Large cystic lympangioma of the pancreas: a case reportum

Lymphangioma of the pancreas is rare and presents as a large cystic mass in the retroperitoneum. The pancreatic origin can be confirmed by careful evaluation of cross sectional imaging. Preoperative differentiation from other pancreatic cystic neoplasms is difficult but possible. Large symptomatic lesions warrant surgery. The diagnosis is confirmed by typical features on histopathology and immunohistochemistry. Presented here is a case report of a pancreatic lymphangioma, discussed in the context of available literature.

Postcholecystectomy benign biliary strictures - long-term results

BACKGROUND

Cholecystectomy is the most frequently performed general surgical procedure. Bile duct injury is a dreaded complication and is associated with serious long-term morbidity.

PATIENTS AND METHODS

Three hundred patients with postcholecystectomy benign biliary strictures were managed from January 1989 to February 2004 at a tertiary care unit in northern India. Demographic data, clinical presentation, and immediate- and long-term results of surgical repair are analyzed from a prospective database.

RESULTS

The time from cholecystectomy (open, n = 262; laparoscopic, n = 38) to stricture repair ranged from 0.2 to 360 (median 7) months. Thirty-six patients (12%) had prior stricture repair. Bismuth classification of the bile duct strictures was 32 type I, 113 type II, 126 type III, 18 type IV, and 11 type V. Two hundred and ninety-two patients (97%) underwent repair by a Roux-en-Y hepaticojejunostomy. One hundred patients (33.3%) had postoperative morbidity following stricture repair. Four patients (1.3%) died during the postoperative period. Of the 149 patients with a minimum available follow-up period of 5 years (mean 9.5, median 9.4 years; range 5-15.4 years), 134 (90%) had an excellent outcome (grade A, n = 122; grade B, n = 12); only 8 patients (5.4%) had a poor outcome.

CONCLUSION

Excellent long-term outcomes with minimal morbidity and mortality can be achieved in the subgroup of benign biliary strictures managed in dedicated units with meticulous attention to the central tenets of biliary surgery.

An audit of postoperative radiotherapy after non-curative resection for cancer of the oesophagus

AIMS

The role of postoperative radiotherapy (PORT) after non-curative resections for cancer oesophagus is not well defined. A policy of offering PORT after non-curative resections for cancer oesophagus has been followed at our institution, and we report an audit of our experience.

MATERIAL AND METHODS

Between March 1990 and September 2002, 139 patients underwent resections for cancer oesophagus. Of these, 86 patients received PORT to a dose of 45-50.4 Gy/25-28 fractions. Eleven of these patients also received concurrent and adjuvant 5-fluorouracil (5-FU). Disease-free survival and overall survival were computed from the day of surgery using the Kaplan-Meier method.

RESULTS

Seventy-six per cent (65/86) of patients had squamous cell carcinoma and 69% (59/86) of patients had tumours in the lower-third of the oesophagus. The median interval between surgery and PORT was 41 days, and 93% of patients received doses as planned. Strictures at the anastomotic site and ulcerations in the stomach mucosa were seen in 17% and 5% of patients, respectively. The median and 5-year disease-free survival was 12 months (95% CI 9.9-14.1) and 14%; whereas the median and 5-year overall survival was 17 months (95% CI 12.4-21.6) and 17%, respectively. Local and distant failures were seen in 29% and 45% of patients, respectively.

CONCLUSIONS

PORT, after a non-curative resection of cancer oesophagus, is well tolerated with acceptable morbidity and survival.

Adjuvant chemo-radiotherapy in ampullary cancers

PURPOSE

Patterns of failure following surgical treatment of ampullary cancers indicate that up to 45% of patients develop loco-regional recurrence. The effect of adjuvant chemo-radiotherapy on survival and loco-regional control is not yet established in this malignancy.

PATIENTS AND METHODS

From January 1989 to December 2000, 113 patients underwent pancreatico-duodenectomy for ampullary cancer. One hundred and four patients who survived the operation were available for analysis to study the effect of adjuvant chemo-radiotherapy on survival and loco-regional control. Forty-nine patients received adjuvant chemo-radiotherapy (median dose 50.4 Gy with concurrent 5-Flurouracil) and long-term outcome in these patients was compared with those 55 who did not receive adjuvant therapy.

