Norman Oneil Machado

Management of Duodenal Perforation Post-Endoscopic Retrograde Cholangiopancreatography. When and Whom to Operate and What Factors Determine The Outcome? A Review Article

CONTEXT Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to primarily therapeutic procedure. With this, the complexity of the procedure and risk of complication including duodenal perforation have increased. In this article, the recent literature is reviewed to identify the optimal management and factors influencing the clinical outcome. METHOD Recent literature in English language from the year 2000 onwards, containing major studies of 9 or more cases on duodenal perforation post ERCP were analyzed. RESULTS Literature review revealed a total of 251 cases of duodenal perforation reported in 10 major reports presenting 9 or more cases each. The mean age of these patients was 58.5 years with nearly two third (62.9%) being female patients. The predominant location of the perforation was: duodenal wall (34.5%), perivaterian (31.3%), common bile duct (23.0%), and unknown in 7.9%.Early diagnosis within 24 hours was made in 78.5%, with 55.8% of these being diagnosed during or immediately after ERCP. CT scan was the most useful investigations in detecting perforations missed during ERCP (44.6%). Conservative management was employed in 62.2%, which was successful in 92.9% of these cases. Ten of these who failed conservative management required salvage surgery (6.4%) and one died of pneumothorax (0.6%). The predominant surgical intervention was closure of perforation (49.0%) with or without other procedures, retroperitoneal drainage (39.0%), duodenal exclusion (24.0%) and common bile duct exploration and T tube insertion (13.0%). The overall mortality was 8.0% which appears to be better than previously reported (16-18%). Among the 20 patients who died, six (30.0%) had salvage surgery, five (25.0%) had delay in diagnosis/intervention beyond 3 days and 3 (15.0%) required multiple operations. CONCLUSION While the patients with duodenal perforation invariably require surgical intervention, most of the patients with perivaterian injuries can be successfully managed conservatively. The most important factors for recent better outcome were early detection and prompt treatment. Delay in diagnosis and intervention, salvage surgery after failed conservative management, multiple operations, and older age group contributed significantly to the poor outcome.

Laparoscopic cholecystectomy in cirrhotics.

This study suggests that laparoscopic cholecystectomy can be safely performed in Child Pugh class A and B cirrhotic patients with symptomatic gallstones with acceptable morbidity and conversion rate.

Laparoscopic vaginoplasty: using a sliding peritoneal flap for correction of complete vaginal agenesis

In this technique of peritoneal neo-vaginoplasty, the recto-vesical space is dissected through the vulva under synchronous laparoscopic monitoring. Then the cranial limit of the pelvic peritoneum is incised circumferentially by laparoscopic approach and the two circular edges sutured sequentially. The isolated pelvic peritoneal sleeve is opened inferiorly and sutured to introital mucosal flaps.

Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach

Most retrosternal goiters are situated in the anterior mediastinal compartment. Posterior mediastinal goiters are uncommon, comprising 10%–15% of all mediastinal goiters. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a large posterior mediastinal goiter extending retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side. It was excised using a transcervical and right thoracotomy approach. The literature is reviewed to clarify the management of retrosternal goiters with regard to the various approaches, indications for extracervical incisions, and their complications. In conclusion, whereas most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. The overall number of complications associated with this approach, however, is higher than that seen with the transcervical approach.

Large duodenal gastrointestinal stromal tumor presenting with acute bleeding managed by a whipple resection. A review of surgical options and the prognostic indicators of outcome.

CONTEXT Duodenal gastrointestinal stromal tumors (GISTs) are uncommon and constitute a relatively small subset of GISTs which presents a unique dilemma having various surgical options. A case of a large ulcerating duodenal GIST arising from the second and third parts of the duodenum and involving the pancreas which was managed by a Whipple resection is presented. The literature is also reviewed to present the current status on surgical options, outcome, prognostic indicators and the role of imatinib mesylate in its management. CASE REPORT A 58-year-old patient presented with acute gastrointestinal bleeding which was diagnosed to be due to a duodenal GIST following CT scan and endoscopic biopsy. The mass which measured about 10x9 cm originated from the 2nd part and extended into the 3rd part of the duodenum. He underwent a Whipple resection, and histopathology confirmed a duodenal GIST having a greater than 10 mitotic count per fifty high power field and areas of necrosis. Postoperatively, he received imatinib mesylate 400 mg bid; however, 4 months later, he presented with multiple disseminated peritoneal metastases and succumbed to the disease 2 months later. CONCLUSION GISTs of the duodenum which are small in size and do not involve the papilla of Vater are better resolved using a limited resection of the duodenum since the outcome in terms of operative risk or disease recurrence is not influenced in these cases. However, large tumors with more extensive involvement would require a pancreaticoduodenectomy to achieve adequate tumor clearance. Even though duodenal GISTs have a relatively better prognosis as compared to GISTs at other sites, their aggressiveness ranges from small indolent tumors to aggressive sarcomas. Following tumor resection, a recurrence rate of about 40% has been reported. A more favorable prognosis in duodenal GISTs is attributed to a lower prevalence of P53 loss, the duodenal location of the tumor, a smaller size of the lesion and a low mitotic count. Imatinib mesylate is reported to play a role in neoadjuvant therapy as well as in the management of metastatic and recurrent disease, although some of these tumors may fail to respond.

