Venkatramani Sitaram

Palliative gastrectomy in advanced gastric cancer : Is it worthwhile?

Background:  Gastric cancer remains one of the leading causes of cancer‐related deaths. Many patients present late, and therefore, resections are often palliative in nature. The aim of this study was to assess the feasibility of resectional operation and the survival advantage of surgical resection in advanced gastric cancer. The effectiveness of palliation and the quality of life following operation for gastric cancer were assessed.

Portal annular pancreas. A rare variant and a new classification.

CONTEXT Portal annular pancreas is a rare congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein/superior mesenteric vein. It is asymptomatic, but could have serious consequences during pancreatic surgery, if unrecognized. We describe a variant of this anomaly encountered during pancreaticoduodenectomy and propose a new classification. CASE REPORT We report a 51-year-old male who underwent a pancreaticoduodenectomy for periampullary carcinoma. After division of the pancreatic neck, a sheath of tissue was found posterior and extending to the left of the portal vein. When we divided this tissue, a large duct was encountered; this duct communicated with the main pancreatic duct. On review of the CT images, the main pancreatic duct was seen to be passing posterior to the portal vein and a smaller accessory pancreatic duct was present anterior to the portal vein. We describe the surgical implications. CONCLUSION This variant of portal annular pancreas has not yet been reported during pancreaticoduodenectomy and we propose a new classification for this fusion anomaly.

Post-cholecystectomy benign biliary stricture with portal hypertension: is a portosystemic shunt before hepaticojejunostomy necessary?

BACKGROUND Portal hypertension develops in 15-20% of patients with benign bile duct stricture. Hepaticojejunostomy in such patients is associated with considerable morbidity and mortality. Preliminary portosystemic shunting has been suggested to reduce intra-operative bleeding. We present our experience without preliminary shunting in such patients. PATIENTS AND METHODS Fourteen consecutive cases of biliary stricture with portal hypertension over a 13-year period (1989-2001) were retrospectively analysed. RESULTS Thirteen patients were operated upon. One patient had a preliminary portosystemic shunt. In another patient, shunt was attempted. One stage hepaticojejunostomy was possible in 11 patients. There were no intra-operative deaths. Nine of the 13 survived and were available for follow-up. One patient had cholangitis. Another had jaundice related both to chronic liver disease and a strictured hepaticojejunostomy. The remaining 7 patients are asymptomatic and anicteric although alkaline phosphatase levels remain elevated in 5 of them. CONCLUSIONS Hepaticojejunostomy without preliminary portosystemic shunting is possible in patients with portal hypertension and benign biliary stricture with acceptable morbidity and mortality rates.

Spontaneous choledochal cyst rupture in pregnancy with concomitant chronic pancreatitis.

Choledochal cysts are rare cystic transformations of the biliary tree that are increasingly diagnosed in adult patients. We report here a case of spontaneous rupture of a choledochal cyst in a pregnant young lady with chronic pancreatitis.

Benign biliary papillomatosis in a patient with a choledochal cyst presenting as haemobilia: a case report

Biliary papillomatosis is a rare condition usually detected on imaging or postoperative histopathology. It may be asymptomatic or present with features of cholangitis. We report the management of a patient presenting with haemobilia.

Inadvertent central venous infusion of enteral feed: a case report.

Inadvertent administration of enteral feed into an intravenous line is preventable usually by design of incompatible connectors, but these may not be available universally. We discuss a case report where this occurred and the subsequent management strategy.

Relentless Progression of Venous Obstruction in a Case of Budd- Chiari Syndrome Related to Heterozygous Protein C Deficiency

AbstractA 28-year-old man with heterozygous protein C deficiency presented with Budd-Chiari syndrome resulting from hepatic vein obstruction. Over the next 40 months, standard oral anticoagulant therapy and multiple percutaneous interventions aimed at relieving hepatic vein obstruction could not prevent progression of the disease ultimately to cirrhosis and death. Serial angiography provided unique documentation of the relentless progression of hepatic venous obstruction, which was related to the disease and to iatrogenic factors. Operative findings obtained during unsuccessful mesocaval shunt surgery revealed that venous disease in protein C deficiency can be far more extensive than is clinically anticipated. The ineffectiveness of therapy in this patient may be related to standard oral anticoagulant therapy being insufficient to offset the risk of recurrent thrombosis and progression to an advanced stage of vascular damage.

Liver metastasis in an adolescent treated for third ventricle germ cell tumor.

Systemic dissemination of intracranial germ cell tumors (GCTs) occur only in 3% of cases and the common sites are bone, lungs, and lymph nodes. Metastasis to the liver is rare. As far as we could find, only six cases of liver metastasis of intracranial GCTs have been reported so far. We report an adolescent girl who presented with hepatic relapse 2½ years after successful completion of treatment of intracranial GCT. She was treated with chemotherapy and right hepatectomy and is doing well 30 months after treatment for the metastatic disease.

Management of colorectal cancer liver metastasis in a patient with immune thrombocytopaenia

Immune thrombocytopaenia (ITP) was referred to previously as idiopathic thrombocytopaenic purpura and is usually of autoimmune or viral aetiology. Colorectal cancer liver metastasis with concomitant ITP is rare and only three cases have been reported in the English literature. Adverse effects of adjuvant chemotherapy may aggravate ITP. The sequencing of chemotherapy, operation for the primary and liver metastasis, and a decision on splenectomy is important. We present our experience in the management of a 52-year-old man who, having undergone anterior resection one year earlier for carcinoma of the rectum, presented with liver metastasis and ITP. He underwent splenectomy with hepatectomy prior to chemotherapy.

Intraductal papillary mucinous neoplasm of the pancreas

Indian J Gastroenterol 2010(January–February):29(1):46 A 53-year-old lady presented with a 2-month history of recurrent attacks of moderate intensity epigastric pain radiating to the back, which was relieved with oral analgesics. There was no fever, anorexia or weight loss. There was no history of smoking or alcohol consumption. Clinical examination was unremarkable. Laboratory investigations revealed – hemoglobin 10.4 g/dL, serum amylase 128 U/L (normal <200 U/L), serum alkaline phosphatase 468 U/L (40–125) and CA19-9 307 U/L (< 33). Abdominal computed tomography (CT) scan (Fig. 1) revealed a 5 cm × 4 cm mass involving the head and uncinate process of pancreas, dilated biliary and pancreatic ducts with no evidence of distant metastasis. A side-viewing duodenoscopy (Fig. 2) revealed gaping of both the major and minor papillae, plugged with mucin, producing the classic “fish-eye appearance” suggestive of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Fluid from the pancreatic duct showed atypical cells. The patient underwent Whipple’s resection. Histopathology examination revealed an IPMN of pancreas (main duct type) with moderate dysplasia. The resection margin and regional lymph nodes were free of tumor. Recurrent abdominal pain associated with a pancreatic mass is a common problem. The common differential diagnosis would include an adenocarcinoma or an inflammatory mass associated with chronic pancreatitis. In our patient, side-viewing duodenoscopy was done to look for duodenal infiltration by a mass. The classic fish-eye appearance suggested the diagnosis of IPMN which was confirmed by microscopic examination of pancreatic juice. Unlike adenocarcinoma of pancreas, complete resection of an IPMN augurs a much better prognosis. Endoscopic ultrasound is being increasingly used to diagnose IPMN. EUS findings that may predict malignant potential of an IPMN of the pancreas are: location of the lesion in the main duct, size of lesion >3 cm (if located in the branch duct) and presence of a mural nodule >5 mm size. Follow up is required because of the association with extrapancreatic malignancies, notably gastric and colonic cancers.