Curative Resection for Metastatic Solid Pseudopapillary Neoplasm of Pancreas-a Case Series.

Solid pseudopapillary neoplasm (SPN) is an unusual tumor of the pancreas. Unlike ductal adenocarcinoma, SPN is commoner in young women and is indolent with better prognosis. Fifteen percent of patients, however, develop metastases, often synchronous and involving the liver or peritoneum. Owing to the paucity of cases, management of the metastatic disease is not clearly defined. Retrospective review of case notes of patients treated between 2006 and 2019. There were 53 patients with SPN of which 4 had hepatic metastases-3 synchronous and 1 metachronous. Two patients underwent simultaneous distal pancreatectomy and splenectomy with liver resection (right posterior sectionectomy and metastasectomy). One required right hepatectomy with metastasectomy for metachronous liver metastases. The other underwent a staged operation-remnant tumor excision with metastasectomy followed by right hepatectomy after portal vein embolization. All four patients are recurrence free on median follow-up of 38.5 months. In view of the excellent prognosis, we recommend radical resection of both the primary lesion and metastases for SPN.

Myofibroblast and pro-fibrotic cytokines in fibrosis of IgG4-related disease (IgG4-RD) patients from South Asia: preliminary data.

INTRODUCTION: Fibrosis is a typical pathological characteristic in IgG4-RD patients and often irreversible. There exists a lack of suitable markers for detection of earlier onset of fibrosis in various organs in IgG4-RD patients. Hence, this study aims at analysing ambispectively the myofibroblasts and the pro-fibrotic cytokines, IFN gamma and IL-33 involved in IgG4-RD associated fibrosis in South Asian patients. METHOD: Archived biopsy samples of definite/probable/possible cases of IgG4-RD, classified according to diagnostic criteria, taken from patients who attended the OPD and IPD of our tertiary care centre during January 2015-January 2020 were chosen for this study. The paraffin sections were examined qualitatively for fibrosis and the excessive collagen deposition by Hematoxylin & Eosin and Masson's Trichrome staining. Also, the presence of alpha-Smooth muscle actin (α-SMA) expressing myofibroblasts and the involvement of pro-fibrotic cytokines (IFN-gamma, IL-33) were assessed by Immunohistochemistry and scored semi-quantitatively (+mild, ++moderate, +++ severe). Serum IL-33 levels were analysed by indirect Elisa (R & D Systems). RESULTS: Myofibroblasts were present in 10/12 biopsy samples, in moderate levels in 4 (33%) and very high levels (+++) in 3 (25%) of the patients. IFN-gamma was expressed at low levels in 6 (50%) and absent in 6 (50%). All patients showed IL-33 expression with very high levels in tissue (6, 50%), as well as in serum samples. CONCLUSION: The findings of this study reinforce the role of myofibroblasts and profibrotic cytokines like IL-33 in fibrosis of Ig4-RD patients, pointing to their potential as earlier predictive markers of onset and extent of fibrosis.

Post cholecystectomy benign biliary stricture-isolated hepatic duct stricture: a proposed modification of the BISMUTH classification.

BACKGROUND: Post-cholecystectomy, benign biliary strictures are challenging for both patients and surgeons. Bismuth classified benign biliary strictures into 5 types. This study aimed to review these isolated hepatic duct strictures which were not included in Bismuth classification. METHODS: The case records of all patients who presented with post-cholecystectomy benign biliary strictures between January 2005 and December 2020 at our centre were reviewed. Data regarding demography, type of stricture, and treatment strategy were entered into the standard proforma. RESULTS: There were 242 patients [type I-3.7%, type II-41.7%, type III-38.0%, type IV-6.6%, and type V-7.8%]. Five (2.1%) patients did not fit the Bismuth classification and were the focus of this study. In each of these patients, an isolated hepatic duct stricture (first-or second-order hepatic duct) was present, with no involvement of the common hepatic duct or hilar confluence. CONCLUSIONS: The addition of isolated hepatic duct stricture [type VI] to the Bismuth classification will enhance the original classification, help in reporting and management of this sub-set of patients.

Perioperative factors impacting intensive care outcomes following Whipple procedure: A retrospective study.

BACKGROUND AND AIMS: Whipple procedure is associated with perhaps the most perioperative morbidity and mortality amongst surgical procedures. Current data regarding their ICU profile and outcomes are lacking. Thus, in the present study, we aimed to determine perioperative factors affecting patient-centred outcomes following the Whipple procedure. METHODS: In a cohort of patients undergoing pylorus-sparing pancreaticoduodenectomies, we strove to determine perioperative variables that may impact outcomes. Unfavourable outcomes (composite of mortality, prolonged ICU stay of more than 14 days or ICU readmission) of patients who underwent the procedure were recorded and logistic regressions analysis of significant variables conducted. RESULTS: Around 68 patients recruited over a 20-month period which included 57 males (83.8%); mean age was 53.4(±11.2) with mean acute physiology and chronic health evaluation (APACHE) II score12.5 (±6.1). Nineteen patients remained intubated at the end of procedures (27.9%). Median ICU stay was 2 days (IQR 2-3). Unfavourable ICU outcomes were 14 in number (20.6%) and 2 (2.9%) hospital deaths occurred. Pulmonary complications occurred in 12 patients (17.7%) and non-pulmonary complications occurred in 41 patients (60.3%). In a multiple logistic regression analysis, the APACHE score 1.34 (1.09-1.64) and pulmonary complications 17.3 (2.1-145) were variables that were identified as predictors of unfavourable outcomes. CONCLUSION: The APACHE II score may reliably predict adverse outcomes following Whipple procedure. Although non-pulmonary complications are common, pulmonary complications in these patients adversely impact patient outcomes.

