Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021

BACKGROUND

Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

METHODS

Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

CONCLUSIONS

These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

Multimodality management, recurrence patterns, and long-term outcome of gastroenteropancreatic neuroendocrine neoplasms: Progress over 17 years

BACKGROUND

Many advances in the management of gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) happened in the last two decades. This study highlights the progress in its management over 17 years, outcomes, recurrence patterns, and follow up protocols.

METHODS

This retrospective analysis of prospectively maintained database at a single tertiary center included GEP-NEN patients from January 2001 to August 2017. Management protocols were based on European Neuroendocrine Tumor Society guidelines. Recurrences were categorized as follows: localized nodal, regional, distant hepatic, or combined. Patients were divided into cohorts: cohort 1 (2001-2006), cohort 2 (2007-2011), and cohort 3 (2012-2017). Survival patterns were analyzed.

RESULTS

One hundred and ninety-two patients were included with 98 (51.04%) grade (G) 1, 64 (33.34%) G2, and 30 (15.63%) G3. One hundred and four (54.16%) underwent curative surgery (58 G1, 27 G2, and 19 G3). Overall follow up ranged from 3 to 276 months; 39 were lost to follow up. Ninety-six patients had recurrences: 44 regional + distant and 40 liver-limited recurrences. One-, 3-, and 5-year survivals show significant differences among different treatment groups (p < 0.05). Significant increase in curative resections, chemotherapy utilization, and reduced recurrences were noted in cohort 3. Curative (R0) resection offered 1- and 3-year overall survival of 93.3% and 66.7% in cohort 1; 95.8% and 83.1% in cohort 2; and 100% and 92.9% in cohort 3.

CONCLUSION

Curative resection is the most significant factor for improved survival. Debulking surgerical procedure have a role whereas upfront peptide receptor radionuclide therapy is questionable. Chemotherapy improves overall survival in inoperable/metastatic setting. Recurrence patterns indicate that a long-term follow up greater than 10 years is necessary.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos)

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1^st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

The role of preoperative C-reactive protein and procalcitonin as predictors of post-pancreaticoduodenectomy infective complications: A prospective observational study

INTRODUCTION

The common causes of morbidity after pancreaticoduodenectomy (PD) are infective complications. Till date, no specific preoperative markers have been identified to determine the probability of developing infective complications. We have studied the factors predicting the occurrence of the infective complication/s in the present study.

METHODS

The present prospective observational study included 133 consecutive patients who underwent PD from January 2011 to June 2016 at a specialized hepatopancreaticobiliary surgical oncology unit. The surgeries were done using a standardized technique. Postoperative complications were segregated into two categories-(a) infective (e.g. cholangitis) and (b) non-infective (e.g. delayed gastric emptying). Increased age, preoperative serum albumin levels, preoperative biliary stenting, pre-stenting serum bilirubin levels, duration of common bile duct stenting, preoperative C-reactive protein [CRP], and procalcitonin [PCT] were evaluated.

RESULTS

Overall morbidity rate was 48.8%. Morbidity associated with infective complications was 21.8%. Increased age, preoperative serum albumin levels, and pre-stenting serum bilirubin levels did not increase the rate of the infective complications. The association between preoperative PCT and preoperative CRP with the infective complications was significant with a p-value of <0.01 (6.75E-07) and <0.01 (4.80E-10), respectively. In the multivariate analysis, only the elevated preoperative procalcitonin was a statistically significant predictor of postoperative infective complications.

CONCLUSION

Preoperative PCT and CRP levels done 48 h before surgery are sensitive, specific, easily available, and cost-effective predictors of infective complications after PD.

Reporting the margin in pancreaticoduodenectomies: R0 versus R1

AIM

This study was conducted to analyze the changes in margin positivity in pancreaticoduodenectomies, on using a standardized protocol, which bread loafs the pancreas and duodenum in the axial plane for adenocarcinomas arising in the pancreatic head, ampulla, terminal common bile duct (CBD), and duodenum, and then to assess whether these tumor subsets involve the margins in different ways.

