Background and objectives Direct cholangiography (DC) involves introducing contrast media into biliary system. Choice of technique, push injection (PIC) or gravity drip (GDC), affects the risk of complications post-procedure. A pilot study conducted at our centre suggested, major adverse reactions were significantly more common in PIC than GDC. We conducted a randomised controlled trial, to validate the results of the pilot study, by comparing two techniques for adverse reactions and efficacy. Also, we describe a, modified GDC technique which is economic and safe. Methods A randomized controlled trial was conducted from November 2023 to May 2024 including all patients requiring DC. Patients with active cholangitis or complete biliary obstruction were excluded. After randomisation in two groups i.e., PIC and GDC, participants were observed within 24 hrs post procedure, for adverse reactions and efficacy of cholangiography. (CTRI/2023/10/059252). Results 64 eligible candidates were randomised into two groups- GDC and PIC groups (32 in each group). 6 had displaced tube and 4 in GDC group had long standing blocked tubes requiring PIC. Procedure failure rate of GDC was 12.9% (v/s 0%, p = 0.001). As per protocol analysis, minor adverse effects were seen in 11.1% in GDC group and 41.9% in PIC group (p = 0.009). While major adverse effects were seen in 7.4% in GDC group and 35.5% in PIC group (p = 0.011). This significant difference in translated into a higher overall treatment cost (3.7% v/s 25.8% p = 0.029). Both techniques were equally efficacious. Conclusion We advocate routine use of modified gravity dependent technique of contrast media administration for its safety.

Background - Roux-en-Y Hepaticojejunostomy (RYHJ), the standard of care for the definitive treatment of a benign biliary stricture (BBS), may not suffice in patients of BBS with non-reconstructable ducts, atrophy Hypertrophy complex, associated vascular injury, chronic cholangiolytic abscesses or suspicion of malignancy. This study aims to analyze and report the experience of a tertiary care Surgical Gastroenterology center in North India on this subset of BBS where Hepatectomy has been offered as an option. Patients and Method - A retrospective analysis of a prospective database of patients with BBS requiring Hepatectomy from January 1989 to December 2022. Results - 962 patients were treated for BBS during the period – Eighteen (1.87%) of them required Hepatectomy. All patients had high strictures (16 type IV and 2 Type V) with extensive scarring leading to non-reconstructable ducts in 9 (50%), atrophy Hypertrophy complex in 9 (50.0%), Hepatolithiasis in 6 (33.3%), chronic cholangiolytic abscesses in 4 (22.2%), and cirrhosis with portal hypertension in one (5.5%). Associated vascular injuries were present in 8 (44.4%). Mean operating time and blood loss were 10.2hours and 889ml, respectively. Clavien-Dindo Grade ≥ 3 morbidity was seen in 38.9% including two post-operative mortalities (11.1%). At a mean follow-up of 62.8 months, good outcome was seen in 87.5%. Conclusion - In patients with high strictures associated with complications like Non-reconstructable ducts, Atrophy-hypertrophy, vascular injury and/or cholangiolytic abscesses, Hepatectomy may be an optimal therapeutic option providing good long term results with acceptable morbidity and mortality.

Diagnosing biliary strictures remains challenging, as benign inflammatory conditions may closely simulate malignancy on clinical and radiological evaluation. With proper patient selection and surgical expertise, minimally invasive surgery (MIS) provides safe staging and definitive management without compromising oncologic principles for suspicious biliary strictures. We report a 30-year-old male presenting with painless progressive jaundice, weight loss, and cholestatic jaundice with imaging features suspicious for malignancy. Despite the endoscopic decompression, the cross-sectional imaging and tumor markers were inconclusive, necessitating surgical exploration. Also, as the pre-operative suspicion was of gall bladder malignancy involving the bile duct and not cholangiocarcinoma, work-up for cholangioscopic biopsy or cytology was not done, nor was any attempt made for the biopsy by the rendezvous technique. The patient underwent laparoscopic extended cholecystectomy with bile duct excision and biliary reconstruction, and histopathology revealed granulomatous cholecystitis with choledochitis without evidence of malignancy. Granulomatous biliary disease, although uncommon, frequently mimics gallbladder or biliary cancer. Post-operatively, the patient was further evaluated and found to be negative for sarcoidosis. This scientific case report underscores the importance of maintaining a high index of suspicion for benign inflammatory mimics and recognizing that histopathology remains the definitive diagnostic standard in granulomatous biliary strictures.

