Publications by authors named "Rajesh Panwar"

34 Publications

Compensated Advanced Chronic Liver Disease in Nonalcoholic Fatty Liver Disease: Two-Step Strategy is Better than Baveno Criteria.

Dig Dis Sci 2022 Jun 7. Epub 2022 Jun 7.

Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

Background: Advanced fibrosis and cirrhosis (compensated advanced chronic liver disease [cACLD]) are clinically indistinguishable and increase risk of developing clinically significant portal hypertension. Baveno VII recommends using elastography to rule out and diagnose cACLD with liver stiffness measurement (LSM) cut-offs of 10/15 kPa.

Methods: In a retrospective analysis of 330 nonalcoholic fatty liver disease (NAFLD) patients, performance of the Baveno VII cut-offs for diagnosing cACLD was compared with newly suggested lower cut-offs (8/12 kPa). A model for detecting cACLD among those with LSM between 8 and 12 kPa was developed and compared with recently published models.

Results: Seventy (21.2%) of the 330 NAFLD patients had biopsy-proven cACLD. The Baveno VII cut-offs (10/15 kPa) had a lower sensitivity of 72.8% (60.9-82.8%) and a specificity of 93.4% (89.7-96.1%). Sensitivity and specificity of lower cut-offs (8/12 kPa) were 91.4% (82.3-96.8%) and 88.5% (83.9-92.1%), respectively. Modeling based on the presence of diabetes (odds ratio [OR] 3.625[1.161-11.320], p = 0.027) and serum aspartate aminotransferase (AST) levels (OR 1.636[1.098-2.436], p = 0.015) correctly identified 75.7% of patients with LSM between 8 and 12 kPa. Our model performed best with an area under receiver operator curve (AUROC) of 0.725 (95%CI 0.609-0.822), compared to Papatheodoridi (AUROC 0.626, CI 0.506-.736) and Zhou (AUROC 0.523, CI 0.403-0.640) models. A two-step strategy comprising application of lower LSM cut-offs followed by the predictive model correctly identified the presence of cACLD in 83% of the patients as compared to 75% by the Baveno VII cut-offs.

Conclusion: A two-step strategy employing lower LSM cut-offs and modeling based on diabetes and AST levels outperforms Baveno VII cut-offs for identifying cACLD in NAFLD patients.
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http://dx.doi.org/10.1007/s10620-022-07579-5DOI Listing
June 2022

Prospective validation of AIIMS index as a predictor of steroid failure in patients with acute severe ulcerative colitis.

Indian J Gastroenterol 2022 Jun 26;41(3):273-283. Epub 2022 Apr 26.

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India.

Background: Optimal outcomes in acute severe ulcerative colitis (ASUC) are related to time-bound management based upon early prediction of response to intravenous (IV) steroids. In an earlier study, we described the All India Institute of Medical Sciences (AIIMS) index (baseline Ulcerative Colitis Endoscopic Index of Severity [UCEIS] ≥ 7 and day 3 fecal calprotectin [FCP] > 1000 μg/g) for predicting failure of IV steroids. The current study is designed to validate this index in a prospective cohort.

Methods: IV steroid-naïve patients with ASUC, satisfying Truelove and Witts' criteria, hospitalized from August 2018 to July 2019 were included. Patients' assessment included baseline sigmoidoscopy, day 1 and 3 FCP, hemogram, biochemistry and day 3 C-reactive protein. All patients received IV steroids, and the primary outcome was steroid failure, defined as the need for colectomy or rescue therapy with cyclosporine (CYC)/infliximab (IFX) during admission.

Results: Of the 47 patients, eight were excluded (four received steroids outside, two were directly taken for surgery/infliximab therapy, one had toxic megacolon, and one had infectious colitis), and 39 patients were included (mean age: 36.1 ± 12.6 years, male: 31%). Fifteen patients (38%) failed IV steroid and required rescue therapy (IFX: 9, CYC: 2, Colectomy: 3, IFX followed by colectomy: 1). On univariate analysis, UCEIS ≥ 7 at baseline (p = 0.006), day 1 FCP (p = 0.03), day 3 FCP > 1000 μg/g (p = 0.001), Oxford criteria (p = 0.04) and AIIMS index (p < 0.001) were significantly different between steroid responders and steroid failures. On multivariate analysis, day 3 FCP > 1000 μg/g (odds ratio (odds ratio (OR)= 6.4;(95% CI =2.2-196.1) and baseline UCEIS ≥ 7 (OR) = 10.1;(95% CI = 2.1-80.2) were independent predictors. The AIIMS index predicted steroid failure with a better specificity (100% vs. 83%, p = 0.04) and positive predictive value (100% vs. 64%, p = 0.03) than Oxford criteria.

Conclusion: AIIMS index has been validated in 39 prospective ASUC patients as an effective early predictor of steroid failure (sensitivity = 53%, specificity = 100%).
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http://dx.doi.org/10.1007/s12664-021-01217-0DOI Listing
June 2022

Clinicopathological profile and outcomes of anorectal melanoma from a tertiary care center in India.

Future Sci OA 2022 Apr 10;8(4):FSO786. Epub 2022 Feb 10.

Department of Biostatistics, AIIMS, Delhi, 110029 India.

Background: Anorectal melanoma (AM) is a rare subtype of melanoma.

Aim: To study the clinic-pathologic features and outcomes in patients with AM.

Materials & Methods: Clinical, pathologic findings and outcomes of patients with AM were recorded.

