Publications by authors named "Srikanth Gadiyaram"

26 Publications

  • Page 1 of 1

Thoracoscopic pericardial patch repair of iatrogenic major bronchial injury during oesophagectomy.

J Minim Access Surg 2022 Jul 11. Epub 2022 Jul 11.

Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India.

Tracheobronchial injuries are rare but dreaded and potentially lethal complications of oesophagectomy. The reported literature on tracheobronchial injuries in thoraco-laparoscopic oesophagectomy is sparse. They may be detected either intraoperatively or in the post-operative period. Those tracheobronchial injuries detected intraoperatively usually need conversion to an open procedure for appropriate management. The surgical approaches and the methods employed for closure depend on the size and location of the rent. The methods of surgical repair include primary closure, gastric patch closure, pericardial patch, pleural patch, pedicled intercostal muscle flap, dural graft and synthetic polytetrafluoroethylene grafts. Herein, we report a thoracoscopic repair of a major bronchial injury encountered in a patient during thoracoscopic oesophagectomy using a pericardial patch. To the best of our knowledge, this is the first report of a thoracoscopic repair of a bronchial injury using a pericardial patch.
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http://dx.doi.org/10.4103/jmas.jmas_67_22DOI Listing
July 2022

Laparoscopic management of Crohn's disease-related complex enterovesical, enterocutaneous and enteroenteric fistula: A case report.

Asian J Endosc Surg 2022 Jun 23. Epub 2022 Jun 23.

Department of Medical Gastroenterology, Bangalore Medical College, Bangalore, India.

The management of Crohn's disease is medical, with surgery reserved for emergencies and complications. Fistulizing Crohn's disease can present with either an internal or external fistula. Internal fistulae are common in patients with ileocolonic disease. Enterovesical fistulae form a very small part of these internal fistulae. An ileovesical fistula with other concomitant internal or external fistulae is a complex fistula. A patient with an ileovesical fistula further compounded by an enteroenteric fistula and an enterocutaneous fistula is a difficult surgical patient to manage because of the resultant dense inflammation. Here we report a case of complex ileovesical fistula (concomitant enterocutaneous fistula and enteroenteric fistula) managed by a laparoscopic approach.
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http://dx.doi.org/10.1111/ases.13091DOI Listing
June 2022

Rare variant of type V choledochal cyst masquerading as a biliary cystadenoma.

Ann Hepatobiliary Pancreat Surg 2022 May 27. Epub 2022 May 27.

Department of Surgical Gastroenterology and MIS, Sahasra Hospitals, Jayanagar, Bangalore, India.

Cystic lesions of the liver are commonly encountered in routine clinical practice with a reported prevalence of 15%-18%. They may range from a benign simple developmental cyst to a malignancy. Therefore, an accurate diagnosis is essential for adequate management. Cystic tumors of the liver are classified based on the content (mucin containing or not), presence of ovarian stroma, and biliary communication. Biliary cystadenoma are a group of hepatobiliary neoplasia which by definition must be multilocular, lined by a columnar epithelium, and have a densely cellular ovarian stroma. We report a case of a cystic lesion in the hilar region of the liver, which had features of biliary cystadenoma on the preoperative imaging. However, on exploration was found to be a diverticular variant of type V choledochal cyst arising from both hepatic ducts. We have discussed the preoperative imaging features, intraoperative cholangiogram, and the management of this cystic lesion.
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http://dx.doi.org/10.14701/ahbps.21-167DOI Listing
May 2022

How to do a laparoscopic repair of a post-hysterectomy rectovaginal fistula?

ANZ J Surg 2022 Apr 29. Epub 2022 Apr 29.

Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bangalore, India.

The exact incidence of iatrogenic post-hysterectomy rectovaginal fistula is unknown. The overall surgical management for this group of patients is different from rectovaginal fistula in general. These are high fistula presenting with a diversion stoma in situ and are characterised well on a rectal contrast pelvic computed tomography (CT). We have described the laparoscopic repair of these fistulae.
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http://dx.doi.org/10.1111/ans.17748DOI Listing
April 2022

Surgery Complicated by Self-Expandable Metallic Stents (SEMS) Tracheal Stent in a Congenital H-type Tracheo-Esophageal Fistula.

