Hepatocellular Carcinoma Evaluation and Management for Physicians: Joint Gastroenterology Research Society and Association of Physicians of India Guidelines

Hepatocellular carcinoma (HCC) is the most common cause of, and accounts for almost 90% of all liver cancers. Data from India is limited especially due to cancer not being a reportable disease and in view of wide variation in diagnostic modalities. This document is a result of a consensus meeting comprising Hepatologists, Interventional Radiologists, Hepatobiliary surgeons, medical and surgical Oncologists nominated by the Association of Physicians of India and Gastroenterology Research Society of Mumbai. The following Clinical Practice Guidelines for practicing physicians is intended to act as an up to date protocol for clinical management of patients with hepatocellular carcinoma. The document comprises seven sections with statements and sub-statements with strength of evidence and recommendation.

Evaluating the efficacy of tumor markers CA 19-9 and CEA to predict operability and survival in pancreatic malignancies.

Aim: Using CA 19-9 and CEA (elevated >2times of normal) as predictors in determining operability and survival in pancreatic tumors. Methods: Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. Results: 16/24 (67%) patients with CA 19-9 levels (<2times) and 19/24 (79%) patients with CEA levels (<2times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p=0.0002-t) and 17/25(70%) patients having elevated CEA levels (p =0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels >1000U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. Conclusion: Elevated levels of CA 19-9 and CEA (>2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels >3times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (>1000U/ml) indicate a dismal survival in non-resectable group of patients.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

Cadaver as a model for laparoscopic training.

BACKGROUND: Though minimally invasive techniques now are routine world over, there is need to develop facilities for training surgeons. Laparoscopy performed on anesthetized animals is an established model but is costly and is not easily available. We report on human cadaver as a training modality for surgeons participating in a laparoscopic training course. METHODS: Unembalmed cadavers were used for training surgeons to appreciate anatomy, practice laparoscopic techniques, and deploy equipment and instruments during a laparoscopic training course. Trainees carried out procedures such as cholecystectomy, appendicectomy, splenectomy, intestinal explorations, mesenteric lymph node biopsy, and varicocele-vein occlusion. We analyzed the trainees' perspective regarding cadaver as a model using the 5-point Likert scale. RESULTS: Thirty-two trainees from five consecutive training courses held at our institution expressed general satisfaction over cadaver as a training model, and 96.9% (31/32) rated the training model as highly satisfactory. The trainees ranked as highly satisfactory their understanding of surgical anatomy (29/32; 90.6%), understanding of laparoscopic technique (29/32; 90.6%) and use of instruments (32/32; 100%). The trainees thought such an approach improved spatial perception of anatomy and they perceived it as a valuable educational experience. CONCLUSIONS: Human cadaveric laparoscopy may offer an ideal surgical environment for laparoscopy training courses, allowing dissection and performance of complicated procedures.