Vijay K. Mittal

Primary repair of colon injuries : a prospective randomized study

Due to the results of a 6-year experience with civilian penetrating colon injuries at Mount Carmel/Grace Hospital, in Detroit, Michigan, which had favored primary repair of colon injuries, a prospective randomized study was performed. Seventy-one patients with penetrating colon injuries were entered in a prospective randomized study. Forty-three patients were treated with primary repair or resection and anastomosis, and 28 patients were treated with diversion. The average Penetrating Abdominal Trauma Index score was 25.5 for the primary repair and 23.4 for the diversion groups. The majority of injuries as assessed by the Colon Injury Score (CIS) for the primary repair group were grades 2 (58%) and 3 (28%). The diversion group predominantly had grades 2 (64%) and 3 (25%). There was no significant difference between the two groups. There were 8 (19%) patients with colon and noncolon-related complications in the primary repair group, and 10 (36%) patients with colon, noncolon, and colostomy-related complications in the diversion group. In addition, there were 2 (7%) patients with complications following colostomy reversal. Independent risk factors for adverse outcomes were compared and used to calculate the probability for adverse outcomes with respect to the mode of treatment. The probability for adverse outcomes was statistically greater in the diversion group. An analysis was also made within the primary repair group comparing the subgroups of primary repair with, and without, resection of colon. It appears that the primary repair with resection of colon may have fewer complications; however, this conclusion is based on a statistically insufficient sample size. The authors contend that primary repair or resection with anastomosis is the method of choice for treatment of all penetrating colon injuries in the civilian population despite any associated risk factors for adverse outcomes.

Primary malignant tumors of the small bowel

Primary malignant tumors of the small bowel are uncommon and are often diagnosed at an advanced stage. A 10 year survey (1967 to 1977) of the clinical records at one hospital revealed 39 cases of primary malignant tumors of the small bowel. The most common symptoms were abdominal pain (89.7 percent) and weight loss (77 percent). Six patients presented with complications of enterovesical fistula, bleeding and perforation. Preoperative diagnosis was suspected in 27 cases (69.2 percent). Adenocarcinoma was the most common tumor, followed by carcinoid tumor, lymphoma, leiomyosarcoma and melanoma. The treatment of choice was surgical resection whenever possible. Curative resection was attempted in 25 cases. Adjuvant radiotherapy and chemotherapy was used in four patients with lymphoma. Twenty-seven patients (69.2 percent) are alive from 1 to 6 years after diagnosis and treatment. The 5 year survival rate is 35 percent. Earlier diagnosis is essential if the prognosis for patients with small bowel malignancy is to be improved.

Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis

BACKGROUND Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangrenous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our experience with laparoscopic cholecystectomy in the treatment of patients with gangrenous cholecystitis. METHODS From January 1994 to March 1999, 281 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Operative and histopathologic data were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patients. Conversion to an open cholecystectomy became necessary in 14 of 44 (32%). A retrospective review comparing these two groups of patients was performed. RESULTS Of the 44 patients, there were 25 males and 19 females, with a mean age of 64.6 years. Mean duration of symptoms prior to presentation was 2.3 and 2.9 days in the laparoscopic and conversion groups, respectively. Clinical presentation included the presence of right upper quadrant pain (98%), leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bilirubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Air in the gallbladder wall and intraluminal membranes were present in 2 patients and 1 patient, respectively. Nuclear scans performed in 29 patients revealed cystic duct obstruction in all 29. The rim sign was present in 1 patient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure became necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients undergoing a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study population. Morbidity occurred in 40% of the laparoscopic group and 71% of the conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversion group required a mean of 2.6 days in the intensive care unit. Postoperative hospital stay was 3.3 versus 5.5 days in the two groups, respectively. CONCLUSIONS Preoperative factors did not predict conversion in patients undergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not significantly prolonged and outcome in terms of morbidity, admission to the intensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful.

