Frederick Vyas

Portal annular pancreas. A rare variant and a new classification.

CONTEXT Portal annular pancreas is a rare congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein/superior mesenteric vein. It is asymptomatic, but could have serious consequences during pancreatic surgery, if unrecognized. We describe a variant of this anomaly encountered during pancreaticoduodenectomy and propose a new classification. CASE REPORT We report a 51-year-old male who underwent a pancreaticoduodenectomy for periampullary carcinoma. After division of the pancreatic neck, a sheath of tissue was found posterior and extending to the left of the portal vein. When we divided this tissue, a large duct was encountered; this duct communicated with the main pancreatic duct. On review of the CT images, the main pancreatic duct was seen to be passing posterior to the portal vein and a smaller accessory pancreatic duct was present anterior to the portal vein. We describe the surgical implications. CONCLUSION This variant of portal annular pancreas has not yet been reported during pancreaticoduodenectomy and we propose a new classification for this fusion anomaly.

Mycobacterium fortuitum: an iatrogenic cause of soft tissue infection in surgery.

Background:   Mycobacterium fortuitum is an uncommon cause of soft tissue infections. Treatment is often inadequate with persistence of infection unless the aetiological agent and its antibiotic sensitivity are accurately established.

Endoluminal formalin application for haemorrhagic radiation proctitis.

Background  Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis.

Management of adult choledochal cysts – a 15-year experience

BACKGROUND Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. METHODS The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. RESULTS The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. CONCLUSIONS Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Benign biliary papillomatosis in a patient with a choledochal cyst presenting as haemobilia: a case report

Biliary papillomatosis is a rare condition usually detected on imaging or postoperative histopathology. It may be asymptomatic or present with features of cholangitis. We report the management of a patient presenting with haemobilia.

Inadvertent central venous infusion of enteral feed: a case report.

Inadvertent administration of enteral feed into an intravenous line is preventable usually by design of incompatible connectors, but these may not be available universally. We discuss a case report where this occurred and the subsequent management strategy.

Management of colorectal cancer liver metastasis in a patient with immune thrombocytopaenia

Immune thrombocytopaenia (ITP) was referred to previously as idiopathic thrombocytopaenic purpura and is usually of autoimmune or viral aetiology. Colorectal cancer liver metastasis with concomitant ITP is rare and only three cases have been reported in the English literature. Adverse effects of adjuvant chemotherapy may aggravate ITP. The sequencing of chemotherapy, operation for the primary and liver metastasis, and a decision on splenectomy is important. We present our experience in the management of a 52-year-old man who, having undergone anterior resection one year earlier for carcinoma of the rectum, presented with liver metastasis and ITP. He underwent splenectomy with hepatectomy prior to chemotherapy.

Synchronous Hepatocellular Carcinoma and Gastric Carcinoma—A Case Report with Review of the Literature

Studies from Japan and Korea have reported synchronous hepatocellular carcinoma (HCC) and gastric carcinoma (GC) and this association has been said to be high [1], but there are no reports of such an association from India. The incidence of GC (mean age-adjusted incidence 3–13.2/ 100,000) and HCC (mean age-adjusted incidence 2.77 in men and 1.28 in women/100,000) are low in India compared to East Asian countries such as Japan, South Korea, and China in which the incidence is high [1–3]. Some studies have reported that in patients with HCC, extrahepatic malignancies did not have any influence on postoperative survival [1, 4, 5]. HCC is usually associated with cirrhosis or chronic viral hepatitis. We report a 66year-old male with synchronous HCC without cirrhosis or chronic liver disease and a poorly differentiated mucinsecreting adenocarcinoma in the stomach. Case report: A 66-year-old male presented to our hospital in January 2010 with symptoms of right-sided pleuritic chest pain, dry cough, and intermittent fever since December 2009. He also described loss of appetite and loss of weight but could not quantify the latter. He had been evaluated elsewhere and was informed that he had fluid in the chest and a lesion in the liver. The patient denied any history of jaundice, melena, abdominal distension, abdominal pain, constipation, vomiting, or breathlessness. He was hypertensive on Atenolol 50 mg once daily for 18 years. He was an ex-smoker, having smoked 15–20 cigarettes per day for 25 years. He also gave a history of daily consumption of alcohol 100–120 ml/day for 25 years. On examination, he was thin with evidence of recent weight loss. He had pallor, but did not have icterus or left supraclavicular lymphadenopathy. Abdominal examination did not reveal any masses or free fluid. There was no organomegaly. Investigations are shown in Table 1. Ultrasonography of the abdomen showed a well-defined isoechoic lesion in the left lobe of liver measuring 4×3.2 cm. Liver was normal in size and echotexture. Ultrasound-guided fine needle aspiration cytology of the liver lesion was done on the 7th of January 2010, which revealed well-differentiated hepatocellular carcinoma (Fig. 1). Gastroscopy was done on the 16th of January. The esophagus was normal without evidence of varices. The stomach showed a 1.5-cm area of mucosal thickening in the distal antrum with an overlying clean-based ulcer. There was no fundal varix. The pylorus and duodenum were normal. Biopsy from this lesion showed Helicobacter pylori-associated moderate chronic atrophic gastritis with acute erosion. On the 19th, he underwent diagnostic pleural fluid aspiration which showed a polymorphic exudate; bacterial culture of fluid and smear for acid fast bacilli (AFB) were negative (WBC total 186,000/mm, polymorphs 98%, lymphocytes 02%, RBC 270,000/mm, glucose <10 mg% LDH 82 U/L, protein 6.4 g%.) Pleural biopsy from the right side showed non-specific inflammatory exudate. Pleural tissue for AFB culture and smear for AFB were negative. B. Ramakrishna (*) :K. Patel Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India 632004 e-mail: banu@cmcvellore.ac.in

Intraductal Hepatocellular Carcinoma without Parenchymal Tumor: A Case Report

IntroductionObstructive jaundice due to hepatocellular carcinoma is rare. We present a case of hepatocellular carcinoma presenting as an intraductal tumor, which was clinically and radiologically diagnosed as cholangiocarcinoma.Clinical PresentationA 59-year-old male was admitted with recurrent episodes of jaundice. He was found to have a tumor in the right hepatic duct extending into intrahepatic ducts, which was clinically and radiologically diagnosed as cholangiocarcinoma.ResultsThe patient underwent right hepatectomy with excision of the bile duct and left hepaticojejunostomy. Histological examination revealed an intraductal moderately differentiated hepatocellular carcinoma. The rest of the liver parenchyma showed features secondary to biliary obstruction but no tumor.ConclusionA case of hepatocellular carcinoma presenting as an intraductal tumor with obstructive jaundice and no evidence of parenchymal tumor is presented.

Intestinal failure: a viable proposition in India

Total parenteral nutrition (TPN) is currently the primary maintenance therapy for patients with irreversible gut failure. It is associated with significant morbidity and mortality and poor quality of life. Liver disease is the most common complication of TPN. Thrombosis at site of insertion, recurrent episodes of catheter related sepsis, dehydration, formation of renal calculi and electrolyte disorders are other common complications [1]. Small bowel transplantation has evolved as a successful therapeutic option in the treatment of irreversible gut failure. Cadaveric small bowel transplantation is associated with satisfactory outcomes at most centers. However, the high mortality rate among patients awaiting intestinal transplants exceeds that among candidates waiting for solid organ transplants in certain age groups especially children.