Results: Twenty-seven patients with AM were identified with median age of 57 years. Most patients presented in stage III (44.4%). Lymph node involvement was seen in 70.4%. The response to chemotherapy and immunotherapy was 16.6 and 25.0%, respectively. At a median follow up of 11 months, median overall survival was 30 months. Ballantine stage 3 and weight loss at presentation were predictors of poor survival.

Conclusion: AM presents at an advanced stage with lymph node and distant metastasis.
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http://dx.doi.org/10.2144/fsoa-2021-0091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8965809PMC
April 2022

Real world analysis on the efficacy and safety of anti-tumor necrosis factor therapy in patients with stricturing Crohn's disease.

Sci Rep 2021 06 3;11(1):11704. Epub 2021 Jun 3.

Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delh, 110029, India.

Crohn's disease (CD) is often complicated by strictures and associated with increased risk for surgery. Inflammatory strictures respond to medical therapy, and anti-tumor necrosis factor (TNF) therapy is often used after the failure of steroids. However, data on efficacy of anti-TNF therapy in stricturing CD is limited. We retrospectively analysed the records of patients with stricturing CD who were treated with anti-TNF therapy and were prospectively followed from January 2005 to July 2020. Treatment success was defined as continuation of anti-TNF without the requirement for steroids or parenteral nutrition, switch to other anti-TNF, endoscopic dilation, surgery and severe adverse events leading to the withdrawal of anti-TNF. Fifty-nine patients were included [50-infliximab, 9-adalimumab; mean age-30.1 ± 15 years; males-69.5%; median disease duration-124 (range 30-396) months; median follow-up duration-42 (range 8-180) months]. Ileum was the most common site of stricture (69.5%), 20.3% of patients had colonic strictures, and 64.4% had multiple strictures. 55.9% of patients were steroid dependent and 37.3% were steroid refractory. The median duration of anti-TNF therapy was 14 (range 2-96) months, and 54.2% (n = 32) patients received concomitant immunomodulators. 88% improved with induction (11.8% primary non-response), secondary loss of response was seen in 52.2%, and the cumulative probability of treatment success at 1, 2 and 5 years was 69%, 51%, and 28% respectively. Anaemia at presentation predicted poor response. Only 30% of patients retained biologics on long-term (lack of response, cost, adverse events). 16.9% had adverse events, the commonest being reactivation of tuberculosis (5.1%). Anti-TNF therapy is associated with good short-term treatment success with modest long-term response in stricturing CD.
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http://dx.doi.org/10.1038/s41598-021-90660-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175366PMC
June 2021

Mutations in two component system (PhoPQ and PmrAB) in colistin resistant Klebsiella pneumoniae from North Indian tertiary care hospital.

J Antibiot (Tokyo) 2021 07 5;74(7):450-457. Epub 2021 Apr 5.

Department of Education and Research, Artemis Hospitals, Sector 51, Gurgaon, Haryana, 122001, India.

Colistin resistance in Gram negative bacteria is mainly attributed to chromosomal mutations in Two Component Systems(TCS) PhoPQ and PmrAB and plasmid-borne genes(mcr and its variants). The aim of this study was to understand the molecular basis of colistin resistance in Klebsiella pneumoniae and determine clonal transmission, in a North Indian tertiary care hospital over a 2.5 year period. Antimicrobial susceptibility was determined by Vitek and colistin resistance was confirmed by broth microdilution. Carbapenemases(bla, bla, bla, bla, bla) and mcr-1 screening was done by PCR. Mutations in chromosomal genes mgrB, phoP, phoQ, pmrA, pmrB were analysed. Sequence typing was performed by Multilocus sequence typing(MLST). OXA-48 was detected in thirteen isolates while three isolates co-expressed OXA-48 and NDM. The mcr-1 gene was absent in all 16 isolates. Deleterious mutations in mgrB included insertion sequences IS903 and ISkpn26 and a premature stop codon. A total of 18 point mutations were identified in PhoPQ and PmrAB TCS; of which, novel mutations were reported in phoQ (K46E, L322V, D152N, F373L, R249G), pmrB (P159R) and pmrA (D149L). Six different sequence types ST231, ST147, ST395, ST42, ST14 and ST101 were identified. Phylogenetic analysis showed that sequence types ST14, ST395 and ST147 are closely related to ST101 and all identified sequence types had a common ancestor ST231. Colistin resistance in K. pneumoniae was attributed to mutations in PhoPQ and PmrAB TCS, while location specific distribution of strains indicates clonal transmission. The results of this study will help in formulation of effective infection prevention and antimicrobial development strategies.
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http://dx.doi.org/10.1038/s41429-021-00417-2DOI Listing
July 2021

Combination of sarcopenia and high visceral fat predict poor outcomes in patients with Crohn's disease.

Eur J Clin Nutr 2021 10 2;75(10):1491-1498. Epub 2021 Feb 2.

Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India.

Background: Sarcopenia and visceral fat independently predict poor outcomes in Crohn's disease (CD). However, combined influence of these parameters on outcomes is unknown, and was investigated in the present study.

Methods: This retrospective study evaluated skeletal muscle index (SMI-cross-sectional area of five skeletal muscles normalized for height), visceral and subcutaneous fat area and their ratio (VF/SC) on single-slice computed tomography (CT) images at L3 vertebrae in CD patients (CT done: January 2012-December 2015, patients followed till December 2019). Sarcopenia was defined as SMI < 36.5 cm/m and 30.2 cm/m for males and females, respectively. Disease severity, behavior, and long-term outcomes (surgery and disease course) were compared with respect to sarcopenia and VF/SC ratio.

