Nilesh Doctor

Stent angioplasty of narrowed portocaval shunt in Budd Chiari syndrome: a case report

BackgroundHepatic vein thrombosis (Budd-Chiari Syndrome) is a rare disorder resulting from an obstruction to the outflow of blood from the liver. Early decompression is needed to prevent liver dysfunction and death. Radiological intervention includes angioplasty of stenosis and webs and the placement of transjugular intrahepatic portosystemic shunts (TIPPS). Side-to-side portacaval shunt (SSPCS) remains the gold standard for achieving good long-term results.Case presentationA 37-year old lady underwent side-to-side portacaval shunt for Budd Chiari syndrome. She had early shunt blockage and this was successfully treated with the placement of a metallic stent across the shunt.ConclusionAt five years, she remains asymptomatic, with normal liver functions, no ascites, and normal flow through the stent on Colour Doppler examination.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP). METHODS Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed. RESULTS Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d. CONCLUSION This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Management of Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients

Objective Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. Design We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). Results Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). Conclusion In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Pancreatic glucagonoma with pancreatic calcification

BACKGROUND Glucagonoma is an uncommon type of pancreatic neuroendocrine tumor [NET] which is characterized by diabetes mellitus, necrolytic migratory erythema, depression and deep vein thrombosis. The typical rash is often misdiagnosed and the diagnosis is delayed by 7-8 years. Pancreatic NETs and other pancreatic tumors are known to show calcifications within the tumor but calcification of the remaining normal pancreas is very uncommon. It occurs when there is ductal obstruction leading to acute or chronic pancreatitis. CASE REPORT We present a case of glucagonoma with coexistent pancreatic calcification. CONCLUSION Glucagonoma should be suspected in a diabetic patient with migratory rash. Pancreatic tumor should be suspected in patient with idiopathic focal pancreatitis.

Left-sided sinistroposition of the gall bladder: incidental presentation during elective cholecystectomy

A 59-year-old male patient presented with mild gallstone pancreatitis. He underwent laparoscopic cholecystectomy during the same admission, where we encountered a left-sided gall bladder (GB). This was managed during laparoscopic surgery by modifying the laparoscopic port positions, and we did not encounter any other variations in the biliary anatomy. Thorough knowledge regarding anatomical variations of the GB will help in managing rare cases and avoid injuries to vital structures.

Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male

Diaphragmatic hernia is an important cause of emergency hospital admission associated with significant morbidity. It usually results from congenital defect or rupture in the diaphragm due to trauma. Prompt and appropriate diagnosis is necessary in patients with this condition, as surgical intervention by either abdominal or thoracic approach may be necessary. Here, we report a case of left-sided diaphragmatic hernia presenting with sudden onset of breathlessness, respiratory distress and left-sided chest pain radiating to the abdomen, mimicking pneumothorax, treated successfully with surgical intervention.

Open pancreatic necrosectomy: the return to the old guard?

W e read with interest the article by Babu et al1 presenting their retrospective data on open pancreatic necrosectomies performed over nearly 9 years. The data is impressive and clearly reflects the expertise of this renowned unit. Surgical literature today is flooded with reports on the feasibility of minimally invasive techniques in possibly every gastrointestinal surgery performed to date. Proponents of minimally invasive surgery, which began as an adjunct to open surgery—with an aim to provide the best possible care to the patient, in recent times appears to be striving to upstage the role of open surgery. Irrespective of whether this is patient-driven, industry-driven or even surgeon-driven, the surgical world slowly seems to be losing objectivity. The mantra appears to be—“either you join the race or you are out.” This has left many a surgical trainee confused (as to which is the best operation for a given indication) and more often underprepared to completely manage a problem encountered at the time of laparoscopy (necessitating a conversion to open surgery). Whether this is for lack of adequate training in open surgery is a matter we had rather leave to the confines of a formal debate. It is in this light that the data of Babu and Siriwardena could not have come at a better time. Their data compares well with our own series of 32 single-staged open necrosectomies for infected pancreatic necrosis. As the search for a specific therapeutic option for acute pancreatitis continues,3,4 we will continue to see patients with infected pancreatic necrosis needing necrosectomies. We can only hope that in the near future more data from large highly experienced centers performing open necrosectomy will become available to permit a more balanced and truly evidence-based development of guidelines for the treatment of infected pancreatic necrosis.