Lileswar Kaman

Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: Recognition and management

Background: Internal pancreatic fistulas are well recognized complications of chronic pancreatitis.

Current management of gall bladder perforations

Background:  Gall bladder perforation is a serious complication of acute cholecystitis. The purpose of the present study is to evaluate the presenting symptoms, diagnosis and management of patients with gall bladder perforations.

Pseudoaneurysm of the cystic artery: a rare cause of hemobilia

Aneurysms are a rare cause of hemobilia, and usually involved are branches of the hepatic and gastro-duodenal arteries. A case of a patient with hemobilia secondary to a pseudoaneurysm of the cystic artery is presented. Fewer than 10 cases have been reported in the literature, and in all of them the condition was associated with inflammation of the gall bladder, as in our case. Selective hepatic angiography is the procedure of choice for diagnosis. Upper gastrointestinal endoscopy with side-viewing scopy can demonstrate bleeding from papilla. Color-Doppler ultrasonography also may prove to be useful in equivocal cases. Cholecystectomy and ligation of cystic artery with proximal control of the hepatic artery was done at laparotomy after diagnosis was made.

Isolated roux loop pancreaticojejunostomy vs single loop pancreaticojejunostomy after pancreaticoduodenectomy

BACKGROUND Pancreatic anastomotic leaks are a major cause of morbidity and mortality following pancreaticoduodenectomy, and no single technique of reconstruction has shown to be superior. The aim of this study was to review the experience of single loop versus isolated Roux loop pancreaticojejunostomy in a series of patients undergoing pancreatic head resection. METHODS A retrospective review involving 111 patients who underwent pancreatic head resections over 13year period (1994-2006) for malignant (n=106) and benign (n=5) disease was performed. Reconstruction of the pancreatic remnant was done using a single loop in 51 patients and by an isolated Roux loop in 60 patients. All pancreatic anastomosis were performed as a duct to mucosa anastomosis, in two layers, with pancreatic stent and closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50ml of amylase rich fluid for more than 7days postoperatively. RESULTS The two groups were comparable as regards to their demographic profiles, preoperative laboratory values and disease status in terms of pathology, pancreatic texture and pancreatic duct diameters. The overall incidence of pancreatic anastomotic leak was 11% (12) and was similar in both the groups; single loop 12% (6) and isolated Roux loop 10% (6). Isolated Roux loop pancreaticojejunostomy was associated with a significant prolongation of operative time (7.25+/-1.14h vs 6.07+/-1.12h) (p<0.05) and the need for more blood transfusion (2.25+/-0.84units vs 2.62+/-0.69units) (p<0.05). There was no significant difference in the morbidity or mortality between the two groups. Forty five percent (23) patients had complications in the single loop group and 48% (29) patients had complications in the isolated group. There were 8% (4) death in the single loop group and 8% (5) in the isolated group (p>0.05). CONCLUSION There does not appear to be a significant difference in the rates of pancreatic fistula following either method of reconstruction. However, performance of an isolated Roux loop pancreaticojejunostomy entails a prolongation of operative time and more intraoperative requirement of blood transfusions.

Necrotizing fascitis after injection sclerotherapy for hemorrhoids

A case report of a patient who underwent submucosal injection sclerotherapy for hemorrhoids is presented. Subsequently developed necrotizing fascitis of the anorectum, perianal region, and scrotum necessitated emergency debridement and defunctioning colostomy. Postoperatively, the patient developed septicemia and renal failure requiring an extended hospital stay. Restoration of bowel continuity was done after three months. A brief review of known complications of this technique was made. It would appear that necrotizing fascitis can be added to this list.

Management of major bile duct injuries after laparoscopic cholecystectomy

Background:The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries (MBDI) after laparoscopic cholecystectomy (LC).Methods:We performed a retrospective analysis of 27 patients who were treated between January 1995 and December 2002 for MBDI after LC at a single unit in a tertiary center. Major bile duct injury was defined according to the Strasberg classification. All patients underwent magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), or endoscopic retrograde cholangiopancreatography (ERCP) to delineate the biliary anatomy and assess the level of injury. On the basis of the cholangiographic findings, all patients underwent Roux-en-Y hepaticojejunostomy after a waiting period of 8-12 weeks.Results:A total of 29 hepaticojejunostomies were performed in 27 patients. Seventeen patients (63%) presented with biliary fistula and ascites; 10 (27%) presented with obstructive jaundice. In 14 patients (52%) the MBDI was identified during the LC. Twenty patients (74%) had undergone one or more procedure before referral. Eight patients (30%) had E1, five patients (18.5%) had E2, nine patients (33%) had E3, and five pattients (18.5%) had E4 injury. Two patients had early anastomotic stricture, for which redo hepaticojejunostomy with access loop was performed.Conclusions:Major bile duct injury after LC commonly presents with biliary fistula and ascites. High-injuries are common after LC. Hepaticojejunostomy repair yields excellent results in these cases.

COMPARISON OF MAJOR BILE DUCT INJURIES FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY AND OPEN CHOLECYSTECTOMY

Background:  The mechanism and extent of major bile duct injuries following laparoscopic cholecystectomy differ from those of open cholecystectomy.

Treatment of Budd-Chiari Syndrome with Inferior Vena Caval Occlusion by Mesoatrial Shunt

OBJECTIVE To report the effectiveness of a mesoatrial shunt in the treatment of Budd-Chiari syndrome caused by combined hepatic vein and inferior vena caval block. DESIGN Retrospective study. SETTING Tertiary care hospital, India. PATIENTS 10 patients (4 men and 6 women; mean age 28, range 18-45) who had operations for Budd-Chiari syndrome between 1994 and 2000. INTERVENTION Mesoatrial shunt. MAIN OUTCOME MEASURES Graft patency, survival, liver function and symptoms. RESULTS One patient died. All grafts were patent over a mean follow up period of 40 months (range 6-71). All survivors have normal liver function and were symptom free at the time of writing. CONCLUSION Mesoatrial shunt is effective in the treatment of Budd-Chiari syndrome caused by combined hepatic vein and vena caval occlusion.

Recent Advances in the Pharmacotherapy of Chronic Anal Fissure: An Update

Surgical sphincterotomy reduces anal tone and sphincter spasm and promotes ulcer healing. Because the surgery is associated with the side effect of faecal incontinence, pharmacological agents to treat chronic anal fissure have been explored recently. Glyceryl trinitrate (GTN) ointment (0.2%) has an efficacy of up to 68% in healing chronic anal fissure, but it is associated with headache as the major and most common side effect. Though botulinum toxin injected into the anal sphincter healed over 80% of chronic anal fissures, it is more invasive and expensive than GTN therapy. Diltiazem ointment achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but was associated with fewer side effects. Other drugs that have been tried are lidocaine, the alpha-adrenergic antagonist indoramin, and the potassium channel opener minoxidil.

Sclerosing Encapsulating Peritonitis: Complication of Laparoscopic Cholecystectomy

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction. It is difficult to make a definite preoperative diagnosis, and most cases are diagnosed at the time of laparotomy. It is usually of unknown origin, although, at times, it may be seen secondary to a variety of conditions. Spillage of bile and gallstones at laparoscopic cholecystectomy is an unusual cause of SEP and has not been reported in literature, to date. Contrast-enhanced computed tomography of the abdomen revealed small-bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle with loculated fluid in the interloop bowel location. Excision of the sac and adhesiolysis was done in our patient for recurrent episodes of intestinal obstruction, who recovered well in the postoperative period.