A left-sided gallbladder (LSGB) is a rare congenital biliary anomaly defined by the location of the gallbladder to the left of its usualanatomical position without situs inversus. True LSGB is further classified into medioposition and sinistroposition based on its relationto the ligamentum teres. With a reported prevalence of 0.04–0.3

BackgroundInfected pancreatic necrosis (IPN) remains a life-threatening complication of acute pancreatitis. While minimally invasive “step-up” strategies are now standard, their implementation in resource-limited settings is often constrained by availability of interventional radiology, advanced endoscopy, and intensive care support. This study describes management pathways, morbidity, and outcomes of surgically treated IPN in a tertiary hepatopancreatobiliary (HPB) unit operating under such limitations.MethodsA retrospective analysis of prospectively maintained data was performed on patients who underwent surgical necrosectomy for IPN between 2015 and 2021. Management followed a step-up philosophy where feasible, incorporating antibiotics, image-guided or endoscopic drainage, and delayed surgery. Clinical characteristics, interventions, complications, and outcomes were analysed descriptively.ResultsSix patients underwent surgery for IPN. Initial interventions included ultrasound-guided percutaneous drainage (n = 3), endoscopic ultrasound-guided drainage (n = 1), and primary surgery (n = 2). All patients ultimately required open necrosectomy due to persistent sepsis or failure of less invasive measures. Early morbidity was substantial, with organ failure occurring in 83.3%, including acute respiratory distress syndrome in 66.6%. Clinically relevant postoperative pancreatic fistula occurred in 50%, and incisional hernia developed in all patients during follow-up. Median ICU and hospital stays were 17.3 and 58.5 days respectively. There was one mortality (16.6%).ConclusionIn resource-limited environments, the step-up approach to IPN is frequently constrained by service availability rather than intent. Open necrosectomy remains an essential salvage strategy when minimally invasive interventions are unavailable or unsuccessful, but is associated with significant morbidity. Careful patient selection, delayed intervention, and multidisciplinary management are critical to achieving acceptable outcomes.

PURPOSE:Hepatopancreatoduodenectomy (HPD) is a potentially curative option for selected patients with advanced cholangiocarcinoma or gallbladder cancer, but it is associated with substantial morbidity. In this study, we evaluated short- and long-term outcomes after HPD and identified prognostic factors. MATERIALS AND METHODS:Patients who underwent HPD at the Seoul National University Hospital, South Korea from 2000 to 2023 were included. Prospectively collected data on patient and tumor characteristics, perioperative and survival outcomes were analyzed. Prognostic factors were assessed using Cox proportional hazards models, and risk factors for disease-free survival (DFS) <12 months were explored using logistic regression. RESULTS:The 30-day mortality rate was 0%, the 90-day mortality rate was 6%, and major complications (Clavien-Dindo grade ≥III) occurred in 58% of patients. The median overall survival (OS) was 21 months, and median DFS was 12 months. The 5-year survival rate was 16%. In multivariable analysis, angiolymphatic invasion was an independent prognostic factor for both OS and DFS. Adjuvant treatment was associated with an improved OS. For DFS <12 months, preoperative carbohydrate antigen (CA) 19-9 level and angiolymphatic invasion were independent risk factors. CONCLUSION:Despite high morbidity, HPD can provide meaningful long-term survival in carefully selected patients. Preoperative CA 19-9 and angiolymphatic invasion may aid risk stratification. Associations between adjuvant treatment and survival outcomes should be interpreted cautiously and warrant confirmation in larger, prospective multicenter studies.

