Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study.

Background: Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ. Methods: A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded. Results: Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ). Conclusions: Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

Extended Total Mesorectal Excision (e-TME) for Locally Advanced Rectal Cancer.

BACKGROUND: Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or multivisceral resection is a complex procedure associated with high morbidity, mortality, and R1 resection rates. However, e-TME in LARC with surrounding organ involvement is the only potential option for cure. The study aims to assess the clinical outcome of patients requiring e-TME for LARC. METHODS: The study is a retrospective review of all patients with LARC requiring multivisceral resection (2013 to 2019). The database includes clinic-demographic profile, pelvic organ involved, operative details, resection margin status, morbidity, mortality, and survival. RESULTS: Seven consecutive patients (9.2%) out of 76 LARC (median age 46 years; 5 females) required multivisceral resection. The organs involved were bladder (4); posterior wall of vagina (2); and uterus (1). The en bloc resection included total cystoprostatectomy - 1; partial cystectomy - 3; posterior vaginectomy - 2; and hysterectomy - 1. Additionally, four required abdominoperineal resection. All were adenocarcinoma: stage III, with R0 resection - 76%. The overall complications were seen in 60% of patients, majority being wound related. There was no operative mortality. The median survival was 32.2 months in the entire series, while one died with the disease at a 28-month follow-up. CONCLUSION: e-TME with curative intent, though a complex procedure, is associated with high wound-related morbidity, R1 resection, but improved median survival benefit.

Inflammatory cap polyp of the sigmoid colon: a case report.

BACKGROUND: Inflammatory cap polyp is a very rare benign entity of the distal left colon, characterized by inflammatory polyp with a "cap" of fibrinopurulent exudates. They are usually multiple and commonly present with bleeding per rectum or mucoid discharge. Solitary polyp presenting with intermittent intussusceptions is rare. CASE PRESENTATION: We report the case of a 45-year-old Nepalese male with a solitary inflammatory sigmoid colon polyp. The patient presented with a 1-month history of rectal bleeding, mucoid discharge, and severe colicky abdominal pain due to intussusceptions. On colonoscopy, there was an exophytic mass with surface exudates. Colonic resection and anastomosis were performed, due to recurring partial intestinal obstruction. At a 6-month follow-up, the patient was asymptomatic. CONCLUSION: Inflammatory cap polyp is a benign entity, and it should be kept in mind as an important differential diagnosis of exophytic colonic mass with surface exudates.

Abdominal cocoon syndrome with military tuberculosis.

Abdominal cocoon syndrome coexistent with military tuberculosis is a very rare entity, and its occurrence in a young adult male has not been previously reported. The disease in combination with military tuberculosis is associated with significant morbidity and mortality if underdiagnosed and untreated; hence, a high index of suspicion is required in a patient with tuberculosis presenting with intestinal pseudo-obstruction. The ideal treatment of the combination is surgical excision of cocoon along with oral anti-tubercular therapy (ATT), when the initial conservative management fails. However, surgery is frequently complicated by iatrogenic enterotomy due to the fibrinous cocoon. The best option in these cases may be a bail-out method of diverting jejunostomy. This helps relieve intestinal pseudo-obstruction and promotes early initiation of ATT as has been demonstrated in the present case.

Jejunal Intussusception in Adolescent Crohn's Disease: An Extremely Rare Complication.

Proximal small bowel intussusception occurring in an adolescent Crohn's disease patient is an extremely rare entity. It is usually primary without a lead point and quite often a transient phenomenon. We report such transient and intermittent jejunal intussusception in a 16-year-old male, developing immediately in a postoperative period after a stoma reversal for jejunal stricture perforation peritonitis.

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal.

OBJECTIVE: With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. METHODS: This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. RESULTS: Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. CONCLUSION: With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

Incarcerated complete rectal prolapse managed by Altemeier's procedure.

Rectal prolapse is a complete protrusion of the rectum through the anal canal, which usually occurs in elderly women. Incarceration is a rare event and can be the first presentation of a rectal prolapse. We present the case of a 54-year-old male patient who presented with incarceration and was managed successfully with Altemeier's procedure.

IMFT of the sigmoid colon: a case report.

Inflammatory myofibroblastic tumor (IMFT) of the colon is a very rare entity, characterized by proliferation of myofibroblast cells admixed with inflammatory infiltrates. The entity was first described in the late 1990s, and since then less than 30 cases have been described. It frequently mimics other neoplasm of the colon, such as adenocarcinoma, lymphoma and stromal tumor, and is very difficult to clinch the diagnosis preoperatively based on the clinical and radiological findings. Here, we discuss an uncommon case of sigmoid IMFT in a 35-year old male, presenting with bleeding per rectum and managed successfully by colectomy.