Role of Donor-derived Cell-free DNA In Predicting Short-term Allograft Health In Liver Transplant Recipients.

Background/Aims: Predicting allograft dysfunction prior to clinical or biochemical evidence remains one of the challenges in transplantation, and a preclinical detection and early management of its cause allows for improved post-transplant outcomes. Donor-derived cell-free DNA (ddcfDNA) has been proposed as an important biomarker of allograft injury and has shown to predict dysfunction prior to any biochemical derangements. We aimed to investigate the diagnostic performance of ddcfDNA in detecting and differentiating the causes of early pre-biochemical detection of graft injury and in predicting the short-term outcomes of graft health using a patented protocol and proprietary set of single-nucleotide polymorphisms. Methods: Blood samples were collected on defined postoperative days (1, 3, 7, and at 3 months) and were analysed through relatively economical patented protocol (Trunome™). Biopsy, biochemical tests, and clinical criteria were analysed between various subgroups. Results: Of a total 50 patients, percentage ddcfDNA (%ddcfDNA) levels were significantly elevated in the rejection group (n = 8) as compared to that in the non-rejection group (n = 42; median elevation: 12.8% vs 4.3%, respectively), with a significant correlation (r = 0.92, P < 0.0001). Area under the receiver operating characteristic curve (AUC-ROC) analysis revealed that the %ddcfDNA levels can predict graft health more precisely than the conventional liver function tests (AUC for %ddcfDNA: 0.86; P < 0.001; AUC for aspartate transaminase 0.65, P = 0.08; AUC for alanine transaminase: 0.75, P < 0.01). Moreover, %ddcfDNA levels (with a threshold of >10.2%) on post-operative day 7 accurately predicted short-term (3 months) health status of the graft with 93.33% sensitivity, 94.44% specificity, 87.50% positive predictive value, 97.14% negative predictive value, and 94.12% accuracy. Conclusion: A single-timepoint ddcfDNA on postoperative day 7 accurately predicts graft health and improves risk stratification in the short-term.

Biphenotypic Immunohistochemical Features and NTRK1 Amplification in Intermediate Cell Carcinoma of the Liver.

Intermediate cell carcinoma is one of the rarest forms of primary liver cancer comprising relatively monomorphic populations of neoplastic epithelial cells demonstrating simultaneous positivity of both hepatocyte and cholangiocyte immunohistochemical markers. Here in, we describe an adult male patient who underwent left hepatectomy for a large liver tumor. The pathological and immunohistochemical analysis revealed the malignant primary liver cancer with intermediate cell morphology and mixed immunophenotypic features consistent with intermediate cell carcinoma. Furthermore, the genomic profiling using the Next-generation sequencing (NGS) platform demonstrated that there is a novel amplification with copy number gain 12 (12 gene copies) in the Neurotrophic Receptor Tyrosine Kinase 1 (NTRK1) gene, being an oncogenic driver of intermediate cell carcinoma. This is the first case report with the amplification in NTRK1 and emphasizes the importance of molecular oncology.

ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS' PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA.

BACKGROUND: Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. AIM: To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. METHOD: All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. RESULTS: From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. CONCLUSION: Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

Perioperative outcome of Whipple's procedure with special attention to the impact of preoperative biliary drainage: a real-life scenario.

The aim of the present study is to report the overall perioperative outcome of Whipple's procedure (WP) with particular attention to the impact of preoperative biliary drainage (PBD) on postoperative clinical outcome. All the patients who underwent WP at our institution between August 2007 and December 2019 were retrospectively reviewed. Impact of PBD and the stent-surgery interval on the postoperative clinical outcome of WP were analyzed. Of the total 404 patients, 254 (63%) were male. The median age at operation was 50 years. The overall morbidity was 57.7%. The most common complication was surgical site infection (SSI) (28.7%). POPF developed in 57 (14.1%) patients. Delayed gastric emptying, intra-abdominal collection, and postpancreatectomy hemorrhage developed in 82 (20%), 23 (5.7%), and 18 (4.5%) patients, respectively. PBD was performed in 175 (43%) patients. The median stent-surgery interval was 59 days. Postoperative overall complications and SSI were significantly more common in PBD patients. No significant difference in postoperative major complications or mortality was observed between PBD and no-PBD patients. Stent-surgery interval more than 6 weeks was not associated with increased postoperative complications or hospital stay. Similarly, PBD solely based on serum bilirubin ≥ 15 mg/dl has no beneficial effect on surgical outcome. The operative mortality was 4.2% (n = 17). The median postoperative hospital stay was 13 (7-68) days. PBD is associated with increased incidence of postoperative overall complications and SSI, but does not affect major complications or mortality. PBD-surgery interval greater than 6 weeks does not have a negative impact on postoperative clinical outcomes.

Short- and long-term outcome of Frey procedure for chronic pancreatitis in adults.

