Retrograde jejunogastric intussusception with jejunojejunal intussusception (double telescoping)

A 55-year-old woman presented with features of gastric outlet obstruction not responding to conservative treatment at a peripheral hospital. She had gastric surgery 15 years before. On examination, there was a globular mass palpable in the epigastrium. Ultrasound and endoscopy findings were suggestive of retrograde jejunogastric intussusception. After initial resuscitation, emergency laparotomy was undertaken which revealed a jejunogastric intussusception at the previous retrocolic gastrojejunostomy site. After manual reduction of the intussuscepted loop by gentle traction, another segment of the jejunum was seen to be telescoping within this loop. On reduction, this jejunal loop was seen to measure around 20 cm and the apex of the intussusceptum was found to be gangrenous and perforated. Resection of the involved segment was done followed by a Roux-en-y anastomosis to restore the continuity.

Development and validation of a new score for measuring post-operative complications

PURPOSE

Assigning a numerical value to post-operative morbidity may improve its usefulness as an outcome measure. The recently developed Comprehensive Complication Index (CCI) is a step forward in this process but assigns an inappropriately high score to a combination of complications.

METHODS

We developed a new score called the complication severity score (CSS) using a mathematical process and compared it with the CCI using a questionnaire-based survey of 49 experienced gastrointestinal and hepato-pancreatico-biliary surgeons. The CSS was modified based on the results of this survey and was correlated with other patient-centered outcomes in a prospective cohort of consecutive patients undergoing elective surgery.

RESULTS

Of the nine sets of scenarios, experienced surgeons' opinion matched with CSS in 6, CSS as well as CCI in 1, and neither CSS nor CCI in 2 scenarios. Of the total 441 responses, 281 matched with CSS while 143 matched with CCI (p = 0.0001, odds ratio: 3.7; 95% CI: 2.8 to 4.8). The modified CSS significantly correlated with the post-operative length of stay (r = 0.76; 95% CI: 0.68 to 0.82; p < 0.001), the length of ICU stay (r = 0.61; 95% CI: 0.50 to 0.70; p < 0.001) and with the difference between pre-operative and post-operative quality of life scores in the physical (r = 0.29; 95% CI: 0.14 to 0.42; p < 0.001) and social (r = 0.29; 95% CI: 0.14 to 0.43; p < 0.001) domains.

CONCLUSIONS

The CSS more often matched the opinion of experienced senior surgeons compared to CCI. The modified CSS significantly correlated with other patient-centered outcomes.

A Case of Large Bowel Obstruction- An Unusual Cause in a Middle Aged Female

Endometriosis is a disease seen among women in reproductive age group. It is characterised by deposition of endometrial tissue outside the uterus. It commonly involves the pelvic organs like ovary, fallopian tube and pelvic ligaments. Involvement of gastrointestinal tract by endometriosis is uncommon and the incidence varies widely among different studies. Colonic endometriosis can be confused as malignancy both clinically and radiologically. In these instances, histopathology is essential for a correct diagnosis. Here, the authors report a case of colonic endometriosis presenting with features of large bowel obstruction in a 49-year-old female with previous history of laparoscopic hysterectomy. Radiological scanning of abdomen and colonoscopic examination were suspicious of sigmoid malignancy. Although colonic biopsy was inconclusive and tumour markers were normal, she underwent sigmoidectomy with lymphnode clearance as per oncological principles with primary anastomosis. Her final histopathological examination revealed features of colonic endometriosis without any evidence of malignancy. Detailed evaluation of the patient didn’t reveal endometriosis at any other site. Patient was discharged after full surgical recovery and was doing well till the last follow-up.

Does the site, size, and number of necrotic collections affect the outcome of necrotizing pancreatitis? - a prospective analysis

PURPOSE

In patients with acute necrotizing pancreatitis (ANP), the site, size, and the number of acute necrotic collections (ANC) may determine the outcome of patients. The current study aimed to correlate the nature of ANC with the adverse outcomes in ANP patients.

METHODS

This was a single-center, prospective study (August 2019-August 2022) recruiting patients with ANP, correlating the site, size, and number of ANC with the length of hospital stay, intensive care unit (ICU) stays, development of organ failure and infection, need for intervention, and mortality.

