Thoracoscopy-Assisted Esophagectomy vs Transhiatal Esophagectomy for Carcinoma Esophagus: a Prospective Comparison of Short-Term Outcomes.

INTRODUCTION: Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. METHODOLOGY: This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. RESULTS: Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). CONCLUSIONS: TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. TRIAL REGISTRATION: This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.

Port site desmoid tumour following laparoscopic cholecystectomy: A case report.

Desmoid tumours are locally aggressive tumours occurring either spontaneously or in familial conditions. History of trauma is invariably present with surgical trauma being a common cause. Port site desmoid tumours are extremely rare conditions. Inadequate treatment results in high recurrence rate and substantial morbidity. Reconstruction, if required, by the appropriate technique is vital to avoid an incisional hernia. Adjuvant therapy may be useful in large locally advanced or recurrent tumours. We describe a young female with large port site desmoid tumour following laparoscopic cholecystectomy managed with wide local excision and mesh placement.

A rare case of post-splenectomy gastric volvulus managed by laparoscopic anterior gastropexy.

We report an extremely rare case of recurrent gastric volvulus after open splenectomy for hereditary spherocytosis. The initial episode was managed by endoscopic derotation. Later, for recurrent symptoms, she was successfully managed by laparoscopic anterior gastropexy.

A new technique of closing a gastroatmospheric fistula with a rectus abdominis muscle flap.

Proximal enteroatmospheric fistulae are difficult to manage and carry high mortality from sepsis and electrolyte imbalances. Conservative management with total parenteral nutrition, exclusion of fistula, resection and anastomosis are conventional methods of treatment with low success rate. Providing muscle cover to manage an enteroatmospheric fistula is a noble concept. A postoperative high-output gastroatmospheric fistula (GAF) was repaired by superior epigastric artery-based rectus abdominis muscle flap (RAMF). Postoperative recovery was uneventful. This technique may be useful for closure of proximal enteroatmospheric fistulae that fail to heal through medical and conventional surgical management.

Comparison of preoperative oral acetazolamide and intraperitoneal normal saline irrigation for reduction of postoperative pain after laparoscopic cholecystectomy.

PURPOSE: Visceral and shoulder tip pain following laparoscopic cholecystectomy is mainly due to carbon dioxide (CO2) insufflation. Various methods have been adopted to eliminate residual CO2. We compared the postoperative analgesic efficacy of intraperitoneal normal saline (30 mL/kg) irrigation with preoperative oral acetazolamide administration in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS: Sixty patients between 20 and 60 years of age were included in this prospective, randomized, double-blind study. Patients in Group I received placebo, Group II patients received preoperative oral acetazolamide (5 mg/kg), and Group III patients received intraperitoneal irrigation with 30 mL/kg of normal saline. Intravenous paracetamol (1 g) was administered every 6 hours for postoperative analgesia. Parietal and visceral pain scores at rest, on movement, and on coughing and shoulder tip pain were recorded using a visual analog scale after arrival in the postanesthesia care unit, at 1, 2, 4, 6, 12, and 24 hours after surgery. Rescue analgesia was provided with an intravenous fentanyl (1 µg/kg) bolus whenever the visual analog scale score was ≥4. RESULTS: Compared with Group I, Group III patients had significantly lower visceral pain scores at all time intervals except at 12 hours. Group III patients also recorded significantly lower visceral pain scores than Group II from 2 to 24 hours. There was no significant difference in shoulder tip pain. The total dose of fentanyl used was significantly less in Group III. CONCLUSIONS: Intraperitoneal normal saline irrigation is more effective than acetazolamide in reducing postoperative visceral pain after laparoscopic cholecystectomy and has significant opioid-sparing effect. However, its effect on shoulder pain is comparable to that of acetazolamide.

Female sex hormone receptors in gallbladder cancer.

