Palaniappan Ravichandran

CENTRAL PANCREATECTOMY FOR BENIGN PANCREATIC PATHOLOGY/TRAUMA: IS IT A REASONABLE PANCREAS‐PRESERVING CONSERVATIVE SURGICAL STRATEGY ALTERNATIVE TO STANDARD MAJOR PANCREATIC RESECTION?

Background:  The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation.

Haemosuccus pancreaticus: diagnostic and therapeutic challenges

BACKGROUND Haemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. The objective of our study was to highlight the challenges in the diagnosis and management of HP. METHODS The records of 31 patients with HP diagnosed between January 1997 and June 2008 were reviewed retrospectively. RESULTS Mean patient age was 34 years (11-55 years). Twelve patients had chronic alcoholic pancreatitis, 16 had tropical pancreatitis, two had acute pancreatitis and one had idiopathic pancreatitis. Selective arterial embolization was attempted in 22 of 26 (84%) patients and was successful in 11 of the 22 (50%). Twenty of 31 (64%) patients required surgery to control bleeding after the failure of arterial embolization in 11 and in an emergent setting in nine patients. Procedures included distal pancreatectomy and splenectomy, central pancreatectomy, intracystic ligation of the blood vessel, and aneurysmal ligation and bypass graft in 11, two, six and one patients, respectively. There were no deaths. Length of follow-up ranged from 6 months to 10 years. CONCLUSIONS Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. Diagnosis is based on investigations that should be performed in all patients, preferably during a period of active bleeding. These include upper digestive endoscopy, contrast-enhanced computed tomography (CECT) and selective arteriography of the coeliac trunk and superior mesenteric artery. Contrast-enhanced CT had a high positive yield comparable with that of selective angiography in our series. Therapeutic options consist of selective embolization and surgery. Endovascular treatment can control unstable haemodynamics and can be sufficient in some cases. However, in patients with persistent unstable haemodynamics, recurrent bleeding or failed embolization, surgery is required.

Transabdominal Modified Devascularization Procedure with or without Esophageal Stapler Transection—An Operation Adequate for Effective Control of a Variceal Bleed. Is Esophageal Stapler Transection Necessary?

In Japan, the original Sugiura procedure reported favorable results in non-cirrhotic patients but in the West, the modified Sugiura procedure is not widely accepted because of high rebleeding, morbidity, and mortality in cirrhotics. We retrospectively analyzed the efficacy of our modified Sugiura procedure i.e., devascularization with/without esophageal transection combined with salvage endotherapy and pharmacotherapy for control of a variceal bleed. Between January 1999 and December 2004, 912 patients with variceal bleeding were treated. Of these, 66 (7.2%) patients were subjected to surgery after failed endotherapy/propranolol. Among these 66 patients, 52 had transabdominal devascularization (16 emergency, 36 elective); 14 patients underwent devascularization with esophageal stapler transection (group I), and 38 patients had devascularization without esophageal stapler transection (group II). Another 14 patients underwent elective end-to-side proximal splenorenal shunt surgery. Postoperative mortality was 7.1% in group I, 10.5% in group II (P > 0.05). Mortality for emergency surgery was 31.2% (5/16) but there were no deaths in the elective surgery group. Overall morbidity was 57.1% in group I and 21.0% in group II (P < 0.05). The rates of variceal rebleeding were 7.1% and 7.8%; residual varices were 30.7% and 32.3%; recurrent varices were 7.6% and 5.8% following the group I and group II procedures, respectively, over a mean follow-up period of 39.9 (7–2) months. Esophageal transection–related morbidity (leak, stricture, and bleeding) was 21.4% (3/14) in group I. Devascularization without esophageal stapler transection is a safe and effective procedure for adequate (urgent and long-term) control of variceal bleeding with similar results and less morbidity when compared to devascularization with esophageal transection in cirrhotic patients, as well as non-cirrhotic patients.

