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Differentiating inflammatory from malignant head mass in the background of chronic calcific pancreatitis (CCP) is difficult, and there is no investigation which can reliably solve this dilemma. An accurate diagnosis is crucial as the treatment is different for the two cases and a failure to identify malignancy before surgery can be disastrous. We aimed to assess the accuracy of platelet–lymphocyte ratio (PLR) and to compare it with CA 19-9 in determining the nature of pancreatic head mass (PHM). Eighty-three patients, who presented with CCP and PHM between 2005 and 2011, were included in the study. Patients identified to have malignancy underwent pancreaticoduodenectomy, while those deemed to have a benign lesion underwent Frey’s procedure. Clinical features of both the groups were compared. CA 19-9 and PLR individually and in combination were compared in both groups. Receiver operating characteristic curves were used to analyze the predictive values of CA 19-9 and PLR individually and together. Histologically, 66.3 % had an inflammatory head mass and 33.7 % had a malignant head mass. Significant clinical features which predicted a malignancy included the presence of a head mass in CCP of tropics, older age, jaundice, sudden worsening abdominal pain, gastric outlet obstruction, and significant weight loss. Sensitivity and specificity of CA 19-9 and PLR in diagnosing malignancy were similar (85.5 vs. 81.2 and 96.4 vs. 92.8 %, respectively), on combining CA 19-9 and PLR, there was an improvement in sensitivity (94.5 %). PLR is at least as good as CA 19-9 as a diagnostic marker to differentiate between malignant and inflammatory head mass in CCP. When used together, PLR improves the predictive value of serum CA 19-9.

Perforation of the gallbladder is a rare, but potentially fatal complication of acute cholecystitis. Gallbladder perforations presenting electively as a space-occupying lesion of the liver are its rarest presentation. We report one such case, which was a diagnostic conundrum. A 50-year-old female presented with upper abdominal pain of 6 months duration. On examination, she was afebrile and had minimal tenderness in the right upper quadrant. All of her blood investigations were unremarkable, and her imaging showed features suggestive of a biliary cystadenoma. Intra-operatively, she was found to have a perforated gallbladder with intrahepatic extension. Cholecystectomy with abscess drainage was done, and her post-operative period was uneventful. Gallbladder perforations can have a myriad of presentations. We report a rare case of a perforated gallbladder mimicking a biliary cystadenoma. A high index of suspicion along with prudent decision-making can help in accurate pre-operative diagnosis, thereby avoiding intraoperative surprises and unnecessary morbidity, especially in cases where a benign pathology mimics malignancy. [Arch Clin Exp Surg 2016; 5(2.000): 113-115]

Background. Xanthogranulomatous cholecystitis (XGC) is often misdiagnosed as gallbladder cancer (GBC). We aimed to determine the preoperative characteristics that could potentially aid in an accurate diagnosis of XGC masquerading as GBC.Methods. An analysis of patients operated upon with a preoperative diagnosis of GBC between January 2008 and December 2012 was conducted to determine the clinical and radiological features which could assist in a preoperative diagnosis of XGC.Results. Out of 77 patients who underwent radical cholecystectomy, 16 were reported as XGC on final histopathology (Group A), while 60 were GBC (Group B). The incidences of abdominal pain, cholelithiasis, choledocholithiasis, and acute cholecystitis were significantly higher in Group A, while anorexia and weight loss were higher in Group B. On CT, diffuse gallbladder wall thickening, continuous mucosal line enhancement, and submucosal hypoattenuated nodules were significant findings in Group A. CT findings on retrospect revealed at least one of these findings in 68.7% of the cases.Conclusion. Differentiating XGC from GBC is difficult, and a definitive diagnosis still necessitates a histopathological examination. An accurate preoperative diagnosis requires an integrated review of clinical and characteristic radiological features, the presence of which may help avoid radical resection and avoidable morbidity in selected cases.

Background Prebiotics and probiotics influence all pathogenic mechanisms of bacterial translocation. Used in combination, they are called synbiotics. Postoperative infective complications in patients undergoing hepatic and pancreatic surgery lead to a significant prolongation of hospital stay and increased costs. While synbiotics are considered to have beneficial effects on human health, their clinical value in surgical patients, especially in South Asia remains unclear given a paucity of applicable clinical studies. In this study we aim to assess their clinical usefulness in patients who undergo hepatic and pancreatic surgery. Methods A prospective monocentric randomised single blind controlled trial is being conducted in patients undergoing major pancreatic resections (Whipple procedure, distal pancreatectomy, Frey procedure) and hepatic resections. Group A received a specific synbiotic composition, 5 days prior and 10 days after the surgery. Group B received a placebo. Primary study end point was the occurrence of postoperative infection during the first 30 days. Secondary outcome measures were mortality, first bowel movement, days in intensive care unit, length of hospital stay, and duration of antibiotic therapy. Side effects of probiotics were evaluated. From previous studies we assumed that perioperative synbiotics reduce the proportion of patients with infectious complications from 50% to 12%, with α of 0.05 and power 80%, the calculated sample size was 35 patients for each group with a dropout rate of 10%. Conclusions This study is intended at determining the impact of perioperative synbiotic therapy on postoperative infectious complications, morbidity and mortality in patients undergoing major pancreatic and hepatic surgery. Clinical trial The Clinical Trials Registry of India (CTRI/2013/06/003737).

