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Incidental gall bladder cancers:Are they truly incidental?

World Journal of Gastrointestinal Oncology 2014年第12期6卷 441-443页

作者： Ashwin Rammohan Sathya D Cherukuri Jeswanth Sathyanesan ravichandran palaniappan Manoharan Govindan The Institute of Surgical Gastroenterology and Liver Transplantation Centre for GI Bleed Division of HPB diseases Stanley Medical College Hospital Stanley Medical College Hospital

AIM: To seek and analyze features suggestive of gallbladder cancer(GBC) on preoperative imaging and intraoperative findings in patients diagnosed as having incidental GBC(IGBC). METHODS: The study was conducted on 79 patients of IGBC managed in our department over a 10-year period(2003-2012). Review of preoperative imaging and operative notes was done to ascertain any suspicion of ***: Of the 79 patients, Ultrasound abdomen showed diffuse thickening, not suspicious of malignancy in 5 patients, and diffuse suspicious thickening was seen in 4 patients. Focal thickening suspicious of malignancy was present in 24 patients. Preoperative computed tomography/magnetic resonance imaging was done in 9 patients for suspicion of malignancy. In 5 patients, dif-ficult Cholecystectomy was encountered due to dense/inflammatory adhesions. Intraoperative findings showed focal thickening of the gallbladder and a gallbladder mass in 9 and 17 patients respectively. On overall analysis, 37 patients had preoperative imaging or intraoperative findings suggestive of malignancy, which was either a missed GBC or an unsuspected/unexpected GBC. In 42(53.2%) patients, there was no evidence suggestive of malignancy and was an unanticipated ***: Our study highlights a potential and not-so-rare pitfall of Laparoscopic Cholecystectomy. A greater awareness of this clinical entity along with a high index of suspicion and a low threshold for conversion to open procedure, especially in endemic areas may avert avoidable patient morbidity and mortality.

关键词： Incidental gallbladder cancer Preoperative detection Imaging

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Retention mucocele of distal viable remnant tip of appendix:An unusually rare late surgical complication following incomplete appendectomy

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World Journal of Gastroenterology 2006年第3期12卷 489-492页

作者： Maria Antony Johnson Damodaran Jyotibasu palaniappan ravichandran Satyanesan Jeswanth Devy Gounder Kannan RajagopalSurendran Department of Surgical Gastroenterology Government Stanley Medical College HospitalThe Tamilnadu Dr.MGR Medical UniversityChennaiIndia.

A 67-year old man was presented with a 6-mo history of recurrent right lower quadrant abdominal pain. On physical examination, a vague mass was palpable in the right lumbar region. His routine laboratory tests were normal. Ultrasonography showed a hypoechoic lesion in the right lumbar region anterior to the right kidney with internal echoes and fluid components. Abdominal contrast-enhanced computed tomography （CECT） showed a well-defined hypodense cystic mass lesion lateral to the ascending colon/caecum, not communicating with the lumen of colon/caecum. After complete open excision of the cystic mass lesion, gross pathologic examination revealed a turgid cystic dilatation of appendiceal remnant filled with the mucinous material. On histopathological examination, mucinous cyst adenoma of appendix was confirmed. We report this rare unusual late complication of mucocele formation in the distal viable appendiceal remnant, which was leftover following incomplete retrograde appendectomy. This unusual complication is not described in the literature and we report it in order to highlight the fact that a high index of clinical and radiological suspicion is essential for the diagnosis of mucocele arising from a distal viable appendiceal remnant in a patient who has already undergone appendectomy presenting with recurrent abdominal pain.

关键词： Retention mucocele Appendix Incomplete appendectomy Surgical complication

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Neuroendocrine carcinoma of the ampulla of Vater:a clinicopathologic evaluation

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Hepatobiliary & Pancreatic Diseases International 2008年第4期7卷 422-425页

作者： Eswaran Selvakumar Shanmugasundaram Rajendran Tirupporur Govindaswamy Balachandar Devy Gounder Kannan Satyanesan Jeswanth palaniappan ravichandran Rajagopal Surendran Department of Surgical Gastroenterology Center for G.I.Bleeding & Division of Hepatobiliary Pancreatic Diseases Government Stanley Medical College Hospitalthe Tamilnadu Dr. M.G.R.Medical UniversityChennai 600001TamilnaduIndia

BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case *** incidence of NET is *** changes in incidence may result from changes in *** study was to determine the relative incidence and clinicopathological characteristics of high- grade neuroendocrine carcinoma(small cell carcinoma and large cell carcinoma)of the ampulla of Vater at a single institution. METHODS:Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple’s procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical *** clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS:The patients were 3 men and 2 women,ranging in age from 39 to 47 years(mean 44 years).Operative procedures included Whipple’s procedure in 4 patients and palliative bypass in 1 *** examination revealed large-cell neuroendocrine carcinoma in 2 patients,small cell carcinoma in 2,and carcinoid in *** patients with high-grade neuroendocrine carcinoma who had undergone Whipple’s procedure died at postoperatively 7,11,and 13 *** patient who had undergone palliative triple bypass died 3 months after ***:The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally *** tumors behave aggressively and have a dismal prognosis despite aggressive treatment.

