Brunner’s gland hyperplasia is an extremely rare benign hamartomatous lesion seen in proximal duodenum. Difficulty in diagnosing the condition pre-operatively puts the surgeon in dilemma for deciding appropriate management. We retrieved details from prospectively maintained retrospective data from January 2014 to April 2018. Four patients were identified of which three were males and one was female. Symptoms ranged from 4 days to 4 years, with abdominal pain, vomiting and malena being predominant. No patients were identified with diagnosis pre-operatively. Diagnosis was made on histopathological examination of the resected specimen and none of them were having malignant features. At a median follow up of 11 months, no patient had recurrence and were symptom free. Brunner’s gland hyperplasia is a rare elusive duodenal pathology, symptomatically mimicking alarming duodenal lesions and mostly diagnosed on histopathology of specimen. Patients may harbour the lesion for long periods with little symptoms and upon treatment have good outcomes.

Introduction. Duodenal perforation is a common surgical emergency and carries mortality ranging from 4% to 30% reported in Western countries, but there is a paucity of reports from India. We aimed to determine the factors which influence the surgical outcomes in patients with duodenal perforation. Methods. We retrospectively analyzed prospectively collected data from January 2010 to December 2018. Results. A total of 55 patients were included in the study of which 69% (38) were males and 31% (17) were females (M : F = 4.5 : 2). The mean age was 52.3 years. The cause for duodenal perforation was duodenal ulcer (n = 25, 45.5%), followed by post-ERCP complications (n = 15, 27.3%), surgery (n = 11, 20%), and blunt trauma (n = 4, 7.2%) with perforations localized at D2 (n = 28, 51%) and at D1 (n = 27, 49%). Patients underwent primary repair with an additional diversion procedure (n = 28, 51%) and repair only in 18 (32.8%). There were 21 (38%) deaths. Patients with ERCP-associated duodenal perforation had longer hospital stay ( P ≤ 0.001 ), ICU stay ( P = 0.049 ), duration of drainage ( P ≤ 0.001 ), and higher leak rate ( P = 0.001 ) and re-exploration rate ( P = 0.037 ). A high mortality rate was seen in patients with preoperative organ failure (n  = 18, 78% versus 9.4%, P = 0.001 ), postoperative leak (n = 7, 64% versus 32%, P = 0.05 ), and longer duration from onset of symptoms to surgery (≥4 days) ( P = 0.045 ). Conclusion. Perforation of the duodenum is associated with high morbidity and mortality regardless of its cause and is higher in those who have a longer interval to surgery, preoperative organ failure, and a postoperative leak.

Diverting loop ileostomy is a frequently done procedure accompanying colorectal surgeries. Dreaded complication is anastomotic leak. Early identification of anastomotic leak and apt management is required for better outcomes. Most often leak presents with fever, abdominal pain, rigidity, fever and hemodynamic instability. We report a rare occurrence of penoscrotal oedema in a patient with anastomotic leak and spontaneously subsiding with drainage of leaked contents.

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Introduction: Routine ligation of spontaneous portosystemic shunts (SPSS) during LDLT is necessary to prevent portal flow steal (PFS) but also increases the risk for portal hyperperfusion syndrome (PHS) even with normal-sized grafts. Splenic artery ligation is proven to be safe and effective in augmenting hepatic artery flow and modulating portal inflow. Our aim is to determine whether combining prophylactic ligation of both SPSS and splenic artery can improve early graft function and to describe its influence on graft hemodynamics. Method: Medical records from 88 adult patients with significant SPSS who underwent LDLT from June 2013 to May 2018 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Patients were divided into Non-ligated [NL (n=42)], Ligated [L (n=40)] and combined SPSS and splenic artery ligation [L+SAL (n=6)] groups. Preoperative and intraoperative data were analyzed using Kruskal-Wallis test followed by pairwise comparison. Liver function and graft hemodynamics within two weeks post-transplant (POD1,3,5,7 and 14) were analyzed using generalized estimating equations. Result: Preoperative data were comparable in all three groups. The L+SAL group had significantly lower posttransplant total bilirubin levels from POD1-14 (P = 0.014, 0.045, 0.023, 0.012, 0.037). Other liver function tests did not show any significant difference between groups. Posttransplant portal vein flow (PVF) was significantly higher in L vs NL (P=0.011) while L vs L+SAL had similar PVF. Hepatic artery velocity was highest in the L+SAL group but the difference did not prove to be significant. Combined incidence of PHS was 20% for (L+NL) vs 0% for L+SAL. Conclusion: Combined prophylactic SPSS ligation and SAL or Splenic devascularization during LDLT appears to work synergistically to prevent post-transplant PFS and PHS leading to improved early graft function and potentially, long-term outcomes.