METHODS

The analysis was performed on 70 consecutive specimens, the pre-protocol specimens serving as the control group.

RESULTS AND CONCLUSIONS

Tumors originating from the pancreatic head, ampulla, terminal CBD, and duodenum showed a consistent increase in their R1 incidence, post-protocol. Ampullary tumors showed the greatest upward change in R1 positivity. The highest incidence of margin positivity was seen in pancreatic head adenocarcinomas (80%), then distal CBD tumors (60%), and finally the ampullary tumors (39%). In pancreatic head adenocarcinomas, R1 increased from 55% to 80%, distal CBD from 50% to 60%, and ampullary from 17% to 39%. Duodenal adenocarcinomas had no R1 in both pre- and post-protocol groups. The tumors also had different patterns of margin involvement. Ampullary tumors involved only the posterior margin, pancreatic adenocarcinomas involved the superior mesenteric vein (SMV) groove more often than the posterior margin, and distal CBD tumors involved the posterior margin and SMV groove equally. The size of the tumor made a significant difference in pancreatic head carcinomas with tumor size less than or equal to 2 cm, showing an R1 incidence of 38%, while those above 2 cm had an R1 incidence of 68%.

Neoadjuvant chemotherapy in patients with locally advanced gallbladder cancer

AIM

Surgery is the only curative option for patients with gallbladder cancer (GBC). This study looks at the outcome of patients treated with neoadjuvant chemotherapy (NACT).

PATIENTS & METHODS

This is retrospective analysis of the prospectively maintained database of patients with locally advanced GBC treated between February 2009 and September 2013 with NACT. Patients received gemcitabine-platinum based regimen.

RESULTS

A total of 37 patients (median age: 54 years, 64.9% females) received NACT. Overall response rate was 67.5%. In total, 17 patients (46%) underwent R0 resection. Median overall survival/progression-free survival of the whole group was 13.4/8.1 months, respectively. Patients who underwent surgery had a significantly better overall survival (median not reached vs 9.5 months) and progression-free survival (25.8 vs 5.6 months), respectively.

CONCLUSION

NACT increases resectability and survival in patients with locally advanced GBC.

An observational study evaluating the expression of HER2 (1+, 2+, and 3+) with HLA A2/A3+ in gastric adenocarcinoma patients

18

Background: Gastric cancer remains a major health issue and results in 800,000 annual deaths worldwide. Despite approximately 50% of the gastric and gastroesophageal (GE) junction adenocarcinomas are diagnosed with resectable disease, 40% of disease recurrence is observed in 24 months. While trastuzumab has shown to increase overall survival in HER2 IHC3+ metastatic disease, no current therapies are available for low expressing, or IHC 1+ or 2+ patients. NeuVax (nelipepimut-S) is an immunogenic peptide epitope derived from the extracellular domain of HER2/nu protein administered in combination with rhGM-CSF. NeuVax binds to HLA-A2 and A3 on tumor and antigen presenting cells (APC) and elicits a proliferation of CD8+ (cytotoxic) T-cell immune response against HER2 expressing cancer cells. A proof of concept clinical study will be conducted to assess the effectiveness of nelipepimut-S to prevent recurrence and increase disease free survival in gastric cancer patients with all levels of HER2 expression with HLA A2+/A3+. This prospective observational study was undertaken to estimate the HLA A2/A3+ and HER2 expression status in the Indian population. Methods: Tumor tissue samples from gastric or GE junction adenocarcinoma patients were collected from S. L. Raheja Hospital, Mumbai, India. A serum sample was collected for HLA testing by quantitative PCR. IHC (DAKO, 1:600 dilution) was employed for detection of HER2. All patients were consented for the study. Results: Of the 50 patients evaluated, 12 (24%) were positive for HER2 (1+, 2+, 3+) with HLA2/A3 alleles, meeting the defined projected clinical protocol population of all levels of expression of HER2 and HLA A2+ and/or A3+. Of the 12 patients, 9 (75%) and 3 (25%) expressed HLA A2 and A3, respectively, with no patient demonstrating HER2 3+ expression. Conclusions: Results from this prospective observational study suggest patients with gastric and GE junction adenocarcinoma have HLA A2+ and/or A3+ expressing tumors with mostly HER2 1+, 2+ expression. The estimated incidence of HER2 3+ expression in this population may be limited by size of current study. Results will inform the screen failure rate of the planned Phase 2 clinical study.

