Kumble Seetharama Madhusudhan

Objective To compare perioperative safety and long-term functional outcomes of esophageal resection versus substitution-alone in patients with corrosive esophageal strictures refractory to endoscopic dilatation. Methods This prospective, single-center, open-label, parallel-group, non-inferiority randomized controlled trial was conducted at a tertiary referral center in India. Patients aged 14–60 years with corrosive esophageal strictures unresponsive to serial dilatation were included. Participants were randomized in a 1:1 ratio to either esophageal resection or substitution-alone group. The primary outcome was incidence of postoperative pulmonary complications (PPC) within 30 days. Secondary outcomes included operative parameters, postoperative morbidity, mortality, and health-related quality-of-life (HRQOL) assessed using the Gastrointestinal-Quality-of-Life-Index (GIQLI). Results Between September 2012 and December 2023, 143 patients were randomized (resection, n=69; substitution-alone, n=74), and all were analyzed. PPC occurred in 11.6% of the resection group and 8.1% of the substitution-alone group (absolute risk difference, 3.5%; 95% CI −6.3% to 13.3%); the prespecified non-inferiority criterion was not met. Mediastinal dissection time was significantly longer in the resection group (48 ± 28 vs 22 ± 8 min; p < 0.001). However, total operative duration, blood loss, cervical anastomotic leak rates, recurrent laryngeal nerve palsy, and length of hospital stay were comparable between groups. One mortality (0.7%) occurred in the resection group due to a colo-colic anastomotic leak. At 12-months, mean GIQLI scores were higher following resection (118.6 ± 11.2 vs. 111.2 ± 12.8; p=0.08). Conclusions Esophageal resection and substitution-alone were associated with comparable perioperative outcomes in patients with corrosive esophageal strictures. Although formal non-inferiority of esophageal resection was not established, no significant difference in PPC was observed. The higher HRQOL scores following resection should be considered exploratory. Trial registration Clinical Trials Registry of India (CTRI/2015/10/006237).

Introduction: SMA‐first‐approach in pancreaticooduodenectomy (PD) was found to be associated with better oncological outcomes as compared to the standard approach both in our pilot study and a few retrospective studies. Hence, we performed a randomized controlled trial to compare these two approaches in terms of resection margins, lymph node‐retrieval, and long‐term survival. Methods: Between January 2014 to December 2018, all the consecutive patients undergoing PD for periampullary cancer at the Department of Gastrointestinal Surgery, AIIMS, New Delhi were assessed for randomization. Primary outcomes were R0 resection rate and number of lymph nodes retrieved. The secondary outcomes were operating time, blood loss, postoperative complications, recurrence free and overall survival. Results: Of 299 patients assessed, 203 were randomized and 183 analyzed (20: excluded after randomization, 90: patients‐SMA, 93: patients‐classical). The median age of the study population was 56 (14‐78) years, with predominantly male (138, 68%) and with periampullary tumors (89%). The demographic profile, preoperative clinical and laboratory parameters were comparable. The blood loss was significantly higher in SMA first group (675 vs 600 ml, p = 0.02), however the operating time and the need for blood transfusion were comparable in both groups. ISGPS Grade B/C pancreatojejunostomy leak (20 vs 24.7%, p = 0.68), post‐pancreatectomy hemorrhage (8.8 vs 14%, p = 0.38), delayed gastric emptying (37.8 vs 40.9%, p = 0.67) and Clavien–Dindo grade ≥III complications(27.7 vs 31.2, p = 0.85) were similar in both the groups. The R0 resection rates (82.2 vs 78.5%, p = 0.53) and total lymphnodes retrieved (18 vs 17, p = 0.63) were similar between the two groups. Both groups were comparable in terms of median recurrence free (48 vs 44 months, p = 0.85) and overall survival (53 vs 51 months, p = 0.69). Conclusions: ‘Posterior (SMA‐first) approach’ and ‘Standard approach’ for pancreatoduodenectomy for periampullary cancer yielded equivalent results in terms of R0 resection rate, number of lymph nodes retrieved, recurrence‐free and overall‐survival.

