The outcome of 100 patients with achalasia cardia following laparoscopic Heller myotomy with blunt dissection technique.

Background: Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique (BDT). Only a few studies have assessed long-term outcomes and relief of dysphagia following LHM. The study reviews our long-term experience following LHM by BDT. Methods: This retrospective study was analysed from a prospectively maintained database (from 2013 to 2021) of a single unit of the Department of Gastrointestinal Surgery at G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. The myotomy was performed by BDT in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered treatment failure. Results: A total of 100 patients underwent surgery during the study period. Of them, 66 patients underwent LHM, 27 underwent LHM with Dor fundoplication and 7 underwent LHM with Toupet fundoplication. The median length of myotomy was 7 cm. The mean operative time was 77 ± 29.27 min and the mean blood loss of 28.05 ± 16.06 ml. Five patients had intraoperative oesophageal perforation. The median length of hospital stay was 2 days. There was no hospital mortality. The post-operative integrated relaxation pressure (IRP) was significantly lower than the mean pre-operative IRP (9.78 vs. 24.77). Eleven patients developed treatment failure, of which ten patients presented with recurrence of dysphagia. There was no difference in symptom-free survival amongst various types of achalasia cardia (P = 0.816). Conclusion: LHM performed by BDT has a 90% success rate. Complication using this technique is rare, and recurrence post-surgery can be managed with endoscopic dilatation.

Laparoscopic-assisted transhiatal oesophagectomy: An experience from a tertiary care centre over 10 years.

Background: Minimally invasive surgeries have become the standard of care in oesophageal surgeries, but the transhiatal approach is still not widely in practice. As in the open surgical approach, laparoscopic transhiatal oesophagectomy has been accepted by many centres worldwide. The laparoscopic-assisted transhiatal oesophagectomy (LATE) has become a time-tested surgery. Many centres across the world have shown its feasibility and superiority regarding the lymph node yield with less morbidity with the added advantage of laparoscopy. We are pleased to share our 10-year experience with LATE and the long-term follow-up. Materials and Methods: Retrospective analysis of prospectively maintained data from our tertiary care centre from January 2010 to January 2021. Forty-six out of 74 patients with carcinoma of the lower end of the oesophagus who underwent LATE were analysed retrospectively. Results: Our study group included 46 patients. Six patients who required conversion to open surgery and those who underwent different procedures were excluded. The mean operative time was 220 (140-360) min. The mean blood loss was 230 (100-500) ml. Four (8.69%) patients had neck leaks. Twelve (26.08%) patients had minor pulmonary complications and one (2.17%) patient had a major pulmonary complication in the form of acute respiratory distress syndrome. The median hospital stay was 10.5 (8-28) days and 90-day mortality was 2.17%. 45 (97.82%) patients had an R0 resection rate with a median lymph node yield of 21 (16-28). The median overall survival was 44 months, with a 3 years disease-free survival rate of 63.04% and a 5-year overall survival rate of 36.50%. Conclusion: LATE is feasible and safe for adenocarcinoma of lower third esophagus and GEJ (gastroesophageal junction). The laparoscopic magnified view of lower mediastinum provides a better vision for lymphadenectomy especially in the neoadjuvant group. It has all the added benefits of minimal invasive surgery with acceptable short and long term oncological results.

Undifferentiated carcinoma with osteoclast-like giant cells of pancreas on cytology: A case report with review of literature.

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGC) is a rare malignant neoplasm accounting for <1% of pancreatic masses. Very few case reports and small series have described the cytomorphological features of this entity. We report a case of UC-OGC arising in the pancreas presenting with liver metastasis in a 56-year-old man diagnosed by guided fine-needle aspiration cytology (FNAC). A characteristic biphasic pattern comprising of malignant mononuclear cells with scattered bland giant cells were the hallmark features for cytological diagnosis. Our case along with review of cytology literature emphasize the utility of FNAC and the cell block in the diagnosis and management of this rare entity.

Laparoscopic versus open surgical management of patients with chronic pancreatitis: Amatched case-control study.

