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.

Auxiliary Partial Orthotopic Liver Transplant as a Rescue Procedure for Acute Liver Failure with Extra-Small-for-Size Grafts: A Report of 2 Cases.

Auxiliary partial orthotopic liver transplant is a complex technique whereby a partial liver graft is transplanted in the orthotopic position, leaving behind a portion of the native liver. In acute liver failure, auxiliary partial orthotopic liver transplant serves as a rescue therapy and bridge for the native liver to regenerate. Auxiliary partial orthotopic liver transplant was initially considered a technically challenging procedure with inferior results versus orthotopic liver transplant. However, advancements in surgical techniques have led to improved results with auxiliary partial orthotopic liver transplant. Auxiliary partial orthotopic liver transplant is now increasingly accepted as a valid treatment option for acute liver failure. We present 2 cases of acute liver failure treated with auxiliary partial orthotopic liver transplant using an extra-small-for-size graft. The first case was a 12-year-old female patient who presented with druginduced acute liver failure and required an auxiliary partial orthotopic liver transplant with an extra-small left lobe graft (graft-to-recipient weight ratio of 0.45). The second case was a 23-year-old male patient with acute liver failure of unknown etiology who underwent an auxiliary partial orthotopic liver transplant with a small right lobe graft (graft-torecipient weight ratio of 0.5). In both cases, computed tomography liver volumetry was performed to determine the appropriate graft size for the recipient. Both patients underwent successful auxiliary partial orthotopic liver transplants, with good postoperative recovery. Follow-up examinations showed satisfactory liver function without evidence of graft failure or rejection. Auxiliary partial orthotopic liver transplant using extra-small grafts can be an effective treatment option for acute liver failure when no other suitable option exists, including as a rescue procedure for small grafts. However, careful patient selection and surgical planning are essential to ensure successful outcomes.