Cureus 2022 Feb 10;14(2):e22109. Epub 2022 Feb 10.

Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Bangalore, IND.

A congenital tracheo-esophageal fistula of the H-type is a rare variant. The diagnosis is usually missed because of mild symptoms. A long history of coughing during liquid intake and nocturnal cough may aid in the diagnosis. A delay in the diagnosis may have a deleterious effect on the lung because of recurrent infections. Surgery is the cornerstone of management. Self-expandable metallic stents (SEMS) do not have a role in the management of these fistulae. We report a case of a missed diagnosis of a congenital H-type fistula managed as an acquired tracheo-esophageal fistula with two attempts at conservative management with a tracheal self-expandable metallic stent. The difficulties and disadvantages of using self-expandable metallic stents for the management of benign tracheo-esophageal fistulae are also discussed.
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http://dx.doi.org/10.7759/cureus.22109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8923044PMC
February 2022

Metastatic Sigmoid Colon Malignancy With a Synchronous Carcinoma Breast: Is Cure Possible?

Cureus 2022 Jan 27;14(1):e21660. Epub 2022 Jan 27.

Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Bangalore, IND.

Malignancies developing in two organs or more in the same patient are called multiple primary malignancies. They can be synchronous or metachronous based on the time of diagnosis of second cancer from the first. We encountered a synchronous stage IV sigmoid colon cancer (resectable liver metastasis) and breast cancer in a lady. The clinical dilemmas that arose with multiple primary malignancies and how they were tackled in our case have been discussed. A second malignancy should not deter the management or alter the clinical decision-making. Multidisciplinary teams are crucial to the management of these rare occurrences. We could successfully manage a synchronous breast and colon cancer with resectable liver metastasis at presentation.
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http://dx.doi.org/10.7759/cureus.21660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8884458PMC
January 2022

LigaSure Vessel Sealing System for Small Bowel Transection During Roux Limb Construction.

Cureus 2022 Jan 16;14(1):e21287. Epub 2022 Jan 16.

Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Jayanagar, Bangalore, IND.

Roux limb construction is an essential part of several major reconstructive hepatobiliary and upper gastrointestinal surgeries. This can be achieved with a stapling device or suturing. For over two decades, the LigaSure vessel sealing systems (Medtronic, MN, USA) have been in use for omental division, mesenteric transection, and sealing of vessels. We used the LigaSure vessel sealing system with a ForceTriad energy platform (Medtronic) for transection of the bowel during the formation of the Roux limb for a Roux-en-Y reconstruction. Between July 2019 and December 2020, patients who had Roux limb construction as part of a pancreato-enteric anastomosis in surgery for chronic pancreatitis were analysed. The data was reviewed from a prospectively maintained database. Fifteen patients had undergone surgery for chronic pancreatitis. The mentioned technique takes approximately eight minutes to construct a Roux limb. There was no bleeding from the gut ends that had been transected. There was no breach in the bowel's seal. The field was free of enteric contamination. In the post-operative course of these individuals, there was no Roux limb-related morbidity. This procedure is useful because it is cost-effective, time-saving, dependable, and prevents contamination and blood loss. It is also simple to learn and apply.
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http://dx.doi.org/10.7759/cureus.21287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8845450PMC
January 2022

A Rare Occurrence of Spontaneous Closure of a Sigmoid Loop Colostomy and an Inevitable Ventral Hernia.

Cureus 2022 Jan 12;14(1):e21161. Epub 2022 Jan 12.

Surgical Gastroenterology & Minimally Invasive Surgery, Sahasra Hospital, Bengaluru, IND.