Results: Forty-four patients [age at onset: 34.4 ± 14.1 years, median disease duration: 48 (24-95) months, follow-up duration: 32 (12-53.5) months, males: 63.6%] were included. Prevalence of sarcopenia was 43%, more in females, but independent of age, disease severity, behavior and location. More patients with sarcopenia underwent surgery (31.6% vs 4%, p = 0.01). VF/SC was significantly higher in patients who underwent surgery (1.76 + 1.31 vs 0.9 + 0.41, p = 0.002), and a cutoff of 0.88 could predict surgery with sensitivity and specificity of 71% and 65% respectively. On survival analysis, probability of remaining free of surgery was lower in patients with sarcopenia (59.6% vs 94.1% p = 0.01) and those with VF/SC > 0.88 (66.1% vs 91.1%, p = 0.1), and still lower in those with both sarcopenia and VF/SC > 0.88 than those with either or none (38% vs 82% vs 100%, p = 0.01).

Conclusions: Combination of sarcopenia and high visceral fat predict worse outcomes in CD than either.
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http://dx.doi.org/10.1038/s41430-021-00857-xDOI Listing
October 2021

Randomised clinical trial: exclusive enteral nutrition versus standard of care for acute severe ulcerative colitis.

Aliment Pharmacol Ther 2021 03 13;53(5):568-576. Epub 2021 Jan 13.

Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

Background: Intravenous corticosteroids are the mainstay of therapy for acute severe ulcerative colitis (ASUC), but 30%-40% of patients fail to respond.

Aim: To investigate the effectiveness of exclusive enteral nutrition (EEN) as adjunctive therapy to intravenous corticosteroids in patients with ASUC.

Methods: This was an open-label randomised controlled trial, in which patients who were admitted with ASUC between August 2018 and May 2020 were randomised 1:1 to EEN or standard of care (SOC). Patients on EEN received a semi-elemental formula for 7 days along with SOC. The primary outcome was corticosteroid failure, defined by the need for salvage medical therapy or colectomy. Faecal microbial analysis was performed on day 1 and day 7 by 16s ribosomal RNA sequencing in some patients.

Results: Of 62 patients (mean age 35.3 ± 12.1 years, 40% male), 32 were randomised to EEN and 30 to SOC. Corticosteroid failure was lower on EEN compared to SOC (intention-to-treat analysis 25% vs 43%, P = 0.051; per protocol analysis 19% vs 43%, P = 0.04), without any difference in colectomy rate (9% vs 13%; P = 0.41). Patients on EEN had a shorter hospital stay [median (range) 10 (8-17) vs 13 (8-24) days; P = 0.04], higher day 7 albumin level (34 ± 4 vs 29 ± 3 g/L, P < 0.01), greater reduction in serum C-reactive protein and faecal calprotectin levels (both P = 0.04) and a lower composite outcome of colectomy/hospitalisation at 6 months (16% vs 39%; P = 0.045) compared to SOC. Patients on EEN showed increased abundance of Erysipelotrichaceae on day 7, with reduced Bifidobacterium and Veillonellaceae compared to SOC.

Conclusions: EEN for 7 days may augment corticosteroid responsiveness in patients with ASUC. (REF/2018/05/019844; CTRI/2020/06/025989).
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http://dx.doi.org/10.1111/apt.16249DOI Listing
March 2021

Relapse rate following withdrawal of anti-TNF therapy in patients with inflammatory bowel disease: A real-life cohort from northern India.

Indian J Gastroenterol 2020 08 3;39(4):388-397. Epub 2020 Sep 3.

Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 019, India.

Background: The decision to withdraw anti-tumor necrosis factor (anti-TNF) therapy in patients with inflammatory bowel disease (IBD) remains controversial, especially in the developing world, where its long-term use is restrained by side effects and prohibitive cost. Present study evaluated the relapse rate and its predictors following anti-TNF withdrawal in a cohort of IBD patients from northern India.

Methods: Patients with IBD who received anti-TNF therapy (induction and beyond), and were under follow-up at All India Institute of Medical Sciences, New Delhi, from January 2005 to July 2018 were included. Demographic features, disease characteristics, duration, response to anti-TNF therapy, and relapse rate after its withdrawal were analyzed.

Results: Among 4600 patients with IBD under follow-up, 90 (1.9%) received anti-TNF therapy, of whom 11 were excluded (8-complete records unavailable; 3-received only single dose). Of 79 patients (mean age-40.1 ± 14.2 years; 53.2% males; 31 [39.2%] ulcerative colitis, 47 [59.5%] Crohn's disease; median follow-up-24 [12-39] months), 9 (11.4%) were primary non-responders, 19 (24.1%) had secondary loss of response, and 51 (64.5%) maintained clinical response on anti-TNF. Anti-TNF was withdrawn in 45 (57%) patients (major causes: financial burden-16.5%; tubercular reactivation-12.7%), of whom 33 were in clinical remission. Over a median follow-up of 26 (7.5-45) months, 15 patients (45.5%) relapsed. Most of them responded to antibiotics, steroids, or anti-TNF agents; only 3 required surgery. On Kaplan-Meier analysis, long disease duration prior to therapy was a significant predictor of relapse (hazard ratio [HR] = 1.33, p = 0.034).

