Early mobilization and delayed arterial ligation (EMDAL) as a surgical technique for splenectomy and shunt surgery in portal hypertension

Backgrounds/Aims

Splenectomy is the most frequently performed procedure as definitive management or as part of shunt surgery or devascularization in portal hypertension. Splenectomy is technically challenging because of the frequent coexistence of multiple collateral varices, splenomegaly, poor liver function, and thrombocytopenia. Early arterial ligation and late mobilization (EALDEM) is the traditional method for splenectomy in portal hypertension. Early spleen mobilization offers good control of the hilum. We aim to compare the effect of the early mobilization and delayed arterial ligation (EMDAL) technique with that of the conventional splenectomy technique in patients with portal hypertension.

Methods

During the study period from September 2011 to September 2022, 173 patients underwent surgical intervention for portal hypertension at our institution. Among these patients, 114 underwent the conventional method of splenectomy (early arterial ligation and late splenic mobilization) while 59 underwent splenectomy with the EMDAL technique. Demographics were compared between the two groups. Intraoperative and postoperative outcomes were analyzed using the Mann-Whitney test in each group. A minimum follow-up of 12 months was performed in each group.

Results

Demographics and type of surgical procedure were comparable in the two surgical method groups. Median blood loss was higher in the conventional group than in the EMDAL method. The median duration of surgery was comparable in the two surgical procedures. Clavien-Dindo grade III/IV complications were reported more frequently in the conventional group.

Conclusions

The splenic hilum can be controlled well and bleeding can be minimised with early mobilization and delayed arterial ligation.

Unconventional shunt surgery for non-cirrhotic portal hypertension in patients not suitable for proximal splenorenal shunt

Backgrounds/Aims

Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH.

Methods

A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices.

Results

During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed.

Conclusions

Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.

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.

Primary Ewings Sarcoma of the Inferior Vena Cava

INTRODUCTION

Sarcomas of vascular origin are rare. A case of Ewings sarcoma of Inferior Vena Cava [IVC] is reported here.

REPORT

A 36-year-old lady presented with a 6-month history of bilateral pitting lower limb swelling and 1-month history of vaginal bleeding. Contrast-enhanced computed tomography of the thorax and abdomen revealed a soft tissue lesion extending from the cavoatrial junction to the junction of the middle hepatic vein with IVC. She underwent IVC resection (suprahepatic) and left lateral hepatectomy with dacron graft reconstruction. The pathology was suggestive of Ewings sarcoma and she received adjuvant chemotherapy.

CONCLUSION

Preoperative tissue diagnosis can be considered in vascular tumors to sequence the various treatment modalities for improved outcomes.

External pancreatic ductal stenting in minimally invasive pancreatoduodenectomy: How to do it?

It has been shown that external pancreatic ductal stenting (EPDS) can reduce the incidence of clinically relevant postoperative pancreatic fistula. Although studies have described EPDS in open pancreaticoduodenectomy (PD), EPDS in minimally invasive PD has not been reported yet. Thus, the objective of this study was to describe the technique of EPDS in minimally invasive PD. The procedure was performed either laparoscopically or using a robot. Once PD was completed, key steps included triple enterotomy, threading of silk-suture through all enterotomies and exteriorization, completing posterior layer of pancreaticojejunostomy (PJ), railroading stent through preplaced silk-suture, intubation of stent into the pancreatic duct, completion of PJ, followed by hepaticojejunostomy and parietalization of jejunum at the stent exit site. EPDS in PD through a minimally invasive approach can be performed safely in selected cases with either a small-sized pancreatic duct or a soft pancreas.

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.

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.

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.

Transient mesoportal shunt: An innovative technique for maintaining portal flow during pancreatoduodenectomy with portal vein resection

Pancreatic cancers exhibit a surgical challenge, in light of frequent vascular involvement. In absence of metastatic spread, vascular invasion is the predominant limiting factor for determining the resectability. With progression of time vascular involvement is no longer considered a surgical contraindication. However these complex procedures are fraught with technical challenges. Portal clamping required for vascular resection and reconstruction results in hepatic ischemia and visceral congestion. In order to mitigate these untoward effects, surgeons have tried diverse techniques including venous shunts. Venous shunting facilitates the resection and allows for an enhanced exposure and a safe procedure. Previously described techniques were either cumbersome or failed to maintain portal flow. We present a technique of transient mesoportal shunt, to facilitate vascular resection during pancreatoduodenectomy. This technique is both simple and maintains portal flow throughout the procedure preventing both hepatic ischemia and visceral congestion.

