Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer: Can It Be Diagnosed Preoperatively?

Background. Xanthogranulomatous cholecystitis (XGC) is often misdiagnosed as gallbladder cancer (GBC). We aimed to determine the preoperative characteristics that could potentially aid in an accurate diagnosis of XGC masquerading as GBC. Methods. An analysis of patients operated upon with a preoperative diagnosis of GBC between January 2008 and December 2012 was conducted to determine the clinical and radiological features which could assist in a preoperative diagnosis of XGC. Results. Out of 77 patients who underwent radical cholecystectomy, 16 were reported as XGC on final histopathology (Group A), while 60 were GBC (Group B). The incidences of abdominal pain, cholelithiasis, choledocholithiasis, and acute cholecystitis were significantly higher in Group A, while anorexia and weight loss were higher in Group B. On CT, diffuse gallbladder wall thickening, continuous mucosal line enhancement, and submucosal hypoattenuated nodules were significant findings in Group A. CT findings on retrospect revealed at least one of these findings in 68.7% of the cases. Conclusion. Differentiating XGC from GBC is difficult, and a definitive diagnosis still necessitates a histopathological examination. An accurate preoperative diagnosis requires an integrated review of clinical and characteristic radiological features, the presence of which may help avoid radical resection and avoidable morbidity in selected cases

Episodic Biliary Obstruction: Intrahepatic Biliary Cystadenoma

Biliary cystadenomas are rare, benign but potentially malignant, multilocular, cystic neoplasms of a biliary origin. They often present with non-specific symptoms. We present a rare case of an intrahepatic biliary cystadenoma causing luminal obstruction to the bile duct. Case report: A 32-year-old female with obstructive jaundice was evaluated and diagnosed as having a cystic lesion in the liver. With a preoperative differential diagnosis of a hydatid cyst, she underwent laparotomy and enucleation of the lesion. Intraoperatively, the tumor was found to be extending into the bile duct, which was occluding the lumen. This was excised and a bilioenteric anastomosis was done. Her postoperative period was uneventful and she was anicteric on follow-up. Conclusion: Biliary cystadenoma should be considered a differential diagnosis when radiologic imaging studies suggest a multilocular cystic hepatic lesion. Presence of jaundice in such patients should raise the suspicion of an intrabiliary component, the omission of which can lead to avoidable postoperative morbidity. [Arch Clin Exp Surg 2014; 3(4.000): 251-253

Transpancreatic Hepatomesenteric Trunk Complicating Pancreaticoduodenectomy

Context Standard celiac and hepatic arterial anatomy occur in approximately 60% of the patients; for the remaining, multiple variations have been described. A thorough knowledge of these anomalies is important in order to avoid unnecessary complications. In this report we describe one of the rarest arterial anomalies, a hepatomesenteric trunk supplying the liver. We attempt to elucidate its implications pertaining to the safe performance of a pancreaticoduodenectomy. Case report A 45-year-old male with a one-month duration painless progressive jaundice was evaluated and diagnosed as having a periampullary growth. Preoperative imaging did not suggest any arterial anomalies. Intraoperatively, the common hepatic artery was found to originate from the superior mesenteric artery. He underwent a pylorus preserving pancreaticoduodenectomy with a meticulous dissection and preservation of the aberrant hepatomesenteric trunk. His postoperative period was uneventful and is doing well on follow up. Conclusion Variations in hepatic and celiac arterial anatomy are common, and may not get picked up on preoperative imaging. A high index of suspicion in every patient along with a precise knowledge of the normal anatomy and awareness of the aberrant anatomy is a sine qua non to the performance of a safe pancreaticoduodenectomy.Image: Post pancreaticoduodenectomy-preserved hepatomesenteric trunk

Ultrasound Guided Fine-Needle Aspiration Cytology (FNAC) of Portal Vein Thrombus: A Novel Diagnostic and Staging Technique for Occult Hepatocellular Carcinoma

Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making. [Arch Clin Exp Surg 2014; 3(2.000): 129-132

Impact of Perioperative Enteral Immunonutrition on Infectious Complications After Major Gastrointestinal Surgery

