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To retrospectively evaluate the magnetic resonance imaging (MRI) features of benign hepatic nodules in patients with extrahepatic portal vein obstruction (EHPVO) and assess predictable features for their development.This retrospective observational study included 18 diagnosed patients of EHPVO who underwent contrast enhanced abdominal MRI at our Institute between June 2016 and May 2017, and who could be followed up for at least two years. The patients with liver nodules formed the study group (n = 8; 4 males, 4 females; mean age: 26.1 ± 10.9 years) and patients without liver nodules were controls (n = 10; 3 males, 7 females; mean age: 24.2 ± 15.1 years). Liver nodules were confirmed as benign by either biopsy or stability on follow up imaging. MRI features of liver nodules were assessed. Clinical details and imaging data of the study group were compared with controls to assess predictable features.There was no statistically significant difference in age, gender, clinical characteristics and upper gastrointestinal endoscopic findings between the study and control groups. The size of the lienorenal collateral, left renal vein and superior mesenteric vein were significantly larger in the study group (Liver nodules in patients with EHPVO are likely to be benign and have characteristic MRI features. Significantly larger lienorenal collateral, left renal vein and superior mesenteric vein were associated with the development of these nodules.

Introduction: Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. Patients and Methods: Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. Results: Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130–250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. Conclusion: LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Background: Both noncirrhotic portal fibrosis (NCPF) and extrahepatic portal venous obstruction (EHPVO) are important causes of noncirrhotic portal hypertension (PH) in the Asian region. In this study, we analyzed the histopathological changes of liver needle-core biopsies from patients with NCPF and EHPVO. Patients and Methods: The patients were diagnosed as per the Asia Pacific Association for the Study of Liver (APASL) criteria. Minimum adequacy criteria for liver core biopsies were defined, and finally, 69 liver biopsies from patients with NCPF and 100 liver biopsies from patients with EHPVO were analyzed. All histological parameters were predefined, and three experienced pathologists analyzed the biopsies after reaching consensus. Institute ethics committee clearance was taken. Results: Although some histological features were overlapping, phlebosclerosis of intra-hepatic branches of the portal vein (PV), periportal aberrant vascular channels, remnant portal tracts, and hepatic fibrosis beyond the portal tracts without the formation of complete hepatic nodules (P < 0.001 for all) were common histological characteristics of NCPF on core-needle liver biopsies; while maintained lobular architecture, nonspecific dilatation of PV branches, absence of intra-hepatic PV phlebosclerosis, aberrant vascular channels, and significant fibrosis were characteristics of EHPVO. Conclusions: Despite the considerable histological overlap between NCPF and EHPVO, careful histological evaluation, supplemented by clinical features, radiological and biochemical findings can help in making a conclusive diagnosis. Patients with NCPF and EHPVO with clinical jaundice show transaminitis, high serum alkaline phosphatase level, more variceal bleed, and histological evidences of nodular regenerative hyperplasia.

Background/Aims To compare splenic stiffness (SS) with intra-operative portal pressures (PPs) in patients of extrahepatic portal vein obstruction (EHPVO). Methods Twenty-one patients (14 males; 7 females) of mean age 20.4 years with clinical and sonographic diagnosis of EHPVO were included in this approved prospective study. Endoscopy for esophageal varices (EV) was done in all patients followed by ultrasonographic 2D shear wave elastography (SWE) of spleen. Three values were taken at different areas of spleen avoiding major vessels and mean was calculated. Intra-operative PP was measured from an omental vein during proximal spleno-renal shunt surgery. The PP was compared and correlated with SS along with other parameters. Results The mean SS was 46.04 ± 8.0 kPa and the mean PP was 33.29 ± 4.1 mmHg. There was no significant correlation between PP and SS (P = 0.61) and between grades of EV and SS (P = 0.38). Significant correlation was seen between grades of EV and PP (0.04). SS also did not show significant correlation with splenic size or duration of disease. Conclusion SS measured by 2D SWE did not correlate with PP and thus may not help in predicting gastrointestinal bleed in patients of EHPVO.