Case matched comparison study of the necrosectomy by retroperitoneal approach with transperitoneal approach for necrotizing pancreatitis in patients with CT severity score of 7 and above

BACKGROUND Minimally invasive necrosectomy through a retroperitoneal approach has shown promising results for the treatment of necrotizing pancreatitis. There is however, little evidence from comparative studies in favor of these techniques over laparotomy. AIM To perform a case matched comparison of patients with necrotizing pancreatitis who underwent necrosectomy by the retroperitoneal approach with transperitoneal approach, thus minimizing the risk of confounding and selection bias. METHODS Between August 2008 and March 2011, 85 patients were admitted with pancreatic necrosis. Each of the 15 patients who underwent necrosectomy by retroperitoneal approach using a small flank incision (RP group) were compared with 15 of those treated with necrosectomy by transperitoneal approach (TP group). These patients were matched for the age (±10 years), status of infection, CT severity score (±2 points), preoperative organ failure and timing for surgery (±7 days). RESULTS Postoperative complications occurred in 4 patients (26.6%) in the RP group and 8 (53.3%) in the TP group (p = 0.248). Reintervention, was required in 4 patients (26.6%) in the RP group and 7 (46.6%) in the TP group (p = 0.366). The median post operative ICU stay was 10 days in the RP group compared to 15 days in the TP group (p = 0.317). Median post operative hospital stay was 26 days in the RP group and 32 days in the TP group (p = 0.431). The total hospital stay among the survivors was 31 days in the RP group and 40 days in the TP group (p = 0.285). CONCLUSIONS The RP approach for pancreatic necrosectomy through a small flank incision was associated with less post operative morbidity compared to TP approach. The surgical outcomes in terms of post operative new onset organ failure and in hospital mortality were similar in both the groups, but the post op ICU/hospital stay and the total hospital stay was lower in the RP approach group. These results still requires to be confirmed by further randomized studies.

Acute Hemorrhage into Adrenal Pseudocyst Presenting with Shock: Diagnostic Dilemmas Report of Three Cases and Review of Literature

We report three cases of acutely bleeding adrenal pseudocysts presenting as hemorrhagic shock. Pregnancy was associated in two cases. The diagnostic dilemmas are discussed with special reference to their unusual presentations, diagnosis, and treatment. We believe that our cases, complicated by intracystic hemorrhage, may be related to pregnancy.

Inflammatory pseudotumour secondary to spilled intra-abdominal gallstones

INTRODUCTION Spillage of calculi in the abdomen is frequent during Laparoscopic Cholecystectomy (LC). Though uncommon, these stones may lead to early or late complications. We describe a rare case of spilled gallstone presenting four years after the index procedure, with a mass in the parietal wall mimicking a neoplastic lesion. PRESENTATION OF CASE A 50 year old male presented with a mass in the right upper quadrant for the past 2 years. His past surgical history included a LC done four years ago. Intraoperative procedural details of the surgery were not available. A Computed Tomography (CT) scan showed an extrahepatic mass in the subdiaphragmatic space extending onto the soft tissues of the parietal wall. He underwent laparoscopic piecemeal excision of this organized mass. His post operative period was uneventful and he was pain-free on follow up. DISCUSSION Gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5cm have been identified as risk factors for complications. Definitive treatment is surgery with excision of the organized inflammatory mass and extraction of gallstones to avoid future recurrence. CONCLUSION Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.

Endoscopic band ligation for peptic ulcer bleed

Introduction: Endoscopic band ligation is commonly used to treat variceal bleeding; the use of band ligation has only been described in selected cases of nonvariceal bleeding. We describe the successful use of endoscopic band ligation to arrest bleeding in two cases of duodenal ulcer hemorrhage. This to our knowledge is only the fourth such report of endoscopic band ligation in English medical literature. Case Presentation: We report the cases of a 47-year-old male and a 32-year-old female presenting with upper GI bleed who were successfully managed by endoscopic band ligation. Conclusion: EBL is an effective, safe and economical endoscopic treatment for acute peptic ulcer bleeding. Larger studies in patients with acute peptic ulcer bleeding are needed to confirm these promising results.