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BACKGROUND: Incidental carcinoma gall bladder and benign disease in radical cholecystectomy specimen is the cause of concern. We attempted to find out the incidence and reasons thereof in the present study. METHODS: Present study is a retrospective analysis of a prospectively maintained database between July 2002 and July 2019. All patients with a diagnosis of carcinoma gall bladder admitted for surgery were included. RESULTS: Out of 148 patients, 110 patients had carcinoma gall bladder (CAGB), while 38 patients (25.7%) had incidental carcinoma (under-diagnosis). Radical resection was done in 61/110 (55.4%) patients with clinical CAGB, where 15 (24.6%) patients had benign pathology ("over-diagnosis"). Overdiagnosis was due to xanthogranulomatous cholecystitis (n = 9), chronic cholecystitis (n = 2), tuberculosis (n = 2) and IgG4 related cholecystitis (n = 2). Among 61 patients, a history of weight loss and anorexia were significantly associated with malignancy. Asymmetrical wall thickness was significantly more common in benign mimickers. Among patients with incidental carcinoma, preoperative ultrasonography reported normal wall thickness of gall bladder in 28 (73.7%), thickened gall bladder wall in 6, and polyp in 3 patients. The resectability rate among incidental carcinoma was 27/38 (71.05%). CONCLUSION: Over-diagnosis of the carcinoma gall bladder was present in 24.6%. On the other hand, incidental carcinoma comprised 25.7% of all admissions for carcinoma gall bladder with resectability of 71%.
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Carcinoma , Colecistite , Neoplasias da Vesícula Biliar , Carcinoma/diagnóstico , Carcinoma/patologia , Carcinoma/cirurgia , Colecistectomia , Colecistite/diagnóstico , Colecistite/epidemiologia , Colecistite/cirurgia , Erros de Diagnóstico , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/cirurgia , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: After laparoscopic cholecystectomy, gallbladder can be extracted either from epigastric/subxiphoid port or umbilical port. We conducted systematic review of randomized controlled trials comparing the two. METHODS: PRISMA-compliant systematic review and meta-analysis was conducted with pre-specified study protocol registered on PROSPERO (CRD42019128662). Multiple databases were searched from inception till 14 September 2019 using search terms "gallbladder", "specimen", "extraction', "extract", "cholecystectomy", "epigastric port", "subxiphoid port" "umbilical port". Outcomes assessed were postoperative pain (visual analog scale at 24 h postoperatively), port-site hernia, port-site infection, operative time and gallbladder retrieval time. Data were analyzed using random-effects models with risk ratios (RR) for dichotomous variables and mean difference (MD) for continuous variables. RESULTS: Of 280 articles retrieved, 9 RCT's with 1036 participants were included. Quality of included studies was judged to be "moderate" to "low". There was no difference in postoperative pain at 24 h (p = 0.76), total operative time (p = 0.11), gallbladder retrieval time (p = 0.72) or surgical site infection (p = 0.93). Umbilical port retrieval was associated with significantly higher risk of port-site herniae (RR 2.68, 95%CI:1.06-6.80, p = 0.04). After sensitivity analysis, operative time was significantly shorter with epigastric retrieval (p = 0.0007). Trial sequential analysis showed that current studies were successful in achieving optimum information size for primary outcome. CONCLUSIONS: There was no difference in postoperative pain and infections between umbilical and epigastric port retrieval. Umbilical port retrieval was associated with significantly higher risk of developing port-site hernia and could also be associated with longer operative time. Epigastric port may be favorable for gallbladder retrieval in multiport laparoscopic cholecystectomy.
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Colecistectomia Laparoscópica , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Vesícula Biliar/cirurgia , Hérnia , Humanos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/cirurgia , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
INTRODUCTION: Peutz-Jeghers syndrome (PJS) is a rare hereditary disorder characterized by gastrointestinal hamartomatous polyps, due to mutation of the STK11/LKB1 gene located on chromosome 19p. The polyps are most commonly found in the small bowel followed by colon. CASE PRESENTATION: Our case series includes 4 patients, three being male and one female. Each of them either presented with abdominal pain and other associated symptoms. Oral cavity and lip melanin pigmentation were common. CT abdomen revealed multiple large jejunal, ileal, gastric and colon polyps. Cancer was found in one patient. Different surgical approaches were adopted. All recovered well. DISCUSSION: PJS is an autosomal dominant disorder with an estimated incidence of 1:50,000 to 1:200,000 cases with a significant family history. Mostly found in small bowel followed by colon, it can also occur in a rare organ like gall bladder as evident in our case. PJS carries a substantial risk for gastrointestinal cancer. The treatment modality depends on the site of polyp, mode of presentation and availability of the expertise. CONCLUSION: PJS is a common disease in our part which is usually observed in teen age groups male. They have a varied presentation, from intestinal obstruction (due to intussusception) to GI bleeding. Colonic malignancy at young age may be the first presentation of the disease. Observation of melanin pigmentations on lips helps diagnose the disease; and one should always look at this findings in a young patient with pain abdomen or in intestinal obstruction to confirm/exclude the disease.
