Heterotopic Pancreas: Unusual Cause of Usual Diarrhoea.

Heterotopic pancreas (HP) also known as ectopic pancreas, pancreatic crest or accessory pancreas is the normal pancreatic tissue, found in a remote area other than its natural location, with no anatomic or vascular connection to main pancreatic tissue. It is a rare congenital anomaly and has been reported at many locations such as stomach (antrum) and small intestine. HP is usually an incidental finding and asymptomatic, however there are reports of pancreatitis, obstruction, perforation and malignant transformation as uncommon manifestations. Diagnosis of HP is primarily based on histological examination either by biopsy or surgical excision. Surgery is the standard treatment for symptomatic HP patients. Herein, we present a case of a 58-year-old female, who presented to us with intractable diarrhoea due to HP in the jejunum and underwent minimally invasive surgery for definitive diagnosis and treatment.

Gastric Schwannoma-Two Unusual Cases with Usual Presentation and Review of Literature.

Schwannomas, also known as neurilemmomas, are characteristically benign, slow growing neoplasms originating from Schwann cell sheath. Gastrointestinal schwannomas are very rare with stomach being the most affected organ representing approximately 0.2% of all gastric tumours. Malignant transformation is rarely reported in these tumors and complete surgical resection with negative margins is the recommended treatment. Herein, we report our experience of 2 cases of gastric submucosal spindle cell tumour (SMT), which were preoperatively assumed to be as gastrointestinal stromal tumor (GIST), however postoperatively confirmed as schwannoma on immunohistochemical examination.

Minimally Invasive Surgery for Pelvic Exenteration in Primary Colorectal Cancer.

BACKGROUND: Minimally invasive surgery (MIS) for pelvic exenteration is not a well-established technique. The aim was to assess the safety and feasibility of MIS for pelvic exenteration in locally advanced primary colorectal cancer and to compare the perioperative outcomes with open surgery. METHODS: This is a retrospective analysis of patients, who had undergone pelvic exenteration for primary colorectal adenocarcinoma from May 2013 to July 2018. The short-term outcomes like perioperative details and histopathological characteristics were compared between the two groups. RESULTS: MIS was performed in 23 patients and open pelvic exenteration was carried out in 72 patients. The mean operative time was significantly more in the MIS group (640 vs. 432 min, p = 0.00). The intraoperative blood loss (900 vs. 1550 ml, p = 0.00) and the requirement for blood transfusion (170 vs. 250 ml, p = 0.03) was significantly less in the MIS group. The overall morbidity (60% vs. 49%, p = 0.306) was comparable between the two groups. The median length of hospital stay in the MIS group was 11 d, compared to 12 d in the open surgery group, (p = 0.634). The rate of R0 resection (87% vs. 89%, p = 0.668) was comparable between the two groups. CONCLUSION: MIS is feasible and safe for total pelvic exenteration and posterior exenteration in carefully selected locally advanced primary colorectal cancer, when performed by an experienced surgical team in high volume centers. An R0 resection with adequate margin can be achieved with good perioperative outcomes in MIS. Long-term oncological outcomes would require further follow up to confirm.

To Do or Not to Do?-A Review of Cancer Surgery Triage Guidelines in COVID-19 Pandemic.

COVID-19 pandemic has emerged as a global health emergency involving more than 200 countries so far. The number of affected population is on rising, so is the mortality. This crisis has overwhelmed the healthcare infrastructures in many affected countries. Due to overall rising cancer incidence and specific concerns, a cohort of cancer patients forms a distinct subset of the population in whom a correct and timely treatment has a huge impact on the outcome. During this period, oncology care is definitely affected owing to many factors like lockdowns, reduced beds and deferral of elective cases to halt the spread of the pandemic. Surgery remains the best line of defence in many solid organ tumours especially in early stage and is potentially curative. China, the source of this pandemic, has taken more than 3 months to enter the post transitional phase of this pandemic. Deferring cancer surgeries for this long period may have a direct impact on the long-term outcomes of cancer patients. Many surgical oncology associations across the globe have come up with triage guidelines for surgical care of cancer patients; however, these are based on expert opinion rather than actual data. Herein, we intend to review these guidelines with respect to the risk of disease progression in cancer patients. In the absence of actual data on cancer surgery care during this pandemic, clinical decisions should be based on careful consideration of disease-related and patient-related factors. While some of the cancer surgeries can be safely delayed for some time, how long we can delay surgeries safely cannot be answered/ explained by any means. Thorough evaluation and discussion by an expert and experienced multidisciplinary team appears to be the most effective way forward.

Correction to: Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

The authors' affiliations are updated as reflected here.