关键词： neuroendocrine tumor carcinoid tumor ampulla of Vater Whipple's procedure

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Long-term outcome of gastric access loop in hepaticojejunostomy

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Hepatobiliary & Pancreatic Diseases International 2008年第2期7卷 152-155页

作者： Eswaran Selvakumar Shanmugasundaram Rajendran Tirupporur G. Balachandar Devy Gounder Kannan Satyanesan Jeswanth palaniappan ravichandran Rajagopal Surendran Department of Surgical Gastroenterology Center for G.I.Bleed & Division of Hepatobiliary Pancreatic Diseases Government Stanley Medical College Hospital The Tamilnadu Dr. M.G.R. Medical University Chennai-600001 Tamilnadu India

BACKGROUND:?The incidence of hepaticojejunostomy stricture is 4%-10% in experienced centres. Many access loops have been designed and used to facilitate endoscopic intervention for this complication of hepaticojejunostomy. In this study, we investigated the effectiveness and safety of gastric access loop. METHODS:A retrospective analysis was conducted on 13 patients who had undergone hepaticojejunostomy with gastric access loop between June 1999 and September 2003. Eleven patients were followed up for a mean period of 51 months (range 20-81 months). Two patients were lost to follow up. RESULTS:?On follow-up, 8 patients had patent jejuno- gastrostomy (end to side anastomosis between Roux loop of jejunum and stomach) and hepaticojejunostomy. Three patients developed stricture of jejunogastrostomy at 41 months, 63 months and 81 months of follow-up. Among these 3 patients, one also had hepaticojejunostomy stricture. In the patient with hepaticojejunostomy stricture, dilatation of jejunogastrostomy stricture was attempted but failed. None of the patients had any evidence of bile gastritis/cholangitis. There was no procedure related morbidity/mortality. CONCLUSIONS:Further studies involving large numbers of patients are required before wide application of gastric access loop in hepaticojejunostomy though it is a safer option than percutaneous transhepatic manipulations or revision surgery.

关键词： access loop hepaticojejunostomy anastomotic stricture biliary stricture

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Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy?

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Hepatobiliary & Pancreatic Diseases International 2010年第1期9卷 65-68页

作者： Sivanpillay Mahadevan Sivaraj Velayutham Vimalraj Palanichamy Saravanaboopathy Shanmugasundaram Rajendran Sathyanesan Jeswanth palaniappan ravichandran Rosy Vennilla Rajagopalan Surendran Institute of Surgical Gastroenterology and Liver Transplantation New Gastroenterology BlockGovernment Stanley Medical College Hospital

BACKGROUND:Although bile infection has been proposed to increase infective complications following pancreaticoduodenectomy,its association with infective complications and non-infective complications like pancreatic fistula is still ***:Seventy-six patients who had undergone pancreaticoduodenectomy between July 2007 and December 2008 were included in a prospective database and their data *** all patients intraoperative bile from the bile duct was ***,intra-operative,and post-operative variables were recorded and ***:Bile culture showed positive growth in 35 patients and negative growth in *** patients in the positive group underwent ERCP and *** patients with a positive bile culture had a higher incidence of infective complications including intra-abdominal abscess (n=8),wound infection (n=27),bacteremia (n=10),and renal insufficiency (n=9).There was no increase in the rate of non-infective complications of pancreaticoduodenectomy including pancreatic fistula (n=7),delayed gastric emptying (n=9),and post-operative hemorrhage (n=3).The hospital stay was significantly prolonged in the patients with a positive bile culture (P=0.0002).CONCLUSIONS:Pre-operative biliary drainage is significantly associated with bile infection,and bile infection increases the overall rates of infective complications and renal *** of the high incidence of complications is associated with infected bile,routine intra-operative bile culture is recommended in patients undergoing ***-operative prophylaxis is dependent on sensitivity of cases to perioperative antibiotics and intraoperative bile culture *** of its significant association with infected bile,biliary stenting should be used in strictly selected cases.

关键词： bactibilia Whipples pancreaticoduodenectomy perioperative outcomes

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Outcome of severe acute pancreatitis: Is there a role for conservative management of infected pancreatic necrosis?

