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Kumar AH, Pamecha V, Patil NS, Mohapatra N, Kilambi R, Sinha PK. Efficacy of rectal indomethacin in prevention of post-operative hyperamylasemia following pancreatoduodenectomy: a randomized controlled trial. Langenbecks Arch Surg 2023; 409:23. [PMID: 38157074 DOI: 10.1007/s00423-023-03212-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Post-operative hyperamylasemia (POH) following pancreatoduodenectomy (PD) may play a key role in pathogenesis of post-operative pancreatic fistula (POPF). Aim of the current study was to evaluate efficacy of perioperative administration of indomethacin in preventing POH. METHODS Single-center, double-blind, randomized controlled trial (RCT) conducted on consecutive patients undergoing PD. Patients received either 100 mg of indomethacin per-rectally at induction of anesthesia or standard care. Primary endpoint was incidence of POH in the two arms. POH was defined as postoperative day (POD) 1 serum amylase (S. amylase) levels greater than the upper limit of normal. RESULTS After exclusion 44 patients were randomized. The two arms were comparable for preoperative and intraoperative parameters. POH was noted in 20/44 (45.5%) with significantly lower incidence of POH (60.9% vs. 28.6%, p = 0.032) in intervention arm (IA). Median S. amylase, POD 1, 3, and 5 drain amylase, and incidence of clinically relevant POPF (CR-POPF) were lower in IA but failed to reach statistical significance (30.4% vs. 14.3%, p = 0.18). The severity of delayed gastric emptying (DGE) was significantly lower in the IA (grade B/C DGE 23.8% vs. 47.8%, p = 0.023). Evaluation of risk factors for POH showed IA to confer an independent protective effect and increased risk with soft pancreas. CONCLUSION Perioperative per-rectal indomethacin administration is effective in decreasing the incidence of POH following pancreatoduodenectomy.
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Affiliation(s)
- Anubhav Harshit Kumar
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Viniyendra Pamecha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Nilesh Sadashiv Patil
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Nihar Mohapatra
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Ragini Kilambi
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Piyush Kumar Sinha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
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Sundararajan VB, Kumar S, Kilambi R, Chattopadhyay TK. Profile of serum total bile acid levels and their value in the evaluation of graft dysfunction in live donor liver transplant. Korean Journal of Transplantation 2022. [DOI: 10.4285/atw2022.f-1233] [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: 11/16/2022] Open
Affiliation(s)
| | - Senthil Kumar
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Continental Hospital, Hyderabad, India
| | - Ragini Kilambi
- Department of Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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Semalti K, Kilambi R, Pal S, Srivastava DN, Sahni P, Madhusudhan KS. Benign Hepatic Nodules in Patients With Primary Extrahepatic Portal Vein Obstruction: Clinical and Magnetic Resonance Imaging Features. J Clin Exp Hepatol 2022; 12:1301-1309. [PMID: 36157149 PMCID: PMC9499837 DOI: 10.1016/j.jceh.2022.04.015] [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: 01/28/2022] [Accepted: 04/15/2022] [Indexed: 12/12/2022] Open
Abstract
Background/objective To retrospectively evaluate the magnetic resonance imaging (MRI) features of benign hepatic nodules in patients with extrahepatic portal vein obstruction (EHPVO) and assess predictable features for their development. Methods This retrospective observational study included 18 diagnosed patients of EHPVO who underwent contrast enhanced abdominal MRI at our Institute between June 2016 and May 2017, and who could be followed up for at least two years. The patients with liver nodules formed the study group (n = 8; 4 males, 4 females; mean age: 26.1 ± 10.9 years) and patients without liver nodules were controls (n = 10; 3 males, 7 females; mean age: 24.2 ± 15.1 years). Liver nodules were confirmed as benign by either biopsy or stability on follow up imaging. MRI features of liver nodules were assessed. Clinical details and imaging data of the study group were compared with controls to assess predictable features. Results There was no statistically significant difference in age, gender, clinical characteristics and upper gastrointestinal endoscopic findings between the study and control groups. The size of the lienorenal collateral, left renal vein and superior mesenteric vein were significantly larger in the study group (P < 0.05). In the study group, the majority had multiple hepatic nodules with most of them being isointense on T1 (18/35; 51.4%) and T2-weighted images (16/35; 45.7%) and showing restriction of diffusion (21/35; 60%). All (n = 35) lesions showed arterial phase hyperenhancement and none showed washout in the venous phase. The patients in the control group did not develop any liver nodules during the follow-up period. Conclusion Liver nodules in patients with EHPVO are likely to be benign and have characteristic MRI features. Significantly larger lienorenal collateral, left renal vein and superior mesenteric vein were associated with the development of these nodules.