Initial experience with hyperthermic intra peritoneal chemotherapy and cytoreductivesurgery

BACKGROUND

Promising results were reported with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal carcinomatosis. Experiences in India are not published. This is a preliminary report.

MATERIALS AND METHODS

From eight patients with peritoneal metastasis, six patients (5 M, 1 F), aged (40-62 years) were treated with CRS and HIPEC between May 2010 and August 2011 from a single institution. Three had Mucinous Adenocarcinoma of Appendix and one each with Mesothelioma, Ovarian Cancer and Colonic Cancer. Four were earlier treated with systemic chemotherapy and recurred. Pre-operative peritoneal cancer index (PCI) was calculated based on recent computerized tomography or positron emission tomography scans. Surgical completeness cytoreduction score (CCS) was classified as macroscopically complete (CCS-0); optimal residual disease ≤2.5 mm in any region (CCS-1); or grossly incomplete: Residual disease >2.5 mm (CCS-2) or >25 mm (CCS-3). They were treated by closed perfusion technique with mitomycin-C (MCC) and cisplatin at 41-42°C, for 60 min.

RESULTS

Optimal cytoreduction (residual tumor nodules <2.5 mm i.e. CC0 and CC1) was performed in four patients (66.67%). There was no operative mortality or Grade 3 and 4 toxicity. Patients with PCI <11 are alive without recurrence with overall survival of 26-31 months. Those with PCI >11 had recurrence with overall survival of 3-19 months. Two patients died at 3 and 9 months.

CONCLUSION

CRS and HIPEC is a promising therapeutic option in selected patients with peritoneal carcinomatosis. These results in six patients are preliminary but encouraging. Patient with low PCI had better disease free survival.

Chemotherapy and targeted therapy for gall bladder cancer

Gall bladder cancer is a common cancer in the Ganges belt of North-eastern India. In view of incidental diagnosis of gall bladder cancer by physicians and surgeons, the treatment is not optimised. Most patients present in advanced stages and surgery remains the only option to cure. This review highlights the current evidence in advances in systemic therapy of gall bladder cancer.

Experience with the technique of pancreas-sparing distal duodenectomy

Pancreas-sparing distal duodenectomy (PSDD) is a novel surgical technique for tumors of distal duodenum below the ampulla to achieve oncologically free margins and avoid multiple anastomoses. We report PSDD performed in five cases, three duodenal adenocarcinoma, and two neuroendocrine tumors (NETs). Three patients had adenocarcinoma of D3 and D4 with free ampulla. PSDD was performed with total excision of regional nodes. In the two patients with NETs, one had a mass lesion close to the pancreatic head. The mass was excised followed by PSDD. There were four small primary NETs in the duodenum, and the mass was metastatic lymph node. The second patient had primary duodenal NET with liver metastases. After transarterial chemoembolization, PSDD with liver metastatectomy was performed. Specimens in all five cases showed clear margins. The patients had a smooth recovery and were well at a median follow up of 10 months.

TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

TG13 indications and techniques for biliary drainage in acute cholangitis (with videos)

The Tokyo Guidelines of 2007 (TG07) described the techniques and recommendations of biliary decompression in patients with acute cholangitis. TG07 recommended that endoscopic transpapillary biliary drainage should be selected as a first-choice therapy for acute cholangitis because it is associated with a low mortality rate and shorter duration of hospitalization. However, TG07 did not include the whole technique of standard endoscopic transpapillary biliary drainage, for example, biliary cannulation techniques including contrast medium-assisted cannulation, wire-guided cannulation, and treatment of duodenal major papilla using endoscopic papillary balloon dilation (EPBD). Furthermore, recently single- or double-balloon enteroscopy-assisted biliary drainage (BE-BD) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) have been reported as special techniques for biliary drainage. Nevertheless, the updated Tokyo Guidelines (TG13) recommends that endoscopic drainage should be first-choice treatment for biliary decompression in patients with non-surgically altered anatomy and suggests that the choice of cannulation technique or drainage method (endoscopic naso-biliary drainage and stenting) depends on the endoscopist's preference but EST should be selected rather than EPBD from the aspect of procedure-related complications. In terms of BE-BD and EUS-BD, although there are many reports on the their usefulness, they should be performed by skilled endoscopists in high-volume institutes, who are good at enteroscopy or echoendosonography, respectively, because procedures and devices are not yet established. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

