Laparoscopic cholecystectomy remains the standard treatment for cholelithiasis. Ever increasing number of patients with myriad of medical illness is being treated by this technique. However, significant concern prevails among the surgical community regarding its safety in patients with cardiac co-morbidity. Patients with significant cardiac dysfunction and multiple co-morbidities were prospectively evaluated. Patients were assessed by cardiologists and anesthesiologists and laparoscopic cholecystectomy was performed. Patient demographics, details of peri-operative management and post-operative complications were studied. Between March 2005 and January 2009, 28 patients (M:F= 21:7) with mean age of 60 years (range 26-78) and having significant cardiac dysfunction had undergone laparoscopic cholecystectomy. Of these, 24 patients were in NYHA class-II, while 4 belonged to class-III. Left ventricular ejection fraction, as recorded by transthoracic echocardiography, was 20-30% in 13 (46%) patients and 30-40% in the rest 15 (54%). In addition, 13 (46%) patients had regional wall motion abnormalities, 11 (39%) patients had cardiomyopathy, 2 (7%) patients had valvular heart disease while 12 (43%) patients had prior cardiac interventions. Following laparoscopic cholecystectomy, hypertension (3), tachyarrhythmia (4) and bradycardia (1) were the commonest events encountered. One patient required laparotomy to deal with peritonitis in the immediate postoperative period and succumbed to myocardial infarction, but all other patients made an uneventful recovery. With appropriate cardiological support, laparoscopic cholecystectomy may be safely performed in patients with significant cardiac dysfunction.

Primary angiosarcoma is an extremely rare and aggressive soft-tissue malignancy of endothelial cell origin that occurs most frequently in the skin and subcutaneous tissues of the extremities. Presence of this disease in the intestine as a primary or metastatic deposit is an extremely uncommon incident, and might causes diagnostic confusion with primary colonic neoplasm. We encountered epithelioid angiosarcoma of the sigmoid colon in a 59-year-old male patient who presented with occasional bleeding per rectum and had also had an angiosarcoma arising from the subcutaneous tissue of the right thigh. Retrospective review of histopathology and immunohistochemistry of the two specimens were helpful in the final diagnosis.

Dear Sir,We read with interest the excellent article by Shukla et al.(Extended pancreatectomy for pancreatic cancers. IJS 2009; 71:2-5). It is a ready-reckoner for the surgeon who is keen to update on the contextual importance of extended pancreatic resection. That extended lymphadenectomy doesn't confer survival advantage, is well proven in randomised trials and meta-analysis [1]. But what constitutes a R0 (complete resection) is still mired in confusion mainly because of lack of unanimity amongst pathologist on a standardized technique of histopathological examination [2]. Achieving negative resection margin is not only a surgical triumph, but could potentially increase survival. A randomized study from a center of repute showed a trend towards increasing survival in pancreatic cancer patients who had extended resection and this was attributed mainly due to higher incidence of negative resection margin in this sub-group [3]. In this respect the retroperitoneal resection margin, often termed as mesopancreas, is finding increasing prominence in the recent literature [4]. This structure extends from the posterior surface of the pancreatic head to behind the mesenteric vessels. In order to excise this tissue en masse the recently described hanging technique is an elegant operative innovation [5]. Briefly, the duodenum is widely Kocherized beyond the medial border of aorta and the origin of superior mesenteric artery (SMA) is identified. A tunnel is dissected between the mesopancreas and the SMA and a tape is passed through. Sustained traction on this tape stretches the retroperitoneal margin, which is then excised in a controlled manner.To some extent, the traditional nihilism surrounding portal vein invasion by pancreatic malignancy has been partially annulled by finding survival equivalence between patients who were operable vis-vis those who required portal vein excision for complete clearance. However, this benefit is limited to patients with superficial invasion into the tunica adventitia [6]. With deeper portal vein wall invasion into the tunica media or intima, the survival is similar to those with non-curative surgery. The depth of portal vein invasion appears to correlate with preoperative CT portogram type C and D and a tumor diameter more than 45 mm [6].Although autologous venous and polytetrafluoroethylene grafts are conduits of choice for portal vein reconstruction, a generous Cattell-Braasch manoeuvre, wherein the ligament of Treitz is incised and hepatic flexure dissected liberally, serves to mobilise the root of mesentery and helps in moving it cranially. Mobilising the liver by incising the falciform, coronary and triangular ligaments causes a caudal displacement of the liver. These two steps in tandem approximate the transected ends of the portal vein and a defect as long as 5 cm could be primarily anastomosed in a tension free manner, thereby obviating the need for a graft [7].