R. Shah

Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy

Preoperative biliary stenting is associated with bacterial contamination of bile and an increased rate of infectious complications after pancreaticoduodenectomy. Preoperative drainage has been found to have conflicting effects on morbidity and mortality, and no studies have been published on the effect of stent complications and duration of stenting on postoperative outcome. This study examined the effects of preoperative biliary stenting on early outcome after pancreaticoduodenectomy.

Calcitonin-Secreting Tumor of the Pancreas

Pancreatic endocrine tumors (PETs) are unusual tumors arising from cells belonging generically to the amine precursor uptake and decarboxylation systems. We present a case of a calcitonin-secreting PET in a 56-year-old female who presented with watery diarrhea, dehydration and hypokalemia. Investigation revealed hypercalcemia, hyperphosphatemia, hypercalcitonemia and a well-defined mass in the head of the pancreas on CT scan. Following a pancreaticoduodenectomy her serum calcitonin levels returned to normal and diarrhea disappeared. The identification of this particularly rare presentation of a calcitonin-secreting PET provides the opportunity to examine this pathological entity within the context of the very few previously reported instances of this disease.

Microcystic serous cystadenoma of the pancreas: a report of two cases with one of diffuse presentation

Microcystic adenoma or serous cystadenoma is an uncommon tumor and accounts for 1–2% of the exocrine neoplasms of the pancreas. Usually unifocal, they present as single, large, well-demarcated multiloculated cystic tumors, ranging in size from 1 to 25 cm. Multifocal variants or diffuse serous cystadenomas are extremely rare. We present 2 cases of which 1 is a diffuse variant affecting the body, tail and part of the neck of the pancreas. In both the patients the tumors were detected incidentally. We highlight on the diffuse variant in view of its rarity and present a review of literature. In this case the entire body and tail of the pancreas was spongy replaced by multicystic lobules and hyalinized fibrocollagenous stroma. The cysts were lined by low cuboidal glycogen containing bland cells. Such a unique presentation wherein the entire body and tail of the pancreas is replaced with multiple cysts is a diffuse presentation of microcystic adenoma and a search through literature revealed only 7 such cases among the 15 cases with multifocal presentation reported.

Surgical Treatment of Liver Metastases in Neuroendocrine Neoplasms

Neuroendocrine neoplasms (NENs) are a distinctive entity, and nearly 10% of patients already have liver metastases at presentation. The management of neuroendocrine liver metastases (NEN-LM) is complex with differing patterns of metastatic presentation. An aggressive approach should be used to resect the primary tumor, to remove regional lymph nodes, and to resect or treat appropriate distant metastases (including liver tumors). Despite having an indolent course, NENs have a significantly reduced survival when liver metastases are untreated. Though a wide range of therapies are now available with a multimodal approach to the treatment, surgical treatment offers the only chance for a significant survival prolongation and/or improvement of symptoms and quality of life. A review of the existing surgical modalities for NEN-LM is discussed in this paper.

Neoadjuvant chemotherapy before surgery of hepatoblastoma

Though surgical resection is the main stay of treatment for childhood hepatoblastoma (HB), many are unsuitable for radical surgery at diagnosis due to extensive intrahepatic and/or extra hepatic disease. We report experience in five patients of HB from a single institution (2001–2005) with preoperative Neoadjuvant chemotherapy (NACT) followed by surgery. Three patients received cisplatin, doxorubicin; and two cisplatin/vincristine/5-fluorouracil. All showed more than 50% reduction in tumor size confirmed by CT scan. Hepatic resection R0 was performed in all. There was no chemotherapy related toxicity nor post surgical morbidity or mortality. All are disease free at median follow up of 4 years. NACT produces adequate down staging of the HB with acceptable toxicity. Though cisplatin with doxorubicin produced good results, new protocol with cisplatin, vincristine and 5FU is promising without cardiotoxicity.

