Ajay P. Belgaumkar

The impact of inflammatory bowel disease post-liver transplantation for primary sclerosing cholangitis.

An association between primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) is well recognized. However, the disease course of IBD following liver transplantation (LT) for PSC remains ill‐defined.

Small bowel haemorrhage associated with partial midgut malrotation in a middle-aged man

We describe a case of life-threatening small bowel haemorrhage in a 56 year old man, who was found to have partial midgut malrotation at laparotomy. An association between congenital malrotation and gastrointestinal haemorrhage has not previously been reported in this age group. We discuss the association between gut malrotation and small intestinal pathology and describe the principles of management in these patients.

The dangers of using stapling devices for cystic duct closure in laparoscopic cholecystectomy.

Laparoscopic stapling devices are used widely in laparoscopic surgery, for division of vessels and creation of anastomoses. Their use in the division of a widened cystic duct at laparoscopic cholecystectomy has been reported earlier. We present 3 different complications occurring after division of the cystic duct using the EndoGIA stapling device. A review of the literature has been performed and safe alternative techniques for laparoscopic ligation of the cystic duct are proposed.

Laparoscopic resection of ruptured liver tumors.

The laparoscopic technique is becoming the approach of choice as surgical expertise in advanced laparoscopy has developed. Laparoscopy is also being increasingly utilized in the management of gastrointestinal emergencies. In this article, we report a series of 3 patients with ruptured liver tumors who underwent laparoscopic liver resection. The issues surrounding safety, feasibility, and appropriateness of laparoscopic surgical management in these cases are discussed. With appropriate patient selection and preoperative stabilization, laparoscopic resection has a place in the management algorithm of ruptured liver tumors.

Robotic Versus Laparoscopic Gastric Resection for Primary Gastrointestinal Stromal Tumors >5 cm: A Size-Matched and Location-Matched Comparison

This study compared robotic (RR) and laparoscopic resection (LR) for primary gastrointestinal stromal tumors (GISTs) of the stomach >5 cm. Twelve consecutive patients who underwent RR from 2012 to 2015 were matched for tumor size and location with 24 patients who underwent LR from 2000 to 2012. The median tumor size was 7.1 cm (range, 5.5 to 11.5). GISTs were resected by wedge resection (91.7%) or distal gastrectomy. The median RR operative time was longer than that of LR (162.5 vs. 130 min, respectively; P=0.004). Only 1 LR patient required conversion. The time to flatus and hospital stay were similar between groups. Overall, 3 patients developed minor postoperative complications that were medically treated. Mortality was nil. All resections were R0. No difference was observed in the incidence of recurrence. RR was significantly more expensive (+21.6%) than LR. RR appears to be safe and feasible for GISTs>5 cm, but is associated with longer operative times and greater costs.

Consequences of metabolic syndrome on postoperative outcomes after pancreaticoduodenectomy

AIM To analyze immediate postoperative outcomes after pancreaticoduodenectomy regarding metabolic syndrome. METHODS In two academic centers, postoperative outcomes of patients undergoing pancreaticoduodenectomy from 2002 to 2014 were prospectively recorded. Patients presenting with metabolic syndrome [defined as at least three criteria among overweight (BMI ≥ 28 kg/m²), diabetes mellitus, arterial hypertension and dyslipidemia] were compared to patients without metabolic syndrome. RESULTS Among 270 consecutive patients, 29 (11%) presented with metabolic syndrome. In univariable analysis, patients with metabolic syndrome were significantly older (69.4 years vs 62.5 years, P = 0.003) and presented more frequently with soft pancreas (72% vs 22%, P = 0.0001). In-hospital morbidity (83% vs 71%) and mortality (7% vs 6%) did not differ in the two groups so as pancreatic fistula rate (45% vs 30%, P = 0.079) and severity of pancreatic fistula (P = 0.257). In multivariable analysis, soft pancreas texture (P = 0.001), pancreatic duct diameter < 3 mm (P = 0.025) and BMI > 30 kg/m² (P = 0.041) were identified as independent risk factors of pancreatic fistula after pancreaticoduodenectomy, but not metabolic syndrome. CONCLUSION In spite of logical reasoning and appropriate methodology, present series suggests that metabolic syndrome does not jeopardize postoperative outcomes after pancreaticoduodenectomy. Therefore, definition of metabolic syndrome seems to be inappropriate and fatty pancreas needs to be assessed with an international consensual histopathological classification.

The Effect of Intraoperative N-Acetylcysteine on Hepatocellular Injury During Laparoscopic Bariatric Surgery. A Randomised Controlled Trial.

BackgroundThe combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG).MethodsPatients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score.ResultsTwenty patients (14 females, mean age 44.5 (SEM ± 2.9) years, mean BMI 60.8 (SEM ± 2.4) kg/m2) were recruited (NAC n = 10, control n = 10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly.ConclusionsNAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis.