Pankaj Kumar Garg

PREDICTIVE FACTORS FOR SUCCESSFUL EARLY LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: A PROSPECTIVE STUDY

BACKGROUND Early laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis. However, the rate of intraoperative conversion to open surgery remains high and has provoked an interest in studying the predictive factors for better patient selection to minimize the conversion rates. MATERIALS AND METHODS 50 patients of acute cholecystitis were operated within 5 days of onset of symptoms. Comparative evaluation of the patient groups undergoing successful versus failed early laparoscopic cholecystectomy was done to identify preoperative factors predicting conversion/failure of the laparoscopic procedure. Predictive factors for intraoperative and histopathological severity of acute cholecystitis were also identified. RESULTS 40 patients underwent successful completion of early laparoscopic cholecystectomy, 8 required conversions to open, while in 2 patients the procedure had to be abandoned due to phlegmon formation. Male sex, preoperative duration of symptoms WBC counts, serum alkaline phosphatase, serum amylase, and serum C-reactive protein were significant predictors of histopathological severity of acute cholecystitis. Intraoperative and histopathological severity of acute cholecystitis had good association with conversion rate of early laparoscopic cholecystectomy. Male sex and serum C-reactive protein levels >3.6 mg/dl at admission were very strong predictors of conversion/failure of early laparoscopic cholecystectomy in acute cholecystitis. CONCLUSION Male patients of acute cholecystitis or patient with serum C-reactive protein levels of >3.6 mg/dl at admission have high risk of conversion in early laparoscopic cholecystectomy and warrant a conservative early management followed by delayed laparoscopic cholecystectomy.

Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy

INTRODUCTION Although laparoscopic cholecystectomy appears to be less traumatic to the patients than open surgery, decreased venous return from lower extremities and hypercoagulability occurring in patients undergoing elective laparoscopic cholecystectomy with CO(2) pneumoperitoneum makes it a potent risk factor for deep venous thrombosis. METHODS The observational study of 50 patients undergoing elective laparoscopic cholecystectomy was designed to study alteration in PT, APTT, D-dimer and antithrombin III, which were measured preoperatively, 6 and 24h postoperatively. It was accompanied by color duplex ultrasound of bilateral lower limbs preoperatively and 7th day postoperatively to look for evidence of deep venous thrombosis. RESULTS Significant postoperative decrease in APTT and antithrombin III suggested activation of coagulation while decrease in d-dimer suggested activation of fibrinolysis. Values of PT had no statistically significant postoperative changes. Age, body mass index and duration of pneumoperitoneum were found to correlate with significant activation of coagulation and fibrinolysis. None of the patients developed clinical or radiological evidence of deep venous thrombosis in the postoperative period. CONCLUSIONS CO(2) pneumoperitoneum enhances the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. Patients with risk factors like old age, obesity or with expected long duration of laparoscopic surgery are likely to have significant activation of coagulation, making them a vulnerable risk group for development of postoperative deep vein thrombosis, warranting some form of thromboprophylaxis.

Staged closure after complete wound dehiscence: Novel technique

Wound dehiscence after exploratory laparotomy for peritonitis has an incidence of 0.25e3% of patients. It commonly presents with serosanguinous discharge from the wound in the first week of surgery. It ranges from superficial breakdown of the skin with intact deeper musculo-aponeurotic layers, to a complete failure of the wound and an exposure of the viscera, i.e. burst abdomen. Restoration of skin cover is of paramount importance in order to avoid faecal fistula formation due to desiccation or iatrogenic trauma to gut. The authors describe a simple and effective measure of wound closure in stages by mobilizing local skin flaps.

Evaluation of subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel in varicose veins: An observational study

INTRODUCTION Conventional modalities used to treat varicose veins with incompetent perforators and subsequent stasis ulceration have proved to be effective, however there are associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence. Recent advances have been made in minimally invasive vein surgery techniques to decrease operative morbidity, number and size of incisions, recovery time, and operative time. METHODS A prospective study of 21 patients of varicose veins with incompetent perforators undergoing subfascial endoscopic perforator vein surgery (SEPS) using harmonic scalpel was designed and various parameters were studied. RESULTS All ulcers healed in 8 weeks with no recurrence in 11.9 months follow-up period. One case of wound infection and each saphenous nerve neuropraxia were the only postoperative complications noted. CONCLUSION Use of ultrasonic scalpel in SEPS is technically feasible, causes less tissue damage as it generates a low thermal effect, and is associated with minimal morbidity.

Hemostatic factors in breast cancer as prognostic/predictive factors

We read the article “Relation between hemostatic parameters and prognostic/predictive factors in breast cancer” by Yigit et al. [1] with great interest. Though they have written that previous chemotherapy and/or radiotherapy could affect hemostatic parameters, they have still included those patients of breast cancer who had either of treatment. The rational of this could not be understood. Chemotherapy seems to cause activation of hemostatic markers by three possible mechanisms [2]. Firstly, chemotherapy leads to destruction of tumor cells causing release of cytokines which may activate hemostatic parameters. Secondly, it causes direct damage to vascular endothelium. And thirdly, it is the direct stimulation of expression of tissue factor procoagulant activity in macrophages and monocytes by some chemotherapeutic agents. So, inclusion of those patients who had chemotherapy earlier in this study requires further clarification.

Sternal tuberculosis presenting as multiple cutaneous sinuses.

Isolated involvement of the sternum with tuberculosis is rare. Only a few cases of sternal tuberculosis have been reported in literature. Tubercular sternal osteomyelitis presenting as multiple cutaneous sinuses over the anterior chest wall is extremely rare. We present a patient with sternal tuberculosis presenting as multiple cutaneous sinuses over the anterior chest wall. Standard antitubercular chemotherapy resulted in complete recovery.

Prostato-ano-cutaneous fistula: unusual complication of prostatic abscess.

A fifty-two-year-old man presented to us with the complaint of persistent discharging sinus at the root of scrotum for the past 6 months, which was associated with dysuria, pus discharge per urethra and low backache. There was no history of fever, trauma, instrumentation, diabetes mellitus, immunosuppressive drug therapy or any other significant comorbid condition. General physical or systemic examination did not show any abnormality. Patient had a discharging sinus at the root of scrotum with an indurated tract going towards anal canal and another going towards urethra. Digital rectal examination showed normal anal tone with an induration felt just above anorectal ring at 12-o’clock position. Prostatic massage led pus discharge per urethra. Proctoscopy did not show any internal opening. Cystoscopy showed an elevation just below verumontanum with no fistulous opening. Retrograde urethrography with fistulogram showed fistula in-ano with a collection in region of prostate with no communication with urethra. Transrectal ultrasound showed heterogeneous collection in both lobes of prostate, with evidence of necrotic material and specks of calcification and rupture of prostatic capsule with small periprostatic collection. Magnetic resonance fistulogram (Fig. 1) delineated prostatic abscess rupturing and communicating with anal canal and to perineal skin, suggesting a prostato-ano-cutaneous fistula. He was taken for exploration. Anocutaneous part of fistula was deroofed and laid open. Tract going to prostatic abscess was curetted adequately along with abscess. Because tract was going above anorectal ring (Fig. 2), a Seton ligature was passed across internal sphincter. Postoperatively, he was continent for faeces and flatus. Histopathological examination of fistulous tract was suggestive of chronic inflammation with no granuloma formation. Seton ligature was changed weekly. Wound healed completely after 10 weeks. He is asymptomatic after 10 months of follow up. Prostatic abscess is an uncommon entity and, moreover, rarely diagnosed. With the widespread use of broad spectrum antibiotics to almost all patients with lower urinary tract symptoms, incidence of prostatic abscess has become negligible and so the complications. Prostatic abscess is usually sequelae of acute bacterial prostatitis, although tubercular and fungal prostatic abscesses are also known to occur. Neisseria gonorrhoeaewas considered to be the most common organism in preantibiotic era, with a mortality rate of 6–30%.1 At present, Escherichia coli and other Gramnegative rods are the most common organisms isolated in 60– 80% of cases.2 Other significant pathogens include Pseudomonas species, staphylococci and occasionally obligate anaerobic bacteria. Predisposing factors for development of prostatic abscess include diabetes mellitus, indwelling catheters, immunosuppressive therapy, instrumentation and chronic renal failure requiring maintenance haemodialysis.3 Complications of prostatic abscess include spontaneous rupture into the urethra, perineum, bladder, or rectum; chronic prostatitis; infertility and sepsis secondary to either a late diagnosis or inadequate drainage of abscess. Prostatic abscess rupturing both in perineum and in anal canal is not reported till today in published work in English. Anocutaneous part of the prostato-ano-cutaneous fistula was laid open with curettage of prostatic abscess through a defect in urogenital diaphragm because adequate drainage of abscess should always be an important consideration while managing such patients. Because the fistulous tract was opening above the anorectal ring in anal canal (like high fistula in-ano), Seton ligature was placed across the anorectal ring so as to preserve anal continence. Because the prostatic abscess was drained nicely in perineum, it healed completely. This case Fig. 1. Magnetic resonance fistulogram of heavily T2-weighted sequence. (a) Coronal section showing intraprostatic collection. (b) Sagittal section showing fistula communicating intraprostatic collection with anal canal and perineal skin. ANZ J. Surg. 2008; 78: 1032–1033 doi: 10.1111/j.1445-2197.2008.04727.x