Hemorrhage complicating the course of severe acute pancreatitis

Vikas Gupta,Pradeep Krishna,Rakesh Kochhar,Thakur Deen Yadav,Venu Bargav,Asheesh Bhalla,Naveen Kalra,Jai Dev Wig 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.3

Backgrounds/Aims: The course of severe acute pancreatitis (SAP) complicated by hemorrhage is associated with poor outcome. Methods: Twenty-four (13%) out of 183 cases of SAP had hemorrhagic complications- 12 intraabdominal & 12 intraluminal, 13 had major & 11 had minor and 16 had de-novo & 8 post-surgical bleeding. The mean duration of pancreatitis prior to bleeding was 27±27.2 days. Results: Predictors of haemorrhage on univariate analysis were delayed admission (0.037), more than one organ failure (p=0.008), presence of venous thrombosis (p=0.033), infective necrosis (0.001) and systemic sepsis – bacterial (0.037) & fungal (p=0.032). On multivariate analysis infected necrosis (OR=11.82) and presence of fungal sepsis (OR=3.73) were the significant factors. Patients presenting with more than one organ failure and bacterial sepsis had borderline significance on multivariate analysis. Need for surgery (50% vs. 12.6%), intensive care stay (7.4±7.9 vs. 5.4±5.2 days) and mortality (41.7% vs. 10.7%) were significantly higher in patients who suffered haemorrhage. Seven of the 13 with major bleeding had pseudoaneurysms-4 were embolized, 4 needed surgery including 1 embolization failure. Seven with intraabdominal bleeding required surgical intervention, 2 had successful embolization and 3 had expectant management. CT severity index and surgical intervention, were significantly associated with intraabdominal bleeding. Organ failure, presence of pseudoaneurysm and surgical intervention were associated with major bleeding. Conclusions: Hemorrhage in SAP was associated with increased morbidity and mortality. Infected necrosis accentuated the degradation of the vessel wall, which predispose to hemorrhage. Luminal bleeding may be indicative of erosion into the adjacent viscera by the pseudoaneurysm.

Comparative Analysis of Oct4 in Different Histological Subtypes of Esophageal Squamous Cell Carcinomas in Different Clinical Conditions

Vaiphei, Kim,Sinha, Saroj Kant,Kochhar, Rakesh Asian Pacific Journal of Cancer Prevention 2014 Asian Pacific journal of cancer prevention Vol.15 No.8

Background: Esophageal squamous cell carcinoma (ESCC) is a common cancer with poor prognosis. It has been hypothesized that Oct4 positive radioresistant stem cells may be responsible for tumor recurrence. Hence, we evaluated Oct4 expression in ESCC in pre-treatment, post neo-adjuvant residual and post-surgical recurrent tumours. Materials and Methods: Endoscopic mucosal biopsies were used to study Oct4 expression and the observations were correlated with histological tumor grades, patient data and clinical background. Results: All patients presented with dysphagia with male predominance and a wide age range. Majority of the patients had intake of mixed diet, history of alcohol and tobacco intake was documented in less than half of the patients. Oct 4 expression was significantly higher in poorly differentiated (PDSCC) and basaloid (BSCC) subtypes than the other better differentiated tumor morphology. Oct4 was also expressed by adjoining esophageal mucosa showing low grade dysplasia and basal cell hyperplasia (BCH). Biopsies in PDSCC and BSCC groups were more likely to show a positive band for Oct4 by polymerase chain reaction (PCR). Dysplasia and BCH mucosa also showed Oct4 positivity by PCR. All mucosal biopsies with normal morphology were negative for Oct4. Number of tissue samples showing Oct4 positivity by PCR was higher than that by the conventional immunohistochemistry (p>0.05). Oct4 expression pattern correlated only with tumor grading, not with other parameters including the clinical background or patient data. Conclusions: Our observations highlighted a possible role of Oct4 in identifying putative cancer stem cells in ESCC pathobiology and response to treatment. The implications are either in vivo existence of Oct4 positive putative cancer stem cells in ESCC or acquisition of cancer stem cell properties by tumor cells as a response to treatment given, resulting ultimately an uncontrolled cell proliferation and treatment failure.

Comparison of Spectrum of Complications after Pancreaticoduodenectomy in Patients with or without Preoperative Biliary Stents

( Thakur Deen Yadav ),( Hari Poudel ),( Vikas Gupta ),( Saroj K Sinha ),( Rakesh Kochhar ),( Virendra Singh ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Preoperative biliary drainage (PBD) prior to Pancraticoduodenectomy (PD) continues to be routine in many centres despite sufficient evidence showing PBD to increase perioperative complications. This study was planned to see complications of PD and compare between stented and non-stented. Methods: Total 59 patients were enrolled in a period of one and half year. During surgery bile aspirate was sent routinely for culture sensitivity. Drain fluid amylase and LFT were obtained on day 3, 7 and 10. Morbidity was graded according to the Clavien-Dindo classification. Pancreatic fistula, haemorrhage and DGE were documented as per international guidelins. USG Abdomen was done on POD7. Patients were assessed daily for complications as per ISGPS definition. Results: Fifty Nine patients were enrolled. 21 were stented and 38 were not stented. Median age was 62 and 55 respectively.. DGE in 13 stented and 24 non-stented patients. Pancreatic fistula occurred in 7 (33%) stented and 8(21%) non -stented group. No significant difference was found in two groups.Fever was documented in 5 stented and 4 non-stented . Post PD haemorrhage occured in three patients and no difference between scented and non-stented. Bile culture was sterile in Two (9.5%) stented and 28 (73%) non stented patients. This was significant. Enterococci were most common isolate on stented patients accounting for 33% . E coli were most common among non-stetted . Conclusions: We could not find significant difference in morbidity, hospital stay and operative time between the stented and non-stented groups after Pancreaticoduodenectomy. There was significant difference in bile culture positivity.

Post-cholecystectomy acute injury: What can go wrong?

Vikas Gupta,Ashish Gupta,Thakur Deen Yadav,Bhagwant Rai Mittal,Rakesh Kochhar 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.2

Backgrounds/Aims: Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries. Methods: We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management. Results: Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy. Conclusions: Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.

Residual gall bladder: An emerging disease after safe cholecystectomy

Vikas Gupta,Anil Kumar Sharma,Pradeep Kumar,Mantavya Gupta,Ajay Gulati,Saroj Kant Sinha,Rakesh Kochhar 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.4

Backgrounds/Aims: Residual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal. Methods: we retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot’s anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen. Results: 21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months. Conclusions: Residual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.