Bile duct cholangioca

Two phenomenally satisfying cases on same day finished in a 12 hr stretch back to back without break.
Bile duct cholangioca status metallic stent placed else where with multiple reinterventions for stent block- an attempted EUS guided biopsy at same place led to a large hematoma with frozen anatomy . After meticulous dissection for hours in frozen planes we were able to do a bile duct excision with right hepatectomy with an extended lympahedenectomy ( as proximal margin was positive)
73 yr old high risk coronary artery disease patient with exophytic right lobe tumor with hepatic vein extending to IVC. Using a unique technique ‘No touch anterior approach ‘we controlled the IVC and right hepatic vein before mobilising the right lobe. Right hepatectomy with removal of IVC thrombus was performed

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Morbid obesity ( weight 106 kg ), uncontrolled diabetes

Mrs SB aged 62 years with morbid obesity ( weight 106 kg ), uncontrolled diabetes and large recurrent ventral hernia with 2 failed previous repairs. We performed Mini gastric bypass - weight came down to 62 kg in 8 months with resolution of diabetes. Subsequently she underwent Abdomnal wall reconstruction and component separation with abdominiplasty. She is doing well 1 yr after surgery. In addition to its beneficial effects on comorbidities, bariatric surgery is now considered mandatory in morbidly obese patients with hernias to prevent reccurance.

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Laparoscopic D2 Gastrectomy for gastric cancer

Laparoscopic D2 Gastrectomy for gastric cancer with specimen retrieval thru a 3 cm periumbical incision. In addition to less postoperative pain the faster recovery ensures patient is ready for chemotherapy by end of second week. Delay in starting adjuvant chemotherapy after cancer surgery has major impact on long term outcomes.

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A complex pancreatic surgery : CANCER WARRIOR

Mr NB age 62 y underwent Whipples pancreaticoduodenectomy with portal vein resection ( a complex pancreatic surgery) for advanced cancer of head of pancreas followed by chemotherapy. At 4yrs follow up he remains cancer free with an excellent quality of life and still continuing with a full time job.

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Gallbladder cancer :CANCER WARRIOR:

Ms RS aged 55 yrs underwent a radical cholecystectomy with enbloc colectomy for gallbladder cancer which is one of the most aggressive GI cancers. Post op chemotherapy and 6 years follow up later she leads an active lifestyle and remains cancer free which is equivalent to a complete cure.

Pace hospitals team successfully completed 100 BARIATRIC SURGERIES

With 3 Bariatric surgeries ( 2 MGB and one sleeve ) last week Pace hospitals team successfully completed 100 BARIATRIC SURGERIES with minimal morbidity , zero leak rates and zero mortality. Our 100 th patient was our units typical high risk patient at weight 180 kg and BMI 62 -super obese category. He presented with DM , COPD and obesity related cardiac failure for which he was on ventilator. After treating him with diuretics and weaning off ventilator to BiPaP gradually to room air. Our ICU and anesthetist team did a marvellous job of optimising him and getting him to table within 2 weeks . He underwent a sleeve Gastrectomy ( as a first part of his 2 stage surgery in view of his high risk) and had a smooth recovery. Many thanks to surgical, Anaesthesist, physcian , dietician, Physio, ICU teams for their tremendous contributions in reaching this landmark

Stent blocks, stent migration , segmental cholangitis

Preoperative biliary drainage in malignant Hilar strictures with PTBD or ERCP is fraught with high incidence of problems of stent blocks, stent migration , segmental cholangitis, abscess and peri PTBD leaks so much that most patients never reach the operative table becoming ‘biliary cripples’. There is clear evidence that preop biliary drainage may be harmful in periampullary but it was considered Mandatory for hepatectomy. There is now enough evidence to demonstrate that in high volume centres atleast left sided resections can be safely done with out biliary drainage in presence of jaundice without cholangitis. This is our second such pt 60 year old with intrahepatic cholangiocarcinoma with Type 3 B block and bilirubin 14 mg %. He underwent a left hepatectomy with caudate lobectomy and bile duct excision. Hepaticojejunostomy was performed to 3 ducts on a right side. Patient had a very smooth recovery and is fit for adjuvant chemo 2 weeks after surgery. This would have been very much delayed with our normal protocol of preop biliary drainage of Rt anterior and posterior and 3 weeks waiting causing all the biliary sepsis issues .

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Donor Liver transplant patient

Our first living donor Liver transplant patient at Pace hospital Madhapur premises completes 1 yr today uneventfully . He is back in his job and normal life for past 9 months. The Pace team together with Dr.Madhusudhan’s team have completed 25 liver transplant combined this year at Pace , Pratima , Osmania and SMS Jaipur.

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isolated polyp of stomach

Rare and unusual case of isolated polyp of stomach causing gastroduodenal Intussesption with gastric outlet obstruction. CT images show a polyp arising from fundus of stomach prolapsing to duodenum extending till D3 D4 junction. Biopsy was inconclusive but from our previous experience these prolapsing polyps are almost always non malignant. The lack of muscle infiltration allows funneling Intussesption of stomach. Patient underwent a greater curve gastronomy reduction of gastric funelling Intussesption followed by a sleeve Gastrectomy protecting GE Jn with a boogie. Postoperative histology shows puetz -Jeghers polyp. No evidence of small bowel or colonic polyps on CT enetroclysis and colonoscopy appears to be an isolated puetzjeghers polyp of stomach. Genetic testing results are awaited

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Type 3 A Hilar cholangiocarcinoma.

Type 3 A Hilar cholangiocarcinoma. Underwent left PTBD followed by extended Rt hepatectomy with caudate lobectomy bile duct excision and left portal vein segmental resection anastomosis. Similar to the long left hepatic duct allowing good bile duct margins for right sided resections the left portal vein also has a longer length and extrahepatic course allowing for technically simpler portal vein resection when needed . As it’s not feasible to differentiate peritumor desmoplasia seen in hilars from actual infiltration it’s preferable to resect the portal vein in doubtful cases to achieve -ve Circumferential margins. The left sided hanging manoeuver illustrated in Pic 2 is a useful tip to avoid injury to MHV/ LHV trunk during complete caudate resection.

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Laparoscopic liver resection for biliary cystadenoma

Laparoscopic liver resection for biliary cystadenoma @ Pace hospitals- using Enseal for parenchymal transection and endoGIA stapler white reload for left hepatic vein and glissonian pedicle control.

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Hemmorgagic complications of liver tumor

Hemmorgagic complications of liver tumor . Liver Tumor bleeds are usually managed by angio embolisation. But in selected stable patients surgery can provide definitive control of both bleed and tumor. We saw two such cases in last month.
Case1. Cystic lesion of liver with intracystic arterial bleed after aspiration attempted outside . Patient presented with anemia high grade fever and severe right upper quadrant pain. CT image (case1) shows active contrast extravasating. As she was hemodynamically stable she was taken up for definitive resection. Histology revealed neuroendocrine neoplasm of liver grade 1. dotatac pet after surgery was clear.
2. Adult male with a sub capsular tumor rupture and hematoma presented with anemia. CT showed left lobe SOL with large subcapsular hematoma. Patient underwent a left hepatectomy. Histology was suggestive of well differentiated HCC.

whipples with PV resection .

whipples with PV resection . In course of whipples PD- portal vein resection of the SMV- PV confluence involves need to ligate splenic vein with it attendant complications . One way to preserve the splenic vein is to remove a sleeve of portal vein with subsequent suturing leaving opposite wall intact . However sleeve can lead to kinking of PV, narrowing and angulation torsion issues during repair with risk of postoperative thrombosis. This is a simple variation of the sleeve by which can do a segmental resection anastomosis avoiding angulation , narrowing of anastomosis while simultaneously avoiding ligation / reimplantation of splenic vein.

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Esophageal cancer : Cancer survivor

Mrs RS aged 62 years underwent neoadjuvant chemo-radiation followed by a thoracoscpic Esophagectomy for esophageal cancer with our team 7 years ago. She is cancer free at 7 years and declared cured from esophageal cancer (the 5 yr rule) with a completely active life style .With newer neoadjuavant protocols , multimodality care and minimally Invasive surgery outcomes and cure rates are improving in these previously dismal cancers.

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Vascular Resections

HPB surgery combined with vascular resections are the most complicated areas of GI cancer surgery giving gratifying results in these difficult scenarios. It was a very satisfying week of complex HPB surgery at PACE HOSPITALS with three portal vein resections - one Main portal vein resection with Whipples for 8 cm giant SPEN in a high risk Pt with 35 % Ejection fraction and- an Extended Right hepatectomy and segmental portal vein resection for Type 3 A - An extended left hepatectomy with resection of portal vein confluence for Type 3 B Hilar cholangiocarcinoma respectively. Topped by a challenging central hepatectomy. The Whipples Pt and central hepatectomy pt were discharged by day 7 and both the Hilar cholangiocarcinoma pts are recovering smoothly.

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Whipples Pancreaticoduodenectomy

 Mrs AL 58 yrs underwent a Whipples Pancreaticoduodenectomy with us 5 years ago for pancreatic ( periampullary ) cancer followed by chemotherapy. She remains cancer free at 5 yrs which is equivalent to a complete cure for pancreatic cancer. 2 years back she presented with malnutrition secondary to pancreatic insufficiency which was subsequently corrected by adequate doses of pancreatic cancer enzyme supplements. This highlights the need for patients after pancreatic surgery to be under long term follow up with a gastroenterologist.

Bile duct exploration

Role of T-TUBE in CURRENT ERA. In current era -primary closure of CBD with or without an internal stent is the evidence-based standard of care after bile duct exploration. Despite this there are selected cases where a T-Tube is still used in our practise. This was one such patient with Type 3 mirrizi with a large CBD stone. In the MRCP you can appreaciate the CBD stone but the gallbladder is not visualised as it is tightly packed with stones and severely contracted. 
At surgery we did a choledochoplasty after preserving a small cuff of GB wall for the repair . But the posterior wall was sloughed off and extremely friable. So after doing the CBD exploration there is a very high risk of bile leak from the choledochoplasty site. In such cases where the CBD or the GB stump is not satisfactory due to poor tissues and high risk of bile leak we have found that a T-tube ensures a good decompression and leak free recovery. 
This patient underwent a lap CBD exploration and a T-tube brought out thru choledochoplasty so she had a bile leak free post op course. The check cholangiogram was normal. In our unit we still find T-Tubes still have a role to protect high risk suture lines in lap and open surgery in highly selected cases ( esp type 3 and 4 mirrizi with CBD exploration)

Liver transplantation

Living donor liver transplantation today @ Osmania General hospital after a long break of 9 months thanks to Covid. In the non- government sector we kept going even during past 12 months but restarting this in government was a different challenge. Kudos to Dr Ch Madhusudhan and his Osmania team for the effort and giving me the continued satisfaction of utilising my skill and knowledge for the needy.

Idiopathic chronic pancreatitis

 40 year old male with idiopathic chronic pancreatitis presented with intractable pain, sitophobia with severe weight loss ( adult male weighs 29 Kg) and history of reccurant episodes of GI bleed. He also has CKD (cr1.7) related to neurogenic bladder. Patient was shifted to us in shock with HB 3 gm % and massive GI bleed. MRI ( done outside ) and CT angio showed a large 6x5 cm Pseudoaneurysm in uncinate process probably arising from inferior pancreaticoduordenal artery causing hemosuccus pancreas . In view of CKD we chose to tackle aneurysm by direct glue embolisation of aneurysm sac to avoid the high volume contrast of conventional angio ( image) Pt was put on NJ feeds in view of severe malnutrition secondary to intractable pain and Sitophobia. Post embolisation 2 months later he came back with weight gain of 8 kg and a stable Hb%. His Rpt CT showed a persistent intrapancreatic head cyst with dilated pD in body and tail. The aneurysm cavity filled with glue cast has shrunk to almost one fifth the initial size. In view of large duct disease with Pseudoaneurysm we decided to go ahead with a Whipples pancreaticoduodenctomy . The post op specimen shows the intrapancreatic cyst and the glue cast of the aneurysm ( yellow arrow) His recovery was uneventful and is completely pain free post procedure .

