Sunday, April 22, 2012

Two staged hepatectomy in marginally resectable liver tumors

Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings

Annals of Surgery. 255(3):405-414, March 2012.
doi: 10.1097/SLA.0b013e31824856f5
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Objective: To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.
Background: Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.
Methods: Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery.
Results: The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197–444 mL). After a median waiting period of 9 days (range = 5–28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273–881 mL), representing a median volume increase of 74% (range = 21%–192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%–0.49%) to 0.61% (range = 0.35–0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60–776 days) with an estimated overall survival of 86% at 6 months after resection.
Conclusions: Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.

Efficacy of the Omental Roll-up Technique in Pancreaticojejunostomy as a Strategy to Prevent Pancreatic Fistula After Pancreaticoduodenectomy

Sae Byeol Choi, MD, PhDJin Suk Lee, MDWan Bae Kim, MD, PhDTae Jin Song, MD, PhDSung Ock Suh, MD, PhD;Sang Yong Choi, MD, PhD 

Arch Surg. 2012;147(2):145-150. doi:10.1001/archsurg.2011.865

Background  Most morbidity and mortality are caused by a pancreatic fistula after pancreaticoduodenectomy (PD), and its prevention is the major concern. We applied the omental roll-up technique around pancreaticojejunostomy and investigated the effectiveness of this technique to prevent a pancreatic fistula.
Design  Retrospective study.
Setting  Tertiary hepatobiliary and pancreas surgery clinic, Korea University Guro Hospital, Seoul.
Patients  Between March 1, 2009, and March 31, 2011, 68 patients underwent PD. The patients were divided into 2 groups according to the surgical application of the omental roll-up technique around the PJ site: group 1 (those who did not undergo the omental roll-up technique) compared with group 2 (those who did undergo the omental roll-up technique).
Main Outcome Measure  The occurrence of a pancreatic fistula.
Results  No differences were noted in the clinical characteristics, including patients' demographics and operation-related factors, between the 2 groups. A pancreatic fistula occurred in 23 of 39 patients in group 1 (59%) and in 6 of 29 patients in group 2 (20.7%). Group 2 had a significantly lower incidence of pancreatic fistula (P = .002), and these fistulas were classified as being grade A using the International Study Group on Pancreatic Fistula Definition showing a transient high amylase level in the drainage fluid without significantly affecting the patient's recovery. Drain removal was performed earlier in group 2 (P < .001). Mean postoperative hospital stay was 23.4 days in group 1 compared with 15.9 days in group 2 (P = .009). Overall mortality was 1.5%; however, no deaths were related to a pancreatic fistula.

Conclusions  The omental roll-up technique for the PJ site definitely reduced the occurrence of a pancreatic fistula. Therefore, the omental roll-up technique is a simple and effective strategy to prevent a pancreatic fistula.

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Randomized Clinical Trial of Total Extraperitoneal Inguinal Hernioplasty vs Lichtenstein Repair

A Long-term Follow-up Study
Hasan H. Eker, MDHester R. Langeveld, MDPieter J. Klitsie, MDMartijne van't Riet, MD, PhD;Laurents P. S. Stassen, MD, PhDWibo F. Weidema, MD, PhDEwout W. Steyerberg, PhDJohan F. Lange, MD, PhD;Hendrik J. Bonjer, MD, PhDJohannes Jeekel, MD, PhD 

Arch Surg. 2012;147(3):256-260. doi:10.1001/archsurg.2011.2023

Hypothesis  Mesh repair is generally preferred for surgical correction of inguinal hernia, although the merits of endoscopic techniques over open surgery are still debated. Herein, minimally invasive total extraperitoneal inguinal hernioplasty (TEP) was compared with Lichtenstein repair to determine if one is associated with less postoperative pain, hypoesthesia, and hernia recurrence.

Design  Prospective multicenter randomized clinical trial.

Setting  Academic research.
Patients  Six hundred sixty patients were randomized to TEP or Lichtenstein repair.
Main Outcome Measures  The primary outcome was postoperative pain. Secondary end points were hernia recurrence, operative complications, operating time, length of hospital stay, time to complete recovery, quality of life, chronic pain, and operative costs.
Results  At 5 years after surgery, TEP was associated with less chronic pain (P = .004). Impairment of inguinal sensibility was less frequently seen after TEP vs Lichtenstein repair (1% vs 22%, P < .001). Operative complications were more frequent after TEP vs Lichtenstein repair (6% vs 2%, P < .001), while no difference was noted in length of hospital stay. After TEP, patients had faster time to return to daily activities (P < .002) and less absence from work (P = .001). Although operative costs were higher for TEP, total costs were comparable for the 2 procedures, as were overall hernia recurrences at 5 years after surgery. However, among experienced surgeons, significantly lower hernia recurrence rates were seen after TEP (P < .001).
Conclusions  In the short term, TEP was associated with more operative complications, longer operating time, and higher operative costs; however, total costs were comparable for the 2 procedures. Chronic pain and impairment of inguinal sensibility were more frequent after Lichtenstein repair. Although overall hernia recurrence rates were comparable for both procedures, hernia recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was also significantly higher after TEP. Therefore, TEP should be recommended in experienced hands.

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A Meta-Analysis of Surgical Morbidity and Recurrence After Laparoscopic and Open Repair of Primary Unilateral Inguinal Hernia

Annals of Surgery:
May 2012 - Volume 255 - Issue 5 - p 846–853
doi: 10.1097/SLA.0b013e31824e96cf

O'Reilly, Elma A. MB, BCh; Burke, John P. PhD, MRCSI; O'Connell, P. Ronan MD, FRCSI

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Background: Laparoscopic inguinal hernia repair (LIHR), using a transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) technique, is an alternative to conventional open inguinal hernia repair (OIHR). A consensus on outcomes of LIHR when compared with OIHR for primary, unilateral, inguinal hernia has not been reached.
Objectives: Perform a meta-analysis of all randomized controlled trials (RCTs) comparing OIHR and LIHR for primary unilateral inguinal hernia. Outcomes were hernia recurrence and surgery-related morbidity.
Methods: A comprehensive search for published RCTs comparing LIHR with OIHR for primary, unilateral, and inguinal hernia was performed. Reviews of each study were conducted and data were extracted. Random effect methods were used to combine data.
Results: Data were retrieved from 27 RCTs describing 7161 patients. An increased risk in hernia recurrence existed when LIHR was compared with OIHR (relative risk [RR] = 2.06, 95% confidence interval [CI] = 1.26–3.37, P = 0.004). TAPP had equivalent recurrence (RR = 1.14, 95% CI = 0.78–1.68, P = 0.491) but TEP had increased recurrence of risk (RR = 3.72, 95% CI = 1.66–8.35, P = 0.001) relative to OIHR. LIHR was associated with greater perioperative complication risk than OIHR (RR = 1.22, 95% CI = 1.04–1.42, P = 0.015). TAPP (RR = 1.47, 95% CI = 1.18–1.84, P < 0.001) but not TEP (RR = 1.05, 95% CI = 0.85–1.30, P = 0.667) was associated with this increased complication risk. LIHR was associated with reduced risk of chronic pain (RR = 0.66, 95% CI = 0.51–0.87, P = 0.003) and chronic numbness (RR = 0.27, 95% CI = 0.12–0.58, P < 0.001) relative to OIHR.
Conclusions: For primary unilateral inguinal hernia, TEP is associated with an increased risk of recurrence relative to OIHR but TAPP is not. TAPP is associated with increased risk of perioperative complications relative to OIHR. LIHR has a reduced risk of chronic pain and numbness relative to OIHR

Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome

Annals of Surgery:
May 2012 - Volume 255 - Issue 5 - p 811–819
doi: 10.1097/SLA.0b013e318250504e

Gerstein, Neal Stuart MD*; Schulman, Peter Mark MD; Gerstein, Wendy Hawks MD; Petersen, Timothy Randal PhD‡,*; Tawil, Isaac MD§

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Objective: To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.
Background: For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.
Methods: We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.
Results/Conclusions: Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.


Old aged male with h/o trauma 8 months back and operated for resection of 3.5 feets of ileum due to mesenteric tare..developed low level fistula from wound....discharging pus...

Was not subsided even after 6 months of surgery...worked up again and fistulogram suggested communication with bowel..taken up Unfortunately scrapping...and biopsy...and some resection was done (exact data not available)  Bx was sent from the fistula site: s/o tuberculosis!!

Following this surgery presented after 20 days of hospital stay with bile discharging from main wound

TLC:  22,000 , And hypotension with tachycardia and distension

CECT : plain and oral contrast demonstrated leak near terminal ileum....

surgery: exploration and removal of of dead omentum, lump, debridment of obscess, Rt quarter colectomy and ileostomy and mucus fistula...wound healed and pt discharged on POD 7 to home.

on exploration, with chronic fistulous tracts and dirty abscesses...

after clearing , lavage and resection...the relatively healthy looking bowel

HPE: s/o  atypical tuberculosis with granuloma p/o M. Kansasi

pt now started on COMBINATION AKT.

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Timing of Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review

Annals of Surgery:
May 2012 - Volume 255 - Issue 5 - p 860–866
doi: 10.1097/SLA.0b013e3182507646

van Baal, Mark C. MD*; Besselink, Marc G. MD, PhD; Bakker, Olaf J. MD; van Santvoort, Hjalmar C. MD, PhD; Schaapherder, Alexander F. MD, PhD; Nieuwenhuijs, Vincent B. MD, PhD§; Gooszen, Hein G. MD, PhD*; van Ramshorst, Bert MD, PhD; Boerma, Djamila MD, PhD; for the Dutch Pancreatitis Study Group

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Objectives: To determine the risk of recurrent biliary events in the period after mild biliary pancreatitis but before interval cholecystectomy and to determine the safety of cholecystectomy during the index admission.
Background: Although current guidelines recommend performing cholecystectomy early after mild biliary pancreatitis, consensus on the definition of early (ie, during index admission or within the first weeks after hospital discharge) is lacking.
Methods: We performed a systematic search in PubMed, Embase, and Cochrane for studies published from January 1992 to July 2010. Included were cohort studies of patients with mild biliary pancreatitis reporting on the timing of cholecystectomy, number of readmissions for recurrent biliary events before cholecystectomy, operative complications (eg, bile duct injury, bleeding), and mortality. Study quality and risks of bias were assessed.
Results: After screening 2413 studies, 8 cohort studies and 1 randomized trial describing 998 patients were included. Cholecystectomy was performed during index admission in 483 patients (48%) without any reported readmissions. Interval cholecystectomy was performed in 515 patients (52%) after 40 days (median; interquartile range: 19–58 days). Before interval cholecystectomy, 95 patients (18%) were readmitted for recurrent biliary events (0% vs 18%,P < 0.0001). These included recurrent biliary pancreatitis (n = 43, 8%), acute cholecystitis (n = 17), and biliary colics (n = 35). Patients who had an endoscopic retrograde cholangiopancreatography had fewer recurrent biliary events (10% vs 24%, P = 0.001), especially less recurrent biliary pancreatitis (1% vs 9%). There were no differences in operative complications, conversion rate (7%), and mortality (0%) between index and interval cholecystectomy. Because baseline characteristics were only reported in 26% of patients, study populations could not be compared.
Conclusions: Interval cholecystectomy after mild biliary pancreatitis is associated with a high risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis. Cholecystectomy during index admission for mild biliary pancreatitis appears safe, but selection bias could not be excluded.

CASE: Strange case of duodenal third part perforation - close loop obstruction

22 yrs male with h/o corrosive ingestion 3 months back
with residual gastric and esophagial scaring

FJ was done for the same 3 months back..

patient presented with sever agonizing pain in abdomen for last 2 days with shock

P: 170/min BP: 70 systolic
resuscitation and
CT SCAN S/O : Retro peritoneal collection with free gas..and dilated duodenum and proximal jejunum till FJ site..distal loops collapsed   ? duodenal perforation

exploration: reveled the same a large perforation in D 3 Bellow the vessels with retroperitoneal sepsis.

primary closure , detwisting of jejunal loop , and a new feeding jejunostomy and drainage was done.

Fortunately pt survived..