Introduction: The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA). Materials and Methods: All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot. Results: A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay. Conclusion: This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.

Tuberculosis presenting as an isolated liver tumour, without active pulmonary or miliary tuberculosis or other evidence of tuberculosis is distinctly rare. These lesions are easily confused with more sinister liver neoplasms. Hence the need for increased awareness of these tumour mimics, particularly in endemic areas, to avert unnecessary morbidity from surgery.

Biliary cystadenomas are rare, benign but potentially malignant, multilocular, cystic neoplasms of a biliary origin. They often present with non-specific symptoms. We present a rare case of an intrahepatic biliary cystadenoma causing luminal obstruction to the bile duct. Case report: A 32-year-old female with obstructive jaundice was evaluated and diagnosed as having a cystic lesion in the liver. With a preoperative differential diagnosis of a hydatid cyst, she underwent laparotomy and enucleation of the lesion. Intraoperatively, the tumor was found to be extending into the bile duct, which was occluding the lumen. This was excised and a bilioenteric anastomosis was done. Her postoperative period was uneventful and she was anicteric on follow-up. Conclusion: Biliary cystadenoma should be considered a differential diagnosis when radiologic imaging studies suggest a multilocular cystic hepatic lesion. Presence of jaundice in such patients should raise the suspicion of an intrabiliary component, the omission of which can lead to avoidable postoperative morbidity. [Arch Clin Exp Surg 2014; 3(4.000): 251-253]

Advanced hepatocellular carcinoma (HCC) is a dreary disease with limited therapeutic options and targeted therapy with sorafenib or regorafenib remain the only standard systemic treatment. These, however have modest efficacy at the expense of associated toxicity (1,2).

Suturing is an integral part of all surgeries. In minimal access surgery, the force exerted is based only on visual perception (tautness of the thread and degree of tissue deformation). An unbalanced suture force can cause tissue rupture or cut-through resulting in avoidable morbidity and mortality. There is a need to find ways of improving surgical dexterity and finesse without adversely affecting patient outcomes. We aimed to calculate the knot-tying force in minimal access pancreatic surgery (MAPS) performed by experienced surgeons (ES) and use this information to develop a surgical suturing model to train the surgical trainees. We have developed a firmware for force sensor calibration and post-data analysis, using which we aimed to compare the differences in forces applied by a trainee as compared to ES. Our technology showed that, as compared to the ES, the trainee’s (TS) knot was unbalanced with significant differences in force applied per knot for each of the knots (P

Postoperative infectious complications in patients undergoing pancreatic surgery are a significant cause for morbidity and mortality. Although synbiotics have beneficial effects on human health, their clinical value in surgical patients remains unclear given a paucity of applicable clinical studies.To determine the impact of perioperative synbiotic therapy on postoperative infectious complications, morbidity and mortality in patients undergoing pancreatic surgery for chronic pancreatitis.A trial was conducted in patients with chronic calcific pancreatitis undergoing Frey's procedure. Group A received a specific synbiotic composition, 5 days prior and 10 days after the surgery. Group B received a placebo. Primary study endpoint was the occurrence of postoperative infection during the first 30 days. Secondary outcome measures were mortality, length of hospital stay, days in intensive care unit, and duration of antibiotic therapy. Using previously accrued data, with α of 0.05 and power 80%, the sample size was calculated as 35 patients for each group with a dropout rate of 10%.Of the 79 patients enrolled, 75 completed the trial [group A (n = 39) and group B (n = 36)]. The incidence of postoperative infectious complications (12.8% vs 39%; P0.05), duration of antibiotics therapy (P0.05), and length of hospital stay (P0.05) were significantly lower in the synbiotic group.Synbiotics significantly reduce septic complications, hospital stay, and antibiotic requirement in patients undergoing pancreatic surgery for chronic pancreatitis. Furthermore, basic and clinical research would clarify the underlying mechanisms of their therapeutic effect and define the appropriate conditions for use.