RESULTS

The overall median survival was 30.1 (range 1.6-140.0) months with actuarial 1, 3 and 5-year survival rates of 79, 43 and 33%, respectively. No significant difference in median survival (34.6 vs 24.5 months; P=0.3) and actuarial 5-year survival rates (38 vs 28%) was seen between those who received and those who did not receive adjuvant therapy. Adjuvant chemo-radiotherapy did not influence the survival in high-risk patients (P=0.84), in various T and N stages and had no impact on loco-regional recurrence (P=0.6).

CONCLUSIONS

Adjuvant chemo-radiotherapy did not improve the long-term survival or decrease recurrence rates in patients with ampullary cancers who had undergone pancreatico-duodenectomy.

Evaluation of bilioenteric anastomosis using quantitative hepatobiliary scintigraphy

BACKGROUND/AIMS

The patterns of quantitative hepatobiliary scintigraphy for bilioenteric anastomoses have not been objectively defined. This study was undertaken to establish the patterns of quantitative hepatobiliary scintigraphy in the patients with bilioenteric anastomoses performed for repair of postcholecystectomy benign biliary strictures.

METHODOLOGY

37 patients with bilioenteric anastomosis (Study group) and 10 postcholecystectomy healthy subjects (Controls) underwent quantitative hepatobiliary scintigraphy. Study group patients were further categorized into: Group A (n=27) - normal clinical and biochemical parameters, and Group B (n=10) - abnormal clinical and/or biochemical parameters. On scintigraphy, time of maximal activity and time of clearance of half of the activity was calculated at the liver parenchyma and hepatic hilum. Time of appearance of activity in the intestine was also recorded.

RESULTS

There was no significant difference in the scintigraphic parameters between Group A and Controls except for earlier appearance of activity in the intestines (p=0.036) in Group A. In Group B there was significant increase in the time of clearance of half of the activity at the liver parenchyma and hepatic hilum compared to Controls (p=0.003 and 0.036 respectively), and at the liver parenchyma compared to Group A (p=0.002).

CONCLUSIONS

Quantitative hepatobiliary scintigraphic patterns in patients with bilioenteric anastomosis were similar to those of postcholecystectomy controls. Patients with abnormal biochemical parameters had significant delay in clearance of activity. Significance of these scintigraphic patterns in this subset of patients can be determined only on long-term follow-up.

Bronchobiliary fistula: an anaesthetic point of view

Bronchobiliary fistula is defined as the passage of bile in the bronchi and in the sputum (bilioptysis). This rare disorder is associated with significant morbidity. Authors review the anaesthetic management of bronchobiliary fistula and recommend the use of double lumen endotracheal tube even in cases with a closed/sealed bronchobiliary fistula.

Squamous cell carcinoma arising from a congenital duplication cyst of the esophagus in a young adult

Squamous cell carcinomas arising from the congenital anomalies in the esophagus are rare. One such case of an 18-year-old man, with an associated history of ventricular septal defect, who developed an epithelial malignancy within the duplication cyst extending to involve the lower third of esophagus is presented here. He responded well to radical treatment using concurrent chemo-irradiation, and continues to be free of disease after a follow-up of 14 months.

Outcome following pancreaticoduodenectomy in patients undergoing preoperative biliary drainage

OBJECTIVE

To assess the role of preoperative biliary drainage (PBD) in the early outcome following pancreaticoduodenectomy (PD) for periampullary tumors.

DESIGN

Retrospective analysis of prospective database.

PATIENTS AND METHODS

121 PDs were performed for periampullary tumors between 1989 and 1998. 54 patients were operated following a PBD (group A) while 67 patients were operated without PBD. 50 patients underwent internal biliary drainage while 4 patients underwent external biliary drainage. Of the 67 patients without PBD, serum bilirubin was >10 mg% in 41 patients (group B) while 26 patients had bilirubin level of <10 mg% (group C).

RESULT

Patients were well matched for age, sex distribution, presence of medical risk factors, duration of surgery, operative blood loss and stage of disease. Group A patients had a higher incidence of wound infection (43 vs. 24%; p = 0.03), intra-abdominal abscess (28 vs. 15%; p = 0.06), pancreaticojejunal anastomotic leak (20 vs. 5%; p = 0.01) and overall infective complications (52 vs. 29%; p = 0.01) compared to group B patients, and a higher overall infective complication rate than group C patients (52 vs. 27%; p = 0.02). Group B patients had a higher incidence of intra-abdominal bleeding compared to group A (20 vs. 6%; p = 0.01) and group C patients (20 vs. 4%; p = 0.03). Reoperation rate was significantly higher in group B compared to group A patients (27 vs. 13%; p = 0.04). The mortality rates were not significantly different in the three groups.

