Intra-operative enteroscopic polypectomy-An innovative hybrid approach using straight sticks.

BACKGROUND: Peutz-Jeghers Syndrome (PJS) is an uncommon intestinal polyposis disorder. Bowel obstructions are a recurring problem in PJS and as many as 50% of these patients require surgery. The current standard of care for these patients is to perform a flexible enteroscopic polypectomy. The traditional push-pull enteroscopy however, might be unavailable or unsuitable in an emergency setting. Alternatively, repeated laparotomies with multiple small bowel resections can lead to short bowel syndrome. METHODS: In our series, we describe an innovative technique where a short midline laparotomy permitted sufficient access to reduce the intussusception(s) and perform a bowel walk. Rigid laparoscopic instruments were introduced within the small bowel lumen via enterotomies, to perform polypectomies along the entire small bowel length. This precludes the need for small bowel resections which can thwart the development of short bowel syndrome. RESULTS: Two patients with PJS presenting with acute small bowel obstruction underwent surgery using the described approach. Another two patients with PJS having multiple intussusceptions on CT underwent an elective prophylactic polypectomy using the same approach. We were able to run the bowel in its entirety and a maximum of 41 polyps were retrieved from the port site enterotomy. The operating times were modest and no unique complications pertaining to this technique were encountered. CONCLUSION: Small bowel polypectomy using rigid instrumentation employing a limited midline laparotomy is an attractive option for both emergency and elective settings in patients with PJS.

Endoscopic parathyroidectomy: a retrospective review of 27 cases.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP). METHODS: Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection. RESULTS: Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids. CONCLUSION: Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

Laparoscopic lateral pancreaticojejunostomy: an evolution to endostapled technique.

BACKGROUND: Chronic pancreatitis (CP) is a debilitating condition resulting in severe pain with progressive deterioration of pancreatic function. "Tropical" pancreatitis represents a variant of the disease with widely dilated ducts, numerous calculi, and few strictures. Traditionally, modified Puestow's procedure has been the treatment of choice for a dilated pancreatic ductal system. However, it has only recently been adapted to laparoscopic approach which is a technically demanding procedure primarily due to need for extensive intra-corporeal suturing. METHODS: Symptomatic cases of CP presenting at our center with minimum 8 mm mean ductal diameter at body and head were selected for laparoscopic modified Puestow's procedure. Those with prior pancreatic surgery, pancreatic head masses, endoscopic pancreatic stenting, and portal hypertension were excluded. Twenty-eight cases meeting selection criteria underwent a laparoscopic procedure. RESULTS: Seven patients (25%) underwent a stapled pancreaticojejunal anastomosis, 17 (60.7%) received a sutured anastomosis. Four patients (14.3%) were converted to open surgery due to failure to localize the pancreatic duct with percutaneous needle aspiration. Of those patients who underwent a successful laparoscopic procedure, a single patient developed a pancreatic fistula which resolved spontaneously; another patient had a difficult post-operative course with prolonged intensive care. We suffered no mortality within the series and no patient had any long-term disability. Anastomotic patency rates of 100% were achieved by the third post-operative month. CONCLUSION: Lateral pancreaticojejunostomy is an effective surgical management for CP with a dilated ductal system. Its laparoscopic adoption is the rational next surgical step. It allows effective duct decompression with low mortality and morbidity. The procedure demands an advanced surgical skill set with an emphasis on intra-corporeal suturing. Those patients suffering from tropical CP with wide ductal dilatation greater than 12 mm are suited to an endostapled anastomosis which helps significantly reduce operative time without any corrosion of outcomes.

A Study on Role of Laparoscopic Sleeve Gastrectomy in the Management of Morbid Obesity.