An intestinal stoma is an opening of the intestinal tract onto the anterior abdominal wall. It is a commonly performed surgical procedure done for various benign and malignant pathologies. The construction of the stoma is temporary or permanent. Loop stoma is usually performed to divert the faecal stream for protection of the downstream anastomosis. They are usually reverted once the purpose of their creation is served. Spontaneous closure is a rare event that could result from a gradual stomal retraction. However, a normal bowel with no distal obstruction would be a prerequisite for it to be asymptomatic. Here, we report a case of spontaneous closure of a diversion loop sigmoid colostomy which had a delayed presentation. This is the second case of spontaneous closure of a sigmoid loop colostomy and the first report on the management of ventral hernias following spontaneously closed stoma in the English literature to the best of our knowledge.
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http://dx.doi.org/10.7759/cureus.21161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8831464PMC
January 2022

Considerations in laparoscopic resection of giant pancreatic cystic neoplasms.

J Minim Access Surg 2022 Jan 4. Epub 2022 Jan 4.

Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bengaluru, Karnataka, India.

Background: Laparoscopic distal pancreatectomy (LDP) with (LDPS) or without splenectomy for cystic tumours in the body and tail has become the standard of care. Data on patients with large tumours of the body and tail of the pancreas are sparse.

Patients And Methods: A retrospective analysis of a prospectively maintained database of patients who were managed with laparoscopic surgery for pancreatic cystic neoplasm since 2010 was done. Patients with cysts more than 8 cm were analysed. Clinical presentation, imaging, details of the surgical procedure and the outcomes were looked into.

Results: Five patients of giant pancreatic cystic neoplasm (GPCN) were managed with LDPS. Four patients were female, mean age was 45 years (range 15-69 years). The mean cyst size was 11.2 cms (range 8-15 cm). The splenic vein was either stretched or thrombosed in all patients. Three patients had sinistral portal hypertension. All patients were operated with a modified five-port placement. None of the patients required conversion. Mean operative duration was 3½ h, blood loss was 80 ml approximately and none required a blood transfusion. One patient had a biochemical leak. All patients were discharged from the hospital by 3 postoperative day. Drain removal was done before discharge except in the patient with biochemical leak (removed on day 6). On a median follow-up of 89 months (range 1-120 months), two patients developed diabetes. There has been no Overwhelming post-splenectomy infections (OPSI).

Conclusion: Laparoscopic distal pancreatectomy is feasible in patients with GPCN and offers the all the short-term benefits, namely lesser pain, no wound infections, early return of bowel activity, early return to orals and early discharge and early return to work. Splenectomy was required in all patients because of splenic vein thrombosis and portal hypertension in three and for technical reasons in the rest.
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http://dx.doi.org/10.4103/jmas.jmas_164_21DOI Listing
January 2022

Laparoscopic resection of VIPoma presenting at an unusual location.

J Minim Access Surg 2022 Jul-Sep;18(3):475-477

Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Bengaluru, Karnataka, India.

VIPoma is an extremely rare neuroendocrine tumour. Majority of the lesions occur in the pancreas. There is usually a long and recurrent history of secretory diarrhoea. Current diagnostic methods help in diagnosing a VIPoma once it is suspected. We herein report a case of VIPoma which had the delay in diagnosis and presented at an extremely unusual location (pyloroduodenal) who underwent laparoscopic resection for the same.
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http://dx.doi.org/10.4103/jmas.jmas_152_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9306119PMC
January 2022

Laparoscopic 'D2 first' approach for obscure gallbladders.

Ann Hepatobiliary Pancreat Surg 2021 Nov;25(4):523-527

Department of Surgical Gastroenterology and MIS, Sahasra Hospitals, Bangalore, India.

Laparoscopic cholecystectomy has a reported incidence of 4%-15% of conversion to an open procedure and one of the main reasons behind the conversion is a gallbladder (GB) wrapped with dense adhesions. It is prudent to convert the procedure to an open operation in patients with particularly dense adhesions when the GB is not visible, preventing safe dissection which carries a potential risk of duodenal or colonic injury. The technique described, namely laparoscopic 'D2 first' approach, enables the completion of laparoscopic procedure in patients with 'obscure' GBs.
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http://dx.doi.org/10.14701/ahbps.2021.25.4.523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8639302PMC
November 2021

Clinical, pathological, and genetic profile of clear cell sarcoma-like tumour of jejunum: report of a rare aggressive tumour of small bowel.

