How much to Push the Boundaries to Achieve R0 Resection : An Interesting Case Report

( Kunal Joshi ),( Sankar S. ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Tumors of the body and tail of the pancreas are often more aggressive that the tumors of the head and have often undergone metastatic spread to other organs at the time diagnosis. Pancreatic cancer arising in background of Chronic pancreatitis accounts for only 0.1-5% of all cases (Tropical pancreatitis : 8.3%.Hereditary pancreatitis : 40 -55%) Surgery is only indicated in those patients in whom there is no evidence of metastatic spread. Surgery is often not possible in cancers of the body and tail of the pancreas if the tumor invades celiac artery. Methods: 56 year old female with chief complaints of pain in left upper quadrant of abdomen since 2 months radiating to back and occasional vomiting on and off was evaluated. CECT abdomen revealed a mass arising from distal pancreas infiltrating the stomach, splenic hilum, left kidney, splenic flexure and the jejunal loop (LPJ loop) and entire pancreas atrophic and completely replaced by fat. Results: This patient underwent En Bloc resection of tumor with : 1.Distal Pancreatectomy with jejunal loop (LPJ) resection 2.Splenectomy 3.Left nephrectomy 4.Total gastrectomy 5.Segmental Colectomy with reconstruction by Esophagojejunostomy, Jejunojejunostomy and Colocolic anastomosis. Conclusions: The infrequent occurrence of tumor in the distal gland and advanced tumor stage at the time of diagnosis have both combined to produce therapeutic nihilism/dilemma in the minds of many surgeons. Multi-organ resection (En bloc resection with distal pancreatectomy, gastrectomy, splenectomy) should be attempted with the intent of achieving R0 status inspite of the complexity of surgery.

Preoperative Volume Rendering Can Pervent Intraoperative Surprises and Post Operative Catastrophe for Pancreaticodudenectomy

( Kunal Joshi ),( Sankar S. ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Pancreatic adenocarcinoma is one the leading cause of cancer related deaths all over the world. Pancreaticoduodenectomy is a complex surgical procedure used to resect tumours of the head of the pancreas, distal common bile duct, and duodenum. There is considerable anatomic variability in the arterial supply to this region and preoperative knowledge of the variants is important. Aim : The purpose of this study was to determine the benefit of preoperative Volume Rendering in predicting the arterial variants that cross the anticipated surgical resection plane in pancreaticoduodenectomy. Methods: Retrospective analysis of prospectively maintained database of 137 patients who underwent pancreaticoduodenectomy with preoperative CT abdomen with 64-MDCT over a period of 3 years. 3D Volume Rendering, Maximum Intensity Projection and Multiplanar Reconstruction were used for evaluation to determine anatomical variation. Results: Out of 137 patients, 27 patients (20%) had replaced Right Hepatic artery, 14 patients (10%) had Accessory Right Hepatic artery, 1 patient (0.73%) with rare variants where common hepatic artery and superior mesenteric artery were arising from the common trunk, 1 patient (0.73%) Common Hepatic artery arising from Superior Mesenteric artery and 1 patient (0.73%) with accessory right and left hepatic artery.. Conclusions: Preoperative three dimensionally constructed MDCT images have been found to prevent the intraoperative surprises and post operative catastrophic complications faced by the surgeons due to aberrant vascular anatomy in pancreaticodudenectomy. The study highlights the incidence of arterial variations encountered in patients of pancreatic malignancy who underwent pancreaticoduodenenctomy.

Potential clinical utility of intraoperative fluid amylase measurement during pancreaticoduodenectomy

Kunal Joshi,Manuel Abradelo,David Christopher Bartlett,Nikolaos Chatzizacharias,Bobby Venkata Dasari,John Isaac,Ravi Marudanayagam,Darius Mirza,Keith Roberts,Robert Peter Sutcliffe 한국간담췌외과학회 2023 Annals of hepato-biliary-pancreatic surgery Vol.27 No.2

Retroperitoneal fibrosis-clinical presentation and outcome analysis from urological perspective

Kunal Kishor Jadhav,Vikash Kumar,Chirag B. Punatar,Vinod S. Joshi,Sharad N. Sagade 대한비뇨의학회 2017 Investigative and Clinical Urology Vol.58 No.5

