Neil Bhardwaj

Experimental application of electrolysis in the treatment of liver and pancreatic tumours: Principles, preclinical and clinical observations and future perspectives

BACKGROUND Electrolytic ablation (EA) is a treatment that destroys tissues through electrochemical changes in the local microenvironment. This review examined studies using EA for the treatment of liver and pancreatic tumours, in order to define the characteristics that could endow the technique with specific advantages compared with other ablative modalities. METHODS Literature search of all studies focusing on liver and pancreas EA. RESULTS A specific advantage of EA is its safety even when conducted close to major vessels, while a disadvantage is the longer ablation times compared to more frequently employed techniques. Bimodal electric tissue ablation modality combines radiofrequency with EA and produced significant larger ablation zones compared to EA or radiofrequency alone, reducing the time required for ablation. Pancreatic EA has been investigated in experimental studies that confirmed similar advantages to those found with liver ablation, but has never been evaluated on patients. Furthermore, few clinical studies examined the results of liver EA in the short-term but there is no appropriate follow-up to confirm any survival advantage. CONCLUSIONS EA is a safe technique with the potential to treat lesions close to major vessels. Specific clinical studies are required to confirm the techniques safety and eventually demonstrate a survival advantage.

The effects of radiofrequency ablation on the hepatic parenchyma: Histological bases for tumor recurrences

BACKGROUND This review examines histological modifications obtained after liver radiofrequency ablation (RFA). METHODS A literature search has been undertaken for all pre-clinical and clinical studies involving RFA and in which ablation zones have been excised for a complete histological examination. RESULTS Two main histological areas are present, a central zone of coagulative necrosis and a peripheral rim of congestion and extravasation. Both corresponded to specific microscopic characteristics that evolved over time and that are influenced by the proximity of patent vessels and the liver perfusion status. Viable cells are not present in the central zone but have been described in the ischemic peripheral rim where they survive the ischemia and inflammation process. These correspond in clinical studies to residual viable tumor cells that lead to failure of the procedure. CONCLUSIONS Histological changes following RFA are complex and interactions take place at both a cellular and tissue level. Changes in the peripheral zone must be considered in future studies in order to extend the volume of reliable tumor destruction and increase the effectiveness of the procedure.

Merkel Cell Carcinoma Metastasis to the Pancreas: Report of a Rare Case and a Review of the Literature

CONTEXT Merkel cell carcinoma is a rare skin tumour which can metastasise to regional lymph nodes and occasionally to distant organs. Merkel cell carcinoma metastasis to the pancreas has been rarely reported. CASE REPORT We describe the case of Merkel cell carcinoma metastasis to the pancreas and review the literature on this rare phenomenon. CONCLUSION Merkel cell carcinomas metastasis should be considered as a differential in patients who present with a pancreatic mass with a previous history of Merkel cell carcinomas.

Benign mesenteric lymphangioma presenting as acute pancreatitis: a case report

Benign mesenteric lymphangiomas are rare intra-abdominal cysts which may be asymptomatic or present with a variety of abdominal symptoms including an acute abdomen. We are however not aware of any reports in the literature linking mesenteric lymphangioma to acute pancreatitis. We present the case of a 62-year-old man who was admitted with signs and symptoms of acute pancreatitis and a palpable abdominal mass. Computerised tomography (CT) of his abdomen confirmed the presence of a mesenteric cystic mass. He underwent a laparotomy at which a large thin walled mass filled with a chylous fluid was resected. Histological analysis of this cyst showed it to be a benign mesenteric lymphangioma.

Management implications of resection margin histology in patients undergoing resection for IPMN: A meta-analysis

INTRODUCTION IPMN is a relatively new clinical entity and surgeons are continuing to develop their understanding of this complex pathology. Little is known of the natural disease process post-resection of an IPMN, particularly the impact of gland histology and margin status on the chance of recurrence and survival in benign and invasive IPMN. METHODS An online search was conducted to evaluate and include those studies which reported on gland histology, margin status and disease recurrence in resected benign and malignant IPMN. A Meta analysis was then performed using a random effects model. RESULTS The chance of recurrence in non-invasive margin positive IPMN is similar to margin negative IPMN. The chance of recurrence is higher in invasive gland IPMN compared to non-invasive gland. The vast majority of recurrences occurred in patients with positive margins demonstrating invasion. CONCLUSION All patients with intra- or post-operative evidence of invasive carcinoma at the resection margin should undergo further resection to achieve a negative margin. Patients with evidence of IPMN at the transaction margin (even with changes of high grade dysplasia/CIS) may not achieve any benefit from further resection. Patients with recurrence in benign/non-invasive IPMN should undergo re-resection, whereas patients with recurrence in invasive IPMN should not.