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Hepatobiliary & Pancreatic Diseases International 2006年第4期5卷 599-604页

作者： Amarapathy Sivasankar Devy Gounder Kannan palaniappan ravichandran Sathyanesan Jeswanth Tirupporur Govindasamy Balachandar Rajagopal Surendran Department of Surgical Gastroenterology Government Stanley Medical College Hospital the Tamilnadu Dr. M.G.R. Medical University Chennai India

BACKGROUND: Infected pancreatic necrosis is associated with high morbidity and mortality and is mandatory for surgical or radiological intervention. A selected group of patients with CT evidence of infected pancreatic necrosis and a comparatively lower APACHE score may be clinically stable throughout the course of their illness. METHODS: Case records of 52 patients with severe acute pancreatitis admitted from October 2000 to September 2005 were retrospectively analysed to assess the feasibility of conservative management of infected pancreatic necrosis. CT evidence of retroperitoneal air pockets, deteriorated clinical condition, sepsis and positive blood culture were used to diagnose infected pancreatic necrosis. RESULTS: In the 52 male patients reviewed, 24 patients had infected pancreatic necrosis. Eighteen patients who had progressively deteriorated clinical conditions required surgical intervention; five patients of whom (27.8%) died. Six patients with transient end organ dysfunction and stable clinical conditions were treated with prolonged administration of antibiotics and ICU support. All these patients recovered and discharged from the hospital, and no symptoms or readmission happened during follow-up of 6-44 months. CONCLUSIONS: Selected patients with infected pancreatic necrosis who are clinically stable with transient end organ dysfunction can be treated conservatively with a favourable outcome. Necrosectomy associated with high morbidityand mortality in these patients can be avoided. The need for intervention should be individualized and based on clinical conditions of the patients.

关键词： acute necrotizing pancreatitis APACHE Ⅱ multiple organ dysfunction syndrome mortality antibiotics

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A gist of gastrointestinal stromal tumors: A review

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World Journal of Gastrointestinal Oncology 2013年第6期5卷 102-112页

作者： Ashwin Rammohan Jeswanth Sathyanesan Kamalakannan Rajendran Anbalagan Pitchaimuthu Senthil-Kumar Perumal UP Srinivasan Ravi Ramasamy ravichandran palaniappan Manoharan Govindan The Institute of Surgical Gastroenterology and Liver Transplantation Centre for GI Bleed Division of HPB Diseases Stanley Medical College Hospital

Gastrointestinal stromal tumors (GISTs) have been recognized as a biologically distinctive tumor type, different from smooth muscle and neural tumors of the gastrointestinal tract (GIT). They constitute the majority of gastrointestinal mesenchymal tumors of the GIT and are known to be refractory to conventional chemotherapy or radiation. They are defined and diagnosed by the expression of a proto-oncogene protein detected by immunohistochemistry which serves as a crucial diagnostic and therapeutic target. The identification of these mutations has resulted in a better understanding of their oncogenic mechanisms. The remarkable antitumor effects of the molecular inhibitor imatinib have necessitated accurate diagnosis of GIST and their distinction from other gastrointestinal mes-enchymal tumors. Both traditional and minimally invasive surgery are used to remove these tumors with minimal morbidity and excellent perioperative outcomes. The revolutionary use of specific, molecularlytargeted therapies, such as imatinib mesylate, reduces the frequency of disease recurrence when used as an adjuvant following complete resection. Neoadjuvant treatment with these agents appears to stabilize disease in the majority of patients and may reduce the extent of surgical resection required for subsequent complete tumor removal. The important interplay between the molecular genetics of GIST and responses to targeted therapeutics serves as a model for the study of targeted therapies in other solid tumors. This review summarizes our current knowledge and recent advances regarding the histogenesis, pathology, molecular biology, the basis for the novel targeted cancer therapy and current evidence based management of these unique tumors.

关键词： Gastrointestinal stromal tumors c-KIT Imatinib mesylate Surgery Review

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Predictors of malignancy in chronic calcific pancreatitis with head mass

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World Journal of Gastrointestinal Surgery 2013年第4期5卷 97-103页

作者： Senthilkumar Perumal ravichandran palaniappan Sastha Ahanatha Pillai Vimalraj Velayutham Jeswanth Sathyanesan Institute of Surgical Gastroenterology and Liver Transplantation Government Stanley Medical College