There is limited literature about the perioperative factors which can predict endocrine insufficiency after pancreaticoduodenectomy (PD). The primary aim was to correlate percentage pancreatic remnant volume (%RV) after PD in nondiabetic patients with the development of new-onset impaired glucose tolerance/diabetes mellitus (IGT/DM). The secondary aim was to identify the risk factors for new-onset IGT/DM.In this prospective study, all consecutive patients with resectable periampullary carcinoma and without IGT/DM were evaluated with fasting and postprandial plasma glucose, HbA1c, insulin, and C-peptide levels preoperatively and at 3 mo postoperatively. After that, all patients were followed up with fasting and postprandial plasma glucose level assessed at 3-mo intervals for 24 mo or till death, whichever occurred earlier. The %RV was determined from computed tomography measurements preoperatively.Of the 50 patients, 11 (22%) patients developed IGT/DM after median follow-up of 32 mo. The patients' with/without IGT/DM were similar in demographic/perioperative variables. The %RV was found to be an independent factor associated with new-onset IGT/DM. A %RV of48.8% was found to be a predictor of new-onset IGT/DM (sensitivity, 89.7%; specificity, 73.6%). Plasma sugar and glycosylated hemoglobin levels were significantly higher postoperatively after PD than the preoperative levels. Insulin and C-peptide levels were significantly lower after PD, irrespective of new-onset IGT/DM.The incidence of IGT/DM after PD was 22%, and %RV48.8% was found to be a significant risk factor for new-onset IGT/DM. (CTRI/2013/12/004233).

Portal hypertension (PHT) due to extrahepatic portal venous obstruction (EHPVO) is common in developing countries. Hypersplenism is a near-constant feature of EHPVO, but its significance, unlike in cirrhotics, is unknown. We aimed to study the relationship between hypersplenism and the severity of PHT in patients with EHPVO. This prospective study was done at a tertiary care center from January 2014 to August 2015. All patients with EHPVO who underwent a splenectomy and a shunt or devascularization were included. Data regarding clinical profile, preoperative parameters, and intraoperative details were recorded. The correlation was studied between hypersplenism and the intraoperatively measured portal pressures and markers of PHT. Of the 40 patients studied (mean [SD] age 22.4 [8.4] years), hematological hypersplenism was present in 39 (97.5%). The mean (SD) hemoglobin, total leukocyte counts (TLC), and platelet counts were 9.9 (2.4) g/dL, 2971 (1239) cells/mm3, and 66,400 (32047) cells/mm3, respectively. The mean (SD) sonographic spleen volume (SV), splenic weight, and intraoperative portal pressure were 1084.7 (553.9) cm3, 1088.7 (454.7) g, and 35.6 (5.1) mmHg, respectively. The TLC and platelet counts correlated inversely with the portal pressure. Additionally, the platelet counts correlated negatively with eradicated variceal status, SV, and weight; hemoglobin with SV and weight; and TLC with SV. Multivariate analysis showed the platelet counts were an independent predictor of portal pressures and platelet counts ≤ 53,500 cells/mm3 indicated significantly high portal pressures. The platelet counts showed a significant inverse correlation with portal pressures in patients with EHPVO and may be used as surrogate markers of PHT. A platelet count ≤ 53,500 cells/mm3 is predictive of significantly high pressures.

