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Anand U, Kodali R, Parasar K, Singh BN, Kant K, Yadav S, Anwar S, Arora A. Comparison of short-term outcomes of open and laparoscopic assisted pancreaticoduodenectomy for periampullary carcinoma: A propensity score-matched analysis. Ann Hepatobiliary Pancreat Surg 2024:ahbps.23-144. [PMID: 38384237 DOI: 10.14701/ahbps.23-144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/23/2024] Open
Abstract
Backgrounds/Aims Postoperative pancreatic fistula is the key worry in the ongoing debate about the safety and effectiveness of total laparoscopic pancreaticoduodenectomy (TLPD). Laparoscopic-assisted pancreaticoduodenectomy (LAPD), a hybrid approach combining laparoscopic resection and anastomosis with a small incision, is an alternative to TLPD. This study compares the short-term outcomes and oncological efficacy of LAPD vs. open pancreaticoduodenectomy (OPD). Methods A retrospective analysis of data of all patients who underwent LAPD or OPD for periampullary carcinoma at a tertiary care center in Northeast India from July 2019 to August 2023 was done. A total of 30 LAPDs and 30 OPDs were compared after 1:1 propensity score matching. Demographic data, intraoperative and postoperative data (30 days), and pathological data were compared. Results The study included a total of 93 patients, 30 underwent LAPD and 62 underwent OPD. After propensity score matching, the matched cohort included 30 patients in both groups. The LAPD presented several advantages over the OPD group, including a shorter incision length, reduced postoperative pain, earlier initiation of oral feeding, and shorter hospital stays. LAPD was not found to be inferior to OPD in terms of pancreatic fistula incidence (Grade B, 30.0% vs. 33.3%), achieving R0 resection (100% vs. 93.3%), and the number of lymph nodes harvested (12 vs. 14, p = 0.620). No significant differences in blood loss, short-term complications, pathological outcomes, readmissions, and early (30-day) mortality were observed between the two groups. Conclusions LAPD has comparable safety, technical feasibility, and short-term oncological efficacy.
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Affiliation(s)
- Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Rohith Kodali
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Basant Narayan Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kislay Kant
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Sitaram Yadav
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Saad Anwar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Abhishek Arora
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
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Anand U, John AG, Priyadarshi RN, Kumar R, Singh BN, Parasar K, Kumar B. Long-term complications after extrahepatic cyst excision for type IV-A choledochal cysts. Ann Hepatobiliary Pancreat Surg 2023; 27:433-436. [PMID: 37128846 DOI: 10.14701/ahbps.23-021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/18/2023] [Accepted: 03/28/2023] [Indexed: 05/03/2023] Open
Abstract
Forty-five adults with type IV-A choledochal cysts (CDC) who underwent extrahepatic cyst excision from January 2013 to December 2021 were followed up for a median interval of 25 months (range, 2 to 10 years) to observe the long-term complications in the remaining intrahepatic cyst. Late complications in varying combinations were seen in 10 patients, which included cholangitis and/or intrahepatic stones in 9 patients, intrahepatic bile duct stenosis with stones in 2 patients, anastomotic stricture in 6 patients, and left lobar atrophy with intrahepatic stones in 3 patients. Out of 6 patients who required re-do hepaticojejunostomy (HJ), three patients had left lobe atrophy with patent HJ anastomosis and a recurrent attack of cholangitis on follow-up at 3, 8, and 10 years. Complications occur frequently after extrahepatic cyst excision for type IV-A CDC and require a long-term follow-up.
