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Backgrounds/aims: The published data had contradictory information on the role of adjuvant therapy on resected periampullary carcinomas (PACA). The study was performed to evaluate the survival benefit of adjuvant treatment., Methods: This was a propensity score matched case-control study from a prospectively maintained database from 2004-2019. The study included patients with nonpancreatic PACA who underwent curative resection. The patients (cases) who received adjuvant chemotherapy were compared with patients (controls) who were observed alone after surgery., Results: Of 510 patients with PACA, 230 patients (cases = 107, controls = 123) formed the unmatched study cohort. After propensity score matching, 140 patients (cases = 70, controls = 70) formed the matched study cohort. The median overall survival (OS) was similar in cases than controls in the unmatched population but doubled non-significantly in cases after matching (unmatched population, 54 months vs. 54 months, p -value = 0.624; matched population, 71 months vs. 36 months, p -value = 0.087). However, the median recurrence-free survival (RFS) was non significantly higher in the control group (unmatched population, 59 months vs. 38 months, p -value = 0.195; matched population, 53 months vs. 40 months, p -value = 0.797). In cox regression analysis, age < 60 years, advanced T stage, and presence of perineural invasion were independent factors for worse RFS, while tumor recurrence was an independent factor for poor OS., Conclusions: Patients with nonpancreatic PACA may have an OS benefit from adjuvant chemotherapy, and this needs to be validated with large prospective randomized studies.

Speckle-Type Poz Protein (SPOP) involved in the regulation of proteasome-mediated degradation of several oncoproteins, resulting in cancer initiation and progression. Mutations in Adenomatous Polyposis Coli (APC) gene is reported in most sporadic and hereditary colorectal cancer (CRC). Identifying the cellular changes involved in carcinogenesis when APC is mutated is an important issue that needs attention. The tumor suppressive function of SPOP and APC has long been a major focus in the research field of colorectal cancer. However, the clinical significance of SPOP and APC gene alteration in CRC has not been established to date. Mutational analysis was performed by single-strand conformational polymorphism followed by Sanger sequencing, methylation status by methylation-specific PCR, and protein expression by immunohistochemistry on 142 tumor tissues along with their adjacent non-cancerous specimens. The overall survival (OS) and recurrence free survival (RFS) were estimated by Kaplan-Meier Curve. Mutation rates of APC and SPOP gene were 2.8% and 11.9% while that of promoter hypermethylation were 37% and 47%, respectively. The grade of differentiation and Lymph node metastasis were significantly correlated with APC methylation pattern (p ≤ 0.05). The down regulation of APC was more often seen in colonic cancer compared to rectal cancer (p = 0.07) and more commonly in T3-4 depth of invasion (p = 0.07) and in patients without lymphovascular and perineural invasion (p = 0.007, p = 0.08 respectively). The median overall survival and recurrence free survival (RFS) was 67 & 36 months while 3-yr and 5-yr OS and RFS were 61.1% & 56.4% and 49.2% & 44.8%, respectively. APC promoter methylation had a better overall survival (p = 0.035) while loss of SPOP expression had a worse survival (p = 0.09). Our findings reveal high percentage of SPOP gene mutations in CRC. A significant link is found between promoter hyper methylation and protein expression in all mutant cases of APC and SPOP, suggesting that both genes may be associated in the development of colorectal cancer in people of Indian decent. Hypermethylation of APC gene and loss of SPOP expression have shown an association with disease prognosis and could be further studied looking at its potential role in planning adjuvant treatment in CRC patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

High-quality cotton fiber begins with variety selection, continues with adherence to all production methods, and concludes with a well-planned and executed harvest. A potential strategy for harvesting cotton in developing nations is cotton harvesters. Even though there have been significant improvements in recent years, there are still difficulties with its implementation in developing countries. Cotton picking is entirely mechanical in developed nations. Mechanization in the agriculture business has intensified in emerging nations such as India due to rising labor prices and shortages. This review provides an overview of cotton harvesting technologies. Recent work on robotics in cotton-picking operations is discussed. The present study thoroughly discusses hand-held, self-propelled, tractor-mounted cotton harvester development and evaluation. Information in this review will fill a gap in cotton harvesting operation mechanization and may contribute to enhancing cotton-picking operation mechanization and improving picking/harvesting intelligence research., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

