Dr. Deep Goel

Description:Introduction Aortoenteric fistula (AEF) is a rare condition where abnormal communication exists between the abdominal aorta and any part of the GI tract, most commonly, the third/fourth part of the duodenum. The incidence rate of primary aorto-duodenal fistula (PADF) on autopsy is 0.04 to 0.7 %, and the post-operative incidence rate of a secondary AEF is 0.5 to 2.3 %. An AEF can be diagnosed using either an upper gastrointestinal endoscopy (UGIE) or a contrast-enhanced computed tomography (CECT) angiography of the abdomen, and urgent repair is required by surgical or endovascular means. Methods We report the case of a 64-year-old gentleman with a bleeding PADF. He was evaluated using UGIE and CT angiography of abdomen and underwent total endovascular repair of the aneurysm. Discussion PADF is a rare cause of GI bleeding, accounting for only 0.2 % of all GI bleeds. The patient can initially show signs of a herald bleed but can also present with the classical triad of pulsatile abdominal lump, GI bleed, and abdominal pain. Endoscopy should be the initial investigation of choice for a stable patient. A negative EGD does not rule out the possibility of a PADF. CECT abdominal angiography can also be a useful diagnostic modality; some consider it superior to UGIE or aortography. Conclusion PADF is a rare but life-threatening condition that requires prompt recognition and intervention, either by surgery or endovascular repair.

Description:Introduction: We propose a step-up approach to achieve the Critical View during laparoscopic cholecystectomy based on objective criteria and fixed landmarks. Methods: Intraoperative assessment of difficulty was performed using the Nassar Scale. (Nassar et al. 1995) For patients with Nassar Grade I/II, a modified critical view was attained using the infundibulo-cystico-hepatic trigone approach. For those with Nassar Grade III/IV, the critical view was obtained using subserosal inner (SSI) layer-oriented dissection above the fixed landmarks of the transverse plane joining the Rouviere’s Sulcus to Segment IV base. A subtotal cholecystectomy was performed if SSI layer dissection could not be achieved. Results: We studied 2205 consecutive laparoscopic cholecystectomies performed between January 2015 and December 2022. The Nassar scale classified 79% as Grade I/II and 21% as Grade III/IV. The critical view was attained in 100% of Grade I/II cases using the infundibulo-cystico-hepatic trigone approach. In Nassar Grade III/IV, the critical view was achieved in 98% and 89% respectively using the landmark-based subserosal inner layer dissection method. The incidence of subtotal cholecystectomy was 1%. Major bile duct injury occurred in one patient (0.04%). The incidence of bile leak was 0.2%, with conversion to open surgery in 0.18% of patients. Nine patients (0.4%) required re-laparoscopy for bleeding, bilioma, or suspected visceral injury. Aberrant anatomy was reported in 4.2% of cases.

Description:Background: The validation of Subserosal Inner (SSI) layer dissection as a method to achieve the critical view of safety (CVS) in laparoscopic cholecystectomy has not yet been established. Methods: Intraoperative assessment of difficulty was conducted using the Nassar Scale (Nassar et al., 1995). A modified critical view was achieved through SSI layer dissection, utilizing the infundibulo-cystico-hepatic trigone above fixed landmarks, such as the transverse plane connecting Rouviere's Sulcus to Segment IV base, serving as the gateway for SSI layer dissection. Subtotal cholecystectomy was performed in cases where SSI layer dissection could not be accomplished. Results: We analyzed 2205 consecutive laparoscopic cholecystectomies performed between January 2015 and December 2022. The Nassar scale categorized 79% as Grade I/II and 21% as Grade III/IV. In Grade I/II cases, the critical view was achieved in 100%, whereas in Nassar Grade III/IV cases, the critical view was attained in 98% and 87%, respectively. The incidence of subtotal cholecystectomy was 1.2%. There was one case (0.04%) of major bile duct injury. Bile leak occurred in 0.3% of cases, and open surgery conversion was necessary in 0.2% of patients. Nine patients (0.4%) required re-laparoscopy for bleeding, bilioma, or suspected visceral injury. Aberrant anatomy was encountered in 4.2% of cases. Nassar Grade III/IV and emergency surgery were significant predictors of failure to achieve CVS. Nassar Grade III/IV also predicted other post-cholecystectomy complications. Conclusion: SSI layer dissection is a feasible technique that can be standardized to achieve CVS, irrespective of different Nassar grades. Inability to dissect in the SSI layer in higher Nassar grades may be considered as an objective strategy to reduce the risk of major bile duct injury.