BACKGROUND: The safety and feasibility of laparoscopic surgery in patients with chronic pancreatitis (CP) have been established, but its outcome has not been compared to that of open surgery. PATIENTS AND METHODS: This retrospective study was conducted on patients with CP who were treated by a single surgical team from 2012 to 2018. The medical records of patients with surgical treatment of CP were reviewed. Patients were divided into laparoscopic group (LG) and open group (OG). Both the groups were matched for age and procedures. The matched groups were compared. RESULTS: The total number of unmatched patients was 99 and post matching, there were 38 patients in each group. The demographic, aetiological, clinical and laboratory parameters were comparable. The number of each surgical procedure including bilio-enteric anastomosis was also similar. Lateral pancreaticojejunostomy was the most common surgical procedure in both the groups. An additional surgical procedure (bilio-enteric bypass) was required in 10.5% of the patients in LG and 21% of the patients in OG groups (P = 0.3). Significantly lower blood loss (100 vs. 120 ml) and higher operation time (300 vs. 210 min) were observed in LG. The post-operative complication rate was 7.9% in LG group versus 10.5% in OG group. More than 85% of the patients in both the groups had a significant relief from pain. The impact of exocrine and endocrine insufficiency was not remarkable in both the groups. The requirement of an additional surgical procedure was associated with a high conversion rate. CONCLUSIONS: The outcomes of laparoscopic surgery in patients with CP were similar to that of open surgery, and requirement of an additional surgical procedure is associated with a high conversion rate.

Bi-segmentectomy versus wedge hepatic resection in extended cholecystectomy for T2 and T3 gallbladder cancer: A matched case-control study.

BACKGROUNDS/AIMS: Extended cholecystectomy (EC) is the mainstay of treatment in most patients with potentially curable gallbladder cancer (GBC). The optimum extent of hepatic resection in EC is debatable. METHODS: This retrospective study was conducted on patients with GBC who received EC from May 2009 to February 2019. Based on the extent of hepatic resection, patients were divided into ECB (EC involving bi-segmentectomy s4b&5) and ECW (EC involving wedge hepatic resection) groups. Patients with T1 GBC, T4 GBC, and benign diseases were excluded. Post-exclusion, both groups were matched for T and N stage. Matched groups were then compared. RESULTS: Out of a total of 161 patients who received EC, 86 patients had ECB and 75 patients had ECW. After exclusion and matching, both ECB and ECW groups had 35 patients. Their demographic and clinical profiles were comparable. Surgical blood loss (p = 0.005) and postoperative complication rate (p = 0.035) were significantly less in the ECB group. For ECB vs. ECW, mean recurrence-free survival (RFS) was 58.2 months vs. 42.3 months (p = 0.264) and overall survival (OS) was 61.5 months vs. 43.4 months (p = 0.161). On univariate analysis, higher T and N stages were associated with poor prognosis. On multivariate analysis, higher T stage, N stage, and American Society of Anaesthesiologists grade were associated with poor RFS and OS. CONCLUSIONS: The survival after ECB for T2 and T3 GBC was not significantly superior to that after ECW. However, surgical blood loss and postoperative complications were lower following ECB.

Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer.

INTRODUCTION: The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking. PATIENTS AND METHODS: This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison. RESULTS: Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001). CONCLUSIONS: The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.

Laparoscopic versus open surgical management of patients with Mirizzi's syndrome: A comparative study.