Chronic calcific pancreatitis complicated by gastric outlet obstruction and fixed duodenal stricture presents a difficulttherapeutic challenge, particularly when endoscopic retrograde cholangiopancreatography (ERCP) is impossible because the ampulla cannot be reached. Conventional bypass procedures relieve obstruction but do not preserve future endoscopic access to the periampullary region. We describe a novelreconstructive approach designed to maintain the possibility of future pancreatic endotherapy. An 18-year-old woman with chroniccalcific pancreatitis presented with recurrent abdominal pain, postprandial vomiting, early satiety, and weight loss. Endoscopy demonstrated an impassableD1/D2 stricture, and repeated ERCP attempts failed because the ampulla was inaccessible. Computed tomography and magnetic resonancecholangiopancreatography revealed diffuse pancreatic calcifications, a 1.2 × 1.0 cm obstructing main pancreatic duct stone at the pancreatic neck, mildductal dilatation, and marked gastric dilatation. The patient underwent retrocolic gastrojejunostomy to relieve gastric outlet obstruction, followed by a sideto-side duodenojejunostomy between D2/D3 and the proximal jejunum to preserve potential future endoscopic access to the periampullary region. A distalside-to-side jejunojejunostomy was added to maintain intestinal continuity and minimize bile reflux. The postoperative course was uneventfulwithout anastomotic leak, hemorrhage, or infective complications. Oral intake was resumed gradually, and the patient was discharged in good condition. Attwo years of follow-up, she remained symptomatically well with satisfactory oral intake, good pain control, and no further episodes of gastric outletobstruction or requirement for pancreatic endotherapy. This novel duodenal access loop reconstruction combines effective surgical relief ofgastric outlet obstruction with preservation of a potential future endoscopic route to the ampullary region. Although future cannulation through the accessloop was not required in this patient, the technique represents a pragmatic and potentially valuable surgical option for carefully selected patients withchronic pancreatitis and inaccessible periampullary anatomy. Further experience is required to validate its reproducibility and long-term utility.

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete mirror-image transposition of the thoracic and abdominal viscera. Pancreaticoduodenectomy (PD), also known as the Whipple procedure in patients with SIT is technically challenging because of altered anatomical orientation. We report the first case of PD for ampullary adenocarcinoma in a patient with SIT from Sri Lanka. A 72-year-old male presented with painless progressive obstructive jaundice and anorexia of one month’s duration. Cross-sectional imaging demonstrated situs inversus totalis and a distal common bile duct obstruction caused by an ampullary lesion. Following biliary decompression and prehabilitation, the patient underwent open PD with mesopancreatic excision. Reconstruction was performed using a modified Blumgart duct-to-mucosa pancreaticojejunostomy, end-to-side hepaticojejunostomy and gastrojejunostomy. Operative duration was 8 h and 45 min with an estimated blood loss of 300 ml. Histopathological examination demonstrated an intestinal-type ampullary adenocarcinoma measuring 35 × 17 × 12 mm. A total of 15 regional lymph nodes were examined, with 5 positive lymph nodes. Lymphovascular invasion was present and perineural invasion was absent. The tumour was staged according to the AJCC 8th edition as pT3N2, and all resection margins were negative (R0). The patient initially recovered and was discharged from the intensive care unit on postoperative day 4. However, he developed severe hospital-acquired bilateral pneumonia requiring ICU readmission and mechanical ventilation on postoperative day 7 and subsequently died of respiratory failure on postoperative day 25. PD in patients with SIT requires meticulous preoperative planning, detailed understanding of mirror-image anatomy, and adaptation of operative strategy. Careful interpretation of preoperative imaging facilitates safe execution of this complex procedure. PD is technically feasible in patients with situs inversus totalis when supported by thorough preoperative assessment and careful operative planning. However, major postoperative complications remain an important determinant of overall outcome following pancreatic surgery.