BACKGROUND:Stomal complications though small in early postoperative period, but poses significant morbidity, therapeutic challenge, delay in adjuvant treatment and sometimes even leads to mortality. Predictive model for early detection of stomal complications is important to improve the outcome. A model including patients and disease related factors, intraoperative surgical techniques and biochemical markers would be a better determinant to anticipate early stomal complications. Incorporation of emerging tools and technology such as artificial intelligence (AI), will further improve the prediction. AIM:To identify various risk factors and models for prediction of early post operative stomal complications in colorectal cancer (CRC) surgery. METHODS:Published literatures on early postoperative stomal complications in CRC surgery were systematically reviewed between 1995 and 2024 from online search engines PubMed and MEDLINE. RESULTS:Twenty-four observational studies focused on identifying various risk factors for early post operative stomal complications in CRC surgery were analyzed. Stomal complications in CRC are influenced by several factors such as disease factors, patient-specific characteristics, and surgical techniques. There are some biomarkers and tools loke AI which may play significant roles in early detection. CONCLUSION:Careful analysis of these factors, changes in biochemical parameters, and application of AI, a predictive model for stomal complications can be generated, to help in early detection, prompt action to achieve better outcomes.

Gall bladder cancer (GBC) remains a highly aggressive disease, with an overall 5-year dismal survival rate of 15%-20%. Its asymptomatic nature in very early stages and non-specific clinical presentations pose significant challenges to timely detection. Consequently, GBC often presents late, making it one of the most challenging cancers to manage. Surgery offers the best chance for long-term survival; however, only 10% of GBC patients are candidates for upfront resection, with the majority presenting in locally advanced or metastatic stages. Furthermore, GBC is generally resistant to chemotherapy and radiotherapy, limiting the effectiveness of systemic therapy. Therefore, early diagnosis is crucial to offer the best treatment through surgical resection and to improve the outcome. Recent advancements in imaging technologies, biomarker discovery, and molecular diagnostics offer promising avenues for enhancing detection rates. Though non-invasive, most of them lack specificity, and the majority fail as an early diagnostic tool. This review examines the current status of early detection strategies for GBC, addresses the limitations of existing approaches, and explores the newer emerging diagnostic tools and techniques and how they can be exploited in future for its early detection.

BACKGROUND:Low rectal cancer poses a significant surgical challenge because of its close proximity to the anal sphincter, often requiring radical resection with permanent colostomy to achieve oncological safety. Revisited rectal anatomy, advances in surgical techniques and neoadjuvant therapies have enabled the possibility of sphincter-preserving procedures, however, it is uniformly not applicable. Selecting appropriate candidates for sphincter preservation is crucial, as an ill-advised approach may compromise oncological outcome or lead to poor functional outcomes. Currently there is no consensus - which clinical, anatomical, or molecular factors most accurately predict the feasibility of sphincter-preserving surgery (SPS) in this subset of patients. By identifying these predictors, the study seeks to support improved patient selection, enhance surgical planning, and ultimately contribute to better functional and oncological outcomes in patients with low rectal cancer. AIM:To identify predictive factors that determine the feasibility of SPS in patients with low rectal cancer. METHODS:A comprehensive literature search was conducted using PubMed/MEDLINE databases. The search focused on various factors influencing the feasibility of SPS in low rectal cancer. These included patient-related factors, anatomical considerations, findings from different imaging modalities, advancements in diagnostic tools and techniques, and the role of neoadjuvant chemoradiotherapy. The relevance of each factor in predicting the potential for sphincter preservation was critically analyzed and presented based on the current evidence. RESULTS:Multiple studies have identified a range of predictive factors influencing the feasibility of SPS in low rectal cancer. Patient-related factors include age, sex, preoperative continence status, comorbidities, and body mass index. Anatomical considerations, such as tumor distance from the anal verge, involvement of the external anal sphincter, and levator ani muscles, also play a critical role. Additionally, a favourable response to neoadjuvant chemoradiotherapy has been associated with improved suitability for sphincter preservation. Several biomarkers, such as inflammatory markers like interleukins and C-reactive protein, as well as tumor markers like carcinoembryonic antigen, are important. Molecular markers, including BRAF and KRAS mutations and microsatellite instability status, have been linked to prognosis and may further guide decision-making regarding sphincter-preserving approaches. Artificial intelligence (AI) can further add in to select an ideal patient for sphincter preservation. CONCLUSION:SPS is feasible in low rectal cancer and depends on patient factors, tumor anatomy and biology, preoperative treatment response, and biomarkers. In addition, tools and technology including AI can further help in selecting an ideal patient for long term optimal outcome.