Colon cancer

 Cytoreductive surgery with HIPEC for colon cancer. Traditionally for stage IV colorectal cancer resection has been a part of multimodality therapy for lung and liver metastasis but for peritoneal carcinomatosis palliative chemotherapy has been only option. Now in selected patients of advanced colorectal cancer with peritoneal disease - Pts with mucinous cancers, with low to moderate PCI in whom a complete cytoreduction is achieved , no small bowel involvement, good response to neoadjuvant chemotherapy - Cytoreductive surgery with Hyperthermic intraperitoneal chemotherapy offers superior disease free survival with upto 20-25 percent complete cure rates. This was one such 40 yr old carcinoma RIght colon with peritoneal disease with good response to 4 cycles of neoadjuvant chemo and PCI of 17. He underwent a colectomy plus peritonectomy complete cytoreduction with on table HIPEC.

Liver transplant

Successfully sending home our first Pediatric live donor liver transplant ( for Wilson’s disease) at Pace hospitals. It was a challenging experience as we did the transplant on April 4th in relative peace just a few days before the Covid tsunami hit Hyderabad. As cases rose exponentially to keep them safe we fast- tracked the donor and recipient discharges( discharged on D5 and Day 7 respectively) For 3 weeks we kept them totally isolated offsite with home sample collections and Dopplers at our day care center. Touchwood everything was smooth At 3 weeks ( after 2 weeks of offsite follow up) we are sending them back to their home town with a plan for home sample collections and online reveiws till the dust settles.

Pancreatic cancer

 Another cancer survivor 47 yr male 4 and half years after his surgery for pancreatic cancer. Chance of reccurance in pancreatic cancer is maximum in first two years and almost zero after 5 years follow up. But patients need long term follow up to manage pancreatic insufficiency which needs care with regular pancreatic enzyme and calcium supplements

Gallbladder cancer

. Unusual case of Left sided gallbladder with gallbladder cancer. Usually gall bladder cancer surgery involves Rt sided resections. This was an interesting case of 40 yr male with left sided gallbladder involving Rt anterior and left portal vein ( CT images) and causing sub segmental separation of Right anterior and segment 4 ducts (MRCP). The right posterior hepatic artery and right posterior branch of portal vein were free with right posterior bile duct blocked at hilum. Patient underwent a Rt posterior PTBD and left PTBD to bring down jaundice. Both PTBD were external as stricture could not be crossed .Following which he received 3 cycles of neoadjuvant chemotherapy to which he showed partial response. The unusual location of the galllbladder allowed us to do a unconventional surgery for gallbladder cancer- left trisectionectomy leaving behind an adequate Right posterior remnant. Patient had evidence of Chemo -associated steatohepatitis at surgery with prolonged cholestatsis after surgery which recovered in 4 weeks post op

Hepatectony for liver cancer

This lovely couple the husband 74 underwent Hepatectony for liver cancer 4 years ago and wife 67 overcame colorectal cancer for which she went through laparoscopic colectomy and chemotherapy 2 and half years ago. Both are leading a full life without looking back and active schedule managing their grandkids. With no evidence of any reccurance in both we expect them to have a long healthy life.

Type lll post cholecystectomy BBS with external biliary fistula

Another illustrative case of type lll post cholecystectomy BBS with external biliary fistula. The drain placed at postoperative rexploration (yellow arrow) was draining abt 600- 700 ml of bile even 4 months after surgery. One traditional view iin these patients to wait for definitive repair till the fistula closes so that biliary dilatation appears . After a mandatory 3 month waiting period for inflammation to subside and fibrosis to stabilise, this approach of prolonged waiting with high output fistula to close has detrimental effects of severe bile privation, fluid electrolyte losses and nutritional deficiencies. For example this patient with 4 month high output fistula had a INR of 4.5 due to VIT K malabsorption and reduced bone density. In these patients with a persistant high output fistula we have demonstrated in previous cases as well that an adequately wide hepaticojejunostomy can be created irrespective of dilatation . In the Hepp-couinad approach The size of side to side HJ anastomoses in post cholecystectomy BBS is determined by the length of the extra hepatic left hepatic duct and not by the severity of duct dilatation unlike in an end to side hepaticojejunostomy . In this patient with minimal dilatation and EBF draining 600-700 output per day as you can see we can easily achieve a more than 3 cm HJ anastomosis.

Reccurant episodes of abdominal pain

25 year old male presented with reccurant episodes of abdominal pain s/o subacute intestinal obstruction. UGI Endoscopy , enteroscopy , colonoscopy and CT abdomen revealed extensive GI polyposis with two large d4 polyps causing Intussesption with SAIO. He had perioral hyper pigmented macules and endoscopic biopsy was consistent with Peutz–Jeghers syndrome . Peutz jegher is an autosomal dominant disorder characterized by the development of hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa. Though polyps are essentially benign ; patients with the syndrome have an increased risk of developing carcinomas of the liver, lungs, breast, ovaries, uterus, testes and other organs . As polyps benign and extensively involve the entire GI tract, treatment is conservative limited to treating the symptomatic polyps avoiding sacrificing bowel . In our patient the largest symptomatic polyps at DJ flexture were removed through an enterotomy and stapled resection . The remaining large polyps were managed by intraoperative endoscopy and endoscopic polypectomy. Patient remains in annual surveillance

Advanced colon cancer

DOUBLE CANCER SURVIVOR ( colon and pancreatic)- Mr RR aged 74 underwent a colectomy for locally advanced colon cancer with my team 6 years ago. He received post operative chemotherapy and radiation therapy. 1.5 years had barely passed he was diagnosed with a periampullary cancer. With this sudden shock of a dual malignancy considering his age and major surgery ( whipples resection) most of his friends and family advised him against going for another round of surgery. But with strong support of his immediate family and an iron will bravely went ahead with a Whipples pancreaticoduodenectomy. Now 5 years after the Whipples surgery he continues to do great and leads an active life. 5 year cancer free post GI cancer in this group of colon/ pancreatic cancer is considered equivalent to a complete cure. God bless him with a long and healthy life.