INTRODUCTION AND IMPORTANCE:Bile duct adenoma (BDA) is a rare benign liver neoplasm, with relatively few cases reported in literature. CASE PRESENTATION:A 55-year-old man diagnosed with symptomatic gallstone disease who underwent elective laparoscopic cholecystectomy. During the procedure, there were multiple liver nodules mimicking hepatic metastases. Histological examination and contrast-enhanced computed tomography (CECT) of the liver confirmed the diagnosis of BDA. DISCUSSION:When incidental liver nodules are encountered intraoperatively, thorough evaluation is essential to confirm the diagnosis. Structured approach using histological examination and imaging (CECT of the liver/ MRI) confirmed the diagnosis of BDA. CONCLUSIONS:BDA is a rare benign liver neoplasm that can be challenging to differentiate from hepatocellular carcinoma or liver metastases. Accurate identification of BDA can prevent overtreatment or mismanagement.

Up to 20% of patients with acute pancreatitis will develop necrosis which may be categorized as either an acute necrotic collection (ANC) or walled-off necrosis (WON). Many patients with pancreatic necrosis require intervention for complications such as infection, gastrointestinal obstruction, persistent pain or inflammation. Current international guidelines advise postponing invasive interventions for pancreatic necrosis until the stage of WON has been reached, that is usually at least 4 weeks after disease onset. We present eleven patients who underwent endoscopic drainage of WON of the pancreas using endoscopic ultrasound (EUS), of which eight patients were successfully (72%) managed and three succumbed to their illness due to complications. Three patients needed additional surgical drainage of endoscopically inaccessible para colic collections. EUS guided drainage is an effective and successful, minimally invasive method to drain WON in the appropriate patient.

Introduction: Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors arising from neuroendocrine cells, with increasing incidence worldwide. Limited data exist on NENs in Sri Lanka. This study describes the demographic, anatomical, and pathological characteristics of NENs in Sri Lanka and compares findings with regional and global data.Methods: A retrospective descriptive study was conducted using histopathology reports from seven centers in Sri Lanka from January 2017 to June 2021. A total of 151 patient records were analyzed, categorized based on the 2022 WHO classification for NENs.Results: The sample included 77 males and 74 females, with a median age of 58 years. Primary NENs accounted for 71% of cases, with gastroenteropancreatic NENs (GEP-NENs) being the most common (75.7%). Pancreatic NENs were the most frequent (41.9%), followed by small intestinal NENs (30.9%). The liver was the most common metastatic site (36%). Immunohistochemical markers chromogranin A and synaptophysin were positive in 82.8% and 79.5% of cases, respectively. Well-differentiated tumors (Grade 1 and 2) comprised 65%, while neuroendocrine carcinomas (NECs) accounted for 35%.Discussion: The pathological characteristics of NENs in Sri Lanka align with global and regional data, with pancreatic and small intestinal NENs being the most common. However, regional variations emphasize the need for localized studies and tailored management approaches.Conclusion: This study enhances understanding of NENs in Sri Lanka, highlighting the need for improved diagnostic expertise, systematic data collection, and further research to improve patient outcomes.

Introduction Duplication of the gallbladder is a rare congenital malformation associated with the development of cholelithiasis. It increases the risk of iatrogenic bile duct injury during cholecystectomy and can lead to symptom recurrence if missed. Although preoperative imaging is helpful, detection rates are around 50 %. Case presentation A 36-year-old healthy female with symptomatic gallstone disease and ultrasonographic evidence of cholelithiasis was scheduled for elective laparoscopic cholecystectomy. Following standard four port entry and dissection of pericholecystic adhesions to duodenum, a V shaped duplicated gallbladder with calculi, and a common cystic duct and artery was noted. The cystohepatic triangle was dissected, critical view of safety demonstrated and the common cystic duct and artery were divided between clips. Discussion Variations in gallbladder morphology has been described by Gross, Boyden and Harlaftis classification. Type 1 (bilobed gallbladder) has a common embryological origin with an invaginating septum separating the lumens while type 2 (double gallbladder) has a double embryological origin with separate gallbladders and their own cystic ducts. Many cases go undetected or are mis-identified as choledochal cyst, diverticulum or Phrygian cap. MRCP is the imaging modality of choice for suspected duplicate gallbladder. Conclusion Careful dissection of the cystohepatic triangle with attention to critical view of safety is important in all cases as numerous variations in hepatobiliary anatomy have been described. Surgical awareness of these variations and good surgical technique will promote safe laparoscopic cholecystectomy even in the most unexpected of encounters.

