Sujoy Pal

Best Supportive Care Compared With Chemotherapy for Unresectable Gall Bladder Cancer: A Randomized Controlled Study

PURPOSE We designed this study to evaluate efficacy of modified gemcitabine and oxaliplatin (mGEMOX) over best supportive care (BSC) or fluorouracil (FU) and folinic acid (FA) in unresectable gall bladder cancer (GBC). PATIENTS AND METHODS Patients with unresectable GBC were enrolled for single center randomized study. Arm A, BSC; arm B, FU 425 mg/m(2) and FA 20 mg/m(2) intravenous (IV) bolus weekly for 30 weeks (FUFA); arm C, gemcitabine 900 mg/m(2) and oxaliplatin 80 mg/m(2) IV infusion on days 1 and 8 every 3 weeks for maximum of six cycles. Eighty-one patients were randomly assigned, arms A (n = 27), B (n = 28), and C (n = 26). RESULTS Complete response plus partial response in the three groups was 0 (0%), four (14.3%), and eight (30.8%) respectively (P < .001). Two patients in the mGEMOX arm and one patient in the FUFA arm underwent curative resection after chemotherapy. One patient in the mGEMOX arm had complete pathologic response. Median overall survival (OS) was 4.5, 4.6, and 9.5 months for the BSC, FUFA, and mGEMOX arms (P = .039), respectively. Progression-free survival (PFS) was 2.8, 3.5, and 8.5 months for the three groups (P < .001). There was no difference in grade 3/4 toxicities in the chemotherapy arms except transaminitis, which was more prevalent in mGEMOX arm (P = .04). Two patients in the FUFA arm and 10 patients in the mGEMOX arm had grade 3 or 4 myelosuppression. Two patients in the mGEMOX group had neutropenic fever that resolved with antibiotics. CONCLUSION This randomized controlled trial confirmed the efficacy of chemotherapy (mGEMOX) compared with BSC and FUFA in improving OS and PFS in unresectable GBC.

Hepatobiliary and pancreatic tuberculosis: A two decade experience

BackgroundIsolated hepatobiliary or pancreatic tuberculosis (TB) is rare and preoperative diagnosis is difficult. We reviewed our experience over a period two decades with this rare site of abdominal tuberculosis.MethodsThe records of 18 patients with proven histological diagnosis of hepatobiliary and pancreatic tuberculosis were reviewed retrospectively. The demographic features, sign and symptoms, imaging, cytology/histopathology, procedures performed, outcome and follow up data were obtained from the departmental records. The diagnosis of tuberculosis was based on granuloma with caseation necrosis on histopathology or presence of acid fast bacilli.ResultsOf 18 patients (11 men), 11 had hepatobiliary TB while 7 had pancreatic TB. Two-thirds of the patients were < 40 years (mean: 42 yrs; range 19–70 yrs). The duration of the symptoms varied between 2 weeks to 104 weeks (mean: 20 weeks). The most common symptom was pain in the abdomen (n = 13), followed by jaundice (n = 10), fever, anorexia and weight loss (n = 9). Five patients (28%) had associated extra-abdominal TB which helped in preoperative diagnosis in 3 patients. Imaging demonstrated extrahepatic bile duct obstruction in the patients with jaundice and in addition picked up liver, gallbladder and pancreatic masses with or without lymphadenopathy (peripancreatic/periportal). Preoperative diagnosis was made in 4 patients and the other 14 were diagnosed after surgery. Two patients developed significant postoperative complications (pancreaticojejunostomy leak [1] intraabdominal abscess [1]) and 3 developed ATT induced hepatotoxicity. No patient died. The median follow up period was 12 months (9 – 96 months).ConclusionTuberculosis should be considered as a differential diagnosis, particularly in young patients, with atypical signs and symptoms coming from areas where tuberculosis is endemic and preoperative tissue and/or cytological diagnosis should be attempted before labeling them as hepatobiliary and pancreatic malignancy.

Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment.

BACKGROUND & AIMS Patients with carcinoma of the gallbladder (GBC) and obstructive jaundice are usually not amenable to curative resection. Effective palliation by biliary decompression is the goal of treatment. Endoscopic stenting (ES) and percutaneous transhepatic biliary drainage (PTBD) can provide biliary decompression. We compared unilateral PTBD and ES in patients with a hilar block caused by GBC and assessed their quality of life (QOL). METHODS Consecutive patients with GBC not suitable for curative resection with Bismuth type 2 or 3 block were randomized to either PTBD or ES with a 10F plastic stent. Technical success, successful drainage, early cholangitis, complications, procedure-related mortality, 30-day mortality, survival, and QOL before and 1 and 3 months after stenting were compared between the 2 groups. All patients were followed up until death. RESULTS Fifty-four patients were randomized to PTBD or ES (27 each). Successful drainage was better in the PTBD group (89% vs 41%; P < .001). Early cholangitis was significantly higher in the ES group (48% vs 11%; P = .002). Procedure-related (4% vs 8%) and 30-day mortality (4% vs 8%) and median survival were similar (60 days in both; P = .71). Although the World Health Organization-Quality of Life 1- and 3-month physical and psychological scores were better after PTBD, the difference was not significant. The European Organization for Research and Treatment of Cancer (EORTC)-Quality of Life Questionnaire 30 global health status at 3 months was significantly better after PTBD (75 vs 30.5, P = .02). The EORTC symptom scores improved in both groups, but only fatigue was significantly better after PTBD. CONCLUSIONS PTBD provides better biliary drainage and has lower complication rates in patients with GBC and hilar block.