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Affiliation(s)
- Kapil Semalti
- Department of Radiodiagnosis and Interventional Radiology. All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Deep N. Srivastava
- Department of Radiodiagnosis and Interventional Radiology. All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kumble S. Madhusudhan
- Department of Radiodiagnosis and Interventional Radiology. All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Sasturkar SV, Agrawal N, Arora A, Kumar MPS, Kilambi R, Thapar S, Chattopadhyay TK. Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression. J Minim Access Surg 2021; 17:351-355. [PMID: 32964890 PMCID: PMC8270052 DOI: 10.4103/jmas.jmas_106_20] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. Patients and Methods Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. Results Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130-250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. Conclusion LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.
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Affiliation(s)
| | - Nikhil Agrawal
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Asit Arora
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - M P Senthil Kumar
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shalini Thapar
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tushar Kanti Chattopadhyay
- Department of Hepato-Pancreato- Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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5
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Vallonthaiel AG, Baloda V, Singh L, Yadav R, Kilambi R, Battu S, Sreenivas V, Pal S, Acharya SK, DattaGupta S, Shalimar, Das P. Histological analyses of trucut liver biopsies from patients with noncirrhotic portal fibrosis and extra-hepatic portal vein obstruction. INDIAN J PATHOL MICR 2021; 64:S127-S135. [PMID: 34135154 DOI: 10.4103/ijpm.ijpm_387_20] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Both noncirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHPVO) are important causes of noncirrhotic portal hypertension (PH) in the Asian region. In this study, we analyzed the histopathological changes of liver needle-core biopsies from patients with NCPF and EHPVO. Patients and Methods The patients were diagnosed as per the Asia Pacific Association for the Study of Liver (APASL) criteria. Minimum adequacy criteria for liver core biopsies were defined, and finally, 69 liver biopsies from patients with NCPF and 100 liver biopsies from patients with EHPVO were analyzed. All histological parameters were predefined, and three experienced pathologists analyzed the biopsies after reaching consensus. Institute ethics committee clearance was taken. Results Although some histological features were overlapping, phlebosclerosis of intra-hepatic branches of the portal vein (PV), periportal aberrant vascular channels, remnant portal tracts, and hepatic fibrosis beyond the portal tracts without the formation of complete hepatic nodules (P < 0.001 for all) were common histological characteristics of NCPF on core-needle liver biopsies; while maintained lobular architecture, nonspecific dilatation of PV branches, absence of intra-hepatic PV phlebosclerosis, aberrant vascular channels, and significant fibrosis were characteristics of EHPVO. Conclusions Despite the considerable histological overlap between NCPF and EHPVO, careful histological evaluation, supplemented by clinical features, radiological and biochemical findings can help in making a conclusive diagnosis. Patients with NCPF and EHPVO with clinical jaundice show transaminitis, high serum alkaline phosphatase level, more variceal bleed, and histological evidences of nodular regenerative hyperplasia.
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Affiliation(s)
| | - Vandana Baloda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Lavleen Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Yadav
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sudha Battu
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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6
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Madhusudhan KS, Kilambi R, Shalimar, Sahni P, Sharma R, Srivastava DN, Gupta AK. Measurement of splenic stiffness by 2D-shear wave elastography in patients with extrahepatic portal vein obstruction. Br J Radiol 2018; 91:20180401. [PMID: 30226081 DOI: 10.1259/bjr.20180401] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE: To assess the accuracy of splenic stiffness (SS) measured by 2D-shear wave elastography (SWE) for predicting variceal bleeding in the patients with extrahepatic portal vein obstruction (EHPVO). METHODS: 52 patients with EHPVO (mean age: 22.29 years; 26 each males and females) were included in the study after obtaining approval from the institute ethics committee. All patients initially underwent upper gastrointestinal endoscopy followed by ultrasonography, including 2D-SWE on the Aixplorer Supersonic Imagine scanner. The SS was measured through the anterior abdominal wall and an average of three measurements was taken. The SS was then compared with clinical symptoms, variceal grade, and other ultrasonography (USG) parameters. USG parameters were also compared with variceal grade. RESULTS: The mean SS was 44.92 ± 12.35 kPa. There was no significant difference in the mean SS of patients with high grade varices (44.30 kPa; n = 25) from those with low grade varices (46.91 kPa; n = 20). The ROC analysis showed a poor area under the curve of 0.477 for the prediction of high grade varices by the SS. The SS did not show any significant correlation with other ultrasonography parameters except splenic size, with which there was a weak but significant correlation. The measurement of SS by 2D-SWE was reliable and Cronbach's alpha was 0.905. CONCLUSION: The SS measured by 2D-SWE is not an accurate predictor of variceal grade and thus bleeding in patients of EHPVO. ADVANCES IN KNOWLEDGE: EHPVO is a vascular pathology with most patients showing splenomegaly and preserved liver function. Although, elastography of spleen has been shown to be useful in patients with cirrhosis for predicting portal hypertension, it does not seem to be helpful in patients with EHPVO.