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Affiliation(s)
- Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Aaron George John
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | | | - Ramesh Kumar
- Department of Medical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Basant Narayan Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Bindey Kumar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Patna, India
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Anwar S, Parasar K, Kodali R, Yadav S, Singh BN. Left paraduodenal hernia: an uncommon cause of chronic abdominal pain. Br J Surg 2022; 110:738. [PMID: 36440621 DOI: 10.1093/bjs/znac419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Saad Anwar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences , Patna , India
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences , Patna , India
| | - Rohith Kodali
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences , Patna , India
| | - Sitaram Yadav
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences , Patna , India
| | - Basant Narayan Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences , Patna , India
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Parasar K, Mohan S, John AG, Nigam J, Anand U, Jha CK. Giant Adrenal Pseudocysts: An Enigma for Surgeons. Surg J (N Y) 2022; 8:e112-e116. [PMID: 35252569 PMCID: PMC8894084 DOI: 10.1055/s-0042-1744153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
Abstract
Adrenal pseudocysts are cystic lesions arising within the adrenal gland enclosed by a fibrous connective tissue wall that lacks lining cells. They can attain a huge size and pose a diagnostic challenge with a broad range of differentials including benign and malignant neoplasms. There are only a few small case series and case reports describing these lesions. We report a series of five patients who presented with “indeterminate” abdominal cystic lesions and were later on found to have adrenal pseudocyst. Four out of five patients presented with non-specific abdominal symptoms, and one patient presented with symptoms suggestive of a functional adrenal tumor. The size of these tumors ranged from 6 to 30 cm. They had variable radiological features and in two cases even a percutaneous biopsy could not establish the diagnosis. In four of these “indeterminate” abdominal masses, an adrenal origin was not suspected preoperatively. Surgical excision provided a resolution of symptoms, ruled out malignancy, and clinched the diagnosis.
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Affiliation(s)
- Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Shantam Mohan
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India.,Department of Gastroenterology, Saroj Madan Gastro and Liver Clinic, Patna, Bihar, India
| | - Aaron George John
- Department of Gastroenterology, Saroj Madan Gastro and Liver Clinic, Patna, Bihar, India
| | - Jitendra Nigam
- Department of Pathology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Chandan Kumar Jha
- Department of General Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
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Anand U, Kumar R, Priyadarshi RN, Kumar M, Kumar R, Ahmed N, John AG, Parasar K, Kumar B. Analysis of outcomes of biliary reconstruction after post-cholecystectomy bile duct injuries. ANZ J Surg 2021; 91:1542-1548. [PMID: 34184389 DOI: 10.1111/ans.17047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Post-cholecystectomy bile duct injury (BDI) is a serious complication that often requires surgical repair. This study aimed to analyze the outcomes of surgery performed for BDI and to determine the factors associated with post-surgical complications. METHODS A retrospective analysis was conducted using a prospectively maintained database of 105 patients who underwent surgical repair for post-cholecystectomy BDI between March 2013 and March 2020. BDI was classified based on the Strasberg-Bismuth system, and the outcomes were graded using the McDonald criteria. Multivariable logistic regression was used to identify the significant variables associated with postoperative complications. RESULTS In a cohort of 105 patients with post-cholecystectomy BDI who underwent bilioenteric repair, 71 (67.6%), 25 (23.8%), 2 (1.9%), and 7 (6.7%) patients had excellent, good, fair, and poor outcomes, respectively, during a median follow-up of 64 months. The incidence of recurrent biliary stricture after definitive surgical hepaticojejunostomy was 6.7% (n = 7). The presence of cholangitis, choledochoduodenal fistula, and hilar biliary strictures was among the significant variables associated with the development of both short-term and long-term complications following surgery. CONCLUSIONS Surgical repair of BDIs with bilioenteric anastomosis can yield excellent results when managed in a tertiary care center where expertise in the reconstruction of the biliary tree is prioritized.
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Affiliation(s)
- Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | | | - Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Rakesh Kumar
- Senior Specialist Medical Officer, CHC Minapur, Muzaffarpur, India
| | - Nehal Ahmed
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Aaron George John
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Bindey Kumar
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Patna, India
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Abstract
Background Prolonged lockdown in our country provided us with a unique opportunity to study the interplay of psychosocial impact on pain in surgically treated patients of chronic pancreatitis. Methods Forty-one patients who underwent surgery for chronic pancreatitis in the last 24 months were followed up, of which 27 were enrolled. The data were collected telephonically. Pain was assessed using the numeric pain rating (NPR) scale and depression using Patient Health Questionnaire (PHQ) 9. In patients having recent onset pain during the lockdown, oral tramadol 50 mg and amitryptiline 25 mg were prescribed and reassessed after two weeks. Results Of the 25 pain-free patients in February (pre-lockdown), 14 developed pain of varying intensity during the lockdown and were prescribed medications. Twelve out of 14 patients had very good resolution of pain after two weeks of medication. Conclusions Operated patients with chronic pancreatitis who developed new-onset depression and pain responded well to low-dose anti-depressants in addition to analgesics. This study gives indirect, objective evidence that covert depression leading to pain in chronic pancreatitis is often downplayed and interpreted as poor results of surgery.