Objective: To study the impact of perioperative, enterally administered whey protein concentrate on infectious complications after major elective gastrointestinal surgery in a tertiary care hospital. Materials and Methods: Prospective non-randomized study conducted from June 2008 and ndash;April 2010, which included 50 consecutive patients who underwent major elective gastrointestinal surgery for benign and malignant diseases. The primary outcome measured was the rate of infectious complications, and the secondary outcome was length of postoperative stay. Results: 50 patients were divided into two equal groups: Group 1 and Group 2 (n=25 each). One group received immune-enhanced enteral nutrition (IMEN) perioperatively, and the control group received standard enteral nutrition (SEN) during the same period. There were no significant differences between the two groups with regard to complications (P=0.26), either infective (P=0.76) or non-infective (P=0.65). There was no significant difference in the duration of postoperative stay (P=0.25) between the two groups. There was also no significant difference in the pre- and postoperative White Blood Cell (WBC) count, C-Reactive Protein (CRP), and albumin levels. However, a subgroup analysis carried out to identify malnourished patients in the immunonutrition group revealed significant reduction in the length of postoperative stay (P=0.03) but not the rate of infectious complications (P=0.20). Conclusion: Perioperatively administered immunonutrition did not decrease the incidence of postoperative infectious complications and the duration of postoperative stay. Malnourished patients given immunonutrition in the perioperative period showed a significant reduction in the length of postoperative hospital stay but not the incidence of infective complications. [Arch Clin Exp Surg 2014; 3(1.000): 16-25

A Modified Laparoscopic Technique for the Removal of Nonfragmentable Giant Gastric Trichobezoar

Bezoars are usually defined as collections of nondigestible matter that most commonly accumulates in the stomach and can sometimes extend to the small bowel. Trichobezoars are a rare entity which is most commonly observed in young psychiatric females with trichotillomania and trichophagia. Here, we report a case of giant gastric trichobezoar and a novel technique of laparoscopic removal in a 16 year old female with trichophagia. The giant gastric trichobezoar weighing about half a kilogram was removed en masse laparoscopically by a novel technique. She had an uneventful postoperative recovery and was discharged after psychiatric counseling

Postbiotics of Naturally Fermented Synbiotic Mixture of Rice Water Aids in Promoting Colonocyte Health

The eubiotic state of the gut microbiota is primarily brought about by various probiotic species that colonize the gut. It is becoming very clear that the probiotic-metabolite mixtures in the gut luminal milieu is central in establishing cross-kingdom signalling networks to maintain gut-multi-organ axes health. Culturally, different fermented foods and beverages have been regional staples since ancient times, and are known to be enriched with probiotics. However, regional variations including the environment, the staple food source (prebiotics), and fermentation methods, among other factors, influence the fermenting probiotic species. Fermented rice water (FRW), an economical, easy to make, simple beverage is a rich source of synbiotics. Therefore, consumption of fermented rice water allows for the intake of a variety of region-specific live probiotics. The secondary metabolites (postbiotics) present in such symbiotic mixtures may also contribute toward maintaining normal intestinal cellular functions. In this study, we highlight that regional staples such as rice consumed in their fermented form may hold promise in alleviating gut-related diseases. Our results show that simple overnight fermentation of cooked edible rice enables the growth of probiotic bacterial species belonging to the Lactic Acid Bacteria group (Leuconostoc lactis, Weisella confusa, Weisella cibacria, Lactococcus lactis, lactococcus taiwanensis, Lactobacillus fermentum, Lactobacillus nagelii, and Lactobacillus delbrueckii ssp. indicus). Metabolomic analysis of the overnight fermented and over two-nights fermented rice water identified more than 200 postbiotic metabolites. Our results show that postbiotics contributing to energy metabolism, gut-multiorgan axes, and microbial paraprobiotics are enriched in the overnight (~10 h) fermented rice water as compared to the over two-nights fermented rice water. Functional analysis via gene expression studies for nutrient absorption (mct-1 and mct-2) and barrier integrity (occludin and zo-1) reveals significant upregulation of these genes upon FRW treatment of HT29 colon cells. This study is a first-of-its-kind to demonstrate the proof-of-principle that postbiotics of naturally fermented rice water positively modulates colonocyte health

Biliary Cystadenomas: A Case for Complete Resection

Introduction and Objective. Biliary cystadenoma is a rare benign neoplasm of the liver with less than 200 cases being reported allover the world. We report a series of 13 cases highlighting the radiological findings and problems related to its management. Materials and Methods. Records of thirteen patients who underwent surgery for biliary cystadenomas, between March 2006 and October 2011, were reviewed retrospectively. Results. Majority of the patients were females (11 out of 13), with a median age of 46 (23–65) years. The most frequent symptom was abdominal pain (92%). Seven patients had presented with history of previous surgery for liver lesions. Five patients had presented with recurrence after partial resection for a suspected hydatid cyst and two after surgery for presumed simple liver cyst. Ten of the 13 patients had complete resection of the cyst with enucleation in 3 patients, 2 of whom in addition required T-tube drainage of the bile duct. There has been no recurrence during the follow-up period ranging from 3 months to 5 years. Conclusion. Biliary cystadenoma must be differentiated from other benign cysts. Hepatic resection or cyst enucleation is the recommended treatment option