Decoding the Conundrum: Navigating Intra-operatively Encountered Suspicious Gallbladder Wall Thickening with Laparoscopic Transhepatic Needle Decompression and Beyond Cystic Plate Cholecystectomy.

BACKGROUND: Suspicious gallbladder wall thickening encountered during laparoscopic cholecystectomy poses challenges in its management. This study aims to address this problem by proposing a technique that involves laparoscopic transhepatic needle decompression and modified cystic plate cholecystectomy. METHODS: In this report, we describe the case of a 36-year-old female with symptomatic gallstone disease and ultrasound findings of a well-distended gallbladder with a uniform wall thickness. Diagnostic laparoscopy revealed a distended, tense gallbladder with suspicious areas of thickness. Transhepatic aspiration was performed for gallbladder decompression, followed by modified cystic plate cholecystectomy with preservation of the thin rim of liver tissue over the cystic plate. The gallbladder was removed in a specimen bag, and final histopathology showed a hyalinized gallbladder wall with calcification and pyloric gland metaplasia, with liver tissue adhered to the gallbladder wall (Video). RESULTS: The proposed technique aimed to minimize the risk of bile spillage and violation of oncological planes while maintaining surgical integrity. It offers a middle path between standard and extended cholecystectomy, reducing the chance of over- or under-treatment. This approach ensures patient safety, minimizes the need for conversion to open surgery, and preserves the tumour-tissue interface. CONCLUSION: Intraoperatively encountered suspicious gallbladder wall thickening can be effectively managed with laparoscopic transhepatic needle decompression and modified cystic plate cholecystectomy.

Pancreaticoduodenectomy in the Portal Annular Pancreas-Mesopancreas Triangle Approach (with Video).

BACKGROUND: Portal Annular Pancreas (PAP) is a relatively uncommon entity with 4% reported incidence. Pancreaticoduodenectomy is challenging in cases with PAP and is associated with higher postoperative pancreatic fistula rate and overall morbidity. PAP is classified according to the pattern and location of fusion around the portal vein as-supra-splenic, infra-splenic & mixed fusion type. Also, the ductal anatomy can vary as pancreatic duct present only in the ante-portal portion or only in the retro-portal portion or ducts in both ante and retro-portal portion. At present, ideal surgical strategy is not defined as per the PAP types. METHODS: The case demonstrated in the video presented with a localized, large duodenal mass with type IIA PAP (supra-splenic fusion with both ante and retro-portal ducts) detected on the preoperative triphasic CT scan. To achieve a single pancreatic cut surface with a single pancreatic duct for anastomosis, an extended pancreatic resection was performed using meso-pancreas triangle approach. RESULTS: Patient had a smooth intraoperative course & the postoperative recovery was also uneventful. Pathology reported pT3 duodenal cancer with negative margins and uninvolved lymph nodes. CONCLUSION: A preoperative knowledge of PAP and its various types is extremely important in order to tailor intraoperative management, specially of the retro-portal portion. In patients with retro-portal duct or both ante and retro-portal ducts (as the case presented in the video), an extended resection is recommended to mitigate postoperative pancreatic fistula.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey.

PURPOSE: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers. METHODS: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era. RESULTS: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase. CONCLUSION: Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

Minimally invasive surgery for pancreatic cancer-are we there yet?-a narrative review.

OBJECTIVE: The aim of this review article is to evaluate the current status of minimally invasive pancreatic resections (MIPR) for pancreatic ductal adenocarcinoma (PDAC), in light of the present evidence. BACKGROUND: Published data, largely in the form of retrospective studies and a few prospective/randomized controlled trials have confirmed feasibility, safety, and equivalent short-term outcomes of MIPR in experienced hands. Hence, several recent evidence-based international consensus guidelines have stated MIPR to be at par with the open approach, when these surgeries are performed at high-volume centers. However, longer operative duration, high conversion rates, inferior oncological outcomes, and increased mortality reported in low-volume centers, especially during minimally invasive pancreaticoduodenectomy remains a matter of concern, questioning its broad applicability. Hence, distal pancreatic resections are adopted more widely with a minimally invasive approach as compared to pancreatic head resections. Also, MIPR for PDAC in particular, remains controversial due to lack of high quality data evaluating long-term outcomes of MIPR for PDAC alone. Considering the ongoing impact of neoadjuvant treatment on pancreatic cancer surgery and the corresponding increase in vascular resections and arterial divestment procedures, applicability of MIPR in this setting remains questionable. METHODS: Medline, PubMed, Embase, Cochrane Library, and various international evidence-based guidelines were searched for the current status of minimally invasive resections for pancreatic cancer (PDAC). CONCLUSIONS: The available evidence establishes the feasibility and safety of MIPR, however for PDAC the widespread application remains controversial owing to a dearth of literature evaluating the long-term outcomes. Apart from the outcomes, establishing the exact indications, appropriate patient selection, enhanced cost, and learning curve issues need further studies.

"Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach"-a narrative review.

BACKGROUND AND OBJECTIVE: Postoperative pancreatic fistula (POPF) is associated with a mortality of up to 25% apart from significant morbid sequelae related to abdominal sepsis and post pancreatectomy hemorrhage. Numerous strategies to curtail the risk of POPF and associated morbidity have been largely unsuccessful. The pancreaticoenteric anastomosis post pancreaticoduodenectomy in a high-risk pancreas represents a significant surgical and clinical challenge. In this narrative review, we present the strategies for early identification and comprehensive management of the high-risk pancreas as per the available literature and present a stepwise algorithmic approach of different fistula mitigation strategies in patients undergoing pancreaticoduodenectomy. METHODS: Medline, PubMed, Embase, Cochrane Library, and various center-specific guidelines were searched for the pancreas, pancreatic cancer, pancreatectomy, pancreatoduodenectomy, Whipple's operation, postoperative, complications, fistula, High-risk pancreas, risk assessment, different predictors, and scoring systems for the high-risk pancreas, current and emerging concepts in the development of POPF and mitigation strategies management and treatment in various combinations. KEY CONTENT AND FINDINGS: Over the years, literature has mainly addressed the technical aspects of pancreatico-enteric anastomosis; however, the impact of different technical modifications has been at the most elusive. Recent literature has focused on other aspects like remnant ischemia, locoregional inflammation, and postoperative acute pancreatitis among others, defining their evolving role in pathophysiology of POPF. Although many pre-operative risk prediction models are available; their intra-operative implications are not clear. Furthermore, the evidence available on the mitigation strategies is limited, heterogeneous, and center specific. Fistula prediction includes numerous potentiating factors in addition to the factors described in various Fistula Risk Scores. Early identification of these high-risk scenarios allows the algorithmic application of mitigation strategies. Management of the high-risk pancreas starts in the pre-operative period by early identifications of the risk factors and then continues into the intra-operative period with strategies to decrease intraoperative blood loss, precise anastomosis, and external stenting wherever feasible; goal-directed fluid therapy as well as total pancreatectomy (TP) in certain highly selected scenarios followed by early identification of complications in the postoperative period and appropriate and early management of the same. The coherent application of these mitigation strategies provides the opportunity for the best possible outcome in this complicated scenario. CONCLUSIONS: At present, the zero post-operative pancreatic fistulae seem unattainable, and time has come to study the strategies outside the operation theatre. Till preventive strategies become mainstream, a strategic personalized algorithmic approach may yield best outcomes.

Organ preserving pancreatic resections offer better long-term conservation of pancreatic function at the expense of high perioperative major morbidity: a fair trade-off for benign or low malignant potential pancreatic neoplasms-a single-center experience.

