Introduction: Pancreaticoduodenectomy is a complex surgical procedure involving meticulous resection and reconstruction steps. Materials and Methods: We analyzed the first 15 laparoscopic pancreaticoduodenectomies performed for ampullary, periampullary, and cephalic pancreatic tumors at the Fundeni Clinical Institute, Bucharest, a high-volume center with extensive expertise in hepatopancreatobiliary surgery. Patient demographics, medical history, intraoperative parameters, early postoperative outcomes, and oncological results regarding radical resection were evaluated. Results: The mean patient age was 59.4 years, with 53.33% males. Cardiovascular comorbidities were present in 60% of patients, while 26.66% had controlled type 2 diabetes mellitus. Previous cholecystectomy was noted in 46.66% of cases, and 60% presented with jaundice at diagnosis. The mean operative time was 360 minutes. Pancreaticogastrostomy was performed in 66.66% of cases and pancreaticojejunostomy in 33.33%, with 26.66% of procedures being fully laparoscopic. Biochemical leakage occurred in 13.33% of cases, while grade B pancreatic fistula developed in 6.67% of cases and was managed conservatively. Moderate biliary fistula occurred in 13.3% of the patients, with remission under conservative treatment. All resections achieved negative margins (R0). The mean number of retrieved lymph nodes was 15.6, and the average hospital stay was 18.7 days. Discussions: Laparoscopic pancreaticoduodenectomy provides oncological outcomes comparable to the open approach and may improve postoperative recovery in experienced centers. Conclusions: Our results are encouraging, with potential for further improvement through careful patient selection and refinement of surgical technique.

Background Laparoscopic cholecystectomy is the accepted standard treatment for symptomatic gallstone disease. However, severe inflammation, fibrosis, adhesions, or anatomical distortion can obscure critical landmarks and increase the risk of bile duct injury. In such cases, timely recognition of operative difficulty and appropriate modification of technique are essential to ensure patient safety. Methods This prospective case series was conducted at a tertiary care center, R L Jalappa Hospital & Research Center, Tamaka, Karnataka, India, in 2024 and included seven adult patients whose intraoperative findings met predefined criteria for difficult laparoscopic cholecystectomy. Demographic data, operative challenges, technical adaptations, postoperative outcomes, and 30-day follow-up findings were documented and analyzed descriptively. Results Operative difficulty was associated with a frozen Calot's triangle, dense omental or bowel adhesions, a mucocele with impacted stones, a short cystic duct, severe fibrosis, and vascular anomalies. Structured bailout strategies were employed based on intraoperative findings. These included fundus-first (dome-down) dissection, fenestrating subtotal cholecystectomy, selective partial cystic ductotomy for impacted stone retrieval, endoloop ligation of the cystic duct stump, and judicious drain placement. In one patient, transient postoperative jaundice resolved spontaneously without intervention. No bile duct injuries or major postoperative complications occurred. All patients recovered satisfactorily, and no delayed morbidity was identified at the 30-day follow-up. Conclusion Difficult laparoscopic cholecystectomy requires vigilance, thorough anatomical knowledge, and the readiness to adapt the operative plan. Familiarity with bailout techniques and individualized intraoperative decision-making can prevent major biliary injuries and enable the safe completion of surgery, even in challenging operative fields.

Leptospirosis is a globally prevalent zoonotic infection caused by pathogenic spirochaetes of the genus Leptospira Although typically associated with mild flu-like symptoms or Weil's disease (characterised by jaundice, renal failure and haemorrhagic manifestations), atypical and severe presentations can mimic other systemic disorders. A man in his 40s presented with fever, myalgia along with rapidly progressive jaundice, thrombocytopenia, microangiopathic haemolytic anaemia and acute kidney injury, preceded by a short episode of diarrhoea. The initial working diagnosis was haemolytic uraemic syndrome (HUS) secondary to Shiga toxin-producing Escherichia coli and he was treated with plasma exchange, transfusions and renal replacement therapy. However, stool examinations were negative for Shiga toxin and bacterial pathogens. Subsequent investigations confirmed leptospirosis. He improved significantly after treatment with doxycycline alongside supportive therapy. This case highlights the importance of considering leptospirosis as a differential diagnosis in patients with HUS, particularly in endemic regions, to avoid delays in targeted treatment.

