Amit Javed

Squamous variant of gallbladder cancer: is it different from adenocarcinoma?

BACKGROUND Literature on squamous variants of gallbladder cancer (GBC) is limited. METHODS This was a retrospective analysis of GBC patients operated on between August 2009 and March 2012. Patients with adenosquamous carcinoma or squamous cell carcinoma were compared with adenocarcinoma for clinicopathologic features and surgical outcomes. RESULTS Of the primary GBC patients resected with curative intent, 14 had adenosquamous carcinoma (10) or squamous cell carcinoma (4) (group A), whereas 122 had adenocarcinoma (group B). Abdominal pain was the most common symptom in both groups; however, presentation with vomiting and an abdominal lump was more common in group A (P = .04 and <.01, respectively). Group A had a significantly larger tumor size (7.9 vs 4.8 cm, P = .01) and a higher incidence of adjacent organ involvement requiring extended resections (85.7% vs 26.2%, P < .01). Despite the higher T stage, node-negative disease was significantly higher in group A (42.9% vs 17.2%, P = .03). There was no significant difference in the median survival after curative resection between the 2 groups (28 vs 31 months, P = .24). CONCLUSIONS The squamous variant of GBC presented at an advanced T stage; however, nodal involvement and distant metastasis were less common. Despite the higher T stage, curative resection could be achieved in the majority with a comparable survival.

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

BACKGROUND Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC). METHODS Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group. RESULTS During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC- 20, IGBC - 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T1b (n = 1), T2 (n = 11) and T3 (n = 8), respectively. The median lymph node yield was 10 (4-31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6-34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site. CONCLUSION LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.

Liver Hydatid with HIV Infection: an Association?

Various opportunistic infections have been reported in patients with human immunodeficiency virus (HIV) infection. Although there are a few reports of echinococcal infection of the lung, spine, and brain, a hydatid cyst of the liver has never been described. In our experience of treating over 150 cases of hydatid cysts of the liver, we identified three patients with large, multifocal hydatid cysts who also had an HIV infection. The current article describes one such patient and discusses the possible host immune-parasite interaction to ascertain if HIV positivity results in increased susceptibility and severity of echinococcal infection.

Laparoscopic retrosternal bypass for corrosive stricture of the esophagus.

IntroductionSurgical management of corrosive stricture of the esophagus entails replacement of the scarred esophagus with a gastric or colonic conduit. This has traditionally been done using the conventional open surgical approach. We herein describe the first ever reported minimally invasive technique for performing retrosternal esophageal bypass using a stomach conduit.MethodsPatients with corrosive stricture involving the esophagus alone with a normal stomach were selected. The surgery was performed with the patient in supine position using four abdominal ports and a transverse skin crease neck incision. Steps included mobilization of the stomach and division of the gastroesophageal junction, creation of a retrosternal space, transposition of stomach into the neck (via retrosternal space), and a cervical esophagogastric anastomosis.ResultsFour patients with corrosive stricture of the esophagus underwent this procedure. The average duration of surgery was 260 (240–300) min. All patients could be ambulated on the first postoperative day and were allowed oral liquids between the fifth and seventh day. At mean follow-up of 6.5 (3–9) months, all are euphagic to solid diet and have excellent cosmetic results.ConclusionsLaparoscopic bypass for corrosive stricture of the esophagus using a gastric conduit is technically feasible. It results in early postoperative recovery, effective relief of dysphagia, and excellent cosmesis in these young patients.

Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study

Background: Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative. Materials and Methods: This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP. Results: During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037). Conclusion: MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.

Use of single-lumen tube for minimally invasive and hybrid esophagectomies with prone thoracoscopic dissection: case series.

Minimally invasive and hybrid minimally invasive esophagectomy (MIE) is a technically challenging procedure. Anesthesia for the same is equally challenging due to special requirements of the video-assisted thoracoscopic technique used and shared operative and respiratory fields. Standard ventilatory strategy for this kind of surgery has been 1-lung ventilation with the help of a double-lumen tube. Prone positioning for thoracoscopic dissection facilitates gravity-dependant collapse of the operative side lung induced by a unilateral capnothorax, thus making the use of single-lumen endotracheal tube a feasible option for this surgery. We report our experience of 10 consecutive cases of minimally invasive esophagectomy conducted in prone position at our center and the use of single-lumen endotracheal tube for ventilation.