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Management of splenic artery aneurysm associated with extrahepatic portal vein obstruction

Hepatobiliary & Pancreatic Diseases International 2012年第3期11卷 330-333页

作者： Pramod Kumar Mishra Sundeep Singh Saluja Ashok K Sharma Premanand Pattnaik department of gastrointestinal surgery surgery gb pant hospital department of gastrointestinal surgery and department of Radiology surgery gb pant hospital Department of Gastrointestinal Surgery GB Pant Hospital

BACKGROUND: Splenic artery aneurysms although rare are clinically significant in view of their propensity for spontaneous rupture and life-threatening bleeding. While portal hypertension is an important etiological factor, the majority of reported cases are secondary to cirrhosis of the liver. We report three cases of splenic artery aneurysms associated with extrahepatic portal vein obstruction and discuss their management. METHODS: The records of three patients of splenic artery aneurysm associated with extrahepatic portal vein obstruction managed from 2003 to 2010 were reviewed retrospectively. The clinical presentation, surgical treatment and outcome were analyzed. RESULTS: The aneurysm was >3 cm in all patients. The clinical symptoms were secondary to extrahepatic portal vein obstruction (hematemesis in two, portal biliopathy in two) while the aneurysm was asymptomatic. Doppler ultrasound demonstrated aneurysms in all patients. A proximal splenorenal shunt was performed in two patients with excision of the aneurysm in one patient and ligation of the aneurysm in another one. The third patient had the splenic vein replaced by collaterals and hence underwent splenectomy with aneurysmectomy. All patients had an uneventful post-operative course. CONCLUSIONS: Splenic artery aneurysms are associated with extrahepatic portal vein obstruction. surgery is the mainstay of treatment. Although technically difficult, it can be safely performed in an experienced center with minimal morbidity and good outcome.

关键词： splenic artery aneurysm extrahepatic portal vein obstruction portal hypertension proximal splenorenal shunt

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Xanthogranulomatous cholecystitis:a premalignant condition?

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Hepatobiliary & Pancreatic Diseases International 2011年第2期10卷 179-184页

作者： Mila Ghosh Puja Sakhuja Anil K Agarwal department of gastrointestinal surgery gb pant Hospita and Maulana Azad Medical College department of Pathology gb pant Hospita and Maulana Azad Medical College

BACKGROUND:Xanthogranulomatous cholecystitis(XGC)is an uncommon variant of chronic cholecystitis,characterized by marked thickening of the gallbladder wall and dense local adhesions.It often mimics a gallbladder carcinoma(gbC), and may coexist with gbC,leading to a diagnostic dilemma. Furthermore,the premalignant nature of this entity is not known.This study was undertaken to assess the p53,PCNA and beta-catenin expression in XGC in comparison to gbC and chronic inflammation. METHODS:Sections from paraffin-embedded blocks of surgically resected specimens of gbC(69 cases),XGC(65), chronic cholecystitis(18)and control gallbladder(10)were stained with the monoclonal antibodies to p53 and PCNA, and a polyclonal antibody to beta-catenin.p53 expression was scored as the percentage of nuclei stained.PCNA expression was scored as the product of the percentage of nuclei stained and the intensity of the staining(1-3).A cut-off value of 80 for this score was taken as a positive result. Beta-catenin expression was scored as type of expression-membranous,cytoplasmic or nuclear staining. RESULTS:p53 mutation was positive in 52%of gbC cases and 3%of XGC,but was not expressed in chronic cholecystitis and control gallbladders.p53 expression was lower in XGC than in gbC(PgbC cases and 11%of XGC,but not in chronic cholecystitis and control gallbladders.PCNA expression was higher in gbC than XGC(P=0.0001),but there was no significant difference between the XGC,chronic cholecystitis and control gallbladder groups.Beta-catenin expression was positive in the gbC,XGC, chronic cholecystitis and control gallbladder groups.But the expression pattern in XGC,chronic cholecystitis and control gallbladders was homogenously membranous,whereas in gbC the membranous expression pattern was altered to cytoplasmic and nuclear.CONCLUSION:The expression of p53,PCNA and beta-catenin in XGC was significantly different from gbC and similar to chronic cholecystitis,thus indicating the inflammatory nature of XGC a