Intracholecystic papillary-tubular neoplasms of the gallbladder - A clinicopathological study of 36 cases.

Intracholecystic papillary-tubular neoplasms (ICPNs) account for <0.5% of all cholecystectomies. There is a lack of significant published data from the Indian subcontinent on ICPN to the best of our knowledge. The objective of the current study was to describe the clinicopathological features of ICPN of gallbladder from the departmental archives during a 5.5-year period. We also aimed to classify them into various histological subtypes and to correlate the clinicopathological parameters of ICPN with invasive adenocarcinoma. This study included 36 cases diagnosed over a period of 5.5 years (2013-2018). Clinical, radiological and histopathological data were analyzed in detail. The incidence of ICPN was 0.8%. The mean age of patients was 45.7 years with a female to male ratio of 1.3:1. Biliary phenotype was associated with invasion (p ≤0.001). Papillary pattern was present in 15 cases (41.6%) and was associated with invasion (p ≤0.001). High grade dysplasia was seen in 34 cases (94.4%), of which invasion was seen in 18 cases (50%). One case in our study also had synchronous common bile duct carcinoma. Majority (92%) of the patients were alive and well at the end of available follow-up (mean of 7 months and 25 days). ICPNs are mass forming neoplasms of the gallbladder with a slight female predominance. Biliary phenotype has an aggressive course, often associated with an invasive adenocarcinoma component. Papillary configuration of the lesion is significantly associated with an invasive component. Diligent follow-up of these lesions is warranted as they can be associated with other malignancies of the biliary system.

Computed Tomography Evaluation of the Arterial Supply to Segment 4 of the Liver.

INTRODUCTION: In a setting of living-donor liver transplant and patients undergoing extended hepatic resections for both primary and metastatic liver tumors, preoperative assessment of hepatic arterial anatomy is very important because of the risk of ischemic complications in the event of inadvertent injury to the arterial supply. Anatomical variations in hepatic arterial supply to the liver are very common and seen in nearly half the population. Identifying anomalous origin of segment 4 hepatic artery is vital since this vessel can cross the transection plane and can result in liver ischemia and liver failure. The purpose of our study is to study the variations in hepatic arterial anatomy to segment 4 of the liver in the Indian population. MATERIALS AND METHODS: A retrospective evaluation of 637 consecutive computed tomography (CT) angiograms over a period of 1 year was performed, and we analyzed the arterial supply to segment 4 of the liver. RESULTS: We found that the arterial supply to segment 4 of the liver originated from left hepatic artery (LHA) in majority of cases, 76.3%. LHA along with the accessory LHA supplied this segment in 6.4%, whereas the accessory LHA solely supplied this segment in 0.4%. The right hepatic artery (RHA) was seen to supply this segment in 10.2%. Dual supply with branches from the RHA and LHA was seen in 6.6% of patients. CONCLUSION: Preoperative mapping of segment 4 hepatic arterial supply using CT angiography will act as a roadmap to surgeons as they attempt to carefully dissect and preserve this segments' arterial supply. Depending on the anatomical variation, surgical techniques will vary to ensure safety of segment 4 arterial supply.

Clinicopathological Features of Intraductal Papillary Mucinous Neoplasms of Pancreas in a Tertiary Care Center: A 14 Year Retrospective Study.

INTRODUCTION: Pancreatic surgeries are usually performed for inflammatory conditions and neoplasms. Intraductal Papillary Mucinous Neoplasm (IPMN) account for approximately 5-7% of all pancreatic neoplasms in western literature. To the best of our knowledge, there has been no published literature in Indian subcontinent on IPMN. AIM: To assess the spectrum of different pancreatic pathologies on pancreatic resection specimens. Also, to review and share the experience on the clinicopathological features of IPMNs in our institute. MATERIALS AND METHODS: This was a 14 year retrospective study of all cases where pancreatic surgeries were done for pancreatic pathology. The slides and blocks of diagnosed cases of IPMNs were retrieved from the department archives, reviewed and a detailed study on the histopathological features was done. RESULTS: Among the 377 pancreatic surgical specimens, pancreatitis was the most common diagnosis followed by exocrine neoplasms and endocrine neoplasms. IPMN constituted 3.2 % of all pancreatic neoplasms. Histologically, the most common type was the gastric foveolar type. Pancreatobiliary type was aggressive and associated with an invasive component and had evidence of metastasis on follow up. CONCLUSION: IPMNs are rare neoplasms of pancreas with a male predominance. They are usually indolent except for the pancreatobiliary type which may have an aggressive course, often associated with an invasive adenocarcinoma component. Diligent follow up is recommended.