Transarterial chemoembolisation for very early and early stage hepatocellular carcinoma: single-centre experience

AIM

To evaluate the safety and efficacy of transarterial chemoembolisation (TACE) in patients with very early and early stage hepatocellular carcinoma (VES-HCC).

MATERIALS AND METHODS

A retrospective analysis was performed for all TACE procedures done at King's College Hospital, a tertiary liver centre, for VES-HCC during a 5-year period (January 2014-December 2018). Patients with solitary tumours ≤5 cm and patients with 2-3 tumours (each ≤3 cm) were included.

RESULTS

Two hundred and thirty-seven eligible patients were included. Technical success was achieved in 233 (98.3%) procedures. TACE using drug-eluting beads (DEB-TACE) was performed in 192 (82.4%) procedures. A complete response was achieved in 109 (45.9%) patients. The recurrence rate was 44% (48 cases), during a median imaging follow-up of 31.9 months (IQR 15.9-44.7). Median overall survival was 71.1 months (95% confidence interval [CI]: 62.9-79.3). Median recurrence-free survival was 58.9 months (95% CI: 47.1-70.7). Sixty-six (27.8%) patients eventually underwent transplantation, and six (2.5%) patients underwent surgical resection. Mild, moderate, and severe adverse events were encountered in 2.9%, 5.4%, and 0.8% of cases, respectively. No 30-day mortality was encountered.

CONCLUSION

DEB-TACE is safe and effective for treating VES-HCC patients, who are unsuitable for thermal ablation or surgery, and may offer comparable survival benefit. It can also be used as a bridge to transplantation for these patients.

Acute presentation of cocoon abdomen as septic peritonitis mimicking with strangulated internal herniation: a case report

Background

Abdominal cocoon syndrome is a rare cause of intestinal obstruction in which loops of small bowel get entrapped inside a fibro-collagenous membrane. Condition is also known in the literature as sclerosing peritonitis and in the majority of cases, it has no known cause. Although the majority of patients exhibit long-standing signs and symptoms of partial bowel obstruction in an out-patient clinic, its acute presentation in the emergency room with features of sepsis is extremely rare. This case report aims to describe the emergency presentation of cocoon abdomen with septic peritonitis.

Case presentation

A 35-year-old male with no known co-morbidity and no prior history of prior laparotomy presented in emergency room first time with a 1-day history of generalized abdomen pain, vomiting, and absolute constipation. He was in grade III shock and had metabolic acidosis. The clinical impression was of the perforated appendix, but initial contrast-enhanced computed tomography (CECT) was suggestive of strangulated internal herniation of small bowel. Emergency laparotomy after resuscitation revealed hypoperfused, but viable loops of small bowel entrapped in the sclerosing membrane. Extensive adhesiolysis and removal of the membrane were performed and the entire bowel was straightened. Postoperatively he remained well and discharged as planned. Histopathology report confirms features of sclerosing peritonitis.

Discussion

Cocoon abdomen is a very rare cause of acute small bowel obstruction presenting in an emergency with features of septic peritonitis. Condition is mostly chronic and generally mimics abdominal TB in endemic areas like India and Pakistan. A high index of suspicion is required in an emergency setting and exploratory laparotomy is diagnostic and therapeutic as well and the condition mimics internal herniation in acute cases.

Conclusion

Cocoon abdomen as a cause of septic peritonitis is extremely rare and might be an unexpected finding at laparotomy. Removal of membrane and estimation of the viability of entrapped bowel loops is the treatment of choice, which may require resection in the extreme case of gangrene.

Post COVID-19 tuberculosis: An emerging threat of pandemic

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) pandemic has hit the world hard. Millions of people have died due to the infection and several have suffered with what are now known as post COVID-19 squeal. Among these squeals one is immunosuppression which leaves patients prone to severe opportunistic infection. We here report a case of young female who was infected by COVID-19 and later developed cavitary pneumonia which upon investigation turned out to be due to mycobacterium tuberculosis.  Through this report we aim to highlight the importance of high index of suspicion for infection like Mycobacterium tuberculosis after COVID-19 infection which developed in a healthy immunocompetent patient.

Tracheal chondrosarcoma and surgical management

Chondrosarcoma is a cancer of cartilage cells, and despite being a common primary bone tumor, tracheal chondrosarcoma is rare with only 18 cases reported in the literature prior to mid-2016. A 60-year-old gentleman presented with progressively increasing cough, severe stridor, and production of phlegm for approximately 2 years. On admission to our tertiary care hospital, he developed complete obstructive apnea within an hour, and was intubated. A tracheal biopsy was performed, followed by resection. Histopathology confirmed chondrosarcoma of the trachea. The patient tolerated the procedure very well and is currently symptom-free on follow-up, with no signs of recurrence.