External validation and comparison of the original, alternative and updated-alternative fistula risk scores for the prediction of postoperative pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Many postoperative pancreatic fistula (POPF) predictions models were developed and validated in western populations. Direct use of these models in the large Indian/Asian population, however, requires proper validation. OBJECTIVE: To validate the original, alternative and updated alternative fistula risk score (FRS) models. METHODS: A validation study was performed in consecutive patients undergoing pancreatoduodenectomy (PD) from January 2011 to March 2018. The area under the receiver operating curve (ROC) and calibration plots were used to assess the performance of original-FRS (o-FRS), alternative FRS (a-FRS) and updated alternative FRS (ua-FRS) models. RESULTS: This cohort consisted of 825 patients of which 66% were males with a median age of 55 years and mean body mass index of 22.6. The majority of tumors (61.8%) were of periampullary origin. Clinically relevant POPF was observed in 16.8% patients. Area under curve (AUC) of ROC for the o-FRS was 0.65, 0.69 for a-FRS and 0.70 for ua-FRS, respectively (p = 0.006). CONCLUSIONS: In this large Indian cohort of predominantly periampullary tumors, the ua-FRS performed better than the a-FRS and o-FRS, although differences were small. Since the AUC value of the ua-FRS is at the accepted threshold there might be room for improvement for a FRS.

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

BACKGROUND: The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. METHOD: A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. RESULTS: A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). CONCLUSION: With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.

Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

BACKGROUND: Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS: 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS: Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION: Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.

Cutting-edge strategies for borderline resectable pancreatic cancer.

Worldwide, pancreatic ductal adenocarcinoma (PDAC) accounts for more than 400 000 deaths every year, being the 12th most common cancer and the seventh most frequent cause of death from cancer. Regardless of the advances in diagnosis and treatment, PDAC continues to have dismal outcomes and fewer than 25% of patients survive for 1 year. In the absence of metastatic disease, radical surgery remains the most important factor for improving survival and possibly offer cure. However, approximately 80% of patients cannot be offered surgery owing to locally advanced or metastatic disease at presentation. At presentation, only 10%-20% patients are eligible for resection, 30%-40% are unresectable/locally advanced and 50%-60% are metastatic. One promising development in recent years has been the inclusion of a new subgroup within the locally advanced tumors of borderline resectable pancreatic cancer (BRPC) comprising approximately 5%-10% of the total patient population. Although its exact definition has been refined over the past few years depending on the vascular involvement around the tumor, the term was initially proposed for tumors that are at a high risk of having margin positivity after resection. Various treatment approaches are still evolving for this entity. Herein, we reviewed the current status of different treatment modalities for BRPC.

Primary hepatic tuberculosis: A rare occurrence.

Primary hepatic tuberculosis is a rare entity and can closely mimic malignancy with respect to clinical presentation and imaging features. We identified five patients at a high volume tertiary care cancer center, whose clinical features and imaging closely mimicked primary liver malignancy or metastases but final histopathology was suggestive of hepatic tuberculosis. Three patients underwent a surgical resection whereas two were diagnosed on a biopsy. Anti-tuberculosis therapy was started for all the patients which was well tolerated. All patients are doing well at the time of the last follow up. This case series stresses the importance of having a high index of suspicion and preoperative biopsy in cases where imaging features are equivocal.

Pelvic Exenteration with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS + HIPEC) for Rectal Cancer-Case Series with Review of Literature.

Incidence of synchronous peritoneal metastases (PM) in colorectal cancer is approximately 5%, with another 5% of the patients develop metachronous PM. Colorectal PM has been hypothesized to be a loco-regional disease rather than a systemic spread, and cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been considered as a viable treatment option. Pelvic exenteration is an established treatment option for locally advanced rectal cancer, but it is associated with significant morbidity. However, there are no studies evaluating the role of such procedure probably because the majority consider it as an exclusion criterion. Here, we present our experience with three cases of locally advanced rectal cancer with PM, treated successfully with pelvic exenteration and CRS-HIPEC.

Pulmonary metastasectomy of colorectal cancer origin: Evaluating process and outcomes.

