Tuberculosis of the Spleen as a Cause of Fever of Unknown Origin and Splenomegaly

( Biju Pottakkat ),( Ashok Kumar ),( Archana Rastogi ),( Narendra Krishnani ),( Vinay K. Kapoor ),( Rajan Saxena ) 대한소화기기능성질환·운동학회 2010 Gut and Liver Vol.4 No.1

Background/Aims: Splenic involvement of tuberculosis, which is rare, warrants better definition in the current era of resurgence of tuberculosis. Methods: Out of 339 splenectomies performed between January 1989 and December 2008 for indications other than trauma, histopathologic analysis of the spleen revealed tuberculosis in 8 patients. Results: All eight patients were referred for splenectomy due to fever of unknown origin (FUO). No patient was infected with HIV, and all had at least moderate splenomegaly and hepatomegaly. Three patients had hypersplenism with bleeding manifestations. Radiologic evaluations demonstrated that splenic lesions were present in five patients. Five patients had evidence of tuberculosis manifested as enlarged splenic hilar lymph nodes, cystic lymph nodes, or liver. Two patients exhibited tubercle bacilli in their sputum during the postoperative period. Conclusions: In areas where tuberculosis is prevalent, tuberculosis should be considered in the differential diagnosis of patients presenting with FUO and splenomegaly. Extrasplenic involvement is usually seen in splenic tuberculosis, although it may not be apparent at presentation. Splenic tuberculosis can present in isolation without extrasplenic involvement, and even in immunocompetent individuals. (Gut Liver 2010;4:94-97)

Free Paper Session : Upper Gastrointestinal Tract 2 ; A Scintigraphic Study Of The Pattern Of Early Delayed Gastric Emptying After Pylorus Preserving Pancreatoduodenectomy

( Biju Pottakkat ),( Deep Parasar ),( Sanjay Gambhir ),( Ashok Kumar ),( Rajan Saxena ),( Vinay Kapoor ) 대한소화기학회 2007 SIDDS Vol.9 No.-

Background/Aims: Early delayed gastric emptying (DGE) is the commonest complication after pylorus preserving pancreato-duodenectomy (PPPD) and an incidence of upto 40% is reported in the literature. Pyloric dysfunction is proposed as the main cause for DGE. This study is aimed to assess the gastric emptying pattern in patients in whom pyloric dilatation was done during PPPD. Methods: All patients who underwent PPPD for periampullary carcinoma between July 2004 and June 2005 were included in this prospective study. Pyloric dilatation was done upto 18 mm with Hegar`s dilators in all patients at operation. Gastric emptying was assessed with nuclear scintigraphy using Tc-99m sulphur colloid labeled semisolid standard meal between post operative day 10 and 14. Time activity curve was plotted for 1 hour and further curve is extrapolated. The clearance half time (T1/2) of gastric emptying was calculated. T1/2 upto 110 minutes is considered as normal. Results: Out of 20 patients who underwent PPPD, study could not be performed in 7 patients because of post operative complications. Gastric emptying was assessed in 13 patients. There were 8 males and 5 females in the age group of 31-57 (mean 48) years. 5/13 (38%) patients had DGE on nuclear scintigraphy inspite of pyloric dilatation. In 4/5 (80%) patients with DGE, time activity curve was flat at 1 hour (Tl/2 indefinite) and in the other patient T1/2 was 290 minutes, 4/5 (80%) patients with DGE demonstrated much delayed clearance in the proximal stomach although the distal pyloric emptying was normal. The other patient had delayed emptying both in proximal stomach and pylorus. 8/13 (62%) patients had normal gastric emptying and the T1/2 ranged between 28-106 (mean 64) minutes. Conclusions: DGE after PPPD as mainly due to the delayed emptying of proximal stomach rather than pylorus. Treatment strategies directed to the pylorus may not alleviate DGE after PPPD.

Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study

Shahana Gupta,Biju Pottakkat,Raja Kalayarasan,Gnanasekaran Senthil,Pagadala Naga Balaji Nitesh 한국간담췌외과학회 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.2

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis. Methods: This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014–2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann–Whitney U test and χ² test. Results: Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group. Conclusions: CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

Unconventional shunt surgery for non-cirrhotic portal hypertension in patients not suitable for proximal splenorenal shunt

Harilal SL,Biju Pottakkat,Senthil Gnanasekaran,Kalayarasan Raja 한국간담췌외과학회 2023 Annals of hepato-biliary-pancreatic surgery Vol.27 No.3

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. Methods: A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. Results: During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Conclusions: Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.