Secretory paraspinal paraganglioma of thoracolumar spine: Case report and review of literature

Background:

Pheochromocytomas are catecholamine secreting tumors of the adrenal medulla chromaffin cells, however, when present extra-adrenally they are called paragangliomas. Paragangliomas rarely produce catecholamine in excess, which is evident by clinical symptoms, urine, and blood biochemistry. Total resection of these tumors can lead to complete clinical and biochemical resolution. This case report presents the clinical features, radiological findings, and neurological outcome in a middle-aged female with a secretory paraganglioma.

Case Description:

We present the case of a 34-year-old female who presented with a 2-year history of dizziness, flushing, headache, palpitations, and hypertension. Her blood workup showed raised urinary catecholamine levels. Magnetic resonance imaging (MRI) and iodine-123-meta-iodobenzylguanidine (MIBG) scans demonstrated a retroperitoneal mass located anterolateral to T11-T12 vertebral bodies reaching up to T12-L1 intervertebral disc. The patient was otherwise neurologically intact. She underwent resection of the tumor after alpha-adrenergic and beta-adrenergic blockade. En bloc resection was achieved without neurological complications. Postoperatively, the patient was initially hypotensive and subsequently became normotensive, and on follow-up, the patient had resolution of her symptoms and was stable.

Conclusion:

Secretory paraganglioma of the dorsal spine are rare and difficult to excise, needs preoperative preparation with pharmacological intervention, good operative technique, and postoperative care.

Epidemiologic Data, Tumor Size, Histologic Tumor Type and Grade, Pathologic Staging and Follow Up in Cancers of the Ampullary Region and Head of Pancreas in 311 Whipple Resection Specimens of Pakistani Patients

AIM

To report the histologic findings on Whipple resection specimens and thus determine the extent and spread of carcinomas of ampullary region and head of pancreas in our population.

SETTING

Section of Histopathology, Department of Pathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan.

MATERIALS AND METHODS

A case series of 311 consecutive Whipple resection specimens received between January 1,2003 and December 31, 2014. Specimens processed for histologic sections and representative sections submitted and histologically examined as per established and standard protocols. All relevant tumor parameters including histologic type, histologic grade, pathologic T and N stage and tumor size were assessed. Epidemiologic data were also recorded. All findings were analysed using SPSS 19.0 software.

RESULTS

Ampullary (periampullary) carcinomas were much more common than carcinomas of the head of the pancreas, especially in males, with an average age of 53 years. Mean tumor size was 2.5 cms, over 54% were well differentiated. A large majority were pT2 or pT3 and N0. Carcinomas of pancreatic head were also more common in males, mean age was 55 years, mean tumor size was 3.5 cms, and over 65% were moderately differentiated. The majority were T2 or T3 and pN1. Prognostically, significant statistical correlation was seen with tumor grade and pathologic T and N stage (p values statistically significant). However, tumor size was not statistically significant.

CONCLUSIONS

Ampullary carcinomas are more common compared to pancreatic carcinomas. Majority of ampullary carcinomas were well differentiated while majority of pancreatic carcinomas were moderately differentiated. Large majority of both types of cases were pT2 or T3. Histologic tumor grade and pathologic T and N stage are significantly related to prognosis in Pakistani patients with ampullary and pancreatic cancers.

Same admission colostomy closure: a prospective, randomised study in selected patient groups

BACKGROUND

Despite a recent trend towards primary repair, colostomy still has an important place in the management of different colorectal pathologies. Timing of colostomy closure is a debatable issue among general surgeons. We carried out a prospective, randomised study to compare the outcome after same admission colostomy closure (SACC) and conventional delayed colostomy closure (CDCC) in patients with predominantly traumatic injury of the large bowel.

METHODS

Sixty patients, the majority with traumatic colorectal pathologies, were prospectively randomised to SACC [30 patients, 23 men, mean age 27.9 +/- 9.7 (range, 18-65) years] or (CDCC) [30 patients, 24 men, mean age 28.6 +/- 10.6 (range, 18-63) years]. All colostomies were closed using an intraperitoneal closure technique. Pre-operative data and post-operative outcomes were collected and analysed.

RESULTS

A total of seven patients (23.3%) with SACC developed complications compared with eight patients (26.6%) having CDCC (p = 0.83). The mean hospital stay (p < 0.01), as well as the overall cost (p < 0.001), were significantly less in the SACC group.

CONCLUSIONS

Same admission colostomy closure is a safe and cost-effective technique for colostomy closure in selected groups of patients.