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Chylothorax is a rare entity associated with morbidity. Surgical thoracic duct ligation (TDL) by thoracoscopic approach is the recommended choice for persistent chylothorax. However, thoracoscopy is not feasible in case of previous pleurodesis. We describe a successful laparoscopic transhiatal en-mass TDL in a 61-year-old lady for persistent spontaneous chylothorax after failed optimal conservative management and three sessions of pleurodesis. The study shows that laparoscopic transhiatal thoracic duct ligation is an effective alternative in a case where thoracoscopy is not feasible due to various reasons.
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Background: Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ. Methods: A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded. Results: Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ). Conclusions: Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.
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INTRODUCTION: Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. METHODOLOGY: This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. RESULTS: Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). CONCLUSIONS: TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. TRIAL REGISTRATION: This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.
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Carcinoma de Células Escamosas , Neoplasias Esofágicas , Assistência ao Convalescente , Carcinoma de Células Escamosas/complicações , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/patologia , Esofagectomia/efeitos adversos , Humanos , Excisão de Linfonodo/efeitos adversos , Alta do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Estudos Retrospectivos , Toracoscopia , Resultado do TratamentoRESUMO
BACKGROUND: Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or multivisceral resection is a complex procedure associated with high morbidity, mortality, and R1 resection rates. However, e-TME in LARC with surrounding organ involvement is the only potential option for cure. The study aims to assess the clinical outcome of patients requiring e-TME for LARC. METHODS: The study is a retrospective review of all patients with LARC requiring multivisceral resection (2013 to 2019). The database includes clinic-demographic profile, pelvic organ involved, operative details, resection margin status, morbidity, mortality, and survival. RESULTS: Seven consecutive patients (9.2%) out of 76 LARC (median age 46 years; 5 females) required multivisceral resection. The organs involved were bladder (4); posterior wall of vagina (2); and uterus (1). The en bloc resection included total cystoprostatectomy - 1; partial cystectomy - 3; posterior vaginectomy - 2; and hysterectomy - 1. Additionally, four required abdominoperineal resection. All were adenocarcinoma: stage III, with R0 resection - 76%. The overall complications were seen in 60% of patients, majority being wound related. There was no operative mortality. The median survival was 32.2 months in the entire series, while one died with the disease at a 28-month follow-up. CONCLUSION: e-TME with curative intent, though a complex procedure, is associated with high wound-related morbidity, R1 resection, but improved median survival benefit.
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Protectomia , Neoplasias Retais , Feminino , Humanos , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Walled-off pancreatic necrosis is a challenging problem and pancreatic necrosectomy is associated with significant morbidity and mortality. Following necrosectomy, postoperative bile leak is a rare complication. We present such a case of delayed bile leak from the distal common bile duct in an 81-year-old lady following pancreatic necrosectomy, which was successfully managed by endoscopic stenting.
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BACKGROUNDS/AIMS: Diabetes mellitus (DM) is a known risk factor for morbidity, length of hospital stay, or mortality after surgery, however, its impact on postoperative course and long-term survival after pancreaticoduodenectomy (PD) is not clear. METHODS: This is a retrospective analysis of prospectively maintained database of 141 patients with periampullary and pancreatic head adenocarcinoma operated between January 2001 and March 2019. Clinico-pathological records and follow-up data were retrieved and analyzed. Cumulative hazard was computed for comparing the survival between DM and non-DM. RESULTS: DM was present in 31/141 (21.9%) patients, while 16/31 (51.6%). were new-onset DM (NODM). Tumor size, lymphovascular & perineural invasion, type of surgery, lymph node positivity and R0 resection rate were comparable between diabetic and non-diabetic. There was no significant difference in postoperative pancreatic fistula, delayed gastric emptying, infectious complication, hospital stay and mortality between DM and nondiabetics. Patients with DM had worse survival at 3 years (OS: HR, 3.11 [1.43-6.76] p=0.004, DFS: HR, 2.61 [1.23-5.53] p=0.01) and 5 years (OS: HR, 3.32 [1.46-7.53] p=0.004, DFS: HR, 2.87 [1.29-6.41] p=0.009). On multivariate analysis, DM (3 year OS: HR, 2.61 [1.14-5.98] p=0.022, DFS: HR, 2.19; p=0.058) (5 year OS: HR, 2.55; p=0.04, DFS: HR, 2.25; p=0.068) and pylorus resecting surgery were significantly associated with worse survival at 3 and 5 years. CONCLUSIONS: Preoperative DM has no significant effect on postoperative course but has negative impact on 3-year and 5-year OS and DFS after PD for pancreatic and periampullary adenocarcinoma.
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A combination of bile and pancreatic duct injuries is very rare. Anomalous ductal anatomy, distorting duodenal fibrosis, and pancreatic atrophy predispose to this untoward complication during performance of distal gastrectomy for benign peptic stricture. The technical challenges posed by this complication and experience gained by managing it are shared.
