BACKGROUND: Postpancreatectomy hemorrhage (PPH) is one of the most severe complications after pancreaticoduodenectomy. METHODS:This prospective study was done in a tertiary care center to find out the role of gastric pH in postpancreatectomy hemorrhage. The gastric pH study is done by Ryle’s tube aspiration – 1) fasting ph value 1 hour before surgery and second value after 48 hrs of surgery. RESULTS: Of the total 27 patients who underwent Whipple’s procedure, 6 patients develop postpancreatectomy hemorrhage. On applying unpaired T test it was found that the difference was significant (p value <0.05) in the mean pH values among those with PPH when compared to those without PPH. The mean pH levels (mean ± Sd) among bleeders was 3.39 ± 1.80 and among non bleeder was 6.33 ± 1.03. The mean pH values were significantly lower in those where bleeding was present. The area under the curve of the ROC analysed and it was found that that the PH of 4.1 had maximum sensitivity (50%) and specificity (95.2%). Based on this, association between bleeding and PH value of 4.1 as cutoff was analysed using chi square test and it was found that the incidence of bleeding was significantly (p value <0.05) higher among those who had a PH value <4.1 (75%) compared to those with PH >4.1 (13%) CONCLUSION: Persistent low gastric pH is associated with increased risk of post pancreatectomy Hemorrhage.Suppression of the intrinsic gastric acid secretion will be helpful in reducing the risk of bleeding after Pancreaticogastrostomy in Whipple procedure.

Intrahepatic cholangiocarcinoma (ICC), which is ordinarily a very invasive tumor and often takes a rapid and fatal course, sometimes shows macroscopic intra bile duct extension. We present a case of a 45-year-old Indian gentleman who presented with jaundice. Further evaluation with contrast enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) abdomen revealed mass lesion in segment 4 of liver with extension into the bile duct. A formal left hepatectomy with gall bladder and bile duct tumour thrombus extraction with bile duct excision followed by a Roux-en-Y hepaticojejunostomy was performed. Intra bile duct growth of ICC may reflect indolent biological behavior and thus warrants an aggressive surgical approach, which appears to give a good prognosis.

Primary aortoenteric fistula (PAEF) is spontaneous development of communication between the native aorta and anywhere within the gastrointestinal tract. It is extremely rare and fatal condition which usually presents as a painless upper gastrointestinal bleed. This condition is often overlooked because of it's rarity and low index of suspicion by physicians despite the availability of a wide range of diagnostic tools. Computed tomography angiography (CTA) is the most common investigation done to diagnosis PAEF. This paper reports a case of 49 years old female with massive upper gastrointestinal (GI) bleeding. A PAEF was diagnosed by CTA which called for an emergency laparotomy with surgical repair of the fistula with a synthetic vascular bypass graft. The patient recovered well.

A 19-year-old male presented to us with complain of acute epigastric pain for 2 weeks duration. The pain was dull aching in nature, radiating to back. On examination he was of average built and nutrition, dysnoic and tachypnoic with pulse rate of 140 /min, respiratory rate 26 /min, blood pressure 140/80 mmHg, saturation on room air 90%, bilateral (b/l) pedal edema present. On per abdomen examination abdomen was distended, fullness was present in bilateral upper abdomen. So, after thorough investigation, diagnosis of acute necrotizing pancreatitis was made and subsequently planned for ultrasonography (USG) guided percutaneous pigtail drainage as step-up approach in view of multiple loculated collections. Nasojejunal tube was inserted for entral nutrition. First perihepatic collection was drained on day 1, then lesser sac and pelvis drainage was done on day 2. At times, the collections may extend into the subhepatic space from the lesser sac through foramen of Winslow. Such subhepatic collections are intraperitoneal rather than retroperitoneal and there is a significant risk of peritoneal leak during endoscopic transmural drainage that may cause peritonitis. The collections may extend to either or both paracolic gutters retroperitoneally and at times to pelvis. In these retroperitoneal collections where endoscopic transmural drainage that may cause peritonitis, percutaneous pigtail drainage as a step-up approach is a feasible option.

We describe a unique case of a 65-year-old woman who had a hepatic adenoma compressing her right lung, inferior vena cava, and right ventricle, which had been the cause of her breathing problems, which had been becoming worse for the preceding six months. Through a right thoracoabdominal incision, an urgent right hepatectomy was carried out to manage her condition.