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Solid pseudopapillary neoplasm (SPN) is an unusual tumor of the pancreas. Unlike ductal adenocarcinoma, SPN is commoner in young women and is indolent with better prognosis. Fifteen percent of patients, however, develop metastases, often synchronous and involving the liver or peritoneum. Owing to the paucity of cases, management of the metastatic disease is not clearly defined. Retrospective review of case notes of patients treated between 2006 and 2019. There were 53 patients with SPN of which 4 had hepatic metastases-3 synchronous and 1 metachronous. Two patients underwent simultaneous distal pancreatectomy and splenectomy with liver resection (right posterior sectionectomy and metastasectomy). One required right hepatectomy with metastasectomy for metachronous liver metastases. The other underwent a staged operation-remnant tumor excision with metastasectomy followed by right hepatectomy after portal vein embolization. All four patients are recurrence free on median follow-up of 38.5 months. In view of the excellent prognosis, we recommend radical resection of both the primary lesion and metastases for SPN., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s), under exclusive licence to Indian Association of Surgical Oncology 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Intracholecystic papillary-tubular neoplasms (ICPNs) account for <0.5% of all cholecystectomies. There is a lack of significant published data from the Indian subcontinent on ICPN to the best of our knowledge. The objective of the current study was to describe the clinicopathological features of ICPN of gallbladder from the departmental archives during a 5.5-year period. We also aimed to classify them into various histological subtypes and to correlate the clinicopathological parameters of ICPN with invasive adenocarcinoma. This study included 36 cases diagnosed over a period of 5.5 years (2013-2018). Clinical, radiological and histopathological data were analyzed in detail. The incidence of ICPN was 0.8%. The mean age of patients was 45.7 years with a female to male ratio of 1.3:1. Biliary phenotype was associated with invasion (p ≤0.001). Papillary pattern was present in 15 cases (41.6%) and was associated with invasion (p ≤0.001). High grade dysplasia was seen in 34 cases (94.4%), of which invasion was seen in 18 cases (50%). One case in our study also had synchronous common bile duct carcinoma. Majority (92%) of the patients were alive and well at the end of available follow-up (mean of 7 months and 25 days). ICPNs are mass forming neoplasms of the gallbladder with a slight female predominance. Biliary phenotype has an aggressive course, often associated with an invasive adenocarcinoma component. Papillary configuration of the lesion is significantly associated with an invasive component. Diligent follow-up of these lesions is warranted as they can be associated with other malignancies of the biliary system., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Choledochal cysts are rare cystic transformations of the biliary tree that are increasingly diagnosed in adult patients. We report here a case of spontaneous rupture of a choledochal cyst in a pregnant young lady with chronic pancreatitis.

Context: Portal annular pancreas is a rare congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein/superior mesenteric vein. It is asymptomatic, but could have serious consequences during pancreatic surgery, if unrecognized. We describe a variant of this anomaly encountered during pancreaticoduodenectomy and propose a new classification., Case Report: We report a 51-year-old male who underwent a pancreaticoduodenectomy for periampullary carcinoma. After division of the pancreatic neck, a sheath of tissue was found posterior and extending to the left of the portal vein. When we divided this tissue, a large duct was encountered; this duct communicated with the main pancreatic duct. On review of the CT images, the main pancreatic duct was seen to be passing posterior to the portal vein and a smaller accessory pancreatic duct was present anterior to the portal vein. We describe the surgical implications., Conclusion: This variant of portal annular pancreas has not yet been reported during pancreaticoduodenectomy and we propose a new classification for this fusion anomaly.

Jejunal perforation is a known complication of abdominal trauma. We report two cases of jejunal perforation presenting nearly 2 months following blunt injury to the abdomen and discuss possible mechanisms for delayed small bowel perforation.

Inadvertent administration of enteral feed into an intravenous line is preventable usually by design of incompatible connectors, but these may not be available universally. We discuss a case report where this occurred and the subsequent management strategy.

A 28-year-old primigravida at seven weeks gestation presented to the Accident & Emergency Department complaining of vomiting for five days. She was admitted and managed as a case of hyperemesis gravidarum. Two days later she developed abdominal distension. Ultrasound scan revealed ascites and common bile duct dilatation. The ascitic fluid was bile stained. At emergency laparotomy spontaneous perforation of the supraduodenal part of the common bile duct was seen. This was closed around a T-tube. She then underwent medical termination of pregnancy. The post-operative T-tube cholangiogram was suggestive of a type I choledochal cyst. Three months later this was excised and biliary enteric continuity restored by performing a hepaticojejunostomy. To the best of our knowledge, spontaneous rupture of a choledochal cyst in a patient of hyperemesis gravidarum has not been reported before. In this article, we discuss treatment options for choledochal cyst during pregnancy.

