Indocyanine green fluorescence in gastrointestinal surgery: Appraisal of current evidence

Applying indocyanine green (ICG) fluorescence in surgery has created a new dimension of navigation surgery to advance in various disciplines. The research in this field is nascent and fragmented, necessitating academic efforts to gain a comprehensive understanding. The present review aims to integrate diverse perspectives and recent advances in its application in gastrointestinal surgery. The relevant articles were selected by using the appropriate keyword search in PubMed. The angiography and cholangiography property of ICG fluorescence is helpful in various hepatobiliary disorders. In gastroesophageal and colorectal surgery, the lymphangiography and angiography property of ICG is applied to evaluate bowel vascularity and guide lymphadenectomy. The lack of objective parameters to assess ICG fluorescence has been the primary limitation when ICG is used to evaluate bowel perfusion. The optimum dose and timing of ICG administration need to be standardized in some new application areas in gastrointestinal surgery. Binding tumor-specific ligands with fluorophores can potentially widen the fluorescence application to detect primary and metastatic gastrointestinal tumors. The narrative review outlines prior contributions, limitations, and research opportunities for future studies across gastrointestinal sub-specialty. The findings of the present review would be helpful for scholars and practitioners to explore and progress in this exciting domain of gastrointestinal surgery.

Minimally invasive surgery for post cholecystectomy biliary stricture: current evidence and future perspectives

Postcholecystectomy bile duct injury (BDI) remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs. Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI, the absolute number remains high as cholecystectomy is a commonly performed surgical procedure. Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent long-term results in most patients. As with many hepatobiliary disorders, a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery. Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy, laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive. While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management, most are retrospective analyses with small sample sizes. Also, long-term follow-up is available only in a limited number of studies. The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches. The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture. Despite increasing use, lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture. High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Risk factor analysis for duodenal margin positivity following gastrectomy for resectable gastric cancer

BACKGROUND

Duodenal margin positivity is a poor prognostic factor following gastrectomy for resectable gastric cancer. Intraoperative frozen section (IFS) analysis allows radical resection to be achieved in a single operation but is time- and resource-consuming. Hence resection is usually performed based on surgeon's judgment and palpation.

AIM OF STUDY

To determine risk factors for duodenal resection margin (RM) positivity following gastrectomy for resectable gastric cancer.

MATERIALS AND METHODS

We retrospectively analyzed prospectively maintained data of 376 patients admitted with diagnosis of gastric cancer from August 2011 to January 2020 in JIPMER, a tertiary center in Puducherry, India. Of these, 146 patients underwent gastric resection with curative intent and were the subject of this study. RM status was assessed by definitive histopathology examination. The potential risk factors were compared between patients with positive margin on definitive histopathology examination and a control cohort of similar patients with negative margins.

RESULTS

Of the 146 patients, 16 patients (10.9%), 11 men and 5 women, had positive duodenal margin. The mean age of study group was 59 years. None of the patient characteristics like age, sex, comorbidities, or addictions were statistically significant with regard to duodenal margin positivity. Among tumor characteristics, locally advanced tumors and pyloroantral tumors were found more frequently in the margin-positive group. High-risk features for duodenal margin positivity were extensive nodal disease, oligometastatic disease, lymphovascular invasion, and perineural invasion. Neoadjuvant chemotherapy and types of surgical access did not have significant impact on RM. Interestingly, both proximal and circumferential resection margin positivity had a linear association with distal margin positivity suggesting that tumor biology may have a significant role in margin positivity. However, none of these factors were statistically significant on multivariate analysis using logistic regression model. Among oligometastatic patients, survival was dependent on R0 resection and was not different from patients without metastases though our study was not powered for survival analysis (mean survival of 11.040 months) and expectedly, duodenal margin positive patients had lower overall survival compared to margin negative patients (mean survival of 5.188 vs. 11.763 months, p = 0.12).

CONCLUSIONS

Locally advanced tumors and pyloroantral tumors are associated with an increased risk of duodenal margin positivity after gastrectomy for carcinoma stomach and may benefit from intraoperative frozen section analysis as survival is negatively affected by positive RM. Patients with high-risk features like extensive nodal and oligometastatic disease have a greater propensity for positive duodenal margin. A prospective study with a large sample size is needed to further validate these results.

Replaced Segment 6 Artery From the Gastroduodenal Artery: A Challenging and Rare Anatomical Variation of Hepatic Artery in Pancreaticoduodenectomy

Variations in the hepatic artery's anatomy can significantly impact planning and executing pancreatic and hepatobiliary surgeries. Of these, the commonest are variations of right and left hepatic arteries originating from superior mesenteric and left gastric arteries, respectively. The anomalous origin of the right hepatic artery from the gastroduodenal artery (GDA) is among the rarest and most challenging anatomy, especially in patients undergoing pancreatoduodenectomy (PD) since GDA ligation is a mandatory step, which may threaten the liver blood supply. We present a 62-year-old male with suspected distal cholangiocarcinoma and plan a robot-assisted pancreatoduodenectomy. Preoperative computed tomography evaluation revealed an anomalous segment 6 artery arising from the GDA and coursing posterolaterally to the common bile duct in the hepatoduodenal ligament. Also, the patient had a replacement left hepatic artery originating from the left gastric artery. The described vascular anomaly has not been previously reported in patients undergoing PD. Awareness of vascular anomalies is the key to performing oncologically radical surgery without increasing bleeding and ischemic complications in patients undergoing complex procedures like PD.

Necrotising Inflammation of Peri-Pancreatic Tissue With Normal Appearance of Pancreas Is a Distinct Entity of Acute Pancreatitis: Report of Two Cases With Review of Literature

Improved insights into the pathophysiology of acute pancreatitis have paved the way for identification of distinct entities in the spectrum of the disease. The presence of necrotising inflammation limited to peripancreatic tissue with a normal appearance of pancreas is one such entity. This entity, described as extrapancreatic necrotising pancreatitis (EPN), is considered a less aggressive form of acute necrotising pancreatitis. This entity needs to be recognized precisely and managed accordingly among patients with acute pancreatitis. However, EPN has not been highlighted in the revised classification of acute pancreatitis. Here we report two patients with EPN with varied presentations and diverse management and outcome.