Saturday, April 21, 2012

CASE: Chronic alcoholic pancreatitis with pseudocyst in head

Middle aged male with severe pain in central abdominal pain severe in intensity ,  for 6 months and 25 kg wt loss. DM II For last 6 months..

evaluated and diagnosed as Chronic alcoholic calcific pancreatitis with pseudo cyst in uncinate process of pancreas..


SURGERY: LPJ With head coring...

Patient discharged on POD 6. without pain.

Sunday, April 15, 2012

CASE: Multiple liver hydatidosis with biliary communication

Young boy with dull aching  pain in RHC region
CECT:; S/O multiple total three, one in seg 6, in seg4b, seg7. hydatid cysts with surrounding biliary radical dilation

PLAN: Pre op ERCP and stenting done

surgery for hydatid cysts 1 week later.

CYSTS Drainage and partial cysto pericystectomy op pt developed bile leak .But due to stenting leak healed in few days and pt was discharged on pod 8.

You Tube : Dr Keyur Bhatt

CASE: A surgery for chronic diarrhoea !!

old  age male with DM , HTN, IHD,
presented with h/o diarrhoea for more than 6 months..

rest all the work up was normal except two large diverticula in jejunam. which was detected since 2002.. but was asymptomatic...

CECT: S/O Two diverticula in jejunum  and Rt lower pole of kidney RCC (coincidentally detected)

Pt is allergic to Metronidazole and lots of other medicines..
all antibiotic trials were given along with probiotics as well with diatery messurement to reduce the diarrhoea...
which failed ultimately taken up for surgery.....and resection anastomosis was done....Along with partial nephrectomy by Urosurgeon...

post op he is relieved from his troubles....and doing great..

You Tube : Dr Keyur Bhatt

case: malrotation with obstruction and a case of Nephrotic syndrome

young male k/c/o nephrotic syndrome on steroids..presented with acute intestinal obstruction with distension....conservative trial failed to manage...taken up for surgery:

previously operated by pediatric surgeon at the age of 3 days for malrotation with obstruction.

SURGERY: Extremely difficult laparotomy more than 7 hrs with dilated gangrenous bowel loops densely 3.5  feets of gangrenous ileum was resected...and jejuno ileal anastomosis done single layer interupted...

fortunately healed on low albumin and on steroid with gangrene...and patient discharged home after 10 days...

CASE : SMA Thrombosis with ischemia -

Young male presented with acute abdominal pain severe in intensity with vomiting and distension, work up s/o acute thrombosis in SMA with more than 90% blcok in CT Angio


 Was kept conservatively and started on IV heparin..and gradually discharged over 5-6 days on oral anticoagulants and full diet.  was kept under close follow up as likely to develop stricture in coming 4-6 weeks

and rightly happened...presented with bilious vomiting after  6 weeks....was admitted and evaluated...found to have stricture in jejunum with dilated proximal bowel loops.... but by that time artery was totally recanalised...

surgery was done and discharged without any undue complication in 5 days..

You Tube : Dr Keyur Bhatt

CASE: Jejunal diverticular perforation at extreme of age with lots of drama

84 yrs male with pain in abdomen and fever with distension and diarrhoea.. HBsAg + ve.
however vitals stable with 76 pulse and 100/70 BP.
Operated for head and neck malignancy and post of chemoradiation 5 yrs back.

CT: S/O jejunal diverticular perforation with localized abscess.
Initial trial of Pig tail drainage was given considering age and other co-morbidity.

however pt failed to improve after 48 hrs and counts increased and pig tail started draining bilious fluid which initially was frank pus only. and  tachycardia as well.

was taken up for surgery with explained due risks...
surgery: went smooth and operated in only epidural anaesthesia and resection anastomosis of perforated jejunal diverticular segment was done..

post op was very dramatic :

pt remained stable for 3 days..gradually started on liquid diet..and was about to be shifted to ward..suddenly had cardiac arrest with Anterior wall MI. --- CPR for 5 mins..revived-- on ventilator...and inotrops...LMWH..Asprin..

gradually improved in 48 hrs and extubaed...started on oral diet..was again about to be shifted from ICU to ward.. now on POD 7..Suddenly had massive melena... Hb Dropped to 6 from 11. total 4 transfusion given..hemodynamics maintained, next day melena continued..another 3 transfusions given..