BACKGROUND: Standard pancreatic resections (SPRs) might have long-term deleterious effects on pancreatic function, without added oncological advantage in low malignant potential (LMP) or benign neoplasms. This study aimed to evaluate outcomes following organ-preserving pancreatic resections (OPPARs) and SPRs. METHOD: Post hoc analysis of patients undergoing OPPAR or SPR for benign or LMP pancreatic tumors from January 2011 to January 2020 at Tata Memorial Hospital, Mumbai. RESULTS: Thirty-six and 114 patients were identified in OPPAR and SPR groups respectively. The overall morbidity (58.3% vs 43.9%, p-0.129) was comparable. Major morbidity (41.7% vs 21.9%, p-0.020), post-operative pancreatic fistula (POPF) (63.9% vs 35.1%, p-0.002), and clinically relevant POPF (41.7% vs 20.2%, p-0.010) were significantly higher with OPPAR. Post-operative endocrine insufficiency (14.9% vs 11.1%, p-0.567), exocrine insufficiency (19.3% vs 0%, p-0.004), and requirement of long-term pancreatic enzyme replacement (17.5% vs 0%, p-0.007) were higher in SPRs. Comparing left-sided and right-sided resections in the entire cohort, incidence of endocrine insufficiency was 17.1% vs 11.2% (p-0.299) and that of exocrine insufficiency was 8.6% vs 20% (p-0.048) respectively. CONCLUSION: OPPAR is associated with high post-operative major morbidity and pancreatic fistula rate but offers long-term benefit due to better preservation of pancreatic function than SPR. The incidence of exocrine insufficiency is higher in right sided as compared to left-sided pancreatic resections.

Towards standardization of management of gallbladder carcinoma with obstructive jaundice: Analysis of 113 cases over 10 years at a single institution.

BACKGROUND: Presence of jaundice in gallbladder carcinoma (GBC) is considered a sign of inoperability with no defined treatment pathways. METHODS: Retrospective analysis of all surgically treated GBC patients from January 2010 to December 2019 was performed for evaluating etiology of obstructive jaundice, resectability, postoperative morbidity, mortality, disease-free survival (DFS) and overall survival (OS). RESULTS: Out of 954 patients, 521 patients (54.61%) were locally advanced gallbladder carcinoma (LAGBC: Stage III and IV) and 113 patients (11.84%) had jaundice at presentation. Thirty-four (30%) patients had benign cause of obstructive jaundice. Median OS of the whole cohort (n=113) was 22 months (16.5-27.49 months) with resectability rate of 62% (70/113). Median OS of curative resection group (n=70) was 32 months and DFS was 25 months. Treatment completion was achieved in 30% (n= 21/70) patients with median OS of 46 months and median DFS of 27 months. Isolated bile duct infiltration subgroup fared the best with median OS of 74 months with a 5-year survival of 66.7%. CONCLUSION: Surgical resection as a part of multimodality treatment improves survival in carefully selected locally advanced gallbladder cancer patients with jaundice. Early introduction of systemic therapy is the key in the management of this disease with aggressive tumor biology.

Is resection for noncolorectal, nonneuroendocrine liver metastases justified?

INTRODUCTION: The role of hepatectomy in non-colorectal, nonneuroendocrine liver metastasis (NCNN) is not clearly defined. This study represents a step towards surgical frame-shift as an integral part of treatment pathway in these heterogeneous, arbitrarily treated tumors. It aims to provide answers regarding favorable tumor types and patient profiles for which liver metastasectomy would prove beneficial. MATERIALS AND METHODS: Retrospective analysis of prospectively maintained database of hepatectomy in NCNN liver metastasis. RESULTS: A total of 50 patients out of 516 patients underwent liver resection during this period. In 27 patients, the liver metastases presented synchronously whereas the other 23 were metachronous. Median disease-free interval (DFI) was 36 months. Gastrointestinal stromal tumors (GIST) were the most common type of primary malignancy (15, 30%). In 41 patients, the liver was the only site of metastases. At a median follow-up of 32.5 months, 24 patients developed recurrences. Five-year overall (OS) and disease-free survival (DFS) for the entire cohort was 60% and 32%, respectively. Median OS was highest in the breast (93 months) followed by GIST (56 months). Patients with longer DFI showed improved OS. (p = .04). CONCLUSION: Liver resection for NCNN metastases is safe and feasible in selected patients with good survival outcomes. Longer DFI correlates with better survival.

Establishing a Multidisciplinary Liver Tumour Clinic in a Limited Resource Scenario: Core Concepts and Our Experience.

Multidisciplinary tumour clinics represent the modern state-of-the-art cancer care. However, liver tumour clinics are resource exhaustive and establishing them in resource restricted scenarios is a challenge. We present core concepts in establishing a multidisciplinary tumour clinic, followed by our 5-year experience of multidisciplinary liver tumour clinic from Tata Memorial Hospital Mumbai, India, which represents one of the largest hepatobiliary oncology units in the country. This study provides a roadmap for setting up a multidisciplinary liver tumour clinic and explains the stepwise real-time working of the clinic. The account will act as a blueprint for the establishment of such clinics in the country and abroad.

Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer.

BACKGROUND: Pancreaticoduodenectomy (PD) is more challenging in the elderly. METHODS: Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL). RESULTS: Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients. CONCLUSION: Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.

Towards Standardization of Liver Resections in India: Five Hundred Consecutive Oncological Liver Resections- Trends, Techniques and Outcomes.

PURPOSE: To study the trends, techniques, outcomes and improvisations of liver resections over the study period. METHODS: We analysed prospectively maintained database of patients undergoing liver resections for oncological indications at Tata Memorial Centre, Mumbai, India from June 2010 to October 2016. RESULTS: Five hundred sixteen patients were operated with median age of 55 years and male to female ratio of 1.6:1. Most commonly operated neoplasms were hepatocellular carcinoma (N = 166), cholangiocarcinoma (N = 72) and metastases from colorectal cancer (N = 129). We performed 219 major hepatic resections (≥3 segments) with overall morbidity of 22.9% (N = 118) and mortality of 4.0% (N = 21). Complex hepatectomies were performed in 78 patients. In order to study the time trends, data was divided into pre-liver clinic era and post liver clinic era. Trend analysis showed improvements in complication grade, hospital stay, blood loss, and overall survival status in post liver clinic era. Liver transection in all our patients was carried out without Pringle manoeuvre under normotensive anaesthesia, only 0.7% of our patients had significant transaminitis beyond POD 5. CONCLUSION: A dedicated multidisciplinary treatment approach along with standardization of liver resections culminates into optimal treatment outcomes.

Primary hepatic neuroendocrine tumours of liver- a rarity: Single centre analysis of 13 patients.

BACKGROUNDS/AIMS: Primary hepatic neuroendocrine tumours (PHNETs) are a rarity and this rarity imparts management complexities. METHODS: A retrospective analysis of prospectively maintained liver database from 2009 to 2018 was performed and patients with PHNETs were identified and studied for clinical, imaging and pathological features, surgical outcomes, disease free and overall survival. RESULTS: Thirteen patients of PHNET were identified following rigorous investigational protocols, which constituted 0.6% of all liver tumours (2095) in our series. The median age of patients was 50 years (14-65), with male to female ratio of 9:4. Eight patients (62%) underwent hepatic resections as primary treatment, while 5 (38%) patients received peptide receptor radiotherapy, trans-arterial chemotherapy, trans-arterial radiotherapy or a combination of these. In the surgical group at a median follow up of 36 months (range 5-114 months), 4 (50%) patients were alive without disease and disease free survival was 20 months. Median OS in surgical group was 47 months (40-53, 95% confidence interval) that was better but not statistically significant from that of non-surgical treatment group (36 months). CONCLUSIONS: PHNETs are rare tumours that require multidisciplinary treatment approach. Liver directed surgery centred management leads to better clinical outcomes in these selected patients.

Hepatocellular carcinoma metastasis to the buccal mucosa masquerading as oral cavity malignancy: Case report of a rare entity.

Hepatocellular carcinoma, a disease of the developing world, is known to present with extrahepatic metastases. Most common site being the lungs, it is not uncommon for metastases to present at unusual sites like the rectum, spleen and the diaphragm, among others. Metastases to the oral cavity is rare, with the most common primaries being lung, breast and the kidney. Metastases of a hepatocellular carcinoma to the oral cavity is a rare entity with extremely limited data in literature. We present one such unique case of oral cavity metastases from a hepatocellular carcinoma who presented to the Division of Head and Neck Oncology services of our hospital with a large oral cavity lesion, on subsequent workup of which, a hepatocellular carcinoma was identified. Awareness of this possibility can aid in accurate diagnosis and early management of a condition associated with an advanced stage at presentation and poorer prognosis.

Performance of Hong Kong Liver Cancer staging system in patients of hepatocellular carcinoma treated with surgical resection: An Indian validation study.