Robotic-Assisted Splenectomy by a Modified Lateral Approach: Technique and Outcomes

Introduction The utilization of robot-assisted technique for splenectomy has recently gained popularity especially in patients undergoing splenectomy for hematological indications owing to its magnification of and easy manipulation of internal abdominal organs. Moreover, robotic splenectomy emerged as an essential teaching module before approaching more complex robotic procedures. Methods  A total of 43 elective splenectomies were performed for hematological indications in Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) between January 2018 to July 2023 of which 14 patients underwent robotic splenectomy. All patients underwent lateral approach of robotic splenectomy with a modification of avoiding the lesser sac dissection. Prospectively maintained data were retrospectively analyzed and results were recorded in terms of intra-operative time taken, blood loss, need for blood and blood product transfusion and postoperative morbidity and mortality. Results The indications for patients who underwent robotic splenectomy include idiopathic thrombocytopenic purpura in eight patients, autoimmune hemolytic anemia in three patients, Evans syndrome in one patient and hereditary spherocytosis in two patients. The median splenic diameter was 14.8cm and the median platelet count before the operation was 10,800 cells/cubic millimeter (7000-3,20,000). The mean operative time was 92 minutes and blood loss was 40ml. The median duration of hospital stay was 2.4 days. All 14 patients had therapeutic success and there was no procedure-related mortality or morbidity. Conclusion Robotic splenectomy using the modified lateral approach can safely be performed with comparable operative time, blood loss and overall morbidity. However further studies are mandatory to confirm the advantage of this modified technique of lateral approach of robotic splenectomy.

Superior Mesenteric Vein Aneurysm With Arteriovenous Communication and Portal Vein Thrombosis: A Rare Presentation in Non-cirrhotic Portal Hypertension

Visceral venous aneurysms are exceedingly rare clinical entities reported in the literature. Venous aneurysms are usually acquired in origin, with most often portal hypertension as the underlying pathology. Most venous aneurysms are incidental findings on imaging. Complications of venous aneurysms like rupture with catastrophic outcomes had been reported. However, no clear guidelines exist regarding the management of portal venous aneurysms as most of the data is available only from case reports. Here, we report a rare finding of fusiform superior mesenteric vein (SMV) aneurysm with arteriovenous communication and portal vein thrombosis in the background of non-cirrhotic portal hypertension.

Radiological parameters to predict pancreatic texture: Current evidence and future perspectives

Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management, thereby minimizing postoperative morbidity. Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease. However, radiological evaluation of pancreatic texture, an important determinant of pancreatic fistula, has not been widely used to predict the risk of postoperative pancreatic fistula. Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture. Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies. With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies, elastography is emerging as a promising tool for predicting pancreatic texture. Also, recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function. Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis, facilitating early intervention. The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences. However, multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey

Purpose

To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers.

Methods

A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era.

Results

There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase.

Conclusion

Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02675-6.

Incretin based therapy and pancreatic cancer: Realising the reality

Incretin-based therapies like glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors help maintain the glycaemic control in patients with type 2 diabetes mellitus with additional systemic benefits and little risk of hypoglycaemia. These medications are associated with low-grade chronic pancreatitis in animal models inconsistently. The incidence of acute pancreatitis was also reported in some human studies. This inflammation provides fertile ground for developing pancreatic carcinoma (PC). Although the data from clinical trials and population-based studies have established safety regarding PC, the pathophysiological possibility that low-grade chronic pancreatitis leads to PC remains. We review the existing literature and describe the relationship between incretin-based therapies and PC.

Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?

BACKGROUND

The commonly used predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) have subjective assessment components and can be used only in the postoperative setting. Also, the available objective predictors based on preoperative cross-sectional imaging were not prospectively studied.

AIM

To evaluate the accuracy of the pancreatic attenuation index (PAI) and pancreatic enhancement ratio (PER) for predicting CR-POPF following PD and its correlation with pancreatic fat fraction and fibrosis.

METHODS

A prospective observational study included patients who underwent PD for benign and malignant pathology of the periampullary region or pancreatic head between February 2019 and February 2021. Patients undergoing extended or total pancreatectomy and those with severe atrophy of pancreatic tissue or extensive parenchymal calcifications in the pancreatic head and neck precluding calculation of PAI and PER were excluded from the study. Preoperatively PAI was measured in the neck of the pancreas by marking regions of interest (ROI) in the non-contrast computed tomography (CT), and PER was measured during the contrast phase of the CT abdomen. Also, the fibrosis score and fat fraction of the pancreatic neck were assessed during the histopathological examination. Demographic, clinical and preoperative radiological indices (PAI, PER) were evaluated to predict CR-POPF. Preoperative pancreatic neck CT indices were correlated with the histopathological assessment of fat fraction and fibrosis.

RESULTS

Of the 70 patients who underwent PD, 61 patients fulfilling the inclusion criteria were included in the analysis. The incidence of CR-POPF was 29.5% (18/61). PAI had no association with the development of CR-POPF. Of the preoperative parameters, PER (mean ± standard deviation [SD]) was significantly lower in patients developing CR-POPF (0.58 ± 0.20 vs 0.81 ± 0.44, P = 0.006). The area under the curve for the PER was 0.661 (95%CI: 0.517-0.804), which was significant (P = 0.049). PER cut-off of 0.673 predicts CR-POPF with 77.8% sensitivity and 55.8% specificity. PAI and PER had a weak negative correlation (Strength-0.26, P = 0.037). Also, PER showed a moderately positive correlation with fibrosis (Strength 0.50, P < 0.001). Patients with CR-POPF had a significantly higher incidence of the intraabdominal abscess (50% vs 2.3%, P < 0.001), delayed gastric emptying (83.3% vs 30.2, P < 0.001), and prolonged mean (± SD) postoperative hospital stay (26.8 ± 13.9 vs 9.6 ± 3.6, P = 0.001).