BACKGROUND: Higher incidence of gallbladder cancer among women suggests a role of female sex hormones in its etiopathogenesis. OBJECTIVES: This paper aims to study the estrogen/progesterone receptor (ER/PR) expression in gallbladder cancer and to correlate the receptor expression with the clinicopathological profile of patients to understand its implication. MATERIALS AND METHODS: Forty-seven patients of gallbladder cancer were studied. Tumor specimens were subjected to histopathologic examination. ER/PR expression was evaluated using immunohistochemistry (IHC). Receptor expression was correlated with the clinicopathological profile of the patients. RESULTS: Of the 47 patients, 11 (23.4 %) patients expressed sex hormone receptors. Of the receptor-positive patients, ER and PR were expressed simultaneously in eight patients while ER and PR were expressed individually in two and one patients, respectively. Metaplasia (p < 0.009) and dysplasia (p < 0.002) were found significantly more in hormone-positive group. The presence of hormone receptor correlated with early/operable stage of the tumor (p < 0.048). Hormone negativity correlated with inoperable/metastatic stage IVB (p < 0.004). The receptor status did not have any correlation with age, sex, menopausal status, presence/absence of gallstones, tumor type, tumor differentiation, desmoplasia, or necrosis. CONCLUSIONS: ER and PR are expressed, mostly simultaneously, in a significant proportion (23.4 %) of patients with gallbladder cancer. Receptor expression correlates with metaplasia, dysplasia, and early/operable stage of tumor, while its non-expression with inoperable/metastatic stage. Receptor study in patients of gallbladder cancer may have prognostic implications.

Intense FDG activity in a case of xanthogranulomatous cholecystitis without elevated fluorothymidine activity.

F-FDG PET/CT is a useful imaging modality to detect malignant gall bladder lesions. We present an image of a patient with a gall bladder mass that was found to be FDG avid but negative on F-fluorothymidine PET/CT imaging. This was later confirmed to be a case of xanthogranulomatous cholecystitis.

Gallbladder malakoplakia in type 2 diabetes mellitus: a rare entity.

Gallbladder malakoplakia in type 2 diabetes mellitus is a rare condition. Differentiating malakoplakia, which is a more aggressive disease condition with possible genetic abnormality from a more benign but closely related condition such as xanthogranulomatous cholecystitis, is of prognostic importance in postoperative patient management and follow-up.

Endoscopic management of pancreatic injury due to abdominal trauma.

CONTEXT: There is limited experience with pancreatic endotherapy in patients with pancreatic injury due to trauma. OBJECTIVE: To retrospectively evaluate our experience of endoscopic management of pancreatic trauma. PATIENTS: Eleven patients (10 males and 1 female; mean age: 21.8±11.9 years) with pancreatic trauma. INTERVENTION: Endoscopic therapy. Patients with pseudocyst and a gastroduodenal bulge were treated with endoscopic transmural drainage. Pseudocysts without bulge or patients with external pancreatic fistula were treated with transpapillary drainage. RESULTS: Seven patients (6 males, 1 female) were treated for symptomatic pseudocyst and 4 patients (all males) were treated for persistent external pancreatic fistula. Three patients with external pancreatic fistula had partial disruption of pancreatic duct (head: 2 cases; tail: 1 case) and were successfully treated with bridging pancreatic stent (2 cases) or bridging nasopancreatic drain (1 case) with resolution of external pancreatic fistula in 4 to 6 weeks. Of seven patients presenting with symptomatic pseudocyst (size range: 4-14 cm), two patients were successfully treated with cystogastrostomy and there has been no recurrence over a follow up of 20 and 16 months, respectively. Five patients underwent transpapillary drainage. Three patients had partial disruption and two had complete disruption. In the former, a bridging nasopancreatic drain was placed in one patient and stent in two patients. All three patients had resolution of pseudocyst within 8 weeks and there has been no recurrence over a follow-up of 11 to 70 months. In two patients with complete disruption, non-bridging stent did not resolve the pseudocysts and required surgery. CONCLUSION: Pancreatic injury due to trauma can be effectively treated endoscopically.

A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy.

Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45-60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity.

Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy--a randomised controlled trial.

INTRODUCTION: Standard pressure pneumoperitoneum for laparoscopic cholecystectomy employs a pressure range of 12-14 mm Hg. An emerging trend has been the use of low pressure pneumoperitoneum in the range of 7-10 mm Hg in an attempt to lower the impact of pneumoperitoneum on the human physiology while providing adequate working space. Our study proposes to compare the use of low pressure pneumoperitoneum with the use of standard pressure pneumoperitoneum. METHODS: A randomised controlled trial consisting of 60 patients with symptomatic gallstone disease who underwent laparoscopic cholecystectomy, of which 30 patients were subjected to standard pressure pneumoperitoneum during the procedure and 30 patients to low pressure pneumoperitoneum. RESULTS: Both groups were comparable in all aspects. The mean operating time with low pressure pneumoperitoneum was 49.07 +/- 5.72 minutes and with standard pressure pneumoperitoneum was 46.43 +/- 6.92 minutes. There was no statistically significant change in blood pressure, heart rate, pain at 6 hours, need for additional analgesia or shoulder tip pain with the use of lower pressure pneumoperitoneum. CONCLUSIONS: Low pressure pneumoperitoneum benefits the patient in the form of lower intensity of postoperative pain but it does not positively impact intraoperative hemodynamics.