TG13 surgical management of acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis.

METHODS AND MATERIALS

Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy.

RESULTS

There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals.

CONCLUSION

Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

TG13 miscellaneous etiology of cholangitis and cholecystitis

This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines

Background

The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world’s first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13).

Methods and materials

We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The “gold standard” for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis.

Results

Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III).

Conclusion

The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.

Population-based study to estimate prevalence and determine risk factors of gallbladder diseases in the rural Gangetic basin of North India

BACKGROUND

A high prevalence of gallbladder diseases (GBD) in Northern India warranted a population survey into environmental risk factors.

METHODS

In 60 villages of Uttar Pradesh and Bihar from 13 334 households, 22 861 persons aged >30 years were interviewed for symptoms of GBD, diet and environmental factors. Subsequently ultrasonography (US) was performed in 5100 and 1448 people with and without symptoms, respectively. Heavy metal and pesticide content in soil and water were estimated.

RESULTS

US revealed a prevalence of GBD of 6.20%. GBD was more common in 5100 persons with symptoms (7.12%) compared with 1448 without (2.99%) (P < 0.05). Adjusted odds ratio (ORs) [95% confidence interval (CI)] revealed a significantly increased risk of GBD in females >50, 1.703 (CI 1.292-2.245); multiparity 1.862 (CI 1.306-2.655) and a genetic history 1.564 (CI 1.049-2.334). An increased risk noted in males with diabetes was 4.271 (CI 2.130-8.566), chickpea consumption 2.546 (CI 1.563-4.146) and drinking unsafe water 3.835 (CI 2.368-6.209). Prevalence of gallstones was 4.15%; more in females 5.59% than males 1.99% (P < 0.05). Cluster analysis identified a positive correlation of nickel, cadmium and chromium in water with a high prevalence of GBD in adjacent villages in Vaishali district, Bihar.

CONCLUSION

A high risk of GBD was observed in older, multiparous women and men with diabetes, intake of chickpeas, unsafe water and villages with heavy metal water pollution.

Postoperative deep vein thrombosis in patients with colorectal cancer

Deep vein thrombosis (DVT) is reported to be common among patients undergoing surgery for colorectal cancer. This randomized controlled trial was aimed to determine the efficacy of low molecular-weight heparin in the prophylaxis of DVT in this high-risk group and was truncated early in view of an unexpectedly low incidence of DVT. Between March 2002 and January 2004, a total of 99 patients with colorectal cancer - selected for surgery in the lithotomy position - were randomized before surgery to either receive dalteparin or no drug (51 and 48 patients, respectively) during the perioperative period. Duplex ultrasonography was performed before and after the surgery. We also looked for distal venous thrombosis, pulmonary embolism, hemorrhage and any mortality. No episode of DVT occurred in either the drug arm or the observation arm. There was no death following surgery. The incidence of DVT in Indian patients operated for colorectal cancer in the lithotomy position was negligible.

Assessment of microsatellite instability in colorectal carcinoma at an Indian center

AIM

The purpose of the present study was to evaluate the frequency of microsatellite instability (MSI) in colorectal cancers in an Indian cohort.

MATERIALS AND METHODS

Paraffin embedded tissue samples of colorectal cancers from 46 patients were assessed for mismatch repair protein expression (hMLH1 and hMSH2) by immunohistochemistry. Subsequently, MSI analysis was done after PCR amplification of five Bethesda markers.