Conclusion: Almost 50% patients with IBD in clinical remission relapse within a year of anti-TNF withdrawal. However, most of these patients have a favorable disease course and respond to medical therapy.
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http://dx.doi.org/10.1007/s12664-020-01043-wDOI Listing
August 2020

Efficacy and tolerability of exclusive enteral nutrition in adult patients with complicated Crohn's disease.

Intest Res 2021 Jul 26;19(3):291-300. Epub 2020 May 26.

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.

Background/aims: Exclusive enteral nutrition (EEN), an established modality for pediatric Crohn's disease (CD) is seldomly utilized in adults. The present study reports the outcome of EEN in adult CD patients at a tertiary care hospital in India.

Methods: This was a retrospective analysis of CD patients who received EEN as a sole modality/adjunct to other treatment. The primary and secondary outcomes changed in Crohn's Disease Activity Index (CDAI), and clinical response (decline in CDAI > 70), respectively, at 4 and 8 weeks. Subgroup analysis evaluated response across different phenotypes, EEN formulations and prior treatment. Linear mixed effect model was created to assess the predictors of EEN response.

Results: Thirty-one CD patients received EEN over median duration of 4 weeks (range, 2-6 weeks). CDAI showed a significant improvement post EEN at 4 (baseline 290 [260-320] vs. 240 [180-280], P= 0.001) and 8 weeks (baseline 290 [260-320] vs. 186 [160-240], P= 0.001), respectively. The cumulative clinical response rates at 4 and 8 weeks were 37.3% and 80.4% respectively. The clinical response rates at 8 weeks across B1 (n = 4), B2 (n = 18) and B3 (n = 9) phenotypes were 50%, 78.8% and 100% respectively (log-rank test, P= 0.093). The response rates at 8 weeks with polymeric (n = 8) and semi-elemental diet (n = 23) were 75% and 82.6%% respectively (log-rank test, P= 0.49). Baseline CDAI (odds ratio, 1.008; 95% confidence interval, 1.002-1.017; P= 0.046) predicted response to EEN.

Conclusions: EEN was effective in inducing clinical response across different phenotypes of CD. Baseline disease activity remained the most important predictor of clinical response to EEN.
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http://dx.doi.org/10.5217/ir.2019.09172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322023PMC
July 2021

Expression and Clinical Implications of Cysteine Cathepsins in Gallbladder Carcinoma.

Front Oncol 2019 22;9:1239. Epub 2019 Nov 22.

Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India.

Gallbladder carcinoma (GBC) exhibits poor prognosis due to its detection at an advanced stage. Upregulation of lysosomal cysteine proteases cathepsin L (CTSL) and cathepsin B (CTSB) has been implicated in several tumorigenic processes. However, no such information in GBC was available. Therefore, the present study was planned to investigate the expression and clinical significance of these cathepsins in GBC. Activities of CTSL and CTSB were assayed in the gallbladder (GB) tissues obtained from GBC patients ( = 43) and control subjects ( = 69). Protein and mRNA levels were quantified using immunohistochemistry and real-time PCR (qPCR), respectively. Finally, serum levels of CTSL and CTSB were estimated by ELISA. Receiver operating characteristic (ROC) curve analysis was used for the assessment of sensitivity, specificity, and diagnostic accuracy of these cysteine cathepsins in GBC. The association of combined CTSL and CTSB activity with overall survival was assessed using Kaplan Meier survival analysis. The expression and activity of both CTSL and CTSB were significantly increased ( < 0.050) in tumors of GBC patients as compared to controls. Enzymatic activity of CTSL+B and CTSB exhibited a strong positive association with tumor stage and lymph node involvement in GBC ( < 0.050). Interestingly, the elevated activity of combined CTSL+B was also associated with increased mortality in these patients. Furthermore, significantly enhanced levels of serum CTSL and CTSB were also observed in GBC ( < 0.050) as compared to controls. ROC analysis revealed high diagnostic significance of serum CTSB and CTSL for distinguishing GBC patients from controls with an area under the curve (AUC) of 82 and 77%, respectively. This study, for the first time, demonstrates the clinical significance of CTSL and CTSB overexpression in GBC. Our findings may help improve the clinical management of this carcinoma.
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http://dx.doi.org/10.3389/fonc.2019.01239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883407PMC
November 2019

Carbapenem resistance in and among Indian and international patients in North India.

Acta Microbiol Immunol Hung 2019 Sep;66(3):367-376

Research and Education,Artemis Hospitals, Gurugram,India.

The aim of the study was to find out the carbapenem resistance rate and prevalence of different carbapenemase genes in and from a North Indian corporate hospital that receives both Indian and international patients. A total of 528 clinical isolates of and were included in the study. All isolates that were found resistant to carbapenems by MIC testing (Vitek II Compact) were screened for NDM, OXA-48, VIM, and KPC genes by PCR. Sequencing of NDM gene and transmissibility by conjugation assay were checked on 22 randomly selected NDM-positive isolates. One hundred and fifty-six isolates (29.54%) were carbapenem-resistant. The rate of carbapenem resistance was significantly higher in as compared to (53.9% vs. 15.6%;  < 0.05). The NDM gene was found in 34.6% (54/156), OXA-48 in 31.4% (49/156), co-expression of NDM + OXA-48 in 15.3% (24/156) of the carbapenem-resistant isolates. VIM and KPC were absent in all isolates. NDM gene was significantly more prevalent in than ( < 0.05) All the tested isolates formed transconjugants and NDM-5 was the most common variant in both species (15/22). The presence of plasmid-based NDM calls for stricter surveillance measures in our hospital settings.
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http://dx.doi.org/10.1556/030.66.2019.020DOI Listing
September 2019

Development and validation of a new score for measuring post-operative complications.

