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Publications

Publications

1) Ann Surg. 2015 Aug;262(2):e74. doi: 10.1097/SLA.0000000000000817.
(Early Cholecystectomy for Acute Cholecystitis: How Early Should It Be? Godbole CB)

  • Doctor NH. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India drnileshbela@gmail.com.

  • Comment in Ann Surg. 2016 Apr;263(4):e59.

  • Comment on Ann Surg. 2013 Sep;258(3):385-93.

  • DOI: 10.1097/SLA.0000000000000817

  • PMID: 24979596 [Indexed for MEDLINE]

2) BMJ Case Rep. 2017 Dec 13;2017:bcr2017222837. doi: 10.1136/bcr-2017-222837.
(Left-sided sinistroposition of the gall bladder: incidental presentation during elective cholecystectomy.)

  • Doctor NH(1), Dhakre VW(1). Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India.

  • A 59-year-old male patient presented with mild gallstone pancreatitis. He underwent laparoscopic cholecystectomy during the same admission, where we encountered a left-sided gall bladder (GB). This was managed during laparoscopic surgery by modifying the laparoscopic port positions, and we did not encounter any other variations in the biliary anatomy. Thorough knowledge regarding anatomical variations of the GB will help in managing rare cases and avoid injuries to vital structures.

  • © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  • DOI: 10.1136/bcr-2017-222837

  • PMCID: PMC5728237

  • PMID: 29237668 [Indexed for MEDLINE]

3) Pancreatology. 2013 May-Jun;13(3):327-9. doi: 10.1016/j.pan.2012.11.308. Epub 2012 Nov 23.
(Pancreatic glucagonoma with pancreatic calcification.)

  • Gupta RA(1), Udwadia FE, Agrawal P, Doctor N. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India.

  • Background: Glucagonoma is an uncommon type of pancreatic neuroendocrine tumor [NET] which is characterized by diabetes mellitus, necrolytic migratory erythema, depression and deep vein thrombosis. The typical rash is often misdiagnosed and the diagnosis is delayed by 7-8 years. Pancreatic NETs and other pancreatic tumors are known to show calcifications within the tumor but calcification of the remaining normal pancreas is very uncommon. It occurs when there is ductal obstruction leading to acute or chronic pancreatitis.

  • Case Report: We present a case of glucagonoma with coexistent pancreatic calcification.

  • Conclusion: Glucagonoma should be suspected in a diabetic patient with migratory rash. Pancreatic tumor should be suspected in patient with idiopathic focal pancreatitis.

4) Ann Surg. 2015 Mar;261(3):e79. doi: 10.1097/SLA.0000000000000304.
(Single-incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate.)

  • Sable SA(1), Nagral S, Doctor N. Author information: Department of Gastrointestinal Surgery, Jagjivan Ram Hospital, Mumbai, India shaileshsable81@gmail.com.

  • Comment on Ann Surg. 2012 Jul;256(1):1-6.

  • DOI: 10.1097/SLA.0000000000000304

  • PMID: 24253154 [Indexed for MEDLINE]

5) Int J Emerg Med. 2016 Dec;9(1):11. doi: 10.1186/s12245-016-0108-5. Epub 2016 Feb 29.
(Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male.)

  • Vyas PK (Department of Emergency and Respiratory Medicine, Jaslok Hospital and Research Centre, 15 Dr. G. Deshmukh Marg, Mumbai, India, Pin-Code 91-400026. drvyaspradeep@gmail.com.)

  • Godbole C (Department of Gastrointestinal-Surgery, Jaslok Hospital and Research Centre, Mumbai, India, 400 026.), Bindroo SK (Department of Emergency and Respiratory Medicine, Jaslok Hospital and Research Centre, 15 Dr. G. Deshmukh Marg, Mumbai, India, Pin-Code 91-400026.)

  • Mathur RS (Department of Emergency and Respiratory Medicine, Jaslok Hospital and Research Centre, Dr. G. Deshmukh Marg, Mumbai, India, Pin-Code 91-400026.)

  • Akula B (Department of Gastrointestinal-Surgery, Jaslok Hospital and Research Centre, Mumbai, India, 400 026.)

  • Doctor N (Department of Gastrointestinal-Surgery, Jaslok Hospital and Research Centre, Mumbai, India, 400 026.).

  • Diaphragmatic hernia is an important cause of emergency hospital admission associated with significant morbidity. It usually results from congenital defect or rupture in the diaphragm due to trauma. Prompt and appropriate diagnosis is necessary in patients with this condition, as surgical intervention by either abdominal or thoracic approach may be necessary. Here, we report a case of left-sided diaphragmatic hernia presenting with sudden onset of breathlessness, respiratory distress and left-sided chest pain radiating to the abdomen, mimicking pneumothorax, treated successfully with surgical intervention.

  • DOI: 10.1186/s12245-016-0108-5

  • PMCID: PMC4770005

  • PMID: 26924754

6) Indian J Surg. 2012 Feb;74(1):40-6. doi: 10.1007/s12262-011-0384-5. Epub 2011 Dec 10.
(Management of severe acute pancreatitis.)

  • Doctor N(1), Agarwal P, Gandhi V. Author information: Department of Gastrointestinal Surgery, Jaslok Hospital and Research Centre, 20 th floor, Pedder road, Mumbai, 400 026 India.

  • Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective reventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

  • DOI: 10.1007/s12262-011-0384-5

  • PMCID: PMC3259170

  • PMID: 23372306

7) Indian J Gastroenterol. 2001 Mar;20 Suppl 1:C108-10.
(Non-hepatic surgery in patients with chronic liver disease.)

  • Doctor N, Author information: Jaslok Hospital and Medical Research Center, Mumbai.

  • PMID: 11293173 [Indexed for MEDLINE]

8) Trop Gastroenterol. 2014 Oct-Dec;35(4):253-6. doi: 10.7869/tg.226.
(Hepatobiliary actinomycosis masquerading as malignancy.)

  • Godbole CB, Mangukiya DO, Kakkar-Kashikar R, Doctor NH.

  • DOI: 10.7869/tg.226

  • PMID: 26349172 [Indexed for MEDLINE]

9) Ann Surg. 2010 Jan;251(1):178; author reply 178. doi: 10.1097/SLA.0b013e3181c76bfb.
(Ischemic complications after pancreatoduodenectomy: incidence, prevention and management.)

  • Philip S, Gandhi V, Nagral S, Doctor N.

  • Comment on: Ann Surg. 2009 Jan;249(1):111-7.

  • DOI: 10.1097/SLA.0b013e3181c76bfb

  • PMID: 20009747 [Indexed for MEDLINE]

10) Trop Gastroenterol. 2015 Oct-Dec;36(4):229-35. doi: 10.7869/tg.296.
(Predictors of outcome after reconstructive hepatico-jejunostomy for post cholecystectomy bile duct injuries.)

  • Gomes RM, Doctor NH.

  • Introduction: Reconstructive hepatico-jejunostomy is recommended for major bile duct injuries (BDIs) during cholecystectomy. Complications of biliary leak, cholangitis, bleeding, anastomotic strictures and biliary cirrhosis remain a major concern affecting a patient's outcome after surgery. The aim of this study was to analyse the results of surgical repair of major BDIs at our institution and identify predictors for the development of major complications.

  • Methods: A retrospective study of 57 patients with major BDI after cholecystectomy referred to a tertiary hepato-biliary centre from July 1999 to July 2011 and subsequently managed with reconstructive bilio-enteric anastomosis was performed.

  • Results: Of 57 patents 35 (61.4%) were primary referred. 22 (38.6 %) were secondary referred, of which 17 were for correct reconstructive surgery performed elsewhere and 5 were following attempted endoscopic management. 17 (29.8%) had local and systemic perioperative complications. 13 (22.8%) had major complications (bile leak, bleed, stricture and/or biliary cirrhosis). No association was found between age, type of cholecystectomy, type of injury, vascular injury and occurrence of major complications. Secondarily referred patients after therapeutic interventions (p = 0.010) and reconstructive surgery after repair performed by non-specialists suffered an increased incidence of major complications (p = 0.032). Secondary referral was also an independent predictor of major complications (p = 0.024).

  • Conclusion: Early referral of patients with no previous intervention to a tertiary hepato-biliary center and specialist surgical repair is recommended for improved outcome after reconstructive hepatico-jejunostomy for major BDIs during cholecystectomy.

  • DOI: 10.7869/tg.296

  • PMID: 27509700 [Indexed for MEDLINE]

11) Ann Surg. 2015 Mar;261(3):e81. doi: 10.1097/SLA.0000000000000410.
(The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial.)

  • Gupta RA(1), Agrawal P, Doctor N, Nagral S. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India rahul.g.85@gmail.com.

  • Comment in: Ann Surg. 2015 Mar;261(3):e81.

  • Comment on: Ann Surg. 2012 Jun;255(6):1032-6.

  • DOI: 10.1097/SLA.0000000000000410

  • PMID: 24368648 [Indexed for MEDLINE]

12) Ann Surg. 2015 Jun;261(6):e167-8. doi: 10.1097/SLA.0000000000000818.
(Practical Application of Predictors for Pancreatic Anastomotic Failure After Pancreaticoduodenectomy, Especially in the Asian Context.)

  • Godbole CB(1), Doctor NH. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India drnileshbela@gmail.com.

  • Comment on: Ann Surg. 2013 Mar;257(3):512-9.

  • DOI: 10.1097/SLA.0000000000000818

  • PMID: 24979597 [Indexed for MEDLINE]

13) Indian J Gastroenterol. 1997 Oct;16(4):144-8.
(Liver resection.)

  • Nagral S(1), Doctor N, Davidson BR. Author information: Department of Surgery, K E M Hospital, Mumbai. nagral@glasbma.vsnl.net.in

  • PMID: 9357187 [Indexed for MEDLINE]

14) Cases J. 2009 Jan 1;2(1):1. doi: 10.1186/1757-1626-2-1.
(Stent angioplasty of narrowed portocaval shunt in Budd Chiari syndrome: a case report.)

  • Doctor N(1), Gandhi V, Shah S, Hussain M, Marar S, Philip S. Author information: Department of strointestinal Surgery, Jaslok Hospital & Research Centre, Mumbai, India. drnileshbela@gmail.com.

  • Background: Hepatic vein thrombosis (Budd-Chiari Syndrome) is a rare disorder resulting from an obstruction to the outflow of blood from the liver. Early decompression is needed to prevent liver dysfunction and death. Radiological intervention includes angioplasty of stenosis and webs and the placement of transjugular intrahepatic portosystemic shunts (TIPPS). Side-to-side portacaval shunt (SSPCS) remains the gold standard for achieving good long-term results.