Transduodenal ampullectomy for ampullary tumors

Transduodenal ampullectomy (TDA) is indicated for large ampullary tumors, for presence of dysplasia on endoscopic biopsy, for poor surgical candidates for pancreaticoduodenectomy, and in cases not indicated for endoscopic ampullectomy. Retrospective review of data from 2009 to 2015 revealed 11 patients who underwent TDA. Magnetic resonance imaging cholangiopancreatography (MRI-MRCP), contrast-enhanced computed tomography (CECT) scan, side-viewing endoscopy, and endoscopic ultrasound (EUS) were used for investigating the patients as required. Preoperative biopsy was done in all. Out of the 11 patients, only one had recurrence. Two patients had adenocarcinoma and were treated with pancreaticoduodenectomy. TDA is a safe surgical procedure for treatment of well-selected benign ampullary pathologies. It is also a treatment option for the cases of ampullary adenomas not amenable to endoscopic resection.

Surgeon Preferences for Liver Transection: Is There an Ideal Technique?

. Brody F, Vaziri K, Kasza J, Edwards C. Single incision laparoscopic cholecystectomy. J Am Coll Surg 2010;210:e9–e13. . Rivas H, Varela E, Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc 2009 Dec 25. [Epub ahead of print]. . Erbella J, Bunch GM. Single-incision laparoscopic cholecystectomy: the first 100 outpatients. Surg Endosc 2010 Jan 29. [Epub ahead of print]. . Merchant AM, Cook MW, White BC, et al. Transumbilical gelport access technique for performing single-incision laparoscopic surgery (SILS). J Gastrointest Surg 2009;13:159–162.

Pancreaticoduodenectomy with Replaced Common Hepatic Artery and Portal Vein Reconstruction in Primary Carcinoma Duodenum: a Case Report and Literature Review.

The role of combined arterial and superior mesenteric-portal venous resection and reconstruction is not established in primary duodenal carcinoma [1, 2]. Arterial resections tend to result in high morbidity [2]. We present here a case of primary duodenal carcinoma wherein a combined vascular resection and primary repair was performed, along with the possible selection criteria for this procedure and a brief literature review.

IgG4-associated sclerosing cholangitis masquerading as hilar cholangiocarcinoma

IgG4-sclerosing cholangitis (IgG4-SC) commonly presents with type 1 autoimmune pancreatitis. Isolated IgG4-SC is rare. Differentiating IgG4-SC from cholangiocarcinoma preoperatively is challenging due to overlapping radio-clinical manifestations and difficult preoperative histology. We present three cases preoperatively diagnosed and surgically treated as hilar cholangiocarcinoma. First and second cases presented with cholangiocarcinoma with portal vein involvement and third with a malignant-appearing hilar stricture. On histopathology, IgG4-SC was diagnosed in the first two cases. Third patient had raised serum IgG4, and histopathology was inconclusive for IgG4-SC and negative for malignancy. However, she responded to steroid therapy.

Fusion Technique for Liver Transection: A New Technique Combining Kelly-Clysis and Harmonic Technology

Liver transection is performed by multiple techniques. Finger fracture (digitoclasia), clamp–crushing (Kelly-clysis), Cavitron ultrasonic surgical aspirator (CUSA), and Hydro-jet need additional coagulation devices for hemostasis. Precoagulation techniques include RF-HABIB 4x, TissueLink, LigaSure, and Gyrus forceps. Lateral parenchymal damage and biliary leak are the disadvantages. None of these are ideal, and there are no convincing data for superiority of a single technique. The choice is often based on individual surgeon preference. An ideal transection technique should be easy to assemble, ergonomically convenient, and cost-effective, replacing multiple expensive devices in the operating room. The fusion technique uses a single instrument providing both precise parenchymal dissection and hemostasis at the same time. Focus® is a 14-inch-long Kelly-like instrument attached to a Harmonic generator. The curved tapered tips of the instrument allow precise dissection with a gentle clamp–crush technique that splits the parenchyma to expose vascular structures. The blood vessels (up to 5 mm) are sealed by coaptive coagulation at low temperatures (50–100 °C). It can be used to seal vessels up to 5 mm, and along with a long curved tip can be used as a dissecting instrument. In high-speed mode, the liver capsule and superficial parenchyma can be split with ease. No instrument exchange for coagulation is a selective advantage of the fusion technique. Focus® with its Kelly-clysis ability provides an easy and rapid parenchymal split, while the Harmonic technology ensures simultaneous adequate coagulation. We have used this technique in all types of hepatic resection and have found it particularly useful in noncirrhotic livers.