Patient with Type 3 B hilar cholangiocarcinoma was admitted with obstructive jaundice. His bilirubin was 15 mg%. He had an attempted ERCP outside which failed so underwent a Rt PTBD. He was readmitted for surgery after 3 weeks with a bili of 2 mg%. At diagnostic lap he had evidence of PtBD catheter displacement with bile leak but as patient was not septic he went ahead with an extended left hepatectomy with enbloc caudate lobectomy and bile duct excision and right hepaticojejunstomy to separate Rt anterior and Rt posterior. Post operative recovery was in eventful
65 year old diabetic Patient with reccurant severe post prandial central abdominal pain and weightloss of 10 kg. CT angio shows celiac and SMA stenosis are origin. Chronic mesenyeric ischemia occurs when 2 or more of the 3 major visceral arterial axis are stenosis. It’s not an uncommon cause of undiagnosed abdominal pain in referral centres and should be considered when routine investigations are negative. Goal of revascularization is to relieve symptoms, improve nutrition and prevent intestinal infection. Most patients undergo percutanous angioplasty. In this patient due to the long segment narrowing and associated CKD (Cr1.8) we chose to do an aortomesenteric by pass using an 8mm PTFE graft from infrarenal aorta to Superior mesenteric artery distal to stenosis. This patient had complete pain relief and weight gainpost procedure and is symptom free 3.5 years after surgery. Due to the CKD we are monitoring post operative graft patency by Doppler alone.
patient with reccuarant inciosional hernia status failed lap and open repair. Initial plan was to do a lap TAR but midline defect size measured intraoperatively was 20 cm . We converted to open with a posterior TAR with anterior component separation to achieve a tension free repair.Images show completed TAR with midline apposition of of posteior rectus 30 x 30 cmesh in reeves stopa space. The midline restrored with external oblique release. Surgery was performed through pffanesteil incision with abdominoplasty of excess skin and fat.
70 year old Kenyan male with grade 2 fatty liver with a 6cm HCC in segment 5 of liver. Normal LFT and no evidence of portal HT /cirrhosis. In view of the age , steatotic liver and central location of tumor he was planned for a central hepatectomy. Images show the central location of tumor in CT and MRI. The right anterior sectoral pedicle being isolated and clamped Causing demarcation of rt anterior (seg 5 and 8) from right posterior ( seg 6 and 7) . The MHV being divided. The remnant liver with preserved rt posterior and left lateral segments . The central hepatectomy specimen showing tumor on cutsection . These parenchyma preserving procedures allow safe hepatectomy in elderly with minimal morbidity.
Technique of colonic pull up for high (post cricoid ) corrosive esophageal strictures. In patients with Esophageal strictures with gastric involvement , and post cricoid stricture (i.e stricture at or above the the cricopharyngeal sphincter no possibility of esophageal anastomosis) the conduit has to reach high - the colon conduit is the preferred reconstruction. Our preference is the Rt colon conduit based on the middle colic artery .It is taken in retro sternal route with resection of medial head of clavicle to widen thoracic inlet (a mandatory step to reduce postoperative dysphasia). In patients with a normal voice with no scarring of the epiglottis ,the vocal cords and aryepiglottic folds the risk of aspiration is very low and we have done away without tracheostomy for high pharyngeal anastomosis . With excellent short and long term results . Most patients need a GJ or antrectomy for associates gastric stricture. Images has shown - the colon after ileocolic division with a bull dog clamp on the the right colic to check the colon viability , the divided Rt colic. Resection of sternal head of clavicle to widen the thoracic inlet, High pharyngeal anastomosis, Simpler esophageal anastomosis in another patient with an esophageal stricture.
Gall bladder cancer with node positivity and bile duct involvement (causing Jaundice) is considered a lost cause and dealt with in a nihilistic approach. Still for lack of better options aggressive resectional surgery followed by adjuvant chemotherapy remains the mainstay in this cancer. This 50 year old lady underwent a radical cholecystectomy with 4B /5 liver resection and bile duct excision with us 3 years ago. It was followed by post op chemotherapy. Now 3 years later she remains cancer free. Since most reccurances occur within first 2 years on gallbladder we are very hopeful of achieving a complete cure in her.