CONCLUSION

Patients with jaundice (>10 mg%) have a higher risk of bleeding complications while those with PBD have more infective complications. PBD should be judicially employed in selected patients.

Surgical management of complicated hydatid cysts of the liver

AIMS

To review the clinical presentation and surgical management of complicated hydatid cysts of the liver.

METHODS

Forty-three patients with hydatid disease of the liver were managed surgically between 1991 and 1998. There were 14 men and 29 women with a median age of 34 years. An abdominal ultrasound, computed tomography and serology established diagnosis. Preoperative endoscopic retrograde cholangiography was performed in patients with associated jaundice and high suspicion of intrabiliary rupture. Eleven (26%) patients had complicated cysts and formed the basis for our study.

RESULTS

Infection (n = 5, 11%) and intrabiliary rupture (n = 4, 9%) were the common complications. Intrathoracic rupture and intraperitoneal rupture were encountered in one patient each. All patients with infected cysts presented with pain and fever (n = 5, 100%) while those with intrabiliary rupture had jaundice (n = 4, 100%), pain and fever (n = 3, 75%). Surgical procedures performed in complicated cysts were-infection: omentoplasty (n = 2) and external drainage (n = 3); intrabiliary rupture: omentoplasty (n = 2) and internal drainage (n = 2). Patient with intrathoracic and intraperitoneal rupture underwent external drainage. There was no mortality. Postoperative morbidity was encountered in 14 patients and was more in complicated cysts (n = 6/11; 55%) compared to uncomplicated cysts (n = 8/32; 25%).

CONCLUSION

Hydatid disease in not an uncommon problem. Around a fourth of patients, present with complications such as infection or intrabiliary rupture. The site, size, number of cysts and presence of complications govern the choice of surgical procedure. Complicated cysts can be successfully managed surgically with good long-term results.

Pseudoaneurysm of gastroduodenal artery associated with mitral valve prolapse presenting as haemobilia

Pseudoaneurysms of the hepatic or gastroduodenal arteries may cause Haemobilia. Mitral valve prolapse associated with mycotic pseudoaneurysm of cerebral and extracerebral arteries have been reported. We report a case of gastroduodenal artery pseudoaneurysm presenting as haemobilia. The patient was successfully treated with indigenously fabricated steel coil embolization followed by surgery.

Determinants of pancreaticoenteric anastomotic leak following pancreaticoduodenectomy

BACKGROUND

The purpose of the present paper was to study the incidence, presentation and management of pancreaticoenteric anastomotic (PEA) leak following pancreaticoduodenectomy (PD) and to identify risk factors associated with PEA leak.

METHODS

One hundred and twenty patients underwent PD for benign and malignant pancreatic and periampullary lesions from 1989 to 1998. Prospectively collected data were analysed for incidence and outcome of PEA leak. Four clinical, three laboratory parameters, preoperative biliary drainage (PBD), perioperative octreotide use, nine intraoperative parameters, site of tumour and stage of malignant tumours were analysed by univariate and multivariate logistic regression analysis to identify factors influencing PEA leak.

RESULTS

Pancreatic leak developed in 15 (12.5%) patients. Nine patients (60%) had a PEA leak that manifested as controlled leak through the drain. All were managed conservatively and the leak stopped after a mean duration of 17 days (range: 6-32 days). Six (40%) patients had associated intra-abdominal complications, and three (50%) died in the postoperative period. Pancreatic fistula healed in the three remaining patients after a mean duration of 18 days (range: 15-25 days). Diabetes (P = 0.02; odds ratio (OR) = 4.60; 95% confidence interval (CI): 1.23-17.18), PBD (P = 0.03; OR = 4.82; 95% CI: 1.21-19.24), sequence of reconstruction (bilioenteric anastomosis as first anastomosis; P = 0.01; OR = 6.25; 95% CI: 1.45-26.83) and duration of surgery > 8 h (P = 0.01; OR: 5.61; 95% CI: 1.54-20.39) were associated with a significantly higher incidence of PEA leak.

CONCLUSION

Pancreaticoenteric anastomotic leak occurred in 12% of patients undergoing PD for pancreatic and periampullary tumours. The majority of these were uncomplicated and healed with conservative treatment. Complicated leaks were associated with high mortality. Diabetes mellitus, PBD, prolonged surgery and the sequence of reconstruction were risk factors associated with an increased incidence of PEA leak.

