Success Stories

Cancer survivors - Liver cancer and Colorectal cancer

Cancer survivors: This lovely couple - the husband 74 years underwent Hepatectomy for liver cancer with us 4 years ago and wife aged 67 overcame colorectal cancer for which she went through laparoscopic colectomy and chemotherapy with us 3 years ago. Both are leading a full life without looking back and active schedule managing their grandkids. With no evidence of any reccurance in both we expect them to have a long healthy life. Age alone is never a deciding factor in winning over cancer.

ERCP with pancreatic duct stent placement for chronic pancreatitis patients

20 year young man is a known case of early idiopathic chronic pancreatitis. The patient was admitted with complaints of recurrent upper abdominal pain radiating to the back, with inability to gain weight. Patient underwent ERCP. Pancreato-gram taken suggested dilated PD throughout the head and body, with multiple intraductal pancreatic stones. Balloon sweeps were taken with removal of multiple small white, shiny pancreatic stones. 7 Fr x 10 cm pancreatic stent was inserted. Post procedure there was a significant improvement in the patient’s quality of life with no recurrent pain episodes and weight gain.

Conclusion: ERCP with PD stenting can improve symptoms in the select group of patients with chronic pancreatitis.

Mr. AK 50 year male 135 kg with comorbidities uncontrolled diabetes Hypertension, COPD and sleep apnea.

Mr. AK 50 year male. BMI 44. 135 kg with comorbidities uncontrolled diabetes Hypertension, COPD and sleep apnea. Underwent Minigastric bypass. Post procedure doing great with 45 kg weight loss and completely cured of his type 2 diabetes, Hypertension and sleep apnea.

5 years old young girl with chronic pancreatitis with rupture in the pancreatic tube

5 years old young girl with suffering from chronic pancreatitis. In addition to chronic pancreatitis she had a rupture in the pancreatic tube causing a mass & swelling in the tail of pancreas. Due to intractable pain and sitophobia (fear of food) for more than an year with severe malnutrition she had stopped stepping out to play and never been to a school in past 2 years. After arranging funds thru CMRF and welfare workers. We performed a distal pancreatic resection with LPJ (pancreatic drainage procedure). As they are from a village she was lost to follow up after a couple of early post op visits. Now 3 years later they heard about warangal visit and came for follow up. Very happy to see that she is completely pain free and doing well. She has transformed to a very active and playful girl who is her class topper and when I asked her said she wishes to be a doctor when she grows up. God bless her with great life.

Challenging emergency during the COVID: Child’s A CLD with HUGE gastric varices uncontrolled 

Child’s A CLD with HUGE gastric varices uncontrolled by Endoscopic glue and attempted EUS coiling. One salvage option would be TIPSS with balloon vascular occlusion but due to logistics we went for modified sugiura procedure. Splenectomy + Gastro esophageal devascularisation with anterior Gastrotomy and overseeing of gastric varices with pyloroplasty. Images show 1 CECT showing large gastric fundal varices. 2,3,4  Gastro Esophageal devasc 5, 6 Large fundal varices before and after oversewing. 7. Anterior gastrotomy 8. Pyloroplasty. Postoperative recovery was uneventful.

Middle aged female patient came with complaints of chronic upper abdominal pain since 6 months. The pain was mild to moderate, dull aching, non-radiating and not related to meals or defecation. It was not associated with vomiting, jaundice or abdominal lump. CT Abdomen suggested a cystic lesion in the distal body of pancreas of size 3x3 cm without communication with PD. Endoscopic Ultrasound guided Fine-needle aspiration (FNA) was performed and aspirated fluid suggested elevated CEA levels to 1168 with elevated amylase and lipase with mucin stain positive. Patient underwent laparoscopic spleen preserving distal pancreatectomy (Warshaw's technique). The resected specimen suggested mucinous cystadenoma of pancreas. The patient is asymptomatic now.