The development of portal cavernoma cholangiopathy (PCC) in cases of extrahepatic portal vein obstruction (EHPVO) presents significant management challenges. Strictures, stones, and extensive collaterals at the porta hepatis contribute to considerable surgical complexity. The traditional surgical approach for such patients involves a portosystemic shunt, followed by hepaticojejunostomy when indicated. In carefully selected cases, left lateral sectionectomy combined with intrahepatic cholangiojejunostomy (Longmire’s procedure) offers a viable and durable long-term solution. We present two cases where this approach was successfully employed. Both the patients had sub-hilar strictures, and a large stone burden localized to the left lateral section of the liver. Conventional hepaticojejunostomy was contraindicated due to a heavily collateralized hilum, which precluded a safe landing zone. In these two cases, left lateral sectionectomy was performed to clear the large intrahepatic stone burden, with intrahepatic cholangiojejunostomy providing effective biliary drainage while avoiding the heavily collateralized hilar and pericholedochal regions.

Chronic constipation is a gastrointestinal condition which significantly affects the quality of life in the majority. Its prevalence is reported to be 14

Background: Anastomotic leak (AL) following colorectal surgery can lead to significant morbidity andmortality, with an incidence ranging from 2% to 14%. Early diagnosis and management are crucial forimproving patient outcomes. However, the clinical detection of leaks is often delayed, adversely affecting theseoutcomes. Therefore, there is a pressing need for serum markers that can serve as diagnostic tools prior to theonset of clinical manifestations. The objective of this study is to investigate the changes in serum C-reactiveprotein (CRP), albumin, leukocyte indices, and interleukin-6 (IL-6), and to access their association with AL incolorectal anastomosis.Methods: This prospective observational pilot study included 30 patients undergoing elective colorectal resectionand anastomosis for both benign and malignant conditions at the Department of Surgical Gastroenterology,SGPGIMS Lucknow, a tertiary care teaching hospital in northern India, from April 2021 to March 2022.Serum C-reactive protein (CRP), albumin, total leukocyte count (TLC), complete blood counts, platelet count,and IL-6 levels were measured preoperatively and postoperatively. Patients were divided into two groups:Group 1, which experienced anastomotic leaks, and Group 2, which did not. Changes in these markers werecompared preoperatively and on postoperative days (POD) 1, 3, and 7. To compare the changes between groups,the Mann–Whitney U test was utilized, and multivariate analysis was conducted to identify predictors ofanastomotic leaks using Firth logistic regression. A P value of <0.05 was considered statistically significant.Results: Group 1 comprised 4 patients (13.3%), while Group 2 included 26 patients (86.7%). A statisticallysignificant difference was observed in serum CRP levels (P=0.001), neutrophil-to-lymphocyte ratio (NLR)(P=0.009), and serum IL-6 levels (P=0.03) on POD 3 between group 1 and group 2. In the multivariate analysisutilizing Firth logistic regression, serum CRP exhibited OR=1.09 and NLR demonstrated OR=1.28.Conclusion: A significant increase in serum CRP, NLR, and IL6 on POD 3 may serve as valuable markers forthe early detection of AL.