Laparoscopic cholecystectomy in the third trimester of pregnancy: Report of 3 cases

Symptomatic cholelithiasis and acute appendicitis are the most common surgical conditions requiring nonobstetric abdominal surgery during pregnancy. Cholelithiasis is diagnosed in 0.07% of pregnancy and in about 40% of these patients surgery may be required. Pregnancy was once considered an absolute contraindication for laparoscopic surgery, but pregnant patients undergoing laparoscopic surgery have been reported increasingly in the past decade. However, most case reports and case series are confined to patients in the first and second trimester. We report here 3 patients who underwent laparoscopic cholecystectomy in the third trimester and review the relevant literature. Methods Pregnant women in the third trimester who underwent laparoscopic cholecystectomy were reviewed between the years 2000 and 2004 at our hospital. Results Three pregnant patients in the third trimester at a gestational age of 28 weeks, and 2 at 26 weeks underwent laparoscopic cholecystectomy. Initial port was placed in all patients by Hasson open technique, few centimeters cephalad to fundal height. The insufflation pressure was maintained between 12 to 14 mm Hg. The duration of surgery ranged from 64 to 80 minutes (mean: 72 min). Obstetric assessment was carried out preoperatively and fetal well-being was monitored postoperatively. Tocolytic agents were used in 2 patients. There were no intraoperative or postoperative complications. All patients were discharged on the second postoperative day. All the 3 patients delivered healthy babies normally at full term (range: 39 to 40 wk). Conclusion Laparoscopic cholecystectomy can be carried out safely in the third trimester of pregnancy with minimal risk to the fetus and the mother.

Splenectomy for haematological disorders: a single center study in 150 patients from Oman.

BACKGROUND Haematological disorders, in particular sickle cell disease (SCD) and thalassaemia, are relatively common in Oman. We report our experience of splenectomy for haematological disorders and review the literature on splenectomy role in their management. OBJECTIVES To review our experience in the management of 150 patients with haematological disorders undergoing splenectomy with emphasis on indications and outcome. To compare our experience with those reported from outside this region. METHODS The records of 150 patients who underwent splenectomy over a thirteen year period were reviewed retrospectively, analyzing the age and sex of the patients, indication for splenectomy, operative procedures, complications, peri-operative management and outcome. RESULTS Of the 150 patients, 96 (64%) had SCD and 34 (22.6%) had beta-thalassaemia; the rest comprised patients with refractory idiopathic thrombocytopenic purpura (ITP) n=12, hereditary spherocytosis (HS) n=6, and auto-immune haemolytic anaemia (AHA) n=2. In SCD patients, the main indications for splenectomy were recurrent splenic sequestration (60.4%) and hypersplenism (36.4%), whereas in thalassaemic patients it was increased requirement of packed red blood cells (PRBC) transfusion (mean 310 ml, range 242-372 of PRBC/kg/year). All patients received prophylactic antibiotics and vaccination against pneumococcal infection and when the vaccine was available for Haemophilus influenzae. PRBC and platelet concentrates as well as intravenous fluids were infused preoperatively as per protocol. Concomitant procedures at laparotomy included liver biopsy (14.6%) and cholecystectomy (8.6%). The postoperative morbidity was low (8.6%) and there was no mortality. All patients were maintained on long term penicillin and proguanil, and the mean follow-up was 4.6 years. In SCD patients splenectomy eliminated the risks of life threatening acute splenic sequestration and improved significantly the blood counts of the hypersplenic cases, while in thalassaemic patients it reduced significantly the mean transfusion requirement by 100ml PRBC/kg/year (p<0.0001). Of the patients with refractory ITP, two thirds had a good response to splenectomy (p<0.0001). All HS and AHA patients benefited from splenectomy. CONCLUSION The predominant indications for splenectomy were recurrent acute splenic sequestration and hypersplenism in SCD patients, and increased transfusion demand in the thalassaemics. Overall, splenectomy proved beneficial in eliminating the risk of splenic sequestration in SCD patients, in improving the blood counts in SCD with hypersplenism and in reducing transfusion requirement in thalassaemic patients, while in ITP group two thirds of the patients benefited.