CECT ABDOMEN: and UGIE: Done s/o stress related severe gastritis and diffuse massive bleed from stomach.

PPI  infusion started and bleed gradually finally discharged walking to home on POD 14...

You Tube : Dr Keyur Bhatt

CASE: Perforated sigmoid diverticula with morbidly obese patient

Middle aged female with MORE than 45  BMI , DM , HTN
Presented with pain in abdomen lower back ache and diarrhoea...with distension..
CECT: S/O perforated Sigmoid colon diverticula with abscess in pelvic cavity

SURGERY : exploratory Laparotomy and resection of sigmoid and descending colon (diverticula barring segment) with intra op bowel lavage and colo rectal anastomosis and proximal diverting ileostomy. 

pt was kept on ventilator for 3 days post op and gradually weaned off..started on oral liquids by day 4 and sent home with minor wound infection on POD 13.

CASE: CA GB with jaundice

Middle aged female with gradually rising jaundice and pain in abdomen.

worked up and s/o cholangio carcinoma involving CHD with SOJ, was ERC And stented in Delhi..later on wroked up in TATA memorial and planned for surgery

Pt came to surat, was evaluated again and found to have CA GB. With SOJ. St stented. now jaundice came to normal.

Surgery:  Radical cholecystectomy with seg 4b , 5 resection of liver and CBD Excision with RYHJ & Lymphadenectomy. without blood transfusion.

Pt discharged on POD 7.

HPE: S/O moderately differentiated Adenocarcinoma of GB , With 1 node positive, liver, proximal and distal CBD margins free of tumor. T3,N1,M0.

Will be subjected to adjuvant chemotherapy.

You Tube : Dr Keyur Bhatt


CA G.B: routinely detected GB malignancy, mostly by imaging.

Missed Ca GB: detected during surgery, and missed during prior work up or imaging.

Incidental CA GB: cholecystectomy done and histology shows GB mailgnancy, or pt presents later on with features of CA GB after cholecystectomy, complete/partial.


60 yrs male presented with pain in rt upper quadrant following cholecystectomy done 2 yrs back in Bihar.
histology report of GB: not available.
USG/ CECT: S/o mass in liver bed, in seg 4b and 5. likely incidental ca GB.

CA 19.9: NORAML.

Surgery: COMPLETION radical cholecystectomy with liver resection and lymphadinectomy, With duodenal sleeve resection and port site excision. no blood transfusion was given.

pt was discharged on POD 6.

HPE: S/O well differentiated adenocarcinoma of GB, all resection margins are free of tumor, and all lymph nodes are negative..port site nodule positive for malignancy...

pt is now subjected to adjuvant chemotherapy.

You Tube : Dr Keyur Bhatt

Saturday, April 14, 2012

CASE: Multiple polyposis coli with ca colon

Middle aged male with recurrent colicky  pain in abdomen for more than 1 year,DM, HTN.

CECT: S/o growth near splenic flexure with dilated proximal large bowel.  and an enlarged single node near splenic flexure, rest NAD.

COLONOSCOPY: S/o non negotiable growth in splenic flexure, with two polyps in descending colon, bx taken.

Plan : Lap assisted redical left hemicolectomy and intra op proximal colonoscopy  to look for polyps..sos total colectomy..

SURGERY: LAP Assisted radical left hemicolectomy done, intra op proximal colonoscopy done s/o 9 more polyps in proximal colon of variable size and type. frozen sent from two of them..s/o moderate to severe dysplasia in both.

TOTAL abdominal colectomy done with ileo rectal anastomosis and proximal diverting ileostomy. 

HPE: T3, N1, G1 adeno ca  of colon, (1/16 nodes positive), all  11 polyps showed moderate to severe dysplasia.., ALL resection margins are free of tumor. 

pt discharged on POD 10. 

CASE: CA RECTUM WITH lower GI massive bleed with left Ca overy

65 yrs female with known HTN, presented at 11 pm  with massive Lower GI BLEED, hypotension , shock

P/A: reveled a huge mass in left flank arising from pelvis
P/R : Growth in upper rectum with ulceration and bleeding.

after resuscitation was taken up fro CT angio: which suggested a pseudoanurismal bleed from superior rectal artery crushed between ca rectum and left ca ovary.