RESULTS

Amongst 46 cases studied, only 5 patients (10.8%) showed MSI. Out of these, two (4.3%) had high microsatellite instability (MSI-H) and three (6.5%) showed low microsatellite instability (MSI-L). Out of 46 cases, 41 were microsatellite stable (MSS). In the 46 cases tested by immunohistochemistry, 7 (15.7%) showed the absence of hMLH1 and 1 case showed the absence of hMSH2.

CONCLUSION

Our study indicates a similar rate of incidence of MSI in colorectal cancers in the Indian cohort compared to the West (10-15%) despite lower incidence of colorectal cancers and predominance of rectosigmoid tumors in the Indian population.

Postsurgical infections are reduced with specialized nutrition support

OBJECTIVE

The objective was to examine the relationship between pre-, peri-, and postoperative specialized nutritional support with immune-modulating nutrients and postoperative morbidity in patients undergoing elective surgery.

METHODS

Studies were identified by searching MEDLINE, review article bibliographies, and abstracts and proceedings of scientific meetings. All randomized clinical trials in which patients were supplemented by the IMPACT formula before and/or after elective surgery and the clinical outcomes reported were included in the meta-analysis. Seventeen studies (n=2,305), 14 published (n=2,102), and 3 unpublished (n=203), fulfilled the inclusion criteria. Ten studies (n=1,392) examined the efficacy of pre- or perioperative IMPACT supplementation in patients undergoing elective surgery, whereas 7 (n=913) assessed postoperative efficacy. Fourteen of the studies (n=2,083) involved gastrointestinal (GI) surgical patients. Postoperative complications, mortality, and length of stay in hospital (LOS) were major outcomes of interest.

RESULTS

IMPACT supplementation, in general, was associated with significant (39%-61%) reductions in postoperative infectious complications and a significant decrease in LOS in hospital by an average of 2 days. The greatest improvement in postoperative outcomes was observed in patients receiving specialized nutrition support as part of their preoperative treatment. In GI surgical patients, anastomotic leaks were 46% less prevalent when IMPACT supplementation was part of the preoperative treatment.

CONCLUSION

This study identifies a dosage (0.5-1 l/day) and duration (supplementation for 5-7 days before surgery) of IMPACT that contributes to improved outcomes of morbidity in elective surgery patients, particularly those undergoing GI surgical procedures. The cost effectiveness of such practice is supported by recent health economic analysis. Findings suggest preoperative IMPACT use for the prophylaxis of postoperative complications in elective surgical patients.

Radiofrequency ablation of liver tumors: experience with open and percutaneous approach

BACKGROUND

Radiofrequency ablation (RFA), a thermal coagulation technique, has been used for ablation of primary and secondary liver tumors.

METHODS

Over a 24-month period, 41 patients, including 20 with hepatocellular cancer (HCC), 14 with liver metastases from colorectal tumors and 7 with metastases from other tumors, underwent RFA in our institution. Ablation was done using intra-operative (n=27) or percutaneous ultrasonographic (n=14) guidance. A zone of ablation larger than the size of the lesion on CT scan indicated successful RFA.

RESULTS

The mean size of lesions was 4.9 cm for HCC and 3.1 cm for metastases. Among 20 patients with HCC, 16 had complete tumor ablation and one had failure of localization. All patients with liver metastases had successful tumor ablation. There was no procedure-related death. Two patients had hemoperitoneum and one experienced skin burn. During a median follow up of 16 months, five patients with HCC and two with colorectal metastases died. One patient had tumor recurrence at the ablation site and two developed fresh solitary metastatic lesions; all three are disease-free after repeat ablation treatment.

CONCLUSIONS

RFA is a safe and promising technique for the treatment of non-resectable HCC and liver metastases, in the short term.