Rectal Histology in Acute Bacillary Dysentery

A recent epidemic of acute Shigella dysentery in West Bengal (India) provided us with an opportunity to examine the rectal mucosal abnormalities seen in this condition. One hundred two patients were investigated using sigmoidoscopy, rectal biopsy, and rectal swab for culture. Pure culture of Shigella was obtained in 37 cases, and the rectal biopsy specimens from these patients were assessed in detail. The mean (+/- SD) duration of illness was 47.8 +/- 27.4 h (range 8-120 h), and most patients (31 of 37, 84%) had diarrhea with blood and mucus in the stools. Significant findings at histology were as follows. (a) Cellular infiltrate was predominantly round cell or mixed round cell and neutrophilic in the majority of patients (27, 73%). (b) Disorganization of crypts was seen in as many as 31 patients (84%); in most subjects the distorted architecture was mild, but in a few the defect was severe with crypt branching and dilatation. (c) In the majority of patients the inflammatory process extended to the muscularis mucosae and submucosa; edema with or without increased cellular infiltrate was seen in the muscularis mucosae in 92% and in the submucosa in 80%. (d) There was no difference in the rectal histology of patients with a short history of disease (less than 48 h) compared with those with a longer history, except for goblet cell depletion which was more in those with diarrhea for more than 48 h. (e) The mucosal abnormalities in patients with watery diarrhea were, in general, milder than in those with dysentery, although the difference was statistically not significant; 2 of 6 patients with watery diarrhea had severe colitis. (f) The mucosal abnormalities were more severe in patients with Shigella dysenteriae infection compared with Shigella flexneri.

Gallbladder cancer in India: A dismal picture

Background: Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited.

Palliative stenting for relief of dysphagia in patients with inoperable esophageal cancer: impact on quality of life

The aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of a self-expanding metal stent (SEMS) is a well-established modality for palliation of dysphagia in such patients. We assessed the QOL after palliative stenting in patients with inoperable esophageal cancer. Thirty-three patients with dysphagia due to inoperable esophageal cancer underwent SEMS insertion between October 2004 and December 2006. All patients had grade III/IV dysphagia and locally advanced unresectable cancer (n = 13), distant metastasis (n = 14), or comorbid conditions/poor general health status precluding a major surgical procedure (n = 6). Patients with grade I/II dysphagia and those with carcinoma of the cervical esophagus were excluded. The QOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3) and EORTC QLQ-Esophagus (OES) 18 questionnaire (a QOL scale specifically designed for esophageal diseases) before and at 1, 4, and 8 weeks after placement of the stent. The mean age of the patients was 56 (range 34-78) years, and 22 were men. A covered SEMS was used in all patients. The most common site of malignancy was the lower third of the esophagus (n = 18, 55%). In 23 (77%) patients, the stent crossed the gastroesophageal junction. Seven patients required a reintervention for stent block (n = 5) and stent migration (n = 2). Dysphagia improved significantly immediately after stenting, and this improvement persisted until 8 weeks (16.5 vs. 90.6; P < 0.01). The global health status (5.8 vs. 71.7; P < 0.01) and all functional scores improved significantly after stenting from baseline until 8 weeks. Except pain (14.1 vs. 17.7; P = 0.67), there was significant improvement in deglutition (22.7 vs. 2.0; P < 0.01), eating (48 vs. 12.6; P < 0.01), and other symptom scales (19.7 vs. 12.1; P = 0.04) following stenting. The median survival was 4 months (3-7 months). Palliative stenting using SEMS resulted in significant improvement in all scales of QOL without any mortality and acceptable morbidity.