PLAN: Emergency angiography and agioembolization of vessel. if unsuccessful --> surgery.

angiography failed to located bleeder..but vessel went in spasm and bleeding decreased..was taken up for rescue surgery next day early..

LOW anterior resection with left ovarian mass removal and descending colostomy, with high ligation of IMA.

Pt discharged on POD 9.

HPE: S/O well differentiated ca rectum and well diff. ca ovary with internal hemorrhagic necrosis.
T3,N1, IHC awaited..

pt subjected to adjuvant chemoradiation..


Middle aged male with pain in abdomen , distension, obstipation for 4 days
known case of DM / HTN on Rx.

Tachycardia, hypo tension at the time of presentation , CT DONE after resuscitation
S/o large bowel obstruction ? ca rectum, with colonic diameter more than 11 cm

Emergency colonoscopy done s/o tight growth in upper rectum, scope not negotiable, tube not passed

SURGERY: Emergency surgery : (T M E) Anterior resection with Hartmann's procedure, closing of distal stump, proximal diverting colostomy.
discharged on POD 8.

HPE: moderately diff. adeno ca rectum with 22/22 nodes positive, T3, N2. M0., All resection margins are free with distal being 7 cm away.

patient now subjected to adjuvant chemo radio..

You Tube : Dr Keyur Bhatt

Rev Med Chil. 2009 Mar;137(3):394-400. Epub 2009 Jun 15.

[Fibrolamellar liver carcinoma: report of two cases and review of the literature].

[Article in Spanish]


Instituto Oncológico Fundación Arturo López Pérez, Santiago,Chile.


Fibrolamellar hepatocellular carcinoma (FLC) is a rare histologic variant of hepatocellular carcinoma that appears most commonly in teenagers and young adults. The diagnosis is often made incidentally and surgical resection is the only curative treatment. Here we report two cases of incidental FLC involving a 19 year-old male, initially diagnosed with screening abdominal ultrasound, and a 14 year-old female that presented with abdominal pain. Diagnostic workup consisted of abdominal PET/CT and MR1 Imaging studies and tissue diagnosis was confirmed with percutaneous liver biopsy. Both patients were treated with radical liver resection/tumor excision. However, tumor recurrence was observed in both during short-term follow-up. The male patient was treated successfully with surgical treatment however the female patient succumbed top regression of disease.

You Tube : Dr Keyur Bhatt

Radiographics. 1999 Mar-Apr;19(2):453-71.

Fibrolamellar carcinoma of the liver: radiologic-pathologic correlation.


Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington DC 20306, USA.


Fibrolamellar carcinoma is a malignant hepatocellular tumor with distinct clinical and pathologic differences from hepatocellular carcinoma. It differs from hepatocellular carcinoma in demographics, condition of the affected liver, tumor markers, and prognosis. Fibrolamellar carcinoma characteristically manifests as a large hepatic mass in adolescents or young adults (without gender predominance). Cirrhosis; elevated alpha-fetoprotein levels; and typical risk factors for hepatocellular carcinoma such as viral hepatitis, alcohol abuse, and metabolic disease are typically absent. Fibrolamellar carcinoma is characterized pathologically by cords of tumor cells surrounded by abundant collagenous fibrous tissue arranged in a parallel or lamellar distribution. Fibrotic lamellae often coalesce to form a central scar. Fibrolamellar carcinoma characteristically appears on radiologic images as a lobulated heterogeneous mass with a central scar in an otherwise normal liver. Radiologic evidence of cirrhosis, vascular invasion, or multifocal disease--findings typical of hepatocellular carcinoma--is uncommon in fibrolamellar carcinoma. Imaging features of fibrolamellar carcinoma overlap with those of other scar-producing lesions including focal nodular hyperplasia (FNH), hepatocellular adenoma and carcinoma, hemangioma, metastases, and cholangiocarcinoma. FNH, in particular, may simulate fibrolamellar carcinoma, since both have similar demographic and clinical characteristics. Because some believe that radiologic diagnosis of FNH is possible, it is important to understand the imaging appearance of fibrolamellar carcinoma to avoid misdiagnosing this malignant tumor as a FNH.

You Tube : Dr Keyur Bhatt