Primary Hodgkin's lymphoma of liver in HIV-a case report and review of literature.

Primary hepatic lymphoma (PHL) is a lymphoma presenting with predominant liver involvement at presentation in the early stage of lymphoma. It accounts to less than 0.4% of all extranodal lymphomas and usually occurs in immunocompromised states. It is more commonly of the non-Hodgkin's lymphoma of B cell variety. Hodgkin's lymphoma presenting as PHL has not been reported before. We report a 55-year-old HIV positive male presenting with an SOL in left lateral segments of liver having typical imaging characteristics of fibrolamellar HCC with normal serum AFP levels. Surgical resection was done and the histopathological analysis and immunohistochemistry of the specimen revealed it to be a Hodgkin's lymphoma. The patient was started on chemotherapy (ABVD regimen) along with highly active antiretroviral therapy (HAART). Primary lymphoma of liver can mimic HCC on imaging. Hence, in the background of an immunocompromised state like HIV with normal serum AFP levels, PHL should be suspected and liver biopsy can clinch the diagnosis.

Krukenberg tumours from gastrointestinal cancers-analysis from a tertiary care centre in India.

BACKGROUND: Krukenberg tumour (KT) is clinically defined as any ovarian metastatic carcinoma derived from a primary malignancy (usually from the gastrointestinal tract). Our aim was to analyse the incidence, demographic profile, clinical features, management and survival of patients with KTs from gastrointestinal tract malignancies at our centre. METHODS: This was a retrospective analysis data at our centre between Jan 2015 and Dec 2017. RESULTS: A total of 8 patients of KTs (2 from gastric and 6 from colorectal cancers) were observed with an incidence of 0.66% in gastric and 2.90% in colorectal cancers. The mean age of all the patients was 40 years (44 in gastric and 39 in colorectal group) and most of them (5 out of 8) occurred in premenopausal women. They were also most commonly bilateral (6 out of 8) and synchronous (6 out of 8). Surgical debulking was possible in 7 patients and all patients underwent systemic chemotherapy. Interestingly, 4 patients in the colorectal KT group with metastasis limited to ovary alone managed by surgical debulking and chemotherapy had a significantly higher 1-year survival compared to the others with peritoneal disease are alive at an average of 14.5 months. CONCLUSIONS: The incidence of KTs from colorectal cancers is on the rise. KTs from colorectal cancers and KTs without peritoneal metastases have a better prognosis showing significantly higher 1-year survival rates following complete surgical resection and systemic chemotherapy.

Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy?

BACKGROUND: Although bile infection has been proposed to increase infective complications following pancreaticoduodenectomy, its association with infective complications and non-infective complications like pancreatic fistula is still controversial. METHODS: Seventy-six patients who had undergone pancreaticoduodenectomy between July 2007 and December 2008 were included in a prospective database and their data analyzed. In all patients intraoperative bile from the bile duct was cultured. Preoperative, intra-operative, and post-operative variables were recorded and analyzed. RESULTS: Bile culture showed positive growth in 35 patients and negative growth in 41. Twenty patients in the positive group underwent ERCP and stenting. The patients with a positive bile culture had a higher incidence of infective complications including intra-abdominal abscess (n=8), wound infection (n=27), bacteremia (n=10), and renal insufficiency (n=9). There was no increase in the rate of non-infective complications of pancreaticoduodenectomy including pancreatic fistula (n=7), delayed gastric emptying (n=9), and post-operative hemorrhage (n=3). The hospital stay was significantly prolonged in the patients with a positive bile culture (P=0.0002). CONCLUSIONS: Pre-operative biliary drainage is significantly associated with bile infection, and bile infection increases the overall rates of infective complications and renal insufficiency. Because of the high incidence of complications is associated with infected bile, routine intra-operative bile culture is recommended in patients undergoing pancreaticoduodenectomy. Pre-operative prophylaxis is dependent on sensitivity of cases to perioperative antibiotics and intra-operative bile culture report. Because of its significant association with infected bile, biliary stenting should be used in strictly selected cases.

Haemosuccus pancreaticus: diagnostic and therapeutic challenges.