The devastating outbreak of Coronavirus Disease (COVID-19) cases in early 2020 led the world to face health crises. Subsequently, the exponential reproduction rate of COVID-19 disease can only be reduced by early diagnosis of COVID-19 infection cases correctly. The initial research findings reported that radiological examinations using CT and CXR modality have successfully reduced false negatives by RT-PCR test. This research study aims to develop an explainable diagnosis system for the detection and infection region quantification of COVID-19 disease. The existing research studies successfully explored deep learning approaches with higher performance measures but lacked generalization and interpretability for COVID-19 diagnosis. In this study, we address these issues by the Covid-MANet network, an automated end-to-end multi-task attention network that works for 5 classes in three stages for COVID-19 infection screening. The first stage of the Covid-MANet network localizes attention of the model to the relevant lungs region for disease recognition. The second stage of the Covid-MANet network differentiates COVID-19 cases from bacterial pneumonia, viral pneumonia, normal and tuberculosis cases, respectively. To improve the interpretation and explainability, three experiments have been conducted in exploration of the most coherent and appropriate classification approach. Moreover, the multi-scale attention model MA-DenseNet201 proposed for the classification of COVID-19 cases. The final stage of the Covid-MANet network quantifies the proportion of infection and severity of COVID-19 in the lungs. The COVID-19 cases are graded into more specific severity levels such as mild, moderate, severe, and critical as per the score assigned by the RALE scoring system. The MA-DenseNet201 classification model outperforms eight state-of-the-art CNN models, in terms of sensitivity and interpretation with lung localization network. The COVID-19 infection segmentation by UNet with DenseNet121 encoder achieves dice score of 86.15% outperforming UNet, UNet++, AttentionUNet, R2UNet, with VGG16, ResNet50 and DenseNet201 encoder. The proposed network not only classifies images based on the predicted label but also highlights the infection by segmentation/localization of model-focused regions to support explainable decisions. MA-DenseNet201 model with a segmentation-based cropping approach achieves maximum interpretation of 96% with COVID-19 sensitivity of 97.75%. Finally, based on class-varied sensitivity analysis Covid-MANet ensemble network of MA-DenseNet201, ResNet50 and MobileNet achieve 95.05% accuracy and 98.75% COVID-19 sensitivity. The proposed model is externally validated on an unseen dataset, yields 98.17% COVID-19 sensitivity., Competing Interests: The authors declare that they have no conflict of interest., (© 2022 Elsevier Ltd. All rights reserved.)

