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.

Structural elucidation of a compound extracted from Streptomyces Sp.NLKB45

A Streptomyces Sp. NLKB45 was isolated from the Nellore coastal region. After checking antimicrobial and antifungal activity the strain was subjected to fermentation in starch casein broth medium. HPLC was used to purify the culture filtrate after it had been extracted with ethyl acetate. The extract showed antibacterial and anticancer properties. The extract was processed and the compound isolated was further analyzed using FTIR, mass spectroscopic method and one- and two-dimensional NMR techniques. Based on the data gathered the compound was identified as 7-((5-methylpyridin-2-ylamino) (phenyl) methyl) quinolin-8-ol with a weight-average molecular weight of about 341 Da.

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center

Introduction

Pancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic.

Methods

Ours is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form.

Results

One patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively.

Conclusion

The pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

Screening and identification of novel isolate Streptomyces sp., NLKPB45 from Nellore costal region for its biomedical applications

Actinobacteria, which are the prolific producers of antibiotics and significant suppliers to the pharmaceutical industry, can produce a wide variety of bioactive metabolites. An actinomycete strain designated NLKPB45 was isolated from mangrove soils samples of Nellore coastal regions Andhra Pradesh and assessed for antibiotic production and activity against pathogenic bacteria. From a total of 9 mangrove soil samples, 143 acinomycetes were isolated. Among the isolated them 6 actinomycetes strains showed potential antibacterial activity against at two tested pathogens gram positive and gram negative bacteria E. coli and S. aureus. The potent strain NLKPB45 was identified by 16S gene isolation and sequencing to the Streptomyces genus. The ethyl acetate extracts also as shown excellent antimicrobial activity against Salmonella sp., staphylococcus aureus, E. coli, and B. subtilus were detected in both the supernatant extract samples from fermentations of culture NLKPB45. The anticancer activity of extracts in the HeLa with IC₅₀ value of 37.1924 μg/ml, MCF-7 IC₅₀ value of 40.9177 μg/ml and HT 29 IC₅₀ value of 43.3758 μg/ml.

Sticky spheres, entropy barriers, and nonequilibrium phase transitions

A sticky spheres model to describe slow dynamics of a nonequilibrium system is proposed. The dynamical slowing down is due to the presence of entropy barriers. An exact steady state analysis of the representative mean field equations, in the case when the clusters are chosen with the same a priori probability, demonstrates a nonequilibrium phase transition from an exponential cluster size distribution to a power law.