Background Pancreaticojejunostomy (PJ is the most widely used reconstruction technique after pancreaticoduodenectomy. Despite several randomized trials, the ideal technique of pancreaticojejunostomy remains debatable. We planned a meta-analysis of randomized trials comparing the two most common techniques of PJ (duct-to-mucosa and dunking) to identify the best available evidence in the current literature. Methods We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled Trials electronic databases till October 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan), Version 5.3. Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous and mean difference for continuous variables. P-value ≤ 0.05 was considered significant. Trial sequential analysis was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Center for Clinical Intervention Research, 2016). Results A total of 8 trials were included, with a total of 1043 patients (DTM: 518; Dunking: 525). There was no significant difference between the two groups in terms of overall as well as clinically relevant POPF rate. Similarly, both groups were comparable for the secondary outcomes. Trial sequential analysis revealed that the required information size had been crossed without achieving a clinically significant difference for overall POPF; and though the required information size had not been achieved for CR-POPF, the current data has already crossed the futility line for CR-POPF with a 10% risk difference, 80% power and 5% α error. Conclusion This meta-analysis found no significant difference between the two techniques in terms of overall and CR-POPF rates. Further, the existing evidence is sufficient to conclude lack of difference and further trials are unlikely to result in any change in the outcome. (CRD42017074886).

Background Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. Methods This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. Results A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. Discussion The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531)

Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of acute corrosive injury has not been described. Here, we present our experience of a case of acute corrosive injury presenting with massive upper gastrointestinal bleeding in the delayed phase which was successfully managed by angioembolization. We discuss the case in light of the literature available and describe markers which may serve to identify potential candidates for angioembolization.

Context: Cysts arising from the hepatobiliary tree are a group of heterogeneous lesions with regard to pathogenesis, clinical presentation, and radiological finding. They can be intrahepatic or extrahepatic, developmental, secondary to infective/inflammatory etiologies, as well as neoplastic. This study was conducted to determine the spectrum of hepatobiliary cysts in surgically intervened cases, with regard to their prevalence, histological spectrum, and clinicoradiological correlation, wherever possible. Methods: In this retrospective observational study, hematoxylin and eosin stained slides of all cases of hepatobiliary cystic lesions, operated between 2009 and 2016 were reviewed. Special stains as reticulin, Masson's trichrome, and periodic acid Schiff were done wherever necessary. Overall prevalence, age-sex distribution, clinical presentation and histopathological patterns were studied. Relevant imaging findings were correlated wherever possible. Results: A total of 312 cases of hepatobiliary cysts were identified, the majority in females. Choledochal cysts (CCs) were the most common type (n = 198,63.5%), followed by hydatid cysts (n = 73,23.3%), simple hepatic cysts (n = 10,3.2%), congenital hepatic fibrosis (n = 10,3.2%), biliary cystadenomas (n = 4,1.2%) hepatic mesenchymal hamartomas (n = 7,2.2%), and cavernous hemangiomas (n = 3,0.9%). Fibropolycystic liver disease (n = 2,0.6%), Caroli's disease (n = 1, 0.3%), liver abscess (n = 2, 0.6%), infantile hemangioendothelioma (n = 1,0.3%), and biliary cystadenocarcinomas (n = 1,0.3%) were rare. Lesions noted mostly in 1st decade of life were: CCs, fibrocystic liver disease, Caroli's syndrome, cystic mesenchymal hamartoma, and infantile hemangioendotheliomas. Conclusion: In our cohort of surgically intervened cases of hepatobiliary cystic lesions from a tertiary care hospital in North India, the CCs, followed by hydatid cyst were the most common lesions. Histology can play vital role in characterization, as often clinical findings and radiology can overlap.

Catheters with inflatable balloons such as a Foley catheter may be used for feeding gastrostomy/jejunostomy. The incorrect or improper use of these catheters can have serious consequences. We report 13 cases of feeding jejunostomy with balloon-inflated catheter's malfunction, some referred to our centre and others operated here over a period of 8 years. The most dramatic consequence of such improper use led to rupture of the small intestine due to inadvertent over-inflation (over 100 ml) of the balloon of the catheter during a contrast study. The patient required a laparotomy with resection and anastomosis of the bowel. Three other patients had similar over-inflation of the balloon leading to severe pain and discomfort. In all three patients, timely deflation of the balloon was sufficient to relieve the symptoms. One patient had intussusception with the inflated balloon acting as a lead point. The patient underwent resection of the small bowel with end jejunostomy and distal mucous fistula. All other patients presented with abdominal pain and distension and intestinal obstruction and were managed non-operatively with deflation of balloon either by aspiration, cutting the balloon port or ultrasound-guided puncture of balloon. Healthcare personnel dealing with patients with indwelling catheters must be educated to suspect, detect and manage such problems. The best measure for such unusual complications of otherwise safe devices would be prevention by training and generation of awareness.