Objectives: The histopathological changes in the liver and their clinical implication in chronic pancreatitis (CP) have not been studied well. We analyzed the incidence, risk factors, and long-term outcomes of these changes in CP., Methods: Chronic pancreatitis patients who underwent surgery with intraoperative liver biopsy from 2012 to 2018 formed the study group. Based on liver histopathology, 3 groups were formed: normal liver, group NL; fatty liver, group FL; and inflammation/fibrosis, group FS. The risk factors and long-term outcomes, including mortality, were evaluated., Results: Among 73 patients, 39 (53.4%) had idiopathic, and 34 (46.6%) had alcoholic CP. The median age was 32 years, 52 (71.2%) were males and comprised NL, n = 40 (55%); FL, n = 22 (30%); and FS, n = 11 (15%). The preoperative risk factors were comparable among NL and FL groups. Overall 14 of 73 patients (19.2%) (NL, 5 of 40; FL, 5 of 22; FS, 4 of 11 [P = 0.82]) had died at median follow-up of 36 months (range, 25-85 months). The main causes of mortality were tuberculosis and severe malnutrition secondary to pancreatic insufficiency., Conclusions: The mortality is higher in patients with inflammation/fibrosis or steatosis in liver biopsy, and such patients need monitoring for progression of liver disease and pancreatic insufficiency., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Gallbladder carcinoma (GBC) has a dismal prognosis even after curative resection. The objective of the study was to evaluate the effect of adjuvant chemotherapy in patients with GBC undergoing curative resection in a randomized control trial (RCT)., Methods: A single-center open-labeled prospective RCT was done from January 2012 to June 2018. R0 curative resected GBC patients were randomized in 1:1 to either surveillance alone (control group) or adjuvant chemotherapy (gemcitabine and cisplatin (GemCis group)) for 6 cycles. The primary outcome was disease-free survival (DFS), and the secondary outcomes were overall survival (OS) and toxicity profile., Results: On the evaluation of 362 patients with GBC, 50 patients were enrolled in each control or GemCis group. Per protocol (PP), it comprised 96 patients. The demographic and clinical profile was similar between the two groups except in the lower nodal stage where patients were higher in the control group (p = 0.01). Recurrences were similar between groups (control 44% vs GemCis 56%; p = 0.23). On the intention to treat (ITT), analyses of median DFS (not reached vs. 24 months, p = 0.14) and OS (not reached vs. 31 months, p = 0.10) were similar between groups. On PP, analyses of median DFS (not reached vs. 24 months, p = 0.16) and OS (not reached vs. 31 months, p = 0.09) were similar between groups. The common toxicity profile was hematological followed by gastrointestinal symptoms., Conclusions: Adjuvant GemCis therapy for 6 cycles does not improve DFS or OS than R0 surgery alone patients with GBC., Trial Registration: NCT02778308 ( https://www.clinicaltrials.gov )., (© 2021. The Society for Surgery of the Alimentary Tract.)

The electroencephalography (EEG) signal is an essential source of Brain-Computer Interface (BCI) technology implementation. The BCI is nothing but a non-muscle communication medium among the external devices and the brain. The basic concept of BCI is to enable the interaction among the neurological ill patients to others with the help of brain signals. EEG signal classification is an essential requirement for various applications such as motor imagery classification, drug effects diagnosis, emotion classification, seizure prediction/detection, eye state prediction/detection, and so on. Thus, there is a need for an efficient classification model that can deal with the EEG datasets more adequately with better classification accuracy, which will further help in developing the automatic solution for the medical domain. In this paper, we have introduced a hybrid classification model for eye state detection using electroencephalogram (EEG) signals. This hybrid classification model has been evaluated with the other traditional machine learning models, eight classification models (Prepossessed + Hypertuned) and six state-of-the-art methods to assess its appropriateness and correctness. This proposed classification model establishes a machine learning-based hybrid model for the classification of eye state using EEG signals with greater exactness. It is also capable of solving the issue of outlier detection and removal to address the class imbalance problem, which will offer the solution toward building the robotic or smart machine-based solution for social well-being., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© The Author(s), under exclusive licence to Springer Nature B.V. 2021.)

The outbreak of novel coronavirus (COVID-19) disease has infected more than 135.6 million people globally. For its early diagnosis, researchers consider chest X-ray examinations as a standard screening technique in addition to RT-PCR test. Majority of research work till date focused only on application of deep learning approaches that is relevant but lacking in better pre-processing of CXR images. Towards this direction, this study aims to explore cumulative effects of image denoising and enhancement approaches on the performance of deep learning approaches. Regarding pre-processing, suitable methods for X-ray images, Histogram equalization, CLAHE and gamma correction have been tested individually and along with adaptive median filter, median filter, total variation filter and gaussian denoising filters. Proposed study compared eleven combinations in exploration of most coherent approach in greedy manner. For more robust analysis, we compared ten CNN architectures for performance evaluation with and without enhancement approaches. These models are InceptionV3, InceptionResNetV2, MobileNet, MobileNetV2, Vgg19, NASNetMobile, ResNet101, DenseNet121, DenseNet169, DenseNet201. These models are trained in 4-way (COVID-19 pneumonia vs Viral vs Bacterial pneumonia vs Normal) and 3-way classification scenario (COVID-19 vs Pneumonia vs Normal) on two benchmark datasets. The proposed methodology determines with TVF + Gamma, models achieve higher classification accuracy and sensitivity. In 4-way classification MobileNet with TVF + Gamma achieves top accuracy of 93.25% with 1.91% improvement in accuracy score, COVID-19 sensitivity of 98.72% and F1-score of 92.14%. In 3-way classification our DenseNet201 with TVF + Gamma gains accuracy of 91.10% with improvement of 1.47%, COVID-19 sensitivity of 100% and F1-score of 91.09%. Proposed study concludes that deep learning modes with gamma correction and TVF + Gamma has superior performance compared to state-of-the-art models. This not only minimizes overlapping between COVID-19 and virus pneumonia but advantageous in time required to converge best possible results., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022.)