BACKGROUND: Haemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. The objective of our study was to highlight the challenges in the diagnosis and management of HP. METHODS: The records of 31 patients with HP diagnosed between January 1997 and June 2008 were reviewed retrospectively. RESULTS: Mean patient age was 34 years (11-55 years). Twelve patients had chronic alcoholic pancreatitis, 16 had tropical pancreatitis, two had acute pancreatitis and one had idiopathic pancreatitis. Selective arterial embolization was attempted in 22 of 26 (84%) patients and was successful in 11 of the 22 (50%). Twenty of 31 (64%) patients required surgery to control bleeding after the failure of arterial embolization in 11 and in an emergent setting in nine patients. Procedures included distal pancreatectomy and splenectomy, central pancreatectomy, intracystic ligation of the blood vessel, and aneurysmal ligation and bypass graft in 11, two, six and one patients, respectively. There were no deaths. Length of follow-up ranged from 6 months to 10 years. CONCLUSIONS: Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. Diagnosis is based on investigations that should be performed in all patients, preferably during a period of active bleeding. These include upper digestive endoscopy, contrast-enhanced computed tomography (CECT) and selective arteriography of the coeliac trunk and superior mesenteric artery. Contrast-enhanced CT had a high positive yield comparable with that of selective angiography in our series. Therapeutic options consist of selective embolization and surgery. Endovascular treatment can control unstable haemodynamics and can be sufficient in some cases. However, in patients with persistent unstable haemodynamics, recurrent bleeding or failed embolization, surgery is required.

Management of esophageal perforation: experience from a tertiary center in India.

BACKGROUND/AIM: The management of esophageal perforations remains controversial in large part due to variability in etiology, time of presentation, location, and underlying esophageal disease. We reviewed our experience in treating patients with esophageal perforations and evaluated the etiology, management and outcome of intervention in a tertiary center. METHODS: Between 1999 and 2007, 48 patients with esophageal perforation were treated in a tertiary referral center in southern India. Postdilatation corrosive stricture perforations constituted the major etiology. RESULTS: Thirty (62.5%) patients were diagnosed early (<24 h) and the remaining 18 (37.5%) were late (>24 h). The 30-day mortality was 6.2%, and mean hospital stay was 13 +/- 9.3 days. Comparing outcomes between early and late groups, statistically significant difference was observed, with increased mortality (p = 0.02) and hospital stay (p = 0.04) following late diagnosis. CONCLUSION: This report suggests that early diagnosis decreases mortality and hospital stay in esophageal perforation. Preservation of esophagus may be attempted while treating esophageal perforations.

Factors affecting outcome after Frey procedure for chronic pancreatitis.

BACKGROUND: Debilitating abdominal pain remains the most common presentation of chronic pancreatitis and the treatment remains challenging. OBJECTIVE: This prospective study analyzed the outcome of Frey's procedure in patients with inflammatory head mass. METHODS: For the period between 2002 and 2007, 77 patients with chronic pancreatitis underwent Frey procedure for intractable abdominal pain. The mean follow-up was 14 months. For the purpose of analysis of the outcome, patients were grouped as poor pain control (19%) and good pain control groups (81%) based on the pain scores during follow-up. RESULTS: There was no 30-day mortality. The logistic regression analysis showed that decreased volume percentage (48%) of head mass resected (p=0.003) and small diameter of the pancreatic duct (p=0.05) were associated with poor pain outcome. Subgroup analysis revealed that patients with small duct disease were associated with increased operative time (p=0.001), poor pain scores (p=0.001), and increased weight loss (p=0.003) during follow-up. CONCLUSIONS: Frey procedure can be performed with zero mortality and low morbidity in a high-volume center. It provides good pain relief in majority of the patients. Volume of the head mass cored affects pain outcome. Correlation between poor results in terms of pain relief and weight loss following Frey's procedure, and small duct disease supports the view that duct diameter is an important predictor of pain relief.

Neuroendocrine carcinoma of the ampulla of Vater: a clinicopathologic evaluation.