Clin J Gastroenterol 2022 Feb 18;15(1):107-111. Epub 2021 Nov 18.

Dept of Surgical Gastroenterology and MIS, Sahasra Hospital, New no 30, 39th Cross, Jayanagar 8th Block, Bangalore, 560082, India.

Clear cell sarcoma-like tumour of the gastrointestinal tract (CCSLGT) is a rare entity which has been recently described as late as 2003. Only around 70 cases have been reported in the English literature till date. CCSLGT is mostly seen in young adults in the late 20 s and early 30 s. CCSLGT are aggressive tumours. They are similar to the clear cell sarcoma of the soft tissue but lack melanocytic differentiation, retain neuroendocrine differentiation, and have osteoclastic giant cells. EWSR1-CREB1 fusion is characteristic of these tumours. Complete surgical excision is the best treatment option available. They have a high recurrence rate and poor prognosis. Currently, effective chemotherapy or a targeted agent is not available for the management of these tumours. Here, we describe a case of clear cell sarcoma-like tumour of jejunum encountered by us in a young man. The immunohistochemical and genetic profiling of these tumours are also discussed.
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http://dx.doi.org/10.1007/s12328-021-01554-9DOI Listing
February 2022

Anterior pancreatic duct split prior to duct-to-mucosa pancreatico-jejunal anastomosis in pancreaticoduodenectomy.

Ann Hepatobiliary Pancreat Surg 2021 Aug;25(3):371-375

Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospitals, Bangalore, India.

A secure pancreatic-enteric anastomosis is widely accepted as the 'Achilles heel' in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the 'duct-to-mucosa' technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.
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http://dx.doi.org/10.14701/ahbps.2021.25.3.371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382864PMC
August 2021

Percutaneous endoscopic gastrostomy re-siting when oral endoscopic access is unavailable: A novel technique.

Dig Endosc 2021 Sep 24;33(6):991-992. Epub 2021 Jun 24.

Department of Surgical Gastroenterology and MIS, Sahasra Hospital, Bangalore, India.

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http://dx.doi.org/10.1111/den.14054DOI Listing
September 2021

Laparoscopic liver resection: wedge resections to living donor hepatectomy, are we heading in the right direction?

World J Gastroenterol 2014 Oct;20(37):13369-81

P Thomas Cherian, Ashish Kumar Mishra, Palaniappen Kumar, Vijayant Kumar Sachan, Anand Bharathan, Mohamad S Rela, Department of HPB Surgery and Liver Transplantation, Global Hospital, Hyderabad 500004, India.

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.
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http://dx.doi.org/10.3748/wjg.v20.i37.13369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188891PMC
October 2014

Single incision laparoscopic distal pancreatectomy with splenectomy for neuroendocrine tumor of the tail of pancreas.

J Minim Access Surg 2013 Jul;9(3):132-5

Department of Surgical Gastroenterology, MILDD, Manipal Hospital, Bangalore, India.

Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas. We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.
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http://dx.doi.org/10.4103/0972-9941.115377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3764658PMC
July 2013

Traumatic tension gastrothorax and pneumothorax.

J Emerg Med 2013 Feb 20;44(2):e279-80. Epub 2012 Aug 20.

Department of Critical Care Medicine, Manipal Hospital, Bangalore, India.

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http://dx.doi.org/10.1016/j.jemermed.2012.07.043DOI Listing
February 2013

Laparoscopic resection of giant liver hemangioma using laparoscopic Habib probe for parenchymal transection.

J Minim Access Surg 2012 Apr;8(2):59-61

Department of Surgical Gastroenterology, Manipal Institute of Liver and Digestive Diseases, Manipal Hospital, Bangalore, India.