Spontaneous regression of a biopsy confirmed hepatocellular carcinoma

A 74-year-old woman was diagnosed with histologically proven multiple bilobar hepatocellular carcinomas (HCC) in 2012. The lesions were inoperable and a repeat CT scan prior to starting chemotherapy revealed spontaneous regression of these lesions. Subsequent repeat scans have revealed continued regression of these lesions despite no active treatment. The case is presented with a literature review and discussion summarising the possible aetiologies of this phenomenon.

Endoloop-Assisted Alignment—a Simple, Effective, Cheap, and Safe Technique to Aid Specimen Extraction Following Sleeve Gastrectomy

Abstractᅟ

Troubleshooting in laparoscopy: how to treat 'poor image quality'.

1. Francois Y, Nemoz CJ, Baulieux J et al. Influence of the interval between preoperative radiation therapy and surgery on downstaging and on the rate of sphincter-sparing surgery for rectal cancer: the Lyon R90-01 randomized trial. J. Clin. Oncol. 1999; 17: 2396–402. 2. Glehen O, Chapet O, Adham M et al. Long-term results of the Lyons R90-01 randomized trial of preoperative radiotherapy with delayed surgery and its effect on sphincter saving surgery in rectal cancer. Br. J. Surg. 2003; 90: 996–8. 3. de Campos-Lobato LF, Geisler DP, da Luz Moreira A et al. Neoadjuvant therapy for rectal cancer: the impact of longer interval between chemoradiation and surgery. J. Gastrointest. Surg. 2010; 15: 444–50. 4. Evans J, Tait D, Swift I et al. Timing of surgery following preoperative therapy in rectal cancer: the need for a prospective randomized trial? Dis. Colon Rectum 2011; 54: 1251–9. 5. Wolthuis AM, Pennickx F, Haustermans K et al. Impact of interval between neoadjuvantchemoradiotherapy and TME for locally advanced rectal cancer on pathological response and oncologic outcome. Ann. Surg. Oncol. 2012; 19: 2833–41. 6. O’Neill BD, Brown G, Heald RJ et al. Non-operative treatment after neoadjuvant chemoradiotherapy for rectal cancer. Lancet Oncol. 2007; 8: 625–33. 7. Dhadda AS, Zaitoun AM, Bessell EM. Regression of rectal cancer with radiotherapy with or without concurrent capecitabine – optimising the timing of surgical resection. Clin. Oncol. (R. Coll. Radiol.) 2009; 21: 23–31. 8. Habr-Gama A, Perez RO, Wynn G et al. Complete clinical response after neoadjuvant chemoradiotherapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis. Colon Rectum 2010; 53: 1692–8.

A rare case of multi-focal angiomyolipoma affecting the pancreas and liver

Angiomyolipoma (AML) are benign tumours composed of varying amounts of thick-walled dysplastic blood vessels, smooth muscle and mature adipose tissue derived from epithelioid cells. We present a previously unreported occurrence of multi-focal pancreatic and hepatic AMLs in a patient and discuss the diagnostic and management difficulties associated with this rare disease. In addition relevant case studies are also reviewed.

Small bowel obstruction caused by a bread clip: a time and time again problem

A 47-year-old man consulted his general practitioner with an 8-week history of vague intermittent abdominal pain. No other significant bowel or constitutional symptoms were reported and the general practitioner organized a computed tomography (CT) scan of his abdomen. This revealed a foreign object in his small bowel which was difficult to define and he was referred to our department for further investigation. The external images were reviewed which confirmed the foreign object in the distal bowel (Fig. 1) and a CT scan was repeated with a three-dimensional reconstruction. This revealed a bread clip (Fig. 2) and the history was revisited with the patient. He did not remember ever ingesting a bread clip but did admit to heavy alcohol use in the past and he wore dentures and so he may have swallowed it without realizing. He was asymptomatic and was discharged home as it was felt that he will pass the bread clip. He re-presented to the surgical department 1 week later with increased abdominal pain and distension. A repeat CT scan showed progression of the clip further down the gastrointestinal tract compared with the previous CT; however, there was no evidence of thickened distal small bowel, surrounding free fluid and proximally dilated small bowel loops. He underwent a laparotomy and the bread clip was felt in the proximal ileum, fixed firmly to the inside of the bowel, at the level of an uninvolved Meckel’s diverticulum. The involved bowel was grossly thickened and oedematous and it was resected with a primary anastomosis formed. On opening the specimen, the bread clip was firmly attached to the small bowel mucosa (Fig. 3). No date was visible on the bread clip. The patient made an uneventful post-operative recovery and was reviewed 4 weeks later in outpatients where he was completely well and was therefore discharged back to the care of his general practitioner.