Type 3 B hilar cholagiocarcinoma

THE STORY OF A MEDICAL MIRACLE : The Patient Mr PS was a 45 yr old hospital admin from near Nagpur who presented with a Type 3 B hilar cholagiocarcinoma with Jaundice bil 24 mg percent in 2016. He underwent a properative biliary drainage followed by a hepatic / bile duct resection and chemotherapy. 1.5 years later he presented with an elevated CA 19-9 (a tumor marker) >300. PET CT showed a solitary liver metastasis for which we did a microwave ablation. 3 months later his CA 19-9 doubled. He sought my opinion on phone from Nagpur I encouraged him to get worked up for palliative chemotherapy. But in my heart I had given up as patients with recurrence in cholangiocarcinoma have barely 6 month survival despite best efforts. I didn’t hear from him for another 18 months so I assumed the worst. To my surprise 3 years after surgery I found his file placed in front of me. I was expecting a frail, gaunt patient in the last stages of his battle with cancer walking in to the OPD. In walked Mr PS looking hale and hearty intact a bit plump . His only complaint was some rash on the chest and his CA19-9 was less than 10. His PET CT was normal . On enquiring when he had the recurrence he refused chemotherapy and went to a native medicine practitioner in Interiors of Rajasthan whose herbal medicine which he is taking to this day. Today he came to us on his 4 th yr follow up Visit he remains cancer free. We talk of percentages in 5 yr survival for the individual patient it’s all or none. Now what worked in this patient- 
A native medicine miracle ?, A patient’s faith ? sheer willpower of father with young children to live? A doctors silent prayer or was it some immunosurveliince induced tumor cell apoptosis. He is neither the first or only such patient I have had . I can quote stories of 5 -6 such cancer patients over my 18 year practise. The true answers we may never know but one take home for me was that even in the cynical world of today miracles do happen. Never give up hope guys .. maybe there could be a bit of magic just around the corner.

Chronic pancreatitis

 IZBICKI procedure for chronic pancreatitis: 40 year old male with ethanolic pancreatitis with a dilated duct in head region ( before PD stenting)with normal duct in body tail region.Despite optimal medical management and four ERCP stent exchanges in past 1 yr he presented to us with debilitating intractable pain in a daily basis for past 6 months. In traditional Frey’s we only do a head coring and simply lay open the duct in body and tail. But in this kind of patient with undilated duct ( post stenting) and normal duct with extensive calcification in body and tail we preferred to do the Izbicki procedure . Izbicki procedure is useful in patients with undilated ducts in whom not just the head the entire body and tail in cored out in a V fashion ( Pancreatic V resection) to ensure a saucerised cavity providing drainage of not just main duct but the secondary and tertiary ducts in the body and tail region. Our patient remains pain free 2 months post op . Our past experience as well as longterm results in literature reveal 70 percent pain relief in these traditionally difficult to treat group of patients.

Stage IV neuroendocrine tumor underwent a total gastrectomy

Cancer survivor-surgical innovations: 40 year old with stage IV neuroendocrine tumor underwent a total gastrectomy ( removal of whole stomach ) with liver metastatectomy 4 years ago. Normally removal of complete stomach which is the eating reservoir leads to severe weight loss and nutritional distrubances. In view of her age we performed a unique procedure called Hunt-Lawrence pouch with which we create a new stomach reservoir using 35 cm of jejunum ( small intestine). 4 years later she is not only cancer free but also nutritionally well preserved without any weight loss thanks to the Neo-stomach.

A hilar cholangiocarcinoma

65 year of man type 3 A hilar cholangiocarcinoma ( complex hepatobiliary malignancy) with deep jaundice
STEP 1 Left PTBD ( to bring down jaundice) 
STEP 2 portal vein embolisation to allow growth of the small remnant left liver 
STEP3 Right sided anterior and posterior PTBD to control persistent fever after initial intervention.
STEP 4 admitted for surgery covid positive CT CoRADs 5 managed medically 
STEP 5 after 3 weeks waiting and repeat covid PCR negative ( couldn’t wait longer for risk of catheter dislodgement while waiting )underwent an Extended Rt hepatectomy with caudate lobectomy bile duct excision Left hepaticojejunostomy 
STEP 6 despite all the trials& tribulations and 7 hr surgery patient had a smooth recovery discharged by D6. An extremely satisfying result in a very difficult malignancy and a super motivated patient.

Atypical giant hemangioma

Atypical giant hemangioma 30 x 25 involving left lobe almost occupying entire abdomen. As there was an associated diffuse nodular hyperplasia component (marked with red and yellow arrow ) we chose to go for a formal left hepatectomy . In in very large hemangioma such as this unless we expect technical difficulty in controlling inflow and out flow there no need for an arterial embolisation. In this case access to hilum was difficult but one we tackled the inflow during the course of surgery the hemangioma almost shrinks to half its size ( same effect as embolisation) and facilitates resection.

Chronic pancreatitis

Splenic vessel sparing distal pancreatectomy in setting of chronic pancreatitis is usually technically not feasible mostly due to frozen peripancreatic planes and associated splenic vein thrombosis. 40 yr old female presented with focal pancreatitis involving body and tail with PD calculi and a tight stricture in mid body - normal PD in head of pancreas she underwent a lap converted to open vessel preserving pancreatic resection after meticulously separating the artery (red arrow) and splenic vein ( blue) and pancreatic transection at neck ( yellow) . Avoiding splenectomy helps avoid OPSI and also post splenectomy thrombocytosis with its sequele like SMV thrombosis and DVT ( an under reported problem).

