Siddharth Mehrotra

Management of bleeding in extrahepatic portal venous obstruction.

Extrahepatic portal venous obstruction, although rare in the western world, is a common cause of major and life threatening upper gastrointestinal bleeding among the poor in developing countries. Patients have large spleens and stunted growth. The diagnosis is easily confirmed by Doppler ultrasonography. Endoscopy sclerotherapy is the best option for the control of acute variceal bleeding. For secondary prophylaxis of bleeding, the choice lies between repeated sclerotherapy and a portosystemic shunt. We believe that due consideration should be given to performing a splenectomy and a lienorenal shunt. Performed by experienced surgeons, it carries a low operative mortality of 1%, a rebleeding rate of about 10%, removes the large spleen, reverses hypersplenism, and is not followed by portosystemic encephalopathy. Most importantly, it is a onetime procedure particularly suited to those who have little access to blood transfusion and sophisticated medical facilities.

New scoring system for differentiating xanthogranulomatous cholecystitis from gall bladder carcinoma: a tertiary care centre experience

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, characterized by a focal or diffuse destructive inflammatory process. The importance of XGC is that it mimics gall bladder carcinoma (GBC) both preoperatively and intra‐operatively, as it can present with pericholecystic infiltration, hepatic involvement and lymphadenopathy. As a result of a misdiagnosis, which is not infrequent, the patient may undergo an unnecessary radical cholecystectomy rather than only a cholecystectomy, which is associated with a greater morbidity and mortality. The main aim of the study is to formulate a simple preoperative scoring system for diagnosis of XGC which might benefit patients by avoiding radical procedures.

Penoscrotal swelling—an unusual occurrence in a patient with an anastomotic leak following ileostomy closure

Abstract Diverting loop ileostomy is a frequently done procedure accompanying colorectal surgeries. Dreaded complication is anastomotic leak. Early identification of anastomotic leak and apt management is required for better outcomes. Most often leak presents with fever, abdominal pain, rigidity, fever and hemodynamic instability. We report a rare occurrence of penoscrotal oedema in a patient with anastomotic leak and spontaneously subsiding with drainage of leaked contents.

Distal Bowel Re-feeding in Patients with Proximal Jejunostomy

BackgroundPatients who have a proximal jejunostomy are difficult to manage because of their high stoma output which results in fluid and electrolyte imbalance with repeated hospital admissions and the necessity for expensive parenteral nutrition (PN). There are few reports on the use of re-feeding of the proximal effluents in this situation.MethodsWe here relate our experience with this manoeuvre in 35 patients between Jan 2010 and Feb 2016 who had stomas less than 120xa0cm away from the duodenojejunal flexure.ResultsThere were 26 males and 9 females, whose median age was 47 (19–74) years. The most common indications for massive bowel resection were gangrene in 25 (71%) and intestinal perforation in 7 (20%). The median proximal and distal small bowel lengths were 45 (15–120) cm and 90 (0–240) cm respectively. The ileocaecal (IC) valve was preserved in 33 (94%) and there was only colon distally (without the ileocaecal valve) in 2 (6%) patients. Twenty-five (71%) patients required post-operative ICU care. Additional PN was required in 6 (17%) patients during their index admission with the average extra cost of treatment being 20,000 rupees. Their median hospital stay was 13 (6–60) days. Patients were discharged without intravenous (IV) lines. Eight (26%) patients required re-admission for acute renal failure which was managed conservatively. No major problems were associated with re-feeding. None of the patients required PN after discharge from hospital. Thirty (86%) patients had their stomas closed at 65 (14–224) days. Both the patients with colon only as their distal bowel remnant died. Sepsis was the cause of mortality in 4 (11%) during index admission and 3 after their discharge. On follow-up after bowel re-connection, 2 patients died after 1 and 12xa0months, both due to intracranial bleeding, and the overall survival was 74%.ConclusionsPatients with proximal jejunostomies can be managed with distal re-feeding. It is a cost-effective and effective substitute for PN, is associated with few problems, and has a fairly good long-term outcome.