AIM: To prospectively analyse the clinical, biochemical and radiological characteristics of the mass lesions arising in a background of chronic calcific pancreatitis (CCP). METHODS: Eighty three patients, who presented with chronic pancreatitis (CP) and a mass lesion in the head of pancreas between February 2005 and December 2011, were included in the study. Patients who were identified to have malignancy underwent Whipple' s procedure and patients whose investigations were suggestive of a benign lesion underwent Frey's procedure. Student t-test was used to compare the mean values of imaging findings [common bile duct (CBD), main pancreatic duct (MPD) size] and laboratory data [Serum bilirubin, carbohydrate antigen 19-9 (CA 19-9)] between the groups. Receiver operating characteristic curve (ROC curve) analysis was done to calculate the cutoff valves of serum bilirubin, CA 19-9, MPD and CBD size. The sensitivity, specificity, positive predictive valve (PPV) and negative predictive value (NPV) were calculated using these cut off points. Multivariate analysis was performed using logistic regression model. RESULTS: The study included 56 men (67.5%) and 27 women (32.5%). Sixty (72.3%) patients had tropical calcific pancreatitis and 23 (27.7%) had alcohol related CCP. Histologically, it was confirmed that 55 (66.3%) of the 83 patients had an inflammatory head mass and 28 (33.7%) had a malignant head mass. The mean age of individuals with benign inflammatory mass and those with malignant mass was 38.4 years and 45 years respectively. Significant clinical features that predicted a malignant head mass in CP were presence of a head mass in CCP of tropics, old age, jaundice, sudden worsening abdominal pain, gastric outlet obstruction and significant weight loss (P ≤ 0.05). The ROC curve analysis showed a cut off value of 5.8 mg/dL for serum bilirubin, 127 U/mL for CA 19-9, 11.5 mm for MPD size and 14.5 mm for CBD size. CONCLUSION: Elevated Serum bilirubin and CA 19-9, and dila

关键词： Chronic calcific pancreatitis Pancreatic head mass Carcinoma head of pancreas Risk factors of malignancy

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Large cell neuroendocrine carcinoma of the ampulla of Vater

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Hepatobiliary & Pancreatic Diseases International 2006年第3期5卷 465-467页

作者： Eswaran Selvakumar Velayutham Vimalraj Shanmugasundaram Rajendran Tirupporur G.Balachandar Devy G.Kannan Satyanesan Jeswanth palaniappan ravichandran Arunachalam Sundaram Rajagopal Surendran Departments of Pathology and Surgical Gastroenterology Center for G.I.Bleeding & Division of Hepatobiliary Pancreatic Diseases Government Stanley Medical College Hospitalthe Tamilnadu Dr.M.G.R.Medical UniversityChennaiTamilnaduIndia

BACKGROUND: Neuroendocrine tumors of the ampulla of Vater are extremely rare, and few cases of large cell neuroendocrine carcinoma (LCNEC) of the ampulla have been reported. METHODS: A 48-year-old male with obstructive jaundice was admitted to our hospital. On examination the patient was found to have a periampullary growth and subsequently underwent the Whipple's procedure. RESULTS: Histopathological examination and immunohistochemistry revealed features of LCNEC of the ampulla of Vater. The patient developed multiple liver metastases 6 months after Whipple's procedure. CONCLUSION: LCNEC of the ampulla of Vater is rare and highly aggressive, with a dismal prognosis.

关键词： large cell neuroendocrine carcinoma ampulla of Vater Whipple's procedure periampullary growth

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Role of plasmapheresis in early allograft dysfunction following deceased donor liver transplantation

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World Journal of Hematology 2017年第1期6卷 24-27页

作者： Ashwin Rammohan Deepti Sachan Satish Logidasan Jeswanth Sathyanesan ravichandran palaniappan Mohamed Rela Institute of Liver Disease and Transplantation Global Hospitals and Health City Institute of Surgical Gastroenterology and Liver Transplantation Govt Stanley Medical College Hospital Institute of Liver Studies King’s College Hospital

The role of plasmapheresis in liver failure and hepatic encephalopathy is undefined and its use as a strategy to salvage patients with severe allograft dysfunction after liver transplantation remains investigational. We present a case of early allograft dysfunction following deceased donor liver transplantation(DDLT) where plasmapheresis was effective as a bridge to recovery and possibly avoiding a retransplantation. A 16 years old boy, known to have decompensated Wilson's disease underwent DDLT at our Public Sector Hospital. He received a healthy liver from a brain-dead donor, whose liver was considered too large for the boy. The graft was reduced in situ to a left lobe graft. Surgery was uneventful and the recipient was well for the initial 96 h. On Doppler and further computed tomography scan, a partial portal vein thrombus was noted. He was reexplored and a Fogarty endothombecteomy was performed. Following the second surgery, he developed severe allograft dysfunction with a peak bilirubin of 40 mg/d L. He underwent imaging to rule out technical causes for the dysfunction, followed by a liver biopsy, which revealed acute cellular rejection. Multiple cycles of plasmapheresis were initiated. Over the next two weeks, the graft demonstrated a gradual recovery. He was discharged on the 30 th postoperative day, with a serum bilirubin of 5.5 mg/d L. He remains well on follow-up, with the liver function tests improving further. Our report demonstrates the beneficial effect of plasmapheresis, which appears to be an effective treatment option for early allograft dysfunction following liver transplantation and may obviate the need for retransplantation.

关键词： Liver transplantation Allograft dysfunction Plasmapheresis

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