Splenoadrenal Shunt for Noncirrhotic Portal Hypertension

( Kalayarasan Raja ),( Biju Pottakkat ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Portosystemic shunt surgery is an established treatment option for preventing variceal rebleeding in patients with noncirrhotic portal hypertension(NCPH). The proximal splenorenal shunt is a widely performed procedure in these patients. In this study, the use of adrenal vein as an alternative conduit has been investigated. Methods: A retrospective analysis of patients with NCPH who underwent proximal splenoadrenal and splenorenal shunt between 2011 and 2015. clinical presentation, intraoperative findings, postoperative morbidity, and shunt patency were studied and compared between the two groups. All patients were followed up for a minimum of 12 months. Results: 97 patients with NCPH underwent shunt surgery (proximal splenoadrenal shunt,8; proximal splenorenal shunt,74; and interposition mesocaval shunt,15). Anomalous anatomy of the left renal vein was the main indication(5/8 patients) for a splenoadrenal shunt. Median fall in portal pressure in patients who underwent splenoadrenal shunt was 11.5 mmHg(range, 2-14 mmHg). The median (range) operative time was 4.5 (3-6) hours and median(range) intraoperative blood loss was 160(100-200) mL. During a median (range) follow-up of 32(12-48) months, shunt thrombosis developed in one patient. Comparison of intraoperative parameters and postoperative outcomes showed no significant difference in median fall in portal pressure( P=0.39), median operative time (P=0.51), median blood loss( P=0.80), Grade III/IV postoperative complications (P=0.56), shunt thrombosis (P=0.93), and varices regression rate (P=0.72) between patients undergoing proximal splenorenal and splenoadrenal shunt. Conclusions: Left adrenal vein is a suitable vascular conduit for porto-systemic shunt surgery, particularly if the performance of splenorenal shunt is precluded because of anatomic abnormality of the renal vein.

ORiginal Article : Risk Factors for Development of Biliary Stricture in Patients Presenting with Bile Leak after Cholecystectomy

( 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)

Congenital bilio-bronchial fistula in an adult: a review of literature and video demonstration of laparoscopic fistula tract excision

Chandrasekar Murugesan,Muniza Bai,Biju Pottakkat,Dharm Prakash Dwivedi,Hemachandren Munuswamy,Pazhanivel Mohan 대한내시경로봇외과학회 2024 Journal of Minimally Invasive Surgery Vol.27 No.1

This article presents a review of the literature on congenital bilio-bronchial fistula (BBF), a rare anomaly characterized by abnormal communication between the bile duct and respiratory tract. Congenital BBF often presents with bilioptysis in early neonates and infants; however, patients with no overt symptoms may occasionally present in adulthood. Our literature search in Medline from 1850 to 2023 revealed 42 reported cases of congenital BBF, primarily managed with thoracotomy and excision of the fistula tract. About one-third of these cases required multiple surgeries due to associated biliary anomalies. The review underscores the importance of diagnostic imaging, including bronchoscopy, in identifying and delineating the extent of the fistula. It also highlights the evolving surgical management, with recent cases showing the efficacy of minimally invasive approaches such as laparoscopy and thoracoscopy. In addition to the literature review, we report a young female patient with a history of recurrent respiratory infections presenting with bilioptysis and extensive left lung damage. Initial management included bronchoscopy-guided glue instillation, left thoracotomy, and pneumonectomy. Following the recurrence of symptoms, the patient was successfully treated with laparoscopic excision of the fistula tract. In recent times, minimally invasive approaches such as laparoscopy and thoracoscopy, with excision of the fistula tract are gaining popularity and have shown good results. We suggest biliary communication being the high-pressure end, tackling it transabdominal may prevent recurrent problems.

Bile duct preserving pancreatic head resection (BDPPHR): Can we conclusively define the extent of head resection in surgery for chronic pancreatitis?