Morbid obesity with weight 170 kg  and BMI 62 with COPD, severe OSA

Before - after Mrs. SF aged 41 sufferers from morbid obesity weight 170 kg BMI 62 with COPD and severe OSA for which she was on home BIPAP. Her Diabetes was uncontrolled and was suffering from bilateral osteoarthritis. Due to all these factors she became almost fully armchair bound at young age. She is now at post gastric bypass with a weight loss of 90 kg with complete resolution of DM and OSS leading active and productive life.

Laparoscopic spleen preserving distal pancreatectomy (WARSHAW TECHNIQUE) for 35 yr old morbidly obese patient

Laparoscopic spleen preserving distal pancreatectomy (WARSHAW TECHNIQUE) 35 yr old morbidly obese patient with a 4 cm mucinous cyst of pancreas confirmed by EUS cytology and CEA level. Planned for a laparoscopic spleen preserving distal pancreatectomy At surgery as the tumor was posterior and densely adherent to splenic artery and vein we opted for the warshaw technique. In this the short gastrics are preserved and a segment of splenic vessels (art & vein) along the resected pancreas are excised removing them at body and again at splenic hilum (as depicted in video). This way spleen is preserved with blood supply based on the short gastrics avoiding the sequela of asplenia such as thrombocytosis and OPSI. The patient had a smooth postoperative recovery.

55 years old NRI patient from Germany came with history of chronic constipation since 10 years in the form of hard stools, straining, feeling of incomplete evacuation and h/o finger evacuation of stools. 

All the neccessary investigations were done and were normal. Ileo-colonoscopy done suggested a sessile polyp in sigmoid colon of size 1x1cm. Endoscopic submucosal resection was performed. Procedure was uneventful. Biopsy suggested adenomatous polyp with low grade dysplasia.

22 yrs young boy presented with intermittent bleeding per rectum, few drops fresh red in colour without any pain during defecation associated with easy fatigue and generalised weakness. CBP Suggested, iron deficiency anemia. Stool for occult blood for positive, CT suggested, multiple polyps with jejuno-jujunalintusseption. UGI scopy suggested multiple gastric and duodenal polyps. Colonoscopy suggested multiple ileal and colonic polyps. Endoscopic mucosal dissection done for the largest polyp in the stomach and rectum. Histopathology suggested hamartomatous polyps. The case is a rare case of Peutz–Jeghers syndrome. 

45 yrs old male k/c/o Ulcerative colitis since 4 years on mesalamine and azoran. Now admitted with bloody diarrhea with weight loss and pedal oedema. CT and MRI abdomen was s/o thickening of sigmoid colon and rectum with mild luminal narrowing. Colonoscopy done confirmed the findings and biopsies were taken. Rectal EUS and FNA biopies were taken. UGI endoscopy suggetsred a gastric mass from which biopsies were taken. Biopies were s/o high grade DLBCL lymphoma. Patient was started on chemotherapy, R-CHOP regimen with significant improvement. This is a rare case of NHL arising denovo in a case of UC in a immunocompetent male.

REVISION BARIATRIC SURGERY Before - After

Miss PM 30 Years, a gifted artist and painter presented to us 3 years ago at 168 kg after a failed sleeve gastrectomy (weight regain post procedure). She underwent a Revision bariatric procedure - her failed Sleeve was converted Minigastric bypass. 3 years post procedure she has shed 80 kgs plus of excess weight to become 84 kg with marked improvement in mobility and breathing difficulties and a renewed focus on her career.

A beautiful case: Left sided Bochdalek Hernia

51 yr old patient with recurrent vomiting and dyspepsia and left sided chest pain. CT, Barium showed fundus and body of stomach in thoracic cavity with Mesentroaxial Volvulus. (image 1-4) Pre-OP thought to be a large sliding paraesophageal hernia operative findings revealed a posterior defect separate from hiatus suggestive of Bochdalek diaphragmatic hernia with a small hiatal hernia. Repair of Bochdalek defect with Crural repair was performed with mesh reinforcement. A 270 degree fundoplication was added (instead of a 360 as Manometry could not be performed preoperatively) (image 6-10) postoperative recovery was smooth (preop-postop xrays image 11-12).