RESULTS

A total of 114 patients (mean age: 37.3 ± 13.4 years, 85.1% males) with ANP were included in the study. The number and maximum diameter of collections significantly correlated with the length of the hospital and ICU stay and the need for intervention. Taking a cut-off size of 8 cm, the sensitivity and specificity for predicting the need for intervention were 82.7% and 74.2%, respectively. ANCs located in the perinephric, paracolic, subhepatic, and epigastric regions had a significant correlation with two or more adverse outcomes. Additional points were added to the modified CT severity index (mCTSI) based on the present study's findings. The new score had significantly higher AUROC than mCTSI for predicting infection, need for intervention, ICU stay > 1 week, and mortality.

CONCLUSION

The site, size, and number of EPNs have a significant correlation with adverse clinical outcomes in patients with ANP. The inclusion of these parameters, along with present scoring systems, will help further improve the prognostication of patients.

Experience of Performing Hepatic Interventional Radiological Procedures in a Tertiary Care Hospital in Odisha: A Case Series

Introduction

During last few decades, radiological interventions have played crucial role in the management of the patients with chronic liver diseases. Various procedures including transjugualar intrahepatic portosystemic shunt (TIPS), transjugular liver biopsy (TJLB), transarterial chemoembilization (TACE)/transarterial radioembolization (TARE), balloon retrograde transvenous obliteration (BRTO) and plug-assisted retrograde transvenous obliteration (PARTO) are being performed safely and have significantly improved clinical outcomes in these patients. The technical and clinical success depend on appropriate patient selection along with thorough knowledge and experience to perform these procedures. On the other hand, few adverse events may also be associated with these procedures. The intervention radiologist and hepatologists should identify and treat these complications at the earliest so as to improve outcome of the patient.

Materials and methods

About 25 hepatic intervention radiology procedures were performed in our center from January 2022 to 2023 May. Among these we have selected five patients who underwent TACE/TIPS/DIPS in our institute. We have selected these cases as in each of these cases we encountered some interesting outcomes/complications which were managed successfully.

Results

The first case describes 33-year-old male with POEM syndrome and Budd Chiari Syndrome (BCS) who underwent TIPS and immediately had blockade of the stent. The second case is of a 43 years old male having BCS, refractory ascites with umbilical and inguinal hernia. The third case is of a 40 years old female with decompensated cirrhosis who underwent TIPS for portal hypertensive gastropathy. The fourth case is of a 51-years' female with decompensated cirrhosis with sarcopenia. Finally, the fifth case describes 24-year-old female with BCS and hepatocellular carcinoma. In this article we discuss the procedure and clinical course of the patients following the procedure.

Conclusion

Hepatic radiological interventions though widely used can be associated with unusual albeit life threatening complications. Appropriate patient selection and thorough knowledge of procedure along with early diagnosis and management of these complications are key to obtain satisfying long term outcomes.

Safety and efficacy of USG-guided catheter drainage in liver abscesses

Background:

This study aimed to evaluate the safety and efficacy of USG-guided percutaneous drainage in liver abscesses of >5 cm. A lot of literature is available on the minimally invasive treatment of liver abscesses since its introduction in the early 1980s. This study focuses on the eastern Indian population and the outcome of treatment of liver abscess of >5 cm by means of catheter drainage and the use of antibiotics.

Patients and Methods:

This is a retrospective study conducted on a total of fifty patients over a period of 1 year, 1 month (from June 2017 to June 2018). Only patients with liver abscess with size >5 cm were included in the study. The demographic characteristics; comorbidities; and clinical, radiological, and bacteriological characteristics of liver abscesses in the eastern Indian population and the safety and efficacy of catheter drainage were evaluated.

Results:

It was found that because of preprocedural empirical antibiotic intake, 70% of the patients had no growth in the pus, whereas 12% had Entamoeba histolytica, 8% had Escherichia coli, and 6% had Klebsiella pneumoniae as the causative agent. The total duration of hospital stay ranged from 3 to 22 days, and the duration of intravenous antibiotics ranged from 1 to 9 days with a clinical success rate of 96% without any drainage-related complications.

Conclusion:

In contradiction to the earlier belief, percutaneous drainage is a safe and effective means of treatment in liver abscesses of >5 cm with high clinical success rate and reduced duration of intravenous antibiotic requirement as well as hospital stay.