Liver transplant

Another Live-donor liver transplant last week at Osmania hospital during # covid times in my role a visiting consultant for liver transplant there. The logistics for a liver transplant during the current lockdown in a government setup is a huge task, kudos to my colleague Dr Madhu ,the OGH anaesthesia and GI team for rising up to the challenge. 1 week later both donor and recipient are doing well. A 10 hour operation in the present high risk covid environment notwithstanding, my voluntary work helping the poor HPB patients at both Osmania and Gandhi ( Hyderabads premier govt institutes) is something i have found extremely satisfying in past 5 years.

CLD with HUGE gastric varices

challenging emergency during the covid lockdown. Child’s A CLD with HUGE gastric varices uncontrolled by Endoscopic glue and attempted EUS coiling. One salvage option would be TIPSS with baloon vascular occlusion but due to logistics we went for modified siguira procedure . Splenectomy + Gastro esophageal devascularisation with anterior Gastrotomy and overseeing of gastric varices with pyloroplasty. Images show 1 CECT showing large gastric fundal varices. 2,3,4 Gastro esophageal devasc 5,6 Large fundal varices before and after oversewing.7. Anterior gastrotomy 8. Pyloroplasty . Postoperative recovery was uneventful

Multiple biliary polyps

60 year old lady diagnosed as High grade MALTOMA of stomach with multiple biliary polyps causing Jaundice and cholangitis  underwent spyscopy and stenting of bile duct by us. Patient underwent ChemoRT for Maltoma following which she underwent an emergency total gastrectomy done outside for massive GI bleed. Bile duct was not addressed at that surgery. Now 3 years later she came back with reccurant cholangitis with hilar stricture with blocked stent in situ. As ERCP access was lost we controlled sepsis by PTBD and then did a bilateral hepaticojejunostomy. The image1 shows the existing anatomy. To make another roux limb we transected distal to the 1st jejunojejunostomy (JJ) and made a double roux limb with another JJ. The first roux is for esophagojejunostomy (EJ) second roux is for Hepaticojejunostomy (HJ) (image 2 3 and 4) She had a smooth postoperative recovery. The bileduct was excised showed fibrotic stricture with no evidence of residual lymphoma.

Distal pancreatectomy

laparoscopic spleen preserving distal pancreatectomy ( WARSHAW TECHNIQUE) 35 yr old morbidly obese patient with a 4 cm mucinous cyst of pancreas confirmed by EUS cytology and CEA level. Planned for a laparoscopic spleen preserving distal pancreatectomy At surgery as the tumor was posterior and densely adherent to splenic artery and vein we opted for the warshaw technique. In this the short gastrics are preserved and a segment of splenic vessels ( art & vein) along the resected pancreas are excised removing them at body and again at splenic hilum (as depicted in video). This way spleen is preserved with blood supply based on the short gastrics avoiding the sequela of asplenia such as thrombocytosis and OPSI. The patient had a smooth postoperative recovery.

Recurrent cholangitis

Oriental cholangiohepatitis is characterised by recurrent cholangitis and calculi within the intrahepatic bile ducts, biliary strictures and an increased risk for cholangiocarcinoma. Patients with both lobes involvement need transplant eventually due to secondary biliary cirrhosis. but in patients with segmental Disease can be cured with resection. Segmental involvement almost always involves the left ductal system in patient it is unusually Rt sided disease. This 55 year old presented with hepatolithiasis and choledocholithiasis and cholangitis for which she underwent stenting . Her MRI shows extensive hepatolithiasis on Rt side with stones forming a cast and dilated CBD with stones . Her left ductal system is mildly dilated due to CBD stone with no strictures or Calculi. We perfomed a Rt hepatectomy with hepaticojejunostomy .The cut ends of the Rt bile ducts show the grossly dilated Rt system with the cut surface of the liver showing the stones forming a cast of bileduct. The left lobe is drained by hepaticojejunostomy just below the confluence.

Distal pancreatectomy with splenectomy for large pancreatic tumors

In large pancreatic tumors (such as SPEN, Mucinous tumors) where the access to splenic vessels is not possible the antegrade approach allows safe surgery without risk of injury to the major vascular structures i.e celiac , common hepatic artery and the SMV portal vein axis. The GDA is divided and pancreas is transacted at neck to expose the junction of splenic vein with SMV portal vein axis . Likewise the common hepatic artery is dissected till celiac origin and then traced onto splenic artery. so that the celiac and hepatic arteries are safegaurded in the distorted vascular anatomy by large tumor size. Only after dividing the pancreas and then dividing the splenic vessels at the origin safeguarding the CHA and SMV -PV axis the the resection can proceed antegrade along the prerenal fascia to achieve medial to lateral resection. For adenocarcinoma we proceed in same fashion but posterior to the anterior fascia (Radical antegrade modular pancreatico splenectomy-RAMPS approach)

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Succesful Revision of failed LPJ depends on careful case selection

Succesful Revision of failed LPJ depends on careful case selection. Not every patient having persistent pain after LPJ can be resolved by revision. Only patients with reccurant pain and imaging suggestive of - inadeqately drained PD in body tail and /or inadequate coring of head with significant ductal stone load will respond to revision surgery. In this case- CT scan reveals mostly undrained duct in body and tail with stricture and stone at neck and PD disruption at neck. Like wise the jejunal limb stops at the neck indicating the head is completely undrained.  After dismantling the anastomosis only pinhole opening in PD (6)is seen showing severe stenosis of an already small anastomosis. The entire PD is laid open with head coring and a 12 cm anastomosis is achieved (7-11)The previous jejunojejunostomy is retained. We have done 4 revision LPJ in such very carefully selected patients with excellent results. This case also illustrates the importance of doing a wide drainage of duct and head coring during LPJ as a short anastomosis may have temporary relief but will inevitably stricture in long run.

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Reccurant severe post prandial central abdominal pain

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 (image 4,5 &6) 
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.