Neoadjuvant chemotherapy before surgery of hepatoblastoma

Though surgical resection is the main stay of treatment for childhood hepatoblastoma (HB), many are unsuitable for radical surgery at diagnosis due to extensive intrahepatic and/or extra hepatic disease. We report experience in five patients of HB from a single institution (2001-2005) with preoperative Neoadjuvant chemotherapy (NACT) followed by surgery. Three patients received cisplatin, doxorubicin; and two cisplatin / vincristine /5-fluorouracil. All showed more than 50% reduction in tumor size confirmed by CT scan. Hepatic resection R0 was performed in all. There was no chemotherapy related toxicity nor post surgical morbidity or mortality. All are disease free at median follow up of 4 years. NACT produces adequate down staging of the HB with acceptable toxicity. Though cisplatin with doxorubicin produced good results, new protocol with cisplatin, vincristine and 5FU is promising without cardiotoxicity.

Elevated levels and fragmented nature of cellular fibronectin in the plasma of gastrointestinal and head and neck cancer patients

BACKGROUND

Tumor invasion occurs following enzymatic degradation of components of the extracellular matrix. The proteolysis-resistant domains of matrix components are likely to appear in the blood plasma during invasion, and could be used as markers of malignancy. Cellular fibronectin (cFN), a major ECM component, possesses 3 alternately spliced principal protease resistant domains; two of which, extra domain A (EDA) and III connecting segment (IIICS), were selected for this study of the nature of the plasma cFN molecules and its levels in normal subjects (n=51), and patients with gastrointestinal (G-I, n=145) or head and neck (H-N, n=127) cancers.

METHODS

ELISA was used to measure the cFN levels in plasma and Western blotting to analyze its fragmented nature in plasma samples from normal individuals and patients with G-I or H-N cancers.

RESULTS

cFN in blood plasma, as probed by anti-EDA and anti-IIICS antibodies on Western blots, is found to exist entirely in a fragmented form in normal subjects and G-I and H-N cancer patients. The cFN polypeptides in plasma have Mr of 160 and 100. The levels of plasma cFN, determined by ELISA using the 2 antibodies, are found to be increased in G-I and H-N cancers. In a significant number of stomach (43%), gall bladder (35%) and colon (17%) cancer cases an additional anti-EDA-reactive 30 kD peptide is seen in the plasma.

CONCLUSIONS

The mean rise for all sites is statistically significant, and 65% of all patients show cFN levels >80th percentile of normal values. The characterization of the 30 kD peptide showed that it does not contain the IIICS domain and also lacks the central cell- and heparin-binding sites.

Primary non-Hodgkin's lymphoma of the spleen presenting as space occupying lesion: a case report and review of literature

Primary splenic lymphoma (PSL) is rare with a reported incidence of less than 1%. Diffuse large cell pathology has been reported in 22-23% of the cases and is felt to have poor outcome. This study reports a 50 year old male who presented with fever and weakness. He was found to have a mass lesion in the spleen documented by CT scan. A splenectomy was performed which showed non-Hodgkin's lymphoma. Immunohistological studies showed a positivity for CD20 and CD30.

Microcystic serous cystadenoma of the pancreas: a report of two cases with one of diffuse presentation

Microcystic adenoma or serous cystadenoma is an uncommon tumor and accounts for 1-2% of the exocrine neoplasms of the pancreas. Usually unifocal, they present as single, large, well-demarcated multiloculated cystic tumors, ranging in size from 1 to 25 cm. Multifocal variants or diffuse serous cystadenomas are extremely rare. We present 2 cases of which 1 is a diffuse variant affecting the body, tail and part of the neck of the pancreas. In both the patients the tumors were detected incidentally. We highlight on the diffuse variant in view of its rarity and present a review of literature. In this case the entire body and tail of the pancreas was spongy replaced by multicystic lobules and hyalinized fibrocollagenous stroma. The cysts were lined by low cuboidal glycogen containing bland cells. Such a unique presentation wherein the entire body and tail of the pancreas is replaced with multiple cysts is a diffuse presentation of microcystic adenoma and a search through literature revealed only 7 such cases among the 15 cases with multifocal presentation reported.

HPV-associated carcinoma of esophagus in the young: a case report and review of literature

Esophageal carcinoma (EC) is rare in the younger age group, with only 15 cases reported in world literature. It is even rarer for an etiological agent to be implicated.A case of a 15-yr-old boy with squamous cell carcinoma of the esophagus is reported. Human papillomavirus (HPV) 16 DNA sequences were detected in the neoplasm and the adjacent mucosa by polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP). The adjacent mucosa also showed virus-induced changes.