Background Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is often considered the preferred surgical treatment for ulcerative colitis. This study was conducted to investigate the early and late complications of ileal pouch-anal anastomosis in patients with ulcerative colitis, as well as the factors associated with these complications. Methodology All relevant clinical and operative data of patients (n = 101) who underwent IPAA for ulcerative colitis between January 1995 and December 2018 were retrieved from a prospectively maintained database. Early complications, various late complications, and their predictive factors were studied. Results A total of 101 patients underwent IPAA. Early complications (≤30 days) occurred in 72 (71.3%) patients, mostly Clavien-Dindo grades 1 and 2. No significant risk factors were associated with early complications. Among the late complications, pouchitis was the most common complication (n = 37, 36.6%), followed by anastomotic stricture (n = 27, 26.7%). Pouch failure was seen in 11 (10.9%) patients. No significant factors were found to be associated with the development of pouchitis. Pelvic sepsis (odds ratio (OR) = 2.704, 95% confidence interval (CI) = 1.041-7.022, p = 0.041) and handsewn anastomosis (OR = 3.943, 95% CI = 1.093-14.229, p = 0.036) were significantly related to the development of anastomotic stricture and pouch-vaginal fistulae, respectively. Conclusions The most common early and late complications following IPAA were pelvic sepsis and pouchitis, respectively. These complications were managed successfully with an acceptable pouch failure rate. No predictive factor was found to be significant with early complications. However, pelvic sepsis and hand-sewn anastomosis were associated with stricture formation and pouch vaginal fistulae, respectively.

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Introduction Metastatic CRC is considered as a heterogenous disease. Its management is therefore complex and dynamic. In order the give a ready reference to community oncologists, we developed this real world recommendations. Methods A group of experts with academic background and real world experience in mCRC got together. We reviewed the current literature and the insights gained from our real world experience. Based on the same we put together these recommendations. Recommendations (Results) Molecular testing should be done wherever possible. Most of these patients will be treated with a palliative approach. Doublet chemotherapy is a long-standing standard of care. Triplet therapy may be offered where a more aggressive approach is indicated. Combination with anti -vascular endothelial growth factor antibodies and/or anti EGFR antibodies is also considered standard. In the first-line setting, pembrolizumab can be used for patients with mCRC and microsatellite instability-high or deficient mismatch repair tumours; Left and right sided tumours are distinct entities. Combination of chemotherapy and targeted therapy is used as per individual patient and tumour characteristics.Oligometastatic disease can be approached with potentially curative intent. Cytoreductive surgery plus chemotherapy can be offered to selected patients with peritoneal only metastases. Stereotactic body radiation therapy can be used as local therapy for patients with oligometastatic liver only disease who cannot be taken up for surgery. New strategies include induction-maintenance chemotherapy and perioperative chemotherapy. All drugs/ regimen included as standard of care in the first line can also be used in subsequent lines. Specific targetable driver mutation tumours can be treated accordingly with their complementary biological therapy. Conclusion Multidisciplinary team management and shared decision making are possible when patient and caregivers choose to become active participants.

Colorectal diseases are increasing due to altered lifestyle, genetic, and environmental factors. Colonoscopy plays an important role in diagnosis. Advances in colonoscope (ultrathin scope, magnetic scope, capsule) and technological gadgets (Balloon assisted scope, third eye retroscope, NaviAid G-EYE, dye-based chromoendoscopy, virtual chromoendoscopy, narrow band imaging, i-SCAN, etc. ) have made colonoscopy more comfortable and efficient. Now in-vivo microscopy can be performed using confocal laser endomicroscopy, optical coherence tomography, spectroscopy, etc. Besides developments in diagnostic colonoscopy, therapeutic colonoscopy has improved to manage lower gastrointestinal tract bleeding, obstruction, perforations, resection polyps, and early colorectal cancers. The introduction of combined endo-laparoscopic surgery and robotic endoscopic surgery has made these interventions feasible. The role of artificial intelligence in the diagnosis and management of colorectal diseases is also increasing day by day. Hence, this article is to review cutting-edge developments in endoscopic principles for the management of colorectal diseases.

Gastrointestinal (GI) surgery has evolved into a crucial super specialty among surgical branches in India. This subspecialty, as such, does not exist in many countries across the world but in organ/system-based specialization. In India too, it is branching into multiple branches by several driving forces—colorectal surgery, HPB (hepato-pancreato-biliary) surgery, upper GI surgery, minimally invasive surgery, liver transplantation, and others. Many GI surgery residents choose to pursue fellowship degrees in various GI subspecialties after completing their MCh training. Others opt to go directly into subspecialty fellowships after completing general surgery training program. This article provides insights into the current status of GI surgery as a superspecialty, focusing on its history, current status, various subspecialties, and the driving forces behind its subspecialization.