Interesting Images March 2019 : Patient came with an early stage carcinoma rectum, underwent Hemicolectomy surgery then lost to follow-up. Later after 9 month patients presented to us with Stage 4 disease (Carcinoma colon with Liver secondaries). Then we started her on treatment with Chemotherapy along with Monoclonal antibodies with six cycle of above said treatment patient achieved near complete remission. We could achieve very good results with chemotherapy even in patients with Stage 4 disease (Carcinoma colon with Liver secondaries). 

270 degree toupet fundoplication for GERD with hiatus hernia. Most patients with intractable GERD and hiatus hernia undergo 360 degree Nissan fundoplication. However all patients undergo high resolution Manometry prior to procedure to assess esophageal body peristalisis. This patient was found to have ineffective peristalisis in lower half of esophagus , doing a Nissens would relieve reflux but lead to dysphasia due to ineffective peristalsis. Therefore such patients we do a 270 degree toupet fundoplication.

Total pancreaticoduodenectomy with splenectomy done for a 45 yr female with main duct IPMN with invasive mid-body cancer with bilateral polycystic kidneys. Her EUS, ERCP and fluid cytology , fluid CEA, serum CA19 -9 were all suggestive and a PET showed high uptake in her solid .She is doing well post op but planned for adjuvant CT Rt as had breached capsule and encased splenic vein. Total pancreaticoduodenectomy was frowned upon as a high morbidity surgery due to severe exocrine and endocrine insufficiency with brittle diabetes and ulcerogenicity due to complete loss of pancreatic bicarbonate secretion. But in recent years with easy availability of enzyme supplements, CGM (continuos glucose monitoring devices), insulin pens and long acting PPI the long term QoL of these patients is comparable with partial pancreatectomy patients

A 50 year old lady presented with a jaundice and pain abdomen. She was previously operated thrice for hydatid cyst of left liver over the past decade. Her CT showed a large recurrent multiloculated left lobe lesion along with a daughter cyst in the bile duct. We did not have the biopsy from previous surgery but with a diagnosis of recurrent hydatid cyst we performed a Left hepatectomy with CBD exploration of the daughter cyst. Post operative recovery was in eventful. Final histopathology was suggestive of biliary cystadenoma. Surprisingly the histology of the daughter cyst we removed from CBD also revealed biliary afenomatous hyperplasia. Biliary cystadenomas present with imaging suspiciously similar to complex hydatid / or even simple cyst. They have a high propensity for recurrence and even chance for malignant transformation . When suspected based on preoperative imaging or intraoperative frozen resection is the best approach.

Patient with Type - 3 B hilar cholangiocarcinoma was admitted with obstructive jaundice. His bilirubin was 15 mg%. He had an attempted ERCP outside which failed so underwent a Rt PTBD. He was readmitted for surgery after 3 weeks with a bili of 2 mg%. At diagnostic lap he had evidence of PtBD catheter displacement with bile leak but as patient was not septic he went ahead with an extended left hepatectomy with enbloc caudate lobectomy and bile duct excision and right hepaticojejunostomy to separate Rt anterior and Rt posterior.

A rare case of gastric schwannoma masquerading as a GIST. 52 year old lady presented with massive GI bleed and severe anemia Hb 5.0 gm. Her CT scan and endoscopy revealed a exophytic lesion 10 x 12 cmof gastric body with a ulceration in stomach. She underwent a lap assisted subtotal gastrectomy with a diagnosis of a GIST. Post operative immunohistochemistry revealed a gastric schwannoma. Gastric schwannoma is a very rare mesenchymal tumor arising from the nerve plexus of gastric wall . Unlike gastric GIST of this size >10 cm which are usually the rare malignant schwannoma are entirely benign with excellent long term prognosis.

