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Rajan Saxena,Nalini Kanta Ghosh,Saurabh Galodha 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.4
Backgrounds/Aims: Hepaticojejunostomy (HJ) for bilioenteric continuity is generally performed with interrupted sutures. This study compares the safety, economics, short- and long-term outcomes of continuous suture hepaticojejunostomy (CSHJ) and interrupted suture hepaticojejunostomy (ISHJ). Methods: A retrospective cohort analysis involving all HJs between January 2014 and December 2018 was conducted. Patients with type IV or V biliary strictures, duct diameter < 8 mm and/or associated vascular injury, and liver transplant recipients were excluded. Patient demographics, preoperative parameters including diagnosis, intra-operative parameters including type and number of sutures, suture time, and postoperative morbidity (based on Clavien-Dindo classification) were recorded. Patients were followed up to 60 months. McDonald’s Grade A and B outcomes were considered favorable. Cost according to suture type and number (polydioxanone 3-0/5-0 mean cost, US$ 9.26/length; polyglactin 3-0/4-0 mean cost, US$ 6.56/length), and operation room charge (US$ 67.47/hour) were compared between the two techniques. Statistical analysis was performed using IBM SPSS ver. 22 software. Results: A total of 556 eligible patients (468 patients undergoing ISHJ and 88 undergoing CSHJ; 47% [n = 261] with malignant and 53% [n = 295] with benign pathology) were analyzed. The two groups were similar. Number of sutures, cost, time, and postoperative bile leak were significantly higher in the ISHJ group. Bile leak occurred in 54 patients (6 CSHJ, 48 ISHJ). Septic shock-induced death occurred in 16 cases (3 CSHJ, 13 ISHJ). Morbidity and the anastomotic stricture rates were comparable in both groups. Conclusions: CSHJ is a safe, economical, and worthy of routine use.
( Saurabh Galodha ),( Rajneesh K Singh ),( Rajan Saxena ),( V K Kapoor ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Aims: Post cholecystectomy biliary strictures can lead to secondary biliary cirrhosis and portal hypertension and present a difficult proposition for management with poorer outcomes. These patients require a major hepatic resection (HR) in certain cases. This study was done to find the factors leading to HR in benign biliary strictures (BBS), the challenges faced and their long-term outcomes. Methods: Analysis of prospectively maintained BBS database of our department from February 1989 to March 2014 done to identify patients who underwent HR. Type of cholecystectomy, bile duct injury (BDI) and BBS, indications for HR, any previous repair, intraoperative parameters and postoperative morbidity were noted. Outcomes classified according to McDonald classification. Results: 648 patients of BBS were included in the study. Out of these 10 patients underwent HR (1.53%). 9 patients had high BBS (type IV and V) while 1 patient was of type III with strictured hepaticojejunostomy (HJ). Laparoscopic cholecystectomy was the primary surgery in 80%(8/10) patients. Median time from cholecystectomy to HR was 545 (226-1566) days. Proximal BBS (type IV and V, P<0.001) and Atrophy-hypertrophy complex (AHC) (P=0.004, OR = 15.4, CI: 2.94-80.99) were predictive factors for HR. Failed previous repair was also associated with HR (20%). Postoperative morbidity was 40%. Perioperative mortality occurred in 2 patients. Outcomes of HR with median follow up of 24 months were good with success rate of 80%. Conclusions: Hepatic resections have distinct role in patients of proximal BBS (type IV and V) with AHC with good long-term results but require meticulous planning and execution. AHC and previous failed repair are strong predictors for need for HR in BBS.
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.
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)