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Affiliation(s)
- Kunal Parasar
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Shantam Mohan
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Aaron G John
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Utpal Anand
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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Anand U, Khandelwal C, Senthilnathan P, Sabnis SC, Palanivelu C, Kumar B, Kumar R, Priyadarshi RN, Parasar K. The Current Concepts and Management of Idiopathic (Tropical) Chronic Pancreatitis. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02780-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Anand U, Kumar R, Priyadarshi RN, Parasar K, John AG. An Unusual Postoperative Complication of Retrosternal Gastric Pull-Up for Corrosive Esophageal Stricture. Cureus 2020; 12:e12323. [PMID: 33520521 PMCID: PMC7837637 DOI: 10.7759/cureus.12323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Retrosternal gastric pull-up with side-to-side esophagogastric anastomosis is the surgery done for corrosive esophageal stricture unresponsive to endoscopic dilatation. This surgery is considered safe in terms of morbidity. Complications due to leak from distal esophageal staple line as a result of partially patent bypassed esophageal lumen have never been reported with this surgery. Herein, we report a case in which a leak from distal esophageal staple line resulted in intraabdominal fluid collection, a life-threatening complication. This complication necessitated a second surgery that involved exclusion of the native esophagus at the neck.
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Affiliation(s)
- Utpal Anand
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Ramesh Kumar
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | | | - Kunal Parasar
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Aaron G John
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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Anand U, Kumar R, Priyadarshi RN, Parasar K, John AG. Proximal Splenorenal Shunt Surgery for Bleeding Gastric Varices in Non-Cirrhotic Portal Hypertension. Cureus 2020; 12:e10464. [PMID: 33083167 PMCID: PMC7566982 DOI: 10.7759/cureus.10464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The optimal management of gastric variceal bleeding in patients with non-cirrhotic portal hypertension (NCPH) is debatable due to the lack of data from large randomized controlled trials. Here we present our experience on proximal splenorenal shunt (PSRS) surgery in NCPH patients with bleeding gastric varices. Methods Over a five-year period, a total of 25 PSRS surgeries were performed and data was collected prospectively. Nineteen extrahepatic portal vein obstruction (EHPVO) and six non-cirrhotic portal fibrosis (NCPF) patients with bleeding fundic or isolated gastric varices and normal liver function were included. The collected data was analyzed retrospectively. Results Of the 25 patients who underwent PSRS five were lost to follow-up. Twenty patients (80%) were followed up for a median of 3.4 (1-5) years. Gastric variceal regression was noted in all 20 patients with the disappearance of varices in eight patients. On follow-up, shunt thrombosis was noted in four (20%) patients of whom, two had rebleeding between six months and three years after shunt surgery. Conclusion PSRS was effective in controlling gastric variceal hemorrhage in 92% (23 of 25) of patients with preserved liver function.
