Kurumboor Prakash

Are some cases of infected pancreatic necrosis treatable without intervention

Background: Infected pancreatic necrosis is considered an absolute indication for interventional management such as percutaneous drainage or surgery. The presence of retroperitoneal air is a sign of anaerobic sepsis. Method: A retrospective review of case records of patients presenting with severe acute pancreatitis and pancreatic necrosis was performed to identify cases in whom conservative treatment was followed by a satisfactory outcome. Results: Four patients were identified over a 3-year period who had pancreatic necrosis and retroperitoneal air; they were treated with antibiotics and intensive care, and they improved without any interventional treatment. Conclusions: Some patients with infected pancreatic necrosis are treatable medically. The clinical status of the patients may well be a more important factor governing the choice of the treatment approach than bacteriological findings of infection alone.

Laparoscopic cholecystectomy in acute cholecystitis

Background: In the light of laparoscopic cholecystectomy increasingly applied to all forms of cholecystitis, this study aimed at evaluating the safety of laparoscopic cholecystectomy applied to all cases of acute cholecystitis, and at determining factors associated with the risk of conversion to open cholecystectomy. Methods: The clinical, biochemical, radiologic, and operative data from 124 consecutive cases of acute cholecystitis were analyzed retrospectively to determine the complications and morbidity after operation. The data were analyzed further by univariate and multivariate analysis to identify factors associated with conversion. Results: No major bile duct injury or mortality occurred. Bile leak from the stump of the cystic duct developed in four patients. These were managed successfully by endoscopic biliary stent placement. The mean duration of hospital stay was 3.8 days in the laparoscopic group and 8.2 days in the open group. Of the 124 patients (18.5%), 23 underwent conversion to open cholecystectomy. Univariate analysis identified the following factors as associated with conversion: common duct dilation greater than 7 mm observed on ultrasound, (p < 0.05), pericholecystic collection seen on ultrasound (p < 0.0001), emphysematous cholecystitis (p < 0.01), endoscopic retrograde cholangiopancreatographic evidence of Mirizzi syndrome (p < 0.05), and pericholecystic collection at operation (p < 0.0001). On multivariate analysis, only pericholecystic collection (p < 0.015) and gallbladder wall thickness greater than 5 mm (p < 0.013) were statistically significant. Conclusions: Laparoscopic cholecystectomy for acute cholecystitis can be applied safely to all comers, offering the advantage of a shortened hospital stay. Pericholecystic collection, as observed on ultrasound, is associated with a high risk of conversion to open cholecystectomy.

Port-site tuberculosis after laparoscopy

In light of the explosive increase in laparoscopic surgery, there is concern about the effectiveness of sterilizing reusable laparoscopic instruments by immersion in 2% glutaraldehyde. This article describes the clinical features of eight patients who presented with biopsy-proven tuberculosis at the port-site unassociated with other clinical features of tuberculosis. Three of the eight patients had positive cultures for Mycobacterium tuberculosis. The port-site sinuses healed with antituberculous chemotherapy. There is conflicting information in the literature regarding the effectiveness of a 20-min instrument soak in 2% glutaraldehyde to clear M. tuberculosis. In light of the preceding information, the current practice of glutaraldehyde disinfection for reusable laparoscopes needs to be reexamined.

Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections

INTRODUCTION: Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames. MATERIALS AND METHODS: This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease. RESULTS: The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01). CONCLUSION: This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.

Biliary access loops for intrahepatic stones: Results of jejunoduodenal anastomosis

Background:  Patients with intrahepatic calculi require multiple interventions following successful surgical stone clearance for recurrent stones and cholangitis. The present paper describes the results of a technique of in‐continuity side‐to‐side jejunoduodenal anastomosis (JDA) that provides endoscopic access to the hepaticojejunostomy and intrahepatic ducts. This operation is compared to other techniques in a critical appraisal of various biliary access procedures described for long‐term management of intrahepatic calculi.

Laparoscopic approach is safe and effective in the management of Mirizzi syndrome.