Pancreatic tuberculosis is often mistaken for malignancy and can pose a diagnostic challenge. A high degree of suspicion is necessary to diagnose this condition which responds well to anti-tuberculosis treatment (ATT). Fine-needle aspiration cytology helps to differentiate malignancy from treatable conditions like tuberculosis. Records of four patients treated for pancreatic tuberculosis between 1997 and 2006 were studied. All patients had a pancreatic mass which was suspected to be malignant at imaging. The diagnosis of tuberculosis was established by FNAC in one case and after laparotomy in one; two had tuberculosis of other systems. All showed good response to ATT which included resolution of the pancreatic mass over mean follow up of 2 years. We suggest that all inoperable masses of the pancreas should be subjected to FNAC to rule out treatable conditions like pancreatic tuberculosis.

A 24-year-old man presented to us 10 days after suffering blunt trauma to the abdomen. He was diagnosed with pancreatic transection and underwent distal pancreatectomy and splenectomy. Two weeks after the operation, he developed intra-abdominal haemorrhage. Selective visceral angiogram revealed left gastric artery pseudoaneurysm, which had embolised. His recovery was uneventful. To our knowledge, ruptured left gastric artery pseudoaneurysm following pancreatic trauma, has not been reported before. In this article, we discuss some vascular complications of pancreatic trauma.

Background: Radiation proctitis is a common complication following radiation therapy for pelvic malignancies. This is associated with significant morbidity which adversely affects the quality of life. Local application of formalin has been used effectively in the treatment of radiation proctitis., Methodology: Thirty patients with haemorrhagic radiation proctitis who underwent endoluminal application of 4% formalin between January 1998 to October 2002 were followed up prospectively to assess the efficacy of the treatment., Results: The follow up ranged from 5 to 36 months (mean 18.1 months). Nineteen (63.3%) patients had complete response to formalin application while 7 (23.3%) patients had partial response. There were 4 (13.3%) failures. No procedure related complication was observed., Conclusion: Local application of formalin is a simple, safe, inexpensive and fairly effective outpatient treatment modality for chronic radiation proctitis.

This is a case report of a 29 year old woman who presented with painless and progressive obstructive jaundice. Imaging investigations of the abdomen revealed a tumour of the common bile duct. She was treated by complete excision of the bile duct and hepaticojejunostomy. The histopathology report of the tumour read as benign schwannoma.

Background: Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology., Methods: The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed., Results: The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months., Conclusions: Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

We report the case of a paraduodenal hernia treated by reduction of the hernia and closure of the hernial orifice.

Background: Mycobacterium fortuitum is an uncommon cause of soft tissue infections. Treatment is often inadequate with persistence of infection unless the aetiological agent and its antibiotic sensitivity are accurately established., Methods: Medical records of 23 patients with chronic soft tissue infection caused by M. fortuitum over a 12-year period from 1991 to 2002 were studied., Results: In 20 patients the cause was iatrogenic, following intramuscular injections (12), laparoscopy (5) and other surgical procedures (3) and in three patients discharging sinuses developed spontaneously. Patients presented with recurrent abscesses or chronic discharging sinuses that did not respond to conventional surgical drainage. The diagnosis was established by isolating M. fortuitum from the tissues in all cases. The treatment consisted of a more aggressive surgical intervention in form of excision, debridement and extensive lay open with curettage and prolonged administration of appropriate antibiotics. The organism showed maximum sensitivity to amikacin and ciprofloxacin. Healing occurred in all cases. Three patients suffered recurrences: two responded to further debridement and antibiotics and are well at 2 and 5 years, respectively., Conclusion: A high index of suspicion based on clinical presentation is essential to diagnose M. fortuitum as a cause of soft tissue infection. Treatment involves aggressive surgical debridement and administration of combination antibiotics based on sensitivity, which should be continued for a period that will ensure complete healing and prevent recurrence.

Cavernous haemangioma of the rectum is an uncommon cause of rectal bleeding. Initial diagnosis is often elusive because of lack of awareness. For accurate diagnosis, investigations such as endoscopy, plain X-ray of the abdomen, barium enema and selective angiography of the inferior mesenteric artery are required. Complete surgical excision of the haemangioma and colo-anal sleeve anastomosis is the most favoured operative procedure to eradicate the disease. We report a case of cavernous haemangioma of the rectum and discuss its salient clinical features, investigations and management.