Gastric Cancer

Miraculous story of a blessed 60 year old from Siddipet who presented to us with advanced gastric cancer involving pancreas and spleen. Advanced gastric cancer ( poorly differentiated variety) has a traditionally poor prognosis with a median survival of 3 to 6 months . After inserting a tube to feed her we followed a strategy of 4 cycles of neoadjuvant (preoperative ) chemoradiation to which she responded beautifully . Subsequently we proceeded with a total gastrectomy with distal pancreatectomy and spelnectomy. Biopsy revealed a near total response to the chemotherapy. She is doing great 5 years after surgery with no evidence of reccurance which is equivalent for her to a complete cure. God bless her with a long and healthy life.

Grade 2 fatty liver Disease

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 . In our series of 6 central hepatectomies in diseased livers peak bilirubin has been 3.0 mg% with only one morbidity of bile leak in a patient and zero mortality (Results presented at AHPBA 2018) . These parenchyma preserving procedures allow safe hepatectomy in elderly with disease livers.

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Type 3 B hilar stricture and extending into bile duct

An unusual case of biliary cystadenocarinoma with papillary adenocarcinoma leading Type 3 B hilar stricture( involving secondary ducts in left side) and extending into bile duct . Patient underwent an extended left hepatectomy including Caudate lobe resection and bile duct t excision . hepaticojejunostomy was done to Rt anterior and Rt posterior ducts after a ductoplasty . intraop picture show the bileduct distended with tumor and left sided complete mobilisation of caudate lobe off IVC with control of common trunk of LHV and MHV. cut section shows the papillary tumor and the tumor extension into Lower bile duct . Caudate resection is mandatory in hilar tumors due to close approximation of the caudate lobe with Hilum as well as early tumor involvement of caudate bile ducts by hilar tumors.

Pancreatic transection

Grade 3 pancreatic injury causing complete pancreatic transection in mid-body of pancreas. In this kind of complete disruption seen on CT scan there is no possibility of bridging the gap with an ERCP stenting. Even if the patient is hemodynamically stable without bleeding. This leads to a isolated pancreatic syndrome in which the distal pancreatic secretions have nowhere to go leading to the cycle collections, pseudocyst , sepsis, pseudoaneuryms and if patient survives strictures duct in distal pancreas leading to chronic pancreatitis in the remnant. This patients with such a wide disruption and isolated pancreas are better served by a distal pancreatectomy at the initial presentation to avoid late complications.

Type 3 B hilar cholangiocarcinoma

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

Gallbladder cancer

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.

carcinoma rectum with synchronous colorectal metastasis

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

Type 4 choledochal cyst with hepatolithiasis underwent resection

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

Whipples Resection

This 12 yr old young man is one of our youngest Whipples ( the youngest being 8 years old) . He presented with a rare childhood tumor called solid papillary tumor 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, Recent 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. 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.

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Liver Cancer surgery

MICROWAVE ABLATION - AN IMPROVED TOOL FOR INOPERABLE HCC : 68 year old HCV positive male child’s B presented with 3x 3 cm HCC ( primary liver cancer ) in seg 1 and 5 of liver , 1 year after a previous laparoscopic surgery by us for 2 cm seg 2 HCC. Traditionally these lesions in Seg 1 of liver were not fit For RFA ( radiofrequency ablation) due to the heat sink effect from the neighbouring blood vessels . However microwave ablation uses electromagnetic waves to cause oscillation of water molecules causing frictional heating and tissue necrosis. It overcomes traditional disadvantages of RFA Which relies on impedance. It has been shown to achieve quicker , more complete ablation with better tumor response than RFA. Patient has been advised listing for transplantation.

Liver Cancer surgery

MICROWAVE ABLATION - AN IMPROVED TOOL FOR INOPERABLE HCC : 68 year old HCV positive male child’s B presented with 3x 3 cm HCC ( primary liver cancer ) in seg 1 and 5 of liver , 1 year after a previous laparoscopic surgery by us for 2 cm seg 2 HCC. Traditionally these lesions in Seg 1 of liver were not fit For RFA ( radiofrequency ablation) due to the heat sink effect from the neighbouring blood vessels . However microwave ablation uses electromagnetic waves to cause oscillation of water molecules causing frictional heating and tissue necrosis. It overcomes traditional disadvantages of RFA Which relies on impedance. It has been shown to achieve quicker , more complete ablation with better tumor response than RFA. Patient has been advised listing for transplantation.

carcinoma rectum with solitary liver metastasis

Cancer survivor: 70 yr old Mr R from east Godavari had carcinoma rectum with solitary liver metastasis which is actually stage IV disease . Traditionally stage IV cancer has extremely poor outcomes with survival in months. But by careful selection even stage 4 rectal cancer can be treated with a curative intent. Despite many people advising to contrary he put his trust in us and underwent a LAR (rectal cancer resection) with a liver resection 4 years ago. Today he came in for his annual check up before permanently migrating to Australia where his 2 kids reside. After the tests I cleared him as disease free at 4 years( 5 yrs equivalent to cure) and we shared this happy picture . May god bless him with a long and healthy life.

Idiopathic chronic calcific pancreatitis

Interesting images october : 45 year old lady with classical presentation of tropical /idiopathic chronic calcific pancreatitis presented with reccurant pain 6 months. Her CT scan showed dilated PD 12 mm with large calculi. CA 19-9 was normal, no evidence of biliary obstructuon, there was no evidence of a mass on CT scan. Underwent a freys LPJ with head coring   Day 3 the intraoperative biopsy came as adenocarcinoma. Normally with preoperative suspision intraoperative frozen would have been done but as it was unsuspected only biopsy was done. Once biopsy confirmed Patient was taken up for whipples on D5 after a detailed discussion of risks and benefits and staging CT Chest. Unciante was compeltely removed baring SMA and sparing accesory right hepatic artery (images 4) Reconstruction was done by LPJ to remnant pancreas ,HJ and antecolic GJ. This case highlights the high incidence of malignancy in 'tropical pancreatitis" and importance of sending head biopsies even in patients where malignancy is unsuspected preoperatively. Wether a frozen needs to be done routinely is debatable considering the costs and logistics.