Sclerosing Encapsulating Peritonitis : Review

Sclerosing encapsulating peritonitis (SEP) is a rare chronic inflammatory condition of the peritoneum with an unknown aetiology. Also known as abdominal cocoon, the condition occurs when loops of the bowel are encased within the peritoneal cavity by a membrane, leading to intestinal obstruction. Due to its rarity and non-specific clinical features, it is often misdiagnosed. The condition presents with recurrent episodes of small bowel obstruction and can be idiopathic or secondary; the latter is associated with predisposing factors such as peritoneal dialysis or abdominal tuberculosis. In the early stages, patients can be managed conservatively; however, surgical intervention is necessary for those with advanced stage intestinal obstruction. A literature review revealed 118 cases of SEP; the mean age of these patients was 39 years and 68.0% were male. The predominant presentation was abdominal pain (72.0%), distension (44.9%) or a mass (30.5%). Almost all of the patients underwent surgical excision (99.2%) without postoperative complications (88.1%).

Pancreatic Metastasis from Colon Carcinoma Nine Years after a Hemicolectomy Managed by Distal Pancreatectomy. A Review of the Literature Regarding the Role and Outcome of Pancreatic Resection for Colorectal Metastasis

CONTEXT Pancreatic metastasis from colorectal malignancy is rare and accounts for less than 2% of all pancreatic metastases. A case of colonic metastasis to the pancreas is reported and the literature is reviewed to assess the role and outcome of pancreatic resection for metastatic tumors from colorectal malignancy. CASE REPORT A 58-year-old female underwent an emergency left hemicolectomy for an obstructing descending colon growth. The lesion was reported to be adenocarcinoma, Dukes C, with involvement of the serosa and 3 lymph nodes. A postoperative staging CT scan showed no other metastases and she received 6 cycles of FOLFOX chemotherapy (folinic acid, 5-flurouracil and oxaliplatin). Nine years after the colectomy during a routine follow-up, there was a sudden rise in her CEA levels. A CT scan revealed a 6.8x4.8 cm mixed consistency lesion in the tail of the pancreas which, on fine needle aspiration cytology, was confirmed to be adenocarcinoma. She underwent a distal pancreatectomy, and histopathology of the resected specimen confirmed a metastatic tumor from colon cancer. She then received 5 cycles of adjuvant chemotherapy. She was symptom free for nine months and subsequently succumbed to recurrent disease. CONCLUSION Pancreatic metastasis from colorectal malignancy is rare. These patients could be asymptomatic in 17% of cases. The time-interval between the diagnosis of colorectal cancer and the detection of pancreatic metastasis varies widely but is approximately 24 months. The median survival time for post-pancreatic resection is 16 months. Pancreatic resection appears to offer good palliation until recurrence of the disease occurs and the possibility of long term cure is rare.

Abdominal tuberculosis--experience of a University hospital in Oman.

OBJECTIVE To determine the clinical presentation and assess the usefulness of various diagnostic modalities and outcome of treatment of abdominal tuberculosis (TB). MATERIALS AND METHODS The files of patients admitted to Sultan Qaboos University Hospital (SQUH) with a diagnosis of abdominal TB from January 91 to December 99 were studied retrospectively and data abstracted. RESULTS Eighteen patients were diagnosed during this period, of which ten were males. The median age was 27 years (range 5-65). The common symptoms were fever, weight loss, anorexia, and abdominal pain. Abdominal signs were less frequent and included hepatomegaly and ascites. Eight patients had co-existent immunocompromised disorders; two of these had active pulmonary TB. Diagnostic investigations included gastrointestinal contrast studies in two, ultrasound (US) guided fine needle aspiration cytology (FNAC) in nine, and laparoscopy and/or laparotomy in seven. All patients underwent antituberculous therapy for 9-12 months, in addition to the treatment of associated disorders. The response to antituberculous therapy was good except in one patient with HIV. Four patients died from associated primary disorders. CONCLUSIONS The clinical presentation was non-specific and nearly half of the patients had associated immunocompromised disorders; thus a high index of clinical suspicion is required. US guided FNAC and selective laparoscopy were the most useful diagnostic modalities. Antituberculous therapy was effective.