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Although peptic ulcer disease (PUD) is a common entity, the rate of its complication has decreased with the advent of proton pump inhibitors. We present a case of complicated PUD in a 49-year-old male patient having a rare combination of bleeding, gastric outlet obstruction, and a large choledochoduodenal fistula (CDF) who presented with shock. After resuscitation and investigations, ligation of bleeder via duodenotomy, Roux-en-Y choledochojejunostomy, and gastrojejunostomy was done for ulcer bleeding, CDF, and pyloric stenosis respectively. The patient improved after surgery. As with other emergency surgery, minimizing morbidity and mortality remains the principle of management. The best treatment in this situation irrespective of hemodynamic stability is surgery, which is a one-time and best treatment for bleeding, obstruction, and CDF.
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OBJECTIVE: With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. METHODS: This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. RESULTS: Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. CONCLUSION: With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.
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Proximal small bowel intussusception occurring in an adolescent Crohn's disease patient is an extremely rare entity. It is usually primary without a lead point and quite often a transient phenomenon. We report such transient and intermittent jejunal intussusception in a 16-year-old male, developing immediately in a postoperative period after a stoma reversal for jejunal stricture perforation peritonitis.
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Introduction Choledochal cysts (CCs) are uncommon biliary lesions. Considering the evolution of imaging, we describe our experience with the presentation and management of choledochal cysts. Methods A review of the records of all patients with choledochal cyst managed in our institute were retrospectively analyzed. The study analyzed clinical presentation, diagnosis, treatment and postoperative outcomes. Results Between 2015 and 2019, 30 CCs (male/female: 7/23) were operated. We observed more adults compared to children (17 vs. 13). The median age at surgery was 18.5 years (4-67 years). The presentation included abdominal pain (90%), pancreatitis (17%0, cholangitis (13%), and incidental diagnosis in (7%). Anomalous union of the bile duct and the pancreatic duct was seen in 17%. Two patients had synchronous cholangiocarcinoma. The cysts were classified (Todani's): I: 26; IV:3; and V: 1. The patients underwent complete excision of the cyst and Roux-en-Y hepaticojejunostomy - 27; pancreaticoduodenectomy - 1; hepaticoduodenostomy - 1; and cholecystectomy with T-tube drainage - 1 patient. The operative complications were observed in 10 (33.3%) patients: biliary leaks (four), superficial surgical site infections (four), and cholangitis (three). Only one patient developed a major complication; required re-operation for bile leak peritonitis. There was no operative mortality. One patient with cholangiocarcinoma died with the disease at three months of surgery. The remaining 29 patients are doing well at a mean follow-up of 29.5 months (12-56). Conclusion Adults CCs now far outnumber children at the time of presentation. The majority were symptomatic Todani's type I cyst. Complete cyst excision and bilio-digestive anastomosis is the best treatment for type I and IV CCs, thus eliminating the risk of malignancy with an excellent operative outcome.
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Gall bladder tuberculosis (TB) is a rare entity and differentiation of gall bladder TB from gall bladder malignancy is difficult. We hereby present an unusual case of incidental diagnosis of gall bladder TB during the evaluation of a gall bladder with suspicion of gall bladder cancer in a 49-year-old woman. The diagnosis of gall bladder TB was made with fine needle aspiration cytology (FNAC) from the gall bladder mass as the disease was found unresectable after cross-sectional imaging. Even with the advancement of cross-sectional imaging, the differentiation of gall bladder TB from gall bladder malignancy is not possible without tissue diagnosis.
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Doenças da Vesícula Biliar/diagnóstico , Doenças da Vesícula Biliar/patologia , Vesícula Biliar/microbiologia , Tuberculose/diagnóstico , Tuberculose/patologia , Antituberculosos/uso terapêutico , Diagnóstico Diferencial , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Feminino , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/patologia , Doenças da Vesícula Biliar/tratamento farmacológico , Doenças da Vesícula Biliar/microbiologia , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/patologia , Humanos , Pessoa de Meia-Idade , Tuberculose/tratamento farmacológico , Tuberculose/microbiologiaRESUMO
BACKGROUND: Foreign body ingestion is seen quite frequently in clinical practice, intestinal perforation due to this is rare. The foreign body often mimics another cause of acute abdomen and requires an emergency surgical intervention. The majority of patients do not recall ingesting sharp foreign bodies. CASE PRESENTATION: We report an interesting case of a fifty five year-old man who presented with pain in the right iliac fossa with localised tenderness which was clinically diagnosed as acute appendicitis. During the operation, the presence of purulent collection and the inflamed bowel with flakes raised suspicion of bowel perforation. The assessment of the proximal small bowel revealed two small perforations in the jejunum. A hard, bony and sharp object was extracted and the perforations were closed. Post-operative recovery was uneventful. Detailed food history was taken following the recovery of the patient from surgery. It revealed the history ingestion of home prepared buffalo meat. The extracted object was identified as 'buffalo bone' by the patient and the care taker of the patient. The jejunum was perforated by the ingested buffalo bone causing local peritonitis in right iliac fossa. CONCLUSION: Intestinal perforation by ingested foreign bodies should be suspected in acute abdomen. It requires a high degree of suspicion and awareness on the part of the clinician.