Context: Mirizzi syndrome (MS), an unusual complication of gallstone disease is due to mechanical obstruction of the common hepatic duct and is associated with clinical presentation of obstructive jaundice. Pre-operative identification of this entity is difficult and surgical management constitutes a formidable challenge to the operating surgeon. Aim: To analyse the clinical presentation, pre-operative diagnostic strategies, operative management and outcome of patients operated for MS in a tertiary care centre. Materials and Methods: This retrospective study identified patients operated for MS between January 2006 and August 2013 and recorded and analysed their pre-operative demographics, pre-operative diagnostic strategies, operative management, and outcome. Results: A total of 20 patients was identified out of 1530 cholecystectomies performed during the study period giving an incidence of 1.4%. There were 11 males and 9 females with a mean age of 55.6 years. Abdomen pain and jaundice were predominant symptoms and alteration of liver function test was seen in 14 patients. Endoscopic retrograde cholangiopancreatography (ERCP) the mainstay of diagnosis was diagnostic of MS in 72% of patients, while the rest were identified intra-operatively. The most common type of MS was Type II with an incidence of 40%. Cholecystectomy was completed by laparoscopy in 14 patients with a conversion rate of 30%. A choledochoplasty was sufficed in most of the patients and none required a hepaticojejunostomy. The laparoscopic cohort had a shorter length of hospital stay when compared to the entire group. Conclusion: MS, a rare complication of cholelithiasis is a formidable diagnostic and therapeutic challenge and pre-operative ERCP as a main diagnostic strategy enables the surgeon to identify and minimize bile duct injury. A choledochoplasty might be sufficient in the majority of the types of MS, while a laparoscopic approach is feasible and safe in most cases as well.

Primary posterior perineal herniation of urinary bladder.

Primary perineal hernia is a rare clinical condition wherein herniation of viscera occurs through pelvic diaphragm. They are usually mistaken for sciatic hernia, rectal prolapse or other diseases in the perineum. Correct identification of the type of hernia by imaging is crucial for planning treatment. We present a case of primary posterior herniation of urinary bladder and rectal wall through levator ani repaired laparoscopically using a mesh repair.

Prevalence and patterns of diverticulosis in patients undergoing colonoscopy in a southern Indian hospital

The prevalence of diverticular disease of colon of colon is reportedly low in Asian compared to Western countries. We analyzed the prevalence of colonic diverticulosis in a selected cohort of patients undergoing colonoscopy. Retrospective study of records of patients undergoing colonoscopy in a tertiary hospital in southern India.

Dense calculi formation resulting in impaction of pancreatic stent

A 35-year-old male had pancreatic duct stenting using a 7 F single-pigtail 10-cm stent 11 years back for chronic pancreatitis. He was lost to follow up and presented recently with recurrent pain of 3 months duration. A computed tomography scan revealed a retained stent with dense calcification extending to side brancheswith the stent embeddedwithin the calculi, filling the entire length of the pancreatic duct (Fig. 1a). Attempts to retrieve the stent endoscopically using rat tooth forceps, biliary balloon, a Soehendra dilator, and a stent passed parallel to the stent to fragment the calculi failed due to dense impaction and friability of the stent. He underwent surgery. At operation, there were dense calculi in the pancreatic duct and side branches, and inseparable dense calcifications around the retained stent (Fig. 1b). The stent was completely occluded. The stent and calculi were removed, and he underwent lateral pancreatojejunostomy. Pancreatic duct stents, placed for various indications, are known to produce duct and parenchymal changes in 36 % to 50 % of cases [1]. Calcific intrapancreatic embedding of a pancreatic stent requiring surgical removal 10 years after initial deployment is reported [2]. To our knowledge, retrieval of a stent 11 years after the initial deployment has never been reported.

Intrahepatic rupture of empyema gallbladder.

A 70-year-old woman presented with right upper quadrant pain and fever since 1 month, with exacerbation of symptoms since 1 week. Clinically, she had tenderness in the right hypochondrium; laboratory parameters showed elevated AST, ALT and alkaline phosphatase values. Ultrasonogram abdomen showed a large abscess in liver with suspicious communication with gallbladder. CT scan of abdomen showed a large irregular thick-walled cystic lesion in segments 5 and 8 of liver suggestive of a liver abscess. This cavity communicated with a thick-walled edematous gallbladder, that contained few calculi (Fig. 1). A diagnosis of empyema gallbladder with intrahepatic rupture and abscess formation in the liver was made. Ultrasound-guided percutaneous drainage of the abscess was done with a plan for elective laparoscopic cholecystectomy. Perforation of the gallbladder is a rare complication that occurs in 2 % to 11 % of acute cholecystitis; delay in diagnoses is a major cause of morbidity and mortality [1]. Niemeier classified gallbladder perforations into 3 types: type I—acute, manifests with generalized peritonitis; type II—subacute, which denotes localization of fluid at the site of perforation with formation of a pericholecystic abscess; and type III—chronic, in which internal or external fistula occur [2]. Our patient had Type II perforation. CT scan is more sensitive than ultrasonogram for the diagnosis of perforation [2], Visualization of the perforation “hole sign”, the demonstration of communication between the abscess and the gallbladder and points towards the diagnosis [3]. References