45 year old lady with classical presentation of tropical /idiopathic chronic calcific pancreatitis presented with reccurant pain 6 months. Her CT scan showed dilated PD 12 mm with large calculi. CA 19-9 was normal, no evidence of biliary obstructuon,there was no evidence of a mass on CT scan. Underwent a freys LPJ with head coring (image 2,3) Day 3 the intraoperative biopsy came as adenocarcinoma. Normally with preoperative suspision intraoperative frozen would have been done but as it was unsuspected only biopsy was done. Once biopsy confirmed Patient was taken up for whipples procedure on D5 after a detailed discussion of risks and benefits and staging CT Chest. Unciante was compeltely removed baring SMA and sparing accesory right hepatic artery (images 4) Reconstruction was done by LPJ to remnant pancreas, HJ and antecolic GJ. This case highlights the high incidence of malignancy in 'tropical pancreatitis" and importance of sending head biopsies even in patients where malignancy is unsuspected preoperatively. Wether a frozen needs to be done routinely is debatable considering the costs and logistics.

Interesting images: Recurrent pyogenic cholangitis (RPC) 67 yr old Bangladeshi lady presented with recurrent episodes of jaundice fever and pain for past 1 year. MRCP and CT scan showed left duct stricture with left sided IHBRD and CBD stones and atrophy of left lateral segment. As she 4 duct was also involved we did a left hepatectomy with hepaticoduodenostomy . Reccurant pyogenic cholangitis is a disease charecterised by multiple instances of biliary bacterial infection, hepatic abcesses , multiple stricturing of bile ducts with pigment stone formation in the intrahepatic and extrahepatic biliary tree. This can cause reccurant episodes of cholangitis, chronic illness ultimately leading to liver failure. It is more common in the far east population. Management includes long term biiary drainage with liver resections for segmental disease and liver transplantation in patients with end stage liver failure . The last CT scan shows another CT scan another similar patient with huge intrahepatic stones and abscesses managed successfully by surgery and long term PTBD.

ALLPS hepatectomy 45 year old child’s A cirrhosis with normal LFT and no portal hypertension.

Interesting images October: ALLPS hepatectomy 45 year old child’s A cirrhosis with normal LFT and no portal hypertension. Planned for a right hepatectomy however intraoperative portal vein pressure was 13 mm ( preferably less than 8 mm) so altered strategy and did ALLPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) In ALLPS stage 1 we ligate portal vein, transect parenchyma fully by hanging and mobilise the right lobe fully. (Image 1,2 and 3) 7 to 10 days (8th day in our Pt)later depending on LFT trend we document the hypertrophy on CT scan and do the completion hepatectomy (pics . Although it has its own shortcomings in selected patients (like in our case ) it has been proven to achieve better degree of hypertrophy compared to Portal vein embolisation / portal vein ligation. Ideally useful for trisectionectomies.

After completing a successful gastric bypass on a 200 kg adult Pace team broke the barrier yet again in super obese by performing bariatric surgery on a 29 year old male with 220 kg weight (BMI 75 Kg/m2) completely bedridden for past 3 months and admitted with obesity related congestive cardiac failure and type 1 respiratory failure . optimisation of cardiac status with diuretics and BiPaP for 2 weeks,we performed a sleeve gastrectomy as a stage 1 procedure following which 2 months patient has now become 180 kg and is ambulant , off oxygen he is planned for a stage 2 gastric bypass after a couple of months. Bariatric surgery on these super obese is a challenging exercise not only for surgeons , but more importantly from a cardiac, Anesthetist, critical care and nursing rehabilitation point of view so Kudos to the Pace team for pulling it off safely and successfully in an extreme high risk Patient.

Interesting images December: Case of post cholecystectomy biliary stricture with complete cutoff and external biliary fistula.Pt was 6 months after injury He was refused surgery elsewhere and told to wait for fistula to close as there was no biliary dilatation. After a complete cutoff the the external biliary fistula mostly closes over a period of time by fistulizing into duodenum. However after 2- 3 month waiting period presence of a persisting fistula there is no need to wait forever. By the hepp- couinad approach the anastomosis is a side to side anastomosis to the extrahepatic left duct which is abt 3-4 cm in length and as you can see in the images despite the apparent lack of dilatation on MRCP we could achieve a wide 3 cm side to side anastomosis to the confluence and left duct. The anastomosis is by a standard parachuting blumgart kelly technique. The lack of biliary dilatation is not a contraindication to reconstructive surgery after BDI after an adequate waiting period.