BACKGROUND: Only 105 cases of neuroendocrine tumor (NET) of the ampulla of Vater have been described, mostly as single case reports. The incidence of NET is rising. The changes in incidence may result from changes in detection. This study was to determine the relative incidence and clinicopathological characteristics of high-grade neuroendocrine carcinoma (small cell carcinoma and large cell carcinoma) of the ampulla of Vater at a single institution. METHODS: Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple's procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical analysis. The clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS: The patients were 3 men and 2 women, ranging in age from 39 to 47 years (mean 44 years). Operative procedures included Whipple's procedure in 4 patients and palliative bypass in 1 patient. Histopathological examination revealed large cell neuroendocrine carcinoma in 2 patients, small cell carcinoma in 2, and carcinoid in 1. Three patients with high-grade neuroendocrine carcinoma who had undergone Whipple's procedure died at postoperatively 7, 11, and 13 months. The patient who had undergone palliative triple bypass died 3 months after surgery. CONCLUSIONS: The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally expected. The tumors behave aggressively and have a dismal prognosis despite aggressive treatment.

Long-term outcome of gastric access loop in hepaticojejunostomy.

BACKGROUND: The incidence of hepaticojejunostomy stricture is 4%-10% in experienced centres. Many access loops have been designed and used to facilitate endoscopic intervention for this complication of hepaticojejunostomy. In this study, we investigated the effectiveness and safety of gastric access loop. METHODS: A retrospective analysis was conducted on 13 patients who had undergone hepaticojejunostomy with gastric access loop between June 1999 and September 2003. Eleven patients were followed up for a mean period of 51 months (range 20-81 months). Two patients were lost to follow up. RESULTS: On follow-up, 8 patients had patent jejunogastrostomy (end to side anastomosis between Roux loop of jejunum and stomach) and hepaticojejunostomy. Three patients developed stricture of jejunogastrostomy at 41 months, 63 months and 81 months of follow-up. Among these 3 patients, one also had hepaticojejunostomy stricture. In the patient with hepaticojejunostomy stricture, dilatation of jejunogastrostomy stricture was attempted but failed. None of the patients had any evidence of bile gastritis/cholangitis. There was no procedure related morbidity/mortality. CONCLUSIONS: Further studies involving large numbers of patients are required before wide application of gastric access loop in hepaticojejunostomy though it is a safer option than percutaneous transhepatic manipulations or revision surgery.

Management of post dilatation oesophageal perforation: an experience from a tertiary centre.

BACKGROUND: Treatment of oesophageal perforation remains controversial. This study shows that native oesophagus should be preserved. Early recognition improves survival. AIM: The aim of this study was to evaluate the outcome of management of post dilatation oesophageal perforation in a tertiary centre. METHODS: Between 1999 and 2007, 35 patients with oesophageal perforation following dilatation were treated. Post dilatation corrosive stricture perforations constituted the major aetiology. RESULTS: Twenty-four (69%) underwent early intervention (< 24 hours) and the remaining 11 (31%) were late (>24 hours). The 30-day mortality was found to be 9%, and mean hospital stay was 14 ± 14.7 days. Comparing outcomes between early and late groups, statistically significant difference was observed, with increased mortality (p=0.001) and hospital stay (p=0.001) following late intervention. CONCLUSION: Early intervention decreases mortality and hospital stay in oesophageal perforation and preservation of oesophagus may be attempted, as native oesophagus is the best conduit.

Pancreaticogastrostomy for pancreatic ascites.

BACKGROUND/AIMS: Management of pancreatic ascites is challenging. The aim of the present study was to study the role of pancreaticogastrostomy in management of pancreatic ascites. METHODOLOGY: Retrospective analysis of twelve operated cases with pancreatic ascites following failed conservative and endoscopic treatment was done for its outcome in terms of morbidity and a successful outcome. Patient data, imaging information and surgical procedure were noted. RESULTS: Four of the 12 patients with leak from the dilated main pancreatic duct had longitudinal pancreaticogastrostomy. The gross edematous jejunum and a shortened mesentery due to sub-acute peritonitis necessitated this surgery. None had recurrence of ascites. Steatorrhea was distinctly absent. None had deterioration of endocrine function. CONCLUSIONS: Longitudinal pancreaticogastrostomy is a viable option in patients with pancreatic ascites and dilated main pancreatic duct especially in those with a shortened mesentery and an edematous small bowel.

Central pancreatectomy for benign pancreatic pathology/trauma: is it a reasonable pancreas-preserving conservative surgical strategy alternative to standard major pancreatic resection?