Primary Pancreatic Squamous Cell Carcinoma: An Incidental Diagnosis of a Rare Entity

Primary Squamous Cell Carcinoma (SCC) of pancreas is a non endocrine tumour showing ductal origin which accounts for approximately 0.5-2% of all malignant pancreatic tumours. Diagnosis is usually made by tissue sampling followed by comprehensive search for primary SCC elsewhere. Hereby, authors report a rare case of primary pancreatic SCC in a young female. A 46-year-old female with history of type 2 diabetes mellitus presented with abdominal pain radiating to back associated with biliary vomiting since five months. Laboratory investigations revealed mild anaemia, neutrophilic leucocytosis and elevated blood glucose. Carcinoembryonic Antigen (CEA) and Cancer Antigen 19-9 (CA 19-9) were within normal limits. Contrast-Enhanced Computed Tomography (CECT) (abdomen and pelvis) showed pancreatic atrophy, multiple stones in head and body along with a pseudocyst in tail of pancreas. Patient underwent triple phase Magnetic Resonance Imaging (MRI) with Magnetic Resonance Cholangiopancreatography (MRCP) which showed chronic pancreatitis with intraductal calculi in the head and distal body region with pseudocyst at tail region. Frey’s procedure was done and tissue sent in multiple pieces. Histopathology revealed features of infiltrating SCC in a background of atrophic pancreas. Immunohistochemistry for CK5/6, P63 and CEA was done for confirmation. It showed strong positivity for CK5/6 and P63, while CEA was negative. Final diagnosis of SCC of pancreas in a background of atrophic pancreas was rendered. Though pancreas is devoid of squamous cells, it is not uncommon to find squamous metaplasia of ductal epithelial cells secondary to chronic inflammation. In the present case, though clinical and radiological features points towards benign lesion, definite diagnosis as SCC is justified by histopathology and immunohistochemistry. Because of the rarity, diagnosis and treatment still remains a challenge.

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations. Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes. Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55). LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

Comparison of Vascular Complications Between Living-donor and Deceased-donor Liver Transplantation - A Systematic Review and Meta-analysis

Background

Vascular complications commonly cause graft loss and morbidity after liver transplantation (LT). Comparative data on the risk of vascular complications are limited. Hence, the present meta-analysis was conducted to analyze the difference in vascular complications between living-donor LT (LDLT) and deceased-donor LT (DDLT).

Methods

A literature search of three databases was conducted for studies comparing the incidence of vascular complications with LDLT and DDLT. The event rates and odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results

A total of 20 studies were included in the final analysis. There was no difference in the incidence of overall vascular complications (9.3%, 95% CI: 6.6-12.0 vs. 8.5%, 95% CI: 5.6-11.4) between LDLT and DDLT with OR 0.94 (95% CI: 0.73-1.21) (15 studies).There was a higher incidence of vascular complications with LDLT in older studies (published before 2013) but not in new studies. When comparing the individual complications, LDLT was associated with a higher incidence of hepatic artery thrombosis (HAT) (3.8%, 95% CI: 2.4-5.2 vs. 1.6%, 95% CI: 1.1-2.2)with OR 2.20 (95% CI: 1.53-3.17) (14 studies)and a significantly lower incidence of intra-abdominal bleeding(4.8%, 95% CI: 3.3-6.2 vs. 7.9%, 95% CI: 5.0-10.7) with OR 0.64 (95% CI: 0.47-0.87) (11 studies). However, there was no difference in the incidence (2.1%, 95% CI: 0.5-3.8 vs. 1.0%, 95% CI: 0.1-1.9) of portal vein thrombosis between LDLT and DDLT with OR 1.85 (95% CI: 0.82-4.18) (6 studies).

Conclusion

Despite a comparable risk of vascular complications between LDLT and DDLT, LDLT was associated with a higher risk of HAT and a lower risk of intraprocedural bleeding. Further studies are required to analyze the effect of donor-recipient characteristics and surgical techniques on the risk of vascular complications.

An Unusual Case Report of Duodenojejunal Flexure Tumor With a Systematic Review of the Literature

The small intestine is the longest segment of the gastrointestinal (GI) tract, but cancers in the small intestine are infrequent. The duodenojejunal (DJ) flexure is an uncommon site for tumors, and those located in these sites are difficult to identify and manage properly. Their rarity, along with ambiguous symptoms that can be readily misattributed to milder conditions, results in a delayed diagnosis when the tumors have significantly advanced. We described the case report of a middle-aged woman presenting with features of intestinal obstruction with gastrointestinal bleeding, showing enteroenteric fistula on enteroscopy and cross-sectional imaging, which was later diagnosed as a case of adenocarcinoma treated with surgical resection. We also systematically reviewed the current literature on DJ flexure tumors and compiled data based on various clinical presentations, radiological findings, associated syndromes, management, and outcomes.