BACKGROUND: This study was undertaken to evaluate the effect of change in policy of computed tomography (CT) scan of the thorax in staging and follow-up of colorectal cancer (CRC). Another objective was to review the outcomes following pulmonary metastasectomies (Pmets) and to determine the prognostic factors affecting outcomes. METHODS: This is a retrospective analysis from a prospective cohort database of patients, who underwent Pmet for CRC origin from August 2004 to February 2016. The outcome measures were number of Pmets per year, overall survival (OS), disease-free survival (DFS), and prognostic factors affecting survival. RESULTS: Of 71 patients, 38% (n = 27) underwent Pmet before 2013 and 62% ( n = 44) had surgery after 2013. The 2-year DFS after Pmet was 49.3% and estimated 5-year OS was 51.4% at a median follow-up of 28 months. There was a significant increase in number of Pmets/year ( P = 0.0015), increased detection of synchronous pulmonary metastasis (PM) ( P = 0.005), increased diagnosis of extra-pulmonary metastases (EPM) ( P = 0.005), and improved OS ( P = 0.026) after introduction of CT scan as staging tool. Site of primary tumor (colon) ( P = 0.045), primary nodal stage ( P = 0.009), and the presence of EPM ( P = 0.01) were independent important prognostic factors affecting survival. CONCLUSION: The CT scan of thorax as a baseline tool for staging and follow-up in CRC increases referral for pulmonary metastasectomy. Surgery achieves excellent prognosis and long-term survival outcomes in CRC with isolated PM and carefully selected patients with solitary liver metastasis.

Extracapsular excision of hepatic hemangioma: A single centre experience.

BACKGROUNDS/AIMS: Hepatic hemangioma is a common non-epithelial neoplasm of the liver. Presence of symptoms and uncertainty in diagnosis are the most common indications for surgery. METHODS: Eighteen patients with hepatic hemangioma, operated on from January 2011 to December 2016 at the Hepato-pancreato-biliary surgical unit of Tata Memorial Hospital, were retrospectively analyzed. RESULTS: Main indications for operation were presence of symptoms, the most common being pain and diagnostic uncertainty. The median size of hemangioma was 9.9 cm (range 3.2 to 24 cm). All patients underwent extra-capsular excision of hemangioma. The median operating time was 180 minutes (range 75 to 460 minutes) and median blood loss was 950 ml (range 100 to 3,500 ml). Median post-operative stay was 5.5 days (range 3 to 10 days). One (5.6%) patient required re-exploration for post-operative hemorrhage, Clavien Dindo (CD) grade IIIb, and one (5.6%) had postoperative purulent intra-abdominal collection requiring percutaneous cutaneous drainage CD grade IIIa. There was no postoperative mortality. Postoperative day 3 liver function tests were within normal limits. Size of the tumor did not correlate significantly with postoperative complications (p=0.135). CONCLUSIONS: Surgical treatment of hemangioma should be guided by presence of symptoms or by the presence of diagnostic uncertainty, not by size alone. The size had no correlation with perioperative complications. The technique of extra-capsular excision is safe and technically feasible in most of the hemangiomas. This technique preserves maximum liver parenchyma, resulting in early postoperative recovery with minimal morbidity.

Solitary fibrous tumor of the liver - An unusual entity: A case report and review of literature.

Solitary fibrous tumor (SFT) of the liver is a rare entity and its presentation is usually delayed till they grow to a substantial size. Clinico-radiological features are non-specific, contributing to increase in the diagnostic dilemma. Definitive diagnosis of SFT is usually made based on the histological features and immunohistochemistry data of the resected specimen. In this case report, we describe the case of an elderly male who presented with a large mass in the left lobe of the liver with normal level of tumor markers and atypical radiological findings. The patient successfully underwent resection of the tumor and the diagnosis was confirmed on histopathology.

Radiological diagnosis alone risks overtreatment of benign disease in suspected gallbladder cancer: A word of caution in an era of radical surgery.

BACKGROUND: Incidental gallbladder cancer (iGBC) is on the rise world over. This may be a good scenario as we get to treat GBC in early stages. However, there is a practice of diagnosing patients based on clinicoradiological findings alone and subjecting them to a radical surgical procedure. This approach over-treats patient and has important implications for resource utilization. METHODS: We performed a retrospective analysis of 284 consecutive patients undergoing upfront surgery for suspected GBC from January 2010 to December 2016. The study cohort was divided into two groups, group A - benign (n = 138, 48.6%) and group B - malignant (n = 146, 51.4%). Both groups were compared with respect to demographic characteristics, tumor marker levels, clinicoradiological features, and perioperative outcomes. RESULTS: Approximately 48.6% patients with clinicoradiological suspicion of GBC turned out to be benign on final histology as confirmed on frozen section evaluation (FS). Only 2 patients who were reported benign on FS required revision surgery for malignancy in the final histopathology report. Demographic and clinicoradiological characteristics in both groups were comparable. However, there was a significant difference in blood loss, postoperative hospital stay, and complications between the two groups (P < 0.005). CONCLUSION: Every other patient who presented to a tertiary cancer center with high index suspicion for malignancy, based on clinicoradiological findings, turned out to be benign on final histology. This emphasizes the fact that, as a norm, for radiologically suspected gallbladder malignancy, we need to have a confirmed histological diagnosis at least during surgery before proceeding to radical resection.