Reccurant pyogenic cholangitis

Interesting images September: Reccurant pyogenic cholangitis (RPC) 67 yr old Bangladeshi lady presented with reccurant episodes of jaundice fever and pain for past 1 year. MRCP and CT scan showed left duct stricture with left sided IHBRD and CBD stones and atrophy of left lateral segment. As she 4 duct was also involved we did a left hepatectomy with hepaticoduodenostomy . Reccurant pyogenic cholangitis is a disease charecterised by multiple instances of biliary bacterial infection, hepatic abcesses , multiple stricturing of bile ducts with pigment stone formation in the intrahepatic and extrahepatic biliary tree. This can cause reccurant episodes of cholangitis, chronic illness ultimately leading to liver failure. It is more common in the far east population. Management includes long term biiary drainage with liver resections for segmental disease and liver transplantation in patients with end stage liver failure . The last CT scan shows another similar patient with huge intrahepatic stones and abscesses managed successfully by surgery and long term PTBD.

Liver Cancer survivor

Liver Cancer survivor : A story of a miracle.
This gentleman from west Godavari underwent a right trisectionectomy( removal of 80% liver) 4 years ago. It was a margin positive resection as tumor was adherent to left vein, meaning the cancer was present at surgical margin. That is a very bad sign and these patients have poor outcomes. After a tumultuous post operative recovery we were just relieved that we could send him home alive and when he was lost to follow up after first few months I suspected the worst. Imagine my surprise ( and Joy !!) when he turned up after 4 and half years later with an appendicular problem. I chided him for his poor follow up but was thrilled to bits when his CT showed no evidence of recurrence. God bless him with a long healthy life!

Pancreaticoduodenectomy with splenectomy

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 component .She is doing well post op but planned for adjuvant CT Rt as tumor had breached capsule and encased splenic vein. Total pancreaticoduodenectomy was previously 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

Liver cancer survivor

Liver cancer survivor: This 72 yr old gentleman came came for follow up after liver cancer surgery 4 years ago. At that time due to his age and small liver remnant he was told to be incurable by other centres but by using a special complicated technique called ALLPS ( first time in my career) we performed a safe surgery and here he is 4 years later with a healthy liver remnant and no evidence of recurrence.After a high risk surgery with all its attendent stress its extremely gratifying have such a pleasing result.


35 year female being treated as CLD underwent a diagnostic laparoscopy as she had normal lFTs and exudative ascites(5gm protein/dl). The laparoscopic revealed pseudo myxoma pertoneii of appendicular origin (low grade).Pseudomyxoma peritonei (PMP) is a clinical condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites. disease is most commonly caused by an appendiceal primary cancer (cancer of the appendix); mucinous tumors of the ovary have also been implicated. It is classifed into low grade diffuse peritoneal adenomiosis (DPAM)or high grade peritoneal carcinomatosis depending on the extent of cellular atypia and mitosis. Our patient had DPAM so se underwent a sugar baker procedure...parietal and pelvic peritonectomy , diaphramatic peritonectomy,omentectomy with liver capsulectomy. Plus visceral resections subtotal gastrectomy with enbloc extended Rt hemicolectomy, cholecystectomy, splenectomy, hysterectomy with bilateral salpingoophorectomy to completely debulk the disease. She also recieved introoperative HIPEC mitomycin based chemotherapy at 45 degree for 90 minutes with the Rand machine.postoperative recovery was smooth discharge by day 10. Histology confirmed DPAM of appendicular origin


Vascular anamolies of hepatic artery-accesory/ replaced right or left hepatic artery are seen in 50 % of population. However a completely replaced common hepatic artery arising from a superior mesenteric artery is a rare anamoly seen in less than 1%.
58 yrold With GB neck mass without jaundice was taken up for Rt hepatectomy. At surgery it was found that the neck had a long mesentery and no liver infiltration so modified to a radical chole with bileduct excision and hepaticojejunostomy.
Its a completely replaced common hepatic artery coming from SMA. I have encountered this anamoly 3-4 times during whipples. clue 1 is when you dont see the common hepatic artery crossing portal vein anterioly at the upper border of pancreas.clue 2 The hepatic artery seems to orginate from the groove between bileduct and portal vein. These two clues should immediately make us look for this anamoly 
Every surgeon must be aware of this rare anamoly.Unrecognised ofcourse... its a potential recipe for disaster in terms of liver ischemia and anastomotic problems.

Peritoneal disease on laparoscopy

Carcinoma GB large fundal growth with (suprisingly) no LN mets on PET and no peritoneal disease on laparoscopy. We did a radical cholecystectomy with seg 4B and seg 5 with extended lymphadenectomy of hepatoduodenal , retropancreatic, common hepatic and celiac LN. Cutsection shows growth limited to fundus with extensive liver infiltration.Once there is no M stage disease and no celiac or aortocaval lN involvement... for fundal growth.If its minimal infiltration we do 2 cm wedge...more extensive such as this patient we do a 4B and 5. However once growth involves the neck and cystic duct Rt hilum of liver is involved and a formal extended Rt hepatectomy with bileduct excision. However most such patients resectability rates and survival are poor. Hopefully this is one with good biological behaviour.

Liver cancer

80 yr old male 10th day after hepatectomy for Rt lobe HCC(liver cancer) . No one looking at him will believe he is 80. Irequested 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.

Carcinoma gallbladder

Carcinoma gallbladder- 67 yr old lady with polypoidal mass growing gradually over past 3 years. undewent 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.

Major Liver Resections

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.

Spyglass cholangioscopy

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

5 yr Cancer survivor

5 yr Cancer survivor: Had a reunion with this gentleman who underwent surgery for cancer head of pancreas in the setting of chronic pancreatitis(CP) with me.Cancer head of pancreas esp in setting of CP has a poor prognosis. But this gentleman after undergoing a whipples and chemo has crossed the 5 year milestone following which we can confidently declare him to be cancer free.
Obesity, smoking , alcohol and underlying chronic pancreatitis are risk factors for pancreatic malignancy.