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Affiliation(s)
| | - Ragini Kilambi
- 2 Department of Gastrointestinal Surgery, All India Institute of Medical Sciences , New Delhi , India
| | - Shalimar
- 3 Department of Gastroenterology, All India Institute of Medical Sciences , New Delhi , India
| | - Peush Sahni
- 2 Department of Gastrointestinal Surgery, All India Institute of Medical Sciences , New Delhi , India
| | - Raju Sharma
- 1 Department of Radiodiagnosis, All India Institute of Medical Sciences , New Delhi , India
| | | | - Arun Kumar Gupta
- 1 Department of Radiodiagnosis, All India Institute of Medical Sciences , New Delhi , India
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7
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Madhusudhan KS, Kilambi R, Shalimar, Pal S, Sharma R, Srivastava DN. Evaluation of Splenic Stiffness in Patients of Extrahepatic Portal Vein Obstruction Using 2D Shear Wave Elastography: Comparison with Intra-Operative Portal Pressure. J Clin Exp Hepatol 2018; 8:250-255. [PMID: 30302041 PMCID: PMC6175726 DOI: 10.1016/j.jceh.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 06/30/2017] [Accepted: 12/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS To compare splenic stiffness (SS) with intra-operative portal pressures (PPs) in patients of extrahepatic portal vein obstruction (EHPVO). METHODS Twenty-one patients (14 males; 7 females) of mean age 20.4 years with clinical and sonographic diagnosis of EHPVO were included in this approved prospective study. Endoscopy for esophageal varices (EV) was done in all patients followed by ultrasonographic 2D shear wave elastography (SWE) of spleen. Three values were taken at different areas of spleen avoiding major vessels and mean was calculated. Intra-operative PP was measured from an omental vein during proximal spleno-renal shunt surgery. The PP was compared and correlated with SS along with other parameters. RESULTS The mean SS was 46.04 ± 8.0 kPa and the mean PP was 33.29 ± 4.1 mmHg. There was no significant correlation between PP and SS (P = 0.61) and between grades of EV and SS (P = 0.38). Significant correlation was seen between grades of EV and PP (0.04). SS also did not show significant correlation with splenic size or duration of disease. CONCLUSION SS measured by 2D SWE did not correlate with PP and thus may not help in predicting gastrointestinal bleed in patients of EHPVO.