BACKGROUND: The aim of this study was to assess the technical feasibility, safety and outcome of central pancreatectomy (CP) with pancreaticogastrostomy or pancreaticojejunostomy in appropriately selected patients with benign central pancreatic pathology/trauma. Benign lesions/trauma of the pancreatic neck and proximal body pose an interesting surgical challenge. CP is an operation that allows resection of benign tumours located in the pancreatic isthmus that are not suitable for enucleation. METHODS: Between January 2000 and December 2005, eight central pancreatectomies were carried out. There were six women and two men with a mean age of 35.7 years. The cephalic pancreatic stump is oversewn and the distal stump is anastomosed end-to-end with a Roux-en-Y jejunal loop in two and with the stomach in six patients. The indications for CP were: non-functional islet cell tumours in two patients, traumatic pancreatic neck transection in two and one each for insulinoma, solid pseudopapillary tumour, splenic artery pseudoaneurysm and pseudocyst. Pancreatic exocrine function was evaluated by a questionnaire method. Endocrine function was evaluated by blood glucose level. RESULTS: Morbidity rate was 37.5% with no operative mortality. Mean postoperative hospital stay was 10.5 days. Neither of the patients developed pancreatic fistula nor required reoperations or interventional radiological procedures. At a mean follow up of 26.4 months, no patient had evidence of endocrine or exocrine pancreatic insufficiency, all the patients were alive and well without clinical and imaging evidence of disease recurrence. CONCLUSION: When technically feasible, CP is a safe, pancreas-preserving pancreatectomy for non-enucleable benign pancreatic pathology/trauma confined to pancreatic isthmus that allows for cure of the disease without loss of substantial amount of normal pancreatic parenchyma with preservation of exocrine/endocrine function and without interruption of enteric continuity.

Large cell neuroendocrine carcinoma of the ampulla of Vater.

BACKGROUND: Neuroendocrine tumors of the ampulla of Vater are extremely rare, and few cases of large cell neuroendocrine carcinoma (LCNEC) of the ampulla have been reported. METHODS: A 48-year-old male with obstructive jaundice was admitted to our hospital. On examination the patient was found to have a periampullary growth and subsequently underwent the Whipple's procedure. RESULTS: Histopathological examination and immuno-histochemistry revealed features of LCNEC of the ampulla of Vater. The patient developed multiple liver metastases 6 months after Whipple's procedure. CONCLUSION: LCNEC of the ampulla of Vater is rare and highly aggressive, with a dismal prognosis.

Acute hemorrhage into adrenal pseudocyst presenting with shock: diagnostic dilemmas--report of three cases and review of literature.

We report three cases of acutely bleeding adrenal pseudocysts presenting as hemorrhagic shock. Pregnancy was associated in two cases. The diagnostic dilemmas are discussed with special reference to their unusual presentations, diagnosis, and treatment. We believe that our cases, complicated by intracystic hemorrhage, may be related to pregnancy.

Acute septal panniculitis. A cutaneous marker of a very early stage of pancreatic panniculitis indicating acute pancreatitis.

CONTEXT: Pancreatitis may occasionally be complicated by panniculitis as a result of the release of pancreatic enzymes. Pancreatic panniculitis is rare, occurring in 2-3% of all patients with pancreatic disorders, with a higher incidence among alcoholic males. CASE REPORT: A 29-year-old male was admitted to our Department with acute abdominal pain one day following alcohol consumption. On physical examination, tender erythematous plaques and nodules were present on the left ankle and the pretibial regions of both lower legs, a clinical sign of panniculitis indicating acute pancreatitis common in alcoholic patients. Abdominal ultrasonography showed a diffusely edematous pancreas suggestive of acute pancreatitis. Abdominal contrast enhanced computerized tomography revealed features suggestive of severe acute pancreatitis with pancreatic necrosis. A skin biopsy confirmed the diagnosis of septal panniculitis without vasculitis or fat necrosis, which is indicative of a very early stage of pancreatic panniculitis suggesting acute alcoholic pancreatitis. CONCLUSION: Septal panniculitis without vasculitis or fat necrosis is a cutaneous clinical marker which denotes a very early stage of pancreatic panniculitis associated with acute alcoholic pancreatitis. The treatment of pancreatic panniculitis is primarily supportive and depends on the underlying pancreatic pathology which may include surgery or endoscopic management.