Neurogenic tumors are the most prevalent tumors of the mediastinum, and schwannomas are the most common type of neurogenic tumor. Primary neurogenic neoplasm of the esophagus is uncommon and malignant schwannoma of the esophagus is extremely rare. We report a case of a 27-year-old female presenting with dysphagia and palpitations who was found to have a lobulated tumor in the mediastinum that was compressing the esophageal lumen. The tumor was successfully treated surgically without recurrence. The final diagnosis, on histopathological examination of the specimen, was malignant schwannoma.

Liver resection is based on a sound understanding of segmental anatomy which essentially defines the relationship between elements of the vasculobiliary tree and its associated parenchyma, made largely of organized cords of hepatocytes. Carl Langenbuch is credited with performing the first elective liver resection in 1888. The initial approaches focussed on directly splitting the parenchyma by mechanical means (finger ‘fracture’ or ‘Kelly-clysis’) with bleeding controlled by sutures as it arose. Pringle, in 1908, reported temporary occlusion of vascular inflow at the porta as a means of reducing blood loss while transecting the liver.

OBJECTIVE: To assess the accuracy of splenic stiffness (SS) measured by 2D-shear wave elastography (SWE) for predicting variceal bleeding in the patients with extrahepatic portal vein obstruction (EHPVO). METHODS: 52 patients with EHPVO (mean age: 22.29 years; 26 each males and females) were included in the study after obtaining approval from the institute ethics committee. All patients initially underwent upper gastrointestinal endoscopy followed by ultrasonography, including 2D-SWE on the Aixplorer Supersonic Imagine scanner. The SS was measured through the anterior abdominal wall and an average of three measurements was taken. The SS was then compared with clinical symptoms, variceal grade, and other ultrasonography (USG) parameters. USG parameters were also compared with variceal grade. RESULTS: The mean SS was 44.92 ± 12.35 kPa. There was no significant difference in the mean SS of patients with high grade varices (44.30 kPa; n = 25) from those with low grade varices (46.91 kPa; n = 20). The ROC analysis showed a poor area under the curve of 0.477 for the prediction of high grade varices by the SS. The SS did not show any significant correlation with other ultrasonography parameters except splenic size, with which there was a weak but significant correlation. The measurement of SS by 2D-SWE was reliable and Cronbach’s alpha was 0.905. CONCLUSION: The SS measured by 2D-SWE is not an accurate predictor of variceal grade and thus bleeding in patients of EHPVO. ADVANCES IN KNOWLEDGE: EHPVO is a vascular pathology with most patients showing splenomegaly and preserved liver function. Although, elastography of spleen has been shown to be useful in patients with cirrhosis for predicting portal hypertension, it does not seem to be helpful in patients with EHPVO.

Isolated, metastatic hemangiopericytoma of liver is an extremely rare entity. We present a case of hemangiopericytoma of the liver, metastatic from a meningeal hemangiopericytoma, who presented 10 years after the surgical excision of the primary tumour and morphologically mimicked a hepatocellular carcinoma. We review the literature regarding this entity and discuss the difficulties in preoperative diagnosis and the need for a thorough preoperative evaluation.

The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC). We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version 0.9.5.5 (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673. A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD − 1.63, 95% CI (− 3.23, − 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD − 379.13, 95% CI (− 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved. Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.