关键词： xanthogranulomatous cholecystitis gallbladder cancer p53 PCNA beta-catenin

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Choledochal cyst with large stone cast and portal hypertension

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Hepatobiliary & Pancreatic Diseases International 2009年第6期8卷 647-649页

作者： Shivendra Singh Laxman Singh Kheria Sunil Puri Amrinder S Puri Anil K Agarwal departments of gastrointestinal surgery gb pant hospital & Maulana Azad Medical College Radiodiagnosis gb pant hospital & Maulana Azad Medical College Gastroenterology gb pant hospital & Maulana Azad Medical College

BACKGROUND:Choledochal cysts in adults are more commonly associated with complications such as cystolithiasis,recurrent cholangitis,portal hypertension and malignancy,than in the pediatric age group.METHOD:We report a case of adult choledochal cyst with long-term complication of large stone cast and portal hypertension due to secondary biliary cirrhosis.RESULTS:A 50-year-old patient presented with obstructive jaundice and hepatosplenomegaly.On investigation,she was diagnosed as having a choledochal cyst with large stone cast and portal hypertension.Single stage resection of the choledochal cyst with Roux-en-Y hepaticojejunostomy was done by meticulous dissection and ligation of collaterals.CONCLUSION:Single stage resection of a choledochal cyst is possible in spite of associated portal hypertension,if the portal vein is patent.

关键词： choledochal cyst cystolithiasis portal hypertension

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Composite pheochromocytoma masquerading as solidpseudopapillary neoplasm of pancreas

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World Journal of Clinical Cases 2015年第5期3卷 474-478页

作者： Geetanjali Gupta Ravindra Kumar Saran Satyajit Godhi Siddharth Srivastava Sundeep Singh Saluja Pramod Kumar Mishra department of Pathology Academic Block GB Pant Hospital New Delhi 110002 India department of Gastroenterology Academic Block GB Pant Hospital New Delhi 110002 India department of gastrointestinal surgery Academic Block GB Pant Hospital New Delhi 110002 India

Pheochromocytoma and ganglioneuroma form rare composite tumours of the adrenal medulla comprising less than 3% of all sympathoadrenal tumours. We present a case of intraoperatively detected adrenal medullary tumour of composite pheochromocytoma and ganglioneuroma diagnosed on histopathology, in a normotensive patient. A 50-year-old male with a past history of chronic obstructive pulmonary disease presented with abdominal pain and significant weight loss since one month. Ultrasound and contrast-enhanced computed tomography abdomen revealed a large lobulated lesion in the distal body and tail of pancreas suggestive of solid and papillary neoplasm of body and tail of pancreas. Intra-operatively, a 15 cm × 10 cm solid lesion with cystic areas was seen arising from the left lower pole of the adrenal gland pushing the pancreas which appeared unremarkable. In our case, exploratory laparotomy with tumour excision was done. Extensive sectioning and microscopic examination of this adrenal tumour confirmed a diagnosis of composite Pheochromocytoma with Ganglioneuroma on histopathology. Immunophenotyping with S-100 further supported the diagnosis. The goal of this report is to increase the awareness of this rare disease and to further identify its variable presentation.

