Ajit Sewkani

Peri‐operative outcomes for pancreatoduodenectomy in India: a multi‐centric study

BACKGROUND There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres. MATERIALS AND METHODS Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India. RESULTS Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days). CONCLUSIONS This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.

Torsion of gall bladder, a rare entity: a case report and review article

IntroductionGallbladder torsion is a rare entity, which is often difficult to diagnose preoperatively. Since its first description in 1898 by Wendel, there have been over 500 documented cases in the literature. It is defined as rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Gallbladder torsion is more frequently encountered in the elderly with peak incidence in the 65-75 year old group, and a 3:1 female predominance. Gallbladder torsion typically presents as an acute abdomen requiring emergency surgery, and most cases are found as a surprise at surgery since preoperative diagnosis of gallbladder torsion is difficult. We report a case of acute gallbladder torsion in an elderly male and review the clinical aspect of gallbladder torsion.Case reportA 54-year old male presented to our department with a 5-day history of sudden onset colicky abdominal pain associated with vomiting, progressive abdominal distension and fever. Laparotomy through a chevron incision was performed and findings at operation included a gallbladder, which was necrotic and gangrenous, not attached to the liver by any mesentery. It was hanging by the attachments of cystic duct and cystic artery only, with a 360-degree clockwise torsion.ConclusionGallbladder torsion is rare surgical emergency which requires a high index of suspicion for early preoperative diagnosis and prompt intervention. Treatment consists of cholecystectomy with a prior detorsion to avoid injury to the common duct.

Percutaneous drainage of tubercular liver abscess.

To the Editor We would like to report our experience of managing tubercular liver abscess. Between 2002 and 2005 we have treated five cases of tubercular liver abscess. All patients were male with mean age of 53 years (34–63 years). All patients presented with clinical features suggestive of amoebic liver abscess. Two patients had received antitubercular treatment in the past; one patient for Pott’s spine 12 years ago and the other for tubercular cervical lymphadenopathy 3 years ago. The laboratory investigations showed leukocytosis with elevated ESR in all patients. Liver function tests showed elevated transaminases (upto three times normal) and minimal elevation of serum bilirubin and alkaline phosphatase. Ultrasonography revealed large right lobe liver abscess (mean diameter 7.5 cm; range 6.5–9 cm) in four patients and a 4.5 cm diameter abscess in the left lobe in the fifth patient. The rest of the liver and other viscera were normal and there was no ascites or retroperitoneal lymphadenopathy in any patient. Plain film of the chest showed elevated right hemidiaphragm in three cases whereas it was normal in the other two patients. All patients were started on metronidazole but did not improve after 48 h. Percutaneous aspiration was carried out in four patients with right lobe abscess and broad spectrum antibiotics were added. Gram stain of the aspirate was negative and cultures were sterile in all four. As there was no improvement after another 48 h of antibiotics and metronidazole, percutaneous drain was inserted in these four patients. After drainage, pus was evaluated for Mycobacterium tuberculosis by acid fast stain and polymerase chain reaction (PCR). Stain for acid fast bacilli (AFB) was positive in two patients and PCR-assay based test for M. tuberculosis was positive in all four. PCR for tuberculosis, Gram stain, AFB stain and culture for pyogenic bacteria was done on the diagnostic aspirate in the patient with left lobe abscess who did not respond to 48 h of metronidazole. Gram stain and AFB stain were negative and culture for pyogenic organisms was sterile whereas PCR for M. tuberculosis was positive. All patients were started on four drug antitubercular therapy (ATT). Four patients with percutaneously placed drains showed gradual improvement in symptoms. Drain output was high in all patients and persisted beyond 2 weeks in all the four patients. The mean duration of drainage was 26 days (19–33 days). ATT in these patients was continued for 12 months. The fifth patient was directly started on ATT after diagnostic aspiration but showed minimal clinical improvement after 3 weeks of treatment. Repeat USG showed 3 cm heteroechoic lesion in the left lobe of liver. This patient underwent laparotomy and left lateral segmentectomy. The histological examination showed features of organized abscess with multiple tubercular granulomas in the wall. He had an uneventful postoperative course and was discharged on ATT for 12 months. On mean follow-up of 17 months (8–21 months) all patient are asymptomatic with normal ESR and liver functions. Primary tubercular liver abscess are uncommon. Most cases are diagnosed late, either after percutaneous drainage or aspiration when the abscess do not respond to antibiotics. Tubercular bacilli may reach the liver via hematogenous route, lymphatics and adjacent abdominal viscera (1, 2). Alvarez has classified tuberculosis of the liver into three types; military, granulomatous hepatitis and localized type (abscess or nodular mass like) (1). Ultrasonographic and computerized tomography features of tubercular liver abscess are nonspecific (3, 4). AFB are sometimes demonstrable in the pus or in the biopsy from the abscess wall. (3, 5). PCR-based test on liver biopsy or aspirated pus may give better yield compared with AFB staining (6, 7). High index of suspicion is required for diagnosis. In patients with liver abscess who do not show typical features of pyogenic/amoebic abscess and who fail to respond to antibiotics/ amoebicidal drugs, the possibility of tubercular abscess should be considered. Radiologically guided diagnostic aspiration with staining for AFB and PCR help in confirming the diagnosis. Antitubercular drugs alone are sufficient for Liver International 2006: 26: 630–631 r 2006 The Authors Journal compilation r 2006 Blackwell Munksgaard