Experience with laparoscopic liver resections is limited. Laparoscopic resection of a variety of liver lesions has been reported and is considered appropriate for lesions in the left lateral segment and inferior segments of the right lobe. Herein, we report a 52-year-old male patient who underwent a laparoscopic resection of giant liver hemangioma with the use of a laparoscopic 4× Habib probe.
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http://dx.doi.org/10.4103/0972-9941.95540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353616PMC
April 2012

A technique for gall bladder fundal traction in single-incision laparoscopic cholecystectomy.

Surg Laparosc Endosc Percutan Tech 2011 Oct;21(5):e239-41

Department of Surgical Gastroenterology, Manipal Institute of Liver and Digestive Diseases, Manipal Hospital, Bangalore, India.

Introduction: The last 2 years have seen numerous reports on single-incision laparoscopic surgery (SILS) in the surgical literature. Achieving an appropriate fundal traction is one among the many technical challenges while performing a SILS cholecystectomy. We describe herein an innovative method of suture traction of gall bladder fundus during SILS cholecystectomy.

Materials And Methods: Prospective data of patients who underwent SILS cholecystectomy from July 2009 to till date in the Department of Surgical Gastroenterology at Manipal Institute of Liver and Digestive Diseases, Bangalore, were analyzed.

Results: Twenty-eight patients, 8 male and 20 female patients, with the age ranging from 24 to 62 years have undergone SILS cholecystectomy for cholelithiasis. The suture technique described herein was performed in the last 25 patients. There was no complication related to the use of this suture technique.

Conclusions: Technological innovations would ultimately find an easier solution for gall bladder retraction in SILS cholecystectomy. Till such time we believe that the suture technique described herein would offer the most satisfactory fundal traction during SILS cholecystectomy and would find application in the vast majority of patients undergoing SILS cholecystectomy. In addition, this technique could be extended for application in a variety of other SILS procedures.
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http://dx.doi.org/10.1097/SLE.0b013e31822cb8a0DOI Listing
October 2011

Liver histology in benign biliary stricture: fibrosis to cirrhosis . . . and reversal?

J Gastroenterol Hepatol 2008 Dec;23(12):1879-84

Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Background: Secondary biliary cirrhosis is a potential complication of post-cholecystectomy bile duct stricture (PCBDS). This study addresses the factors that determine the severity of pathological changes on liver biopsy and the correlation with long-term outcome following repair.

Methods: Liver biopsies obtained at surgery for repair of PCBDS in 71 patients were reviewed and pathological changes were scored from 0 to 3. Patients with fibrosis score 0-2 were categorized as the non-cirrhotic group and those with score 3 (secondary biliary cirrhosis) were categorized as the cirrhotic group. Clinical and biochemical parameters, stricture type and outcome were analyzed by univariate and multivariate analysis for correlation with degree of fibrosis. Follow-up liver biopsies (3-60 months) after stricture repair were obtained in five patients.

Results: There were 58 patients in the non-cirrhotic group and 13 in the cirrhotic group. On univariate analysis, portal hypertension and prolonged injury-repair duration correlated with secondary biliary cirrhosis. Patients with a fair outcome in the cirrhotic group (4/13) had derangements in liver function tests but had patent biliary enteric anastomosis on evaluation. Of the five patients in whom liver biopsies were obtained at follow up, two had regression, two were static, and one had progression.

Conclusion: All patients with PCBDS had varying degrees of fibrosis. Prolonged injury-repair interval and portal hypertension were the important parameters correlating with secondary biliary cirrhosis. Early repair of biliary stricture is recommended to prevent liver fibrosis. A successful relief of biliary obstruction may halt and/or reverse pathological changes in the liver.
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http://dx.doi.org/10.1111/j.1440-1746.2007.04901.xDOI Listing
December 2008

External pancreatic fistula as a sequel to management of acute severe necrotizing pancreatitis.

Dig Surg 2005 10;22(6):446-51; discussion 452. Epub 2006 Feb 10.

Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Background/aims: External pancreatic fistula (EPF) is a common sequel to surgical or percutaneous intervention for infective complications of acute severe pancreatitis. The present study was aimed at studying the clinical profile, course and outcome of patients with EPF following surgical or percutaneous management of these infective complications.