Introduction: Carcinoids of the duodenum are rare and have an indolent course. Most of these patients have been conventionally subjected to extensive surgery based on the site of the tumor. In this report, we have explored the safety and feasibility of endoscopic banding for such tumors. This to our best knowledge is only the second such report in English medical literature. Case report: In a 50-year-old woman with history of abdominal pain and vomiting, upper gastrointestinal endoscopy revealed a 0.5 cm umbilicated nodular lesion along the medial wall of the first part of duodenum. Biopsy of the lesion confirmed it to be a carcinoid, and endoscopic ultrasonography (EUS) showed the carcinoid was confined to the submucosa. Endoscopic banding with resection of the lesion was done. Patient tolerated the procedure well and is asymptomatic on follow-up. Conclusion: Small duodenal carcinoids confined to the submucosa can be safely and effectively managed by endoscopic banding and preoperative. Larger studies in patients with duodenal carcinoids tumors are needed to confirm these promising results.

Role of plasmapheresis in early allograft dysfunction following deceased donor liver transplantation

Introduction We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity. Case report A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm3, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter's hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery. Conclusion Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.

AIM: To seek and analyze features suggestive of gallbladder cancer (GBC) on preoperative imaging and intraoperative findings in patients diagnosed as having incidental GBC (IGBC). METHODS: The study was conducted on 79 patients of IGBC managed in our department over a 10-year period (2003-2012). Review of preoperative imaging and operative notes was done to ascertain any suspicion of malignancy-in-retrospect. RESULTS: Of the 79 patients, Ultrasound abdomen showed diffuse thickening, not suspicious of malignancy in 5 patients, and diffuse suspicious thickening was seen in 4 patients. Focal thickening suspicious of malignancy was present in 24 patients. Preoperative computed tomography/magnetic resonance imaging was done in 9 patients for suspicion of malignancy. In 5 patients, difficult Cholecystectomy was encountered due to dense/inflammatory adhesions. Intraoperative findings showed focal thickening of the gallbladder and a gallbladder mass in 9 and 17 patients respectively. On overall analysis, 37 patients had preoperative imaging or intraoperative findings suggestive of malignancy, which was either a missed GBC or an unsuspected/unexpected GBC. In 42 (53.2%) patients, there was no evidence suggestive of malignancy and was an unanticipated diagnosis. CONCLUSION: Our study highlights a potential and not-so-rare pitfall of Laparoscopic Cholecystectomy. A greater awareness of this clinical entity along with a high index of suspicion and a low threshold for conversion to open procedure, especially in endemic areas may avert avoidable patient morbidity and mortality.

Context Standard celiac and hepatic arterial anatomy occur in approximately 60% of the patients; for the remaining, multiple variations have been described. A thorough knowledge of these anomalies is important in order to avoid unnecessary complications. In this report we describe one of the rarest arterial anomalies, a hepatomesenteric trunk supplying the liver. We attempt to elucidate its implications pertaining to the safe performance of a pancreaticoduodenectomy. Case report A 45-year-old male with a one-month duration painless progressive jaundice was evaluated and diagnosed as having a periampullary growth. Preoperative imaging did not suggest any arterial anomalies. Intraoperatively, the common hepatic artery was found to originate from the superior mesenteric artery. He underwent a pylorus preserving pancreaticoduodenectomy with a meticulous dissection and preservation of the aberrant hepatomesenteric trunk. His postoperative period was uneventful and is doing well on follow up. Conclusion Variations in hepatic and celiac arterial anatomy are common, and may not get picked up on preoperative imaging. A high index of suspicion in every patient along with a precise knowledge of the normal anatomy and awareness of the aberrant anatomy is a sine qua non to the performance of a safe pancreaticoduodenectomy., JOP. Journal of the Pancreas, Vol 14, No 6 (2013): November - p. 603-693

Detection of portal vein tumor invasion in hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Patients with portal vein thrombus (PVT) due to tumor are considered to have advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately differentiate benign from malignant PVT.In this study, 20 patients presenting to the out-patient department with a PVT and a diagnosis/diagnostic suspicion of HCC were subjected to FNAC of PVT. Clinical, cytological, and histopathological data for these patients were analyzed.The patients had a median age of 58 years, with majority being cirrhotic (80%) and males (80%). Thirteen patients had a prior radiological diagnosis of HCC at the time of FNAC. In three patients without any mass on imaging, FNAC made the initial diagnosis and staged the disease simultaneously. 50% of the thrombi were limited to 1st-order portal vein branches (vp3). Sixteen of the aspirates were positive for malignancy with 50% of the tumors being moderately differentiated. On histologic follow-up, three of the patients with negative aspirates had bland thrombi in their portal veins. No complications resulted from the procedure.FNAC of PVT is a simple, safe, effective, well-tolerated, and economical method for staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.