Endoscopic management of traumatic hepatobiliary injuries.

BACKGROUND: Non-surgical treatment has become the therapeutic method of choice in hemodynamically stable patients with liver trauma. There are a few reports of endoscopic management of traumatic hepatobiliary injuries in such patients; however, the optimal intervention is not known. METHODS: Twenty patients with traumatic hepatobiliary injuries from May 1997 to November 2005 were retrospectively evaluated. RESULTS: There were 18 male and two female patients with a mean age of 21.45 +/- 10.17 years (range 7-42 years). Seven patients were children. Patients presented 19.4 +/- 17.04 days following trauma. Computed tomography (CT) revealed hepatic laceration in right lobe in 14 (70%) and in left lobe in six (30%) patients. Endoscopic retrograde cholangiopancreatography (ERCP) revealed biliary leak in right duct in 14 (70%) and in left duct in six (30%) patients. Five patients also had bilhemia and one had hemobilia. Thirteen patients (65%) were treated by endoscopic sphincterotomy with nasobiliary drainage and seven (35%) were treated by nasobiliary drainage alone, which enabled fistula closure in 15.76 +/- 4.22 days and 12.14 +/- 3.93 days, respectively (P > 0.05). One patient in sphincterotomy group died due to multiple bony injuries and fat embolism. Two patients developed fever following ERCP, which responded to antibiotic treatment. CONCLUSIONS: Endoscopic treatment with nasobiliary drainage without sphincterotomy is the optimal method of management of traumatic hepatobiliary injuries in hemodynamically stable patients.

Endoscopic intraluminal brachytherapy and metal stent in malignant hilar biliary obstruction: a pilot study.

BACKGROUND/AIMS: Malignant hilar biliary obstruction carries a poor prognosis, as the disease is often unresectable at the time of diagnosis. Various palliative measures as surgical/radiological/ endoscopic drainage with or without radiotherapy/chemotherapy have been tried with dismal outcome. We prospectively studied the effect of unilateral metal stent with intraluminal high dose rate (HDR) brachytherapy in patients with type II malignant hilar biliary obstruction. METHODS: Eight patients with type II malignant hilar biliary obstruction were treated with contrast-free unilateral metal stenting followed by endoscopic intraluminal brachytherapy (ILBT). A retrospectively analyzed group of 10 patients treated only with contrast-free unilateral metal stenting served as historical controls. RESULTS: A successful drainage was achieved in all, cholangitis occurred in none and no patient died within 30 days in both groups. The mean (+/-SD) patency of metal stent was 305 (+/-183.96) days and 143.9(+/-115.11) days in patients with and without intraluminal brachytherapy, respectively (P=0.03). Mean (+/-SD) survival of these patients was 310 (+/-192.68) days and 154.9 (+/-122.51) days in patients with and without intraluminal brachytherapy, respectively (P=0.05). Kaplan-Meier analysis showed estimated median survival of 225 (95% CI; 169.5, 280.4) days in brachytherapy and 100 (95%CI; 94.1, 105.8) days in control group (P=0.025). No major complications related to metal stent or ILBT were observed. CONCLUSIONS: Contrast-free unilateral metal stenting with HDR ILBT in type II malignant hilar biliary obstruction is a safe and effective method of palliation and appears to prolong patient survival as well as patency of stent in these patients, however, a larger, randomized trial is required to validate the same.

Evaluation of the role of prophylactic antibiotics in elective laparoscopic cholecystectomy: a prospective randomized trial.