Endometriosis of the appendix presenting as acute appendicitis

Abstract Sixteen cases of endometriosis of the appendix are reported. Ten were found as a result of incidental appendectomy at the time of laparotomy. Six patients (37.5 percent) had symptoms of acute appendicitis. There is a good correlation between the site and depth of appendiceal wall involvement, the presence of hemorrhage, and the symptoms of acute appendicitis.

Prognostic factors in primary adenocarcinoma of the small intestine: 13-year single institution experience

BackgroundAdenocarcinoma of the small bowel is a relatively rare malignancy as compared to the other malignancies of the gastrointestinal tract. Nonspecific presentation and infrequent occurrence often leads to a delay in diagnosis and consequent poor prognosis. Various other factors are of prognostic importance while managing these tumors.MethodsThe medical records of a total of 27 patients treated for adenocarcinoma of the small bowel at Providence Hospital and Medical Centers from year 1990 through 2003 were reviewed retrospectively. Data were analyzed using SPSS software (version 10.0; SPSS, Inc., Chicago, IL). Survival analyses were calculated using the Kaplan Meier method with the log rank test to assess the statistical significance. The socio-demographics (age, gender) were calculated using frequency analyses.ResultsThe patients included nine males and eighteen females with a median age at diagnosis of 62 years. Only 48% of the patients had an accurate preoperative diagnosis while another 33% had a diagnosis suspicious of small bowel malignancy. None of the patients presented in stage 1. The cumulative five-year survival was 30% while the median survival was 3.3 years. There was no 30-day mortality in the postoperative period in our series.ConclusionThe univariate analysis demonstrated that tumor grade, stage at presentation, lymph nodal metastasis and resection margins were significant predictors of survival.

Setons in the Treatment of Anal Fistula: Review of Variations in Materials and Techniques

Aim: Anorectal fistulas have been a common surgical problem since ancient times. Age-old seton techniques are still practicedsuccessfully in the treatment of complex anal fistulas. Many variations in materials and techniques are described in the literature. The selection of a seton type and technique depends on personal preferences. Our aim was to put together all the available variations in materials and techniques for seton treatment. This comprehensive review will help the surgeon to become more familiar with the various options available with regard to materials and techniques. Methods: A review of the literature using Medline was done using the Key Words ‘anal fistula’ and ‘seton’. All articles published in English were reviewed. The articles which had variations in materials and techniques for seton treatment were studied. Results: Various aspects of variations in materials, insertion techniques, maintenance of tension, mechanisms of action, drainage techniques and changing the seton have been elaborated in detail. Conclusions: Throughout this paper we present the various available variations in setons with regard to materials, placement and maintenance techniques. This study will help clinicians in choosing a new seton variation or modifying their current method of treatment with setons.

C-reactive protein estimation does not improve accuracy in the diagnosis of acute appendicitis in pediatric patients

BACKGROUND Appendectomy is the treatment of choice in acute appendicitis in children. Delayed diagnosis of acute appendicitis in children can lead to complications like perforation. Studies on the diagnostic value of WBC and CRP in establishing the diagnosis of appendicitis have contradictory results. Our study evaluates the role of CRP in diagnosing appendicitis in a pediatric population. METHODS A retrospective chart study on 130 patients aged less than 19 years who had an appendectomy at Sparrow hospital during years 2002-2006 formed the basis for this report. Based on histology appendicitis was classified as simple or perforated (complicated). RESULTS Patients (75 boys, 55 girls) were 6-18 years of age (median 14 years). The appendix was normal in 9/130 cases. Appendicitis was simple in 58/130 cases and perforated in 63/130 cases. Overall WBC count had the highest sensitivity in the prediction of (diagnosis) appendicitis at 88% whereas CRP was 69% and, WBC and CRP combined was 60%. PPV of WBC was highest at 0.81 (47/58) for simple appendicitis and 0.93 (59/63) for perforated appendicitis, when compared to CRP at 0.57 (33/58) and 0.81 (51/63); and CRP and WBC combined at 0.45 (26/58) and 0.75 (47/63). CONCLUSION The sensitivity and PPV of WBC were better than CRP alone, or in combination with WBC. We conclude that CRP does not aid in the diagnosis of appendicitis. Simple appendicitis was seen in spite of normal WBC and CRP.

