Wednesday, February 29, 2012

CASE: HEPATOBLASTOMA in adolescence female- left hepatectomy

15 yrs female with vague pain in epigastric region
O/E : large 15 x 12 cm mass palpable arising from liver left lobe, hard, nontender.
NO Anorexia, No wt loss.
AFP, CEA,CA 19.9, CA 125 Were normal

CT / MR Abdomen angio:
s/o malignant liver mass from segment 3, hanging in nature with doubtful lesion in seg 4b as well.







SURGERY: Left hepatectomy with excision of seg 4b lesion, DURATION: 4.5 hrs. No blood transfusion required..and pt was shifted to ward post operatively..








was discharged on POD 5, With normal diet, and without any undue complication..

HPE : IHC S/o Hepatoblastoma, node negative, resection margins free of tumor..
pt subjected to adjuvent chemotherapy to totally eradicate the disease..

Tuesday, February 28, 2012

CASE: Corrosive esophagial stricture - esophago colo plasty

14 yrs girl with accidental ingestion of corrosive poison before 3 yrs..was kept on dilatation for initial years and feeding gastrostomy... grade 4-5 dysphagial with undilatable esophagus and long stricture for last one year..

SURGERY: Esophago colo plasty (retrosternal condute, based on LCA)





dye study on POD 5 demonstrated no leak.


was started on oral liquids to semisolids..and discharged on POD 7. After one month feeding gastrostomy was removed as patient gained 2 kg wt with taking normal diet orally..and back to school on day 20.

Monday, February 20, 2012

CASE: Infactive bowel gangrene- RA

Middle aged male with severe pain in abdomen for 2 days with nausea and vomiting
and abdominal distension.
Known DM case for last 5 yrs on OHA.
NO H/O HTN.
or surgery in past...or other medical disease.
presented with shock and hypotension not responding to fluid challenge..and started with inotrops..and low urine output

CECT: S/O intestinal obstruction...with terminal ileal ishcemia?

SURGERY: Exploratory laparotomy and resection of Gangrenous bowel. and jejuno ileal anastomosis..was done and discharged in time..without any undue complications.





Sunday, February 19, 2012

CASE: Chronic pancreatitis - LPJ

Young male with severe pain in central abdomen for 6 months
recently detected DM
wt loss of more than 25 kg..with anorexia  and postprandial severe pain

Diagnosis of chronic pancreatitis was made after CECT & MRCP.

SURGERY: LPJ With Head coring.







pt discharged pain free after 5 days with normal diet.

Fibrolamellar carcinoma: a review with focus on genetics and comparison to other malignant primary liver tumors.



Source

The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, Mount Sinai School of Medicine, New York, USA. Stephen.Ward@mssm.edu

Abstract

Fibrolamellar carcinoma is a rare primary malignant liver neoplasm that usually affects adolescents and young adults with no underlying liver disease. Morphologically, the tumor cells resemble oncocytic hepatocytes arranged in cords with a stroma of lamellated collagen fibers. Immunohistochemical studies have found that fibrolamellar carcinomas express markers associated with both biliary (CK7 and epithelial membrane antigen) and hepatocytic (heppar-1and glypican-3) differentiation, as well as markers associated with hepatic progenitor cells (CK19 and EpCAM) and stem cells (CD133 and CD44). Genetic studies show fewer alterations compared with classic hepatocellular carcinoma. Pooled data from comparative genomic hybridization studies show that fibrolamellar carcinomas have fewer and less frequent genomic alterations when compared with classic hepatocellular carcinoma, cholangiocarcinoma, and hepatoblastoma. Of the alterations seen in fibrolamellar carcinoma, the most frequent are gains in 1q and 8q (also frequently seen in other hepatic tumors) and loss of 18q. Fibrolamellar carcinoma also has less frequent methylation of tumor suppressor promoters compared with hepatocellular carcinoma and minimal alterations in mitochondrial DNA. Fibrolamellar carcinoma is associated with better survival than hepatocellular carcinoma and cholangiocarcinoma, presumably due to the young age of the patients and the lack of cirrhosis. These features make more aggressive surgical therapy possible. There is currently very little information on the effectiveness of chemotherapy for fibrolamellar carcinoma.

Survival analysis for patients with hepatocellular carcinoma according to stage, liver function and treatment modalities

[Article in Korean]

Source

Center for Liver Cancer, National Cancer Center, Goyang, Korea.

Abstract


BACKGROUND/AIMS:

Hepatocellular carcinoma (HCC) is 3rd leading cause of cancer in Korea and the prognosis for HCC patients is poor. For assessing the present treatment outcome, this study analyzed the three-year survival rate (3-YSR) and the prognostic factors for patients with HCC in Korea.

METHODS:

Between November 2000 and December 2003, 905 patients with HCC who were diagnosed and treated at the National Cancer Center Korea were enrolled in this study. The clinical variables, tumor characteristics and survival periods were analyzed.

RESULTS:

The mean age of all patients was 56.2+/-10.3 years and 732 (80.9%) patients were male (M:F=4.2:1). 508 (56.1%) patients died and the median survival period was 15.3 months. The overall 3-YSR of the patients with modified UICC stage I, II, III, IVa and IVb were 67.4%, 65.2%, 30.7%, 9.0% and 5.0%, respectively. The modified UICC stage could not differentiate stage I from II, and stage IVa from IVb, on the 3-YSR. The 3-YSR of the Child-Pugh class A patients with modified UICC stage I or II was 85.4% by surgical resection and it was 69.6% by transcatheter chemoembolization (TACE), respectively (P= .461), and those values for patients with stage III were 49.2% and 36.8%, respectively (P=.081). As compared with systemic chemotherapy or conservative therapy, TACE increased the survival rate more for the Child-Pugh class A patients with stage IV. The independent prognostic factors were serum AFP, portal vein thrombosis, the Child-Pugh classification and the stage of HCC.