Background Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common inherited enzymatic disorder and a major risk factor for neonatal hyperbilirubinemia. This study aims to identify baseline risk factors and evaluate clinical outcomes associated with G6PD deficiency in neonates. Methods A case-control study was conducted, including 150 neonates, comprising 50 G6PD-deficient cases and 100 controls. Demographic characteristics, clinical variables, and laboratory parameters were compared between groups. Categorical variables were analyzed using chi-square (χ[2]) tests, and continuous variables were analyzed using the Mann-Whitney U test. A p-value <0.05 was considered statistically significant. Results Significant associations were observed between G6PD deficiency and male sex, ethnicity, family history of G6PD deficiency, prolonged hospital stay, phototherapy requirement, and presence of jaundice (p <0.001). G6PD-deficient neonates had significantly higher total bilirubin levels and lower G6PD enzyme levels compared with controls. No significant associations were found with gestational age, feeding type, mode of delivery, or maternal and fetal complications. Conclusions G6PD deficiency was significantly associated with key risk factors like male gender, ethnicity, family history of G6PD, and clinical outcomes, including neonatal hyperbilirubinemia, jaundice, prolonged hospitalization, and increased phototherapy requirement.

Epstein-Barr virus (EBV) typically causes infectious mononucleosis, but in rare cases, it may lead to complications such as autoimmune hemolytic anemia (AIHA) and hepatitis. We report the case of an 18-year-old previously healthy female who presented with jaundice, red urine, and arthralgia. Laboratory workup revealed direct hyperbilirubinemia, elevated transaminases, and a direct antiglobulin test positive for IgG (negative for C3d), consistent with warm autoimmune hemolytic anemia in the context of EBV infection. Imaging ruled out biliary obstruction. The patient was managed conservatively, with cautious steroid use, and demonstrated clinical improvement without progression to hepatic failure. This case underscores the importance of recognizing atypical hepatic presentations of EBV and carefully managing overlapping autoimmune complications.

Pancreatic cancer is a major cause of cancer-related mortality and is frequently diagnosed at advanced stages when surgery is no longer an option. Most patients require palliative care to manage symptoms, such as jaundice, pain, and gastric outlet obstruction (GOO). Therapeutic endoscopic options, including endoscopic ultrasound (EUS)-guided techniques, have become essential for improving quality of life. We conducted a literature review focusing on the current palliative endoscopic therapy options for advanced pancreatic cancer. Malignant biliary obstruction is primarily treated using endoscopic retrograde cholangiopancreatography. However, when this method is complex or unsuccessful, EUS-guided biliary drainage is considered a reliable and safe alternative. Irradiating stents may increase stent patency times and patient survival. EUS-guided gastroenterostomy, if technical expertise is available, is becoming the first option for GOO in patients with longer survival, with enteral stenting being preferred for patients with limited life expectancies or when the EUS option is not available. Although EUS-guided celiac plexus neurolysis and pancreatic duct drainage play a role in pain management, EUS-guided radiofrequency ablation remains under investigation. In conclusion, endoscopic and EUS-guided interventions provide safe, minimally invasive, and highly effective approaches for the palliative care of pancreatic cancer, enhancing patients' quality of life and minimizing the need for more invasive surgical procedures.

Phellodendri amurensis Cortex is the dried bark of the cork tree (Phellodendron amurense Rupr.) from the Rutaceae family, and possesses traditional efficacy in clearing heat, drying dampness, purging fire, relieving steaming sensations, detoxifying, and healing sores. Clinically, it is commonly used for treating symptoms such as damp-heat diarrhea and dysentery, jaundice with reddish urine, leukorrhea with vaginal itching, painful and difficult urination due to heat strangury, flaccidity and weakness of the lower limbs, bone-steaming and consumptive fever, night sweats and seminal emission, sores, ulcers, swellings, and toxins, eczema, damp sores, and urinary tract infections. Modern pharmacological studies have further revealed its diverse bioactivities, including antioxidant, antibacterial, anti-inflammatory, immunosuppressive, and anticancer effects. To provide an updated and comprehensive review of the research into Phellodendri amurensis Cortex, this study conducted a thorough literature search and analysis based on databases such as SciFinder, Web of Science, and China National Knowledge Infrastructure. The review integrates information on the plant's botanical characteristics, geographical distribution, traditional applications, chemical components, quality control methods, and pharmacological effects to present a current and holistic overview of its research status. To date, approximately 170 compounds have been isolated and identified from Phellodendri amurensis Cortex, primarily including alkaloids, phenolics, terpenoids, sterols, lignans, flavonoids, and others. Among these, alkaloids exhibit significant antioxidant and anti-inflammatory activities and demonstrate potential pharmacological value in antibacterial, anticancer, hypoglycemic, and multi-organ protective effects. Although substantial foundational research exists, the mechanisms of action and quality control of Phellodendri amurensis Cortex require further in-depth exploration. Future efforts should focus on clarifying its pharmacodynamic material basis, uncovering new targets and pathways, and improving analytical methods for component analysis and quality control to advance the scientific development and rational utilization of this medicinal material.