  • Case Presentation: A 37-year old lady underwent side-to-side portacaval shunt for Budd Chiari syndrome. She had early shunt blockage and this was successfully treated with the placement of a metallic stent across the shunt.

  • Conclusions: At five years, she remains asymptomatic, with normal liver functions, no ascites, and normal flow through the stent on Colour Doppler examination.

  • DOI: 10.1186/1757-1626-2-1

  • PMCID: PMC2648948

  • PMID: 19117529

15) Ann Gastroenterol. 2013;26(4):340-345.
(No 72-hour pathological boundary for safe early laparoscopic cholecystectomy in acute cholecystitis: a clinicopathological study.)

  • Gomes RM : Department of Surgical Gastroenterology (Rachel M. Gomes, Nilesh H. Doctor) NUSI Wockhardt Hospital, Goa, India.

  • Mehta NT, Varik V, Doctor NH : Department of Surgery (Niraj T. Mehta, Vanesha Varik), Bhatia Hospital, Mumbai, India.

  • Background: The pathological boundary of acute cholecystitis (AC) between early edematous and late chronic fibrotic inflammation beyond 72 h is well-described. Early laparoscopic cholecystectomy (ELC) is safe in AC but the timing still remains controversial. The aim of this study was to analyze the impact of the duration of symptoms on clinical severity, pathology and outcome in patients who underwent laparoscopic cholecystectomy (LC) for AC during the urgent admission.

  • Methods: A retrospective analysis of a prospectively collected database of 61 patients who underwent LC for AC over a 6-month period was performed.

  • Results: Of 61 patients 21 (34.43%) received ELC at <72 h and 40 (65.57%) received late LC (LLC) at >72 h. Clinically in the ELC group the majority were mild and in the LLC group the majority were moderate and severe in severity grading as per Tokyo guidelines (P<0.001). Surgical findings and histopathology showed no significant difference in the distribution of simple, phlegmonous and gangrenous cholecystitis between both groups (P=0.94). The majority were completed by a standard four port technique and only one required subtotal cholecystectomy. There was no significant difference between operating time, return to normal activities or hospital stay between both groups. There were no conversions to open cholecystectomy, no wound infections, no intra-abdominal collections, no biliary tract injury or mortality in either group.

  • Conclusions: The degree of inflammatory change in AC is not dependent on time. LC can be safely performed in AC regardless of timing with a standardized surgical strategy in experienced units.

  • PMCID: PMC3959483

  • PMID: 24714318

16) J Postgrad Med. 2010 Oct-Dec;56(4):287-9. doi: 10.4103/0022-3859.70942.
(Recurrent cholangitis in the tropics: worm or cast?)

  • Jain PA(1), Gandhi VV, Desai P, Doctor NH. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India.

  • The development of biliary casts is very rare, especially in non-liver transplant patients. The etiology of these casts is uncertain but several factors have been proposed which lead to bile stasis and/or gallbladder hypo-contractility and promote cast formation. Here, we report a 54-year-old male, with diabetes and ischemic heart disease, who presented with recurrent attacks of cholangitis. Magnetic resonance cholangiopancreatography revealed linear T1 hyperintense and T2 hypointense filling defects in the right and left hepatic ducts extending into the common hepatic duct, and a calculus in the lower common bile duct, raising a suspicion of worm in the biliary tree. In view of failed attempts at extraction on endoscopy, patient underwent surgery. At exploration, biliary casts and stones were extracted from the proximal and the second order bile ducts, with the help of intraoperative choledochoscopy and a bilio-enteric anastomosis was accomplished. Although endoscopic retrieval of the biliary cast can be employed as first-line management, surgery should be considered in case it fails.

  • DOI: 10.4103/0022-3859.70942

  • PMID: 20935401 [Indexed for MEDLINE]

17) Trop Gastroenterol. 2011 Jul-Sep;32(3):214-8.
(Major hemobilia--experience from a specialist unit in a developing country.)

  • Gandhi V(1), Doctor N, Marar S, Nagral A, Nagral S. Author information: Department of Gastrointestinal Surgery, Jaslok Hospital and Research Centre, Mumbai - 400026, India.

  • Background & Aim: Hemobilia is a rare but potentially life threatening problem, which can be difficult to diagnose and treat. In the last few decades there has been a change in the etiologic spectrum and management of this problem in the West. The aim of this study was to analyze the etiology, clinical features, management and outcome of major hemobilia in a tertiary referral centre from western India.

  • Methods: A retrospective analysis was undertaken on 22 patients (16 males, 6 females; mean age 39 years, range 13 to 74) who presented with major hemobilia over a 5-year period.

  • Results: The etiology was iatrogenic in 13 patients (percutaneous transhepatic biliary drainage 8, post laparoscopic cholecystectomy 3, endoscopic retrograde cholangiopancreatography 1, and liver biopsy 1), liver trauma in 6 and liver tumors in 3 patients. Twenty patients presented with gastrointestinal bleeding (melena 20 patients, hemetemesis with melena 8 patients), 5 with jaundice and 8 had fever. Abdominal angiography was performed in 20 patients. Angiography revealed pseudoaneurysm of the right hepatic artery or its branches in 14 patients, left hepatic artery in 2, an arterio-biliary fistula in 1, tumor blush in 1 and the source could not be located in 2 patients. Seventeen of the 22 patients were treated with radiological intervention, 3 required surgery (liver resection for tumors 2, laparotomy for venous collateral bleeding of portal cavernoma 1) and two were managed conservatively. Radiological intervention involved embolisation with coils and/or glue in 16, and chemoembolisation in 1 patient. Sixteen of 17 patients responded to embolisation. Overall there were two deaths.