Langenbecks Arch Surg 2018 Dec 9;403(8):1021-1027. Epub 2018 Aug 9.

Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room No. 1007, Academic Block, Ansari Nagar, New Delhi, Delhi, 110029, India.

Purpose: Assigning a numerical value to post-operative morbidity may improve its usefulness as an outcome measure. The recently developed Comprehensive Complication Index (CCI) is a step forward in this process but assigns an inappropriately high score to a combination of complications.

Methods: We developed a new score called the complication severity score (CSS) using a mathematical process and compared it with the CCI using a questionnaire-based survey of 49 experienced gastrointestinal and hepato-pancreatico-biliary surgeons. The CSS was modified based on the results of this survey and was correlated with other patient-centered outcomes in a prospective cohort of consecutive patients undergoing elective surgery.

Results: Of the nine sets of scenarios, experienced surgeons' opinion matched with CSS in 6, CSS as well as CCI in 1, and neither CSS nor CCI in 2 scenarios. Of the total 441 responses, 281 matched with CSS while 143 matched with CCI (p = 0.0001, odds ratio: 3.7; 95% CI: 2.8 to 4.8). The modified CSS significantly correlated with the post-operative length of stay (r = 0.76; 95% CI: 0.68 to 0.82; p < 0.001), the length of ICU stay (r = 0.61; 95% CI: 0.50 to 0.70; p < 0.001) and with the difference between pre-operative and post-operative quality of life scores in the physical (r = 0.29; 95% CI: 0.14 to 0.42; p < 0.001) and social (r = 0.29; 95% CI: 0.14 to 0.43; p < 0.001) domains.

Conclusions: The CSS more often matched the opinion of experienced senior surgeons compared to CCI. The modified CSS significantly correlated with other patient-centered outcomes.
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http://dx.doi.org/10.1007/s00423-018-1701-2DOI Listing
December 2018

Perioperative antiemetic efficacy of dexamethasone versus 5-HT3 receptor antagonists: a meta-analysis and trial sequential analysis of randomized controlled trials.

Eur J Clin Pharmacol 2018 Oct 1;74(10):1201-1214. Epub 2018 Jun 1.

Anesthesiology and Perioperative Medicine, Lewis Katz School of Medicine, Temple University Health System, Philadelphia, PA, 19140, USA.

Background: Dexamethasone has many desirable pharmacologic properties for perioperative use. Its antiemetic potential has been a focus of many recent trials.

Methods: Trials comparing dexamethasone to 5-HT3-receptor antagonists (5HT3-RA) for 24 h postoperative vomiting incidences published till August 2017 were searched in the medical database. Comparisons for antiemetic efficiency variables (vomiting incidence, nausea incidence, rescue antiemetic need, and patients with complete response) during early (until 6 h) and late postoperative phase were made. Comparative analgesic requirements were also evaluated.

Results: Twenty randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar (Fixed-effects, P = 0.86, I = 2.94%). Trial sequential analysis (TSA) confirmed non-inferiority of dexamethasone for 24-h vomiting incidence. (α = 5%, β = 20%, δ = 10%) with "information size" being 1619 (required > 573). Equivalence was also verified from early and delayed nausea rate as well using TSA. Pooled results did not demonstrate superiority/inferiority of 5-HT3-RAs over dexamethasone in all other antiemetic efficacy variables (early and delayed). Heterogeneity was found to be low in all of the comparisons. Linear-positive dose-response curve for dexamethasone 24-h vomiting and nausea incidence was seen (correlation coefficient being 0.21 and 0.28, respectively). Dexamethasone reduced the analgesic need (MH-odds of 0.64 (95% CI being 0.44 to 0.93) P = 0.02, I2 = 0)). Possibility of publication bias could not be ruled out (Egger's test, X-intercept = 1.41, P = 0.04).

Conclusions: Dexamethasone demonstrates equal antiemetic efficacy compared to 5-HT3 receptor antagonists. The agents perform equally well both in early postoperative phase and up to 24 h after surgery. Use of dexamethasone replacing 5-HT3 RAs offers an additional advantage of lowering the opioid requirements during the perioperative period.
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http://dx.doi.org/10.1007/s00228-018-2495-4DOI Listing
October 2018

Spectrum of hepatobiliary cystic lesions: A 7-year experience at a tertiary care referral center in North India and review of literature.

Indian J Pathol Microbiol 2017 Oct-Dec;60(4):487-500

Department of Pathology, AIIMS, New Delhi, India.

Context: Cysts arising from the hepatobiliary tree are a group of heterogeneous lesions with regard to pathogenesis, clinical presentation, and radiological finding. They can be intrahepatic or extrahepatic, developmental, secondary to infective/inflammatory etiologies, as well as neoplastic. This study was conducted to determine the spectrum of hepatobiliary cysts in surgically intervened cases, with regard to their prevalence, histological spectrum, and clinicoradiological correlation, wherever possible.

Methods: In this retrospective observational study, hematoxylin and eosin stained slides of all cases of hepatobiliary cystic lesions, operated between 2009 and 2016 were reviewed. Special stains as reticulin, Masson's trichrome, and periodic acid Schiff were done wherever necessary. Overall prevalence, age-sex distribution, clinical presentation and histopathological patterns were studied. Relevant imaging findings were correlated wherever possible.

