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Bile duct injury during laparoscopic cholecystectomy: An Indian e-survey
Supriya Sharma,Anu Behari,Ratnakar Shukla,Mukteshwar Dasari,Vinay K. Kapoor 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.4
Backgrounds/Aims: In the absence of national registry of laparoscopic cholecystectomy (LC) or its complications, it is impossible to determine incidence of bile duct injury (BDI) in India. We conducted an e-survey among practicing surgeons to determine prevalence and management patterns of BDI in India. Our hypothesis was that majority of surgeons would have experienced a BDI during LC despite large experience and that most surgeons who have a BDI tend to manage it themselves. Methods: An 18-question e-survey of practicing laparoscopic surgeons in India was done. Results: 278/727 (38%) surgeons responded. 240/278 (86%) respondents admitted to a BDI during LC and 179/230 (78%) affirmed to more than one BDI. A total of 728 BDIs were reported. 36/230 (15%) respondents experienced their first BDI even after >10 years of practice and 40% had their first BDI even after having performed >100 LCs. 161/201 (80%) of the respondents decided to manage the BDI themselves, including 56/99 (57%) non-biliary surgeons and 44/82 (54%) surgeons working in non-biliary center. 37/201 (18%) respondents admitted to having a mortality arising out of a BDI; the mortality rate of BDI was 37/728 (5%) in this survey. Only 13/201 (6%) respondents have experienced a medico-legal case related to a BDI during LC. Conclusions: Prevalence of BDI is high in India and occurs despite adequate experience and volume. Even inexperienced non-biliary surgeons working in non-biliary centers attempt to repair the BDI themselves. BDI is associated with significant mortality but litigation rates are fortunately low in India.
Mishra, Kumudesh,Behari, Anu,Kapoor, Vinay Kumar,Khan, M. Salman,Prakash, Swayam,Agrawal, Suraksha Asian Pacific Journal of Cancer Prevention 2015 Asian Pacific journal of cancer prevention Vol.16 No.14
Gall bladder cancer (GBC) is a gastro-intestinal cancer with high prevalence among north Indian women. Platelet derived growth factor-B (PDGFB) and human epidermal growth factor receptor-2 (HER2) may play roles in the etiology of GBC through the inflammation-hyperplasia-dysplasia-carcinoma pathway. To study the association of PDGFB and HER2 polymorphisms with risk of GBC, 200 cases and 300 controls were considered. PDGFB +286A>G and +1135A>C polymorphisms were investigated with an amplification refractory mutation system and the HER2 $Ile^{655}Val$ polymorphism by restriction fragment length polymorphism. Significant risk associations for PDGFB +286 GG (OR=5.25) and PDGFB +1135 CC (OR=3.19) genotypes were observed for GBC. Gender wise stratification revealed susceptibility for recessive models of PDGFB +1135A>C (OR=3.00) and HER2 $Ile^{655}Val$ (OR=2.52) polymorphisms among female GBC cases. GBC cases with gall stones were predisposed to homozygous +286 GG and +1135 CC genotypes. Significant risk associations were found for ACIle (OR=1.48), GAVal (OR=1.70), GAIle (OR=2.00) haplotypes with GBC cases and GCIle haplotype with female GBC cases (OR=10.37, P=<0.0001). Pair-wise linkage disequilibrium revealed negative associations among variant alleles. On multi-dimensional reduction analysis, a three factor model revealed significant gene-gene interaction for PDGFB +286A>G, PDGFB +1135A>C and HER2 Ile165Val SNPs with GBC. Protein-protein interaction showed significant association of PDGFB and HER2 with the epidermal growth factor receptor signaling pathway.
Management of Chronic Pancreatitis- Step Up?
( Peeyush Varshney ),( Rk Singh ),( Anu Behari ),( Ashok Kumar ),( Vk Kapoor ),( Rajan Saxena ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1
Aims: Endoscopic treatment is used in several units prior to surgical treatment for pain in chronic pancreatitis. There is limited information on patients who undergo surgical ‘salvage’ after endoscopic failure. We conducted a comparative study between patients who had undergone surgery after prior non-surgical intervention and upfront surgery. Methods: Patients who underwent surgical drainage in our institution over the last 6 years were reviewed, in two groups- Group A (n=29) - surgery with prior non-surgical interventions (ESWL and/or endoscopy); Group B (n=79) - upfront surgery. Pain scores and QOL scores were measured prospectively. Results: The two groups were comparable for baseline characteristics except that group A patients had more strictures/ stones in body and tail region (P<0.05). Short term morbidity was more in Group A vs Group B (65% vs 26%, P<0.01) - wound infection (45% vs 10%, P<0.01; Gastroparesis (10% vs nil, P<0.01). On long term followup complete pain relief was worse in Group A patients (37% vs 68%, P=0.05). Quality of life scores (WHOQOL- BREF) in social domain was significantly better in Group B. Improvement in exocrine and endocrine insufficiency was similar in both groups. Conclusions: Patients with chronic pancreatitis who undergo ‘salvage’ surgery after non-surgical interventions are at increased risk of postoperative morbidity, lower quality of life and poor pain control as compared to those who undergo upfront surgery. Patients with pancreatic body/tail strictures/ stones have poor outcomes with non-surgical interventions and may be considered for upfront surgery.