  • Conclusions: The spectrum of hemobilia seen in India is now similar to that in the developed world with iatrogenic causes being the commonest. Interventional radiology can treat a majority of patients reducing the need and morbidity associated with surgery.

  • PMID: 22332338 [Indexed for MEDLINE]

18) Trop Gastroenterol. 2012 Jul-Sep;33(3):207-13. doi: 10.7869/tg.2012.50.
(Three level risk assessment for pancreatic fistula formation after distal pancreatectomy with a strategy for prevention.)

  • Gomes RM, Doctor N. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India. dr.gomes@rediffmail.com

  • Background: Distal pancreatectomy (DP) has a high post-operative morbidity predominantly due to pancreatic fistula though the mortality is very low. Data on distal pancreatectomy was reviewed to analyse the risk factors that contribute to this morbidity.

  • Methods: Thirty three patients underwent distal pancreatectomy with sutured closure of the remnant, over a 5-year period between May 2006 and April 2011. Pancreatic fistula (PF) was defined according to the International Study Group on Pancreatic Fistula definition. Patient and surgical risk factors were subdivided as those reflecting a poorer pre-morbid status, those associated with increased complexity of surgery and those related to pancreas gland and were analyzed for incidence of pancreatic fistula.

  • Results: Indications for DP included 16 (51.5%) pancreatic tumours, 13 (39.4%) chronic pancreatitis and 3 (9.1%) trauma. Spleen was preserved in 12 patients (36.4%). There was no mortality while the morbidity rate was 45.5% (n = 15). Incidence of pancreatic fistula was 30.3% (n = 10); eight were grade A (80%) and two were grade C (20%). Incidence of clinically significant pancreatic fistulae was 6.1%. PF was significantly more common if the pancreatic duct was not identified (p = 0.024) was significantly less with extensive peri-pancreatic adhesions (p = 0.036).

  • Conclusions: Identification and ligation of main pancreatic duct can help reduce the incidence of pancreatic fistulae. The identification of patients at high risk of developing a PF helps to implement prevention strategies.

  • DOI: 10.7869/tg.2012.50

  • PMID: 23600052 [Indexed for MEDLINE]

19) HPB (Oxford). 2016 Jan;18(1):49-56. doi: 10.1016/j.hpb.2015.07.003. Epub 2015 Dec 20.
(Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study.)

  • Van Grinsven J: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Dutch Pancreatitis Study Group, St. Antonius Hospital, Nieuwegein, The Netherlands. Electronic address: j.van.grinsven@antoniusziekenhuis.nl.

  • Van Brunschot S: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.

  • Bakker OJ: Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

  • Bollen TL: Dept. of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

  • Boermeester MA: Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Bruno MJ: Dept. of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.

  • Dejong CH : Dept. of Surgery, Maastricht University Medical Center, Maastricht and NUTRIM School for Nutrition, Toxicology and Metabolism, The Netherlands.

  • Dijkgraaf MG: Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands.S

  • Van Eijck CH : Dept. of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.

  • Fockens P: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.

  • Van Goor H: Dept. of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Gooszen HG: Dept. of OR/Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Horvath KD: Dept. of Surgery, University of Washington Medical Center, Seattle, United States.

  • Van Lienden KP: Dept. of Radiology, Academic Medical Center, Amsterdam, The Netherlands.

  • Van Santvoort HC: Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Besselink MG: Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Electronic address: m.g.besselink@amc.nl.

  • Background: The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis is subject to debate. We performed a survey on these topics amongst a group of international expert pancreatologists.

  • Methods: An online survey including case vignettes was sent to 118 international pancreatologists. We evaluated the use and timing of fine needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy.

  • Results: The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. Lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention vs. 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention vs. 41% non-invasive).

  • Discussion: The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.

  • DOI: 10.1016/j.hpb.2015.07.003

  • PMCID: PMC4766363

  • PMID: 26776851 [Indexed for MEDLINE]

20) Br J Surg. 1998 May;85(5):627-32. doi: 10.1046/j.1365-2168.1998.00662.x.
(Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy.)

  • Doctor N(1), Dooley JS, Dick R, Watkinson A, Rolles K, Davidson BR. Author information: Department of Surgery, Royal Free Hospital and Medical School, London, UK.

  • Comment in: Br J Surg. 1998 Oct;85(10):1450-1.

  • Background: Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed.

  • Methods: Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm.

  • Results: Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention.

  • Conclusions: Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.

  • DOI: 10.1046/j.1365-2168.1998.00662.x

  • PMID: 9635808 [Indexed for MEDLINE]

21) Ann Surg. 2011 May;253(5):1049 author reply 1051. doi: 10.1097/SLA.0b013e3182172166.
(Open pancreatic necrosectomy: the return to the old guard?)

  • Barreto SG, Doctor NH.

  • Comment on: Ann Surg. 2010 May;251(5):783-6.

  • DOI: 10.1097/SLA.0b013e3182172166

  • PMID: 21490455 [Indexed for MEDLINE]

22) Trop Gastroenterol. 2010 Apr-Jun;31(2):123-4.
(Ruptured subcapsular giant haematoma of the spleen--a rare complication of acute pancreatitis.)

