Ragini Kilambi

Laparoscopic management of pseudocyst of the pancreas in a pregnant patient.

Gallstone pancreatitis is a rare problem in pregnant patients. A primigravida with persistent symptoms of abdomen pain, nausea, vomiting, and inability to tolerate oral diet presented at 5 weeks of pregnancy. A laparoscopic cystogastrostomy with cholecystectomy was performed at 13 weeks of pregnancy. There are only 10 case reports in literature of pseudocyst in pregnancy and in none of them ante partum surgical management was done.

Pancreaticojejunostomy: Does the technique matter? A randomized trial

Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct‐to‐mucosa and dunking) in a randomized trial.

Malignant Schwannoma of the Esophagus: A Rare Case Report

Neurogenic tumors are the most prevalent tumors of the mediastinum, and schwannomas are the most common type of neurogenic tumor. Primary neurogenic neoplasm of the esophagus is uncommon and malignant schwannoma of the esophagus is extremely rare. We report a case of a 27-year-old female presenting with dysphagia and palpitations who was found to have a lobulated tumor in the mediastinum that was compressing the esophageal lumen. The tumor was successfully treated surgically without recurrence. The final diagnosis, on histopathological examination of the specimen, was malignant schwannoma.

A study of preoperative factors associated with a poor outcome following laparoscopic bile duct exploration

The authors’ study on the preoperative factors associated with a poor outcome after laparoscopic bile duct exploration made an interesting read [1]. It seems to have been proven beyond doubt that laparoscopic bile duct exploration is more efficient and as safe as endoscopic sphincterotomy in young patients fit for GA. However, its efficiency and safety in the elderly age group and those with comorbidities remains debatable. It is interesting to note that your own study had brought out that laparoscopic CBD exploration is equally safe in the elderly [2]. Furthermore, this study has brought out certain relevant facts regarding the influence of the learning curve. However, it is not clear as to what exactly is meant by the learning curve and until what number of cases do the authors feel they are still inexperienced especially in the context of laparoscopic CBD exploration. Also no mention has been made of the operative time—a factor known to be significantly affected by the learning curve— and how it has correlated with patient outcome. We in our limited experience of approximately 90 cases are in concurrence with your observation that learning curve does not influence the complication rate, although it may affect the conversion rate. In your study, bile leak was the most common complication, occurring in 15.6% of patients. We have reported a transient bile leak of 13.3% in our study [3]. It would be interesting to know the authors’ comments about the possible causes of bile leak. In our opinion, minor bile leaks are associated with a large number of laparoscopic CBD explorations done by choledochotomy due to spasm of lower end of the CBD probably due to instrumentation.

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis

BackgroundThe ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC).MethodsWe searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673.ResultsA total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD − 1.63, 95% CI (− 3.23, − 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD − 379.13, 95% CI (− 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved.ConclusionsSingle-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.

Duct-to-mucosa versus dunking techniques of pancreaticojejunostomy after pancreaticoduodenectomy: Do we need more trials? A systematic review and meta-analysis with trial sequential analysis

Pancreaticojejunostomy (PJ is the most widely used reconstruction technique after pancreaticoduodenectomy. Despite several randomized trials, the ideal technique of pancreaticojejunostomy remains debatable. We planned a meta‐analysis of randomized trials comparing the two most common techniques of PJ (duct‐to‐mucosa and dunking) to identify the best available evidence in the current literature.

An Alternative Approach to Life-Threatening Gastrointestinal Bleeding After Corrosive Ingestion

Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of acute corrosive injury has not been described. Here, we present our experience of a case of acute corrosive injury presenting with massive upper gastrointestinal bleeding in the delayed phase which was successfully managed by angioembolization. We discuss the case in light of the literature available and describe markers which may serve to identify potential candidates for angioembolization.

