Laparoscopic management of median arcuate ligament syndrome: a video vignette.

Median arcuate ligament syndrome (MALS) is a rare condition and a diagnosis of exclusion. We present a 30-year-old man, who had postprandial upper abdominal pain and weight loss of 6 kg in 3 months. His gastroscopy and abdominal ultrasound results were both unremarkable. Computed tomographic angiography showed characteristic compression of the celiac artery by thickened median arcuate ligament causing a 'J' shaped course of artery with poststenotic dilatation and dilated branches of the celiac artery. The patient underwent laparoscopic release of the median arcuate ligament. The intraoperative blood loss was 20 mL and duration of the procedure was 140 minutes. The patient had an uneventful recovery and was discharged on postoperative day 2. The symptoms subsided 2 months following surgery and he started gaining weight. Laparoscopic division of the median arcuate ligament is a minimally invasive, safe, and effective method to decompress the celiac artery.

Laparoscopic right posterior sectionectomy for a large hepatocellular carcinoma close to inferior vena cava.

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

Transarterial chemoembolization in patients with hepatocellular carcinoma beyond Barcelona-Clinic Liver Cancer- B and portal vein tumor thrombosis: Experience from a tertiary care center.

Background: Transarterial chemoembolization (TACE) is the preferred treatment for patients with intermediate-stage hepatocellular carcinoma (HCC) without portal vein tumor thrombosis (PVTT). However, select patients with advanced HCC and with PVTT have shown improved survival with TACE. This study was undertaken to evaluate the outcome of TACE in patients with HCC beyond Barcelona-Clinic Liver Cancer- B (BCLC - B) and those with HCC and PVTT. Methods: Patients with unresectable HCC, subjected to TACE were included. HCC patients with PVTT involving main portal vein and, poor performance status were excluded from the study. Patients were stratified according to performance status, alpha feto protein (AFP) values, and up-to-seven criteria. Individually and using various combinations, the influence of these variables on survival was also estimated. Results: A total of 50 patients were included in the study. PVTT was present in 12 patients. Clinically, significant liver failure was observed in two patients. The average overall survival of patients beyond BCLC-B following TACE was 13 months. Survival was not influenced by tumor invasion into the portal vein. Patients with higher AFP levels had comparable survival provided their tumor load was satisfying up-to-seven criteria. Conclusion: We conclude that TACE could improve survival in selective HCC patients beyond BCLC-B and with PVTT not extending to the main portal vein.

Does Neutrophil-to-Lymphocyte Ratio (NLR) Predict Pathologic Response to Neoadjuvant Chemoradiotherapy in Patients with Esophageal Squamous Cell Carcinoma?

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT), followed by surgery, is the current standard of care for patients with locally advanced esophageal squamous cell carcinoma. However, up to 30% of the patients do not respond to nCRT. Hence, a simple, cost-effective marker to predict response before initiation of nCRT is needed. Neutrophil-to-lymphocyte ratio (NLR) has been reported as a prognostic marker in various cancers. However, its role as a predictive marker in patients with esophageal SCC planned for nCRT has not been prospectively analyzed. MATERIALS AND METHODS: All consecutive patients with locally advanced (T1N1 and T2-T4a with or without nodal involvement) SCC planned for nCRT (CROSS protocol) followed by esophagectomy with total two field lymphadenectomy between December 2013 and December 2019 were included in this prospective analytical cohort study. NLR was calculated 1 week before starting the nCRT and was correlated with the histopathological response [Mandard tumor regression grade (TRG)]. RESULTS: Of the 216 patients with esophageal cancer evaluated during the study period, 57 patients with SCC who fulfilled the inclusion criteria were included. A good pathologic response (TRG 1 and 2) to nCRT was seen in 28 (49.1%) patients. Using a ROC curve, the optimal cutoff value of pretherapy NLR for predicting good pathologic response was 2.33. With an NLR cutoff value of 2.33, 53.3% of patients had a good pathologic response to nCRT compared with 47.6% patients with NLR ≥ 2.33 (P = 0.77). CONCLUSION: In patients with locally advanced esophageal SCC, NLR is not a useful marker to predict pathologic response to nCRT.

Circumferential intramural esophageal dissection with large mucosal defect.

Intramural esophageal dissection (IED) is an uncommon entity characterized by mucosal rupture creating a false lumen. It usually develops following endoscopy or in old patients with bleeding tendencies and spontaneous presentation possesses diagnostic dilemma. Managing partial IED is simpler than circumferential IED. Due to rarity of presentation, management is not standardized. We report circumferential IED in a young patient and challenges faced during diagnosis and management.

Emergency Pancreaticoduodenectomy for Exsanguinating Ampullary Malignancy.

How to cite this article: Subbarayan R, Anand S, Selvaraj S. Emergency Pancreaticoduodenectomy for Exsanguinating Ampullary Malignancy. Indian J Crit Care Med 2020;24(12):1279-1280.

Mucinous cystic neoplasm of the liver with biliary communication: an exception to the current classification.

Cystic neoplasms of the liver are rare tumours. According to the recent WHO classification, they are classified into mucinous cystic neoplasm and intraductal papillary neoplasm based on the presence of ovarian-like stroma and biliary communication. We report two rare cases of mucinous cystadenoma of the liver with biliary communication and discuss the shortcomings of current classification.

Asymptomatic intraperitoneal ascariasis: Importance of diagnostic laparoscopy.

Migration of Ascaris from intestine into peritoneal cavity is rare and usually presents as acute abdomen. We report a case of 41-year-old male who was admitted for laparoscopic mesh rectopexy for rectal prolapse. During the initial laparoscopy, purulent fluid was seen in pelvis. A complete diagnostic laparoscopy was done. An omental nodule was found, which was excised and extracted in a bag. On histopathology, the omental nodule revealed gravid Ascaris lumbricoides.