关键词： Ganglioneuroma Pheochromocytoma Adrenal

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Gastric conduit perforation

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World Journal of Clinical Cases 2014年第8期2卷 398-401页

作者： Nilesh Patil Arvind Kaushal Amit Jain Sundeep Singh Saluja Pramod Kumar Mishra department of gastrointestinal surgery Academic BlockGB Pant Hospital and Maulana Azad Medical CollegeNew Delhi 110002India

As patients with carcinoma of the esophagus live longer, complications associated with the use of a gastric conduit are increasing. Ulcers form in the gastric conduit in 6.6% to 19.4% of patients. There are a few reports of perforation of a gastric conduit in the English literature. Almost all of these were associated with serious complications. We report a patient who developed a tension pneumothorax consequent to spontaneous perforation of an ulcer in the gastric conduit 7 years after the index surgery in a patient with carcinoma of the gastroesophageal junction. He responded well to conservative management. Complications related to a gastric conduit can be because of multiple factors. Periodic endoscopic surveillance of gastric conduits should be considered as these are at a higher risk of ulcer formation than a normal stomach. Long term treatment with proton pump inhibitors may decrease complications. There are no guidelines for the treatment of a perforated gastric conduit ulcer and the management should be individualized.

关键词： Gastric conduit Ulcer formation Perforation Carcinoma of the esophagus Proton pump inhibitors

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Accessory Leaflet of Tricuspid Valve Masquerading as Infective Endocarditis Preoperatively and Causing RVOT Obstruction Postoperatively

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World Journal of Cardiovascular surgery 2015年第2期5卷 7-10页

作者： Nishith Bhargava Saket Agrawal Deepak K. Tempe Deepak K. Satsangi department of Cardiothoracic and Vascular surgery (CTVS) GB Pant Hospital (GBPH) New Delhi India gb pant and GNEC hospitals New Delhi India

Accessory tricuspid valve tissue is a rare congenital anomaly. We report a case where preoperative echocardiogram was suggestive of infective vegetations over the tricuspid valve but intra-operatively it was found to ... 详细信息

关键词： Accessory Tricuspid Valve Endocardial Vegetations Echocardiogram

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Palliative surgical bypass for unresectable periampullary carcinoma

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Hepatobiliary & Pancreatic Diseases International 2008年第3期7卷 308-312页

作者： Shivendra Singh Ajay Kumar Sachdev Adarsh Chaudhary Anil Kumar Agarwal department of gastrointestinal surgery Govind Ballabh Pant Hospital&Maulana Azad Medical CollegeNew Delhi 110002India

BACKGROUND:Around 60%to 80%of patients with periampullary carcinoma are unresectable either due to distant metastasis or local vascular invasion.With the advancement of endoscopic interventional procedures,the role of surgical bypass has diminished.However,surgical bypass is still appropriate in patients with unresectable disease discovered at the time of surgery.This study was conducted to assess the results of palliative surgical bypass for patients with unresectable periampullary carcinoma at our hospital,a tertiary referral center of Northern India. METHOD:The study group comprised 204 patients who had undergone surgical bypass for advanced periampullary carcinoma over the last 15 years. RESULTS:Between January 1990 and December 2004,204 patients(128 males,76 females)consisting of 179 patients with carcinoma of head of the pancreas,14 patients with ampullary carcinoma,8 patients with lower end cholangiocarcinoma and 3 patients with duodenal carcinoma underwent surgical bypass.Their average age was 51 years (range 20-78 years).Both biliary and gastric bypasses were done in 158(77.45%),biliary bypass alone in 37(18.13%) and gastric bypass alone in 9(4.32%).Biliary bypass was done by Roux-en-Y hepaticojejunostomy,and gastric bypass by retrocolic gastrojejunostomy.The overall postoperative mortality and morbidity were 0.98%and 26.9%,respectively The patients who died had undergone previously endoscopic intervention.Complications included wound infection in 12.25%of the patients,bile leak in 5.12%,delayed gastric emptying in 5.38%,ascitic leak from drains in 8.8%,and upper gastrointestinal bleeding in 1.96%.The incidences of wound infection and bile leak both were significantly higher in patients who had had preoperative biliary stenting None of the patients who had undergone Roux-en-Y hepati cojejunostomy+retrocolic gastrojejunostomy required any intervention later in their life.CONCLUSIONS:Surgical bypass is a safe procedure with negligible mortality and minimal morbidity.It has not lost its relevance and is an

关键词： surgical bypass periampullary carcinoma

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Endoscopic management of postoperative bile leaks