Impacted denture causing tracheo-esophageal fistula

We report a 35-year-old man with an impacted denture resulting in tracheo-esophageal fistula. In view of significant local fibrosis and esophageal stenosis distal to the fistula, he was managed by subtotal esophagectomy and cervical esophagogastric anastomosis.

Laparoscopic bile duct injuries: spectrum at a tertiary-care center

BACKGROUND AND PURPOSE

Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries.

PATIENTS AND METHODS

From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients.

RESULTS

Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up.

CONCLUSION

The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.

Implantation metastasis following external biliary drainage in biliary tract cancers--cause for concern!

Three patients with periampullary cancer developed tumor seedings along the T-tube choledochostomy tract, thus precluding curative resection in two patients and an early recurrence at the choledochostomy exit site in the third patient. External biliary drainage and intraoperative bile spill should be avoided in patients with curable biliary tract neoplasms.

Gall bladder cancer: proposal for a modification of the TNM classification

Gall bladder cancer is the commonest biliary tract malignancy. The TNM classification of AJCC-UICC is the most widely accepted and most commonly used system for staging. We propose some modifications in the existing classification and recommend guidelines for management based on the stage of the disease.

Role of nutrition support during induction chemoradiation therapy in esophageal cancer

BACKGROUND

Preoperative chemoradiation therapy (CRT) potentially benefits a subgroup of patients with esophageal cancer. The ability to administer aggressive CRT may depend on the initial nutritional status and the ability to sustain nutrition during therapy. Parenteral nutrition support during CRT may lead to complications that limit its usefulness and negate any potential benefit.

METHODS

Data were analyzed to evaluate the role of parenteral nutrition support (PNS) in patients receiving CRT. Forty-five consecutive patients with locoregional esophageal cancer, enrolled in a phase I/II trial of induction CRT, were analyzed. On the basis of the nutrition support received, two groups were defined as follows: group I (with PNS, n = 30) and group II (without PNS, n = 15). Results were compared in terms of chemotherapy (CT) dose tolerated, morbidity of CRT, response rates, and surgical outcome in groups with and without PNS.

RESULTS

The two groups were comparable for demographic data, stage and site of disease, and performance status. There was no significant difference between the groups in the nutritional parameters (weight and serum albumin) before and after CRT. Group I patients received significantly more (% of total calculated dose) CT compared with group II (5-fluorouracil [5-FU], 86.4% vs 68.8%, p = .02; cisplatin [CDDP], 90.8% vs 78.2%, p = .05; and interferon alpha-2b [IFN-alpha], 95.4% vs 79.8%, p = .05, in groups I and II, respectively). Major (grade III/IV) adverse effects of CT were hematologic (group I, 93.3% vs group II, 86.6%, p = .59) and gastrointestinal (group I, 56.67% vs group II, 33.3%, p = .2). Postsurgical staging revealed complete response in 10 (22%) and a major response in 23 (51%) patients, although the response rates were similar in the two groups (group I, 76.6% vs group II, 66.6%, p = .8). Surgical morbidity (51.8% vs 61.5%, p = .73), mortality (7.4% vs 7.6%, p = 1.00), and hospital stay (22.5 vs 19.6 days, p = .63) were also similar in the two groups.

CONCLUSIONS

PNS can be provided to these patients without an increased risk of CRT or resection-related morbidity. Although early and prolonged PNS facilitates administration of complete CRT doses, no benefit is derived from the administration of more CRT in the present regimen. The utility of PNS in this setting is unclear and, until further clarified, should not be applied routinely to this cohort of patients.

Malignant gastroparesis and outlet obstruction in carcinoma gall bladder

INTRODUCTION

Malignant gastroparesis and mechanical gastric outlet obstruction are two major accompaniments of advanced upper abdominal malignancies. The incidence of such problems has not been well documented in patients of carcinoma gall bladder. The aim of this study was to determine the incidence of gastric outlet problems in patients of carcinoma gall bladder and correlate them with clinical presentation. The role of prophylactic gastrojejunostomy (GJ) and its postoperative outcome was also evaluated.

PATIENTS AND METHODS

Thirty seven patients of carcinoma gall bladder were prospectively studied. Twenty five patients underwent radio labelled solid meal gastric emptying study and eleven of these underwent prophylactic GJ and followup gastric emptying study in early postoperative period.