Major hepatectomy in borderline liver- 68 yr old male carcinoma rectum with synchronous colorectal metastasis. Patient underwent RT followed by LAR and 8 cycles of chemotherapy. Post chemotherapy MRI and PET CT shows 5 mets in Right lobe with involvement of MHV (MRI Image 1 &2) In view of age , post chemo changes in liver on imaging ) , MHV involvement and 32 % remnant volume we decided for right portal vein embolisation. PVE deprives the nutrition to right half of liver causing hypertrophy of the future remnant liver .Post embolosation liver volume increased from 370 to 520 ( approx 35% increase) At surgery the liver showed post chemochanges but due to preop embolisation we could go ahead with an extended right hepatectomy including full MHV. Using a water jet dissection we could transect the diseased liver bloodlessly without using inflow occlusion (video) Patient had ascites post op but resolved and discharged by day of 10. This case illustrates the role of PVE in improving safety of Hepatectomy in borderline /diseased livers.
A 28 year old girl Type 4 choledochal cyst with hepatolithiasis underwent resection of extrahepatic choledochal cyst 6 years ago with duodenal access loop else where. She presented to us 2 years after surgery with persisting symptoms with reccurent epioses of pain with jaundice and cholangitis. 3 ICU admissions in septic shock. Out side attempted endoscopic interventions through duodenal access and PTBD did not relieve symptoms. When we saw the patient her MRI and CT scan images showed multiple cholangiolytic abcess with large stones in the left lobe . On imaging Majority of stones were in the Left lobe and with a few stones inthe right posterior segment wheras the right anterior segment was completely disease free. Traditionally the approach for bilateral hepatolithiasis would a transplant with attended risk in a septic patient and cost. in view of segmental disease we tried a different approach. After stabilising for 2 weeks on antibiotics we took her up semi electively for left hepatectomy for left sided disease and intraoperative choledochoscopy of right posterior segment calculi .after clearing all stones we placed an intraoperative retrograde PTBD in R post segment to promote better drainage and did a 3 cm revision HJ to the right duct. Patient has bile leak from cut surface post op but subsequently settled. Rt PTBD was removed after 1 year. 4 years later the patient is completely symptom free and Check CT (image) shows no residual stones. This way we successfully avoided the risk of a potential liver transplant in a septic patient with excellent longterm results.
This 12 year old young man is one of our youngest Whipples (the youngest being 8 years old). He presented with a rare childhood tumour called Solid Papillary Tumour of pancreas, 8 cm in size with the portal vein (main blood vessel of liver) splayed out over it. In view of vascular involvement he was told be a very high risk for surgery in Vijaywada and came to us. We did a technically challenging Whipples resection with a portal vein reconstruction 6 months ago. Doing great postoperatively, recently he received a letter that that he has been selected for a NASA scholarship for 2 weeks and came to me for a fitness certificate. He found to be a very lively and jovial fellow. I asked him if he wants to be a GI surgeon - he could come and work with me later. His reply, “No thanks. I see you always in tension. I’d rather become an Astronaut”. God bless him with a long and plentiful life.
A 68 year old male patient had carcinoma rectum with synchronous colorectal metastasis. The patient underwent RT followed by LAR and 8 cycles of chemotherapy. Post chemotherapy MRI and PET CT shows 5 meters in right lobe with involvement of MHV (MRI Image 1 & 2) In view of age , post chemo changes in liver on imaging ) , MHV involvement and 32 % remnant volume we decided for right portal vein embolisation. PVE deprives the nutrition to right half of liver causing hypertrophy of the future remnant liver .Post embolosation liver volume increased from 370 to 520 ( approx 35% increase) At surgery the liver showed post chemo changes but due to preop embolisation we could go ahead with an extended right hepatectomy including full MHV. Using a water jet dissection we could transect the diseased liver bloodlessly without using inflow occlusion (video) Patient had ascites post op but resolved and discharged by day of 10. This case illustrates the role of PVE in improving safety of Hepatectomy in borderline /diseased livers
Gall bladder cancer with node positivity and bile duct involvement (causing Jaundice) is considered a
lost cause and dealt with in a nihilistic approach. Still for lack of better options aggressive resection
surgery followed by adjuvant chemotherapy remains the mainstay in this cancer.