Malignant biliary obstruction is commonly treated with biliary stenting either endoscopically or percutaneously; however, tumor ingrowth might occlude the stent, often leading to recurrent jaundice and repeat interventions. Endobiliary microwave ablation (MWA) is an emerging adjunct intended to devitalize intraductal tumors and potentially prolong stent patency. This review assesses the state of the art of endobiliary ablation for malignant biliary obstruction, focusing on the technique and safety of percutaneous procedures, as well as patient outcomes. It also discusses the use of flexible endobiliary MWA for hilar cholangiocarcinoma. The review covers ablation methods such as radiofrequency and MWA, which can be performed endoscopically or percutaneously. Research indicates that endobiliary thermal ablation is technically feasible and can be safely combined with stenting. Some studies suggest it may prolong stent patency and decrease the necessity for repeat procedures compared with stenting alone. Percutaneous techniques may be particularly helpful in complex hilar cases, allowing accurate energy delivery, protection of secondary bile ducts, and tailored stent placement. New microwave systems can heat tissue more deeply and evenly than radiofrequency ablation, which may improve local tumor control. Endobiliary thermal ablation appears to be a useful supplement to stenting, especially for patients with unresectable hilar cholangiocarcinoma. Flexible percutaneous MWA probes could make this treatment more widely available. Still, more high-quality studies are needed to find optimal ablation settings, identify which patients benefit most, and compare this method with standard stenting.

Background/Objectives: Malignant distal biliary obstruction (MDBO) is a frequent complication of pancreatic cancer and often leads to obstructive jaundice, impaired liver function, and delayed oncologic treatment. Endoscopic biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the standard minimally invasive approach for restoring biliary flow. However, clinical outcomes and complication rates vary across studies depending on stent design, placement technique, and patient characteristics. The aim of this systematic review was to evaluate the clinical outcomes and complications associated with endoscopic biliary stenting in pancreatic cancer-related MDBO. Methods: A systematic literature search was performed in PubMed/MEDLINE, ScienceDirect, Web of Science, and the Cochrane Library for studies published between January 2016 and January 2026. Studies evaluating ERCP-guided biliary stenting in adult patients with pancreatic cancer-related malignant distal biliary obstruction were included. Study selection followed PRISMA 2020 guidelines, and methodological quality was assessed using the Newcastle-Ottawa Scale. Clinical outcomes including technical success, clinical success, stent patency, recurrent biliary obstruction, and procedure-related complications were analyzed. Results: Eighteen studies involving a total of 3291 patients were included in the qualitative synthesis. Technical success rates were consistently high, reaching up to 100% in several studies, while clinical success rates generally exceeded 90%. Median time to recurrent biliary obstruction ranged from approximately 102 to 541 days depending on stent type and placement technique. Recurrent biliary obstruction was the most frequently reported complication, occurring in 30.7% of patients. Stent migration occurred in 14.9% of cases, while post-ERCP pancreatitis was reported in approximately 4.2% of patients. Several studies demonstrated longer patency with self-expandable metal stents compared with plastic stents. Conclusions: Endoscopic biliary stenting performed during ERCP is an effective and safe strategy for the management of malignant distal biliary obstruction in pancreatic cancer. Self-expandable metal stents provide more durable biliary drainage and reduce the need for repeat interventions. Nevertheless, recurrent biliary obstruction remains a common limitation, highlighting the need for further improvements in stent technology and optimized placement strategies.

Background/Objectives: Acute-on-chronic liver failure (ACLF) is a severe syndrome in chronic liver disease (CLD) patients, characterized by multi-organ failure and high mortality. Living donor liver transplantation (LDLT) is vital in donor-scarce areas. This study compares baseline characteristics, perioperative complications, and long-term survival between ACLF and non-ACLF patients, emphasizing etiology, ACLF grading, and graft factors. Methods: Data from a prospective registry of 591 adult LDLT recipients (2019-2023) were analyzed. ACLF was defined by EASL-CLIF (multi-organ failure, grades 1-3) and APASL (jaundice/coagulopathy with complications) criteria, evaluated at initial assessment and within 24 h pre-LDLT. Results: ACLF patients (n = 101, 17.1%) showed higher MELD-Na (27 vs. 20, p < 0.001), bilirubin (6.84 vs. 1.75 mg/dL, p < 0.001), creatinine (108 vs. 70.5 μmol/L, p < 0.001), metabolic/genetic etiologies (9.9% vs. 2.8%, p = 0.001), and chronic kidney disease (23.7% vs. 8.1%, p < 0.001), and lower HCC rates (11.8% vs. 29.6%, p < 0.001). GRWR was marginally lower in ACLF patients (0.59 vs. 0.66, p = 0.10). The ACLF group had elevated infection (27.7% vs. 10.4%, p < 0.001), bleeding (14.9% vs. 6.3%, p = 0.004), and biliary complications (15.8% vs. 7.8%, p = 0.010), with longer ICU (5 vs. 3 days, p < 0.001) and hospital stays (33.66 vs. 20.7 days, p = 0.036). Five-year overall survival was reduced in ACLF patients (log-rank p = 0.001), worsening with grade (EASL-CLIF grade 3: 55% vs. 81% for no ACLF, p = 0.002). Graft survival was also lower (75% vs. 85%, p = 0.02). Multivariable analysis identified chronic kidney disease as an independent mortality predictor (HR 2.09, 95% CI 1.11-3.95, p = 0.023). Conclusions: LDLT for ACLF involves higher perioperative risks and poorer long-term survival than non-ACLF patients, with outcomes deteriorating by ACLF grade. Chronic kidney disease independently predicts mortality. Timely LDLT is essential in donor-limited regions.

