Sujit Vijay Sakpal

A Comprehensive Review of Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) Techniques for Cholecystectomy

IntroductionSurgery of the gallbladder has evolved tremendously over the last century. Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. In recent times, innovative techniques of natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been applied in gallbladder removal as a step towards even more less-invasive procedures.DiscussionWhile NOTES and SILS represent the advent of essentially scarless surgery, limited applications of these technologies in human subjects exists. In this article, we present a comprehensive review of the potential benefits, limitations and risks of these novel techniques.ConclusionWhile much remains unknown and unanswered surrounding these procedures, it is clear that extensive research and development with regards to the ethics and the technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential.

Laparoscopic cholecystectomy conversion rates two decades later.

Male patients greater than 50 years of age and cases performed by low-volume surgeons were found to have a higher rate of conversion to open procedures.

Surgical management of hepatolithiasis

BACKGROUND Globalization and intercontinental migration have not just changed the socioeconomic status of regions, but have also altered disease dynamics across the globe. Hepatolithiasis, although still rare, is becoming increasingly evident in the West because of immigration from the Asia-Pacific region, where the disease prevails in endemic proportions. Such rare but emerging diseases pose a therapeutic challenge to doctors. METHODS Here, we briefly introduce the topic of hepatolithiasis and describe features of intrahepatic stones, the aetiology of hepatolithiasis and the symptoms and sequelae of the condition. We then provide a comprehensive review of the various management modalities currently in use to treat hepatolithiasis. CONCLUSIONS In our opinion, and as is evident from the literature, surgery remains the definitive treatment for hepatolithiasis. However, non-surgical procedures such as cholangiography, although limited in their therapeutic capabilities, play a vital role in diagnosis and preoperative evaluation.

Eosinophilic cholangitis and cholangiopathy: a sheep in wolves clothing.

Background. Eosinophilic cholangitis (EC) is a rare benign disorder of the biliary tract which can cause biliary obstruction. Similar to other disease processes involving the bile ducts, this disorder can pose a difficult diagnostic challenge as it can mimic cholangiocarcinoma. Methods. A systematic search of the scientific literature was carried out using PubMed to access all publications related to EC. Search keywords that were utilized included “eosinophilic cholangitis,” “etiology,” “treatment,” and “obstructive jaundice.” Results. Twenty-three cases of EC have been reported. Nineteen patients (82.6%) who presented with EC remain disease-free; 15 of these 19 patients (78.9%) with followup time remain disease-free at a mean of 9.7 months (range, 2–24 months). Conclusion. EC is a rare form of biliary obstruction which can masquerade as a malignancy. Unlike cholangiocarcinoma, EC occurs more commonly in younger patients and in men. Most patients will require surgical treatment.

Iatrogenic bile duct injury associated with anomalies of the right hepatic sectoral ducts: a misunderstood and underappreciated problem.

Although laparoscopic cholecystectomy (LC) has been widely accepted as the standard of care, it continues to have a higher complication rate than open cholecystectomy. Bile duct injury with LC has often been attributed to surgical inexperience, but it is also clear that aberrant bile ducts are present in a significant number of patients who sustain biliary injuries during these procedures. We present three cases of right sectoral hepatic duct injuries which occurred during LC and provide a discussion of the conditions which are likely to lead to these injuries, as part of a strategy to prevent them.

Medullary thyroid carcinoma metastatic to skin.

Cutaneous metastases are a rarity, even more so when they arise from a medullary thyroid carcinoma (MTC) which accounts for only 8% of all thyroid cancers. MTC arises from C‐cells that produce calcitonin, and it most commonly metastasizes to lymph nodes in the neck. Distant metastases of MTC may involve bone, lung and liver. We report a case of a 56‐year‐old man, who presented with an ulcerated, nodular lesion on his scalp that proved to be a metastasis from his MTC diagnosed 2 years earlier. Cutaneous metastases from MTC generally signify widespread disease and carry a poor prognosis. A case discussion and relevant review of the literature is provided.