This 50 year old lady underwent a radical Cholecystectomy with 4B / 5 Liver resection and bile duct excision with us 3 years ago. It was followed by post OP Chemotherapy. Now 3 years later she remains cancer free. Since most recurrences occur within first 2 years on Gall Bladder. We are very hopeful of achieving a complete cure in her.
Interesting images June: misleading diagnosis. A 50 year old lady presented with a jaundice and pain abdomen. She was previously operated thrice for hydatid cyst of left liver over the past decade. Her CT showed a large reccurant mutiloculated left lobe lesion along with a daughter cyst in the bile duct. We did not have the biopsy from previous surgery but with a diagnosis of reccurant hydatid cyst we performed a Left hepatectomy with CBD exploration of the daughter cyst. Post operative recovery was in eventful. Final histopathology was suggestive of biliary cystadenoma. Surprisingly the histology of the daughter cyst we removed from CBD also revealed biliary afenomatous hyperplasia. Biliary cystadenomas present with imaging suspiciously similar to complex hydatid / or even simple cyst. They have a high propensity for reccurance and even chance for malignant transformation . When suspected based on preoperative imaging or ontraoperative frozen resection is the best approach.
Interesting images June: Total pancreaticoduodenectomy with splenectomy done for a 45 yr female with main duct IPMN with invasive mid-body cancer with bilateral polycystic kidneys. Her EUS, ERCP and fluid cytology , fluid CEA , serum CA19 -9 were all suggestive and a PET showed high uptake in her solid .She is doing well post op but planned for adjuvant CT Rt as had breached capsule and encased splenic vein. Total pancreaticoduodenectomy was frowned upon as a high morbidity surgery due to severe exocrine and endocrine insufficiency with brittle diabetes , and ulcerogenicity due to complete loss of pancreatic bicarbonate secretion. But in recent years with easy availability of enzyme supplements, CGM ( continuos glucose monitoring devices), insulin pens and long acting PPI the long term QoL of these patients is comparable with partial pancreatectomy patients
Interesting images (May): case of familial adenomatous polyposis with carcinoma rectum upper 3rd. We did a laparoscopic total proctocolectomy with JPouch through a small supra pubic incision. The treatment of FAP by J pouch in presence of Ca rectum is a dilemma due to possible need for radiotherapy postop affecting pouch function and risk of reccurant dysplasia in 2- 3 cm of remnant rectum over dentate line. TPC with permanent permanent ileostomy is a valid option in this group of patients with FAP with invasive Rectal cancer. However this patient patient had refused option of a permanent stoma. Also it was an anterior rectal tumor in the peritonealised upper 3rdrectum which is equivalent to a rectosigmoid in CRM terms. So after explaining all pros and cons with family we did a TPC with J pouch. Biopsy is T3 N1 and now planned for chemotherapy.
Interesting images December: Case of post cholecystectomy biliary stricture with complete cutoff and external biliary fistula.Pt was 6 months after injury He was refused surgery elsewhere and told to wait for fistula to close as there was no biliary dilatation.After a complete cutoff the the external biliary fistula mostly closes over a period of time by fistulizing into duodenum. However after 2- 3 month waiting period presence of a persisting fistula there is no need to wait forever. By the hepp- couinad approach the anastomosis is a side to side anastomosis to the extrahepatic left duct which is abt 3-4 cm in length and as you can see in the images despite the apparent lack of dilatation on MRCP we could achieve a wide 3 cm side to side anastomosis to the confluence and left duct. The anastomosis is by a standard parachuting blumgart kelly technique. The lack of biliary dilatation is not a contraindication to reconstructive surgery after BDI after an adequate waiting period.
Interesting images October: 30 yr female presented with reccurent episodes of upper abdominal and lower chest pain since past 2 years. Her endoscopy, Manometry, PH merry ,ultrasound EUS ,CT abdomen ,porphyria and autoimmune workup was normal.CT angio revealed compression of Celiac origin with hook shape deformity and post stenotic dilatation suggestive of median arcuate ligament syndrome. She underwent Laparoscopic release involves dissection of the splenic, left gastric and common hepatic artery till celiac origin and division of crus to expose supraceliac aorta . Both windows are joined by meticulous dissection and in the process the tight band of median arcuate ligament crossing the aorta and compression of celiac origin from above is divided to completely free the celiac origin.