CONCLUSION

PER exhibited good accuracy in predicting the development of CR-POPF. PER additionally showed a good correlation with PAI and fibrosis scores and may be used as an objective preoperative surrogate for assessing pancreatic texture. However, ROI-based PAI did not show any association with CR-POPF and pancreatic fat fraction.

Modified binding pancreaticogastrostomy vs modified Blumgart pancreaticojejunostomy after laparoscopic pancreaticoduodenectomy for pancreatic or periampullary tumors

BACKGROUND

Laparoscopic pancreaticoenteric anastomosis is one of the technically challenging steps of minimally invasive pancreaticoduodenectomy (PD), especially during the learning curve. Despite multiple randomized controlled trials and meta-analyses, the type of pancreatico-enteric anastomosis as a risk factor for post-pancreatectomy complications is debatable. Also, the ideal technique of pancreatic reconstruction during the learning curve of laparoscopic PD has not been well studied.

AIM

To compare the short-term outcomes of modified binding pancreaticogastrostomy (PG) and Blumgart pancreaticojejunostomy (PJ) during learning curve of laparoscopic PD.

METHODS

The first 25 patients with resectable pancreatic or periampullary tumors who underwent laparoscopic PD with modified binding PG or modified Blumgart PJ between January 2015 and May 2020 were retrospectively analyzed to compare perioperative outcomes during the same learning curve. A single layer of the full-thickness purse-string suture was placed around the posterior gastrotomy in the modified binding PG. In the modified Blumgart technique, only a single transpancreatic horizontal mattress suture was placed on either side of the pancreatic duct (total two sutures) to secure the pancreatic parenchyma to the jejunum. Also, on the ventral surface, the knot is tied on the jejunal wall without going through the pancreatic parenchyma. Post pancreatectomy complications are graded as per the International Study Group for Pancreatic Surgery criteria.

RESULTS

During the study period, modified binding PG was performed in 27 patients and modified Blumgart PJ in 29 patients. The demographic and clinical parameters of the first 25 patients included in both groups were comparable. Lower end cholangiocarcinoma and ampullary adenocarcinoma were the primary indications for laparoscopic PD in both groups (32/50, 64%). The median operative time for pancreatic reconstruction was significantly lower in the binding PG group (42 vs 58 min, P = 0.01). The clinically relevant (Grade B/C) postoperative pancreatic fistula (POPF) was significantly more in the modified PJ group (28% vs 4%, P = 0.04). In contrast, intraluminal postpancreatectomy hemorrhage (PPH) was more in the binding PG group (32% vs 4%, P = 0.02). There was no significant difference in the incidence of delayed gastric emptying between the two groups.

CONCLUSION

During the learning curve of laparoscopic PD, modified binding PG reduces POPF but is associated with increased intraluminal PPH compared to PJ using the modified Blumgart technique.

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding

Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.

Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study

Backgrounds/Aims

Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis.

Methods

This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ² test.

Results

Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group.

Conclusions

CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

Robotic fluorescence-guided anatomical segment IVb and V liver resection with radical lymphadenectomy for gall bladder cancer

Radical surgery remains the primary treatment option for gall bladder cancer (GBC). Margin-negative liver resection is a critical component of radical cholecystectomy. Anatomical segment IVb and V resection is preferred in primary GBC with liver infiltration and incidental GBC patients with puckering of gall bladder (GB) bed. Despite the initial scepticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb and V resection using the minimally invasive approach is scarcely reported. The standardised technique of robotic (daVinci®Xi^TM) anatomical Segment IVb and V liver resection guided by indocyanine green fluorescence is described here. The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC.

Hepatic Hydatid Cyst With Cystobiliary Communication and Cystoduodenal Fistula

The liver is the most common site affected by hydatid disease. Hepatic hydatid cyst (HHC) with cystoduodenal fistula is an unusual and infrequent complication. We present a 48-year-male diagnosed with an HHC with cystobiliary communication (CBC) and cystoduodenal fistula. The patient underwent partial cystectomy. Intraoperative demonstration of CBC was done with injection propofol, followed by primary closure of the CBC. The duodenal fistula was closed primarily with an omental patch, also known as a Graham patch. The patient improved well without any complications, and there was no recurrence of the symptoms for the subsequent five-month follow-up.

A case of unusual evisceration through laparoscopic port site

Drain site eviscerations have been reported as a rare complication following abdominal surgery. An 82-year-old women was diagnosed with carcinoma stomach and underwent laparoscopic subtotal gastrectomy. A few hours following removal of the duodenal stump drain, she developed small bowel evisceration through the drain site. It was successfully managed with immediate bedside release of fascial constriction followed by definitive repair later. Although herniations and eviscerations via larger drain sites have been reported, eviscerations from small laparoscopic port sites used for drains are rare. Here, we report the first case of small bowel evisceration with strangulation through a 5-mm port site.

Advanced training in laparoscopic gastrointestinal surgical procedures using Genelyn®-embalmed human cadavers: A novel model

Background:

Human cadaver is ideal for learning and acquiring new surgical skills. While cadavers preserved using Thiel’s embalming method are commonly used for training in laparoscopic surgery, it is a cumbersome technique. We report our experience of using Genelyn^®-embalmed cadavers for training in advanced laparoscopic gastrointestinal procedures.

Materials and Methods:

A cross-sectional satisfaction survey corresponding to level 1 of the Kirkpatrick model for training evaluation was performed among 19 participants of advanced laparoscopy surgical skills training workshop, in December 2019, using Genelyn^®-embalmed cadavers. Visual, haptic and tactile characteristics of the organs and tissues were assessed along with overall satisfaction of the workshop using Likert scale.