Results: A total of 312 cases of hepatobiliary cysts were identified, the majority in females. Choledochal cysts (CCs) were the most common type (n = 198,63.5%), followed by hydatid cysts (n = 73,23.3%), simple hepatic cysts (n = 10,3.2%), congenital hepatic fibrosis (n = 10,3.2%), biliary cystadenomas (n = 4,1.2%) hepatic mesenchymal hamartomas (n = 7,2.2%), and cavernous hemangiomas (n = 3,0.9%). Fibropolycystic liver disease (n = 2,0.6%), Caroli's disease (n = 1, 0.3%), liver abscess (n = 2, 0.6%), infantile hemangioendothelioma (n = 1,0.3%), and biliary cystadenocarcinomas (n = 1,0.3%) were rare. Lesions noted mostly in 1st decade of life were: CCs, fibrocystic liver disease, Caroli's syndrome, cystic mesenchymal hamartoma, and infantile hemangioendotheliomas.

Conclusion: In our cohort of surgically intervened cases of hepatobiliary cystic lesions from a tertiary care hospital in North India, the CCs, followed by hydatid cyst were the most common lesions. Histology can play vital role in characterization, as often clinical findings and radiology can overlap.
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http://dx.doi.org/10.4103/IJPM.IJPM_691_16DOI Listing
July 2018

Gastrointestinal Stromal Tumor of the Jejunum With Active Bleeding Demonstrated on Dual-Energy MDCT Angiography: A Case Report.

Curr Probl Diagn Radiol 2019 May - Jun;48(3):298-301. Epub 2017 Oct 31.

Department of Radio-diagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract and may occasionally present with acute gastrointestinal bleed (GIB). Multidetector computed tomography (MDCT) angiography is extremely useful in demonstrating the tumor as well as the presence of active hemorrhage, thereby guiding subsequent interventional or surgical management. We report a case of a 38-year-old man who presented with acute-onset melena and compensated shock, whose source of bleed remained elusive on endoscopy. MDCT angiography performed on a dual-energy scanner showed a jejunal tumor with active intraluminal contrast extravasation. The tumor was subsequently resected and the patient did well on follow-up. This was one of the few instances when MDCT angiography demonstrated active bleeding in a GIST and the first such case demonstrated on a dual-energy scanner.
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http://dx.doi.org/10.1067/j.cpradiol.2017.10.008DOI Listing
August 2019

Surgical Management of Life Threatening Bleeding after Endoscopic Cystogastrostomy.

J Invest Surg 2018 Dec 25;31(6):503-508. Epub 2017 Sep 25.

a Department of Gastrointestinal Surgery & Liver Transplantation , All India Institute of Medical Sciences , New Delhi 110029 , India.

Postprocedural bleeding is a rare but life threatening complication of endoscopic cystogastrostomy which may require surgical management in some patients. The presence of adhesions and inflammation due to antecedent acute pancreatitis, difficult location of the bleeding site and breach in the posterior wall of stomach pose significant challenges during the surgical management. Here we have described the surgical approach and technique that we used to manage three patients who required surgery for life threatening bleeding after endoscopic cystogastrostomy.
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http://dx.doi.org/10.1080/08941939.2017.1362081DOI Listing
December 2018

Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome.

Int J Colorectal Dis 2018 Jan 17;33(1):79-82. Epub 2017 Sep 17.

Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room 1005, 1st floor Academic Block, New Delhi, 110029, India.

Purpose: Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy. We implemented this policy and report the results of our experience.

Methods: The clinical records of all patients with ASUC who underwent emergency colectomy after failure of medical therapy between January 2005 and July 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery, in-hospital mortality and post-operative complications.

Results: Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these, 75 (85.2%) were operated within 7 days of initiation of intensive medical therapy [n = 51 (58%) were operated < 5 days]. One patient who was operated on day 8 following steroid therapy died postoperatively. The current post-operative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series [8/51 (15.6%); p = 0.001]. In addition, the incidence of overall (9/13 vs. 23/75; p = 0.012) and clinically significant (12/75 vs. 6/13; p = 0.022) complications was significantly higher in patients operated after 7 days as compared to those operated within 7 days.

Conclusion: The policy of early colectomy, within 7 days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality and morbidity.
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http://dx.doi.org/10.1007/s00384-017-2903-8DOI Listing
January 2018

Pancreatic heterotropia in wall of extra-hepatic choledochal cysts: A retrospective analysis of thirteen of such cases from north India.

Pathol Res Pract 2017 Sep 25;213(9):1109-1111. Epub 2017 Jul 25.

Department of Pathology, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Introduction: Heterotopic pancreas (HP) has rarely been identified in the wall of choledochal cyst (CC).

Methods: Retrospectively we screened 200 excised specimens of CC received at our Institute over a period of last eight years and looked for presence of HP rests in them. All the specimens were processed in their entirety.

Result: HP was identified in the wall of 13 (6.5%) CCs, out of which 11 were Heinrich Type 2, and two were Heinrich Type 1. In half of the cases peribiliary mucous glands were observed intermingled with the HP rests. Features of chronic fibrosing pancreatitis were identified in these rests, with ulceration of overlying cyst lining.

Conclusions: HP rests in the wall of CC though rare; their coexistence with peribiliary glands may possibly indicate their common embryonic origin. As a common site of inflammation, HP rest may be one of the common causes of CC.
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http://dx.doi.org/10.1016/j.prp.2017.07.018DOI Listing
September 2017

Letter to the Editor for "Low Versus Standard Urine Output Targets in Patients Undergoing Major Abdominal Surgery".

