Twenty five percent of total liver volume (TLV) is considered as the ideal functional liver remnant (FLR) in major liver resections. In patients with macro-vesicular steatosis, early cirrhosis, and post-neoadjuvant chemotherapy (NACT), hepatocellular injury is common. In such instances, up to 40% of FLR may be required. So in cases of marginal FLR, pre-operative portal vein (PV) embolization or two-stage hepatectomy with PV occlusion is used. Both of which take up to 14 weeks between stages and 30% of patients fail to reach the second resection either due to inadequate FLR growth or disease progression. Associated liver partition and portal vein ligation (ALPPS) procedure has become the gold standard for those cases. A 57-year-old male presented with rectosigmoid growth + multiple right liver and segment 4B metastases. Post-NACT MRI showed interval progression of lesions. Preoperative CT (computed tomography) volumetric scan showed a FLR/TLV (future liver remnant/total liver volume) of 22%. Since patient received 10 cycles of NACT, ALPPS procedure was planned ahead of direct liver resection. Robotic ALPPS stage 1 sparing left lateral segment and 4A + anterior resection was done. We transected the parenchyma between the FLR and the diseased part of the liver with concomitant right portal vein ligation done robotically. CT abdomen done on POD7 showed hypertrophied left lateral segment. Second stage was performed on the eighth post-operative day with FLR/TLV increasing to 37%. Robotic ALPPS procedure for stage one is a safe and feasible technique in experienced centers with advanced robotic skills.
Introduction: Acute pancreatitis is a common presentation of acute abdomen in emergency room. Identifying the patients who might develop severe disease is a challenging task. Neutrophil-Lymphocyte ratio (NLR) is being used in various conditions to predict severity and same has been extended to pancreatitis. Materials And Methods:We did as retrospective analysis of patients admitted with mild pancreatitis during the period of March 2021 to July 2022 by comparing the NLR, BISAPscore in mild acute pancreatitis. Results:There were 26 patients admitted with mild acute pancreatitis during this period, 20 males and 6 females. They belong to mean age group of 39.07years (SD 12.54). Gallstone and alcohol were most common cause of pancreatitis. The mean NLR was 5.78 (SD 3.15). 20 patients had BISAPscore of 0. Conclusion: NLR is an economical, one time investigation that can be done at the time of admission which can predict severity of pancreatitis. However, optimal cut-off values are yet to be dened.
Multiple neoplasms in a single individual is not a common nding. Genetic, environmental, lifestyle and hormonal factors have been implicated in the development of multiple neoplasms. Periampullary carcinoma has been associated with colonic cancer, endometrial cancer, melanoma as a part of syndromic association. Distal cholangiocarcinoma has not been seen associated with any other neoplasms till now in the literature. Here we would like to report a rare case of distal cholangiocarcinoma along with adrenal adenoma and duodenal well differentiated neuroendocrine tumor.
Introduction: Minimally invasive approach has been widely utilized in gastrointestinal surgeries, even for patients with malignancy. However, laparoscopic resection for hilar cholangiocarcinoma is still not universally accepted and only a few reports could be tracked, due to the difficulty of performing oncologic resection and the lack of consensus regarding the adequacy of this approach. Accumulating experience in laparoscopic liver resections and extensive lymphadenectomy in laparoscopic Whipple surgeries enable us to successfully perform a totally laparoscopic resection and reconstruction in a selected patient with Bismuth IIIa type hilar cholangiocarcinoma. Methods: A 68-year-old man with right upper quadrant pain and jaundice was referred for evaluation. Computed tomography and Magnetic resonance imaging showed tumor obstructing the hepatic duct bifurcation and the proximal right hepatic duct, without main vessels involvement. A totally laparoscopic right hepatectomy with hilar lymphadenectomy and Roux-en-Y hepaticojejunostomy was performed. Results: The operative time was 420 min. Estimated blood loss was 400 ml, without the need for transfusions. Postoperative recovery was uneventful, and the patient was discharged on the 8th postoperative day. Final pathology confirmed the diagnosis of adenoma arising from bile duct. Surgical margins were free. Patient is well with no evidence of the disease 14 months after the procedure. Conclusions: Laparoscopic approaches for hilar cholangiocarcinoma seem feasible and safe in highly selected patients. Large, prospective studies with longer follow-up will be necessary to see the benefit and results of this approach over open surgery for hilar biliary malignancy.
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