( Saurabh Galodha ),( Rajneesh K Singh ),( Anu Behari ),( Ashok Kumar Gupta ),( V K Kapoor ),( Rajan Saxena ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: Portal hypertension (PHT) and secondary biliary cirrhosis (SBC) are found in 7-20% patients of postcholecystectomy benign biliary strictures (BBS), which can lead to significant morbidity and mortality. This study was done to look for factors associated with PHT and SBC in BBS and its effect on perioperative morbidity and final outcomes. Methods: A retrospective analysis of 613 patients of BBS managed between January 1989 and December 2012 was done. Preoperative and intraoperative parameters and perioperative morbidity were registered. Outcomes were analyzed with McDonald grading with grades A and B considered as success. Results: A retrospective analysis of 613 patients of BBS managed between January 1989 and December 2012 was done. Preoperative and intraoperative parameters and perioperative morbidity were registered. Outcomes were analyzed with McDonald grading with grades A and B considered as success. Nineteen patients of BBS with PHT were operated. PHT was seen more commonly in BBS grade III and above (n=12,63%). The median time to repair in patients with PHT was more than 4 times that of patients without PHT (826 days vs. 210 days). Two patients with PHT had strictured previous primary repair in the form of Roux-en Y hepaticojejunostomy (RYHJ). In all patients RYHJ with liver biopsy was performed. None of the patients required prior portosystemic shunting. In patients with PHT mean operating time (4.6 ± 2.8 vs. 3.5 ± 2 hours) as well as median blood loss (400 ml vs. 200 ml) was increased but there was no significant increase in perioperative morbidity. Median follow up for these patients was 54 months. Success rate for RYHJ was 89% and only 1 patient required a revision RYHJ due to stricture and recurrent cholangitis. Conclusions: Delayed repair, higher grade of BBS and failed primary repair are factors associated with development of PHT in BBS. RYHJ is feasible without need of portosystemic shunting in all these patients with minimal morbidity and good long-term results.
Ikoma, Toshikazu,Kapoor, Vinay Kumar,Behari, Anu,Mishra, Kumudesh,Tsuchiya, Yasuo,Asai, Takao,Endoh, Kazuo,Okano, Kiyoshi,Nakamura, Kazutoshi Asian Pacific Journal of Cancer Prevention 2016 Asian Pacific journal of cancer prevention Vol.17 No.7
Our recent studies conducted in South America have shown that mycotoxin contamination of red chili peppers (RCPs) may be associated with an increased risk of gallbladder cancer (GBC). Whether this relationship exists in India, a country with a high incidence of GBC and high consumption of RCPs, is unclear. We therefore measured concentrations of aflatoxins (AFs) and ochratoxin A (OTA) in RCPs from areas of low, medium, and high incidence of GBC in India, and compared these concentrations with GBC incidence in each area. Twenty-one RCP samples were collected from nine cities (eight from a low-incidence area, five from a medium-incidence area, and eight from a high-incidence area). Concentrations of AFs and OTA were measured using high-performance liquid chromatography. No significant differences in mean concentrations of AFs and OTA were found in the three areas. AFB1 levels in the low-incidence area ($10.81{\mu}g/kg$) and high-incidence area ($12.00{\mu}g/kg$) were more than 2.2 and 2.4 times higher compared with the maximum permitted level of AFB1 in spices ($5.0{\mu}g/kg$) set by the Commission of the European Communities, or that ($4.4{\mu}g/kg$) obtained in our previous study in Chile. Our results show that the mean concentrations of mycotoxins in RCPs are similar among the three areas in India with different incidences of GBC. Further studies with human subjects are needed to evaluate any association between AFB1 and GBC.
Ashok Kumar,Ganesan Senthil,Anand Prakash,Anu Behari,Rajneesh Kumar Singh,Vinay Kumar Kapoor,Rajan Saxena 한국간담췌외과학회 2016 한국간담췌외과학회지 Vol.20 No.1
Backgrounds/Aims: Mirizzi’s syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome. Methods: Prospectively maintained data of all surgically treated MS patients were analyzed. Results: A total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669). Conclusions: Preoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.
( Hosur Mayanna Lokesh ),( Biju Pottakkat ),( Anand Prakash ),( Rajneesh Kumar Singh ),( Anu Behari ),( Ashok Kumar ),( Vinay Kumar Kapoor ),( Rajan Saxena ) The Editorial Office of Gut and Liver 2013 Gut and Liver Vol.7 No.3
Background/Aims: This study was aimed at determining the factors associated with the development of benign biliary stricture (BBS) in patients who had sustained a bile duct injury (BDI) at cholecystectomy and developed bile leaks. Methods: A retrospective analysis of 214 patients with BDI who were referred to our center between January 1989 and December 2009 was done. Results: One hundred fifty-three (71%) patients developed BBS (group I), and 61 (29%) were normal (group II). By univariate analysis, female gender (p=0.02), open cholecystectomy as the index operation (p=0.0001), delay in the referral from identification of injury (p=0.04), persistence of an external biliary fistula (EBF) beyond 4 weeks (p=0.0001), EBF output >400 mL (p=0.01), presence of jaundice (p=0.0001), raised serum total bilirubin level (p=0.0001), raised serum alkaline phosphatase level (p=0.0001), and complete BDI (p=0.0001) were associated with the development of BBS. Furthermore, open cholecystectomy as the index operation (p=0.04), delayed referral (p=0.02), persistent EBF (p=0.03), and complete BDI (p=0.001) were found to predict patient outcome in the multivariate analysis. Conclusions: For the majority of patients with BDI, the risk of developing BBS could have been predicted at the initial presentation. (Gut Liver 2013; 7:352-356)