Methods: A retrospective analysis of clinical data of patients with EPF following intervention (surgical or percutaneous) for acute severe pancreatitis managed between January 1989 and April 2002 recorded on a prospective database was done. Univariate analysis of various factors (etiology, imaging findings prior to intervention, fistula characteristics and management) that could predict early closure of fistula was performed.

Results: Of 210 patients with acute severe pancreatitis, 43 (20%) patients developed EPF (mean age 38 (range 16-78) years, M:F ratio 5:1) following intervention for infected pancreatic necrosis (n=23) and pancreatic abscess (n=20) and constituted the study group. The fistula output was categorized as low (<200 ml), moderate (200-500 ml) and high (>500 ml) in 29 (67%), 11 (26%) and 3 (7%) patients, respectively. Fifteen patients (35%) had morbidity in the form of abscess (n=5), bleeding (n=1), pseudoaneurysm (n=2) and fever with no other focus of infection (n=7). Spontaneous closure of the fistula occurred in 38 (88%) patients. The average time to closure of fistula was 109+/- 26 (median 70) days. Fistula closed after intervention in 5 patients (2 after endoscopic papillotomy, 1 after fistulojejunostomy and 2 after downsizing the drains). Of the 38 patients with spontaneous closure, 9 (24%) patients developed a pseudocyst after a mean interval of 123 days of which 7 underwent surgical drainage of the cyst. Univariate analysis of various factors (etiology, imaging findings prior to intervention, fistula characteristics and management) failed to identify any factors that could predict early closure of fistula.

Conclusions: EPF is a common sequel following intervention in acute severe pancreatitis. The majority of these are low output fistulae and close spontaneously with conservative management. One-fourth of patients with spontaneous closure develop a pseudocyst as a sequel, requiring surgical management.
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http://dx.doi.org/10.1159/000091448DOI Listing
September 2006

Should laparoscopic cholecystectomy be performed in patients with thick-walled gallbladder?

J Hepatobiliary Pancreat Surg 2004 ;11(1):40-4

Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, 226014, Lucknow, India.

Background/purpose: Laparoscopic cholecystectomy is the procedure of choice for patients with symptomatic cholelithiasis. This procedure is contraindicated in patients with gall-bladder cancer (GBC) because of fear of dissemination of the disease. One of the findings raising the suspicion of GBC is a thick-walled gallbladder (TWGB).

Methods: A prospective study of patients with TWGB was done over a period of 10 months at a tertiary-level referral hospital in northern India. We studied the clinical profiles, investigations (ultrasound [US] and computerized tomography [CT]) and management plans in these patients.

Results: A total of 60 patients were included in the study. After cholecystectomy, histopathology of gallbladders showed GBC in 2 (3.3%) patients. The remaining 58 patients had chronic cholecystitis, of whom 28 (48%) had xanthogranulomatous variant chronic cholecystitis. Cholecystectomy by the laparoscopic method was attempted in 46 (77%) patients and by open technique in the remaining 14 (23%) patients. Laparoscopic cholecystectomy was successful in 40 of the 46 (87%) patients in whom it was attempted. Obscure anatomy, suspicion of GBC, and bile duct injury were the causes of conversion, in the remaining 13% (6/46). None of the 11 patients who had a CT examination because of clinical or US suspicion of malignancy turned out to have GBC at final histology. Both the cases of GBC in this study were incidental findings on final histopathology.

Conclusions: Laparoscopic cholecystectomy can be successfully performed in the majority of patients with diffuse TWGB, with appropriate selection. There is, however, an increased chance of conversion to open cholecystectomy in these patients. If there is an intraoperative suspicion of GBC, early conversion to open cholecystectomy and frozen section/imprint cytology will help to decide the further treatment during surgery.
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http://dx.doi.org/10.1007/s00534-003-0866-3DOI Listing
June 2005

Extrahepatic portal venous obstruction and obstructive jaundice: approach to management.

