Sudhir Kumar Jain

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.

A prospective, randomized study of comparison of clipless cholecystectomy with conventional laparoscopic cholecystectomy.

INTRODUCTION Laparoscopic cholecystectomy has become a gold standard in the treatment of symptomatic gallstone disease. Amalgamation with upcoming technology makes the present-day procedure faster and safer. Ultrasonic shears, which perform dissection and ligation by cavitation and coaptation of vessels, are the latest addition to the armamentarium of laparoscopic surgeons. Acceptance of its safety and efficacy awaits its use as the sole instrument in the widely accepted procedure. METHODS A prospective, randomized control trial was conducted in 200 patients with symptomatic gallstone disease, who were randomly divided into two comparable groups, one undergoing cholecystectomy using ultrasonically activated shears and the other using conventional clip and electrocautery. Various parameters such as duration of surgery, removal of gallbladder, blood loss, postoperative pain scores, analgesic requirement, duration of stay, and complications were compared between the two groups. RESULTS Patients who underwent laparoscopic cholecystectomy using ultrasonic shears had a faster surgery (64.7 versus 50 minutes; P < .002) and removal of gallbladder from gallbladder bed (3.94 versus 7.46 minutes; P < .001) with less blood loss and pain scores (1.86 versus 3.01; P < .002). They had a shorter duration of hospital stay (1.89 versus 2.52 days; P < .001) and decreased risk of gallbladder perforation (9 versus 18; P < .005). The analgesic requirement was also less on the first postoperative day. There was no incidence of any major complication or bile leak during a 6-month follow-up period in either of the groups. CONCLUSION Ultrasonically activated scalpel can be used safely in laparoscopic cholecystectomy without risk of major injuries or leaks. It fairs better than electrocautery in terms of faster and safer surgery with decreased associated morbidity, less pain, and early return back home.

Evaluation of holmium laser versus cold knife in optical internal urethrotomy for the management of short segment urethral stricture.

Objectives: Sachse cold knife is conventionally used for optical internal urethrotomy intended to manage urethral strictures and Ho: YAG laser is an alternative to it. The aim of this study was to evaluate the role of urethral stricture treatment outcomes, efficacy, and complications using cold knife and Ho: YAG (Holmium laser) for optical internal urethrotomy Materials and Methods: In this prospective study included, 90 male patients age >18 years, with diagnosis of urethral stricture admitted for internal optical urethrotomy during April 2010 to March 2012. The patients were randomized into two groups containing 45 patients each using computer generated random number. In group A (Holmium group), internal urethrotomy was done with Holmium laser and in group B (Cold knife group) Sachse cold knife was used. Patients were followed up for 6 months after surgery in Out Patient Department on 15, 30 and 180 post-operative days. At each follow up visit physical examination, and uroflowmetry was performed along with noting complaints, if any. Results: The peak flow rates (PFR) were compared between the two groups on each follow up. At 180 days (6 month interval) the difference between mean of PFR for Holmium and Cold knife group was statistically highly significant (P < 0.001). Complications were seen in 12.22% of cases. Conclusion: Both modalities are effective in providing immediate relief to patients with single and short segment (<2 cm long) urethral strictures but more sustained response was attained with Cold knife urethrotomy.

Primary mesenteric liposarcoma: An unusual presentation of a rare condition

Primary mesenteric liposarcoma is a rare neoplasm. Here, we report the case of a 50 year old Indian man with a pleomorphic liposarcoma of the mesentery. The clinical findings pointed towards a retroperitoneal growth but imaging resolved the issue. A laparotomy was performed and a 20 cm × 20 cm multilobulated tumour arising from the mesentery and weighing 1.8 kilograms was excised with a segment of jejunum. The cut surface had a variegated appearance with regions of necrosis. The histological features were suggestive of pleomorphic liposarcoma. Tumour cells were positive for S-100 and negative for SMA/Desmin. Complete resection is curative although the role of chemotherapy remains to be established.

Rare case of internal pancreatic fistula in a young adult presenting with massive bilateral pleural effusion.

Pancreatic pleural fistula is a rare sequel of acute or chronic pancreatitis. The diagnosis is usually delayed due to low index of suspicion and the need for advanced diagnostic tools. The clinical presentation is often misleading because respiratory rather than abdominal symptoms predominate. The majority of reported cases of pancreatic pleural fistula present as unilateral pleural effusion; presentation as bilateral pleural effusion is extremely rare. We report a case of a 16-year-old boy with traumatic acute pancreatitis who presented with a massive bilateral pleural effusion caused by pancreatico-pleural fistula.