Reoperative pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

Potentially resectable periampullary tumours may not be treated appropriately due to lack of local expertise in both assessment of resectability and resection in referring centres. Tata Memorial Hospital is a major referral centre for oncology and these patients are finally referred to this institution. In carefully selected patients, resection can be accomplished. The purpose of the present paper was to determine the perioperative morbidity and mortality for patients undergoing reoperative pancreaticoduodenectomy at a major comprehensive cancer centre.

METHODS

Between January 1991 and December 2001 15 patients, who had undergone previous non-resectional surgery for operable periampullary carcinoma, underwent re-exploration. The perioperative morbidity and mortality were analysed and compared with that of the group of patients undergoing primary pancreaticoduodenectomy (143 patients) in the same period.

RESULTS

All the 15 patients undergoing re-exploration had a successful resection by pancreaticoduodenectomy. In the reoperative group eight patients (53%) underwent classic pancreaticoduodenectomy and seven patients (46%) had a pylorus-preserving pancreaticoduodenectomy, as compared to 102 (71%) and 41 (29%) patients in the primary surgery group, respectively. Although the mean operative time and the estimated blood loss were higher in the reoperative group, the morbidity and mortality rates were similar in the two groups. The overall 30-day mortality rate was 6.6% and 6.9% in the reoperative and the primary surgery group, respectively. Major morbidity occurred in two of the 15 patients (13.3%), and one patient (6.6%) died following surgery in the reoperative group.

CONCLUSION

Reoperative pancreaticoduodenectomy can be performed safely in carefully selected patients with resectable, localized periampullary tumours with similar morbidity and mortality to patients undergoing primary surgery.

Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy

BACKGROUND

Preoperative biliary stenting is associated with bacterial contamination of bile and an increased rate of infectious complications after pancreaticoduodenectomy. Preoperative drainage has been found to have conflicting effects on morbidity and mortality, and no studies have been published on the effect of stent complications and duration of stenting on postoperative outcome. This study examined the effects of preoperative biliary stenting on early outcome after pancreaticoduodenectomy.

METHODS

Details of 144 patients undergoing pancreaticoduodenectomy from 1992 to 2001 were entered into a database. Variables included biliary stenting, duration of stenting, stent complications and bile culture results. Details of surgery and postoperative complications were noted. Patients were grouped as stented and non-stented. Factors likely to affect postoperative mortality and morbidity were analysed.

RESULTS

Preoperative biliary stenting was performed in 74 of the 144 patients; post-stenting complications developed in 18 patients (24 per cent) before surgery. After surgery there were nine deaths (6.3 per cent) and 60 (41.7 per cent) of the 144 patients developed complications, with no significant difference in morbidity rate between stented and non-stented patients. Logistic regression showed that a positive intraoperative bile culture was the only factor significantly associated with operative morbidity (P < 0.001) and mortality (P = 0.019). Biliary stenting was not significantly associated with a positive culture (P = 0.073), but stenting that resulted in complications (P = 0.006) and drainage for less than 6 weeks (P = 0.011) was associated with significantly greater culture positivity. Stenting followed by complications was shown by logistic regression to be the only factor significantly associated with a positive culture (P = 0.012).

CONCLUSION

A positive intraoperative bile culture was associated with higher morbidity and mortality rates following pancreaticoduodenectomy. A positive culture in the stented group was related to stent complications and duration of stenting. Uncomplicated stenting was not associated with increased morbidity or mortality.

Calcitonin-secreting tumor of the pancreas

Pancreatic endocrine tumors (PETs) are unusual tumors arising from cells belonging generically to the amine precursor uptake and decarboxylation systems. We present a case of a calcitonin-secreting PET in a 56-year-old female who presented with watery diarrhea, dehydration and hypokalemia. Investigation revealed hypercalcemia, hyperphosphatemia, hypercalcitonemia and a well-defined mass in the head of the pancreas on CT scan. Following a pancreaticoduodenectomy her serum calcitonin levels returned to normal and diarrhea disappeared. The identification of this particularly rare presentation of a calcitonin-secreting PET provides the opportunity to examine this pathological entity within the context of the very few previously reported instances of this disease.