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 succesfully 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 pateint 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 undewent a surgery outside where she had massive bleeding due to colletarals . 10 units blood given abomen was packed and shifted to us for further care. After a 10 hr gruelling operation We removed the tumor 2yrs ago and today i got the good news that she just had a baby boy this morning.
- A whipples in a high risk patient performed skin to skin in 2 hours (my personal record..though im not a proponent of 'Fast and furious ' surgeons)
-Few total laparoscopic pancreatic resections , 3 extended whipples with portal vein resections, unique parenchyma preseving central pancreatic resections (central pancreatectomy).
- adoption of 'PG binding' technique in last 20 whipples that has led to zero leak rate in our center and paper being prepared for scientific publication. 
Of course we had some difficulties and failures in this journey despite our best efforts and they taught us valuable lessons. I thank my gastroenterology collegues,aneasthetists intensivists, our staff my surgical team of young and eager surgeons who have taught me and learnt from me in this journey.

60 year old male with HCV related well compensated CLD

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 invoving 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 presercing 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 preseved 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.

Gastric cancer.

A 5yr survivor after  D2 gastrectomy for gastric cancer. Today shared the happy news that he is free from recurrence 5 yrs after surgery and can be declared as cured. He runs a garage in maharashtra with a wife and 2 daughters and came  assiduously for   followup every 3months for the past  5 years though I told him that such close follow up wasn't needed.

Cystic neoplasms of pancreas

Cystic neoplasms of pancreas 
32 year old female with recurrant 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 calcifications 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 s0lenic vein was inseparable)

Hydatid cyst of liver

A rare childhood tumor.
6 yr old child presented with pain right upper quadrant. USG suggestive of cystic multispectral mass. CT done and diagnosed a
Multispetated 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.

colectomy with resection

A brave heart who underwent a colectomy with resection of solitary liver metastases for colon cancer at a ripe 84 years and lived to tell 5 years later. Touching 90 but still young and playful at heart she is one of my favourite patients. No one will believe she's 90.

Chronic pancreatitis (CP) and maliganancy

Chronic pancreatitis (CP) and maliganancy
35 yr old patient with chronic pancreatitis presented with obstructive jaundice Bilirubin 25mg%. He had no history of pain. CT and Endoscopic ultrasound (EUS) did not pick up a mass. However based on high suspiscion due to very high bilirubin an intraoperative frozen section was done that showed malignancy . patient underwent a whipples pancreaticoduodenectomy.
Lessons learnt
1. Always screen CP patients for malignancy with annual imaging and CA 19-9.
2.Any new worsening in previously stable disease suspect malignancy
3. High bilirubin is a 'red flag' unlikely in inflammatory strictures so even if EUS CT inconclusive play cautious using frozen sections.
4. EUS is a very useful tool for preoperative decision making.

Advances in Liver surgery

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 mnner 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.

Extended whipples for ductal adenocarcinoma

Extended whipples resection done for a case of ductal adenocarcinoma of the head extending beyond the neck into mid body with the transection margin in the distal body at the level of splenic artery. The resection is started from the left of the portal vein by SMA first approach followed by dissection of splenic vein, splenic -portal Jn and portal vein in reverse order.
We can see the transection level of pancreas at the splenic arterial origin.Used judiciously extended whipples can help us achieve margin positive resection in these patients albiet with higher risk of diabetes postoperatively

Pancreatic cancer surgery

Second time lucky : An unresectable giant pancreatic tumor cured by a complex pancreatic surgery including hepatic artery and portal vein resection
25 yr old young software employee underwent attempted whipples (complex pancreatic surgery) for a 15 x15 cm pancreatic tumor unfortunately at surgery the tumor was found involving hepatic artery and portal vein ( the main blood supply of the liver) and she was told that it is incurable as the crucial blood vessels to liver were involved. 
However biopsy revealed solid papillary cystic neoplasm. This is a rare tumor that usually affects young girls, tumor does not respond to chemotherapy or radiotherapy and surgery is the only option. 
with no hope of cure and a large tumor occupying the whole abdomen with severe pain abdomen and vomiting.She came to PACE hospitals HPB unit with hope. After a detailed discussion about risks involved patient undewent a gruelling 12 hour operation (due to extensive vascular adhesions) of whipples pancreaticoduocenectomy with a resection and anastomosis of hepatic artery and portal vein. postoperative recovery was smooth
She continues to do well 1 yr after surgery getting back to her job and life.

Liver metastases indicates stage IV disease

Cancer spread to liver is not always the end of the road !

In Gastrointestinal or No GI malignacies (ovary,uterus, breast etc) the presence of liver mestastases indicates stage IV disease with poor survival. Neurendocrine tumors (and colorectal cancers) are an exception to this rule. Patients with neuro endocrine tumors have good 10 and 20 yr survival rates especially the well differentiated cancer. This was a patient with a neuroendocrine type I gastric tumor with spread to lymphnodes and a solitary liver metastasis who underwent a gastrectomy (removal tumor bearing stomach) with a D2 Lymphadenectomy (very extnesive lymphadenectomy) and non anatomical resection of liver metastases. We expect an excellent long time survival in this patient despite stage IV disease. other modalities like RFA of liver metasases and Trans arterial chemoembolisation are available for these patients now.

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Liver Resection

2 year girl with rare childhood liver tumor sucessfully managed with a major liver resection

Hepatoblastoma is a rare childhood tumor which usually occurs in children younger than 3 years of age. It is usually managed by surgery with chemotherapy before or after surgery. gita was a 2 yr old child with tumor involving right half of liver with elevated alfa fetoprotein suggestive of hepatoblastoma. Most of these patients usually present in a more advanced stage and are managed by chemotherapy followed by surgery. In case of gita tumor was involving on 4 out of 8 segments of liver so she was planned for a primary surgery. followed by chemotherapy. She undewent a surgery in which approximately 65% of liver was removed with the tumor. Post operative recovery was smooth. Kudos to the anaesthesist and critical care team for helping us accomplish this rare surgery in a young child.

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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 pnacreatectomy 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 has excellent longterm outcomes.

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