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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.
Management of residual gall bladder
Ashish Singh,Abhimanyu Kapoor,Rajneesh Kumar Singh,Anand Prakash,Anu Behari,Ashok Kumar,Vinay Kumar Kapoor,Rajan Saxena 한국간담췌외과학회 2018 Annals of hepato-biliary-pancreatic surgery Vol.22 No.1
Backgrounds/Aims: A residual gallbladder (RGB) following a partial/subtotal cholecystectomy may cause symptoms that require its removal. We present our large study regarding the problem of a RGB over a 15 year period. Methods: This study involved a retrospective analysis of patients managed for symptomatic RGB from January 2000 to December 2015. Results: A RGB was observed in 93 patients, who had a median age of 45 (25-70) years, and were comprised of 69 (74.2%) females. The most common presentation was recurrence pain (n=64, 68.8%). Associated choledocholithiasis was present in 23 patients (24.7%). An ultrasonography (USG) failed to diagnose RGB calculi in 10 (11%) patients; whereas, magnetic resonance cholangio-pancreatography (MRCP) accurately diagnosed RGB calculi in all the cases except for 2 (4%) and, additionally, detected common bile duct (CBD) stones in 12 patients. Completion cholecystectomy was performed in all patients (open 45 [48.4%]; laparoscopic 48 [51.6%] and 19 [20.4%] patients required a conversion to open). The RGB pathology included stones in 90 (96.8%), Mirizzi’s syndrome in 10 (10.8%) and an internal fistula in 9 (9.7%) patients. Additional procedures included CBD exploration (n=6); Choledocho-duodenostomy (n=4) and Roux-en-Y hepatico-jejunostomy (n=3). The mortality and morbidity were nil and 11% (all wound infection), respectively. Two patients developed incisional hernia during follow up. The mean follow up duration was 23.1 months (3-108) in 65 patients and the outcome was excellent and good in 97% of the patients. Conclusions: Post-cholecystectomy recurrent biliary colic should raise suspicion of RGB. MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.
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.
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.
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)
( 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.