The Internet School of Medicine: Use of Electronic Resources by Medical Trainees and the Reliability of those Resources

BACKGROUND Electronic sources of medical information are plentiful, and numerous studies have demonstrated the use of the Internet by patients and the variable reliability of these sources. Studies have investigated neither the use of web-based resources by residents, nor the reliability of the information available on these websites. METHODS A web-based survey was distributed to surgical residents in Michigan and third- and fourth-year medical students at an American allopathic and osteopathic medical school and a Caribbean allopathic school regarding their preferred sources of medical information in various situations. A set of 254 queries simulating those faced by medical trainees on rounds, on a written examination, or during patient care was developed. The top 5 electronic resources cited by the trainees were evaluated for their ability to answer these questions accurately, using standard textbooks as the point of reference. RESULTS The respondents reported a wide variety of overall preferred resources. Most of the 73 responding medical trainees favored textbooks or board review books for prolonged studying, but electronic resources are frequently used for quick studying, clinical decision-making questions, and medication queries. The most commonly used electronic resources were UpToDate, Google, Medscape, Wikipedia, and Epocrates. UpToDate and Epocrates had the highest percentage of correct answers (47%) and Wikipedia had the lowest (26%). Epocrates also had the highest percentage of wrong answers (30%), whereas Google had the lowest percentage (18%). All resources had a significant number of questions that they were unable to answer. DISCUSSION Though hardcopy books have not been completely replaced by electronic resources, more than half of medical students and nearly half of residents prefer web-based sources of information. For quick questions and studying, both groups prefer Internet sources. However, the most commonly used electronic resources fail to answer clinical queries more than half of the time and have an alarmingly high rate of inaccurate information.

Pancreatic schwannoma: literature review.

Pancreatic schwannoma is a rare neoplasm. Accurate preoperative diagnosis remains difficult, but computed tomography (CT) scanning and magnetic resonance imaging (MRI) help to establish the diagnosis, and definitive diagnosis requires immunohistochemical examination. Cystic pancreatic schwannomas should be considered in the differential diagnosis of cystic neoplasms and pseudocysts. Simple enucleation may be adequate for pancreatic schwannoma. In this report, we examine a case of benign pancreatic schwannoma in a 56-year-old woman. She was being evaluated for an ovarian teratoma, and an 8-cm cystic mass was incidentally found in the head of the pancreas. She underwent a pylorus preserving Whipple procedure with bilateral oopherectomy. Only 37 cases have been reported in the English literature. We present a thorough review with an emphasis on the clinical presentation, diagnostic modalities, and treatment options in the management of this rare clinical entity.

Topical gentamicin does not provide any additional anastomotic strength when combined with fibrin glue

BACKGROUND We evaluated the effect of a combination of fibrin sealant and topical gentamicin on a colonic anastomosis in a rat model. METHODS Partial anastomosis in the transverse colon was performed in 70 male Sprague-Dawley rats aged 6 to 10 weeks using 5 interrupted sutures. The rats were divided into 4 groups (control, gentamicin, fibrin glue, and combination). On postoperative days 3 and 5, the rats in each group were killed, anastomotic bursting pressures scores and bowel loop adhesions were determined, and histologic examination was performed. RESULTS No significant difference was noted in the bursting pressures, adhesions, inflammatory infiltrates, fibroblasts, or neoangiogenesis between the fibrin-glue only and the combination groups for both the day 3 and day 5 subgroups. CONCLUSIONS The combination of topical gentamicin and fibrin glue had little effect because the combination did not provide additional anastomotic strength or decrease the number of adhesions when compared with fibrin glue alone.