Objective: Dilated common bile duct (CBD) (8-15 mm) with normal liver function tests is seen not infrequently, while management of such patients is ambiguous. We propose a treatment algorithm for this cohort of patients after observing them over a period of 8 years., Methods: Seventy-eight such patients were managed from 2009 to 2017 and categorized as: Group A-dilated CBD with post-cholecystectomy status (n = 15); B-dilated CBD with cholelithiasis (n = 34); C-dilated CBD without cholelithiasis (n = 16); D-dilated CBD with no cause identified and underwent CBD excision (n = 13). Causes for CBD dilatation were evaluated. The outcome of patients in Group B + C without any cause (n = 33) was compared with Group D., Result: Median age, CBD diameter, bilirubin and alkaline phosphatase were 51 years (13-79), 10 mm (8-20), 0.6 mg/dl (0.2-2.5) and 126 IU (60-214), respectively. Group-A patients who did not manifest any cause of CBD dilatation were managed conservatively. The aetiology was identified in 17/50 patients in Group B & C [acute pancreatitis (n = 6), passed CBD calculi (n = 3), perivaterian diverticulum (n = 3), viral aetiology (n = 4) and tumour (n-1)]. In Group-C, 7 patients with no obvious cause underwent endoscopic sphincterotomy, pancreatoduodenectomy (n = 1), and the rest were managed conservatively (n = 8). There was no significant difference in the complication between Group B + C (without any cause) and Group D (3/33 vs. 1/13; p = 0.58) at a median follow-up of 72 months (30-90)., Conclusion: Dilated CBD with normal LFT's without apparent cause is mostly benign and of no consequence. Excision of the CBD is not required for most of these patients., (© 2021. Société Internationale de Chirurgie.)

Virus based epidemic is one of the speedy and widely spread infectious disease which can affect the economy of the country as well as it is life-threatening too. So, there is a need to forecast the epidemic lifespan, which can help us in taking preventive measures and remedial action on time. These preventive measures and corrective action may consist of closing schools, closing malls, closing theaters, sealing of borders, suspension of public services, and suspension of traveling. Resuming such restrictions is depends upon the outbreak momentum and its decay rate. The accurate forecasting of the epidemic lifespan is one of the enormously essential and challenging tasks. It is a challenging task because the lack of knowledge about the novel virus-based diseases and its consequences with complicated societal-governmental factors can influence the widespread of this newly born disease. At this stage, any forecasting can play a vital role, and it will be reliable too. As we know, the novel virus-based diseases are in a growing phase, and we also do not have real-time data samples. Thus, the biggest challenge is to find out the machine learning-based best forecasting model, which could offer better forecasting with the limited training samples. In this paper, the Multi-Task Gaussian Process (MTGP) regression model with enhanced predictions of novel coronavirus (COVID-19) outbreak is proposed. The purpose of the proposed MTGP regression model is to predict the COVID-19 outbreak worldwide. It will help the countries in planning their preventive measures to reduce the overall impact of the speedy and widely spread infectious disease. The result of the proposed model has been compared with the other prediction model to find out its suitability and correctness. In subsequent analysis, the significance of IoT based devices in COVID-19 detection and prevention has been discussed., (© Springer Science+Business Media, LLC, part of Springer Nature 2021.)

Background: Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP)., Methods: The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival., Results: Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045)., Conclusion: Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.