Results:

Five Genelyn^®-embalmed cadavers were used for the workshop. All the 19 participants perceived that the cadavers were odourless and allowed adequate insufflation for laparoscopic procedures. Most of the participants(n=16, 84%) agreed that the appearance and tactile fidelity of the solid organs, luminal structures and tissues in Genelyn^®-embalmed cadavers were similar to that of a live patient. There was a strong agreement among participants that the workshop will help improve the laparoscopic skills(median Likert score–4).

Conclusion:

The participants of the surgical skill training workshop felt that the Genelyn^®-embalmed cadavers were ideal for use in practicing advanced laparoscopic procedures.

Diabetes and pancreatic cancer: Exploring the two-way traffic

Pancreatic cancer (PC) is often associated with a poor prognosis. Long-standing diabetes mellitus is considered as an important risk factor for its development. This risk can be modified by the use of certain antidiabetic medications. On the other hand, new-onset diabetes can signal towards an underlying PC in the elderly population. Recently, several attempts have been made to develop an effective clinical tool for PC screening using a combination of history of new-onset diabetes and several other clinical and biochemical markers. On the contrary, diabetes affects the survival after treatment for PC. We describe this intimate and complex two-way relationship of diabetes and PC in this review by exploring the underlying pathogenesis.

Impact of surgery for chronic pancreatitis on the risk of pancreatic cancer: Untying the Gordian knot

Pancreatic ductal adenocarcinoma is an aggressive tumor with poor long-term outcomes. Chronic pancreatitis (CP) is considered a risk factor for the development of pancreatic cancer (PC). Persistent pancreatic inflammation and activation of pancreatic stellate cells play a crucial role in the pathogenesis of CP-related PC by activating the oncogene pathway. While genetic mutations increase the possibility of recurrent and persistent pancreatic inflammation, they are not directly associated with the development of PC. Recent studies suggest that early surgical intervention for CP might have a protective role in the development of CP-related PC. Hence, the physician faces the clinical question of whether early surgical intervention should be recommended in patients with CP to prevent the development of PC. However, the varying relative risk of PC in different subsets of CP underlines the complex gene-environment interactions in the disease pathogenesis. Hence, it is essential to stratify the risk of PC in each individual patient. This review focuses on the complex relationship between CP and PC and the impact of surgical intervention on PC risk. The proposed risk stratification based on the genetic and environmental factors could guide future research and select patients for prophylactic surgery.

Laparoscopic hepatopancreatoduodenectomy for locally advanced gall bladder cancer

Hepatopancreatoduodenectomy (HPD) can offer a survival advantage in selected patients with locally advanced gall bladder cancer (GBC). While the safety and feasibility of minimally invasive radical cholecystectomy have been recently documented, laparoscopic HPD for GBC has not been previously reported. A 73-year-old male with GBC infiltrating the bile duct underwent laparoscopic HPD to achieve R0 resection. The patient had an uneventful post-operative course except for delayed gastric emptying that improved with conservative management. The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series.

The technique of precise and systematic vascular control during robotic pancreaticoduodenectomy for periampullary and pancreatic tumours

Robotic pancreaticoduodenectomy (PD) remains one of the most advanced robotic procedures. Improved ergonomics and stable 3D vision with robotic platform helped overcome the technical challenges of pancreatic reconstruction in minimally invasive PD. However, inadequate understanding of the complex vascular anatomy of the pancreatic head and uncinate process often results in intra-operative bleeding and prolongs the learning curve. The technique of precise identification and systematic control of the vessels supplying the head and the uncinate process is described in this report. A good understanding of the common vascular anatomy and variations along with stepwise precise vascular control described in this report could minimise intra-operative bleeding and shorten the learning curve associated with robotic PD.

Perforated High-Grade Mixed Neuroendocrine Nonneuroendocrine Neoplasm of Cecum: Unusual Presentation of Rare Disease

Mixed neuroendocrine nonneuroendocrine neoplasms (MiNENs) are rare neoplasms of the gastrointestinal tract, where the neuroendocrine as well as the nonneuroendocrine components each comprise at least 30% of the tumor. Of all cases of colorectal malignancies, MiNENs constitute around 3-9.6%, with only a few cases reported to be arising in the cecum. Since majority present with nonspecific clinical and radiological findings, its diagnosis preoperatively is almost impossible and these are usually diagnosed after histopathological examination of the resected specimen. Owing to the rarity of these tumors as well as lack of complete molecular characterization, optimal treatment remains unestablished. We, here, report a rare case of MiNENs of the cecum infiltrating the right psoas muscle and presenting with perforation for which right hemicolectomy and en bloc excision of the involved psoas muscle was done followed by adjuvant chemotherapy.

The technique of fourth jejunal artery-based jejunal conduit for oesophagojejunostomy after thoracolaparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour

Background:

Locally advanced long Siewert type II tumor requires total gastrectomy and D2 lymphadenectomy with distal esophagectomy and mediastinal lymphadenectomy for curative resection. In this scenario, a laparoscopic transhiatal approach is not feasible, and the conventional left thoracoabdominal approach is associated with increased morbidity.

Aims and Objectives:

To describe a novel technique of fourth jejunal artery based jejunal conduit for thoracoscopic esophagojejunostomy after laparoscopic esophagogastrectomy.

Materials and Methods:

The laparoscopic total gastrectomy with distal esophagectomy specimen is extracted through the periumbilical incision. A pedicled jejunal conduit based on the fourth jejunal artery is prepared, and the jejunal conduit is placed in the mediastinum under laparoscopic guidance. Using the thoracoscopic approach in a prone position, additional esophageal clearance and subcarinal lymphadenectomy are performed. Handsewn end to side esophagojejunostomy is performed at the level of the carina.

Results:

Three patients with long Siewert type II underwent this procedure after neoadjuvant chemotherapy. None of the patients had conduit related complications. All three patients had abdominal lymph node involvement and two patients had mediastinal lymph node involvement.

Conclusion:

Pedicled jejunal conduit based on the fourth jejunal artery is safe for intrathoracic anastomosis after minimally invasive esophagogastrectomy for locally advanced Siewert type II tumor.