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Affiliation(s)
- Kumble S. Madhusudhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India,Address for correspondence: Kumble S. Madhusudhan, Associate Professor, Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deep N. Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
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8
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Das P, Sharma P, Nakra T, Ghosh S, Yadav R, Gupta B, Khanna G, Madhusudhan KS, Panwar R, Anoop MK, Kilambi R, Singh AN, Dash NR, Pal S, Gupta SD. Spectrum of hepatobiliary cystic lesions: A 7-year experience at a tertiary care referral center in North India and review of literature. INDIAN J PATHOL MICR 2018; 60:487-500. [PMID: 29323060 DOI: 10.4103/ijpm.ijpm_691_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Cysts arising from the hepatobiliary tree are a group of heterogeneous lesions with regard to pathogenesis, clinical presentation, and radiological finding. They can be intrahepatic or extrahepatic, developmental, secondary to infective/inflammatory etiologies, as well as neoplastic. This study was conducted to determine the spectrum of hepatobiliary cysts in surgically intervened cases, with regard to their prevalence, histological spectrum, and clinicoradiological correlation, wherever possible. METHODS In this retrospective observational study, hematoxylin and eosin stained slides of all cases of hepatobiliary cystic lesions, operated between 2009 and 2016 were reviewed. Special stains as reticulin, Masson's trichrome, and periodic acid Schiff were done wherever necessary. Overall prevalence, age-sex distribution, clinical presentation and histopathological patterns were studied. Relevant imaging findings were correlated wherever possible. RESULTS A total of 312 cases of hepatobiliary cysts were identified, the majority in females. Choledochal cysts (CCs) were the most common type (n = 198,63.5%), followed by hydatid cysts (n = 73,23.3%), simple hepatic cysts (n = 10,3.2%), congenital hepatic fibrosis (n = 10,3.2%), biliary cystadenomas (n = 4,1.2%) hepatic mesenchymal hamartomas (n = 7,2.2%), and cavernous hemangiomas (n = 3,0.9%). Fibropolycystic liver disease (n = 2,0.6%), Caroli's disease (n = 1, 0.3%), liver abscess (n = 2, 0.6%), infantile hemangioendothelioma (n = 1,0.3%), and biliary cystadenocarcinomas (n = 1,0.3%) were rare. Lesions noted mostly in 1st decade of life were: CCs, fibrocystic liver disease, Caroli's syndrome, cystic mesenchymal hamartoma, and infantile hemangioendotheliomas. CONCLUSION In our cohort of surgically intervened cases of hepatobiliary cystic lesions from a tertiary care hospital in North India, the CCs, followed by hydatid cyst were the most common lesions. Histology can play vital role in characterization, as often clinical findings and radiology can overlap.
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Affiliation(s)
| | | | - Tripti Nakra
- Department of Pathology, AIIMS, New Delhi, India
| | | | - Rajni Yadav
- Department of Pathology, AIIMS, New Delhi, India
| | | | | | | | | | - M K Anoop
- Department of Radiology, AIIMS, New Delhi, India
| | | | | | - Nihar R Dash
- Department of GI Surgery, AIIMS, New Delhi, India
| | - Sujoy Pal
- Department of GI Surgery, AIIMS, New Delhi, India
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9
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Singh AN, Kilambi R, Madhusudhan KS, Pal S. An Alternative Approach to Life-Threatening Gastrointestinal Bleeding After Corrosive Ingestion. Indian J Surg 2018; 80:187-189. [PMID: 29915486 DOI: 10.1007/s12262-018-1739-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 07/16/2017] [Accepted: 01/30/2018] [Indexed: 11/30/2022] Open
Abstract
Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of acute corrosive injury has not been described. Here, we present our experience of a case of acute corrosive injury presenting with massive upper gastrointestinal bleeding in the delayed phase which was successfully managed by angioembolization. We discuss the case in light of the literature available and describe markers which may serve to identify potential candidates for angioembolization.
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Affiliation(s)
- Anand Narayan Singh
- 1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- 2Department of Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Sujoy Pal
- 1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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10
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Singh AN, Kilambi R, Das P, Madhusudhan KS, Pal S. Malignant Hemangiopericytoma of the Liver Masquerading as Hepatocellular Carcinoma. Indian J Surg Oncol 2018; 9:256-259. [PMID: 29887712 DOI: 10.1007/s13193-018-0734-x] [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] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/21/2018] [Indexed: 11/26/2022] Open
Abstract
Isolated, metastatic hemangiopericytoma of liver is an extremely rare entity. We present a case of hemangiopericytoma of the liver, metastatic from a meningeal hemangiopericytoma, who presented 10 years after the surgical excision of the primary tumour and morphologically mimicked a hepatocellular carcinoma. We review the literature regarding this entity and discuss the difficulties in preoperative diagnosis and the need for a thorough preoperative evaluation.