Background: Colonic lipomas are rare benign neoplasms within the gastrointestinal tract.They are often asymptomatic but can cause abdominal pain and other symptoms when they exceed 2 cm.Diagnosis involves imaging and colonoscopy, while surgical excision is recommended for symptomatic cases.Case Report: A 48-year-old female patient with a medical history of hypothyroidism and hypertension presented with colicky abdominal pain, nausea, and vomiting.Imaging revealed a large lipoma in the transverse colon, confirmed by colonoscopy.Surgical excision was performed, resulting in symptom resolution.Conclusion: Awareness of colonic lipomas and their potential for symptomatic presentation and role of imaging techniques is important for prompt diagnosis and appropriate management.

Backgrounds/Aims:Hemangiomas are the most common benign liver lesions; however, they are usually asymptomatic and seldom require surgery. Enucleation and resection are the most commonly performed surgical procedures for symptomatic lesions. This study aims to compare the outcomes of these two surgical techniques.Methods:A retrospective analysis of symptomatic hepatic hemangiomas (HH) operated upon between 2000 and 2021. Patients were categorized into the enucleation and resection groups. Demographic profile, intraoperative bleeding, and morbidity (Clavien-Dindo Grade) were compared. Independent t-test and chi-square tests were used for continuous and categorical variables respectively. p-value of < 0.05 was considered significant.Results:Sixteen symptomatic HH patients aged 30 to 66 years underwent surgery (enucleation = 8, resection = 8) and majority were females (n = 10 [62.5%]). Fifteen patients presented with abdominal pain, and one patient had an interval increase in the size of the lesion from 9 to 12 cm. The size of hemangiomas varied from 6 to 23 cm. The median blood loss (enucleation: 350 vs. resection: 600 mL), operative time (enucleation: 5.8 vs. resection: 7.5 hours), and postoperative hospital stay (enucleation: 6.5 vs. resection: 11 days) were greater in the resection group (statistically insignificant). In the resection group, morbidity was significantly higher (62.6% vs. 12.5%, p = 0.05), including one mortality. All patients remained asymptomatic during the follow-up.Conclusions:Enucleation was simpler with less morbidity as compared to resection in our series. However, considering the small number of patients, further studies are needed with comparable groups to confirm the superiority of enucleation over resection.

Background: Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic vein and/or left renal vein may make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions. Methods: From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper. Results: The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7 +/- 3.1 mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up. Conclusion: Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.

Introduction: Gallbladder cancer (GBC) is the most common biliary tract malignancy.There is conflicting evidence in literature regarding curative surgery in presence of retroperitoneal lymph nodal (interaorto-caval and para-aortic) metastasis.This is a study of patients, in whom a curative resection was abandoned due to the presence of retroperitoneal lymph node metastasis (RLNM) or distant metastasis (DM), to see the effect of RLNM on survival of the GBC patients.Methods: A retrospective analysis of the patients with GBC found to have RLNM or DM on frozen section biopsy at surgery, between January 2013 and December 2018.Data was analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 22.0).Survival in these two groups (RLNM and DM) was compared with log rank test.p-value of < 0.05 was considered significant.Results: 235 patients with ostensibly resectable GBC underwent surgical exploration.The planned curative resection was abandoned in 91 (39%) patients because of RLNM (n = 20, 9%) or DM (n = 71, 30%) on frozen section biopsy.Demographic profile and blood parameters were similar in the two groups.The median survival for RLNM and DM groups were 5 (range 2-26; interquartile range [IQR] 3-11) and 6 (range 2-24; IQR 4-10) months, respectively.No significant difference was documented on log rank test (p = 0.64).There was no 3-year in either group.Conclusions: RLNM should be considered as DM and every effort should be made to target suspicious RLNM pre-operatively.At surgery retroperitoneal lymph nodes should be sampled as a routine for frozen section histological examination to avert a futile exercise.