RESULTS

Mechanical gastric outlet obstruction was seen in 10 (27%) patients. Delayed gastric emptying on scintigraphic study was found in 10 (40%) of remaining patients (n = 25). Only 6 (60%) of these patients were actually symptomatic. All patients who had delayed gastric emptying also had an advanced disease. No correlation was found between delayed gastric emptying and presence of jaundice and/or serum levels of bilirubin. Prophylactic GJ had 18% postoperative morbidity as compared to 28.5% for therapeutic GJ done during the same period. Oral feed were started latest by 11th postoperative day. Prophylactic GJ did not affect gastric emptying patterns in early postoperative period.

CONCLUSION

Mechanical gastric outlet obstruction was present in 27% patients. Delayed gastric emptying was seen in 40% of remaining patients with carcinoma gall bladder. Delayed gastric emptying correlated well with symptoms of gastric stasis and the stage of disease. Functioning of gastrojejunostomy was not fully dependent on presence or absence of malignant gastroparesis.

Technical complications of feeding jejunostomy: a critical analysis

INTRODUCTION

A retrospective review of patients undergoing feeding jejunostomy (FJ) was undertaken in order to evaluate procedure related complications and their impact on final outcome.

PATIENTS AND METHODS

Ninety six patients had FJ at the department of Surgical Gastroenterology, SGPGIMS from January 1989 to December 1995.

RESULTS

FJ as an adjunct was performed in 89 patients with predominantly oesophageal (n = 62) and pancreatic surgery (n = 17). Seven patients had FJ as the only procedure. Fifteen patients (15.2%) had complications related to FJ. Minor complications (7.2%) included dislodgement (n = 3), blockage of the tube (n = 2) and pericatheter leak (n = 2). Major complications (8.3%) which needed surgical intervention were, detachment of the jejunostomy from the abdominal wall (n = 3), leak into the peritoneal cavity (n = 3), jejunal perforation by the tip of the catheter (n = 1) and peritonitis after removal of the tube (n = 1). Procedure related mortality was 3.2%.

CONCLUSIONS

FJ should not be treated as a minor procedure and due attention to the technical details is required in its performance, otherwise it may well become the cause of a poor result following a very successful major operation.

Post-cholecystectomy external biliary fistula

BACKGROUND

External biliary fistula (EBF) following bile duct injury is a serious complication of cholecystectomy.

METHODS

From January 1989 to December 1994, 37 patients with post-cholecystectomy external biliary fistula were seen at this centre. There were 14 partial, 22 complete and one sub-vesical duct of Luschka injury. Sixteen patients had a controlled EBF at presentation; 10 patients had intra-abdominal collections and seven patients presented with peritonitis.

RESULTS

A staged approach to the management of these patients was adopted in which the initial management aimed at creating a 'controlled' fistula. This approach comprised conservative treatment (n = 9), percutaneous catheter drainage of intra-abdominal collections (n = 10), biliary drainage (n = 6), and surgical intervention (n = 7). One patient died because of progressive liver failure in spite of intensive management. Definitive management comprised the surgical repair of biliary strictures wherever indicated, after waiting for the acute problems to settle.

CONCLUSIONS

By adopting a staged approach along with a judicious use of endoscopy, radiology and surgery that were based on clinical circumstances, it was possible to achieve satisfactory results for this otherwise distressing condition.

Duodenogastric reflux after choledochoduodenostomy

Duodenogastric reflux (DGR) has been implicated in several disease processes. The present study was carried out to document the incidence and evaluate the clinical significance of DGR after choledochoduodenostomy (CDD). A total of 13 patients who had undergone cholecystectomy with a standard side-to-side CDD for choledocholithiasis or chronic pancreatitis were studied by symptom evaluation, scintigraphy, endoscopy, and gastric mucosal histology at least 6 months after surgery. The scintigraphic findings were then compared with those of 10 patients who had undergone cholecystectomy alone. Only two patients (15%) had mild dyspeptic symptoms. The incidence of DGR after CDD was 69% compared to 20% in the cholecystectomy alone group (P < 0.05). In the majority of patients the DGR was only mild to moderate and the severity correlated well with the degree of endoscopic gastritis, but not with the clinical symptoms or histological findings. These results indicate that while CDD is associated with a high incidence of DGR, its occurrence does not produce significant clinical symptoms.