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Affiliation(s)
- Anand Narayan Singh
- 1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- 1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- 2Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujoy Pal
- 1Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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11
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Kilambi R, Singh AN, Madhusudhan KS, Pal S, Saxena R, Shalimar, Dash NR, Sahni P. Portal hypertension and hypersplenism in extrahepatic portal venous obstruction: Are they related? Indian J Gastroenterol 2018; 37:202-208. [PMID: 29936618 DOI: 10.1007/s12664-018-0864-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 05/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Portal hypertension (PHT) due to extrahepatic portal venous obstruction (EHPVO) is common in developing countries. Hypersplenism is a near-constant feature of EHPVO, but its significance, unlike in cirrhotics, is unknown. We aimed to study the relationship between hypersplenism and the severity of PHT in patients with EHPVO. METHODS This prospective study was done at a tertiary care center from January 2014 to August 2015. All patients with EHPVO who underwent a splenectomy and a shunt or devascularization were included. Data regarding clinical profile, preoperative parameters, and intraoperative details were recorded. The correlation was studied between hypersplenism and the intraoperatively measured portal pressures and markers of PHT. RESULTS Of the 40 patients studied (mean [SD] age 22.4 [8.4] years), hematological hypersplenism was present in 39 (97.5%). The mean (SD) hemoglobin, total leukocyte counts (TLC), and platelet counts were 9.9 (2.4) g/dL, 2971 (1239) cells/mm3, and 66,400 (32047) cells/mm3, respectively. The mean (SD) sonographic spleen volume (SV), splenic weight, and intraoperative portal pressure were 1084.7 (553.9) cm3, 1088.7 (454.7) g, and 35.6 (5.1) mmHg, respectively. The TLC and platelet counts correlated inversely with the portal pressure. Additionally, the platelet counts correlated negatively with eradicated variceal status, SV, and weight; hemoglobin with SV and weight; and TLC with SV. Multivariate analysis showed the platelet counts were an independent predictor of portal pressures and platelet counts ≤ 53,500 cells/mm3 indicated significantly high portal pressures. CONCLUSIONS The platelet counts showed a significant inverse correlation with portal pressures in patients with EHPVO and may be used as surrogate markers of PHT. A platelet count ≤ 53,500 cells/mm3 is predictive of significantly high pressures.
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Affiliation(s)
- Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. .,Department of HPB Surgery, Institute of Liver and Biliary Sciences, D-1, Acharya Shree Tulsi Marg, Vasant Kunj, New Delhi, 110 070, India.
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | | | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
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12
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Kilambi R, Singh AN. Duct-to-mucosa versus dunking techniques of pancreaticojejunostomy after pancreaticoduodenectomy: Do we need more trials? A systematic review and meta-analysis with trial sequential analysis. J Surg Oncol 2018; 117:928-939. [DOI: 10.1002/jso.24986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Ragini Kilambi
- Department of Hepatobiliary Surgery and Liver Transplant; Institute of Liver and Biliary Sciences; New Delhi India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery and Liver Transplantation; All India Institute of Medical Sciences; New Delhi India
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Dash NR, Singh AN, Kilambi R. Balloon-Inflated Catheters for Enteral Feeding: a Word of Caution. Indian J Surg 2018; 80:14-18. [PMID: 29581679 PMCID: PMC5866795 DOI: 10.1007/s12262-016-1542-6] [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] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 08/14/2016] [Indexed: 10/21/2022] Open
Abstract
Catheters with inflatable balloons such as a Foley catheter may be used for feeding gastrostomy/jejunostomy. The incorrect or improper use of these catheters can have serious consequences. We report 13 cases of feeding jejunostomy with balloon-inflated catheter's malfunction, some referred to our centre and others operated here over a period of 8 years. The most dramatic consequence of such improper use led to rupture of the small intestine due to inadvertent over-inflation (over 100 ml) of the balloon of the catheter during a contrast study. The patient required a laparotomy with resection and anastomosis of the bowel. Three other patients had similar over-inflation of the balloon leading to severe pain and discomfort. In all three patients, timely deflation of the balloon was sufficient to relieve the symptoms. One patient had intussusception with the inflated balloon acting as a lead point. The patient underwent resection of the small bowel with end jejunostomy and distal mucous fistula. All other patients presented with abdominal pain and distension and intestinal obstruction and were managed non-operatively with deflation of balloon either by aspiration, cutting the balloon port or ultrasound-guided puncture of balloon. Healthcare personnel dealing with patients with indwelling catheters must be educated to suspect, detect and manage such problems. The best measure for such unusual complications of otherwise safe devices would be prevention by training and generation of awareness.