INTRODUCTION: Open surgical management is considered as 'standard of care' for patients with Mirizzi's syndrome (MS). Laparoscopic management of MS has been reported, but comparative studies are lacking. PATIENTS AND METHODS: This retrospective study included patients with MS who were treated by a single surgical team from May 2009 to December 2017. Patients with total laparoscopic surgery were included in laparoscopic group (LG) and patients with total open surgery were included in open group (OG). Patients with conversion to open surgery and patients with gallbladder cancer (GBC) were excluded from the study. RESULTS: Total patients were 75; six patients with GBC and 11 patients with open conversion were excluded from comparison. LG had 32 patients and OG had 26 patients. Demographic, clinical and laboratory parameters were similar. Laparoscopic versus open preoperative diagnosis rate was 87.5% versus 69.2% (P = 0.08), respectively. OG had a large number of patients with concomitant bile duct stone; therefore, bile duct exploration rate was higher in OG (P = 0.009). Laparoscopic versus open, mean duration of surgery - 137 min versus 145 min (P = 0.664); mean blood loss - 45 mL versus 70 mL (P = 0.04); mean hospital stay - 4.5 versus 8.1 days (P = 0.027). Post-operative complication rate was 21.8% in LG and 42.3% in OG (P = 0.355); bile leak was noted in OG only (P = 0.042). LG versus OG mean follow-up was 50 versus 38 months (P = 0.189); no remote complication was observed in both groups. CONCLUSION: The results of laparoscopic surgery in patients with Mirizzi's syndrome are not inferior to that of open surgery; rather it may help to improve perioperative outcome in selected patients.

An Unusual Case of Giant Arterio-Venous Malformation of Anterior Abdominal Wall.

Arterio-Venous Malformations (AVMs) are high flow vascular anomalies, commonly seen in head, neck and extremities. AVMs represent a direct connection between the arterial and the venous systems. They are congenital, often asymptomatic and rarely manifest before adolescence. Depending on the site, size and symptoms, treatment options varies from conservative management to surgical resection. Here, we report a case of 20-year-old male patient with long standing lump in the anterior abdominal wall with no typical clinical features of vascular lesions. However, imaging findings were suggestive of vascular malformation, and final histopathological examination revealed arterio-venous malformation.

Laparoscopic excision of the choledochal cyst in adult patients: An experience.

BACKGROUND: Laparoscopic choledochal cyst excision (LCCE) in adult patients is not common. AIMS: The aim is to report our experience of LCCE in adult patients. PATIENTS AND METHODS: This study includes a retrospective review of twenty adult patients (age >18 years) with choledochal cyst (CC) who underwent LCCE by a single surgical team from February 2011 to April 2016. RESULTS: The mean age was 45.5 years. Nineteen (95%) patients had Type-I CC, and one patient (5%) had Type-IV CC (Todani's classification). Fifteen patients (75%) presented with pain in the abdomen, and five patients (25%) presented with jaundice and/or cholangitis. LCCE was successful in 16 (80%) patients, whereas four patients (20%) required conversion to open method. The reason for conversion was technical difficulty due to the initial learning curve, adhesion and inflammation. The mean blood loss, operation time and post-operative stay were 117.5 ml, 299.5 min and 8.15 days, respectively. Bilioenteric anastomosis leak and formation of pseudoaneurysm occurred in one patient (5%); this patient later died due to uncontrolled intra-abdominal haemorrhage. There were no remote complications during a mean follow-up of 17.2 months. CONCLUSION: LCCE in adult patients is safe and feasible, but bilioenteric anastomosis leak may have fatal consequences.

Laparoscopic removal of a needle from the pancreas.

Foreign bodies inside the pancreas are rare and usually occur after the ingestion of sharp objects like fish bone, sewing needle and toothpick. Most of the ingested foreign bodies pass spontaneously through the anus without being noticed but about 1% of them can perforate through the wall of stomach or duodenum to reach solid organs like pancreas or liver. Once inside the pancreas they can produce complications like abscess, pseudoaneurysm or pancreatits. Foreign bodies of pancreas should be removed by endoscopic or surgical methods. We hereby report our experience of successful removal one a sewing needle from pancreas.

Ampullary xanthogranulomatous inflammation mimicking periampullary cancer: report of a case.

CONTEXT: Xanthogranulomatous inflammation commonly affects the gallbladder. To date, there have been no reports of xanthogranulomatous inflammation of the ampulla. CASE REPORT: A 48-year-old female presented to us with fever, jaundice and a palpable gallbladder. Evaluation revealed features of periampullary malignancy. The patient underwent a Whipple's pancreaticoduodenectomy. Histopathology revealed a xanthogranulomatous inflammation affecting the ampulla and the gallbladder. CONCLUSION: Xanthogranulomatous inflammation should be added to the differential diagnosis of patients presenting with a suspected periampullary lesion accompanied by a thick-walled gallbladder.