Interesting images December: Disseminated hydatidosis: 58 yr old male underwent emergency surgery for ruptured hydatid cyst 5 years ago. No details of benzimidazole therapy at previous surgery. Now presented with extensive abdominal hydatidosis involving liver (including a large caudate lobe hydatid) ,spleen, pancreas sub diaphragmatic , omental , pelvic and paracolic. We started on albendazole for 1 m but in view of recurrent saio related to peritoneal and omental hydatid we did an extensive debunking including a partial pericystectomies of liver and lesser sac hydatid, omentectomy, excision and peritonectomy for for paracolic and pelvic hydatid. Patient is doing well now 3 months after surgery he is planned for 6 cycles of albendazole with 14 day breaks( literature shows no benefit beyond 6). Reviewing literature in patients with free peritoneal rupture of hydatid in addition to benzimidazoles using praziquantel 600 mg thrice a day can be added as an additional scolicidal to decrease subsequent disseminated hydatidosis. It can act on free scolices but does not penetrate the cyst wall once formed.
Bariatric surgery in senior citizen: At an age of 65 with Mrs V from warangal was 120 kg with a BMI of 42 and suffering from uncontrolled diabetes , bilateral knee osteoarthritis and breathing difficulty. She approached the Pace obesity and metabolic surgery team..She was offered a gastric bypass but underwent a sleeve gastrectomy with Pace team led by Dr Phani Krishna Ravula . With a smooth recovery she is now 5 months post op with 27 kg weight loss and rid of all her medical issues with normal blood sugars.
The Pace bariatric unit recently performed a Gatstric bypass surgery its highest weight 200 kg patient (BMI 58) and 40 YEAR old lady with multiple obesity related problems. Patient succesfully discharged by 3rd postoperative day. Success in such high risk patients requires concerted efforts of the surgical, anaesthesia critical care, dietician, nursing care and physical rhabilitation teams.in addition to specialised bariatric instruuments and bariatric operation tables and wheelchairs.Patient has lost 20 kg of weight in 2.5 months and is doing well.
Mrs PT from Hyderabad suffered from morbid obesity wt 132 kg (BMI 52) with issues of uncontrolled diabetes , hypertension needing 3 anti hypertensives , high cholesterol and triglycerides and bilateral knee pain. 6 months after gastric bypass by the Pace bariatric team led by Dr Phani krishna Ravula, she has lost 38kg weight and taken off all her diabetic, hypertensive and cholesterol medication with excellent quality of life
Central pancreatectomy involves removal of only the tumor bearing portion of pancreas after meticulously separating it from vessels. The distal pancreas is preserved in contrast to the standard distal pacreatectomy for students. This leads to better preservation of exocrine and endocrine function. If expertise in pancreatic surgery is available this operation in selected patients of cystic pancreatic neoplasms allows a better quality of life after surgery. Postoperative recovery was smooth. Biopsy revealed a serous cystadenoma of pancreas which heals excellent long term outcomes.
Radiofrequency ablation (RFA) is a adjunct for liver resection. In this process a Multipronged needle creates a sphere like zone of ablation around the tumor to completely destroy the tumor with a margin in a minor akin to a surgery. RFA is as good as surgery for tumors upto 3 cm and for 3-5 it needs to be combined with a modality like embolisation. its extremely useful in patients where surgery is not feasible such as with medical comorbidities, liver cirrhosis or when the tumor is so deep seated such that removing a small tumor entails removal of a major part of liver.
6 yr old child presented with pain right upper quadrant. USG suggestive of cystic multi spectral mass. CT done and diagnosed a Multiseptated mass involving Right lobe of liver. Diagnosed as a hydatid cyst of liver. However Review of the CT scan revealed several septae to be enhancing. AFP was normal. A diagnosis of mesenchymal hama romaine was made and a right hepatectomy performed. Mesenchymal hamartoma is a benign childhood tumor which is considered a developmental anamoly and may reach huge sizes.it is to be differentiated from hepatoblastoma which is associated with raised AFP and solid/ necrotic component.
