Hepatology and Pancreatic Science

Background: The ideal management of cholecysto-choledocholithiasis is an open cholecystectomy (OC) with the CBD exploration worldwide. The single setting 2-stage approach- Endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy (EST) and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy (LC) offers advantages, mainly by reducing the hospital stay and the morbidity.Objective: To compare the ERCP + LC single setting approach with an OC with the CBD exploration for the treatment of cholecysto-choledocholithiasis.
Methods: We included the retrospective review of the open procedure which was maintained database from November 2012 onwards at our hospital and did a prospective study of the ERCP +LC procedure October 13 to October 2015 at Lumbini Medical College and Teaching Hospital, Palpa, Lumbini. The open cases were our control group. Patients with cholecysto-choledocholithiasis underwent 2-stage ERCP + LC in a single setting was compared with the 2-stage OC with CBD exploration in a single setting approach. All the cases included in the study are elective. The primary objective is to study the feasibility of the procedure, whereas secondary objectives are to 1). Detect the morbidity (Post-ERCP, Cholangitis, Pancreatitis, Abdominal collection, Wound infection) 2). The length of stay and 3). Stone clearance respectively. This is an interim analysis with 83 patients in ERCP + LC and 77 in open group respectively.

Colorectal cancer is the second cause of death in the world and genomic alteration plays an important role in this disease. Much of the underlying genetic ???Cancer Driver??? mutations/variants in sporadic colorectal cancer (CRC) have not been characterized by race. Here, we report the identification of distinct novel variants from CRC patients in mismatch repair (MMR) genes MSH2, MHS3, MSH6 and APC. We developed a panel of 20 frequently altered colon cancer genes for targeted sequencing in 138 colon tissues using next generation sequencing to examine 98.8% of the targeted exons and splice junctions at a depth of sequencing that allowed for high confidence variant calling. After alignment and variant calling, we annotated the variants with information from the 1000 Genomes Project, Catalogue of Somatic Mutations in Cancer (COSMIC), Polymorphism Phenotyping v2 (PolyPhen-2) and PFAM domain and transcription factor motifs. Excluding synonymous SNVs, 212 deleterious variants in adenoma, 760 in advanced adenoma and 2624 variants in tumors were detected. Novel variants (1591 and 1363) were found in MMR genes (MSH6 and MSH3) and APC gene, respectively. These findings further highlight the relevance of APC gene in CRC onset but also the potential underestimation of the MSI-H in sporadic CRC as many of the novel mutations so called ???uncertain significance??? in MMR genes detected here were of a deleterious nature with a therapeutic interest.

Background: Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcome of such injuries have been shown in cases managed in a specialized center.
Objective: Evaluation of biliary injuries management in major referral hepatobiliary center.
Patients & Methods: 472 consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major Hepatobiliary center in Egypt over 10 years period using endoscopy in 232 patients, percutaneous techniques in 42 patients and surgery in 198 patients.
Results: Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 (42%) for major duct transection, ligation, major leakage and massive stricture. Surgery was done urgently in 62 patients and electively in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. One mortality after surgery due to biliary sepsis and postoperative Stricture was in three cases (1.5%) treated with percutaneous dilation and stenting.
Conclusion: Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center.

We report a 59 year old man with controlled hypertension, diabetes mellitus and irritable bowel syndrome who was visiting surgical clinic for Per-rectal bleeding secondary to piles. He was referred for colonoscopy to rule out any other colonic pathologies. A colonoscopy was done on March 27, 2016 that revealed two small colonic polyps with no other mucosal pathology. Biopsy of one polyps showed tubular adenoma. He started to have abdominal pain the 2nd day post colonoscopy. This pain was dull aching moderate to severe associated with intermittent Per-rectal bleeding. The pain was attributed to Irritable Bowel syndrome (although this pain was different from the pain he used to have before) and the Per-rectal bleeding was attributed to piles. Despite the fact that he was operated for piles three weeks later, he continued to complain of abdominal pain with recurrent visits to Emergency room and out-patients clinic. A repeat colonoscopy was done three weeks post operation to assess the cause for the continued abdominal pain and the Per-rectal bleeding. The second colonoscopy showed severe colitis involving upper sigmoid, descending colon and distal transverse with sloughed mucosa and black spots. The histology was consistent with ischemic colitis. He had chronic course with pain required recurrent admissions with conservative treatment, he refused surgical intervention. He improved very slowly. A third colonoscopy with biopsy after 19 months showed completely normal mucosa with normal histology. This case represents a rare cause of ischemic colitis precipitated by colonoscopy.
The clinician should be aware of such scenario if patient continues to have unexplained abdominal pain post colonoscopy. There are few cases reported in the literature. No reported case from the kingdom.

In regard of permanent discussion about necessity and possibility of multi visceral resections in advanced malignancy, we present a clinical case Multi visceral resection total gastrectomy, pancreaticoduodenal resection and the extended right colectomy. A woman 39 years was examined about the violation of gastric emptying and symptoms of gastric bleeding, appeared 2 months prior to treatment. After the examination stomach cancer (poorly differentiated adenocarcinoma, antrum, body and Borrmann III) with the spread to duodenum, invasion of pancreatic head, with involvement of perigastral lymph node without distant metastases was diagnosed. At intraoperative examination circular tumor of stomach with involvement of antrum, body, subcardia, spreading to proximal part of duodenum and Invasion of pancreatic head, right flexure of the colon, right Para colon and mesocolon with middle colic vessels, metastatic lesion of lymph node in groups 3, 4d-7, 15 were detected (oT4N1M0, fT4N2M0 (R0)). Total gastrectomy, pancreatoduodenectomy, extended right colectomy with regional lymphadenectomy D2-3 (lymph nodes of groups 1-13, 14v, 15, 16b1 were removed) were performed. Reconstructive phase of surgery included the formation of nutritional and biliopancreatic loops of the small intestine by Y-en-Roux. In time of the alimentary loop formation esophagoenterostomy and Iliodescendostomy were performed. In the biliopancreatic loop have been performed invaginated pancreaticoenterostomy and hepaticoenterostomy. Surgery was completed insertion of transnasal feeding tube in the alimentary loop and four drainages in the abdominal cavity. Postoperative period has been executed according to ERAS with enteral nutritional and physical activation at one day after surgery. There were no complications in the postoperative period. Final diagnosis was the patient was discharged on day 10 in a good condition for adjuvant chemotherapy (XELOX). Within 12 months of observation after 6 months of the adjuvant treatment no local or metastatic progression of tumor and no dyspeptic symptoms have been identified.