An Unusual Cause of Chylothorax after Esophagectomy

Chylothorax due to inadvertent thoracic duct injury after esophagectomy is a well-known complication and requires careful postoperative management and timely intervention to prevent potential morbidity and mortality. We present a case of high-output chylothorax after esophagectomy where the source of chyle leak was not in the thorax.

Thoracoscopic Esophagectomy for a Huge Leiomyosarcoma

Esophageal leiomyosarcoma is the commonest of all esophageal sarcomas but yet has a very low incidence. These tumors have been resected by the open approach so far. We describe the steps and challenges involved in the thoracoscopic excision of a huge leiomyosarcoma of the esophagus.

Laparoscopic Repair of a Right Paraduodenal Hernia

Laparoscopic repair of a right paraduodenal hernia has been described sparingly in literature. We present an account of how we laparoscopically repaired a right paraduodenal hernia along with a review of the current literature as regards the various techniques that have been attempted. With the patient in supine position, and with umbilical camera port and three 5 mm ports, we mobilized the cecum and ascending colon up to the third part of the duodenum, thereby widening the neck of the hernia sac in the Waldeyer fossa. This method is ideal for the less severe incomplete rotation presenting with right paraduodenal hernia where there are no Ladd's bands and there is no requirement for fetalization of the bowel.

The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study

Background  Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors.

Methods  Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula.

Results  Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112, p  = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented ( p  = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476, p  = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617, p  = 0.027) were the significant factors affecting pancreatic fistula.

Conclusion  Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.

What can be done when the cored specimen in a Frey procedure for chronic pancreatitis is reported as adenocarcinoma?

The aim of this study is to analyze the outcomes of patients with chronic pancreatitis who underwent the Frey procedure and who had a histologic evidence of adenocarcinoma in the cored out specimen.The type of analysis is retrospective. Out of 523 patients who underwent Frey procedure for chronic pancreatitis, seven (five males and two females; age range 42 to 54 years) had histologically proven adenocarcinoma. In the first four cases, intraoperative frozen section was not done. The diagnosis was made on routine histopathology and only one out of four could undergo attempted curative therapy. In the remaining three cases, intraoperative frozen section confirmation was available, and curative resection performed. Only four out of seven had a clear-cut mass lesion: (a) cancer can occur in chronic pancreatitis in the absence of a mass lesion and (b) intraoperative frozen section of the cored specimen is crucial to exercising curative therapeutic options and must be performed routinely. If frozen section is reported as adenocarcinoma, a head resection with repeat frozen of the margins of resection is appropriate. If the adenocarcinoma is reported on regular histopathology after several days, then a total pancreatectomy may be more appropriate.

Young onset colorectal cancer: How does it differ from its older counterpart?

BACKGROUND

Colorectal cancer in the young has been a debated topic in literature with conflicting reports as to its pattern of occurrence and survival as compared to the older age group.

MATERIALS AND METHODS

Retrospective study to analyze the clinicopathological characteristics, treatment modalities and survival of sporadic young-onset colorectal cancer (YOCR) patients (<40 years) and compare them with the older group (>40 years).

RESULTS

Of 172 patients managed, 72 (42%) were in the YOCR group. Among 72 patients, six were excluded because of hereditary syndromes. Incontinence (P = 0.02) and obstruction at time of presentation (P = 0.03) was significantly more common in the YOCR group. Left sided disease was more common in YOCR group (47/66) compared to the older group (65/100), but the difference was not statistically significant (P = 0.45). The proportion of rectal cancers was significantly more in the YOCR group (39/47) compared to the older group (39/65) (P = 0.01). Significant difference in resectability was noted in the left sided (YOCR 26/47 vs. older 49/65 P = 0.04) and the rectal cancers (YOCR 18/39 vs. Older 29/39 P = 0.02). The survival was similar among the two groups.

CONCLUSIONS

Sporadic colorectal cancers in the young are more advanced and less resectable when compared to older population. Genetic studies are needed to elaborate the reasons for left sided predominance and aggressiveness of sporadic colorectal cancers in the younger subgroups.

Perforated Gastric Gangrene without Pneumothorax in an Adult Bochdalek Hernia due to Volvulus

Bochdalek hernia is the most frequent congenital diaphragmatic hernia which occurs due to a defect in the posterior attachment of the diaphragm when there is a failure of closure of the pleuroperitoneal membrane in utero. It rarely presents for the first time in adults. We report one such case of a 23-year-old male patient who presented with an acute abdomen. Chest X-ray showed air under diaphragm and he was taken up for an emergency laparotomy. Intraoperatively an organoaxial volvulus of the stomach was found in a bochdaleks hernia with a focal gangrene of the stomach fundus with perforation and peritonitis. However, there was no breach of pleural cavity. A sleeve resection of the gangrenous portion of the stomach was performed and the diaphragmatic defect was repaired. Patient made an uneventful postoperative recovery. Gastric gangrene with perforation as a manifestation of the adult bochdalek hernia is indeed rare. A concomitant pneumothorax occurs along with this condition which requires an intercostal drainage tube prior to the laparotomy. We report this case for its unique presentation without pneumothorax.

Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study

BACKGROUND

Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative.

MATERIALS AND METHODS

This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP.

RESULTS

During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).

CONCLUSION

MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.