruction. Seven patients underwent extended resection (>5 segments), five right hepatectomy, two modified right hepatectomy, one modified right hepatectomy with wedge resection of segment six, two left hepatectomy, and one left lateral sectionectomy. On histopathology, 12 were solitary and six were multiple, the median tumor diameter was 9 cm (5-18 cm). All 18 patients had R0 resection. Eight patients had cirrhosis, six had fibrosis, and four had chronic hepatitis. Vascular invasion was noticed in 12 and out of these, six had large-vessel embolization. Morbidity according to Clavien-Dindo class was grades 1-11, grades 2-5, grade 3B-1, and grades 5-1. After a median follow-up of 32 months (6-54 months), the overall survival at 1 and 3 years was 83 and 54 %, respectively. The disease-free survival at 1 and 3 years was 75 and 54 % respectively. In carefully selected patients with large and locally advanced HCC, acceptable perioperative and medium term outcomes can be achieved with major liver resection.

Progressive Familial Intrahepatic Cholestasis (PFIC) in Indian Children: Clinical Spectrum and Outcome.

OBJECTIVE: To study the clinical and laboratory profile of children with progressive familial intrahepatic cholestasis (PFIC) and evaluate their outcome. METHODS: The study is a retrospective review of all cases diagnosed with PFIC between January 2011 and July 2015. All children underwent histopathological examination and immunostaining. Management was done as per institute's protocol. RESULTS: There were a total of 24 PFIC cases (PFIC 1-2, PFIC 2-19, PFIC 3-3). Eleven presented as neonatal cholestasis, whereas 13 others presented after 6 months of life. Median age of presentation in PFIC 2 was 5.5 months with a time lag of 13 months in diagnosis. PFIC 1 and 2 presented in infancy, whereas PFIC 3 presented late. Familial clustering was seen in 12 of 24 cases. Pruritus resolved with medical management in two-thirds of cases, 3 cases required biliary diversion (BD) with dramatic improvement. One child improved after liver transplantation. CONCLUSIONS: PFIC accounts for 8% of neonatal cholestasis and 34% of cholestasis in older children with PFIC 2 being the commonest subtype. Medical therapy is successful in majority. Partial internal BD should be offered to non-cirrhotic low gamma glutamyl transferase PFIC with intractable pruritus. Progression to cirrhosis may be prevented or delayed by early diagnosis and timely intervention.

Selection and outcome of the potential live liver donor.

BACKGROUND AND AIM: A thorough donor evaluation in the living donation process is mandatory to ensure a safe outcome in an otherwise healthy individual. The aim of the current study was to evaluate the reasons for not proceeding to donation and the outcome of live liver donors. METHODS: A prospective study of potential donors who underwent evaluation and proceeded to surgery from 1 April 2012 to 31 January 2015 was conducted. The process of donor selection, its outcome and peri-operative complications were recorded. RESULTS: A total of 460 donors were evaluated in a stepwise manner for 367 potential recipients. Of the 321 (69.7 %) donors not proceeding to donation, the reasons were donor-related in 63.6 % and recipient-related in the rest. Common donor-related reasons were: donor reluctance (23.5 %), negative liver attenuation index (16.2 %), anatomic variations (10.3 %), inadequate remnant liver volume (9.8 %), unacceptable liver biopsy (8.8 %), and inadequate graft volume (5.4 %). A majority of donors (82.8 %) were turned down early in the (steps 1 and 2) evaluation process. Recipient death was the most common recipient-related reason [n = 51 (43.6 %)] for not proceeding to donation. There was no donor mortality. The overall complication rate was 19.8 % and major complication rate (grade 3 or higher) was 4.4 %. CONCLUSIONS: A stringent stepwise donor evaluation process leads to early recognition of unsuitable donors and a low complication rate.

Liver transplantation in acute on chronic liver failure: challenges and an algorithm for patient selection and management.

Acute on chronic liver failure is an entity distinct from acute liver failure and acute decompensation of chronic liver disease. Despite best medical therapy, it is associated with high short-term mortality due to infection and organ failure. Liver transplantation is a potentially curative treatment option that has been shown to have good outcomes in this setting. As there are no reliable ways of predicting which subset of patients will recover spontaneously, early transplantation before establishment of full blown sepsis or organ failure is expected to have favorable outcomes with an acceptable risk. This article reviews current literature on liver transplantation for acute on chronic liver failure, discusses challenges in patient selection, and proposes an algorithm for management.

Liver Transplantation After Bone Marrow Transplantation for End Stage Liver Disease with Severe Hepatopulmonary Syndrome in Dyskeratosis Congenita: A Literature First.

Dyskeratosis congenita is a multisystem genetic disorder. Although hepatic involvement is reported in about 7% of patients with dyskeratosis congenita, it is not well characterized and often attributed to hemochromatosis from frequent blood transfusions. A few case reports describe cirrhosis and hepatic cell necrosis in affected individuals in autosomal dominant pedigrees. Bone marrow failure and malignancies are the principal causes of death in dyskeratosis congenita. We describe the first case of living donor liver transplantation, in dyskeratosis congenita for decompensated cirrhosis with portal hypertension. The patient also had associated severe hepatopulmonary syndrome, interstitial lung disease, bilateral hip replacement for avascular necrosis of the head of femur, and a past history of bone marrow transplantation for bone marrow failure.

Postcholecystectomy bile duct injury and its sequelae: pathogenesis, classification, and management.

A bile duct injury sustained during cholecystectomy can change the life of patients who submit themselves to a seemingly innocuous surgery. It has far-reaching medical, socioeconomic, and legal ramifications. Attention to detail, proper interpretation of variant anatomy, use of intraoperative cholangiography, and conversion to an open procedure in cases of difficulty can avoid/lessen the impact of some of these injuries. Once suspected, the aims of investigation are to establish the type and extent of injury and to plan the timing and mode of intervention. The principles of treatment are to control sepsis and to establish drainage of all liver segments with minimum chances of restricturing. Availability of expertise, morbidity, mortality, and quality of life issues dictate the modality of treatment chosen. Endoscopic intervention is the treatment of choice for minor leaks and provides outcomes comparable to surgery in selected patients with lateral injuries and partial strictures. A Roux-en-Y hepaticojejunostomy (HJ) by a specialist surgeon is the gold standard for high strictures, complete bile duct transection and has been shown to provide excellent long-term outcomes. Percutaneous intervention is invaluable in draining bile collections and is useful in treating post-HJ strictures. Combined biliovascular injuries, segmental atrophy, and secondary biliary cirrhosis with portal hypertension are special circumstances which are best managed by a multidisciplinary team at an experienced center for optimal outcomes.