Transcatheter arterial embolization in the management of hemobilia

BackgroundThis retrospective analysis evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) in the treatment of significant hemobilia. The imaging findings, embolization technique, complications, and efficacy are described.MethodsThirty-two consecutive patients (21 male, 11 female, age range 8–61 years) who were referred to the radiology department for severe or recurrent hemobilia were treated by TAE. Causes of hemobilia were liver trauma (n = 19; iatrogenic in six and road traffic accident in 13), vasculitis (n = 6), vascular malformations (n = 2), and hepatobiliary tumors (n = 5). Iatrogenic liver trauma was secondary to cholecystectomy in those six patients. Four of five hepatobiliary tumors were inoperable malignant tumors and one was a giant cavernous hemangioma. Arterial embolization was done after placing appropriate catheters as close as possible to the bleeding site. Embolizing materials used were Gelfoam, polyvinyl alcohol particles or steel coils, alone or in combination. Postembolization angiography was performed in all cases to confirm adequacy of embolization. Follow-up color Doppler ultrasound and contrast-enhanced computed tomography was done in all patients.ResultsUltrasonic, computed tomographic, and angiographic appearances of significant hemobilia were assessed. Angiogram showed the cause of bleeding in all cases. Three patients with liver trauma due to accidents required repeat embolization. Eight patients required surgery due to failed embolization (continuous or repeat bleeding in four patients, involvement of the large extrahepatic portion of hepatic artery in two, and coexisting solid organ injuries in two). Severity of hemobilia did not correlate with grade of liver injury. All 13 patients with blunt hepatic trauma showed the cause of hemobilia in the right lobe. No patient with traumatic hemobilia showed an identifiable cause in the left lobe. There were no clinically significant side effects or complications associated with TAE except one gallbladder infarction, which was noted at surgery, and cholecystectomy was performed with excision of the hepatic artery aneurysm.ConclusionTAE is a safe and effective interventional radiologic procedure in the nonoperative management of patients who have significant hemobilia.

Differentiation between benign and malignant hilar obstructions using laboratory and radiological investigations: A prospective study

BACKGROUND Preoperative determination of the aetiology of bile duct strictures at the hilum is difficult. We evaluated the diagnostic accuracy of laboratory parameters and imaging modalities in differentiating between benign and malignant causes of hilar biliary obstruction. PATIENTS AND METHODS Fifty-eight patients (26 men) with a history of obstructive jaundice and liver function tests (LFTs) and ultrasound suggestive of biliary obstruction at the hilum were studied. They were evaluated by tumour marker assay (CA19-9), CT and MRI/MRCP. A single experienced radiologist, blinded to the results of other tests, evaluated the imaging. The final diagnosis was made either from histology of the resected specimen, operative findings or image-guided biopsy in inoperable patients. A receiver operator characteristic (ROC) curve was constructed for each laboratory parameter to determine optimal diagnostic cut-off to predict malignant biliary stricture (MBS). RESULTS In all, 34 patients had a benign and 24 had malignant aetiology. The mean age of benign patients was 38 years compared with 54 years for MBS. Forty-seven patients were treated with surgery while 11 had ERCP/PTC and stenting. The ROC curve showed that preoperative bilirubin level >8.4 mg/dl (sensitivity 83.3%, specificity 70%), alkaline phosphatase level >478 IU (sensitivity 63%, specificity 49%) and CA19-9 levels >100 U/L (sensitivity 45.8%, specificity 88.2%) for predicting MBS. The sensitivity, specificity and diagnostic accuracy of MRI/MRCP (87.5%, 85.3%, 82.7%, respectively) was marginally superior to CT (79.2%, 79.4%, 79.3%, respectively). CONCLUSIONS Patients with a bilirubin level of >8.4 mg% and CA19-9 level >100 U/L were more likely to have malignant aetiology. MRI/MRCP was a better imaging modality than CT.

En bloc resection of right-sided colonic adenocarcinoma with adjacent organ invasion

BackgroundRight-sided colon cancers that invade the adjacent organs are often missed on preoperative imaging. These patients are often considered unresectable at laparotomy as the surgeon is not prepared for en bloc resections. A few centers have reported extended survival after en bloc resection in such tumors. We therefore decided to evaluate the outcome of our patients after en bloc right hemicolectomy.Patients and methodsThe records of all patients who underwent en bloc resection of adjacent organs for right colon cancers were analyzed.ResultsBetween 1992 and 2004, 11 patients had an en bloc right hemicolectomy for right-sided colon cancer. There were ten males and one female with a mean age of 44 years (35–80 years). All patients had anaemia at presentation and most had weight loss and a fixed palpable lump. Preoperative CT scan was able to detect adjacent organ infiltration in nine patients. Six patients had an en bloc pancreaticoduodenectomy, three patients had en bloc local excision of duodenal wall, one patient had en bloc resection of segments 5 and 6 of the liver and one patient had en bloc distal gastrectomy. There was one operative mortality after an en bloc pancreaticoduodenectomy. The median disease-free survival was 54 months.ConclusionRight-sided colon cancers that invade adjacent organs in the absence of distant spread may be a subset of tumors that behave in a locally aggressive manner without causing hematogenous spread. En bloc resection of these tumors is possible, in select centers, with low mortality and morbidity and extended survival.

Spontaneous Rupture of a Giant Hepatic Hemangioma – Sequential Management with Transcatheter Arterial Embolization and Resection

Hemangioma is the most common benign tumor of liver and is often asymptomatic. Spontaneous rupture is rare but has a catastrophic outcome if not promptly managed. Emergent hepatic resection has been the treatment of choice but has high operative mortality. Preoperative transcatheter arterial embolization (TAE) can significantly improve outcome in such patients. We report a case of spontaneous rupture of giant hepatic hemangioma that presented with abdominal pain and shock due to hemoperitoneum. Patient was successfully managed by TAE, followed by tumor resection. TAE is an effective procedure in symptomatic hemangiomas, and should be considered in such high risk patients prior to surgery.