Adarsh Chaudhary

Elective Surgery for Corrosive-Induced Gastric Injury

Abstract. Gastric cicatrization is a well recognized late sequela of corrosive gastric injury, but the optimum timing and type of surgery for this complication are still unclear. Over a 7-year period (1988–1994) 34 patients underwent elective surgery for gastric lesions secondary to corrosive ingestion. A total of 18 (53%) patients had an associated esophageal stricture and presented with dysphagia, 15 (44%) patients had features of gastric outlet obstruction, 6 (18%) had diffuse gastric injury, and 28 (82%) had a segmental lesion. A tube jejunostomy was done in 23 (68%) patients to improve nutrition and resulted in a significant increase in weight and in the serum protein level after 8 weeks of tube feeding. Elective surgery was performed 3 to 24 months (average 7 months) after ingestion of the corrosive substance. Gastric resection was done in 20 (59%) patients and gastrojejunostomy (without vagotomy) in 11 (32%); at follow-up the latter group did not exhibit development of a stomal ulcer. In patients with an associated esophageal stricture, endoscopic dilatation was successful in 89% patients and simplified the surgical approach. In conclusion, the success of surgery for corrosive-induced gastric injury depends on selecting the right procedure and intervening at the appropriate time.

Diagnosis and outcome of isolated rectal tuberculosis

PURPOSE: Segmental colonic tuberculosis commonly involves the ascending, transverse, or sigmoid colon. Rectal involvement in tuberculosis is uncommon and poorly characterized. This study describes the clinical presentation, endoscopic features, and outcome of isolated rectal tuberculosis. METHODS: Isolated rectal tuberculosis was defined as focal lesions of the rectum in the absence of radiologically demonstrable lesions in the small and large bowel on barium contrast studies. Diagnosis of rectal tuberculosis was based on characteristic endoscopic appearance of lesions, histopathologic features of tuberculosis in biopsy/ resected material, and response to antitubercular therapy. RESULTS: Eight patients with rectal tuberculosis were seen during a four-year period at our hospital. Hematochezia was the most common presenting feature (88 percent), followed by constitutional symptoms (75 percent) and constipation (37 percent). Rectal examination revealed a tight stricture within 10 cm of the anal verge in seven patients. Barium enema showed stricture of variable length, with focal areas of deep mucosal ulceration and increase in presacral space. Proctoscopic findings were tight stricture (7), nodularity with ulceration (6), and multiple aphthous ulcers (1). Granulomatous infiltration was detected in seven of eight patients in biopsy material obtained at endoscopy (6) or surgery (1). Cessation of hematochezia, resolution of constitutional symptoms, and weight gain were seen in all patients following treatment with antitubercular drugs. CONCLUSION: Our data suggest that tubercular involvement of rectum, although uncommon, is an important cause of rectal strictures in India. Response to antitubercular chemotherapy is uniformly good, and surgery is seldom required in these patients.

Peri‐operative outcomes for pancreatoduodenectomy in India: a multi‐centric study

BACKGROUND There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres. MATERIALS AND METHODS Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India. RESULTS Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days). CONCLUSIONS This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.

Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability!

BACKGROUND Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems. AIM To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity. PATIENTS & METHODS Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors. RESULTS A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity. CONCLUSION Optimization of MSBOS protocols for PD is required for more judicious use of blood products.

Management of achalasia cardia: Expert consensus statements: Expert consensus: Achalsia cardia

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per‐oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short‐term to mid‐term follow‐up studies. POEM is less invasive than Hellers myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Hellers myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

The cost of Pancreatoduodenectomy – An analysis of clinical determinants

BACKGROUND Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD). METHODS The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed. RESULTS Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD. CONCLUSIONS It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

Improving Survival of Pancreatic Cancer. What Have We Learnt

Pancreatic adenocarcinoma still ranks high among cancer-related deaths worldwide. In spite of substantial strides in preoperative staging, surgery, perioperative care, and adjuvant treatment, the survival still remains dismal. A number of patient-, disease-, and surgeon-related factors play a role in deciding the eventual outcome of the patient. The aim of this commentary is to review the current knowledge of various factors and the recent advances that impact the survival of patients with pancreatic adenocarcinoma. A search of scientific literature using Embase and MEDLINE, for the years 1985–2015, was carried out for search terms “pancreatic cancer” and “survival.” Further search was based on the various specific prognostic factors that contribute towards survival of patients with pancreatic cancer found in the literature. Most of the studies used for this review include those that deal with pancreatic head cancers, some include patients with pancreatic cancers in all locations while very few included patients with tumors of body and tail only. In spite of significant developments in pre- and perioperative management, increased rates of margin-negative resections, and use of adjuvant treatment, the survival rates of pancreatic cancer patients remains poor. A paradigm shift with more effective adjuvant regimen and genetic interventions may help change the outcomes of patients with pancreatic cancer.

Predictors of septic shock following gastrointestinal anastomotic leaks: Only signposts, no destination

Anastomotic leaks are associated with a high risk of morbidity and even mortality.[1] Owing to this, surgeons have made considerable efforts to determine the clinico-biochemical factors that may help predict the development of anastomotic leaks or at least signal their development prior to their clinical manifestation (which usually precedes the development of septic shock if rapid action is not taken). Such parameters have been based on the markers of systemic inflammatory response syndrome (SIRS). The reason for making these efforts is the appreciation of the potential for rapid downward spiral (toward septic shock) once the anastomotic leak manifests clinically, and to thereby permit early detection which will aid the institution of effective measures, viz. “source control,” along with supportive measures such as fluid resuscitation and antimicrobials. The problem with such studies has been that surgery is in itself an insult that may be accompanied by SIRS, and hence, the factors studied tend to lack sensitivity.[2]