Does Radiation Dose to Gastric Fundus during Neoadjuvant Chemoradiotherapy for Esophageal Carcinoma Have an Impact on Postoperative Anastomotic Leak?

Background

Radiation dose received by the gastric fundus (GF) in neoadjuvant chemoradiotherapy (NACRT) may influence the development of postoperative anastomotic leak (AL) in the management of resectable esophageal carcinoma (EC) by trimodality therapy. The present study aims to evaluate dose-volume parameters of the GF and their association with occurrence of AL in EC.

Materials and Methods

A retrospective analysis was performed of 27 patients with EC who underwent NACRT followed by esophagectomy with cervical esophagogastric anastomosis between January 2015 and July 2018. The GF was retrospectively contoured; dose-volume parameters of the GF were recorded. Postoperative AL was identified from surgical records. Logistic regression analysis was used to identify risk factors associated with AL.

Results

The mean age of the patients was 51 ± 10.5 years; 56% (15/27) had involvement of lower 1/3 esophagus, 10/27 (37%) midthoracic esophagus, and 2/27 (7%) upper thoracic esophagus; 40% (11/27) patients developed postoperative AL and 7/11 had distal and 4/11 had mid thoracic esophageal lesions. Four of five (80%) patients treated by 3-dimensional conformal radiotherapy versus 7/22 (32%) patients treated by volumetric modulated arc therapy developed AL (p = 0.12). Univariate logistic regression revealed no significant correlation between D_mean, D_max, V20, V25, V30, V35, D50, and AL. 8/27 patients underwent ischemic preconditioning of gastric conduit, and 2/8 had AL; 19/27 did not undergo preconditioning, and 9/19 patients experienced AL (p = 0.4).

Conclusion

There was no significant negative impact of the dose received by the GF in NACRT upon AL rates. Further studies with a larger sample size are required to clarify this issue.

Minimally invasive oesophagectomy with a total two-field lymphadenectomy after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of the oesophagus: A prospective study

Introduction:

In the era of neoadjuvant chemoradiotherapy (NACTRT), the safety and clinical significance of radical lymphadenectomy specifically lymphadenectomy along the recurrent laryngeal nerve (RLN) has been questioned. Furthermore, the compliance to NACTRT with the CROSS regimen has not been well studied in the Indian population. This prospective study aimed to determine the compliance with CROSS regimen, feasibility and short-term outcomes of minimally invasive oesophagectomy (MIE) with a total two-field lymphadenectomy after NACTRT.

Methods:

A prospective study (January 2014 to December 2018) of patients with locally advanced oesophageal squamous cell carcinoma (SCC) eligible for NACTRT (cT1-4a, N0-1, M0) with CROSS regimen followed by MIE with total two-field lymphadenectomy. The compliance rate, post-operative complications and the pathological response rate were assessed.

Results:

Of the 166 patients with locally advanced SCC, 76 (45.8%) were eligible for NACTRT and 34 completed NACTRT followed by MIE with a total two-field lymphadenectomy (study group). Twenty-nine (38.1%) patients did not complete NACTRT due to complications or poor compliance. Median (range) blood loss was 125 (50–450) ml and the median (range) operation time for the thoracoscopic phase was 205 (155–325) min. Total median (range) lymph node count and mediastinal lymph node counts were 20 (11–33) and 12, (8–21) respectively. Most common post-operative complications were pneumonia (n = 12, 35.3%) followed by RLN palsy (n = 10, 29.4%). Of the 22 patients who had a complete pathological response of the primary tumour, 7 (31.8%) patients had a node-positive disease.

Conclusion:

NACTRT followed by MIE is feasible in patients with locally advanced SCC. The nodal disease is common even in patients with the complete pathological response of the primary tumour. The dropout rate with NACTRT using the CROSS regimen is high in the present study.

Learning Gains of Liver Resection and Transplantation Workshop on Genelyn® Embalmed Human Cadavers: Surgical Gastroenterologists' Perceptions

BACKGROUND

In the light of increased requirement for liver transplantation procedures, it is pertinent to develop bankable human expertise in the areas of liver resection and anastomoses. The alternative simulator sources available for learning surgical skills might not always provide the realistic learning gains as provided by human cadavers, especially in terms of haptic and tactile fidelity. For the first time, we have used Genelyn® embalmed cadavers (GEC) for training the surgical gastroenterologists in liver resection and transplantation procedures and we wish to document our experience of using them to facilitate the learning of liver resection procedures.

MATERIALS AND METHODS

A cross-sectional satisfaction survey fitting to the first level of the Kirkpatrick model for training evaluation was performed among participating surgical gastroenterologists of liver resection and transplantation training workshop using GEC. Visual, haptic and tactile characteristics of the liver and related structures were assessed along with overall satisfaction of the workshop.

RESULTS

Eleven surgical gastroenterologists had participated in the workshop conducted using three GEC. Nine participants agreed that the transection of liver parenchyma was similar to reality. However, two opined that the liver parenchyma was a bit harder to resect. Identification of portal pedicle, dissection of the peri-portal area and securing vascular anastomoses also had an acceptable level of similarity to real life. The two parameters that received a unanimous degree of the agreement are mobilization of liver and cannulation of key vessels for perfusion.

CONCLUSION

Participants of the cadaveric surgical skills training workshop opined that the soft-embalmed cadaver using Genelyn® is an excellent realistic model for practicing liver resection and transplantation surgery.

Frey's plus versus Frey's procedure for chronic pancreatitis: Analysis of postoperative outcomes and quality of life

Backgrounds/Aims

Additional surgical procedures are often required in patients with chronic pancreatitis (CP) related complications. The present study aims to analyze the type of additional procedures required in patients who underwent Frey’s procedure (Frey’s plus) and to compare the short-term outcomes and quality of life with patients who underwent only Frey’s procedure.