Background. Hemosuccus pancreaticus (HP) is a very rare and obscure cause of upper gastrointestinal bleeding. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the challenges in the diagnosis and management of HP and to formulate a protocol to effectively and safely manage this condition. Methods. We retrospectively reviewed the records of all patients who presented with HP over the last 15 years at our institution between January 1997 and December 2011. Results. There were a total of 51 patients with a mean age of 32 years. Nineteen patients had chronic alcoholic pancreatitis; twenty-six, five, and one patient had tropical pancreatitis, acute pancreatitis, and idiopathic pancreatitis, respectively. Six patients were managed conservatively. Selective arterial embolization was attempted in 40 of 45 (89%) patients and was successful in 29 of the 40 (72.5%). 16 of 51 (31.4%) patients required surgery. Overall mortality was 7.8%. Length of followup ranged from 6 months to 15 years. Conclusions. Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.

Wireless capsule endoscopy is a new tool in the armamentarium of the gastroenterologist to evaluate the small bowel non-invasively. It allows improved diagnostic yield with low complication rates relative to traditional modalities. But this new technology has its own set of complications, some which can lead to significant morbidity. Here, we present a case of complete small bowel obstruction following a capsule endoscopy. A 65-year-old female with a long standing history of anemia and obscure gastrointestinal bleed presented to the Emergency Department 72 hours after a wireless capsule endoscopy procedure complaining of worsening abdominal pain, distension, and frequent vomiting. An X-ray was suggestive of complete distal small bowel obstruction with the capsule at the transition point of dilated proximal and collapsed distal small bowel. The patient was resuscitated and taken up for an explorative laparotomy where a short segment stricture was noted with the capsule endoscope caught proximal to it. The segment was resected and patient made an uneventful recovery. Wireless capsule endoscopy is now becoming the preferred method to image the small bowel. Our report illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel may be with a contrast series prior to wireless capsule endoscopy to avoid any post procedural morbidity.Keywords: Bowel obstruction, capsule endoscopy, complicationJournal of Surgical Technique and Case Report | Jul-Dec 2011 | Vol-3 | Issue-2

Curative therapies for hepatocellular carcinoma (HCC), such as resection and liver transplantation, can only be applied in selected patients with early tumors. More advanced stages require local or systemic therapies. Resection of HCC offers the only hope for cure. Even in patients undergoing resection, recurrences are common. Chemoembolization, a technique combining intra-arterial chemotherapy with selective tumor ischemia, has been shown by randomized controlled trials to be efficacious in the palliative setting. There is now renewed interest in transarterial embolization/transarterial chemoembolization (TACE) with regards to its use as a palliative tool in a combined modality approach, as a neoadjuvant therapy, in bridging therapy before transplantation, for symptomatic indications, and even as an alternative to resection. There have also been rapid advances in the agents being embolized trans-arterially (genes, biological response modifiers, etc.). The current review provides an evidence-based overview of the past, present and future trends of TACE in patients with HCC.

Kikuchi-Fujimoto disease (KFD) is a rare, self-limiting disorder that typically affects the cervical lymph nodes. Recognition of this condition is crucial, especially because it can easily be mistaken for tuberculosis, lymphoma, or even adenocarcinoma. Awareness of this disorder will help prevent misdiagnosis and inappropriate treatment.From January 2006 to December 2008, 30 patients who underwent a biopsy of a cervical lymph node and proved histologically to have KFD were enrolled in this study. We studied clinical manifestations, laboratory results, treatment, and recurrence for each patient. Patients were followed up for a mean period of 2 years.There were 24 women and 6 men, with a mean age of 18 years. Two patients had a past history of tuberculosis. Major clinical symptoms and signs were fever (70%) and lymphadenopathy (100%). The affected cervical lymph nodes were most commonly located in the posterior cervical triangle. Unilateral and bilateral cervical lymph nodes were affected in 25 and 5 patients, respectively. The affected lymph nodes were most commonly less than 3 cm in size. Leukopenia was observed in 46.7%, and a raised erythrocyte sedimentation rate was seen in 56.7% of the cases. Treatment strategies included no medication, nonsteroidal antiinflammatory drugs (NSAIDs) alone, steroids alone, or a combination of NSAIDs and steroids. Ninety percent improved within 3 months, whereas one patient showed improvement only after 9 months of continued treatment. No recurrence has since been noted.KFD is a benign disease that masquerades as other more sinister diseases and can lead to unnecessary treatment-induced physiologic, psychological, and financial morbidity to the patient. Tissue diagnosis is necessary in all cases, and an effective communication between the surgeon and the pathologist is imperative in making an accurate diagnosis.