Objectives: Neonatal hyperbilirubinemia is a common disease in the neonatal period. In this meta-analysis, we aim to evaluate the efficacy of adjuvant drugs combined with phototherapy in the treatment of neonatal hyperbilirubinemia. Methods: Randomized controlled trials (RCTs) published before September 2025 were searched from PubMed, Embase, Web of Science, and the Cochrane Library. A Bayesian random-effects network meta-analysis was performed to calculate mean differences and 95% confidence intervals. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) and probability of being the best treatment (PbBT). Results: Thirty-five RCTs involving 4060 neonates were included. Compared with phototherapy alone, clofibrate, ursodeoxycholic acid, fenofibrate, and calcium phosphate significantly reduced bilirubin levels and shortened admission duration. Clofibrate showed the greatest efficacy in bilirubin reduction within 48 h (SUCRA = 0.91, PbBT = 60.9%) and in shortening hospitalization (SUCRA = 0.84, PbBT = 40.83%). Probiotics, zinc, and agar exhibited relatively modest effects, while phenobarbital showed no significant benefit. Conclusions: Adjunctive therapies were associated with greater reductions in bilirubin levels compared with phototherapy alone. Future high-quality RCTs are needed to confirm the long-term efficacy and safety of these adjuvant therapies.

A 47-year-old woman with metastatic pancreatic adenocarcinoma, diagnosed five months earlier and treated with palliative chemotherapy, was admitted with fever, jaundice, and right upper quadrant pain consistent with ascending cholangitis. Treatment with antibiotics was initiated and an endoscopic retrograde cholangiography was performed, whereby a biliary stent was placed to relieve malignant biliary obstruction. Physical examination revealed moderate ascites. Careful inspection of the umbilicus revealed a small nodular lesion located within the umbilical fold that became visible only after eversion of the umbilicus. The lesion had developed gradually over several weeks. Computed tomography confirmed the known pancreatic malignancy with metastatic disease and ascites. On re-review of the images, a small soft tissue nodule replacing the umbilicus was also visible. The lesion was clinically consistent with a Sister Mary Joseph nodule, an umbilical metastasis most commonly associated with advanced gastrointestinal or gynecologic malignancies. These lesions may arise through lymphatic or hematogenous spread or through direct extension into the umbilicus. This case highlights that umbilical metastases may be subtle and located within the umbilical fold, requiring careful physical examination to be detected.

BackgroundTo reduce avoidable Special Newborn Care Unit (SNCU) admissions by 15% over a 4-month period through focused quality improvement (QI) interventions at a high-volume tertiary care hospital in Kolkata, India.MethodsThis QI study was conducted from August to November 2024. Baseline data revealed that 25% of weekly SNCU admissions were avoidable. A multidisciplinary team implemented evidence-based admission criteria, enhanced perinatal care practices, and strengthened postnatal monitoring. Key interventions included improved delivery room practices (respiratory support with CPAP, delayed cord clamping, early skin-to-skin contact, and early initiation of breastfeeding) and standardized triage protocols. Feeding support, prefeeding oromotor stimulation, antibiotic stewardship, and reverse transport to nearby SNCUs were also integrated. Four Plan-Do-Study-Act (PDSA) cycles supported infrastructure planning, staff training, protocol implementation, and sustainability.ResultsAvoidable admissions declined from 25% to 10% over 4-months. Bed occupancy dropped from a peak of 125% to 102%. Process indicators improved significantly: delayed cord clamping increased from 30% to 88%, early initiation of breastfeeding from 40% to 90%, and exclusive breastfeeding at discharge from 67% to 81%. Admissions for neonatal jaundice decreased following the implementation of updated AAP guidelines, with 21% of cases managed without phototherapy. Only five re-admissions (0.59%) and one emergency NICU transfer (0.13%) occurred.ConclusionsNeonatal care should extend beyond SNCU optimization to include strengthened delivery point and postnatal-ward practices. When integrated with protocol based SNCU management, this continuum helps reduce morbidity, ease overcrowding, enhance efficiency, and optimize resource utilization in high-burden, resource-limited settings.