Objective: The aim of the study was to evaluate the long-term functional outcome (exocrine and endocrine) and morphological changes in remnant pancreas after pancreatoduodenectomy and its clinical impact., Methods: Periampullary carcinoma patients with minimum follow-up of 2 years and without recurrence were included (N = 102). Exocrine insufficiency includes clinical steatorrhea and fecal elastase-1 (FE-1) levels; endocrine insufficiency, glucose levels and glycated hemoglobin; and morphological changes, main pancreatic duct (MPD) diameter and thickness of remnant pancreas., Results: The mean (standard deviation) follow-up period was 59 (26) months. Of the 102 patients, 81 (80%) had severely deficient FE-1 (0-100 μg/g). The preoperative MPD was significantly more and thickness of remnant pancreas was significantly less in patients with severely deficient FE-1. Overall, 15.6% (16/102) developed steatorrhea and improved on enzyme replacement therapy. The presence of MPD stricture (P = 0.008) and weight loss (P = 0.001) were significantly associated with steatorrhea. New-onset diabetes was seen in 17% (15/90) patients, of whom 3 of 5 developed it after 4 years (range, 4-7 years). The blood glucose was controlled on oral hypoglycemics in 2 (10/15) of 3 patients., Conclusions: The assessment by FE-1 indicates loss of exocrine function in more than 90%, whereas only 1 of 6 developed steatorrhea and new-onset diabetes. Morphological changes especially MPD stricture affect the functional status of remnant pancreas.

Background: Pharyngoesophageal stricture (PES) is an Achilles' heel in the management of corrosive injury. Advances in endoscopic techniques were utilized in its management. We classified the stricture as per its dilatability and then planned their treatment., Methods: PES was sub-categorized based on endoscopic dilatation and availability of cervical oesophagus: group-1 stricture with available cervical oesophagus; group-2 stricture with some part of upper oesophagus made available after endoscopic dilatation and anastomosis in cervico-pharyngeal area; group-3 stricture not amenable for dilatation, anastomosis done at the pharynx. Endoscopic dilatation was performed using through-the-scope pyloric balloon. Number and duration of dilatation sessions before surgery, incidence of tracheostomy, time and incidence for re-stricture and present status of swallowing were evaluated., Results: Of 226 patients managed, 46 underwent oesophageal replacement for PES. Group 1, 2 and 3 had 12, 14 and 20 patients, respectively. An average 3 (2-4) preoperative balloon dilatation sessions were performed over 6-8 weeks. Tracheostomy was required in 1, 0, 8 patients (p = 0.010), and median hospital stay was 10, 9 and 13 days (p = 0.09) in group 1, 2, 3, respectively. Re-stricture developed in 4/12, 4/14, 9/20 patients with average sessions of dilatation required in post-operative period was 4, 3.5 and 8 in group 1, 2, 3, respectively. >90% of patients are taking normal diet in each group., Conclusion: We attempted to avoid the high anastomosis by dilating the PES and step down the level of anastomosis in two-third patients. We thereby avoided tracheostomy, aspiration and swallowing problems related to high strictures.

O-6-methylguanine-DNA methyltransferase, DNA repair gene, has been found to be involved with the pathogenesis of the esophageal cancer. DNA hypermethylation and other factors have been suggested to downregulate O-6-methylguanine-DNA methyltransferase. In this communication, the methylation status of O-6-methylguanine-DNA methyltransferase gene and the corresponding O-6-methylguanine-DNA methyltransferase protein expression in esophageal cancer from North India has been studied. In all, 80 samples of tumor tissue along with adjacent normal tissue as controls were analyzed for messenger RNA level of O-6-methylguanine-DNA methyltransferase gene, protein expression, and subcellular localization. The messenger RNA expression was studied using real-time quantitative polymerase chain reaction, protein expression, and its subcellular localization by Western blotting and immunohistochemistry. DNA methylation was assessed through methylation-specific polymerase chain reaction. Clinicopathological parameters were recorded and correlated with the O-6-methylguanine-DNA methyltransferase expression. O-6-methylguanine-DNA methyltransferase messenger RNA expression was found to be downregulated in 65% cases (52/80). The expression of O-6-methylguanine-DNA methyltransferase at the protein level was also found to be absent in 65% (52/80) cases. In all, 52 cases had low or no expression of the protein, whereas out of those 28 remaining cases, 11.25% (09/80) cases had high O-6-methylguanine-DNA methyltransferase protein expression. The absence of O-6-methylguanine-DNA methyltransferase protein coincided with the methylated cases in 84% (38/45), whereas in 07 cases, out of the 45 methylated, O-6-methylguanine-DNA methyltransferase protein was present. The aggressive esophageal cancer patients having methylated O-6-methylguanine-DNA methyltransferase had more than 50% cases with no/mild expression of the O-6-methylguanine-DNA methyltransferase protein ( p > 0.001). Loss of O-6-methylguanine-DNA methyltransferase protein was very frequent in the incidence of esophageal cancer from North Indian patients, and methylation of the promoter region of O-6-methylguanine-DNA methyltransferase was significantly associated in its downregulation.