To evaluate liver stiffness (LS) in patients of primary extrahepatic portal vein obstruction (EHPVO) using 2D shear wave elastography (SWE) and compare it with healthy volunteers.Fifty patients (mean age: 22.4 years) of EHPVO and 25 healthy volunteers were included in the study. Liver function tests and viral markers were done in both groups and endoscopy in EHPVO group, followed by ultrasonography and SWE of liver. Liver elastography was done with patients/volunteers in supine position through right intercostal space. The LS for right lobe of liver was recorded in kilopascals. Three such measurements were taken and the mean of both groups were compared. The variables were also correlated with mean LS using Pearson's correlation coefficient in EHPVO group.There was no significant difference in the mean LS in patients of EHPVO (5.96 kPa) and healthy volunteers (5.47 kPa) (SWE of liver may be used as a simple additional tool in the diagnosis of patients of EHPVO who show LS values similar to normal liver.

Pseudoaneurysmogastric fistula is a rare consequence of pseudoaneurysms occurring in the vicinity of stomach. They are the result of pseudoaneurysms eroding into the stomach, and represent a life threatening emergency. Urgent surgical intervention is often necessary to salvage the patient. Data regarding the presentation and management of this condition is sparse. Herein, we present our experience with four cases of pseudoaneurysmogastric fistula, their clinical context, presentation, management and outcomes. We attempt to outline an algorithm for the diagnosis and management of this unusual complication.

The word stoma is a Greek word that stands for mouth or opening. The earliest descriptions of stomas date back to the thirteenth century when these were exteriorization of lacerated intestinal wounds [1]. The first stoma was a caecostomy done by Pillore for an obstructing rectal cancer in 1776. The patient succumbed on day 28 postoperatively, possibly due to non-operative causes. However, it wasn’t until 1793, that the first successful stoma was created by Duret for an imperforate anus. This was the era of loop stomas. The first attempt at an end stoma was made by Schitsinger and Madelung in 1881. Till then, only the large intestine had been used to create a stoma. Nearly a 100 years after the first colostomy, Maydl in 1883 did the first successful ileostomy. However, the early ileostomies were crude and associated with large volumes of caustic effluent, leading to skin excoriation requiring pouch systems. The effluent also caused serositis of the bowel, leading to dysfunction of the stoma and eventually obstruction. These ileostomies were 2–3 in. long, to avoid contact of the effluent with the skin and were emptied using a catheter. Eventually the catheter was removed and the stoma matured by itself. In 1952, Brooke in his seminal article described a simple technique of mucosal eversion to avoid serositis. This step significantly reduced the complications of ileostomy. However, the problem of a large volume of effluent continued. To overcome these issues, Kock attempted a continent ileostomy, but this too was associated with problems and did not become very popular. Today, as technology and understanding have evolved, we have come a long way from the crude bags used to collect faeces to sophisticated appliances with skin protective barrier pastes and wafers [1–3]. A brief knowledge of this history is useful to understand how surgical advances have been gradually made to overcome complications and drawbacks of existing procedures. The primary aim of creating a stoma is diversion of enteric contents, either temporary or permanent, depending on the underlying pathology.

The ideal method for managing concomitant gallbladder stones and common bile duct (CBD) stones is debatable. The currently preferred method is two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). This prospective randomized trial compared the success and cost effectiveness of single- and two-stage management of patients with concomitant gallbladder and CBD stones. Consecutive patients with concomitant gallbladder and CBD stones were randomized to either single-stage laparoscopic CBD exploration and cholecystectomy (group 1) or endoscopic retrograde cholangiopancreatography (ERCP) for endoscopic extraction of CBD stones followed by LC (group 2). Success was defined as complete clearance of CBD and cholecystectomy by the intended method. Cost effectiveness was measured using the incremental cost-effectiveness ratio. Intention-to-treat analysis was performed to compare outcomes. From February 2009 to October 2012, 168 patients were randomized: 84 to the single-stage procedure (group 1) and 84 to the two-stage procedure (group 2). Both groups were matched with regard to demographic and clinical parameters. The success rates of laparoscopic CBD exploration and ERCP for clearance of CBD were similar (91.7 vs. 88.1 %). The overall success rate also was comparable: 88.1 % in group 1 and 79.8 % in group 2 (p = 0.20). Direct choledochotomy was performed in 83 of the 84 patients. The mean operative time was significantly longer in group 1 (135.7 ± 36.6 vs. 72.4 ± 27.6 min; p ≤ 0.001), but the overall hospital stay was significantly shorter (4.6 ± 2.4 vs. 5.3 ± 6.2 days; p = 0.03). Group 2 had a significantly greater number of procedures per patient (p