At present the use of prophylactic antibiotics in elective laparoscopic cholecystectomy is controversial. This prospective study was carried out to define the role of prophylactic antibiotics in elective laparoscopic cholecystectomy to prevent postoperative infection. Ninety three patients were randomly placed in two groups. Group A comprised of 40 while group B consisted of 53 patients. Patients in Group A received 1.5 grams of second generation cephalosporin (cefuroxime sodium) diluted in 100ml of normal saline, at the time of induction of anesthesia. Group B patients received an equal volume of normal saline only. A sample of gall bladder bile was collected by direct gall bladder puncture intra-operatively for aerobic and anaerobic culture. Age, sex, weight of the patient, American Society of Anesthesiologists classification grade, presence of diabetes mellitus, episodes of colic 30 days preceding surgery, intra-operative gall bladder rupture, stone and / or bile spillage, results of bile culture, gall bladder histology, length of hospital stay, and number of septic complications were recorded and analyzed. In group A, one patient (2.5%) had post operative wound infection and in group B, two patients (3.8%) had post operative infection which was statistically similar (p>0.1). There was no difference between the two groups in terms of demographic, intra operative and post operative denominators. Therefore the study concluded that prophylactic antibiotics did not have a significant role to play in prevention of postoperative wound infection in elective laparoscopic cholecystectomy.

Endoscopic management of intrabiliary-ruptured hepatic hydatid cyst.

BACKGROUND/AIM: Intrabiliary rupture of hepatic hydatid cyst causes serious morbidity and mortality. These patients are usually managed surgically. We evaluated the feasibility and outcome of an alternative method of treatment of these patients. METHODS: Seven patients with ruptured hepatic hydatid into the biliary tract underwent endoscopic treatment consisting of endoscopic sphincterotomy, cyst material extraction and hypertonic saline lavage via nasocystic catheter. RESULTS: Median age of patients was 40 years (range 17-50 years) with a male:female ratio of 2:5. Abdominal pain, jaundice and fever were seen in all patients. Six out of seven patients were positive for hydatid serology. All patients were successfully treated by endoscopic sphincterotomy, clearance of cyst material and hypertonic saline lavage. On a follow-up of 6 months to 4 years (median, 3.5 years), ultrasonography, computed tomography of the abdomen and magnetic resonance imaging of the abdomen showed a complete cure. There were no complications related to procedure. CONCLUSIONS: This study demonstrates endoscopic treatment as one of the therapeutic options of ruptured hepatic hydatid cyst into the biliary tract.

Relevance of day care laparoscopic cholecystectomy in a developing nation.

Feasibility, safety and success of day care laparoscopic cholecystectomy (DCLC) has been well established in advanced countries. The information on (DCLC) is not available from developing nations. All patients of gallstone disease undergoing laparoscopic cholecystectomy under the care of the two participating surgeons at the post graduate Institute of Medical Education & Research were considered for day care laparoscopic cholecystectomy. The selection criteria were: elective cases only, patients less than 70 years, American Society of Anesthesiologists (ASA) grade I and Grade II, living within 20 Kilometers of the hospital, availability of a responsible adult carer at home, access to a telephone and a means of transportation to hospital if needed. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge. Out of the total 236 laparoscopic cholecystectomy performed over a period of 26 months, 106 patients (44.9%) underwent laparoscopic cholecystectomy as day care procedure. Five patients (4.8%) were admitted after surgery. Four patients were admitted because of conversion and one patient was admitted because of suspected myocardial infarction. Hundred and one patients (95.2%) were discharged on the same day. There was no major morbidity and patient's acceptance was high. Day care laparoscopic cholecystectomy is feasible, safe, and acceptable to patients.

Significance of serum endotoxin and antiendotoxin antibody levels in predicting the severity of acute pancreatitis.

PURPOSE: A close association between endotoxemia and acute pancreatitis has been reported, and attempts have been made to predict the severity of pancreatitis by estimating the levels of endotoxin. The present study was designed to correlate endotoxemia with the severity and complications of acute pancreatitis as graded by contrast-enhanced computed tomography and Blamey's criteria. METHODS: We examined 20 patients with acute pancreatitis, using Blamey's criteria to assess the severity of pancreatitis. The endotoxin level was estimated by the Limulus Amoebocyte Lysate method and the antiendotoxin antibody level was assayed by the enzyme-linked immunoassay technique measuring combined levels of IgG and IgM. RESULTS: Severe pancreatitis was confirmed in 9 of the 20 patients, 17 (85%) of whom were found to have endotoxemia. There was no correlation between the presence and level of endotoxemia and the severity of pancreatitis; however, antiendotoxin antibody titers were significantly lower in patients with severe disease ( P < 0.05), those who suffered of major complications ( P < 0.01), and those who died of the disease ( P < 0.01). CONCLUSION: The findings of this study demonstrated that the presence of endotoxemia accompanied by a fall in antiendotoxin antibody titer predicts poor outcome in patients with acute pancreatitis.