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.

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.

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.

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.

Intestinal lymphangiectasia: a rare cause of intussusception in an adolescent

Intussusception in adolescents is usually idiopathic in nature. A 17-year-old woman with diffuse large B cell lymphoma presented with signs of intestinal obstruction after initiation of induction chemotherapy. On evaluation, the patient was diagnosed to have ileoileal intussusception with intestinal lymphangiectasia as the lead point. Intestinal lymphangiectasia as a rare cause for intussusception and its relationship with lymphoma is discussed in this case report.

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 Splenectomy for Immune Thrombocytopenic Purpura (ITP) Patients with Very Severe Thrombocytopenia

Laparoscopic approach is considered as gold standard for splenectomy in patients with Immune Thrombocytopenic purpura (ITP). The evidence for safety and feasibility of laparoscopic splenectomy (LS) in patients with very severe thrombocytopenia (< 10,000 μL) is limited. A retrospective study of 32 ITP patients who underwent LS between July 2012 and November 2016. The ITP patients who had platelet counts < 10,000 μL (Group A, n = 15) and > 10,000 μL (Group B, n = 17) were compared with respect to operative time, blood loss, conversion rate, perioperative blood transfusion, the length of hospital stay and postoperative complications. There was no significant difference between the two groups with respect to operative time (p = 0.07), intraoperative blood loss (p = 0.75), postoperative complications (p = 0.23) and hospital stay (p = 0.15). None of the patients in the two groups required conversion to open procedure. No intra operative blood transfusion was required. In Group A, 3 patients (with platelet count less than 2000 μL) received platelet transfusion at induction of anesthesia while 10 others received after ligation of the splenic artery. There was no difference in the operative time, blood loss, postoperative complications and hospital stay between them. LS is a safe and feasible procedure for ITP patients with very severe thrombocytopenia. In these patients, the timing of intraoperative platelet transfusion does not influence perioperative and anesthetic complications.

Eosinophilic oesophagitis: an otolaryngologist's perspective

Eosinophilic oesophagitis is a diagnosis that is being made more frequently in the assessment of dysphagia in both adults and children. It is unclear whether this is a result of increased prevalence or improved diagnostic methods. Children present commonly to paediatric institutions with foreign body impaction. Research indicates that food impaction may predispose to eosinophilic oesophagitis. This article presents eosinophilic oesophagitis from an otolaryngologist's point of view. It details the clinical features present in the disease as well as how it is diagnosed and managed. It illustrates early signs of eosinophilic oesophagitis so that primary physicians and emergency physicians know when to refer on to otolaryngologists.

Hospital financing and neonatal intensive care

OBJECTIVE

To investigate the relationship between hospital financing patterns and hospital resources for the care of babies born at low birthweight in New York City.

DATA SOURCES AND STUDY SETTING

Data on neonatal care beds in New York City hospitals for 1991, obtained from the Greater New York Hospital Association, which were matched to 1991 hospital-specific birthweight and payment distributions from the New York State Department of Health.

STUDY DESIGN

Statistical analyses were used to assess the relationship between insurance and beds across all hospitals and across hospitals classified by ownership and teaching status.

PRINCIPAL FINDINGS

After adjusting for low birthweight and other measures of patient need and for hospital affiliation, the study finds that hospitals with more privately insured patients, especially those with more privately insured low-birthweight newborns, have statistically significantly more neonatal intensive care beds than do those with fewer such patients. This result persists within hospital affiliation categories.

CONCLUSIONS

These results suggest that differences in the care received by privately insured, Medicaid insured, and uninsured low-birthweight babies may stem from differences in the resources available to the hospitals that treat these patients.