Methods

Retrospective analysis of a prospectively maintained database of patients who underwent surgery for CP between January 2012 and February 2018 and completed at least one year of follow-up. Patients who underwent non-Frey’s surgical procedures were excluded. Clinical parameters, postoperative pain relief (using Izbicki pain score) and functioning scale score (EORTC QLQ C30) of patients who underwent Frey’s plus procedure and only Frey’s procedure were compared.

Results

Of the 146 patients who underwent surgery for CP during the study period, 100 patients (Frey’s procedure–68, Frey’s plus procedure–32) were included in this study. Roux-en-Y hepaticojejunostomy was the commonly performed additional procedure (n=12). The demographic and clinical parameters were comparable, except for more patients with jaundice (28.1% vs. 2.9%, p=0.01) and prolonged operative time (374.6 mins vs. 326.3 mins, p=0.01) in Frey’s plus group. However, there was no significant difference in mean intraoperative blood loss, postoperative morbidity or duration of hospital stay. At median (range) follow up of 34 (12-86) months, there was no significant difference in the pain control and quality of life between two groups.

Conclusions

Frey’s plus procedure for chronic pancreatitis can be safely performed wherever indicated without adversely affecting the postoperative outcome or quality of life.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Minimally Invasive Retrosternal Esophageal Bypass Using a Mid-Colon Esophagocoloplasty for Corrosive-Induced Esophageal Stricture

INTRODUCTION

Colonic bypass for corrosive-induced esophageal stricture is traditionally performed using an open approach. The laparoscopic mid-colon retrosternal esophageal bypass has not been previously reported. The present study is aimed to report the feasibility of laparoscopic mid-colon esophagocoloplasty and to compare the short- and medium-term outcomes with the open approach.

MATERIALS AND METHODS

Patients who underwent surgery for corrosive esophageal stricture between August 2016 and August 2019 were retrospectively analyzed. Laparoscopic procedure was preferred in patients with stricture starting at or below the level of cricopharynx and without prior laparotomy. The perioperative and medium-term outcomes of patients who underwent open and laparoscopic mid-colon bypass were compared.

RESULTS

Of the 15 patients, seven patients underwent laparoscopic mid-colon bypass, and eight patients underwent the open procedure. The duration of surgery was less in the laparoscopic group, but the difference was not significant (440 vs. 510 min, P = 0.93). Intraoperative blood loss (median) and postoperative analgesic requirement (median days) were significantly lower in laparoscopic group (200 mL vs. 350 mL, P = 0.03 & 3 vs. 5, P = 0.02). There was no significant difference in the postoperative complications, ICU and hospital stay between the two groups. At a median (range) follow-up of 14 (7-42) months, all patients in the minimally invasive colon bypass group were euphagic to regular Indian diet. Two patients in the open group developed anastomotic stricture requiring endoscopic dilatation.

CONCLUSION

Minimally invasive mid-colon esophageal bypass is a feasible procedure for selected patients with corrosive esophageal stricture with favorable short-term and comparable medium-term outcomes.

Atypical Presentation of Gastrointestinal Stromal Tumor as Multiple Intra-Abdominal Cysts: A Case Report

Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial solid neoplasms involving the alimentary tract. We report a case of cystic GIST with multiple cystic metastases. A 61-year-old man presented with upper abdominal pain for two months. Further evaluation revealed a large intra-abdominal cyst in the lesser sac and another cyst over the segment VII of the liver on imaging. Multiple intra-abdominal hydatidoses were suspected based on the imaging and its endemic nature in the geographical area. However, the hydatid serology was normal. In view of hemorrhagic cyst fluid, an intraoperative frozen biopsy of the cyst wall was done, which revealed features suspicious of a mesenchymal tumor. Sleeve gastrectomy with en-bloc excision of the gastric cyst, excision of the hepatic cyst, and complete excision of multiple other intra-abdominal cysts were performed considering GIST as a possibility. Histology revealed a clear cell variant of GIST. Gastric GISTs primarily presenting as multiple intra-abdominal cysts and of clear cell histological variants had never been reported in the literature. The patient was started on imatinib, and he has shown no evidence of recurrence after 12 months of follow-up.

A high index of suspicion, intraoperative frozen section, meticulous surgery, and immunohistochemistry are all crucial for the effective management of atypical cases. GIST may be considered as a part of differential diagnosis in clinical scenarios with multiple intra-abdominal cysts, especially in the equivocal setting.

Pathological abnormalities in splenic vasculature in non-cirrhotic portal hypertension: Its relevance in the management of portal hypertension

BACKGROUND

Portal hypertension (PH) is associated with changes in vascular structure and function of the portosplenomesenteric system (PSMS). This is referred to as portal hypertensive vasculopathy. Pathological abnormalities of PSMS has been described in the literature for cirrhotic patients. Raised portal pressure and hyperdynamic circulation are thought to be the underlying cause of this vasculopathy. In view of this, it is expected that pathological changes in splenic and portal vein similar to those reported in cirrhotic patients with PH may also be present in patients with non-cirrhotic PH (NCPH).

AIM

To investigate pathological abnormalities of splenic vein in patients with NCPH, and suggest its possible implications in the management of PH.

METHODS

A prospective observational study was performed on 116 patients with NCPH [Extrahepatic portal vein obstruction (EHPVO): 53 and non-cirrhotic portal fibrosis (NCPF): 63] who underwent proximal splenorenal shunt (PSRS), interposition shunt or splenectomy with devascularization in JIPMER, Pondicherry, India, a tertiary level referral center, between 2011-2016. All patients were evaluated by Doppler study of PSMS, computed tomography porto-venogram and upper gastrointestinal endoscopy. An acoustic resonance forced impulse (ARFI) scan and abdomen ultrasound were done for all cases to exclude cirrhosis. Intraoperative and histopathological assessment of the harvested splenic vein was performed in all. The study group was divided into delayed and early presentation based on the median duration of symptoms (i.e. 108 mo).