Morbidity and mortality of laparoscopic cholecystectomy in an institutional setup

Laparoscopic cholecystectomy (LC) though a very safe operative procedure does have its own morbidity and mortality. The present study was undertaken to analyze the morbidity and mortality of this procedure in an institutional setting. Between October 1992 and October 1995 a total of 433 patients received LC. Conversion to open cholecystectomy was required in 62 patients (14.3%). The decision to convert was made because the surgeon was forced to convert (3.7%) or the conversion was the operator's choice (10.6%). There was no difference in the conversion rate of consultants versus residents (14.4% vs. 14.2%). Major intraoperative and postoperative morbidity was encountered in 8.3% of patients. One patient required reexploration. The incidence of common bile duct (CBD) injury was 2.5%. There was no operative or 30 days mortality. However, two patients died in the follow-up period due to procedure-related complications. Low threshold for conversion, early recognition of morbidity, and prompt and judicious management of such complications under guided supervision is necessary in order to avoid major postoperative problems. The experience in a teaching hospital training program is different from that of an individual surgical setup.

Intrahepatic segment III cholangiojejunostomy in advanced carcinoma of the gallbladder

The majority of patients with advanced carcinoma of the gallbladder have irresectable disease and require palliation for jaundice, pruritus and cholangitis. Intrahepatic segment III cholangiojejunostomy has been described for palliation of high biliary obstruction in these patients. Forty-one patients with stage IV gallbladder cancer underwent intrahepatic segment III cholangiojejunostomy. Subsequent jaundice, pruritus and cholangitis were documented; liver function tests and isotope hepatobiliary scans were performed. All patients had jaundice, 29 had pruritus and 12 had cholangitis. Postoperative complications included anastomotic leak in six patients and wound infection in six. Five patients died within 30 days of operation. Thirty-two patients were available for follow-up. The procedure failed to relieve jaundice, pruritus or cholangitis in four patients; 18 were free of jaundice, pruritus and cholangitis until death or last follow-up, and ten had recurrent jaundice or cholangitis. Isotope scanning was found to be useful to predict success of the procedure. Intrahepatic segment III cholangiojejunostomy provided excellent palliation from jaundice, pruritus and cholangitis with acceptable mortality and morbidity rates in patients with advanced carcinoma of the gallbladder.

Neonatal cholestasis syndrome: an appraisal at a tertiary center

OBJECTIVE

To know the magnitude, etiology and clinical profile, the efficacy of various investigations and the outcome in patients with neonatal cholestasis syndrome (NCS).

DESIGN

Prospective evaluation of 60 consecutive infants with NCS (mean age 3.9 +/- 1.9 months; 49 males) over a period of 3.5 years.

SETTING

Tertiary level referral gastroenterology center in North India.

METHODS

Liver function tests, urine examination, serum antibodies against Cytomegalovirus (CMV), Rubella and Toxoplasma; abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy were done. In appropriate setting, laparotomy and surgical corrections were done for biliary tract disorders.

RESULTS

NCS constituted 19% of pediatric liver diseases. Considerable delay in presentation was observed [mean delay, extrahepatic biliary atresia (EHBA) = 4 +/- 2.0 months, neonatal hepatitis (NH) = 2.2 +/- 1.3 months]. Thirty three (55%) infants had EHBA, 14 (23%) NH (4 CMV, 2 galactosemia, 1 urinary tract infection and 7 idiopathic), 2 (3%) paucity of intralobular bile ducts and 11 (18%) were of indeterminate etiology. Liver biopsy was the most accurate (96.4%) investigation in discriminating between EHBA and NH. Of the 18 operated infants with EHBA (portoenterostomy-15 and hepatico-jejunostomy-3), 10 were alive (mean follow up = 22.8 +/- 8.6 months) of which 4 were completely asymptomatic.

CONCLUSIONS

(i) NCS is an important cause of liver disease in Indian children. (ii) It requires prompt referral, quick investigative approach and targeted management. (iii) Liver biopsy is highly accurate in differentiating EHBA and NH. (iv) infants with EHBA and compensated status of liver should undergo corrective surgery irrespective of age at presentation.