Authors:
Rajesh Panwar

Ann Surg 2018 07;268(1):e22-e23

Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1097/SLA.0000000000002488DOI Listing
July 2018

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy.

Hepatobiliary Pancreat Dis Int 2017 Aug;16(4):353-363

Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.

Background: A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.

Data Source: We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.

Results: Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.

Conclusions: ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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http://dx.doi.org/10.1016/S1499-3872(17)60037-7DOI Listing
August 2017

Efficacy and safety of metallic stents in comparison to plastic stents for endoscopic drainage of peripancreatic fluid collections: a meta-analysis and trial sequential analysis.

Clin J Gastroenterol 2017 Oct 18;10(5):403-414. Epub 2017 Jul 18.

All India Institute of Medical Sciences, Department of Anesthesia, New Delhi, 110029, India.

Metallic stents are being increasingly used for endoscopic drainage of peripancreatic fluid collections (PFCs) but their superiority over plastic stents has not been proven. We carried out a meta-analysis to consolidate the results from available studies and to suggest evidence-based recommendations. Studies that compared plastic and metallic stents for endoscopic drainage of PFCs and published before October 2016 were searched. Comparisons were performed for clinical success, adverse events, salvage interventions, mortality, technical success and recurrence. We included six studies with 856 patients (479 in the metallic stent group and 377 in the plastic stent group). The clinical success rate was significantly higher with metallic stents than with plastic stents (Mantel-Haenszel odds ratio [MH-OR] 3.22; 95% CI 1.87-5.54; P < 0.001). The rate of adverse events (MH-OR 0.40; 95% CI 0.24-0.65; P < 0.001) and the need for salvage procedures (MH-OR 0.31; 95% CI 0.13-0.70; P = 0.01) were also significantly lower with the use of metallic stents. Subgroup analysis for the type of PFC also found better results with the metallic stents. The results of Egger's regression test (X-axis intercept at -0.63, P = 0.47) and funnel plot did not suggest any significant publication bias. We conclude that compared to plastic stents, the use of metallic stents for endoscopic drainage of PFCs is associated with significantly better clinical success and significantly lower rates of adverse events and the need for salvage procedures. However, further high-quality randomized trials are required to confirm these findings.
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http://dx.doi.org/10.1007/s12328-017-0763-yDOI Listing
October 2017

Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis.

Surg Obes Relat Dis 2017 Aug 10;13(8):1434-1446. Epub 2017 Mar 10.

Hospital of the University of Pennsylvania and Perleman School of Medicine, Philadelphia, Pennsylvania.

Background: Opioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile.

Methods: Trails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups.

Results: Six trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required "sample size" (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I = 34.37%), lower pain scores (scale of 0-10±2.27, I = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I = 94.04%). No adverse events were reported across trials.

Conclusion: Perioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events.
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http://dx.doi.org/10.1016/j.soard.2017.02.025DOI Listing
August 2017

Efficiency and Safety Effects of Applying ERAS Protocols to Bariatric Surgery: a Systematic Review with Meta-Analysis and Trial Sequential Analysis of Evidence.

Obes Surg 2017 02;27(2):489-501

Anesthesiology and Perioperative, Medicine, Drexel University College of Medicine, 245 N. 15th Street; MS 310, Philadelphia, PA, 19102, USA.

Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I  = 93.07 %). The sample size in ERAS was well past the "information size" variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I  = 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings.
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http://dx.doi.org/10.1007/s11695-016-2442-3DOI Listing
February 2017

Erratum to:Hepatic resection for predominantly large size hepatocellular carcinoma: Early and long-term results from a tertiary care center in India.

Indian J Gastroenterol 2016 09;35(5):403-404

Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, 110 029, India.

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http://dx.doi.org/10.1007/s12664-016-0697-1DOI Listing
September 2016

Hepatic resection for predominantly large size hepatocellular carcinoma: Early and long-term results from a tertiary care center in India.

Indian J Gastroenterol 2016 Jul 12;35(4):280-6. Epub 2016 Aug 12.

Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, 110 029, India.

Background And Aim: There are no large series on hepatic resection for hepatocellular carcinoma (HCC) from India. We present the results of consecutive patients of HCC treated with hepatic resection at a tertiary care center in India.

Methods: The records of all patients who underwent hepatic resection for HCC in the Department of Gastrointestinal Surgery, All India Institute of Medical Sciences (New Delhi), were reviewed. The relevant perioperative and follow up data were extracted from a prospectively maintained database.

Results: Between January 1987 and December 2013, 81 patients [71 males; mean age: 49.2 ± 15.6 years] underwent hepatic resection for HCC. Of these, 23 (28 %) were cirrhotic and 36 (49 %) had hepatitis B. Hepatitis B was significantly more common in cirrhotic (77 % vs. 37 %; p = 0.001). Most patients had locally advanced disease at presentation [tumor size ≥10 cm in 61 (75 %); vascular tumor thrombus in 10 (12 %)]. Anatomical resection was done in 61 (75 %) including 56 major hepatic resections (≥3 segments). Overall in-hospital mortality was 13 (16 %) [cirrhotic 5 (22 %) vs. noncirrhotic 8 (14 %), p = 0.503]. Grade III-V complications (modified Clavien-Dindo classification) occurred in 25 (31 %) patients (cirrhotic 48 % vs. noncirrhotic 24 %; p = 0.037). Follow up information was available for 51 (75 %) patients. The median time to recurrence was 12 months, and most (86 %) occurred within 1 year. The recurrence-free survival at 1, 3, and 5 years was 48 %, 40 %, and 36 %, respectively. Positive resection margin and vascular invasion were significantly associated with very poor prognosis.