J Gastroenterol Hepatol 2005 Jan;20(1):56-61

Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Background: Patients with long-standing extrahepatic portal venous obstruction (EHPVO) develop extensive collaterals in the hepatoduodenal ligament as a result of enlargement of the periportal veins. These patients are also prone to develop obstructive jaundice as a result of strictures and/or choledocholithiasis. Surgical management of obstructive jaundice in such patients becomes difficult in the presence of these collaterals.

Aim: To review the approach to management of patients with EHPVO and obstructive jaundice.

Methods: Retrospective review of patients with EHPVO and obstructive jaundice requiring surgical and/or endoscopic management between 1992 and 2002.

Results: Thirteen patients (nine males, aged 12-50 years) with EHPVO and obstructive jaundice were evaluated. No patient had underlying cirrhosis or hepatocellular carcinoma. Five patients (group A) had biliary stricture; three (group B) had choledocholithiasis; and five (group C) had biliary stricture with choledocholithiasis. Primary surgical management was performed in group A (portosystemic shunt in four-strictures resolved in three; hepaticojejunostomy in one). In group B (n = 3) endoscopic stone extraction was successful in two patients. One patient underwent staged procedure (portosystemic shunt followed by biliary surgery). In group C, initial endoscopic management failed in four patients in whom it was attempted. All five patients thereafter underwent surgery (staged procedure, one; choledochoduodenostomy, one; devascularization, one; abandoned, two). Repeat postoperative endoscopic management was successful in two of the group C patients. Overall (group B and C), massive intraoperative hemorrhage occurred in three patients (one died). Postoperative hemorrhage occurred in one patient.

Conclusion: In patients with EHPVO and obstructive jaundice, primary biliary tract surgery has significant morbidity and mortality. Endoscopic management should be the preferred modality. In patients with endoscopic failure, a staged procedure (portosystemic shunt followed by biliary surgery) should be preferred. Strictures alone may resolve after a portosystemic shunt. Endoscopic stenting may be required as an adjunct.
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http://dx.doi.org/10.1111/j.1440-1746.2004.03528.xDOI Listing
January 2005

Hilar benign biliary strictures: need for subclassification.

ANZ J Surg 2003 Jul;73(7):484-8

Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Background: A uniformly accepted classification allows an accurate comparison of results and formulation of a standardized treatment plan. Suggested herein is a subclassification of Bismuth type III post-cholecystectomy benign biliary strictures (BBS).

Methods: Fifty-seven patients (41%) with Bismuth type III and eight patients (6%) with type IV BBS out of a total of 139 patients with BBS were analysed retrospectively. Strictures were subclassified as type IIIA where the confluence was healthy and type III B where the roof of the confluence was healthy and right and left ductal continuity was maintained, although the floor of the confluence was scarred.

Results: Of 57 patients with type III BBS, 44 were subclassified as type IIIA and 13 as type IIIB. Statistically significant differences were observed in the mean operative blood loss (317 vs 635 mL, P = 0.004; 317 vs 606 mL, P = 0.006), blood transfused (0.8 vs 2.2 units, P = 0.0007; 0.8 vs 2.0 units, P = 0.0008), and duration of surgery (3.8 vs 5.1 h, P = 0.002; 3.8 vs 5.6 h; P = 0.0004) between type IIIA and IIIB, and between type IIIA and IV strictures, respectively. There were no differences in the operative parameters between type IIIB and IV strictures. There was no difference in the overall morbidity (18% vs 15% vs 25%) and septic complications among the three groups. At a mean follow up of 36.4 months, 87%, 91% and 100% of patients had excellent/good outcome in type IIIA, IIIB and IV, respectively.

Conclusions: Type III biliary strictures need to be subclassified, based on whether the floor of the confluence is healthy or scarred because it influences the degree of operative difficulty and morbidity. Type IIIB BBS behave like and should be classified with type IV strictures for uniformity of result evaluation.
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http://dx.doi.org/10.1046/j.1445-1433.2002.02585.xDOI Listing
July 2003
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