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Affiliation(s)
- Utpal Anand
- Surgical Gastroenterology, All India Institute of Medical Sciences Patna, Patna, IND
| | - Ramesh Kumar
- Gastroenterology, All India Institute of Medical Sciences Patna, Patna, IND
| | | | - Kunal Parasar
- Surgical Gastroenterology, All India Institute of Medical Sciences Patna, Patna, IND
| | - Aaron G John
- Surgical Gastroenterology, All India Institute of Medical Sciences Patna, Patna, IND
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Abstract
Obstructive jaundice caused by periampullary duodenal diverticulum in absence of choledocholithiasis or tumor is known as Lemmel syndrome. This is a rare cause of obstructive jaundice. We report here a patient of blunt trauma abdomen who underwent emergency laparotomy whose sequelae was a controlled external biliary fistula which healed and led to obstructive jaundice. What appeared to be a clear cut diagnosis of benign biliary stricture or bilioma gave a surgical surprise on opening the pandoras box. The uniqueness of this case lies in its etiopathogenesis as well as the dearth of available literature related to post traumatic Lemmel syndrome. This case provides us with a insight into an easy to be overlooked cause of obstructive jaundice in the absence of duodenal diverticula.
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Affiliation(s)
- Kunal Parasar
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Aaron G John
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Shantam Mohan
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Utpal Anand
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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Kumar R, Anand U, Priyadarshi RN, Mohan S, Parasar K. Management of amoebic peritonitis due to ruptured amoebic liver abscess: It's time for a paradigm shift. JGH Open 2019; 3:268-269. [PMID: 31276048 PMCID: PMC6586569 DOI: 10.1002/jgh3.12144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 12/29/2018] [Indexed: 01/11/2023]
Abstract
Amoebic peritonitis secondary to rupture of amoebic liver abscess (ALA) has been reported to occur in 2.4 to 13% of cases with a high fatality rate. There is still no consensus as to how a ruptured ALA associated with diffuse amoebic peritonitis be optimally managed. The mortality rates following surgical therapy in patients with ruptured ALA freely into the peritoneum have ranged from 20%‐ to 50%. The introduction of percutaneous catheter drainage (PCD) has opened a new therapeutic possibility for this group of patients and emerging data suggest that PCD should be the preferred option in such group of patients.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology All India Institute of Medical Sciences Patna India
| | - Utpal Anand
- Department of Surgical Gastroenterology All India Institute of Medical Sciences Patna India
| | - Rajeev N Priyadarshi
- Department of Radiodiagnosis All India Institute of Medical Sciences Patna India
| | - Shantam Mohan
- Department of Gastroenterology All India Institute of Medical Sciences Patna India
| | - Kunal Parasar
- Department of Surgical Gastroenterology All India Institute of Medical Sciences Patna India
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Gupta R, Anand U, Parasar K, Kumari M, Bhadani P. Ampullary Neuroendocrine Tumor With Multiple Gastrointestinal Stromal Tumors in a Patient with Von Recklinghausen’s Disease Patient: A Case Report. MAMC J Med Sci 2019. [DOI: 10.4103/mamcjms.mamcjms_51_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Parasar K, Varshney VK, Mishra PK, Saluja SS. Gall Bladder Carcinoma in Patients with Portal Hypertension. Am Surg 2018. [DOI: 10.1177/000313481808401204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kunal Parasar
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Pramod Kumar Mishra
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Sundeep Singh Saluja
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
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Parasar K, Varshney VK, Mishra PK, Saluja SS. Gall Bladder Carcinoma in Patients with Portal Hypertension. Am Surg 2018; 84:e510-e513. [PMID: 30606359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Parasar K, Saluja SS, Varshney VK, Deepak B, Mishra PK. Early recurrence after laparoscopic radical cholecystectomy in a patient with gallbladder cancer. J Minim Access Surg 2018; 15:74-76. [PMID: 29794366 PMCID: PMC6293673 DOI: 10.4103/jmas.jmas_97_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Laparoscopic radical cholecystectomy for gallbladder cancer (GBC) has been performed at various oncology centres reporting its technical feasibility. Considering GBC an aggressive malignancy, laparoscopic radical cholecystectomy should be dealt with caution. We recently encountered a case of carcinoma gallbladder who underwent laparoscopic radical cholecystectomy elsewhere and presented with early recurrence. The patient's records were evaluated and he underwent re-resection. Hereby, we discuss the factors that could lead to early recurrence after laparoscopic radical cholecystectomy and measures that can be taken to prevent it.
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Affiliation(s)
- Kunal Parasar
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Sundeep Singh Saluja
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - B Deepak
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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