Gallbladder Neuroendocrine Tumors: Is There a Need for a Specific Approach?

Neuroendocrine tumors (NETs) of the gallbladder or the biliary tree are rare. Most of the current guidelines and protocols are derived from the experience of managing lung small cell neuroendocrine carcinoma or gastrointestinal NETs. But, the overall outcome of gallbladder NETs (GB-NETs) seems worse than similarly staged lung NETs and adenocarcinoma of the gallbladder. This may be due to its rarity and lack of literature for a focused approach toward its treatment. Hence, the need for a specifically designed approach might help improve results of treatment for these rare tumors. We share our experience of 2 patients with GB-NETs and their 5-year outcome.

A Prospective Review of Preoperative Nutritional Status and Its Influence on the Outcome of Abdominal Surgery.

Aim To assess the incidence of malnutrition in a surgical gastroenterology unit and analyze its impact on postoperative complication rates. Method Data were prospectively accrued from patients admitted for emergency or elective surgery to the gastrointestinal surgery unit at Jaslok Hospital between May 2013 and May 2014. The nutritional status was preoperatively assessed by using anthropometric parameters like body mass index (BMI), midarm circumference (MAC), and tissue skinfold thickness (TSFT). In addition, a subjective global assessment scale (SGA), serum albumin, and absolute lymphocyte count (ALC) were used. Patients with BMI <18.5, MAC <24 cm in males and <22 cm in females, and TSFT <10 mm were considered malnourished. Patients with serum albumin between 3 and 3.5 g/dl were considered mild, 2.4-2.9 g/dl was moderate, and <2.4 g/dl were severely malnourished. Patients with ALC between 1200 and 2000/cm were labelled mild, between 800 and 1199/cm were moderate, and <800/cm were severely malnourished. As per SGA, well-nourished had less than 5% weight loss or if more than 5%, with recent gain and improved appetite, mild/moderately malnourished had 5% to 10% weight loss with no gain, mild subcutaneous fat loss, and those severely malnourished had more than 10% weight loss, severe subcutaneous fat loss, and muscle wasting. Postoperative complications were graded as per the Clavien-Dindo classification. Patients with grades 1 and 2 complications were labelled as minor and the rest as major. Result Men in the age group of 40-60 years comprised the majority of the study population. The most frequent reason for admission was cholelithiasis. The overall incidence of malnutrition was 22.16%. Out of the 96 patients who had complications, 45 had minor and 41 had significant complications. Amongst the well-nourished, the incidence of complications was 26.62% of which the majority were minor complications. Severely malnourished patients had a high complication rate (63.38%); 32% out of the 63.38% developed significant complications. The majority of the patients suffering from severe malnutrition belonged to the sub-group with chronic pancreatitis and carcinoma of the pancreas. According to the chi-square analysis of the data, ALC, serum albumin, and SGA correlate with the postoperative complication rate with a p-value <0.05 as significant. On the contrary, BMI, MAC, and TSFT did not correlate with postoperative complications. Conclusion Preoperative malnutrition is common among patients undergoing abdominal surgeries in the urban private health care sector. Although there have been studies that have analyzed the incidence of malnutrition in patients undergoing oncological surgeries, there is limited literature on malnutrition among patients subjected to gastrointestinal surgeries. We conclude that simple bedside nutritional assessment tools like serum albumin, absolute lymphocyte count, and SGA can accurately identify malnourished patients preoperatively and are good predictors of postoperative complications. Hence, it is imperative to assess and attempt to improve the nutritional status of the patients preoperatively.

Undiagnosed Hepatic Tuberculosis Presenting With Intraabdominal Rupture and Hemoperitoneum, Requiring Urgent Hepatic Resection.

Tuberculosis (TB) affecting the liver is unusual, and isolated liver TB presenting as a liver abscess more so, even in countries where the disease is endemic. As clinical symptoms and imaging are not typical, a high index of suspicion is necessary for diagnosis. We present here a lady who was admitted with fever and chills. Ultrasound imaging showed a liver abscess. She developed bleeding into the abscess cavity, necessitating an emergency right liver resection. Final histology confirmed mycobacterial granulomatous infection of the liver. Isolated hepatic abscess of tubercular origin is a rare cause of hemorrhage but should be considered as a differential diagnosis. Suspicious features on computerized tomography (CT) scan should prompt microbiological assessment of aspirate from the abscess, establishing the diagnosis, so appropriate treatment can be started, avoiding such complications.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients.