  • Gandhi V(1), Philip S, Maydeo A, Doctor N. Author information: Department of Surgical Gastroenterology, Jaslok Hospital & Research Centre, Mumbai. drgandhivv@gmail.com

  • PMID: 20862992 [Indexed for MEDLINE]

23) TJ Postgrad Med. 1992 Jul-Sep;38(3):112-4, 111.
(Hyperbaric oxygen therapy in diabetic foot.)

  • Doctor N(1), Pandya S, Supe A. Author information: Dept of Surgery, Seth GS Medical College, Parel, Bombay, Maharashtra.

  • To study the effect of hyperbaric oxygen therapy in chronic diabetic foot lesions, a prospective controlled study was undertaken. Thirty diabetics with chronic foot lesions were randomised to study group (conventional management and 4 sessions of hyperbaric oxygen therapy) and control group (conventional management). The patients were assessed for average hospital stay, control of infection and wound healing. The control of infection spread was quicker. Positive cultures decreased from initial 19 to 3 in study group as against from 16 to 12 in the control group. (p < 0.05). This difference was most pronounced for Escherichia coli. Also, the need for major amputation was significantly less in the study group (n = 2) as against the control group (n = 7) (p < 0.05). The average hospital stay was not affected. We conclude that hyperbaric oxygen therapy can be safely used and is beneficial as an adjuvant therapy in chronic diabetic foot lesions.

  • PMID: 1303408 [Indexed for MEDLINE]

24) World J Gastroenterol. 2011 Jan 21;17(3):366-71. doi: 10.3748/wjg.v17.i3.366.
(Analysis of the delayed approach to the management of infected pancreatic necrosis.)

  • Doctor N(1), Philip S, Gandhi V, Hussain M, Barreto SG. Author information: Department of Gastrointestinal Surgery, Jaslok Hospital and Research Center, Mumbai 400026, India. drnileshbela@gmail.com

  • AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP).

  • Methods: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed.

  • Results: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.

  • Conclusions: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

  • DOI: 10.3748/wjg.v17.i3.366

  • PMCID: PMC3022298

  • PMID: 21253397 [Indexed for MEDLINE]

25) HPB (Oxford). 2015 Oct 17. doi: 10.1111/hpb.12491.
(Online ahead of print. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study.)

  • Van Grinsven J: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands; Dutch Pancreatitis Study Group, St. Antonius Hospital, Nieuwegein, The Netherlands. Electronic address: j.van.grinsven@antoniusziekenhuis.nl.

  • Van Brunschot S: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.

  • Bakker OJ: Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

  • Bollen TL: Dept. of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

  • Boermeester MA: Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Bruno MJ: Dept. of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.

  • Dejong CH : Dept. of Surgery, Maastricht University Medical Center, Maastricht and NUTRIM School for Nutrition, Toxicology and Metabolism, The Netherlands.

  • Dijkgraaf MG: Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands.S

  • Van Eijck CH : Dept. of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.

  • Fockens P: Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.

  • Van Goor H: Dept. of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Gooszen HG: Dept. of OR/Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Horvath KD: Dept. of Surgery, University of Washington Medical Center, Seattle, United States.

  • Van Lienden KP: Dept. of Radiology, Academic Medical Center, Amsterdam, The Netherlands.

  • Van Santvoort HC: Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Besselink MG: Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Electronic address: m.g.besselink@amc.nl.

  • Background: The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis are subject to debate. A survey was performed on these topics amongst a group of international expert pancreatologists.

  • Methods: An online survey including case vignettes was sent to 118 international pancreatologists. The use and timing of fine-needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy were evaluated.

  • Results: The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. A lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention versus 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention versus 41% non-invasive).

  • Discussion: The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.

  • DOI: 10.1111/hpb.12491

  • PMID: 26475650

26) Br J Surg. 2000 Jun;87(6):790-5. doi: 10.1046/j.1365-2168.2000.01427.x.
(Experimental study of a novel fibrin sealant for achieving haemostasis following partial hepatectomy.)

  • Davidson BR(1), Burnett S, Javed MS, Seifalian A, Moore D, Doctor N. Author information: University Department of Surgery and Comparative Biology Unit, Royal Free and University College School of Medicine, London, UK.

  • Methods: Ensuring adequate haemostasis is a major difficulty in the field of liver surgery. This study aimed to evaluate a novel fibrin sealant (Vivostat), designed for autologous preparation, in a porcine model of partial hepatectomy.

  • Results: Median (range) blood loss in the control group was 94.3 (17.3-467.0) g, and was significantly reduced with Vivostat (13.8 (5.5-150.9) g) and Surgicel (22.8 (5.8-67.3) g). Median (range) time to haemostasis in controls (31 (12-52) min) was also significantly reduced by Vivostat (8 (0-32) min) and Surgicel (10 (0-19) min) (both P < 0.001 versus controls, Kruskal-Wallis test).

  • Conclusion: The novel fibrin sealant, Vivostat, is as effective as Surgicel cellulose gauze in achieving haemostasis after porcine partial hepatic lobectomy.

  • PDOI: 10.1046/j.1365-2168.2000.01427.x

  • PMID: 10848861 [Indexed for MEDLINE]

27) Indian J Gastroenterol. 2007 Mar-Apr;26(2):88-9.
(Reversal of severe hepato-pulmonary syndrome in congenital hepatic fibrosis after living-related liver transplantation.)