Early carcinoma of the gallbladder: an elusive disease

Prognosis of carcinoma of the gallbladder can be improved by diagnosing the disease in the early stages. Records of 14 patients with early (UICC AJCC TNM stages I and II) carcinoma of the gallbladder were analyzed. Clinical presentation in all these patients was like benign biliary disease. Ultrasonography could diagnose carcinoma of the gallbladder in only five patients; in the remaining nine patients, even the ultrasonographic diagnosis was benign biliary disease. All patients were operated; carcinoma of the gallbladder was diagnosed at operation in two more patients, but it was first detected only after histological examination in seven patients. All patients except four had associated gallstones. Preoperative diagnosis of early carcinoma of the gallbladder is difficult. The only way to diagnose early carcinoma of the gallbladder is by early surgical treatment of patients with clinical features of benign biliary disease.

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty-five patients presenting with postoperative bile leak, 11 had complete tie-off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.

Choledochoduodenostomy: influence of risk factors in post-operative morbidity

BACKGROUND

Choledochoduodenostomy is performed for a variety of lower common bile duct lesions.

AIMS

To analyse the influence of risk factors on the post-operative morbidity following choledochoduodenostomy.

METHODS

Relation of risk factors including age more than 60 years, medical Illness, hemoglobin less than 10 g/dL, albumin less than 3 g/dL, bilirubin more than 10m/dL, presence of cholangitis at admission (treated pre-operatively), use of pre-operative endoscopic sphincterotomy and common bile duct diameter at surgery were related to the occurrence of post-operative morbidity was studied using univariate analysis.

RESULTS

Fifty patients underwent choledochoduodenostomy. One patient (2%) died; major post-operative morbidity occurred in 12 patients (24%). Presence of cholangitis at admission was the only factor related (p = 0.00012) to the occurrence of post-operative morbidity. No long-term complications were encountered in 35 patients (70%) mean with followup period of 28 (range 8-60) months.

CONCLUSIONS

Choledochoduodenostomy is a safe permanent drainage procedure for benign lower biliary obstruction.

Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis

BACKGROUND

Role of endoscopic sphincterotomy (ES) in high risk patients with choledocholithiasis is established but its role in good risk patients is unclear.

DESIGN

A prospective randomized trial of endoscopic sphincterotomy followed by surgery (ES + S) versus surgery alone (SA) in good risk patients with choledocholithiasis.

SETTING

A tertiary level referral hospital in north India; July 1991 to October 1993.

PATIENTS AND METHODS

Thirty three out of 60 patients with choledocholithiasis were found suitable for randomization--16 were randomised to ES + S group and 17 to SA group.

RESULTS

Common bile duct clearance was achieved in 11/13 (85%) patients in ES + S group and in 13/15 (87%) in SA group. Major complications occurred in 4/13 (31%) patients in ES + S group and 3/16 (19%) patients in SA group. These differences were not statistically significant, but patients in ES + S group were exposed to morbidity twice, procedure related morbidity of ES being 23%. No significant differences were observed in hospital stay and cost of treatment.

CONCLUSIONS

Results of this trial do not support use of precholecystectomy ES in good risk patients with choledocholithiasis, since it did not offer any advantage over surgery alone.

'Latent' portal hypertension in benign biliary obstruction

A prospective study was undertaken to evaluate the changes in portal venous pressure in patients with benign biliary obstruction (BBO) but without overt clinical, endoscopic or radiological evidence of portal hypertension. Portal venous pressure was measured at laparotomy in 20 patients (10 each with either benign biliary stricture or choledocholithiasis) before and after biliary decompression. Pressure was found to be on the high side in seven patients (> 25 cm of saline in three patients and > 30 cm of saline in four). The mean fall of pressure was 3.4 cm of saline after biliary decompression. No correlation could, however, be found between portal venous pressure and duration of biliary obstruction, serum bilirubin or bile duct pressure. Liver histology showed mild to moderate cholestatic changes but maintained portal architecture in all. Benign biliary obstruction may therefore, lead to elevation of portal pressure, even though the patient may not necessarily have any clinical, endoscopic or radiological manifestations of portal hypertension. The pathogenesis of this 'latent' portal hypertension is probably multifactorial. If biliary obstruction is left untreated the development of overt portal hypertension may become a possibility in the future.

Unusual tumors causing extrahepatic portal venous obstruction

Extrahepatic portal vein obstruction has been reported to be associated with tumors of liver, bile ducts and pancreas. We report two cases, one with gastric leiomyosarcoma and another with Non Hodgkin's lymphoma, complicated by portal vein block and presenting with gastric variceal bleeding. Portal vein block in both cases was due to direct vascular infiltration. Development of portal hypertension posed difficulties in management.

