Adult choledochal cysts….surgery better late than never

Choledochal cysts are focal dilations of the extra and/or intrahepatic bile ducts without mechanical distal obstruction. The cause is debatable ranging from intrauterine infections to abnormal reflux of pancreatic juices into the choledochus. A majority present by the first decade of life. The problem is functional obstruction to the flow of bile leading to stasis, stone formation, infection and pancreatitis. In a minority of cases the symptoms are vague and often mild in nature leading to misdiagnosis until adulthood. The prolonged biliary stasis can lead to persistent hepatocyte damage and eventually fibrosis and even cirrhosis. More importantly perisistent inflammation can result in metaplasia, dysplasia and carcinogenesis within the biliary tract. In fact more than half adults operated for choledochal cysts may contain malignancy. I recently operated a 55 year old man with jaundice and liver fibrosis who had abdominal symptoms for 15 years but never investgated until he developed jaundice. Fortunately there was no malignancy in the specimen.

Operation for choledochal cyst in an adult with jaundice and liver fibrosis

Uncommon pancreatic tumours…..when in doubt cut them out, procrastination is the thief of time

Neuroendocrine tumours are rare pancreatic tumours that may not produce symptoms until they assume a fairly large size. Sometimes they may be detected by the effects of the hormones that they produce in excess and by this time they may have metastasized and become inoperable. Some patients have these tumours detected incidentally and are fortunate enough to be eligible for potenially curative surgery. Notable examples being Steve Jobs (Apple CEO). I recently operated a young lady with such a tumour who was being managed conservatively for gallstones and hence had a follow-up ultrasound that detected the tumour.

Unusual pancreatic tumour

Intraoperative photograph with loop around neck of pancreas

Finally the farce (ie elections) is over! ….let’s get on with the real world

What a relief!! The charade's finally over

Its hard not to notice that since the beginning of this year, India has got nothing from its government and opposition except jingoism and hard-to-keep populist promises and that too in a financial meltdown. Its time the election commission took a hard look at whether all this mobilisation of resources and enforced virtual paralysis of administrative machinery in the name of free and fair elections and model code of conduct can be justified for an election that continued ad nauseum.

I have a theory, people voted for a status quo out of sheer boredom with the extended process and hoping it is not repeated sooner than it has to be. There is likely to be no change however badly the incumbent performs unless the term is extended to at least 20 years when the ennui wears off.

Liver metastasis from colorectal cancer…. not the end of the road.

I think its time the AJCC changes the nomenclature of stage IV colorectal carcinoma.

Metastasis to liver and/or lung  that are resectable cannot be included with peritoneal or bone metastasis.

Stage IV has an inbuilt nihilism that removes all hope in the mind of patients and more often that not his primary physician at least in India.

Transhiatal oesophagectomy in situs inversus totalis…no longer a contraindication

Right neck incision for esophagectomy instead of left

Mirror image organs in situs inversus totalis

Situs inversus totalis is a rare condition in which the orientation of abdominal and thoracic organs is in a ‘mirror-image’  to what is conventional arrangement.

Usually the arch of aorta (the largest artery) is right sided in such cases making it difficult to dissect the oesophagus (food-pipe) which lies close to it. In such cases thoracic dissection transhiatally is considered contraindicated and left sided thoracotomy ( surgical opening of the left chest cavity) is recommended. However thoracotomy increases post-operative pain and affects breathing in patients with poor lung reserve.

I recently performed transhiatal oesophagectomy in such a patient for oesophageal cancer…..probably this is the first such case done with this technique (transhiatal dissection).

Late presentation in GI cancers… too little too late

Gastrointestinal hollow organ cancers usually have vague initial signs…sad but true….one out of every three cancer patients I see has too advanced disease because they have neglected subtle signs.

Why is our health our lowest priority that we can never find to listen to our body till it is ready to quit on us?

Hello world!

Welcome to my blog

I shall be writing about the highly interesting field of gastrointestinal,hepatobiliary, pancreatic and liver transplant surgery with ocassional remarks about my views on the world around me

Enjoy