Bile cultures and sensitivity patterns in malignant obstructive jaundice

BACKGROUND

Bactibilia is one of the important factors in the development of postoperative septic complications. We undertook this retrospective analysis to identify the organisms present in bile and their antibiotic susceptibility patterns in patients with malignant obstructive jaundice.

METHODS

Bile specimens were obtained during endoscopic cholangiography (ERC; n=65), by flushing biliary stents (n=15), intra-operatively before incising the common bile duct (n=7) or during percutaneous transhepatic biliary drainage (PTBD; n=1). Eighty-eight samples from 65 consecutive patients were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant septic complications such as wound infection and cholangitis were also assessed.

RESULTS

Of 65 patients (hilar block 39, distal block 26), 17 (26.1%) had bactibilia at initial ERCP; in addition, 3 of 7 bile specimens obtained during surgery, one collected during PTBD, and 13 of 15 stent flushings grew bacterial organisms. Cholangitis developed in 15 patients (12 with hilar block, 3 with distal block). Blood cultures were positive in 3 cases, and initial bile culture was positive in four patients with cholangitis. The most commonly found organisms were Escherichia coli (36.6%), Klebsiella pneumonia (18.3%), Pseudomonas aeruginosa (8.3%), Proteus vulgaris (8.3%) and coagulase-negative staphylococci (8.3%). The organisms found on ERC were similar to those found at wound cultures in 3 of the 4 cases who developed wound infection. Amikacin, gentamicin, cefotaxime, ceftazidime, and cefoperazone-sulbactam combination showed good activity against E. coli and K. pneumonia.

CONCLUSION

Approximately one-fourth of patients with malignant obstructive jaundice have positive bile cultures at initial ERC. Post-ERC cholangitis is common in hilar blocks.

Pancreatic tuberculosis: an elusive diagnosis

BACKGROUND

Pancreatic tuberculosis is a rare disease. Its presenting features are usually vague and non-specific, while the radiological features mimic pancreatic malignancy in many cases and pancreatitis in others. Ultrasound- or CT-guided fine-needle aspiration cytology (FNAC) or biopsy may show caseating granulomatous inflammation but microbiological confirmation may not always be possible. Laparotomy may be required if other investigations prove inconclusive. The response to treatment is good.

CASE OUTLINES

We report two young men with pancreatic tuberculosis. The diagnosis was obtained by FNAC in one and laparotomy in the other. Each patient responded to anti-tuberculous chemotherapy and is now asymptomatic.

CONCLUSION

Tuberculosis should be considered in the differential diagnosis of an obscure pancreatic mass, and the condition is readily curable.

Anorectal melanoma: a large clinicopathologic study from India

Anorectal melanoma is a rare tumor. It has dismal prognosis; only 10% of patients live longer than 5 years. It commonly presents as bleeding from the rectum or as a hemorrhoidal mass. The management of this tumor is controversial. Some authors believe that a palliative local excision is the treatment of choice, whereas others recommend radical surgery in localized disease. We present a retrospective analysis of 72 patients who were managed at our center between 1990 and 2001. This is the largest series from India. Most patients (48/72; 66%) presented with distant metastases. Twenty-four patients (24/72; 33%) underwent an abdomino-perineal resection. Nineteen patients (19/24) had positive lymph node disease, and the mean disease-free survival in these patients was 10.3 months. Disease-free survival in the node-negative patients was 26.5 months. A subset of patients with localized disease can benefit from radical surgery. In patients with large bulky localized disease, radical surgery provides better palliation than local excision.

Isolated caudate lobe resection for metastasis from rectal carcinoma

Isolated caudate lobe excision is an uncommon procedure. We report a 41-year-old lady who underwent isolated caudate lobe excision for a solitary metastatic lesion from a previously operated adenocarcinoma of rectum. This is the first such reported case from India.