CASE STUDIES

Success Stories

Hepatectomy for Rt lobe HCC (liver cancer)


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 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.

Radical cholecytectomy for carcinoma gallbladder


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


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


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.

50th Pancreatic Cancer Resection in 2 years


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.

Central hepatectomy


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.

Cystic neoplasms of pancreas 


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)

A rare childhood tumor


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.

Chronic pancreatitis (CP) and malignancy


35 yr old patient with chronic pancreatitis presented with obstructive jaundice Bilirubin 25mg%. 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 . 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.

Advances in Liver surgery


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 for ductal adenocarcinoma


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 can help us achieve margin positive resection in these patients albiet with higher risk of diabetes postoperatively.

Cancer spread to liver is not always the end of the road !


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.

Complex pancreatic surgery


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

2 year girl with rare childhood liver tumor sucessfully managed with a major liver resection


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.

Unique pancreas preserving operation


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.

Awards & Recognition 

Over the years, PACE has been recognized by numerous organizations for its commitment to exceptional patient outcomes, leadership, innovations and excellence. PACE stands at par with most progressive and advanced standards of health and healthcare delivery and has received the 2015 awards for :-

Awarded Best Gastroenterology Hospitals in South India

*by Worldwide achievers

Awarded Best Nephrology and Urology
Hospitals in South India

*by Worldwide achievers
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