OBJECTIVE: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. DESIGN: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). RESULTS: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). CONCLUSION: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Left-sided sinistroposition of the gall bladder: incidental presentation during elective cholecystectomy.

A 59-year-old male patient presented with mild gallstone pancreatitis. He underwent laparoscopic cholecystectomy during the same admission, where we encountered a left-sided gall bladder (GB). This was managed during laparoscopic surgery by modifying the laparoscopic port positions, and we did not encounter any other variations in the biliary anatomy. Thorough knowledge regarding anatomical variations of the GB will help in managing rare cases and avoid injuries to vital structures.

Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male.

Diaphragmatic hernia is an important cause of emergency hospital admission associated with significant morbidity. It usually results from congenital defect or rupture in the diaphragm due to trauma. Prompt and appropriate diagnosis is necessary in patients with this condition, as surgical intervention by either abdominal or thoracic approach may be necessary. Here, we report a case of left-sided diaphragmatic hernia presenting with sudden onset of breathlessness, respiratory distress and left-sided chest pain radiating to the abdomen, mimicking pneumothorax, treated successfully with surgical intervention.

Predictors of outcome after reconstructive hepatico-jejunostomy for post cholecystectomy bile duct injuries.

INTRODUCTION: Reconstructive hepatico-jejunostomy is recommended for major bile duct injuries (BDIs) during cholecystectomy. Complications of biliary leak, cholangitis, bleeding, anastomotic strictures and biliary cirrhosis remain a major concern affecting a patient's outcome after surgery. The aim of this study was to analyse the results of surgical repair of major BDIs at our institution and identify predictors for the development of major complications. METHODS: A retrospective study of 57 patients with major BDI after cholecystectomy referred to a tertiary hepato-biliary centre from July 1999 to July 2011 and subsequently managed with reconstructive bilio-enteric anastomosis was performed. RESULTS: Of 57 patents 35 (61.4%) were primary referred. 22 (38.6 %) were secondary referred, of which 17 were for correct reconstructive surgery performed elsewhere and 5 were following attempted endoscopic management. 17 (29.8%) had local and systemic perioperative complications. 13 (22.8%) had major complications (bile leak, bleed, stricture and/or biliary cirrhosis). No association was found between age, type of cholecystectomy, type of injury, vascular injury and occurrence of major complications. Secondarily referred patients after therapeutic interventions (p = 0.010) and reconstructive surgery after repair performed by non-specialists suffered an increased incidence of major complications (p = 0.032). Secondary referral was also an independent predictor of major complications (p = 0.024). CONCLUSION: Early referral of patients with no previous intervention to a tertiary hepato-biliary center and specialist surgical repair is recommended for improved outcome after reconstructive hepatico-jejunostomy for major BDIs during cholecystectomy.

Pancreatic glucagonoma with pancreatic calcification.

BACKGROUND: Glucagonoma is an uncommon type of pancreatic neuroendocrine tumor [NET] which is characterized by diabetes mellitus, necrolytic migratory erythema, depression and deep vein thrombosis. The typical rash is often misdiagnosed and the diagnosis is delayed by 7-8 years. Pancreatic NETs and other pancreatic tumors are known to show calcifications within the tumor but calcification of the remaining normal pancreas is very uncommon. It occurs when there is ductal obstruction leading to acute or chronic pancreatitis. CASE REPORT: We present a case of glucagonoma with coexistent pancreatic calcification. CONCLUSION: Glucagonoma should be suspected in a diabetic patient with migratory rash. Pancreatic tumor should be suspected in patient with idiopathic focal pancreatitis.

No 72-hour pathological boundary for safe early laparoscopic cholecystectomy in acute cholecystitis: a clinicopathological study.