Introduction: Anastomotic leak is one of the main causes of morbidity following esophageal resection for carcinoma of the esophagus and gastroesophageal junction. We compared hand sewn and stapled cervical esophagogastric anastomotic techniques in terms of postoperative complications., Methods: All patients who underwent esophagectomy with cervical esophagogastric anastomosis at a single academic center from 2004 to 2014 were included in the study. Both early and late complications were analyzed., Results: 153 patients underwent resection for carcinoma of the esophagus and gastroesophageal junction. Of these 140 patients had esophagectomy with cervical esophagogastric anastomosis. 66 patients underwent a hand sewn anastomosis and 74 patients had a side-to-side stapled anastomosis fashioned. Both groups were comparable with respect to preoperative characteristics. There was no difference in the operative blood loss and T and N stage of the disease. The overall morbidity and mortality was 32.8% and 6.4%, respectively. Overall leak rate was 17%. There was no difference in the leak rates among two groups (12 in the hand-sewn group & 12 in the Stapled stapled group; p = 0.82). The rate of anastomotic stricture was significantly higher for the hand sewn group (16.1% vs 4.3%; p = 0.03) at median follow up of 30 months., Conclusion: Both hand sewn and stapled anastomotic techniques are equally effective way of performing a cervical esophagogastric anastomosis. However, patients having anastomotic leak develop anastomotic stricture more often in those having hand-sewn anastomosis compared to stapled anastomosis.

Gallbladder cancer (GBC) is an aggressive malignancy usually diagnosed in an advanced stage. We investigated the effects of alterations of the phosphatase and tensin homologue (PTEN) gene on the occurrence and development of GBC, which has not been previously reported. A total 141 cases of GBC were analyzed for mutation, expression, and methylation across the nine exons of the PTEN gene. DNA sequencing methods were applied for mutation detection, whereas protein expression and methylation status were evaluated by immunohistochemical and methylation-specific PCR analysis, respectively. Novel PTEN mutations were observed in 6.3% of cases (9/141), and they included two silent mutations. In mutant cases, according to changes in codons, the respective amino acid sequences were also changed, which caused of proteins. A high percentage (72%) of loss of protein expression was observed more often in cases than in control samples. Interestingly, all nine cases with mutations showed loss of PTEN expression, whereas four of these nine cases showed positive promoter methylation. Hypermethylation was significantly more common in older patients than in younger ones (P<0.02). These findings suggest that PTEN mutations and inactivation may play an important role in the development and progression of gallbladder carcinoma., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Despite advances in speciality care, mortality and morbidity remain the most important issues in the management of post-cholecystectomy bile duct injuries. We analysed the peri-operative management of post-cholecystectomy bile duct injuries to assess their outcomes. Of 150 patients with post-cholecystectomy bile duct injuries, 13 patients who presented with strictured hepaticojejunostomy were excluded from the analysis. The records of the remaining 137 patients were analysed for type of presentation, management and follow-up. Of 137 injuries, 88 were open and 49 were laparoscopic. Various presentations include acute bile duct injury (n = 5), bile collection (n = 45), external biliary fistula (n = 46) and stricture (n = 41). After initial management, three patients died (sepsis, n = 2; pseudoaneurysmal bleed, n = 1). Of 107 patients who underwent definitive repair, three died (portal hypertension, n = 2; sepsis, n = 1). At median follow-up of 30 months, 100 patients had good outcome (grade A, B), and only 4 had bad outcome (grade C, D) as per McDonald grading. Peritonitis and sepsis in the early phase and portal hypertension and cirrhosis in the late phase are the main causes of mortality in patients sustaining bile duct injury during cholecystectomy. Successful management in a specialist hepatobiliary centre can limit the morbidity in more than 90 % cases.