Objectives To evaluate the safety, efficacy and clinical scenarios of ultrasound guided direct percutaneous embolization (DPE) of abdominal artery pseudoaneurysms (PAs). Materials and methods This retrospective study included 28 patients (mean age: 36.3 years; 23 males) who presented with abdominal hemorrhagic symptoms, showed PA on CT angiography and underwent DPE under ultrasound guidance between January 2016 and December 2023. The scenarios, clinical and embolization details, success rates and complications were evaluated. All patients were followed up with 24-hour US and then clinically (n = 28) and by imaging (n = 6) for 30 days. Results Etiology of PAs were inflammatory (n = 16) and iatrogenic (n = 12). Right hepatic artery was the most common source (n = 9). DPE was performed upfront in 12 patients (42.9%), after angiography failed to show the source artery in 7 patients (25.0%) and in combination with endovascular embolization in 4 patients (14.3%). In the remaining 5 patients (17.9%), DPE was performed for recurrence of the PA after endovascular embolization. The technical success was 100.0%. N-butyl cyanoacrylate (NBCA) with iodized oil was the embolic agent used in all the patients (mean volume 1.13 ± 0.88 mL, median concentration 50.0%). Thrombin was used in addition to NBCA in two patients. The primary clinical success was 89.3% (25/28), with three patients showing patent PA at 24 hour follow up ultrasound. These underwent successful repeat DPE with NBCA (n = 2) and thrombin (n = 1) with a secondary clinical success rate of 100.0% (3/3). There were no major complications. Clinically insignificant non-target embolization was seen in two patients. Conclusion Ultrasound-guided direct percutaneous embolization appears to be a feasible, safe, and effective treatment option for abdominal artery pseudoaneurysms in selected patients with short-term follow-up.

Congenital anomalies of the biliary tracts are diverse and involve the intrahepatic and extrahepatic bile ducts, gallbladder, and cystic duct. Prompt imaging evaluation and accurate diagnosis are important for optimal management. Ultrasonography is often the first-line modality that gives a clue to the diagnosis. Magnetic Resonance Cholangiopancreatography is, however, required in most cases for a proper diagnosis. Computed Tomography, hepatobiliary scintigraphy, and direct cholangiography may be needed in selective cases. Integration of multimodality imaging not only enhances the diagnostic accuracy but also guides optimal surgical approaches. This review aims to enhance the understanding of the imaging spectrum of congenital biliary anomalies for radiologists.

Biliary strictures are narrowings involving any part of the biliary tree, intrahepatic or extrahepatic. This pathology has various etiologies, including benign and malignant. Patients mostly present with jaundice and features of cholangitis. Although ultrasonography is the initial modality in most cases, computed tomography scan and magnetic resonance imaging form the main imaging techniques that help in the localization and characterization of the strictures and assist in providing a definite or possible diagnosis. This review provides an overview of the role of imaging in the evaluation of biliary strictures.

Purpose To compare the image quality, definition of vascular invasion and radiation dose of split bolus dual energy CT (DECT) with standard multiphase CT in biliary malignancies. Materials and methods This prospective study performed from December 2020 to November 2022 included 88 patients of biliary malignancies randomized into two groups and scanned on rapid-switching dual energy CT scanner. Group 1 (n = 43, mean age: 54.6 years, 12 males) underwent the standard multiphase protocol (MPP; arterial, venous phases), while group 2 (n = 45, mean age: 52.6 years, 20 males) underwent split bolus dual-energy protocol (SBP; split-bolus phase). The mean attenuation, contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of tumor, liver and hepatic vessels were measured and compared between the two groups along with dose-length product. Two readers independently assessed image quality and vascular invasion (5-point Likert scale) in each phase and inter-reader agreement was compared within groups. Mann Whitney U-test and kappa statistics were used for comparison. Results The mean attenuation, CNR and SNR of arteries were significantly higher in the arterial phase of group 1 and significantly lower in the venous phase of group 1 than the SBP of group 2 (p < 0.001). The quantitative parameters of veins and tumor between venous phase (group 1) and SBP (group 2) were comparable. Good-to-strong inter-reader agreement (k = 0.45 to 0.75) for image quality for both protocols was observed. For hepatic arterial invasion, the SBP had significantly higher inter-reader agreement compared to the arterial phase of MPP (p < 0.001). The SBP had a 37% lower radiation dose than the MPP (p < 0.001). Conclusion The image quality of SBP was non-inferior to the standard MPP for biliary malignancies. However, SBP showed significantly better inter-observer agreement for arterial invasion indicating better assessment of vascular involvement with significantly lower radiation dose. Clinical relevance Biliary malignancies are better defined in the venous phase in which arteries are indistinct, making arterial invasion assessment tough. SBP overcomes this by clearly depicting arteries and tumor in the same phase for confident assessment.