Pancreatogastric fistulas are rare but serious complications of chronic pancreatitis that can lead to life-threatening gastrointestinal bleeding due to erosion of nearby blood vessels. We present a case of a 43-year-old man with chronic calcific pancreatitis and a history of alcohol misuse, who experienced recurrent hematemesis and melena over 2 months. Despite multiple endoscopies and transfusions, the bleeding source remained unidentified until imaging revealed a fistulous tract between the pancreas and the posterior gastric wall. After failed endoscopic control, surgery confirmed the fistula and bleeding vessel, which were managed with vessel ligation and gastric resection. This case underscores the need to consider pancreatogastric fistulas in patients with chronic pancreatitis and unexplained gastrointestinal bleeding, particularly when standard investigations are inconclusive and conservative measures fail.

Pancreatic lymphangiomas are extremely rare benign cystic lesions of the pancreas, with fewer than 100 cases reported in the literature. They can mimic other cystic pancreatic neoplasms, posing a diagnostic challenge. This case adds to the limited literature and supports conservative management as a safe option in selected patients. A 15-year-old South Asian male presented with right-sided upper abdominal pain persisting for 5 months. Imaging revealed a large, multiloculated cystic lesion involving the neck and body of the pancreas. Aspiration cytology and cyst fluid analysis (low carcinoembryonic antigen, elevated amylase, lymphocytes) were suggestive of pancreatic lymphangioma. The patient became asymptomatic and was managed conservatively with close monitoring. No surgical intervention was performed. This case demonstrates that conservative management of pancreatic lymphangiomas may be appropriate in asymptomatic or minimally symptomatic adolescents with benign imaging and biochemical features. It reinforces the importance of individualized treatment to avoid unnecessary surgery.

Introduction: Insulinomas are the most common pancreatic neuroendocrine tumors. They secrete insulin and result in endogenous hyperinsulinaemic hypoglycemia. The diagnosis of insulinoma was classically based on the fulfillment of Whipple’s triad; hypoglycaemia (plasma glucose <50mg/dL), neuroglycopaenic symptoms, and the prompt relief of such symptoms with the administration of glucose. Preoperative localization of the insulinoma will help to plan the type of surgery necessary, either enucleation or pancreatic resection, and also decide on the approach, either open or laparoscopic. Case description: A 53-year-old farmer presented with neuroglycopenia symptoms with biochemical evidence of endogenous hyperinsulinaemic hypoglycemia during the mixed meal test. Imaging evidence in the form of CT and MRI showed a benign, approximately 1cm, solitary pancreatic tail insulinoma. Intraoperative ultrasonography confirmed the findings and the patient underwent enucleation of the tumor. Histology revealed a grade 2 pancreatic neuroendocrine tumor with confirmation of an insulinoma on immunohistochemistry. Conclusion: Pancreatic insulinomas, a rare pancreatic tumor, the commonest of the pNET present with neuroglycopenia. Diagnosis entails biochemical confirmation of endogenous hyperinsulinaemic hypoglycemia on a 72-hour prolonged fasting test. Noninvasive imaging in the form of CT as the first line, followed by MRI is used for localization and assessment of resectability. EUS and ASVS are additional invasive imaging in diagnostic difficulty. Enucleation and intraoperative ultrasonography is the treatment of choice for small, benign, pancreatic insulinomas.

Hyponatraemia is an uncommon complication of external biliary drainage. We report on a 62-year-old male with hilar cholangiocarcinoma who developed refractory severe hyponatraemia despite sodium replacement during preoperative external biliary drainage. Nasojejunal bile refeeding restored sodium levels to normal.