A Review of 2255 Emergency Abdominal Operations Performed over 17 years (1996–2013) in a Gastrointestinal Surgery Unit in India

There is little information regarding the clinical spectrum and outcome of emergency abdominal operations from specialized units in India. We examined these in our gastrointestinal surgery and liver transplantation unit from a prospective database maintained between July 1996 and April 2013. Out of 9966 operations performed, 2255 (26%) were emergency procedures (reoperations during the same admission, e.g., for necrotizing pancreatitis were excluded). The primary outcome was 30-day postoperative mortality. The mean age of the patients was 47xa0years (range 1–107) and included the following age groups: 0–18xa0years (nxa0=xa0105, 4.7%); 19–64xa0years (nxa0=xa01766, 78.3%), and >65xa0years (nxa0=xa0384, 17.0%). The majority were males (1609, 71%), and there were 646 females (29%). The most common indications were small bowel emergencies (598, 26.5%), followed by pancreatic (417, 18.5%) and colonic (281, 12.5%) emergencies. Pancreatic operations were the second commonest in the adult and middle aged group. Colorectal operations were the second commonest in the geriatric age group (>65xa0years). Emergency operations for other conditions were: postoperative complications following elective operations 171 (7.5%), gastroduodenal bleeding or perforation in 144 (6.3%), and liver surgery in 93 patients (4.1%) patients. In the small bowel emergencies, 223 patients (37.2%) had primary diagnosis of adhesive obstruction, gangrene in 135 patients (22.5%), perforation in 121 patients (20%), and fistula in 56 patients (9.3%). Mesenteric venous thrombosis was found to be the primary cause of small bowel emergencies, either as a primary cause in gangrene or as a secondary cause in perforations and adhesions. The postoperative mortality after emergencies was 12.6% compared to 2% in elective procedures. Mortality was significantly higher in males (14%) than females (9.6%), pxa0<xa00.005. Category wise mortality was as follows: pancreatic surgery (nxa0=xa086, 20.6%), surgery for postoperative complications (nxa0=xa033, 19.3%), duodenal surgery (nxa0=xa018, 12.5%), small intestinal surgery (nxa0=xa068, 11.4%), and colonic surgery (nxa0=xa035, 12.45%). Emergency operations comprise a significant proportion of a GI surgical unit’s workload. The mortality is greatest after pancreatic operations followed by those done for postoperative complications. Despite advances in surgical and postoperative care, emergency operations for abdominal emergencies are associated with mortality which is six times higher compared to elective procedures.

Live donor liver transplantation for acute liver failure: A single center experience

IntroductionAcute liver failure (ALF) is an indication for emergency liver transplantation (LT). Although centers performing only deceased donor liver transplants (DDLT) have shown improved outcomes in this situation, they still have relatively long waiting lists. An alternative would be living donor liver transplantation (LDLT), which has shown equivalent outcomes in the elective situation but there is limited evidence of its results in ALF.AimThe purpose of this study was to assess the outcomes in patients with ALF undergoing emergency LDLT in our center in Delhi, India.MethodsWe prospectively collected data on 479 patients who underwent LT in our hospital between January 2009 and December 2015 to evaluate the outcomes of those with ALF. The ALF patients were listed for transplantation after they met the Kings’ College criteria and rapid evaluation was done following a protocol consisting of three phases. Patients with grade III/IV encephalopathy were put on mechanical ventilation. Data regarding their postoperative course, morbidity, and mortality were analyzed.ResultsThirty-six (7.5%) out of the 479 patients underwent emergency LT for ALF. Their mean age was 27.5xa0years (range 4–59xa0years) and the male to female ratio of 2:3. Preoperative intubation was required in 15 of 25 patients who had encephalopathy. Wilson’s disease was the most common cause of ALF in children while in adults, it was acute viral hepatitis. The time interval between listing and transplantation was a mean of 36u2009±u200912.4xa0h. The mean graft to recipient weight ratio (GRWR) was 1.06u2009±u20090.3. The recipients were extubated postoperatively after a mean period of 2.6xa0days and their mean ICU stay was 6.3xa0days. Postoperative infection was the most common complication and required upgradation of antifungal and antibiotic treatments. Neurological complications occurred in five patients. Thirty-one of 36 (86.1%) patients survived and progressive cerebral edema and sepsis were the most common causes of mortality. Patients who died had higher model for end-stage liver disease scores, longer cold ischemia time (CIT), and higher grades of encephalopathy (though 80% patients with encephalopathy survived). There was no donor mortality. At long-term follow up of a median of 56xa0months, 29 (80.5%) of 36 patients were still alive.ConclusionsIn our experience, LDLT is an alternative procedure to DDLT in patients with ALF and is associated with good outcomes even in patients with high grades of encephalopathy.

