Introduction. Splenic artery Pseudoaneurysm, a complication of chronic pancreatitis, presenting as massive hematemesis is a rare presentation.Case Report. We present a case of 38-year-old male admitted with chief complaints of pain in the upper abdomen and massive hematemesis for the last 15 days. On examination there was severe pallor. On investigating the patient, Hb was 4.0 gm/dL, upper GI endoscopy revealed a leiomyoma in fundus of stomach, and EUS Doppler also supported the UGI findings. On further investigation of the patient, CECT of the abdomen revealed a possibility of distal pancreatic carcinoma encasing splenic vessels and infiltrating the adjacent structure. FNA taken at the time of EUS was consistent with inflammatory pathology. Triple phase CT of the abdomen revealed a splenic artery pseudoaneurysm with multiple splenic infarcts. After resuscitation we planned an emergency laparotomy; splenic artery pseudoaneurysm densely adherent to adjacent structures and associated with distal pancreatic necrosis was found. We performed splenectomy with repair of the defect in the stomach wall and necrosectomy. Postoperative course was uneventful and patient was discharged on day 8.Conclusion. Pseudoaneurysm can be at times a very difficult situation to manage; options available are either catheter embolisation if patient is vitally stable, or otherwise, exploration.

Peeyush Varshney, Vignesh N, Vaibhav Kumar Varshney, Subhash Soni, Selvakumar B, Lokesh Agarwal, Ashish Swami. Journal of Minimally Invasive Surgery 2023;26:28-34. https://doi.org/10.7602/jmis.2023.26.1.28

Peeyush Varshney, Saphalta Baghmar, Bhawna Sirohi, Ghassan K Abou-Alfa, Hop Tran Cao, Lalit Mohan Sharma, Milind Javle, Thorsten Goetze, Vinay K Kapoor. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.24-223

Hepato-pancreato-biliary (HPB) tuberculosis (TB) is a rare form of extra-pulmonary TB that poses a diagnostic dilemma and is a great masquerader of malignancy. It is almost always curable but requires a high degree of suspicion and corroboratory evidence to document its existence. Medline/PubMed was searched with keywords “hepatic”, “liver”, “biliary” and “pancreatic” with “tuberculosis”. Data were gathered and analyzed. Common symptoms of HPB TB include jaundice, weight loss, abdominal pain and other constitutional symptoms that make it indistinguishable from malignancy. Imaging modalities such as ultrasonography, computed tomography, magnetic resonance imaging may reveal dilated intrahepatic biliary radicles, mass lesion, and biliary stricture or enlarged necrotic lymph nodes. Fine-needle aspiration cytology/biopsy, brush biopsy, acid-fast bacilli (AFB) staining and molecular testing may help clinch the diagnosis. Most cases require biliary drainage and initiation of anti-tubercular therapy (ATT) whereas surgery is reserved for medically refractory cases or fibrotic strictures. However, most cases are diagnosed post-operatively on histopathology where pre-operative diagnosis is malignancy. A high index of suspicion, coupled with streamlined investigations, may help identify patients pre-operatively to be managed with ATT as TB is completely curable with medical management in most of the cases.

Background: Esophageal carcinosarcoma is an uncommon histologic variant of esophageal malignancy, occurring in approximately 0.5% to 2.8% of patients. Esophageal carcinosarcoma usually involves the middle and lower esophagus and consists of both epithelial and mesenchymal components. Case Report: A 54-year-old male presented with painless progressive dysphagia associated with loss of weight for 2 months. Esophagogastroduodenoscopy suggested an ulceroproliferative polypoidal growth in the lower thoracic esophagus. Biopsies from the growth showed leiomyosarcoma with tumor cells immunopositive for vimentin, h-Caldesmon, and smooth muscle actin and negative for pan-cytokeratin. Imaging suggested a heterogeneously enhancing polypoidal growth arising in the lower third of the esophagus. Thoracoscopic-assisted McKeown esophagectomy with gastric pull-up and standard 2-field lymphadenectomy was performed. A minor epithelial component was identified on final pathologic examination in addition to the leiomyosarcoma found on the preoperative biopsy. This epithelial component was invasive squamous cell carcinoma and was positive for pan-cytokeratin and p40, both of which were negative in the sarcomatous component. The patient received 4 cycles of adjuvant chemotherapy (carboplatin and paclitaxel). However, he developed a recurrence in the left cervical lymph node 4 months after adjuvant treatment and died 2 months after the diagnosis of recurrence. Conclusion: Carcinosarcoma can be easily missed in the presence of predominantly sarcomatous components even on immunohistochemical analysis. These tumors may be associated with poor prognosis and may have early recurrence despite surgery and adjuvant treatment.

Peeyush Varshney, Vaibhav Kumar Varshney. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.22-036