Management of the pancreatic stump following pancreaticoduodenectomy

Pancreaticoduodenectomy is the procedure of choice in patients with periampullary and pancreatic cancers. Dramatic improvements in morbidity and mortality rates following pancreaticoduodenectomy have been reported in the past 5 years. Consequently, the indications for pancreaticoduodenectomy are becoming more liberal, with some authors suggesting its use as a palliative procedure in pancreatic cancer and as definitive treatment for benign diseases such as chronic pancreatitis. Complications are frequently related to the pancreatic stump and can have a fatal outcome. Several methods of managing the pancreatic stump have been described, with variable results. Modifications of standard techniques have evolved over time in an effort to reduce the incidence of major complications. The results of these methods, the role of perioperative adjuncts and the long-term outcome of pancreaticoenteric anastomosis are reviewed.

Bile leak after T-tube removal--a scintigraphic study

BACKGROUND/AIMS

A prospective study was performed to evaluate the incidence of bile leak after T-tube removal, using 99mTc labelled BULIDA scintigraphy.

PATIENTS AND METHODS

Thirty seven patients with choledocholithiasis underwent choledocholithotomy and T-tube drainage. T-tubes were removed on 9--26 postoperative day (mean 13.4 days).

RESULTS

Six (16%) patients had scintigraphic evidence of bile leak; 4 patients had leak demonstrated in the early phase only. One patient each had partial persistent leak and complete bile leak. All patients were managed nonsurgically; conservative treatment: (4), percutaneous drainage (PCD) of intra-abdominal collection (1) and endoscopic sphincterotomy and PCD of intra-abdominal collection (1). There was no significant difference in the leak rate when T-tubes were removed at < 2 weeks versus later than 2 weeks (P=.97).

CONCLUSIONS

T-tubes should be removed with extreme caution and treatment of symptomatic patients should be guided by clinical and scintigraphic findings.

Laparoscopic cholecystectomy--can conversion be predicted?

The possibility of conversion to open cholecystectomy (OC) always exists while performing a laparoscopic cholecystectomy (LC). This study has been performed with the aim of identifying factors predicting conversion to OC. From October 1992-April 1994, LC was attempted in 150 patients and conversion to OC was required in 29 (19%) patients. Ten preoperative factors were analyzed retrospectively to identify parameters significantly correlating with conversion to OC. Preoperative factors analyzed were age, sex, duration of symptoms, BMI (Body Mass Index), past history of jaundice, previous abdominal surgery, associated medical risk factors, palpable lump on clinical examination, USG, and OCG findings. Univariate and multiple stepwise regression analysis identified male sex, USG finding of contracted/thick-walled gall bladder, and a palpable gall bladder lump on examination as significant preoperative factors predicting conversion to OC.

Predictors of survival in patients with carcinoma of the gallbladder

BACKGROUND

The role of resectional surgery in patients with advanced stages of gallbladder carcinoma has not been fully defined. It is generally believed that the survival depends on the stage of the disease, rather than on the treatment option.

METHODS

Seventeen selected risk factors were analyzed using univariate and multivariate analyses to predict survival in 87 patients with gallbladder carcinoma who had undergone some form of surgical treatment. Similarly, a subset of 55 patients with American Joint Committee on Cancer Stage IV disease also was analyzed separately.

RESULTS

Palpable mass, tumor (T) status, local infiltration, lymph node involvement, distant metastasis, TNM stage, and the type of surgical treatment (laparotomy alone, bypass, or resection) were significant risk factors by univariate analysis. In addition to palpable mass and the type of surgical treatment, age was also a significant predictor of survival by multivariate analysis. Multivariate analysis of patients with Stage IV disease revealed the same three factors to be significant. In this subset of patients, the median survival after resectional surgery was 16.3 months; after biliary and/or gastric bypass, 4.8 months; and after laparotomy alone, 1.6 months.

CONCLUSIONS

The type of surgical treatment significantly influenced survival. Resectional surgery was associated with better survival compared with biliary and/or gastric bypass or laparotomy alone for patients with all stages of the disease, including those with advanced carcinoma of the gallbladder.

Conversions in laparoscopic cholecystectomy--need for a new nomenclature

Reasons for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) were analysed in 47 patients. In 35 patients, the surgeon converted LC to OC by choice because of difficult anatomy or difficult pathology while in 12 patients the surgeon was forced to convert from LC to OC because of complications. We propose that conversions from LC to OC should be classified into two groups-"conversions-by-choice" and "conversions-per-force".