Introduction: Mesh rectopexy for complete rectal prolapse is associated with complications such as fecal impaction, constipation and rarely recurrence. Mesh erosion following rectopexy is rare. We report three such cases managed successfully in our unit., Presentation of Cases: All three patients presented with constipation. In addition, one patient had sense of incomplete evacuation and another had protrusion of mesh through anal canal with recurrence of rectal prolapse. There was a delayed presentation in one patient at 15 years after initial surgery, while other two presented at 2 years and 5 years following rectopexy. Diagnosis was made by either per rectal examination or sigmoidoscopy. Two patients underwent trans abdominal removal of mesh along with anterior resection of rectum. In one patient, mesh was removed by transanal approach and sutured rectopexy was added to tackle the recurrent prolapse. All patients are symptom free on follow up with no recurrence of prolapse., Discussion: Mesh erosion following rectopexy has multifactorial aetiology with diverse presentation. It is important to recognise this significantly morbid complication as it amenable to surgical correction. Management depends up on the location of erosion, the severity of mesh protrusion into rectal lumen and the degree of fibrosis around the area of mesh., Conclusion: The management of mesh erosion following rectopexy should be individualized. Although it is complex, acceptable functional outcome and quality of life can be achieved with proper treatment., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Context: Choledochal cysts are benign congenital cystic dilatations of the common bile duct. They are usually associated with pancreatobiliary malunion resulting in long-term complications, such as acute pancreatitis and bile duct cancer. However, the occurrence of chronic pancreatitis with a choledochal cyst is rarely reported., Case Reports: We report three cases of choledochal cysts associated with chronic pancreatitis with their presentation and management. The choledochal cysts were classified according to the Alonso-Lej classification with Todani modifications, based on radiographic and operative findings. Chronic pancreatitis was defined using Marseille criteria (1984). Two patients had a type I choledochal cyst and one had a type IV-A. All cases had chronic calcific pancreatitis with a grossly dilated main pancreatic duct. Abdominal pain was the most common presentation, present in all three patients while jaundice was seen in one patient. The laboratory parameters and MRI/MRCP helped to confirm the diagnosis. All patients underwent cyst excision with drainage and had an uneventful postoperative course. At a median follow-up of 9 months, two patients were asymptomatic and one patient, who developed duodenal obstruction, underwent gastrojejunostomy., Conclusions: the association of a choledochal cyst with chronic pancreatitis may be etiologically related. Excision of the cyst with lateral pancreaticojejunostomy can be performed safely and is usually curative.

A 45-year-old female presented with upper abdominal pain. Ultrasound and CECT both showed a mass in the pancreatic head and uncinate process suggestive of carcinoma of the head of the pancreas. A Whipple's pancreaticoduodenectomy was carried out. Microscopic examination showed numerous epithelioid cell granulomas in the pancreas infiltrating the duodenal mucosa. No evidence of malignancy was seen. Acid fast bacilli were positive. The patient was started on anti-tubercular therapy. Cases of isolated pancreatic tuberculosis are very rare and can mimic pancreatic carcinoma clinically and radiologically. A differential diagnosis of pancreatic tuberculosis must be made in a patient presenting with a pancreatic mass and the patient must be thoroughly investigated to confirm or rule out malignancy or tuberculosis. We herein present a case of primary pancreatic tuberculosis and discuss the clinicopathological features of this condition. We have also proposed an algorithm for the management of patients presenting with a pancreatic mass and a clinical suspicion of pancreatic tuberculosis.