Measurement of splenic stiffness by 2D-shear wave elastography in patients with extrahepatic portal vein obstruction

OBJECTIVE: To assess the accuracy of splenic stiffness (SS) measured by 2D-shear wave elastography (SWE) for predicting variceal bleeding in the patients with extrahepatic portal vein obstruction (EHPVO). METHODS: 52 patients with EHPVO (mean age: 22.29 years; 26 each males and females) were included in the study after obtaining approval from the institute ethics committee. All patients initially underwent upper gastrointestinal endoscopy followed by ultrasonography, including 2D-SWE on the Aixplorer Supersonic Imagine scanner. The SS was measured through the anterior abdominal wall and an average of three measurements was taken. The SS was then compared with clinical symptoms, variceal grade, and other ultrasonography (USG) parameters. USG parameters were also compared with variceal grade. RESULTS: The mean SS was 44.92 ± 12.35 kPa. There was no significant difference in the mean SS of patients with high grade varices (44.30 kPa; n = 25) from those with low grade varices (46.91 kPa; n = 20). The ROC analysis showed a poor area under the curve of 0.477 for the prediction of high grade varices by the SS. The SS did not show any significant correlation with other ultrasonography parameters except splenic size, with which there was a weak but significant correlation. The measurement of SS by 2D-SWE was reliable and Cronbachs alpha was 0.905. CONCLUSION: The SS measured by 2D-SWE is not an accurate predictor of variceal grade and thus bleeding in patients of EHPVO. ADVANCES IN KNOWLEDGE: EHPVO is a vascular pathology with most patients showing splenomegaly and preserved liver function. Although, elastography of spleen has been shown to be useful in patients with cirrhosis for predicting portal hypertension, it does not seem to be helpful in patients with EHPVO.

Presentation and Management of Pseudoaneurysmogastric Fistula: A Life Threatening Emergency.

ABSTRACT Pseudoaneurysmogastric fistula is a rare consequence of pseudoaneurysms occurring in the vicinity of stomach. They are the result of pseudoaneurysms eroding into the stomach, and represent a life threatening emergency. Urgent surgical intervention is often necessary to salvage the patient. Data regarding the presentation and management of this condition is sparse. Herein, we present our experience with four cases of pseudoaneurysmogastric fistula, their clinical context, presentation, management and outcomes. We attempt to outline an algorithm for the diagnosis and management of this unusual complication.

Spectrum of hepatobiliary cystic lesions: A 7-year experience at a tertiary care referral center in North India and review of literature

Context: Cysts arising from the hepatobiliary tree are a group of heterogeneous lesions with regard to pathogenesis, clinical presentation, and radiological finding. They can be intrahepatic or extrahepatic, developmental, secondary to infective/inflammatory etiologies, as well as neoplastic. This study was conducted to determine the spectrum of hepatobiliary cysts in surgically intervened cases, with regard to their prevalence, histological spectrum, and clinicoradiological correlation, wherever possible. Methods: In this retrospective observational study, hematoxylin and eosin stained slides of all cases of hepatobiliary cystic lesions, operated between 2009 and 2016 were reviewed. Special stains as reticulin, Massons trichrome, and periodic acid Schiff were done wherever necessary. Overall prevalence, age-sex distribution, clinical presentation and histopathological patterns were studied. Relevant imaging findings were correlated wherever possible. Results: A total of 312 cases of hepatobiliary cysts were identified, the majority in females. Choledochal cysts (CCs) were the most common type (n = 198,63.5%), followed by hydatid cysts (n = 73,23.3%), simple hepatic cysts (n = 10,3.2%), congenital hepatic fibrosis (n = 10,3.2%), biliary cystadenomas (n = 4,1.2%) hepatic mesenchymal hamartomas (n = 7,2.2%), and cavernous hemangiomas (n = 3,0.9%). Fibropolycystic liver disease (n = 2,0.6%), Carolis disease (n = 1, 0.3%), liver abscess (n = 2, 0.6%), infantile hemangioendothelioma (n = 1,0.3%), and biliary cystadenocarcinomas (n = 1,0.3%) were rare. Lesions noted mostly in 1st decade of life were: CCs, fibrocystic liver disease, Carolis syndrome, cystic mesenchymal hamartoma, and infantile hemangioendotheliomas. Conclusion: In our cohort of surgically intervened cases of hepatobiliary cystic lesions from a tertiary care hospital in North India, the CCs, followed by hydatid cyst were the most common lesions. Histology can play vital role in characterization, as often clinical findings and radiology can overlap.