Pagadala Naga Balaji Nitesh,Biju Pottakkat 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.3

The role of surgical management for chronic pancreatitis in providing pain relief and improving quality of life is significant. Surgical techniques involving pancreatic head resection scored more over the drainage procedures. Among the resection procedures, Frey’s procedure received widespread acceptance. However, the exact extent of pancreatic head resection to be performed and the limits of the resection are still debatable. The present report of bile duct preserving pancreatic head resection (BDPPHR) describes an innovative approach to the pancreatic head and conclusively defines the extent of head resection. The simplicity, feasibility and easy reproducibility of the BDPPHR is also reiterated.

Early mobilization and delayed arterial ligation (EMDAL) as a surgical technique for splenectomy and shunt surgery in portal hypertension

Harilal S L,Biju Pottakkat,Kalayarasan Raja,Senthil Gnanasekaran 한국간담췌외과학회 2024 Annals of hepato-biliary-pancreatic surgery Vol.28 No.1

Backgrounds/Aims: Splenectomy is the most frequently performed procedure as definitive management or as part of shunt surgery or devascularization in portal hypertension. Splenectomy is technically challenging because of the frequent coexistence of multiple collateral varices, splenomegaly, poor liver function, and thrombocytopenia. Early arterial ligation and late mobilization (EALDEM) is the traditional method for splenectomy in portal hypertension. Early spleen mobilization offers good control of the hilum. We aim to compare the effect of the early mobilization and delayed arterial ligation (EMDAL) technique with that of the conventional splenectomy technique in patients with portal hypertension. Methods: During the study period from September 2011 to September 2022, 173 patients underwent surgical intervention for portal hypertension at our institution. Among these patients, 114 underwent the conventional method of splenectomy (early arterial ligation and late splenic mobilization) while 59 underwent splenectomy with the EMDAL technique. Demographics were compared between the two groups. Intraoperative and postoperative outcomes were analyzed using the Mann-Whitney test in each group. A minimum follow-up of 12 months was performed in each group. Results: Demographics and type of surgical procedure were comparable in the two surgical method groups. Median blood loss was higher in the conventional group than in the EMDAL method. The median duration of surgery was comparable in the two surgical procedures. Clavien-Dindo grade III/IV complications were reported more frequently in the conventional group. Conclusions: The splenic hilum can be controlled well and bleeding can be minimised with early mobilization and delayed arterial ligation.

Early experience with robot-assisted Frey’s procedure surgical outcome and technique: Indian perspective

Ankit Shukla,Senthil Gnanasekaran,Raja Kalayarasan,Biju Pottakkat 대한내시경로봇외과학회 2022 Journal of Minimally Invasive Surgery Vol.25 No.4

Purpose: Robotic surgery for pancreatic diseases is currently on the rise, feasible, well-accepted, and safe. Frequently performed procedures in relation to pancreatic diseases include distal pancreatectomy and pancreatoduodenectomy. The literature commonly describes robotic lateral pancreaticojejunostomy; however, data on robot-assisted Frey’s is scarce. Methods: We herein, describe our series and technique of robot-assisted Frey’s procedure at our tertiary care center between November 2019 and March 2022, and its short-term outcomes in comparison to the open Frey’s. Patients with chronic pancreatitis having intractable pain, dilated duct, and no evidence of inflammatory head mass or malignancy were included in the study for robot-assisted Frey’s. Results: In our study, out of 32 patients, nine patients underwent robot assisted Frey’s procedure. The duration of surgery was significantly longer in robotic group (570 minutes vs. 360 minutes, p = 0.003). The medians of intraoperative blood loss and postoperative analgesic requirement were lower in robotic group, but the difference was not statistically significant (250 mL vs. 350 mL, p = 0.400 and 3 days vs. 4 days, p = 0.200, respectively). The median length of hospital stay was shorter in the robotic group, though not significant (6 days vs. 7 days, p = 0.540). At a median follow-up of 28 months, there was no significant difference in the postoperative complications and short-term outcomes between the two groups. Conclusion: Robotic surgery offers benefits of laparoscopic surgery in addition it has better visualization, magnification, dexterity, and ergonomics. Frey’s procedure is possible robotically with acceptable outcomes in selected patients.