Raghav Nayar

Mukesh Kumar Olaniya, Raghav Nayar, Subash Gupta, Ruchi Rastogi, Hetal Pampaniya, Peush Sahni. Clin Transplant Res -0001;0:. https://doi.org/10.4285/ctr.26.0019

Introduction: Postoperative nutrition after pancreatoduodenectomy (PD) remains controversial. Although many centers routinely place a feeding jejunostomy tube (FJT) after PD, it is associated with morbidity. We conducted this study to compare the perioperative outcomes with and without FJT placement post‐PD. Methods: This was an open‐label randomized controlled trial, in which the FJT was placed in one arm and the nasojejunal tube (NJT) in the other. All patients with periampullary neoplasm who underwent pylorus resecting PD were included in this study. The primary outcome assessed was clinically relevant delayed gastric emptying (CR‐DGE), and the secondary outcomes were clinically relevant postoperative pancreatic fistula (CR‐POPF), postoperative complications, and hospital stay. Results: Forty patients were allocated to the FJT and NJT groups, and the two groups were comparable in baseline demographics, disease characteristics, and perioperative outcomes, including CR‐POPF rates. The FJT group had a significantly higher CR‐DGE rate (55% vs. 25%, p = 0.006), required increased use of prokinetic drugs (77.5% vs. 45%, p = 0.003), and had a longer median postoperative hospital stay (11 vs. 9 days, p = 0.007). Both groups had similar tube‐related complications. In the NJT group, 22.5% of the patients with CR‐DGE required parenteral nutrition. On multivariate analysis, the presence of FJT [adjusted odds ratio (aOR), 6.030 (1.431–25.402), p = 0.014] and intra‐abdominal collection [aOR, 7.108 (1.026–49.224), p = 0.047] were independent risk factors for CR‐DGE. Conclusion: Post‐PD placement of FJT was an independent risk factor for CR‐DGE. Hence, the routine use of the FJT can be omitted after PD without compromising postoperative morbidity and nutrition. Trial Registration: The trial was registered with the Clinical Trial Register with CTRI number: CTRI/2021/02/030942 ( https://ctri.nic.in/Clinicaltrials/advancesearchmain.php )

Corrosive-induced stricture of the esophagus is associated with long-standing morbidity. Though required in particular situations, esophagectomy circumvents the long-term complications of the remnant scarred native esophagus. We performed a robotic Ivor-Lewis esophagectomy for corrosive esophageal stricture and demonstrated its feasibility for the same. A young male patient presented with a history of caustic ingestion, leading to a long segment stricture in the lower third of the esophagus. He developed absolute dysphagia, which was refractory to endoscopic dilatation. A robotic approach was utilized to create a gastric conduit followed by intrathoracic esophagogastric anastomosis. He had a smooth postprocedure course, was discharged on a soft diet on the seventh postoperative day, and is doing well after six months of follow-up. The robotic Ivor-Lewis approach can be safely performed for corrosive esophageal stricture, akin to esophageal malignancy. Besides the comfort of performing the procedure, especially intra-thoracic anastomosis, it helps alleviate the chances of mucocele formation and sequelae of cervical neck anastomosis.

Duodenal gastrointestinal stromal tumours (D-GISTs) are a rare disease. It may arise commonly from the second or third part of the duodenum and can be erroneously diagnosed as a pancreatic head tumour due to proximity and morphology on imaging studies. We present a case of a 60-year-old woman who presented with abdominal pain and was diagnosed as a case of pancreatic neuroendocrine tumour on radiologic imaging and granulomatous lesion on aspiration cytology. A ~5×3 cm mass was noted in the pancreatic head on laparotomy, and pancreatoduodenectomy was performed. Histopathology reported an exophytic GIST arising from the second part of the duodenum. Hence, D-GIST can invade the pancreas and mimic pancreatic head tumours; therefore, these tumours should be kept in the differential diagnosis of an atypical pancreatic head mass.

Feeding jejunostomy (FJ) is a common surgical procedure for patients presenting with absolute dysphagia. Jejunostomy tube-induced intussusception is an extremely rare complication associated with it and its recognition and proper management are necessary to prevent subsequent bowel ischemia of the intussusception. We present a rare case with simultaneous intussusception at two sites in a patient who underwent Fl with Foley's catheter one month back and subsequently managed by surgical reduction and repositioning of the FJ tube.

Endoscopic retrograde cholangiography related duodenal perforation is an infrequent complication and associated with significant morbidity. The management of such perforations, especially in the setting of malignancy, is not standardized given the paucity of literature. We encountered a patient who was diagnosed with periampullary carcinoma and had a perforation in the duodenum during endoscopy. Emergency pancreatoduodenectomy (EPD) was performed considering it to be a resectable disease with minimal contamination. He had a prolonged hospital course due to surgical site infection and hepaticojejunostomy leak, however, which was managed successfully. At one year follow up, he is healthy with no evidence of recurrence. We conclude that EPD can be attempted for selected iatrogenic duodenal perforations with co-existent resectable malignancy in a stable patient. It may help to avoid the morbidity of a second surgery in the setting of a distorted anatomy and simultaneously preventing the probable upstaging of disease due to peritoneal seedling.

Corrosive-induced stricture of the digestive tract is a dreaded complication following corrosive ingestion. When surgical reconstruction is needed, esophagectomy helps to avoid the long-term complications related to leaving behind the scarred native esophagus. We tried to ascertain the feasibility and safety of a thoracolaparoscopic-assisted esophagectomy in such a setting. A 32-year-old male presented with corrosive-induced esophageal stricture that lead to progressive dysphagia not amenable for endoscopic dilatation. Thoracoscopic approach was used for mobilization of the scarred esophagus under vision. Laparoscopic approach was used in mobilizing the stomach and creating a conduit. Esophagogastric anastomosis was performed in the neck. The patient had an uneventful recovery postoperatively and was discharged after six days on a semisolid diet. Thoracolaparoscopic-assisted esophagectomy can be safely performed for corrosive strictures of the esophagus. Besides improving the ease of performing the procedure, it also helps mitigate the morbidity associated with conventional open surgery in such cases.