  • Nagral A(1), Nabi F, Humar A, Nagral S, Doctor N, Khubchandani SR, Amdekar YK. Author information: Department of Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India. nagral@vsnl.com

  • We report a 5-year-old girl with congenital hepatic fibrosis who presented with clubbing and cyanosis. Partial pressure of oxygen was 40 mmHg with oxy-gen saturation of 70% on room air, which improved to 128 mmHg and 92% on inhalation of 100% oxygen. Macroaggregated albumin scan showed 58% shunting to the brain, suggestive of severe hepatopulmonary syndrome. Echocardiogram and pulmonary angiogram ruled out pulmonary hypertension. Four weeks after living-related liver transplantation, she had normal blood gases and reduction in shunting to 7% on macroaggregated albumin scan.

  • PMID: 17558074 [Indexed for MEDLINE]

28) Liver Transpl. 2000 Mar;6(2):201-6. doi: 10.1002/lt.500060215.
(Results of choledochojejunostomy in the treatment of biliary complications after liver transplantation in the era of nonsurgical therapies.)

  • Davidson BR(1), Rai R, Nandy A, Doctor N, Burroughs A, Rolles K. Author information: Hepatobiliary and Liver Transplantation Unit, Royal Free Hospital and Royal Free and University College Medical School, London, UK.

  • Advances in radiological and endoscopic techniques have allowed many biliary complications after orthotopic liver transplantation (OLT) to be managed without surgery. The influence of nonsurgical management on the outcome of patients requiring surgical revision has not been addressed. We reviewed our 10-year experience (October 1988 to January 1998) of Roux-en-Y choledochojejunostomy (CDJ) to treat biliary complications after OLT. Forty-six patients underwent CDJ for biliary complications (32 men, 14 women; age, 22 to 65 years; median, 60 years). Biliary reconstruction at the time of OLT was duct to duct in 41 patients, primary CDJ in 3 patients, and gall bladder conduit in 2 patients. T-tubes were used only in patients with gallbladder conduit. The indication for CDJ was biliary leak (23 patients), stricture (20 patients), biliary stones (2 patients), and biliary sludge (1 patient). Two patients (4.3%) had associated hepatic artery thrombosis. The bile leaks were diagnosed at a median of 29 days post-OLT (range, 2 to 65 days) and strictures at a median of 2 years (range, 33 days to 6.5 years) post-OLT. Before surgery, 25 patients (54%) underwent an attempt at radiological or endoscopic therapeutic intervention that failed. Median follow-up was 5 years (range, 9 months to 10 years). Early complications occurred in 12 patients (26%); the most common was chest infection (4 patients). There were 3 perioperative deaths (6%); 1 death was directly related to surgery. Late complications, mainly anastomotic strictures, occurred in 10 patients (22%), half of which were successfully treated by biliary balloon dilatation. The complication rate post-CDJ was less in those who underwent a failed nonsurgical approach than those proceeding straight to surgery (9 of 25 patients; 36% v 13 of 21 patients; 62%; P =.21, not significant). The procedure-related mortality for surgical revision of biliary complications after OLT is low, but early and late complications are common. A failed attempt at nonsurgical management does not increase the complications of reconstructive surgery. Strictures after CDJ should be considered for biliary balloon dilatation.

  • DOI: 10.1002/lt.500060215

  • PMID: 10719021 [Indexed for MEDLINE]

29) Indian J Gastroenterol. 2001 Jan-Feb;20(1):32-3.
(Laparoscopic cholecystectomy in patient with portal cavernoma and portal hypertension.)

  • Dalvi AN(1), Deshpande AA, Doctor NH, Maydeo A, Bapat RD. Author information: Department of General Surgery, King Edward VII Memorial Hospital and Seth G S Medical College, Mumbai. abhaydalvi@hotmail.com

  • Successful laparoscopic cholecystectomy has been reported in patients with cirrhosis of liver with portal hypertension; the procedure has, however, not been reported in patients with portal vein thrombosis, portal cavernoma and portal hypertension. We report an 18-year-old man with portal hypertension due to portal vein thrombosis and portal cavernoma who had symptomatic gallstone disease and was successfully treated with laparoscopic cholecystectomy.

  • PMID: 11206876 [Indexed for MEDLINE]

30) JOP. 2007 Sep 7;8(5):609-12.
(Successful partial pancreatotomy as a salvage procedure for massive intraoperative bleeding during head coring for chronic pancreatitis. Report of a case.)

  • Barreto SG(1), Shah H, Choksi C, Doctor NH. Author information: Department of Surgery, Jaslok and Bhatia General Hospital, Mumbai, India.

  • Context: Chronic pancreatitis is a continuous inflammatory disease of the pancreas resulting in scarring and fibrosis with consequent decline in exocrine and endocrine function. The inflammatory process leads to the development of a head mass, and strictures and stones in the pancreatic duct which present as pain, or loco regional complications such as duodenal obstruction and biliary obstruction. The gold standard for the treatment of pain and loco regional complications remains surgery, which is usually a combination of drainage and partial resection (coring). This can be hazardous due to adhesions, inflammation or portal hypertension.

  • Case Report: We report a case in which severe bleeding from the pancreatic duct was encountered during a Frey procedure. It was from the superior mesenteric vein/splenic vein confluence and would have warranted a Whipple procedure.