Obesity has assumed a pandemic and is responsible for serious medical, social, psychological, and economic implications, affecting all ages and socioeconomic groups. Hence, this prospective study was carried out to study the surgical benefits in such patients. A Prospective interventional study was carried out from June 2010 to November 2012 at IGGMC Nagpur performing laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients, and its efficacy was determined. A total of 56 patients were studied. 26 (46.42 %) being males and 30 (53.57 %) females. The maximum number of patient's, i.e., 32 (57.14 %) were in the range of BMI 40-44.99 kg/m(2) with mean BMI-43.25 kg/m(2). Mean weight was 117 kg (range 92-180 kg). Common comorbidities observed were hypertension in 43 (76.78 %), bronchial asthma in 31 (55.35 %), and diabetes in 21 (37.5 %). All patients treated with LSG had a mean operative time of 154.9 min (range 110-310 min) with 0 % leak, one conversion to open, and no mortality. Postoperative hospital stay was 3.54 days (range 3-7). Complications were minimal with prolonged vomiting seen significantly in 28 (50 %) patients. Follow up at 24 months showed mean weight 74.72 kg (68-81 kg) with mean excess weight loss of 67.71 % (62.79-71.05 %) causing a mean BMI of 28.42 kg/m(2) (26.56-30.44 kg/m(2)). It also reduced mean BP to 120.36 mmHg (110-144 mmHg) and mean fasting blood sugar to 100.63 mg/dl (80-146 mg/dl). Surgery for obesity is definitely an answer for this gift of modernization, and LSG is a safe and effective technique for achieving weight loss. Quality of life improves astonishingly and adds confidence to this mentally traumatic entity called "OBESITY".

Laparoscopic Management of Hydatid Cyst of Liver with Palanivelu Hydatid System over a Period of 3 Years: A Case Series of 32 Patients.

The aim of this article is to evaluate the role and safety of laparoscopic management of hydatid disease of liver using Palanivelu hydatid system (PHS)(1) with initial results. A prospective study of hepatic hydatid cyst underwent laparoscopic management using PHS, during the period from June 2008 to October 2010, in department of general surgery in a tertiary care institute. Selective patients were included in our study. Preoperatively 2 weeks and post operatively 6 weeks of Albendazole were given. All patients underwent surgery under general anesthesia. Hydatid cyst evacuation and omentoplasty were done with PHS system to prevent spillage. Cyst was irrigated with 2 % savlon. Drainage tube was kept near the cyst. There were 32 patients with 35 liver hydatid cysts operated. The mean operative time was 93.78 (70-180) min. Intraoperative complications were noted in two patients (6.2 %). Conversion was required in one patient (3.1 %). The mean duration of hospital stay was 3-10 days with an average of 5 days. There was no recurrence in mean follow-up of 3 years. There was no mortality with good subjective and objective cosmetic results. The laparoscopic cyst evacuation and omentoplasty using PHS are feasible and safe for treating the hydatid cyst of liver in selected patients. It aids early recovery with good cosmetic results.

A randomized study comparing outcomes of stapled and hand-sutured anastomoses in patients undergoing open gastrointestinal surgery.

Although stapling is an alternative to hand-suturing in gastrointestinal surgery, recent trials specifically designed to evaluate differences between the two in surgery time, anastomosis time, and return to bowel activity are lacking. This trial compared the outcomes of the two in subjects undergoing open gastrointestinal surgery. Adult subjects undergoing emergency or elective surgery requiring a single gastric, small, or large bowel anastomosis were enrolled into this open-label, prospective, randomized, interventional, parallel, multicenter, controlled trial. Randomization was assigned in a 1:1 ratio between the hand-sutured group (n = 138) and the stapled group (n = 142). Anastomosis time, surgery time, and time to bowel activity were collected and compared as primary endpoints. A total of 280 subjects were enrolled from April 2009 to September 2010. Only the time of anastomosis was significantly different between the two arms: 17.6 ± 1.90 min (stapled) and 20.6 ± 1.90 min (hand-sutured). This difference was deemed not clinically or economically meaningful. Safety outcomes and other secondary endpoints were similar between the two arms. Mechanical stapling is faster than hand-suturing for the construction of gastrointestinal anastomoses. Apart from this, stapling and hand-suturing are similar with respect to the outcomes measured in this trial.

Video endoscopy: removal of retained sewing needles from the duodenum.

We report an interesting case of a 21-year-old unmarried girl who swallowed six sewing needles. Her complaints were pain in the epigastrium, associated with nausea and vomiting. On examination, there was mild tenderness in the epigastrium. X-ray of the abdomen and endoscopy confirmed the presence of six needles in the duodenum, with tips lodged in the duodenal wall. Psychiatric opinion was sought which was normal. Under video endoscope (Pentax 2.8, EG 27708) guidance with Captura biopsy forceps without spikes (Cook DBF-2.4-160-S), six sewing needles were removed successfully from the duodenum through the endoscope channel without any complications. However, a video endoscopic removal of the retained six needles from duodenum is probably being reported for the first time.