Interesting images October: 30 yr female presented with recurrent episodes of upper abdominal and lower chest pain since past 2 years. Her endoscopy, Manometry, PH metry, ultrasound EUS, CT abdomen, porphyria and autoimmune workup was normal. CT angio revealed compression of Celiac origin with hook shape deformity and post stenotic dilatation suggestive of median arcuate ligament syndrome. She underwent Laparoscopic release involves dissection of the splenic, left gastric and common hepatic artery till celiac origin and division of crus to expose supraceliac aorta . Both windows are joined by meticulous dissection and in the process the tight band of median arcuate ligament crossing the aorta and compression of celiac origin from above is divided to completely free the celiac origin.

Interesting images December: Disseminated hydatidosis: 58 yr old male underwent emergency surgery for ruptured hydatid cyst 5 years ago. No details of benzimidazole therapy at previous surgery. Now presented with extensive abdominal hydatidosis involving liver (including a large caudate lobe hydatid) ,spleen, pancreas sub diaphragmatic , omental , pelvic and paracolic. We started on albendazole for 1 m but in view of recurrent saio related to peritoneal and omental hydatid we did an extensive debunking including a partial pericystectomies of liver and lesser sac hydatid, omentectomy, excision and peritonectomy for for paracolic and pelvic hydatid. Patient is doing well now 3 months after surgery he is planned for 6 cycles of albendazole with 14 day breaks( literature shows no benefit beyond 6). Reviewing literature in patients with free peritoneal rupture of hydatid in addition to benzimidazoles using praziquantel 600 mg thrice a day can be added as an additional scolicidal to decrease subsequent disseminated hydatidosis. It can act on free scolices but does not penetrate the cyst wall once formed.

Interesting images December: Modified siguira procedure for 36 year old female with extrahepatic portal hypertension taken up for surgery for recurrent gastric variceal bleed . Patient was planned for a shunt but at surgery no shuntable veins so plan changed to modified siguira procedure. It involves splenectomy + devascularization of the distal esophagus through the diaphragm hiatus and the superior two-thirds of the greater and lesser gastric curve taking careful consideration to not ligate the left gastric vein and preserve continuity with azygous. Gastric transection (tanner’s modification) is performed to complete the disconnection. Pyloroplasty is routinely followed to facilitate gastric emptying.

80 yr old male 10th day after hepatectomy for Rt lobe HCC (liver cancer) . No one looking at him will believe he is 80. I requested to share his story to inspire us. The general tendency among people including cancer specialists is to write off patients based solely on advanced age. But like I keep repeating age is just a number. Every patient needs to assessed induvidually. A 60 yr may not be fit for a haircut while a 90 yr old may be fit for a whipples surgery or liver resection (as was the case last year with one of our patients). its the physiological age and frame of mind which matters more than the chronological age. And this is not just in hepatobililiary surgery but in every aspect of life.

Carcinoma gallbladder- 67 yr old lady with polypoidal mass growing gradually over past 3 years. underwent a radical cholecytectomy with 2 cm liver wedge and extended lymphadenectomy of hepatoduodenal, retropancreatic, common hepatic and celiac LN. biopsy revealed papillary adenocarcinoma with no LN involvement. papillary Ca GB has a better prognosis compared to the more common infiltrative variant where resctability rates and outcomes are poor. fundus and proximal body masses may be treated 2 cm wedge or segment 4b and 5 resection while neck masses infiltratate the hilum early , presnt with jaundice and need major liver resections with biliary reconstructio. and poor survival rates.