Giant Gastrointestinal Stromal Tumor Presenting as a Palpable Abdominal Mass: An Unusual Presentation

Gastrointestinal stromal tumors (GIST-) account for the majority of mesenchymal tumors arising within the gastrointestinal tract. GIST presenting as a palpable abdominal mass is extremely rare. We report four additional cases of a GIST presenting as an abdominal mass along with a pertinent review of the literature. Twenty five cases of GISTs presenting with an abdominal mass, including 4 cases discussed here, have been reported in the world literature since 2001. The mean duration of symptoms was 152.7 days. Twenty one of 25 (84%) patients received surgical resection. The mean tumor size was 17.2 cm, with an average mitotic index of 7.6 per 50 high power fields. Thirteen of 14 (92.9%) patients had a high-risk tumor. Five patients were disease-free at a mean followup of 11 months, 2 patients had stable disease and 2 patients had progressive disease, and one patient had a partial response. In conclusion, symptomatic patents have an increased incidence of high-risk tumors and metastases at presentation. Adjuvant therapy with imatinib improves disease-free survival in patients with large abdominal GIST tumors, but no change in overall survival was noted. Finally, GISTs should be considered in the differential diagnosis of an abdominal mass in an elderly patient.

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.

Pleurobiliary Fistula Secondary to Choledocholithiasis—A Rare Entity

Pleurobiliary fistula secondary to common bile duct obstruction due to stone is a very rare clinical entity. A 55-year-old female patient presented in the emergency department with features of septicaemia with left pleural effusion. Intercostal tube drainage drained 5 L of bile on the first day and around 500-600 mL of bile each day subsequently. Magnetic resonance cholangiopancreaticography showed choledocholithiasis with pleurobiliary fistula. The patient underwent bilioenteric bypass and ligation of the fistulous tract with complete cure.

Vesical dermoid: An unusual presentation

Dermoid cysts are considered developmental anomalies and consist of tissue from more than one germ cell layer. They occur most commonly in the ovaries, but might also be found at other sites, especially in the midline. Dermoid cysts are particularly rare in the urinary bladder. We herewith present one such case. A 26-year-old woman presented with complaints of the passage of hair in her urine for the past 2 years associated with two episodes of gross hematuria. She had no other genito-urinary or bowel complaints. The clinical, routine blood and urine examinations were normal. An ultrasound of the abdomen showed an irregular, echogenic lesion measuring 5.6 ¥ 6 ¥ 5.3 cm within the lumen of the urinary bladder. On trans-vaginal sonography, both ovaries and the uterus were found to be normal. Cystoscopy showed a 5 ¥ 5 cm mass arising from the dome of the urinary bladder with multiple hairs projecting from it. Computed tomography showed a well-defined lesion in the urinary bladder measuring 5.2 ¥ 3.1 ¥ 4.5 cm showing variegated attenuation of fat, soft tissue and bone. The patient underwent open surgery through lower midline incision. A 6 ¥ 5.5 cm mass was found to be arising from the right posterolateral wall of the bladder. It was covered with skin and hair on its surface. A tooth was also seen arising from the mass. The right ovary, which appeared normal on inspection, was densely adherent to the bladder wall at one of its poles. The intravesical mass was excised with a 1-cm rim of normal bladder mucosa, and right salpingo-oopherectomy was carried out because the ovary could not be separated from the bladder wall (Fig. 1). The bladder was repaired in two layers. The patient had an uneventful recovery. The histopathology report showed a mature teratoma with ectodermal, mesodermal and endodermal elements. The teratoma was reported to be confined to the bladder wall with no extension outside. The excised right ovary and tube did not reveal any pathology. Dermoid cysts are developmental anomalies and are considered teratomas. Leblanc in 1831 coined the term dermoid cyst when he removed a lesion at the base of a horse’s skull, which he called a “kyste dermoid”. Developmentally, dermoid cysts are a result of the sequestration of skin along the lines of embryonic closure that contain mature skin complete with hair follicles and sweat glands, sometimes clumps of long hair, and often pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage and thyroid tissue. Because it contains mature tissue, a dermoid cyst is almost always benign. Dermoid cysts are rare in the urinary bladder and can pose a diagnostic problem. A review of the literature revealed just nine reported cases. The passage of hair in the urine (pilimictia) is a pathognomonic sign of urinary bladder dermoid. The origin from primordial germ cells is now the most widely accepted theory of pathogenesis of dermoid cysts. Dermoids are recognized as often being trigerminal and containing practically any type of tissue. The treatment should be conservative considering the benign nature of the entity.

Pseudocyst of the spleen caused by tuberculosis: a rare entity.

Splenic cysts can be primary or secondary, depending upon the aetiology and pathology. Secondary cysts can be of inflammatory, infective, degenerative or traumatic aetiology. Splenic cysts can be true (lined by epithelium) or secondary (pseudocyst, not lined by epithelium). True splenic cysts are mainly congenital and pseudocysts are mainly traumatic in origin. Pseudocyst of the spleen due to tuberculosis is extremely rare .We report one such case of pseudocyst of the spleen caused by tuberculosis together with a relevant review of literature. Our case probably represents the first reported case of tubercular pseudocyst of the spleen.