BACKGROUND: Hong Kong Liver Cancer staging (HKLCS) system lacks external validation. AIMS AND METHODS: We conducted a study to validate the prognostic and clinical utility of HKLCS system in the patients with hepatocellular carcinoma (HCC) of heterogeneous etiologies treated with hepatic resection with curative intent at Tata Memorial Centre, Mumbai, India. RESULTS: A total of 144 patients underwent resection for HCC. Our patient cohort was comparable to the original developmental cohort in median age and gender distribution but differed in etiology, liver function status, and tumor venous invasion. On Kaplan-Meier survival curve analysis for overall and disease-free survival, we could achieve statistically significant separation of curves in both Barcelona Clinic Liver Cancer staging (BCLCS) and HKLCS staging systems (P < .000). Interstage discrimination between early and intermediate stages for survival was higher in HKLCS system (P value of .039 vs .091). The area under the receiver operating characteristic curve for the survival of BCLCS and HKLCS systems for the entire patient population was 0.66 and 0.60, respectively, which was not statistically significant (P = .31). CONCLUSION: The HKLCS system offered higher interstage discrimination power in the patients with HCC treated with resection and may be equally applicable to nonalcoholic steatosis-related chronic liver disease and noncirrhotic patient population.

Management of gallbladder cancer in India.

Gallbladder cancer is a highly aggressive disease with variable prevalence across the globe. Particularly the Indo-Gangetic belt in Northern India has an incidence as high as 21/100,000. Majority of cases are detected either incidentally on pathological evaluation of cholecystectomy specimens or present with advanced disease. Radical surgery remains the mainstay of cure but only a small subset of patients is operable at presentation, and even with curative surgery recurrence rates remain high. Much debate surrounds the management of gallbladder cancer, with continuously evolving standards regarding the extent of hepatic resection and lymphadenectomy, curative resection in patients presenting with jaundice, routine excision of bile duct, and the role of neoadjuvant chemoradiotherapy. In this review we present a synopsis of currently available evidence and emerging approaches in the management of gallbladder cancer in India.

A Review of 2255 Emergency Abdominal Operations Performed over 17 years (1996-2013) in a Gastrointestinal Surgery Unit in India.

There is little information regarding the clinical spectrum and outcome of emergency abdominal operations from specialized units in India. We examined these in our gastrointestinal surgery and liver transplantation unit from a prospective database maintained between July 1996 and April 2013. Out of 9966 operations performed, 2255 (26%) were emergency procedures (reoperations during the same admission, e.g., for necrotizing pancreatitis were excluded). The primary outcome was 30-day postoperative mortality. The mean age of the patients was 47 years (range 1-107) and included the following age groups: 0-18 years (n = 105, 4.7%); 19-64 years (n = 1766, 78.3%), and >65 years (n = 384, 17.0%). The majority were males (1609, 71%), and there were 646 females (29%). The most common indications were small bowel emergencies (598, 26.5%), followed by pancreatic (417, 18.5%) and colonic (281, 12.5%) emergencies. Pancreatic operations were the second commonest in the adult and middle aged group. Colorectal operations were the second commonest in the geriatric age group (>65 years). Emergency operations for other conditions were: postoperative complications following elective operations 171 (7.5%), gastroduodenal bleeding or perforation in 144 (6.3%), and liver surgery in 93 patients (4.1%) patients. In the small bowel emergencies, 223 patients (37.2%) had primary diagnosis of adhesive obstruction, gangrene in 135 patients (22.5%), perforation in 121 patients (20%), and fistula in 56 patients (9.3%). Mesenteric venous thrombosis was found to be the primary cause of small bowel emergencies, either as a primary cause in gangrene or as a secondary cause in perforations and adhesions. The postoperative mortality after emergencies was 12.6% compared to 2% in elective procedures. Mortality was significantly higher in males (14%) than females (9.6%), p < 0.005. Category wise mortality was as follows: pancreatic surgery (n = 86, 20.6%), surgery for postoperative complications (n = 33, 19.3%), duodenal surgery (n = 18, 12.5%), small intestinal surgery (n = 68, 11.4%), and colonic surgery (n = 35, 12.45%). Emergency operations comprise a significant proportion of a GI surgical unit's workload. The mortality is greatest after pancreatic operations followed by those done for postoperative complications. Despite advances in surgical and postoperative care, emergency operations for abdominal emergencies are associated with mortality which is six times higher compared to elective procedures.