Gallstone pancreatitis is a rare problem in pregnant patients. A primigravida with persistent symptoms of abdomen pain, nausea, vomiting, and inability to tolerate oral diet presented at 5 weeks of pregnancy. A laparoscopic cystogastrostomy with cholecystectomy was performed at 13 weeks of pregnancy. There are only 10 case reports in literature of pseudocyst in pregnancy and in none of them ante partum surgical management was done.

HVOTO and HCC was assessed. Results: Sixteen HVOTO-HCC patients (10 females, 6 males) of mean age of 38 + 11.5 years were studied. Pain was their commonest presenting symptom 10/ 16 (62.5%). No signs of hepatic decompensation were noted. AFP was markedly elevated (mean 43447.1 ng/ ml). On MPCT, all had cirrhosis, mean mass size was 6.2 + 4.7 cm, 14/16 (87.5%) were well-defined, had necrosis 10/16 (62.5%), capsulated 11/16 (68.7%) and predominantly exophytic 10/16 (62.5%). Combined inferior vena cava (IVC) + hepatic vein(HV) block was commonest 12/16 (75%) followed by isolated IVC or HV block in 2 (12.5%) patients each. For HVOTO, 12 patients received therapy [Transjugular intrahepatic portosystemic shunt 1, IVC angioplasty 5, IVC angioplasty + stenting1, HV angioplasty + stenting 3, IVC + HV angioplasty 2]. Complete (CR)/partial response (PR) was achieved in 10 patients, one procedure failed and in one response could not be assessed. For coexistent HCC, 12 patients were treated [Trans-arterial chemoembolization (TACE) 5, TACE plus acetic acid ablation 3, TACE followed by transarterial chemotherapy (TAC) 1, TAC 2 and oral chemotherapy 1]. Tumor response could be assessed in 9 patients (CR 5, PR 4). Conclusion: HVOTO-HCC has unique clinical and imaging features. Treatment requires great skill and expertise as it is mandatory to treat both HVOTO and HCC for an effective outcome.

The authors’ study on the preoperative factors associated with a poor outcome after laparoscopic bile duct exploration made an interesting read [1]. It seems to have been proven beyond doubt that laparoscopic bile duct exploration is more efficient and as safe as endoscopic sphincterotomy in young patients fit for GA. However, its efficiency and safety in the elderly age group and those with comorbidities remains debatable. It is interesting to note that your own study had brought out that laparoscopic CBD exploration is equally safe in the elderly [2]. Furthermore, this study has brought out certain relevant facts regarding the influence of the learning curve. However, it is not clear as to what exactly is meant by the learning curve and until what number of cases do the authors feel they are still inexperienced especially in the context of laparoscopic CBD exploration. Also no mention has been made of the operative time—a factor known to be significantly affected by the learning curve— and how it has correlated with patient outcome. We in our limited experience of approximately 90 cases are in concurrence with your observation that learning curve does not influence the complication rate, although it may affect the conversion rate. In your study, bile leak was the most common complication, occurring in 15.6% of patients. We have reported a transient bile leak of 13.3% in our study [3]. It would be interesting to know the authors’ comments about the possible causes of bile leak. In our opinion, minor bile leaks are associated with a large number of laparoscopic CBD explorations done by choledochotomy due to spasm of lower end of the CBD probably due to instrumentation.