Purpose: To study clinical presentation, laboratory results, imaging findings and treatment options and outcomes of retroperitoneal fibrosis (RPF). To determine whether it follows the same natural course and response to treatment in the Asian population as in the Western world. Materials and Methods: Medical records of patients diagnosed with RPF on imaging and histopathology between February 2010 and April 2016 were reviewed. Results: Of the 21 patients analyzed, mean age at presentation was 50.81 years. The male to female ratio was 0.9:1. Pain was most common presenting complaint (95.23% cases), almost 85% cases were idiopathic and rests were postradiation induced. The median creatinine level was 1.8 mg/dL. The mean erythrocyte sedimentation rate (ESR) was 53.2 mm/h. Hydronephrosis was present in all patients and 47.6% had atrophic kidneys. Diffuse retroperitoneal mass was present in 61.1%. Ureterolysis with lateralization, omental wrapping or gonadal pedicle wrap was done in 17 cases. Two patients underwent uretero-ureterostomy. One patient underwent ileal replacement of ureter, and one ileal conduit. Eighteen patients received concurrent medical treatment, 11 were given tamoxifen, 2 steroids (Prednisolone), and five were given both. Of the 20 patients with follow-up, 70% had complete symptomatic relief; ESR improvement was seen in 77.8%. Follow-up ultrasound showed resolved and decreased hydronephrosis in 20% and 55% respectively. One patient had treatment failure and 17.65% had disease recurrence. Conclusions: RPF is a rare disease with varied presentation and outcomes. The male to female ratio may be equal in Asians and smoking could be lesser contributing factor. More Asian cohort studies are required to support same.

Routine double-J stenting for live related donor kidney transplant recipients: It doesn't serve the purpose, but does it serve a better purpose?

Vikash Kumar,Chirag B Punatar,Kunal K Jadhav,Jatin Kothari,Vinod S Joshi,Sharad N Sagade,Madhav H Kamat 대한비뇨의학회 2018 Investigative and Clinical Urology Vol.59 No.6

Purpose: Despite meticulous techniques, surgical complications continue to be problematic in kidney transplant recipients. Role of routine stenting to reduce complications is controversial. In this study, we compare incidence of early urological complications, lymphoceles, urinary tract infections (UTI) and graft function; with or without double-J stenting. Materials and Methods: All patients who underwent live related donor renal transplantation from February 2014 to February 2016 were included. Transplants prior to February 2015 were without routine stenting; subsequent transplants were with routine stenting. Patients with neurogenic bladder, previously operated bladder and delayed or low urinary output were excluded. Follow-up was for at least three months. Descriptive statistics was performed for all parameters. Chi square test and Fisher's Exact test were used for qualitative variables. For quantitative variables, Mann-Whitney test was used to test median difference and independent samples t-test for mean difference. The p-value ≤0.05 was considered significant. Results: We analysed 74 patients (34 stented and 40 non-stented). There was no difference in the incidence of urinary leak, anastomotic obstruction, lymphoceles or UTI (p>0.4 for all comparisons). However, mean estimated glomerular filtration rate at sixth day, 14th day, one month and two months were 76.1 vs. 61.5 (p=0.025), 72.1 vs. 56.6 (p=0.005), 79.4 vs. 63.1 (p=0.002) and 82.0 vs. 63.3 (p=0.001) in the stented versus non-stented groups. Conclusions: Placement of ureteral stent in renal transplant does not significantly affect the incidence of early urinary complications or UTI. However, graft function is significantly better in stented recipients, at least in the short term.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes

Anisa Nutu,Michael Wilson,Erin Ross,Kunal Joshi,Robert Sutcliffe,Keith Roberts,Ravi Marudanayagam,Paolo Muiesan,Nikolaos Chatzizacharias,Darius Mirza,John Isaac,Bobby V. M. Dasari Korean Association of Hepato-Biliary-Pancreatic Su 2022 Annals of hepato-biliary-pancreatic surgery Vol.26 No.3

Backgrounds/Aims: Middle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy. Methods: Patients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation. Results: A total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52). Conclusions: Resection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.

Painless injections-a possibility with low level laser therapy

Jagtap, Bhagyashree,Bhate, Kalyani,Magoo, Surabhi,Santhoshkumar, S.N,Gajendragadkar, Kunal Suhas,Joshi, Sagar The Korean Dental Society of Anesthsiology 2019 Journal of Dental Anesthesia and Pain Medicine Vol.19 No.3

Background: Dental procedures commonly involve the injection of local anesthetic agents, which causes apprehension in patients. The objective of dental practice is to provide painless treatment to the patient. The purpose of this study was to evaluate the effect of Low Level Laser Therapy (LLLT) in reducing the pain due to local anesthetic injection. Materials and Methods: A prospective, split-mouth study was conducted on 25 patients. In Condition A, LLLT was administered followed by the administration of a standard local anesthetic agent. Patients' perception of pain with use of LLLT was assessed based on a Visual Analogue Scale (VAS). In Condition B, LLLT was directed to the mucosa but not activated, followed by the administration of local anesthesia. VAS was used to assess the pain level without the use of LLLT. Results: Comparison between Condition A and Condition B was done. A P value < 0.001 was considered significant, indicating a definite statistical difference between the two conditions. Conclusion: In our study, we observed that LLLT reduced pain during injection of local anesthesia. Further multi-centric studies with a larger sample size and various modifications in the study design are required.