32 year old female with recurrent episodes of abdominal pain since past 3 years was found to have a 6 cm cystic lesion in body and tail of pancreas. Initially thought to be a pseudo cyst due history of recurrant pain. CT showed no evidence of calcification or ductal changes. EUS revealed thick mucinous contents. Mucinous cysts of pancreas are unilocular cysts with malignant potential . They can range from benign to borderline to malignant. Diagnosis is by CT scan and cyst fluid analysis. This patient was managed by a laparoscopic distal pancreatectomy with splenectomy (as solenic vein was inseparable)
Interesting case: 60 year old male with HCV related well compensated CLD , Childs A status with normal platelets and no varies on endoscopy. presented with HCC involving segment 4, 5 and 8. As we see in imaging option was Rt trisectionectomy which would have been too risky. As right hepatic vein was free. We performed central hepatectomy in which segment 4, 5 and 8 are removed preserving the right posterior segment are preserved.In this unique parenchyma preserving operation the segment 4 and RT anterior pedicure are divided by glissonian approach and MHV is divided. RHV is preserved by CUSA dissection. there by despite central location of tumor enough parenchyma is preserved for safe recovery.it's a very rare and complex surgery only my 3rd in 10 years.
A small celebration with patient and our team at discharge of our 50th pancreatic cancer resection patient in 2 years at PACE hospitals including 35 whipples resections and other types of pancreatic resections. Highlights of this journey have been. A successfully discharged whipples operation in a 89 year old gentleman from East Godavari. Several of our patients were more than 75 yrs. I strongly believe age is just a number and no patient should be written off just based on age without considering physiological status.A remarkable story of whipples with portal vein and hepatic artery resection in a young woman with a 9 kg pancreatic tumor (SPEN) . She underwent a surgery outside where she had massive bleeding due to colletarals . 10 units blood given abdomen was packed and shifted to us for further care. After a 10 hr grueling operation We removed the tumor 2 yrs ago and today i got the good news that she just had a baby boy this morning.
Spyglass cholangioscopy : Genuine indications for spy glass scopy are few. The patients in whom diagnosis is not established by standard investigations such as CT scan , MRCP and EUS guided biopsy and in whom the decision for surgery or further intervention depends on biopsy. This was an interesting case of a 70 year old lady with secondary sclerosing cholangitis of unknown etiology for which our gastroenterology team Dr Govind Verma and Dr Vamshidhar Reddy did a spy glass scopy and biopsy followed by ERCP stenting. Biopsy and histology followed by IHC were suggestive of MALT lymphoma.which completely alters the complete managment plan of the patient. This case illustrated the defining role of spyglass in altering managment plan of selected patients with hepatobiliary and pancreatic tumors.
Major Liver Resections made safer by preoperative portal vein embolisation. 62 year old male with Hepatocellular carcinoma involving segment 4, 5, 6,7 and 8. Approximately 75% of the liver was involved by the tumor.By standard approach the remnant liver 25% (left half) would not be sufficient and lead to high risk of liver failure and death. By preoperative portal vein embolisation (blocking blood supply and nutrition) of the right half of liver the left half was made to grow before surgery so that after resecting the tumor the liver remnant is approximately 40% . By this approach supra major liver resections (removing more than 70% of liver can be safely achieved in even in elderly patients. This patient had a smooth recovery and was discharged by POD7.
Carcinoma gallbladder- 67 yr old lady with polypoidal mass growing gradually over past 3 years. underwent a radical cholecytectomy with 2 cm liver wedge and extended lymphadenectomy of hepatoduodenal, retropancreatic, common hepatic and celiac LN. biopsy revealed papillary adenocarcinoma with no LN involvement. papillary Ca GB has a better prognosis compared to the more common infiltrative variant where resctability rates and outcomes are poor.fundus and proximal body masses may be treated 2 cm wedge or segment 4b and 5 resection while neck masses infiltratate the hilum early , presnt with jaundice and need major liver resections with biliary reconstructio. and poor survival rates.
80 yr old male 10th day after hepatectomy for Rt lobe HCC (liver cancer). No one looking at him will believe he is 80. I requested to share his story to inspire us. The general tendency among people including cancer specialists is to write off patients based solely on advanced age. But like I keep repeating age is just a number. Every patient needs to assessed induvidually. A 60 yr may not be fit for a haircut while a 90 yr old may be fit for a whipples or liver resection (as was the case last year with one of our patients). its the physiological age and frame of mind which matters more than the chronological age. And this is not just in hepatobililiary surgery but in every aspect of life.