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Affiliation(s)
- Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, 1002, Teaching block, First floor, New Delhi, 110029 India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, 1002, Teaching block, First floor, New Delhi, 110029 India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, 1002, Teaching block, First floor, New Delhi, 110029 India
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Kilambi R, Singh AN, Madhusudhan KS, Das P, Pal S. Choledochal cyst of the proximal cystic duct: a taxonomical and therapeutic conundrum. Ann R Coll Surg Engl 2017; 100:e34-e37. [PMID: 29181996 DOI: 10.1308/rcsann.2017.0201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Isolated choledochal cysts involving the cystic duct are rare. We present a case of a choledochal cyst involving only the proximal cystic duct, and discuss the taxonomic and therapeutic challenges. There is a need for a clearly defined classification system for these cysts as they may be categorised as either type II or type VI cysts. The optimal treatment remains debatable, with some authors recommending a bilioenteric reconstruction owing to the wide cystic duct-bile duct junction. However, we suggest that a cholecystectomy should be performed with examination of the specimen and frozen section in case of any abnormality rather than upfront bile duct excision. In addition, given the rarity of this condition and the paucity of long-term data, we recommend meticulous follow-up for development of any malignancy.
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Affiliation(s)
- R Kilambi
- All India Institute of Medical Sciences , New Delhi , India
| | - A N Singh
- All India Institute of Medical Sciences , New Delhi , India
| | | | - P Das
- All India Institute of Medical Sciences , New Delhi , India
| | - S Pal
- All India Institute of Medical Sciences , New Delhi , India
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Singh AN, Pal S, Mangla V, Kilambi R, George J, Dash NR, Chattopadhyay TK, Sahni P. Pancreaticojejunostomy: Does the technique matter? A randomized trial. J Surg Oncol 2017; 117:389-396. [PMID: 29044532 DOI: 10.1002/jso.24873] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 07/17/2017] [Accepted: 09/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. METHODS This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. RESULTS A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. DISCUSSION The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).
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Affiliation(s)
- Anand N Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Mangla
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Joseph George
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar R Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar K Chattopadhyay
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Primary malignant melanoma of the gastrointestinal tract is extremely rare. A 35-year-old man presented with complaints of abdominal pain and weight loss. Contrast enhanced computed tomography showed a large mass involving the duodenum and the superior mesenteric vessels. Upper gastrointestinal endoscopy demonstrated a large, friable mass along the duodenal wall and biopsy was suggestive of malignant melanoma. A detailed physical examination and whole body imaging (positron emission tomography and computed tomography) did not reveal any other lesion. The patient underwent a pancreaticoduodenectomy with segmental resection and anastomosis of the superior mesenteric vein as well as a segmental colectomy. His postoperative recovery was uneventful. The histopathology of the operative specimen showed a malignant amelanotic melanoma arising from the duodenum with lymph nodal involvement. He received oral temozolomide. However, he developed liver metastasis at six months and again at ten months, which was managed with radiofrequency ablation both times. He is doing well at 32 months of follow-up review. Multimodality treatment including surgery, adjuvant chemotherapy and salvage therapy appears to be a promising tool for achieving long-term survival in such patients.
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Affiliation(s)
- R Kilambi
- All India Institute of Medical Sciences , New Delhi , India
| | - A N Singh
- All India Institute of Medical Sciences , New Delhi , India
| | - N R Dash
- All India Institute of Medical Sciences , New Delhi , India
| | | | - P Das
- All India Institute of Medical Sciences , New Delhi , India
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Madhusudhan KS, Sharma R, Kilambi R, Shylendran S, Shalimar, Sahni P, Gupta AK. 2D Shear Wave Elastography of Liver in Patients with Primary Extrahepatic Portal Vein Obstruction. J Clin Exp Hepatol 2017; 7:23-27. [PMID: 28348467 PMCID: PMC5357710 DOI: 10.1016/j.jceh.2016.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 06/22/2016] [Accepted: 12/22/2016] [Indexed: 12/12/2022] Open
Abstract
AIMS To evaluate liver stiffness (LS) in patients of primary extrahepatic portal vein obstruction (EHPVO) using 2D shear wave elastography (SWE) and compare it with healthy volunteers. METHODS Fifty patients (mean age: 22.4 years) of EHPVO and 25 healthy volunteers were included in the study. Liver function tests and viral markers were done in both groups and endoscopy in EHPVO group, followed by ultrasonography and SWE of liver. Liver elastography was done with patients/volunteers in supine position through right intercostal space. The LS for right lobe of liver was recorded in kilopascals. Three such measurements were taken and the mean of both groups were compared. The variables were also correlated with mean LS using Pearson's correlation coefficient in EHPVO group. RESULTS There was no significant difference in the mean LS in patients of EHPVO (5.96 kPa) and healthy volunteers (5.47 kPa) (P = 0.093). There was no significant correlation between LS with duration of symptoms, hematemesis, esophageal varices, total bilirubin, serum alkaline phosphatase and aspartate aminotranferase levels in EHPVO group. CONCLUSION SWE of liver may be used as a simple additional tool in the diagnosis of patients of EHPVO who show LS values similar to normal liver.