RESULTS

The study group comprising of 116 patients [77 (66%) females and 39 (34%) males] with NCPH had a median age of 22 years. Median duration of symptoms was 108 mo. The most common presentation in both EHPVO and NCPF patients was upper gastrointestinal bleeding (hematemesis and melena). The ARFI scan revealed a median score of 1.2 (1.0-1.8) m/s for EHPVO and 1.5 (0.9-2.8) m/s for NCPF. PSRS was performed in 84 patients (two of whom underwent interposition PSRS using a 10 mm Dacron graft); splenoadrenal shunt in 9; interposition mesocaval shunt in 5; interposition 1^st jejunal to caval shunt in 1 patient and devascularization with splenectomy in 17 patients. Median pre-splenectomy portal pressure was 25 (range: 15-51) mm Hg. In 77% cases, the splenic vein was abnormal upon intraoperative assessment. Under macroscopic examination, wall thickening was observed in 108 (93%), venous thrombosis in 32 (28%) and vein wall calcification in 27 (23%) cases. Upon examination under a surgical magnification loupe, 21 (18%) patients had intimal defects in the splenic vein. Histopathological examination of veins was abnormal in all cases. Medial hypertrophy was noted in nearly all patients (107/116), while intimal fibrosis was seen in 30%. Ninety one percent of patients with intimal fibrosis also had venous thrombosis. Vein wall calcification was found in 22%, all of whom had intimal fibrosis and venous thrombosis. The proportion of patients with pathological abnormalities in the splenic vein were significantly greater in the delayed presentation group as compared to the early presentation group.

CONCLUSION

Pathological changes in the splenic vein similar to those in cirrhotic patients with PH are noted in NCPH. We recommend that PH in NCPH be treated as systemic and pulmonary hypertension equivalent in the gastrointestinal tract, and that early aggressive therapy be initiated to reduce portal pressure and hemodynamic stress to avoid potential lethal effects.

Corrosive Ingestion

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion.

HOW TO CITE THIS ARTICLE

Kalayarasan R, Ananthakrishnan N, Kate V. Corrosive Ingestion. Indian J Crit Care Med 2019;23(Suppl 4):S282-S286.

The drain fluid amylase level on the first postoperative day predicts pancreatic fistula in chronic pancreatitis patients undergoing Frey procedure

Backgrounds/Aims

Abdominal drains are routinely placed following Frey procedure for chronic pancreatitis (CP) despite the low incidence of pancreatic fistula (PF). The utility of the first postoperative day (POD1) drain fluid amylase (DFA) value in predicting PF in CP patients undergoing Frey procedure has not been previously reported.

Methods

A prospective study of patients with CP who underwent Frey procedure between August 2014 and April 2018. A standard technique of head coring with single layer continuous pancreatojejunostomy was done in all the patients. Amylase level of the drain placed close to the pancreatojejunostomy was recorded on POD1 and 3. Postoperative PF was defined and graded as per the updated International Study Group of Pancreatic Fistula (ISGPF) guidelines.

Results

Fifty-five patients with CP who fulfilled the inclusion criteria were included in the study. All had normal preoperative serum amylase level. Three patients developed a biochemical leak and four patients developed postoperative PF (Grade B - 3 and Grade C - 1). Receiver operating characteristics (ROC) curve identified a POD1 DFA cut-off value of 326 U/L that predicted a postoperative PF with sensitivity, specificity and negative predictive value of 100%, 70%, and 100% respectively.

Conclusions

The POD1 DFA is a reliable predictor of postoperative PF in CP patients who have undergone Frey procedure. The PF can be confidently excluded in patients who have a POD1 DFA less than 326 U/L.

Minimally Invasive Esophagectomy with Thoracic Duct Resection Post Neoadjuvant Chemoradiotherapy for Carcinoma Esophagus-Impact on Lymph Node Yield and Hemodynamic Parameters

BACKGROUND

Neoadjuvant therapy followed by surgery is the current recommended treatment for locally advanced esophageal carcinoma. Thoracic duct (TD) resection was indicated for radical mediastinal lymphadenectomy. However, TD resection can cause hemodynamic disturbances. The presence of metastasis in TD has not been previously studied.

METHODS

Twenty-two patients who underwent minimally invasive esophagectomy with D2 lymphadenectomy after neoadjuvant chemoradiotherapy for esophageal squamous cell carcinoma were analyzed. Ten patients had their TD resected from thoracic inlet till the esophageal hiatus. Multiple histopathological sections of the TD were examined for evidence of tumor spread. Intraoperative and immediate (48 h) postoperative hemodynamic parameters, lymph node yield, and postoperative morbidity were compared between TD-resected and TD-preserved groups.

RESULTS

The median postoperative day 1 fluid requirement (3310 mL vs. 2875 mL, P = 0.059) and the median postoperative day 2 pulse rate were higher in the TD-resected group (111/min vs. 95/min, P = 0.043). There was no significant difference in the intraoperative fluid infusion, blood loss, urine output, mean blood pressure, pulse rate, postoperative urine output, and mean blood pressure between two groups. Median (range) mediastinal lymph node count was similar in TD-resected and TD-preserved groups [15(11-32) vs. 14(9-31), P = 0.283]. Pathological examination of TD did not reveal tumor cells in any of the patients. There was no significant difference in the postoperative morbidity between two groups except for cervical anastomotic dehiscence (P = 0.007).

CONCLUSIONS

Minimally invasive esophagectomy with TD resection causes minor hemodynamic changes in the immediate postoperative period, without adversely affecting the postoperative outcome. In the setting of neoadjuvant chemoradiotherapy, TD resection does not increase lymph node yield.

Proximal Splenorenal Shunt in a Rare Renal Vein Anomaly: A Case Report

Left renal vein (LRV) has been considered as the most suitable vein for proximal splenorenal shunt (PSRS), a commonly performed shunt for non-cirrhotic portal hypertension. Anatomical anomalies in LRV that can pose technical difficulty during shunt procedure are reported in 10% cases. We report a rare anomaly of LRV which precluded performance of standard end-to-side proximal splenorenal shunt and describe its management by performing an interposition end-to-end proximal splenorenal shunt.