Major Liver Resections made safer by preoperative portal vein embolisation. 62 year old male with Hepatocellular carcinoma involving segment 4, 5, 6,7 and 8. Approximately 75% of the liver was involved by the tumor.By standard approach the remnant liver 25% (left half) would not be sufficient and lead to high risk of liver failure and death. By preoperative portal vein embolisation (blocking blood supply and nutrition) of the right half of liver the left half was made to grow before surgery so that after resecting the tumor the liver remnant is approximately 40% . By this approach supra major liver resections (removing more than 70% of liver can be safely achieved in even in elderly patients. This patient had a smooth recovery and was discharged by POD7.

Spyglass cholangioscopy: Genuine indications for spy glass scopy are few. The patients in whom diagnosis is not established by standard investigations such as CT scan, MRCP and EUS guided biopsy and in whom the decision for surgery or further intervention depends on biopsy. This was an interesting case of a 70 year old lady with secondary sclerosing cholangitis of unknown etiology for which our gastroenterology team Dr Govind Verma and Dr Vamshidhar Reddy did a spy glass scopy and biopsy followed by ERCP stenting. Biopsy and histology followed by IHC were suggestive of MALT lymphoma.which completely alters the complete managment plan of the patient. This case illustrated the defining role of spyglass in altering managment plan of selected patients with hepatobiliary and pancreatic tumors.

A small celebration with patient and our team at discharge of our 50th pancreatic cancer resection patient in 2 years at PACE hospitals including 35 whipples resections and other types of pancreatic resections. Highlights of this journey have been. A successfully discharged whipples operation in a 89 year old gentleman from East Godavari. Several of our patients were more than 75 yrs. I strongly believe age is just a number and no patient should be written off just based on age without considering physiological status. A remarkable story of whipples with portal vein and hepatic artery resection in a young woman with a 9 kg pancreatic tumor (SPEN) . She underwent a surgery outside where she had massive bleeding due to colletarals . 10 units blood given abdomen was packed and shifted to us for further care. After a 10 hr grueling operation We removed the tumor 2 yrs ago and today i got the good news that she just had a baby boy this morning.

Interesting case: 60 year old male with HCV related well compensated CLD , Childs A status with normal platelets and no varies on endoscopy. presented with HCC involving segment 4, 5 and 8. As we see in imaging option was Rt trisectionectomy which would have been too risky. As right hepatic vein was free. We performed central hepatectomy in which segment 4, 5 and 8 are removed preserving the right posterior segment are preserved.In this unique parenchyma preserving operation the segment 4 and RT anterior pedicure are divided by glissonian approach and MHV is divided. RHV is preserved by CUSA dissection. there by despite central location of tumor enough parenchyma is preserved for safe recovery.it's a very rare and complex surgery only my 3rd in 10 years.

32 year old female with recurrent episodes of abdominal pain since past 3 years was found to have a 6 cm cystic lesion in body and tail of pancreas. Initially thought to be a pseudo cyst due history of recurrant pain. CT showed no evidence of calcification or ductal changes. EUS revealed thick mucinous contents. 

Mucinous cysts of pancreas are unilocular cysts with malignant potential . They can range from benign to borderline to malignant. Diagnosis is by CT scan and cyst fluid analysis. This patient was managed by a laparoscopic distal pancreatectomy with splenectomy (as solenic vein was inseparable)

6 yr old child presented with pain right upper quadrant. USG suggestive of cystic multi spectral mass. CT done and diagnosed a Multiseptated mass involving Right lobe of liver. Diagnosed as a hydatid cyst of liver. However Review of the CT scan revealed several septae to be enhancing. AFP was normal. A diagnosis of mesenchymal hama romaine was made and a right hepatectomy performed. Mesenchymal hamartoma is a benign childhood tumor which is considered a developmental anamoly and may reach huge sizes.it is to be differentiated from hepatoblastoma which is associated with raised AFP and solid/ necrotic component.

35 yr old patient with chronic pancreatitis presented with obstructive jaundice, Bilirubin 25 mg%. He had no history of pain. CT and Endoscopic ultrasound (EUS) did not pick up a mass. However, based on high suspicion due to very high bilirubin, an intraoperative frozen section was done that showed malignancy. The patient underwent a whipples pancreaticoduodenectomy. Lessons learnt :

• Always screen CP patients for malignancy with annual imaging and CA 19-9.
  