  • Conclusion: We describe a pancreatotomy for exposure and control of the bleeding, with re-suturing of the cut pancreas and completion of the pancreaticojejunostomy.

  • PMID: 17873468 [Indexed for MEDLINE]

31) Indian J Gastroenterol. 1998 Jan;17(1):28-9.
(Primary squamous carcinoma of liver: presentation as liver abscess.)

  • Doctor N(1), Dafnios N, Jones A, Davidson BR. Author information: University Department of Surgery, Royal Free Hospital and School of Medicine, London, England.

  • Comment in: Indian J Gastroenterol. 1998 Jul-Sep;17(3):117.

  • Primary keratinizing squamous carcinoma of the liver has been reported as arising in a hepatic cyst, in association with prolonged cholestasis or chronic biliary sepsis. We describe the occurrence of such a tumor without predisposing factors, with presentation similar to that of hepatic abscess.

  • PMID: 9465512 [Indexed for MEDLINE]

32) Eur J Gastroenterol Hepatol. 1999 Jul;11(7):775-80. doi: 10.1097/00042737-199907000-00016.
(Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents.)

  • Doctor N(1), Dick R, Rai R, Dafnios N, Salamat A, Whiteway H, Dooley J, Davidson BR. Author information: Department of Surgery, Royal Free Hospital and Medical School, London, UK.

  • Background: Endoscopic stenting is an effective method of relieving biliary obstruction in patients with unresectable malignancy. If this fails, optimal management is controversial. Percutaneous insertion of plastic or mesh metal stents has been advocated.

  • Aim: To review the outcome of percutaneous plastic stents and compare this with contemporary data from the literature on mesh metal stenting. PATIENTS AND METHODS: Over a period of six years, 400 patients had attempted endoscopic stenting for distal malignant biliary obstruction which failed in 54 (13.5%). These 54 patients were treated with percutaneously placed plastic stents.

  • Results: Percutaneous stenting was technically successful in 48 patients (89%). Early complications occurred in 13 patients (24%), the commonest being acute cholangitis in seven (12%). There was no procedure-related mortality but a 30-day mortality of 11 % (n = 6). Ten patients (18%) required re-admission after 30 days for stent block (mean period 4 months). Forty-seven patients (87%) were followed up until death. The median survival for the patients undergoing palliative stenting was 3 months (5 days to 17 months).

  • Conclusion: These results suggest that percutaneous plastic stents can be used safely and effectively in patients who have failed endoscopic stenting.

  • DOI: 10.1097/00042737-199907000-00016

  • PMID: 10445799 [Indexed for MEDLINE]

33) Indian J Gastroenterol. 2002 Jul-Aug;21(4):163-4.
(Treatment of symptomatic polycystic liver disease with resection-fenestration.)

  • Bhandari M(1), Shah S, Nagral S, Doctor N. Author information: Department of Surgical Gastroenterology, Jaslok Hospital and Research Center, Mumbai.

  • Polycystic liver disease with severe symptoms is difficult to treat. We report a 35-year-old man with advanced disease, who had a successful outcome after resection and fenestration.

  • PMID: 12385552 [Indexed for MEDLINE]

34) Indian J Gastroenterol. 2008 May-Jun;27(3):132-3.
(Unusual presentation of intraductal papillary mucinous neoplasm of the bile duct.)

  • Doctor NH, Barreto SG, Hussain M, Khubchandani S.

  • PMID: 18787287 [Indexed for MEDLINE]

35) Postgrad Med J. 1995 Feb;71(832):116-7. doi: 10.1136/pgmj.71.832.116.
(Assessment of pancreatic duct damage following trauma: is endoscopic retrograde cholangiopancreatography the gold standard?)

  • Doctor N(1), Dooley JS, Davidson BR. Author information: Hepatobiliary and Liver Transplant Unit, Royal Free Hospital and School of Medicine, London, UK.

  • A 12-year-old girl was admitted as an emergency with blunt pancreatic trauma. Computed tomography (CT) showed an intact pancreas. She failed conservative treatment. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated division of the pancreatic duct at the neck of pancreas. At laparotomy, however, there was complete necrosis of the pancreatic head. She recovered well following enteric drainage of the body of pancreas. CT and ERCP are considered the optimal imaging for pancreatic trauma but the findings may be misleading.

  • DOI: 10.1136/pgmj.71.832.116

  • PMCID: PMC2397958

  • PMID: 7724424 [Indexed for MEDLINE]

36) Eur J Gastroenterol Hepatol. 2000 Oct;12(10):1095-100. doi: 10.1097/00042737-200012100-00005.
(Predicting early mortality following percutaneous stent insertion for malignant biliary obstruction: a multivariate risk factor analysis.)

  • Rai R(1), Dick R, Doctor N, Dafnios N, Morris R, Davidson BR. Author information: University Department of Surgery, Royal Free and University College Medical School, London, UK.

  • Background: Percutaneous stent placement is an accepted method of palliation in malignant biliary bstruction. Factors predicting early mortality after this procedure have not been identified.

  • Methods: We performed a retrospective study of 141 patients with malignant biliary obstruction who underwent percutaneous stent placement for biliary decompression to identify the risk factors associated with early mortality (< or = 30 days).