Conclusion: Majority of Indian HCC patients present with locally advanced disease. Despite this, surgical resection provides a chance for long-term recurrence-free survival in a third of them.
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http://dx.doi.org/10.1007/s12664-016-0678-4DOI Listing
July 2016

Why are we Poor Organ Donors: A Survey Focusing on Attitudes of the Lay Public From Northern India.

J Clin Exp Hepatol 2016 Jun 30;6(2):81-6. Epub 2016 Apr 30.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: Knowledge, sociocultural views, and awareness about organ donation in the general population are important for the success of deceased organ donation. There is an urgent need to gather this information in order to find out the reasons for poor organ donation rates in India.

Methods: A 30-item questionnaire was designed in the English and Hindi language and was administered to the lay people in order to assess their knowledge, views, and attitude regarding brain death and organ donation.

Results: Three hundred and fifty-two people (male:female = 202:150; mean age = 30.6 ± 13.9 years) completed the questionnaire. Only 70% of the people were aware that the organs can be donated after brain death and only 44% thought that they understood the meaning of brain death. Media and Internet were the preferred sources for seeking information on brain death and organ donation. The majority of people (81.2%) were willing to donate organs after brain death but only 1.4% had registered for organ donation. Lack of awareness (80.1%), religious beliefs and superstitions (63.4%), and lack of faith in the healthcare system (40.3%) were believed to be the most important reasons for poor deceased organ donation rates in India. The survey also highlighted the importance of the opinion of family members and the religious leaders in making the decision for organ donation. Educational qualification above matriculation was significantly associated with the knowledge of brain death and the willingness for organ donation.

Conclusion: Lack of awareness appears to be the most important factor for low donation rates in India. Educating people by using media and Internet and conducting awareness programs may help in improving the donation rates.
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http://dx.doi.org/10.1016/j.jceh.2016.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4963316PMC
June 2016

Pancreatic mixed serous neuroendocrine neoplasm with clear cells leading to diagnosis of von Hippel Lindau disease.

Pathol Res Pract 2016 Aug 28;212(8):747-50. Epub 2016 Apr 28.

Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.

Mixed serous neuroendocrine neoplasms are extremely rare tumors that are usually seen in female patients and are often associated with von Hippel Lindau (VHL) disease. We describe the case of a 38-year-old male who presented with complaints of anorexia, weight loss, and abdominal pain. CT abdomen showed a mass in the head of the pancreas, multiple small nodules in the body of pancreas, and bilateral adrenal masses. Fine needle aspiration cytology (FNAC) from the mass showed features of a neuroendocrine tumor, with many of the cells demonstrating abundant clear cytoplasm. Histopathological examination of the pancreaticoduodenectomy specimen showed a mixed serous neuroendocrine neoplasm with two components viz. serous cystadenoma and neuroendocrine tumor (NET) World Health Organization (WHO) grade 2. In addition, he was diagnosed to have bilateral pheochromocytomas and a paraganglioma. The synchronicity of these tumors suggested the possibility of VHL disease. Thus, identification of a NET with clear cells or of a mixed serous neuroendocrine neoplasm should raise suspicion of VHL disease. In a mixed tumor, FNAC may identify only one of the two components. Thorough processing of all pancreatic serous tumors for pathological examination is recommended, as NET may occur as a small nodule within the serous cystadenoma.
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http://dx.doi.org/10.1016/j.prp.2016.04.008DOI Listing
August 2016

Retracted: Measuring Postoperative Complications: On the Right Path but Far Away From the Destination.

Ann Surg 2017 Aug 22. Epub 2017 Aug 22.

Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.

Objective: The aim of the present study was to compare the proposed complication severity score (CSS) with comprehensive complication index (CCI) using a questionnaire-based survey of experienced gastrointestinal and hepato-pancreatico-biliary surgeons.

Background: Morbidity rate has become an important outcome measure, as the mortality rates of most surgical procedures have decreased substantially. The recently developed CCI for measuring complications is a step forward in this process but has some drawbacks. We developed a new scoring system for calculating morbidity and compared it with CCI.

Methods: We designed a questionnaire with 9 scenarios wherein each scenario compared a hypothetical patient who developed a number of lower grade complications with another hypothetical patient who underwent the same surgical procedure but developed a single higher grade complication. The questionnaire was sent to 50 experienced surgeons who were asked to choose the patient who in their opinion had more severe complication. The results thus obtained were compared with the CSS and the CCI for these patients.

Results: Forty-nine of fifty experienced surgeons replied. Of the 9 sets of scenarios, experienced surgeons' opinion matched with CSS alone in six, CSS as well as CCI in one, and neither CSS or CCI in two scenarios. Of the total 441 responses, 281 matched with CSS while 143 matched with CCI (P = 0.0001, odds ratio: 3.7; 95% CI 2.8-4.8).

Conclusions: CCI was not accurate in calculating the severity of a combination of postoperative complications. The CSS more often matched the opinion of experienced senior surgeons but requires further modifications.
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http://dx.doi.org/10.1097/SLA.0000000000001616DOI Listing
August 2017

Spontaneous perforation of an ileal J pouch.

Trop Gastroenterol 2016 Apr-Jun;37(2):143-5

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October 2018
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