A 50-year-old female presented with recurrent episodes of upper gastrointestinal bleed for five years. She was pale and had a massive splenomegaly. There were no signs of encephalopathy. Upper gastrointestinal (UGI) endoscopy revealed three columns of grade 3 esophageal varices, large fundal varices and mild portal hypertensive gastropathy. Duplex ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of non-cirrhotic portal fibrosis. She underwent an interposition end-to-end proximal splenorenal shunt with inferior branch of left renal vein. She developed partial shunt thrombosis at follow-up of 18 months and underwent balloon angioplasty and metallic stenting of shunt. She is doing well at 24 months follow-up with no recurrence of symptoms and a patent shunt.

In conclusion, the presence of renal vein abnormalities does not preclude performance of PSRS with suitable modifications. A high index of suspicion is required to detect them preoperatively to avoid technical difficulties and to plan modifications of PSRS. Interposition end-to-end graft proximal splenorenal shunt is a valid option with good primary-assisted patency rate and clinical outcome.

Change in insulin resistance, beta cell function, glucagon-like peptide-1 and calcitonin levels two weeks after bariatric surgery

AIM OF THE STUDY

Bariatric surgery causes profound improvement in metabolic parameters by increasing plasma glucagon like peptide - 1 (GLP-1) level even few weeks after surgery. GLP-1 analogues can cause calcitonin secreting medullary thyroid carcinoma in animals. The studies relating to the mechanisms that underlie these changes are few. The objectives of the study were to measure the change in insulin resistance, beta cell function, GLP-1 and calcitonin levels before and 2 weeks after bariatric surgery.

METHODS

Patients above 18 years of age who underwent either laparoscopic sleeve gastrectomy or Roux-en Y gastric bypass were recruited into the study. Measured indices were homeostatic model assessment 2 for insulin resistance (HOMA2-IR), an index for hepatic insulin resistance; Matsuda index, an index of whole body insulin sensitivity; and insulin secretion and sensitivity index (ISSI-2), a marker of beta cell secretion.

RESULTS

Twenty eight patients completed the study. HOMA2-IR was lower (2.72 ± 1.28 vs. 2.04 ± 0.9; P = 0.001) and ISSI-2 was higher (0.80 (0.51-1.26) vs. 1.04 (0.56-1.38); P = 0.019) at 2 weeks after surgery compared to baseline. Matsuda index also improved after surgery but was not statistically significant (2.02 (1.1-2.94) vs. 2.84 (1.56-4.12); P = 0.078). Fasting GLP-1 and calcitonin levels did not change while both peak GLP-1, and area under curve for GLP-1 were higher after surgery.

CONCLUSIONS

At 2 weeks following bariatric surgery, hepatic insulin resistance decreased while beta cell function improved due to increase in postprandial GLP-1 level without any change in fasting calcitonin levels.

Is histopathological examination of sleeve gastrectomy specimens necessary in areas endemic for gastric cancer?

Background

The value of histopathological examination of a laparoscopic sleeve gastrectomy (LSG) specimen in areas endemic for Helicobacter pylori (H. pylori) and gastric cancer is not known. We assessed the histopathological findings of LSG specimens to determine whether routine histopathological examination of these would be useful in patients with normal preoperative upper gastrointestinal endoscopy findings in an area endemic for gastric cancer.

Methods

We did a retrospective analysis of the histopathological findings of LSG specimens in patients who underwent the procedure between March 2015 and March 2017. We ascertained the association of positive histopathological findings with the clinical profile of patients and preoperative upper gastrointestinal endoscopy findings.

Results

Twenty-six patients (16 females) with a mean age of 37.5 years underwent LSG during the study period. On preoperative upper gastrointestinal endoscopy, 18 patients had unremarkable findings. Of the three patients with gastric or duodenal erosions on upper gastrointestinal endoscopy, two had H. pylori infection. On histopathological examination, 14 patients had unremarkable findings. Chronic gastritis with or without follicle formation was the most common finding (n=7). None of the patients with normal upper gastrointestinal endoscopy findings had significant histopathological findings or evidence of H. pylori infection. No significant association was found between age, gender, body mass index, smoking and alcohol intake with positive histopathological findings (p=0.64, 0.91, 0.90, 0.10 and 0.94, respectively).

Conclusions

We did not find clinically important histopathological findings on routine examination of the LSG specimen in bariatric patients with normal preoperative upper gastrointestinal endoscopy findings.

Total laparoscopic Billroth-I gastrectomy for corrosive-induced antropyloric stricture

Antro-pyloric stricture with gastric outlet obstruction is a common manifestation of corrosive-induced gastric injury. Surgical management is the only curative option as endoscopic dilatation usually fails in the long term. Billroth I gastrectomy with gastroduodenostomy is the preferred surgery as it restores normal alimentary pathway, reduces dumping and does not complicate colon mobilisation for the future oesophageal bypass. Conventionally, it is performed by the open approach. The present report is the first technical description of total laparoscopic Billroth-I gastrectomy using the laparoscopic linear cutter for corrosive-induced antropyloric stricture. The two patients who underwent this procedure had patent gastroduodenal anastomosis on the post-operative contrast study and tolerating normal diet at 9 and 6 months follow-up, respectively.

Laparoscopic Removal of an Ingested Foreign Body with Transesophageal Migration into the Mediastinum

Removal of a transesophageal migrated foreign body is recommended to prevent injury to adjacent structures. As the endoscopic approach is not feasible for a transesophageal foreign body migrated into the mediastinum, the thoracoscopic approach is recommended. The thoracoscopic approach often requires single lung ventilation and is associated with more pulmonary complications. The use of a laparoscopic approach to remove a mediastinal foreign body has not been reported earlier. In this report, the authors describe a laparoscopic approach for the removal of a transesophageal migrated foreign body into the lower mediastinum.