  • Results: Of 14 clinicopathological and laboratory variables analysed blood urea, albumin, haemoglobin and alkaline phosphatase were found to be significant on univariate analysis. The age and gender of the patient along with cancer type, level of obstruction, presence of pyrexia and bilirubin level had no influence on early mortality. tepwise logistic regression identified the haemoglobin level and blood urea to be independently significant in predicting early mortality. Overall 30-day mortality was 20.5% (29/141). Patients with blood urea over 4.3 mmol/l and a haemoglobin less than 10.9 g/dl had a mortality rate of 52% (12/23) compared with 14% (17/118) in the remainder. Using these two variables a regression equation has been derived which allows calculation of the probability of survival at 30 days after the percutaneous procedure.

  • Conclusion: Laboratory variables in patients with malignant obstructive jaundice can be used to predict mortality following percutaneous stent insertion.

  • DOI: 10.1097/00042737-200012100-00005

  • PMID: 11057454 [Indexed for MEDLINE]

37) J Postgrad Med. 1995 Jul-Sep;41(3):61-3.
(Anterior seromyotomy with posterior truncal vagotomy in uncomplicated chronic duodenal ulcer.)

  • Supe A(1), Bhalla R, Pandya SV, Doctor NH, Bapat VN. Author information: Department of Surgery, Seth GS Medical College, Parel, Bombay, India.

  • Thirty cases of uncomplicated duodenal ulcer treated by anterior superficial lesser curvature seromyotomy and posterior truncal vagotomy were studied to evaluate the efficacy of this procedure. There was completeness of vagotomy in all the cases as shown by endoscopic Congo Red test. Twenty-seven cases were asymptomatic at 1-48 months (Mean 22.3) follow up, while 3 patients had controllable side effects such as dumping and diarrhoea. There was no mortality. This procedure is safe, effective and is a favourable alternative to highly selective vagotomy.

  • PMID: 10707716 [Indexed for MEDLINE]

38) Indian J Gastroenterol. 1995 Jan;14(1):19.
(Abdominal cocoon--the cauliflower sign on barium small bowel series.)

  • Navani S(1), Shah P, Pandya S, Doctor N. Author information: Department of Radiology, K E M Hospital, Bombay.

  • We report a case of abdominal cocoon encasing the small bowel diagnosed pre-peratively on radiology. Barium small bowel series showed the ileal loops clumped together as within a sac, giving a cauliflower-like appearance on sequential films. At surgery, the membrane enclosing the loops was thin and flimsy.

  • PMID: 7860113 [Indexed for MEDLINE]

39) Br J Surg. 1997 Feb;84(2):197
(Peritoneal seeding of pancreatic head carcinoma following percutaneous transhepatic drainage and stenting.)

  • Doctor N(1), Dafnios N, Dick R, Davidson BR. Author information: University Department of Surgery, Royal Free Hospital School of Medicine, London, UK.

  • Comment in: Br J Surg. 1997 Aug;84(8):1171.

  • PMID: 9052432 [Indexed for MEDLINE]

40) Gut. 2018 Apr;67(4):697-706. doi: 10.1136/gutjnl-2016-313341. Epub 2017 Aug 3.
(Minimally Invasive and Endoscopic Versus Open Necrosectomy for Necrotising Pancreatitis: A Pooled Analysis of Individual Data for 1980 Patients)

  • Authors: Sandra van Brunschot : Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.

  • Robbert A Hollemans: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Olaf J Bakker: Department of Surgery, University Medical Center Utrecht, Utrecht.

  • Marc G Besselink: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Todd H Baron: Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.

  • Hans G Beger: Department of Surgery, University of Ulm, Ulm, Germany.

  • Marja A Boermeester: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

  • Thomas L Bollen: Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands.

  • Marco J Bruno: Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.

  • Ross Carter: West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.

  • Jeremy J French: Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK.

  • Djalma Coelho: Department of Surgery, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

  • Björn Dahl: Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany.

  • Marcel G Dijkgraaf: Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands.

  • Nilesh Doctor: Department of Gastrointestinal Surgery, Jaslok Hospital and Research Center, Mumbai, India.

  • Peter J Fagenholz: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

  • Gyula Farkas: Department of Surgery, University of Szeged, Szeged, Hungary.

  • Carlos Fernandez Del Castillo: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

  • Paul Fockens: Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.

  • Martin L Freeman: Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA.

  • Timothy B Gardner: Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire, USA.

  • Harry van Goor: Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Hein G Gooszen: Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Gerjon Hannink: Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Rajiv Lochan: Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK.

  • Colin J McKay: West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.

  • John P Neoptolemos: Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.

  • Atilla Oláh: Department of Surgery, Petz-Aladár Teaching Hospital, Györ, Hungary.

  • Rowan W Parks: Department of Surgery, University of Edinburgh, Edinburgh, UK.

  • Miroslav P Peev: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

  • Michael Raraty: Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.

  • Bettina Rau: Department of Surgery, University of Rostock, Rostock, Germany.

  • Thomas Rösch: Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

  • Maroeska Rovers: Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

  • Hans Seifert: Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany.

  • Ajith K Siriwardena: Department of Surgery, Manchester Royal Infirmary, Manchester, UK.

  • Karen D Horvath: Department of Surgery, University of Washington, Seattle, USA.

  • Hjalmar C van Santvoort: Hjalmar C van Santvoort

  • PMID: 28774886

  • DOI: 10.1136/gutjnl-2016-313341

Abstract

Objective: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

Design: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

Results: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

Conclusion: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.