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Hepatobiliary & Pancreatic Diseases International 2006年第2期5卷 273-277页

作者： Naresh Agarwal Barjesh Chander Sharma Sanjay Garg Rakesh Kumar Shiv K Sarin department of Gastroenterology gb pant hospital New DelhiIndia

BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at

关键词： biliary fistulae endoscopic retrograde cholangiopancreatography sphincterotomy biliary stent nasobiliary drain common bile duct stones

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Management of hypersplenism in non-cirrhotic portal hypertension:a surgical series

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Hepatobiliary & Pancreatic Diseases International 2012年第2期11卷 165-171页

作者： Rajesh Rajalingam Amit Javed Dharmanjay Sharma Puja Sakhuja Shivendra Singh Hirdaya H Nag Anil K Agarwal department of gastrointestinal surgery G. B. Pant Hospital and Maulana Azad Medical College Delhi University New Delhi India department of Pathology G. B. Pant Hospital and Maulana Azad Medical College Delhi University New Delhi India

BACKGROUND:Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension(NCPH).While a splenectomy alone can effectively relieve the hypersplenism,it does not address the underlying portal hypertension.The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH.The relationship of symptomatic hypersplenism,severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed.METHODS:A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done.Of 252 patients with NCPH,64(45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group.Statistical analysis was done using GraphPad InStat.Categorical and continuous variables were compared using the chi-square test,ANOVA,and Student’s t test.The MannWhitney U test and Kruskal-Wallis test were used to compare non-parametric variables.RESULTS:The mean age of patients in the study group was 21.81±6.1 years.Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%,recurrent anemia at 34.4%,and recurrent infection at 29.7%.The mean duration of surgery was 4.16±1.9 hours,intraoperative blood loss was 457±126(50-2000) mL,and postoperative hospital stay 5.5±1.9 days.Following surgery,normalization of hypersplenism occurred in all patients.On long-term followup,none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding(2 after a splenectomy alone,1 each after an esophago-gastric devascularization and proximal splenorenal shunt).Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older,had a longer duration of symptoms,and a higher incidence of variceal bleeding and postoperative morbidity.In addition,patients with triple cell line defects had elevated portal pres

关键词： portal hypertension hypersplenism splenorenal shunt lienorenal shunt

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Pancreatic ductal adenocarcinoma associated with pancreatic ductal intraepithelial neoplasia:report of a case

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Hepatobiliary & Pancreatic Diseases International 2007年第5期6卷 553-556页

作者： Rajkumar Krishnasamy Shaleen Agarwal Shivendra Singh Sunil Puri Puja Sakhuja Anil K Agarwal department of gastrointestinal surgery Govind Ballabh Pant Hospital and Maulana Azad Medical College(Delhi University)New Delhi 110002India department of Radiology Govind Ballabh Pant Hospital and Maulana Azad Medical College(Delhi University)New Delhi 110002 department of Pathology Govind Ballabh Pant Hospital and Maulana Azad Medical College(Delhi University)New Delhi 110002

BACKGROUND:The presence of pancreatic ductal intraepithelial neoplasia in patients with chronic pancreatitis is a risk factor for development of pancreatic adenocarcinoma. METHOD:A case of pancreatic ductal adenocarcinoma associated with pancreatic ductal intraepithelial neoplasia was diagnosed in the setting of chronic pancreatitis. RESULTS:Distal pancreatectomy combined with splenec- tomy was performed with a diagnosis of pancreatic body carcinoma.Histopathological examination suggested adenocarcinoma associated with pancreatic ductal intraepithelial neoplasia.The tumor was detected in the remaining head of the pancreas,for which a total pancreatectomy was done. CONCLUSIONS:When a patient with pancreatic ductal intraepithelial neoplasia associated with adenocarcinoma of the pancreas in the setting of chronic pancreatitis is at an increased risk of recurrence in the remaining pancreatic parenchyma,total pancreatectomy may be feasible.

关键词： pancreatectomy pancreatic ductal carcinoma chronic pancreatitis

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