CASE: ANURSM LIGATED DOUBLY SURGICALLY...DELAYED HEMORRHAGE IN A CASE OF LIVER TRAUMA ? PSEUDOANURISM OF Rt hepatic artery^-www.drkeyurbhatt.in*

HISTORY:

30 YRS male
h/o fall and liver contusion/hematoma 26 days back in Rajasthan
USG : s/o no e/o free fluid and only liver hematoma.
Rx conservatively...........
remained well till 14 days ...sudden increase in pain----CECT was done : s/o 11 x10 cm size liver contusion
no free fluid....conservative Rx....in 3 days sudden fall in Hb. with gross haemoperitoneum, shock, anuria, and renal failure with Creat progressed to  6.2
Explored---- liver laceration and 2 liters of hemorrhage drained....no active bleeding....drains kept...Repair of laceration tried near GB fosa.

PRESENTATION :

post op pt remained stable...on day 2 developed biliary fistula draining frank bile in both drains later localized to sub hepatic drain 200 ml / day.

remained stable for 12 days and was walking / tolerating oral normal diet, normal urine out put with creat of 2.5

suddenly 2 liter of fresh bleeding in drain no hemoperitoneum. resucitation given again after 3 hrs massive bleeding of 2 liters....and hemoperitoneum as well.

DIAGNOSIS: Rt hepatic artery pseudo anurism was suspected...... as CECT/MRI OUT OF question in view of on going ARF and Pt in Shock....

Explored cholecystectomy and Rt hepatic artery ligated 1.5 liters of hemoperitoneum drained...and all bleeding secured...abdomen closed with drains and repair of liver laceration....IN HOPE OF STABILITY.....

now as expected pt is confirmed having Rt hepatic artery pseudoanurism...and the sad part is that anurism has now taken supply from left hepatic artery and is still getting filled.......its of 1 cm in size (quite big for a segmental hepatic branch..3 times bigger)....all radiological options are out of question in view of previous life saving attampt and ligation of RHA....will require formal resection / doubble ligation on both side of anurism surgically.....

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CASE: Flo reed abdominal TB with millions of tubercles and adhesive mid small bowel obstruction^-www.drkeyurbhatt.in*

24 yrs guy with CEREBRAL PALSY.
pain in abdomen with distension for 7 days and constipation
conservative Rx given for a week....distension increased with frank obstruction and features of early sepsis...

CECT : showed mid small bowel obstruction with ascitis...

on exploration....kink at jejuno ileal inter phase with grossly distended jejunal loops....adhesiolysis done....

oooooooohhhhhhhhh

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Clinical resistance to Imatinib (Gleevec)^-www.drkeyurbhatt.in*

Unfortunately, the majority of patients treated with imatinib mesylate will develop clinical resistance to this
agent and eventual progression of disease. Much research has been focused on the predictors and potential mechanisms of the development of recurrence to targeted therapy. A review of 934 patients with advanced GISTs treated with imatinib determined that patients who developed early resistance (defined as resistance within 3 months of initiating therapy) were more likely to have lung metastases without liver metastases, low hemoglobin, and a high granulocyte count . On the other hand, prognostic factors for the development of late resistance (after 3 months of initiating therapy) were found to be a high baseline granulocyte count, large size of tumor, and nongastric primary.


Because progression eventually develops in a significant number of patients with GISTs treated with imatinib,
additional targeted inhibitors have been evaluated for the treatment of these patients. As yet, only sunitinib has been approved by the US Food and Drug Administration (FDA) for patients with imatinib-resistance or imatinib-intolerance. Sunitinib is a multitargeted agent, an inhibitor of tyrosine kinase, of KIT and PDGFRA/B and of the vascular endothelial growth factor receptors (VEGFRs)-1, -2 and 3, FMS-like tyrosine kinase-3 (FLT3), colony stimulating factor 1 receptor (CSF-1R), and glial cell-line derived neurotrophic factor receptor.

In any patient with advanced GIST who underwent targeted therapy, the treating physician should periodically reassess the potential operability, after the completion of a certain course of imatinib or other form of therapy. 

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Gastrointestinal Stromal Tumors (GISTs): An Updated Experience^-www.drkeyurbhatt.in*

Review article: Dig Dis Sci (2010) 55:3315–3327

summary:

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal tumors of the gastrointestinal tract. Over the last decade, GISTs have gained an extremeinterest, not only for surgeons but also for oncologists. The role of targeted therapy with tyrosine kinase inhibitors has revolutionized the care of these patients, and has made GISTs the paradigm for molecular cancer therapy. For patients with primary GISTs surgery is the treatment of choice. A combination of imatinib therapy and surgery may be effective in a subset of patients with metastatic or unresectable primary GISTs. Meanwhile, the advances in the understanding of the pathogenesis and treatment of these tumors may render feasible, in the near future, the advent of newer and more efficacious treatment options.

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Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in JAPAN^-www.drkeyurbhatt.in*

Int J Clin Oncol (2008) 13:416–430

The Japan Society of Clinical Oncology 2008


Toshirou Nishida · Seiichi Hirota · Akio Yanagisawa
Yoshinori Sugino · Manabu Minami
Yoshitaka Yamamura · Yoshihide Otani
Yasuhiro Shimada · Fumiaki Takahashi · Tetsuro Kubota

SPECIAL ARTICLE


Clinical practice guidelines for gastrointestinal stromal tumor (GIST)
in Japan: English version

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