CONCLUSIONS:

This follow-up study will be helpful in assessing the results of treatments for HCC and it will provide data for the establishment of a more effective treatment strategy.

Wednesday, February 15, 2012

Surgical therapy of hepatic fibrolamellar carcinoma


2007 Jan-Feb;78(1):53-8.


[Article in Italian]

Source

Università di Pavia, Clinica Chirurgica I, Fondazione I.R.C.C.S. Policlinico San Matteo, Unità di Chirurgia Epato-Biliare. f.meriggi@smatteo.pv.it

Abstract

Hepatic fibrolamellar carcinoma (FLC) is an uncommon tumour that differs from hepatocellular carcinoma (HCC) in demographics, condition of the affected liver, tumour markers, and prognosis. FLC characteristically manifests as a large hepatic mass in adolescents or young adults with female predominance (mean age 23 years). Cirrhosis, elevated alpha-fetoprotein levels, and risk factors for HCC such as viral hepatitis are typically absent. FLC is usually associated with serum tumour markers such as vitamin B12 binding protein, and neurotensin. FLC is characterized pathologically by cords of tumour cells surrounded by abundant collagenous fibrous tissue arranged in a parallel or lamellar distribution. FLC usually appears on radiologic images as a lobulated heterogeneous mass with a central scar in an otherwise normal liver. The clinical presentation of patients with FLC is variable. These patients commonly have pain, and palpable right upper quadrant abdominal mass. An uncommon presenting sign is gynaecomastia in men. Use of percutaneous biopsy (FNAB) is beneficial if there is diagnostic uncertainty about the radiologic diagnosis (US, CT MRI). Although FLC is frequently recurrent, patients have a better prognosis than those with HCC, and aggressive surgical liver resection with extended lymphadenectomy or liver transplantation may be indicated. The presence of advanced-stage disease, direct invasion of adjacent organs, lymphadenopathy, or limited metastasis does not preclude attempts at curative resection. In inoperable cases, the patient may benefit from chemotherapy, permitting in up to 50% of these cases a curative resection. The case is reported of a 18-year-old man with bilateral gynecomastia secondary to an unknown hepatic fibrolamellar carcinoma producing oestrogens. Serum alpha-fetoprotein was negative; des-gamma-carboxy prothrombin (DCP) level was elevated. CT scan and MRI showed a solid hepatic tumour (theta 10 cm) without evidence of extrahepatic spreading. By a needle biopsy a fibrolamellar carcinoma was diagnosed. On March 1995 a right hemihepatectomy was performed. The postoperative course was uneventful and the patient recovered. Specimen's histologic examination confirmed the preoperative diagnosis. Intracellular (hepatocytes) oestrogens were found, but oestrogen and androgen receptors were negative. After surgery DCP and oestradiol levels rapidly decreased and gynaecomastia disappeared. A follow-up program was established. On April 2000 a probable recurrence within the caudate lobe was discovered by a liver CT scan without evidence of extrahepatic spreading. Tumour markers, FNAB, and bone scintigraphy were negative. On July 2000 the patient underwent second look laparotomy. Only a coeliac lymphadenopathy was found and a lymphadenectomy performed. Specimen's histologic examination showed a metastatic lymph nodal disease (FLC). The postoperative course was uneventful and the patient recovered. He is currently alive without evidence of recurrence 5 years after the second operation.

Monday, February 6, 2012

CASE: Achalesia cardia - lap haller's myotomy and anterior fundoplication

young male with dysphagia and 6 kg wt loss.
on Barium s/o achalesia


scopy : confirmed it


SURGERY: Lap haller's myotomy and anterior fundal wrap.



CASE: procedencia -- reduction & rectopexy

Middle aged male with procedencia ..for 1 day with inability for reduction.
history of rectal prolapse for15 yrs on and off

glycerene MGSO4 and surgar pack applied and external maual reduction tried but failed..

Surgery: Laparotomy and bi manual reduction with suture rectopexy





CASE: cholecysto duodenal and cholecysto colonic fistula with perforated GB

Elderly female with chronic pain in RHC, DM, HTN, IHD..
USG: S/O chronic calculus cholecystitis..1 yr back

presented with high grade fevere, pain in RHC, Nausea..

USG: S/o gangrenous perforated GB with peri GB Collection.

SURGERY: Open cholecystectomy with dividsion of cholecystoduodenal and cholecysto colonic fistula..lavagae and drainage..






Acute on chronic mesenteric ischemia: bowel gangrene..

Middle aged male known HTN,
Pain in abdomen for 5 days..progressive..with nausea, vomiting and distension and febal bowel sounds..
CT: s/o chronic infacrts in kideny, spleen..and acute gangrenous changes in small bowel..
2DECHO: s/0 35% EF with dilated RA/LV..And dilated descending aorta with small thrombus

Bolus heparin with later on infusion given..
next day taken up for surgery in view of downgoing abdominal conditions..
SURGERY: Gangrenous segment of jejunum resected and anastomosis done. pt was discharged in due time..