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Affiliation(s)
- Kumble S. Madhusudhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India,Address for correspondence: Raju Sharma, Professor, Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sudhin Shylendran
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Arun K. Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
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Dash NR, Kilambi R, Singh AN, Pal S, Asfan MA. Presentation and Management of Pseudoaneurysmogastric Fistula: A Life Threatening Emergency. J INVEST SURG 2016; 30:314-317. [DOI: 10.1080/08941939.2016.1244312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Anand Narayan Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Mohammed Adil Asfan
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Mishra B, Madhusudhan KS, Kilambi R, Das P, Pal S, Srivastava DN. Malignant Schwannoma of the Esophagus: A Rare Case Report. Korean J ThoracCardiovascSurg 2016; 49:63-6. [PMID: 26889451 PMCID: PMC4757402 DOI: 10.5090/kjtcs.2016.49.1.63] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/16/2015] [Accepted: 08/25/2015] [Indexed: 12/22/2022]
Abstract
Neurogenic tumors are the most prevalent tumors of the mediastinum, and schwannomas are the most common type of neurogenic tumor. Primary neurogenic neoplasm of the esophagus is uncommon and malignant schwannoma of the esophagus is extremely rare. We report a case of a 27-year-old female presenting with dysphagia and palpitations who was found to have a lobulated tumor in the mediastinum that was compressing the esophageal lumen. The tumor was successfully treated surgically without recurrence. The final diagnosis, on histopathological examination of the specimen, was malignant schwannoma.
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Affiliation(s)
- Biswajit Mishra
- Department of Radiodiagnosis, All India Institute of Medical Sciences
| | | | - Ragini Kilambi
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences
| | - Sujoy Pal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences
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Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc 2013; 28:875-85. [PMID: 24162138 DOI: 10.1007/s00464-013-3237-4] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 09/21/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The ideal method for managing concomitant gallbladder stones and common bile duct (CBD) stones is debatable. The currently preferred method is two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). This prospective randomized trial compared the success and cost effectiveness of single- and two-stage management of patients with concomitant gallbladder and CBD stones. METHODS Consecutive patients with concomitant gallbladder and CBD stones were randomized to either single-stage laparoscopic CBD exploration and cholecystectomy (group 1) or endoscopic retrograde cholangiopancreatography (ERCP) for endoscopic extraction of CBD stones followed by LC (group 2). Success was defined as complete clearance of CBD and cholecystectomy by the intended method. Cost effectiveness was measured using the incremental cost-effectiveness ratio. Intention-to-treat analysis was performed to compare outcomes. RESULTS From February 2009 to October 2012, 168 patients were randomized: 84 to the single-stage procedure (group 1) and 84 to the two-stage procedure (group 2). Both groups were matched with regard to demographic and clinical parameters. The success rates of laparoscopic CBD exploration and ERCP for clearance of CBD were similar (91.7 vs. 88.1 %). The overall success rate also was comparable: 88.1 % in group 1 and 79.8 % in group 2 (p = 0.20). Direct choledochotomy was performed in 83 of the 84 patients. The mean operative time was significantly longer in group 1 (135.7 ± 36.6 vs. 72.4 ± 27.6 min; p ≤ 0.001), but the overall hospital stay was significantly shorter (4.6 ± 2.4 vs. 5.3 ± 6.2 days; p = 0.03). Group 2 had a significantly greater number of procedures per patient (p < 0.001) and a higher cost (p = 0.002). The two groups did not differ significantly in terms of postoperative wound infection rates or major complications. CONCLUSIONS Single- and two-stage management for uncomplicated concomitant gallbladder and CBD stones had similar success and complication rates, but the single-stage strategy was better in terms of shorter hospital stay, need for fewer procedures, and cost effectiveness.
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Affiliation(s)
- Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India,
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Kilambi R, Bansal VK, Misra MC. A study of preoperative factors associated with a poor outcome following laparoscopic bile duct exploration. Surg Endosc 2010; 25:2050; author reply 2051. [PMID: 20976475 DOI: 10.1007/s00464-010-1438-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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