• Any new worsening in previously stable disease suspect malignancy
  
• High bilirubin is a 'red flag' unlikely in inflammatory strictures, so even if EUS CT inconclusive, play cautious using frozen sections.
  
• EUS is a very useful tool for preoperative decision-making. 
  

Radiofrequency ablation (RFA) is a adjunct for liver resection. In this process a Multipronged needle creates a sphere like zone of ablation around the tumor to completely destroy the tumor with a margin in a minor akin to a surgery. RFA is as good as surgery for tumors upto 3 cm and for 3-5 it needs to be combined with a modality like embolisation. its extremely useful in patients where surgery is not feasible such as with medical comorbidities, liver cirrhosis or when the tumor is so deep seated such that removing a small tumor entails removal of a major part of liver.

Extended whipples resection done for a case of ductal adenocarcinoma of the head extending beyond the neck into mid body with the transection margin in the distal body at the level of splenic artery. The resection is started from the left of the portal vein by SMA first approach followed by dissection of splenic vein, splenic -portal Jn and portal vein in reverse order.

We can see the transection level of pancreas at the splenic arterial origin.Used judiciously extended whipples surgery can help us achieve margin positive resection in these patients albiet with higher risk of diabetes postoperatively.

In Gastrointestinal or No GI malignancies (ovary,uterus, breast etc) the presence of liver mestastases indicates stage IV disease with poor survival. Neurendocrine tumors (and colorectal cancers) are an exception to this rule. Patients with neuro endocrine tumors have good 10 and 20 yr survival rates especially the well differentiated cancer. This was a patient with a neuroendocrine type I gastric tumor with spread to lymphnodes and a solitary liver metastasis who underwent a gastrectomy (removal tumor bearing stomach) with a D2 Lymphadenectomy (very extnesive lymphadenectomy) and non anatomical resection of liver metastases. We expect an excellent long time survival in this patient despite stage IV disease.other modalities like RFA of liver metasases and Trans arterial chemoembolisation are available for these patients now.

Second time lucky : An unresectable giant pancreatic tumor cured by a complex pancreatic surgery including hepatic artery and portal vein resection

25 yr old young software employee underwent attempted whipples (complex pancreatic surgery) for a 15 x15 cm pancreatic tumor unfortunately at surgery the tumor was found involving hepatic artery and portal vein ( the main blood supply of the liver) and she was told that it is incurable as the crucial blood vessels to liver were involved. After a detailed discussion about risks involved patient underwent a grueling 12 hour operation (due to extensive vascular adhesion) of whipples pancreaticoduocenectomy with a resection and anastomosis of hepatic artery and portal vein. postoperative recovery was smooth. She continues to do well 1 yr after surgery getting back to her job and life

Hepatoblastoma is a rare childhood tumor which usually occurs in children younger than 3 years of age. It is usually managed by surgery with chemotherapy before or after surgery. gita was a 2 yr old child with tumor involving right half of liver with elevated alfa fetoprotein suggestive of hepatoblastoma. Most of these patients usually present in a more advanced stage and are managed by chemotherapy followed by surgery. In case of gita tumor was involving on 4 out of 8 segments of liver so she was planned for a primary surgery. followed by chemotherapy. She underwent a surgery in which approximately 65% of liver was removed with the tumor. Post operative recovery was smooth. Kudos to the anaesthesist and critical care team for helping us accomplish this rare surgery in a young child.

Central pancreatectomy involves removal of only the tumor bearing portion of pancreas after meticulously separating it from vessels. The distal pancreas is preserved in contrast to the standard distal pacreatectomy for students. This leads to better preservation of exocrine and endocrine function. If expertise in pancreatic surgery is available this operation in selected patients of cystic pancreatic neoplasms allows a better quality of life after surgery. Postoperative recovery was smooth. Biopsy revealed a serous cystadenoma of pancreas which heals excellent long term outcomes.