BACKGROUND: The pathological boundary of acute cholecystitis (AC) between early edematous and late chronic fibrotic inflammation beyond 72 h is well-described. Early laparoscopic cholecystectomy (ELC) is safe in AC but the timing still remains controversial. The aim of this study was to analyze the impact of the duration of symptoms on clinical severity, pathology and outcome in patients who underwent laparoscopic cholecystectomy (LC) for AC during the urgent admission. METHODS: A retrospective analysis of a prospectively collected database of 61 patients who underwent LC for AC over a 6-month period was performed. RESULTS: Of 61 patients 21 (34.43%) received ELC at <72 h and 40 (65.57%) received late LC (LLC) at >72 h. Clinically in the ELC group the majority were mild and in the LLC group the majority were moderate and severe in severity grading as per Tokyo guidelines (P<0.001). Surgical findings and histopathology showed no significant difference in the distribution of simple, phlegmonous and gangrenous cholecystitis between both groups (P=0.94). The majority were completed by a standard four port technique and only one required subtotal cholecystectomy. There was no significant difference between operating time, return to normal activities or hospital stay between both groups. There were no conversions to open cholecystectomy, no wound infections, no intra-abdominal collections, no biliary tract injury or mortality in either group. CONCLUSIONS: The degree of inflammatory change in AC is not dependent on time. LC can be safely performed in AC regardless of timing with a standardized surgical strategy in experienced units.

Three level risk assessment for pancreatic fistula formation after distal pancreatectomy with a strategy for prevention.

BACKGROUND: Distal pancreatectomy (DP) has a high post-operative morbidity predominantly due to pancreatic fistula though the mortality is very low. Data on distal pancreatectomy was reviewed to analyse the risk factors that contribute to this morbidity. METHODS: Thirty three patients underwent distal pancreatectomy with sutured closure of the remnant, over a 5-year period between May 2006 and April 2011. Pancreatic fistula (PF) was defined according to the International Study Group on Pancreatic Fistula definition. Patient and surgical risk factors were subdivided as those reflecting a poorer pre-morbid status, those associated with increased complexity of surgery and those related to pancreas gland and were analyzed for incidence of pancreatic fistula. RESULTS: Indications for DP included 16 (51.5%) pancreatic tumours, 13 (39.4%) chronic pancreatitis and 3 (9.1%) trauma. Spleen was preserved in 12 patients (36.4%). There was no mortality while the morbidity rate was 45.5% (n = 15). Incidence of pancreatic fistula was 30.3% (n = 10); eight were grade A (80%) and two were grade C (20%). Incidence of clinically significant pancreatic fistulae was 6.1%. PF was significantly more common if the pancreatic duct was not identified (p = 0.024) was significantly less with extensive peri-pancreatic adhesions (p = 0.036). CONCLUSIONS: Identification and ligation of main pancreatic duct can help reduce the incidence of pancreatic fistulae. The identification of patients at high risk of developing a PF helps to implement prevention strategies.

Management of severe acute pancreatitis.

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Analysis of the delayed approach to the management of infected pancreatic necrosis.

AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP). METHODS: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed. RESULTS: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d. CONCLUSION: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Major hemobilia--experience from a specialist unit in a developing country.

BACKGROUND AND AIM: Hemobilia is a rare but potentially life threatening problem, which can be difficult to diagnose and treat. In the last few decades there has been a change in the etiologic spectrum and management of this problem in the West. The aim of this study was to analyze the etiology, clinical features, management and outcome of major hemobilia in a tertiary referral centre from western India. METHODS: A retrospective analysis was undertaken on 22 patients (16 males, 6 females; mean age 39 years, range 13 to 74) who presented with major hemobilia over a 5-year period. RESULTS: The etiology was iatrogenic in 13 patients (percutaneous transhepatic biliary drainage 8, post laparoscopic cholecystectomy 3, endoscopic retrograde cholangiopancreatography 1, and liver biopsy 1), liver trauma in 6 and liver tumors in 3 patients. Twenty patients presented with gastrointestinal bleeding (melena 20 patients, hemetemesis with melena 8 patients), 5 with jaundice and 8 had fever. Abdominal angiography was performed in 20 patients. Angiography revealed pseudoaneurysm of the right hepatic artery or its branches in 14 patients, left hepatic artery in 2, an arterio-biliary fistula in 1, tumor blush in 1 and the source could not be located in 2 patients. Seventeen of the 22 patients were treated with radiological intervention, 3 required surgery (liver resection for tumors 2, laparotomy for venous collateral bleeding of portal cavernoma 1) and two were managed conservatively. Radiological intervention involved embolisation with coils and/or glue in 16, and chemoembolisation in 1 patient. Sixteen of 17 patients responded to embolisation. Overall there were two deaths. CONCLUSION: The spectrum of hemobilia seen in India is now similar to that in the developed world with iatrogenic causes being the commonest. Interventional radiology can treat a majority of patients reducing the need and morbidity associated with surgery.