INTRODUCTIONSpillage of calculi in the abdomen is frequent during Laparoscopic Cholecystectomy (LC). Though uncommon, these stones may lead to early or late complications. We describe a rare case of spilled gallstone presenting four years after the index procedure, with a mass in the parietal wall mimicking a neoplastic lesion.PRESENTATION OF CASEA 50 year old male presented with a mass in the right upper quadrant for the past 2 years. His past surgical history included a LC done four years ago. Intraoperative procedural details of the surgery were not available. A Computed Tomography (CT) scan showed an extrahepatic mass in the subdiaphragmatic space extending onto the soft tissues of the parietal wall. He underwent laparoscopic piecemeal excision of this organized mass. His post operative period was uneventful and he was pain-free on follow up.DISCUSSIONGallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5cm have been identified as risk factors for complications. Definitive treatment is surgery with excision of the organized inflammatory mass and extraction of gallstones to avoid future recurrence.CONCLUSIONSpilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.

INTRODUCTIONDesmoid tumours of the breast are rare. Although benign, they can mimic breast cancer on physical examination, mammography and breast ultrasound and can also be locally invasive. Even though they occur sporadically, they can also be seen as a part of Gardner's syndrome. We describe a case of desmoid tumour in a woman with Gardner's syndrome where the lesion was mammographically occult.PRESENTATION OF CASEA 63-year old woman presented with four months history of a painful left breast lump. She had a screening mammogram seven months ago which was normal. She is known to have Gardner's syndrome and had a total colectomy, she has also had multiple abdominal desmoids excised in the past. On examination there was a 4cm×5cm firm, mobile lump in the left breast. Her mammograms in the clinic were also normal. Ultrasound suggested a benign lesion of the breast and a core biopsy showed it to be a benign spindle cell lesion. She underwent wide local excision of the lump, the intraoperative mammograms of the excised specimen also failed to detect the lesion. Histopathology of the excised specimen confirmed the tumour to be a benign desmoid tumour. She has now been offered radiotherapy and nonsteriodal anti-inflammatory drugs (NSAIDs) to reduce her chances of a local recurrence.CONCLUSIONA high index of suspicion and a thorough triple examination protocol is necessary to detect rare lesions like a desmoid tumour which can masquerade as breast carcinoma.

Background The search for the perfect insufflating gas has been elusive. Even though Carbon dioxide (CO 2 ) is the most commonly used gas, it has numerous cardiovascular, respiratory and hemodynamic side effects, which have often been taken for granted. In the current scenario of ever expanding and complex indications for Laparoscopic Surgery these changes have an increasing implication of placing the patient at risk. Nitrous Oxide (N 2 O) has now made a comeback and shown by recent studies to be as safe as CO 2 for creating pneumoperitoneum (PP). The purpose of our study is to determine whether benefits of N 2 O (PP) outweigh those of CO 2 PP in Laparoscopic Surgery. Material and methods All patients undergoing Laparoscopic Surgery over an 8 week period were divided into two groups. Data were collected prospectively for Group I {N 2 O( n = 38)} and Group II {CO 2 PP( n = 39)}. Heart rate, Mean Arterial Blood Pressure, End-Tidal CO 2 , Arterial pH, Peak Airway Pressure, Minute Ventilation and O 2 Saturation were recorded before PP, 15 minutes after PP and 10 minutes after exsufflation. Intraoperative anesthetic agent and postoperative pain medication use was recorded. Pain was assessed by means of visual analog scale (VAS) at postoperative hours 2 and 4 and on day1. Results tabulated and analyzed statistically. Results There was no statistical difference in age, sex, weight, complexity of surgery (type of procedure and duration of PP), Anesthetic risk, and duration of hospitalization between the two groups. Mean End-Tidal CO 2 increase was greater despite a greater mean intraoperative increase in Minute Ventilation in group II, Heart Rate, Arterial pH, Mean Arterial Pressure under anesthesia were significantly higher in group II. The quantum of intraoperative anesthetic agent and postoperative pain (as assessed by Visual Analog Scale) was less in group I. Conclusion This is an initial study assessing the use of N 2 O for insufflation; the results of our study suggest N 2 O PP has a definitive advantage over CO 2 PP. Further multicentric randomized trials are necessary before N 2 O becomes the standard insufflating agent.

Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making. [Arch Clin Exp Surg 2014; 3(2.000): 129-132]