Limited distal duodenal resection: Surgical approach and outcomes. A case series

Introduction Tumours involving the duodenum are usually treated with pancreaticoduodenectomy, which may be associated with considerable morbidity. Limited distal duodenal resection, a relatively smaller procedure, can be done in some of these patients. We describe our experience with this operation for such lesions. Methods We retrospectively analyzed, from prospectively collected data 10 consecutive patients who underwent limited duodenal and proximal jejunal resection between March 2011 and Nov 2015. Results There were 8 males and 2 females who had a median age of 47 years. Their common presentations were abdominal pain (50%) and upper gastrointestinal bleeding (40%). Five had malignancy (adenocarcinoma: 2, neuroendocrine tumours: 2, non Hodgkins lymphoma 1). Three had gastrointestinal stromal tumours (GISTs) and 2 had other benign tumours (lipoma 1, ectopic pancreas 1). The 30-day post-operative morbidity rate was 60% (nu202f=u202f6) with mostly minor complications (Clavien grade 1 or 2). Median post-operative stay was 9 (range, 6–13) days. All ten patients were alive without recurrence after a median follow up of 26.5 months. Conclusion Limited distal duodenal resection is a feasible surgical alternative to a pancreaticoduodenectomy in carefully selected patients with benign and some malignant tumours of the third and fourth part of the duodenum.

Strategies for Differentiating Gallbladder Carcinoma from Xanthogranulomatous Cholecystitis—a Tertiary Care Centre Experience

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, characterized by focal or diffuse destructive inflammatory process. The importance of XGC is that it mimics gallbladder carcinoma (GBC) both preoperatively and intra-operatively, since it can present with pericholecystic infiltration, hepatic involvement and lymphadenopathy. As a result of this misdiagnosis which is not infrequent, the patient may need to undergo an unnecessary radical cholecystectomy rather than only a cholecystectomy which is associated with greater morbidity and mortality. Patients who underwent gallbladder and gallbladder-related operations during period of 5xa0years between 2010 and 2014 were reviewed (nxa0=xa0462). A comparison of clinical, biochemical, radiological and operative features were made between patients with carcinoma gallbladder (nxa0=xa0101) and xanthogranulomatous cholecystitis (nxa0=xa022). Patient with a long history of recurrent abdominal pain with leucocytosis and who on imaging are found to have a diffusely thickened gallbladder wall (pxa0<xa00.01), with cholelithiasis, choledocholithiasis and sub-mucosal hypoattenuated nodules (pxa0<xa00.05) are likely to have XGC while those with anorexia, weight loss, focal thickening of the gallbladder wall on imaging (pxa0<xa00.01) and dense local organ infiltration are more likely to have GBC. The presence of lymph nodes on imaging and the loss of fat plane interface between the liver and gallbladder are not differentiating factors. Differentiating XGC from GBC in preoperative setting is necessary to avoid radical procedures being done for a benign process. Certain clinical, radiological and intra-operative features aid in differentiating these benign and malignant process. However, the definitive diagnosis still remains a histopathological examination to avoid radical resection in patients who have a benign condition.