OBJECTIVE: To report our experience with Frey procedure (FP) for chronic pancreatitis (CP) in adults. METHODS: Adult patients with CP, who underwent a FP between August 2007 and July 2018, were retrospectively reviewed. RESULTS: Of the total 138 patients, 95 (69%) were male. The median age at operation was 36.5 years. The median pain-surgery interval was 48 months. Alcohol abuse was identified in 64 (46%) patients. The major indication for surgery was disabling pain (94%). There was no postoperative mortality. Postoperative complications developed in 43 (31%) patients. Median postoperative hospital stay was 9 days. Over a median follow-up of 65 months, 84% of patients had complete pain relief. Continuous pain and high preoperative Izbicki pain score were associated with incomplete pain control. New-onset diabetes and exocrine insufficiency developed in 31% and 27% of patients respectively. Longer duration of disease and previous pancreatic surgery were associated with the development of new-onset diabetes after the FP. CONCLUSIONS: Frey procedure is safe with an acceptable perioperative complications and good long-term pain control.

Alcoholic vs. non-alcoholic chronic pancreatitis: surgeons' perspective from a tertiary centre in india / Perspectiva dos cirurgiões sobre pancreatite crônica alcoólica vs. não-alcoólica de um centro terciário na índia

ABSTRACT Background: Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. Aim: To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. Method: All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. Results: From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. Conclusion: Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

RESUMO Racional: Embora o álcool seja a causa mais comum de pancreatite crônica em todo o mundo, a forma idiopática é prevalente na Índia. A história natural e a progressão da doença são diferentes entre esses dois grupos. Há escassez de dados comparando o resultado cirúrgico e a qualidade de vida entre eles. Objetivo: Avaliar as características clínicas, o resultado cirúrgico e a qualidade de vida entre esses dois grupos de pacientes. Método: Todos os pacientes com pancreatite crônica operados foram revisados ​​retrospectivamente. Resultados: Do total de 98 pacientes, 42 eram alcoolistas. O número de homens e a idade média no momento da operação foi significativamente maior nos alcoolistas. Tabagismo, taxa de internação pré-operatória e prevalência de complicações locais como massa inflamatória da cabeça do pâncreas, estenose biliar e hipertensão portal do lado esquerdo foram distintamente mais comuns no grupo de alcoolistas e o procedimento de Frey foi exigido mais comumente neste grupo. A média de internação pós-operatória e a taxa geral de complicações pós-operatórias foram comparáveis ​​entre os dois grupos. Ao longo de acompanhamento médio de 18 meses houve melhora significativa na qualidade de vida e pontuação de dor em ambos os grupos. A melhora no escore de funcionamento físico foi significativamente maior no grupo de alcoolistas, mas a necessidade de medicamentos analgésicos foi significativamente maior nos alcoolistas. No entanto, a perda de apetite foi mais percebida pelo grupo não alcoólico. Conclusão: A pancreatite crônica alcoólica se apresenta com mais complicações locais associadas à pancreatite crônica. O procedimento de Frey é operação segura e bem aceita neste grupo. Embora exigissem mais necessidade de analgésicos no acompanhamento em curto prazo, outros aspectos da qualidade de vida são semelhantes ao grupo não alcoólico.

Short- and long-term outcome of surgery for chronic pancreatitis in children: a single surgeon experience.

OBJECTIVE: The aim of this study was to report on the short-and long-term outcomes of surgery for chronic pancreatitis (CP) in children. METHODS: All the children, who underwent surgery for CP between August 2007 and July 2019 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. RESULTS: Of the total 54 patients, 33 (61%) were girls. The median age at operation was 16.5 years. The median duration between onset of pain and surgery was 36 months. 26% of patients were referred after failure of endotherapy. The most common indication for surgery was pain (94%). Surgery performed included modified Puestow (n = 26), Frey (n = 25), and Izbicki procedures. Twelve postoperative complications developed in ten (18.5%) patients. Most common complication was wound infection. Pancreatic leak developed in four (7.4%) patients (type A = 3, type B = 1). Median postoperative hospital stay was 8 days. There was no in-hospital mortality. Over a median follow-up of 48 months, 83% of patients had complete pain control. Weight gain was achieved in 77% of patients. New-onset diabetes and exocrine insufficiency developed in 4 and 14% of patients, respectively. CONCLUSIONS: Surgery is safe with fairly acceptable perioperative complications and good long-term pain control.

Frey Procedure Combined with Biliary Diversion for the Treatment of Chronic Pancreatitis-Related Biliary Obstruction: Impact of the Types of Diversion.

BACKGROUND: Frey procedure (FP) has become the standard of treatment for patients with painful chronic pancreatitis and inflammatory head mass. Biliary diversion (BD) is necessary when there is persistent biliary obstruction after adequate head coring. The aim of the present study was to assess the impact of types of biliary diversion on short-term outcome and rates of stricture recurrence. METHODS: All the patients, who underwent FP combined with BD between August 2007 and July 2017 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India, were retrospectively reviewed. The types of BD performed were choledochojejunostomy (Group A) or opening of the CBD in the resection cavity (Group B). RESULTS: During the study period, 36 patients underwent FP with BD. Choledochojejunostomy was performed in 21 patients and opening of the CBD in the resection cavity in 15 patients. Preoperative characteristics and early surgical outcomes were comparable except the postoperative stay which was longer in those who underwent choledochojejunostomy (p = 0.044). Pain control was similar. Over a median follow-up of 72 months, five patients in the Group B developed stricture recurrence which was significantly higher than those of Group A (p = 0.008). CONCLUSION: Choledochojejunostomy combined with FP achieves efficient BD with a lower rate of restricture compared with opening of the CBD in the resection cavity.