Laparoscopic appendectomy conversion rates two decades later: an analysis of surgeon and patient-specific factors resulting in open conversion.

BACKGROUND The role of laparoscopy in appendicitis has gained increased popularity but remains controversial. Despite more than 20 y of experience in laparoscopy, the nationwide laparoscopic appendectomy (LA) conversion rate is reportedly 8.6%. We sought to analyze the impact of patient-specific and surgeon-specific factors that may contribute to open conversion during LA. MATERIALS AND METHODS A retrospective analysis of 745 LAs (49.9% females and 50.1% males; average age of 37.8 y performed at a large tertiary community teaching hospital over a 5-y period (May 2004-October 2008) was performed. RESULTS The overall conversion rate for the study period was 4.16% (n = 31). The most common reason for open conversion was severe acute inflammation (38.7%). Among converted cases, 77.42% had no prior abdominal surgery and only 25.81% of cases were converted due to adhesions. Females and patients ≥ 65-y-old had a higher likelihood of open conversion (4.30% versus 4.02%, P < 0.99 and 9.26% versus 3.76%, P < 0.1107). The overall conversion rate of cases performed by high-volume surgeons (≥ 50 total cases) in comparison to low-volume surgeons (10-49 total cases) was higher (4.86% versus 3.30%, P < 0.39). Conversion rates were lower among surgeons who completed residency training after 1990 (3.72% versus 4.35%, P < 0.82) and those with fellowship training (1.42% versus 5.18%, P < 0.034). CONCLUSIONS Laparoscopic conversion continues to gain popularity and remains the gold standard procedure for appendectomy. Older patients have a higher likelihood of conversion with severe acute inflammation being the most common reason for conversion. Additional minimally invasive fellowship training was the only surgeon-specific factor that significantly impacted conversion rate.

Peripheral artery leiomyosarcoma

Vascular leiomyosarcomas are extremely rare tumors and represent only 0.001% of all malignancies. Venous leiomyosarcomas occur five times more often than arterial ones, with 50% of them originating in the inferior vena cava (IVC). Arterial leiomyosarcomas are most commonly encountered in the great vessels with less than 50% of them occurring in the peripheral circulation. A total of only seven cases of arterial leiomyosarcomas involving the femoral artery have been reported in literature to date. We report a case of an arterial leiomyosarcoma involving the profunda femoris artery, and provide a comprehensive review on peripheral arterial leiomyosarcomas-distribution, clinical presentation, radiological and histological diagnosis, staging, and treatment.

Agenesis of the dorsal pancreas and its association with pancreatic tumors.

Morphogenesis of the pancreas is a complex process; nevertheless, congenital anomalies are rare. At embryogenesis, the pancreas develops from the endoderm-lined dorsal and ventral buds of the duodenum. The ventral bud gives rise to the lower head and uncinate process of the pancreas; whereas, the dorsal bud gives rise to the upper head, isthmus, body, and tail of the pancreas. Rarely, developmental failure of the dorsal pancreatic bud at embryogenesis results in the agenesis of the dorsal pancreas-neck, body, and tail. Even rarer is the association of pancreatic tumors with agenesis of the dorsal pancreas. In addition to citing our case, we provide a comprehensive review on agenesis of the dorsal pancreas and its association with pancreatic tumors.

The Page kidney phenomenon secondary to a traumatic fall.

Page kidney is a rare phenomenon of hyperreninemic hypertension caused by compression of the renal parenchyma. It has been reported in healthy individuals after blunt abdominal or flank trauma, and in patients after invasive nephrological interventions. We present a case of acute on chronic renal failure and Page kidney phenomenon in an elderly male after a traumatic fall, who underwent effective medical management until spontaneous recovery to baseline was observed. A brief discussion on the Page kidney phenomenon is provided with a suggested algorithmic approach towards the management of this process.