Elective laparoscopic cholecystectomy in the presence of common bile duct stent.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure done in patients with common bile duct (CBD) stones. Some clinicians insert a CBD stent at the time of ERCP. Such patients may then present for laparoscopic cholecystectomy (LC) with CBD stents in situ. The aim of this study was to examine the impact of the presence of a CBD stent on the outcome of elective LC. METHODS: This was a case-controlled study conducted from January 2005 to June 2008. The patients were divided into three comparable groups: group 1, those having LC preceded by ERCP; group 2, those having LC preceded by ERCP and stent insertion; and group 3, those having LC alone. RESULTS: Four hundred one LC procedures were performed, five of which were excluded (two had had previous upper abdominal surgery, two had isolated pancreatic stents, and one had the stent removed the day before surgery). Of the 396 patients studied, there were 31 patients in group 1, 35 patients in group 2, and 330 patients in group 3. The incidence of conversion, postoperative bile leak, operating time, and length of stay was significantly higher in Group 2 (p<0.05). The incidence of conversion increased with the duration of in-situ stent placement (Spearman correlation coefficient=0.34, p<0.05). There was one case of abandoned cholecystectomy, two cases of CBD erosion, one case of CBD injury, and two cases of in-hospital mortality, all involving patients in group 2 only. CONCLUSIONS: We conclude that LC in the presence of CBD stents poses significant risk to patients, particularly if they are left in-situ for long periods of time. Caution should be exercised in stenting a CBD with an intact gallbladder, particularly in those awaiting cholecystectomy.

Computed tomography colonography: a retrospective analysis of outcomes of 2 years experience in a district general hospital.

BACKGROUND: Colonoscopy is the gold-standard investigation for direct luminal visualization of the large bowel. Studies have shown the efficacy of computed tomography colonography (CTC) is equivalent to colonoscopy in both cancer and polyp detection. METHODS: A retrospective review of patients undergoing CTC from January 2013 to October 2014 was performed. Patient demographics, indication for investigation, computed tomography findings, optical colonoscopy findings and histology results were recorded. RESULTS: Seven hundred and fifty-eight CTC were performed. Three hundred and seventeen patients were male (42%) and 441 (58%) were female. Endoscopy was advised in 209 cases. One hundred and twenty (16%) were deemed suspicious for cancer of whom 96 (80%) had optical colonoscopy. A total of 12 colorectal cancers were detected. Potential polyps were noted in 58 cases (8%). Forty-four patients underwent endoscopy (75%) and 17 polyps confirmed (38%). Two patients had foci of invasive cancer histologically. Significant extracolonic findings were identified in 60%, including five cases of gastric carcinomas. The most common other findings were gallstones and hernias. CONCLUSION: The rate of colorectal cancer detection in this study was 2%. The rate of biopsy proven cancer was 10% following a suspicious colonogram. Endoscopic correlation was not obtained in 20% of cases of radiological suspicion. CTC is as efficacious as optical colonoscopy for colorectal cancer and polyp detection.

Biliary contents in the chest drain tube: a finding not to ignore.

A 45-year-old man presented with a left-sided pneumothorax following an episode of forceful vomiting. His chest drain revealed biliary contents and his CT chest with oral contrast confirmed the diagnosis of oesophageal rupture. He was transferred for surgical repair to a tertiary centre. Biliary contents within a chest tube are an important clinical finding and should raise suspicion of Boerhaave's syndrome. Any delays should be avoided due to the high mortality.

Improving outcome following life-threatening gastrointestinal bleeding not amenable to endoscopy in an ASA grade 5 patient: lessons learned.

We present a 74-year-old woman, who developed massive haematemesis and hypovolaemic shock. Her management was challenging, as the bleeding site could not be identified during oesophagogastroduodenoscopy, she was not fit for a general anaesthesia and not able to lie flat due to heart failure, caused by pericardial effusion. She underwent an emergency laparotomy and gastrotomy under a combined thoracic epidural and lumbar spinal regional anaesthesia in a sitting position, 45° to horizontal plane. The bleeding site was identified as a Dieulafoy lesion on the posterior wall of the stomach and was controlled by under running the lesion. She had an uneventful recovery and is symptom-free post-surgery for a year at present.

Concurrent caecal and transverse colonic tuberculosis masquerating synchronous colonic carcinoma.

We present a 46-year-old Somalian woman, who attended our hospital, with 1 week history of worsening epigastric pain and vomiting, worse after eating on a background of 3 months history of four stones loss of weight, malaise and decreased appetite. CT scan of the abdomen revealed an annular 10 cm long mass of the right transverse colon with a second mass of the caecum raising concerns of a synchronous colonic cancer. She underwent an extended right hemi-colectomy due to the development of obstruction from the transverse colon lesion. The histology revealed caseating, transmural granulomatous inflammation consistent with tuberculosis. She had an uneventful recovery and was discharged on the tenth postoperative day on antituberculosis (anti-TB) medications. She reports complete resolution of her symptoms 4 months after discharge.

Right-sided colonic tuberculosis: a rare cause of ilio-psoas abscess.

Ilio-psoas abscess due to right colon origin is rare and normally occurs secondary to Crohn's disease, diverticulitis or cancer. We report a case of a caecal tuberculosis (TB) presented initially with an appendicular mass and systemic symptoms of fever and fatigue and 3 weeks after, with right-sided anterior thigh pain and found to have an ilio-psoas abscess. Colonoscopy and histology confirmed the diagnosis of caecal-TB. She had a CT drainage of the abscess and was discharged with anti-TB treatment and her drain in situ. Repeat pelvic MRI 10 days after treatment showed the abscess resolving and her systemic symptoms improving.

Traumatic splenectomy in a cirrhotic patient with hepatitis C and alcoholic liver disease.

Non-operative management is the management of choice for haemodynamically stable patients with blunt splenic injury. However, coexistent liver cirrhosis poses significant challenges as it leads to portal hypertension and coagulopathy. A 52-year-old man sustained blunt abdominal trauma causing low-grade splenic injury. However, he was found to have liver cirrhosis causing haemodynamic instability requiring emergency laparotomy. His portal hypertension led to severe bleeding only controlled by aortic pressure and subsequent splenectomy. Mortality from emergency surgery in cirrhotic patients is extremely high. Despite aggressive resuscitation, they may soon become haemodynamically unstable. Therefore, traumatic splenectomy may be inevitable in such patients with portal hypertension and splenomegaly secondary to liver cirrhosis even in low-grade injury.

Changing trends in the pattern and outcome of stab injuries at a North London hospital.

OBJECTIVE: To study the incidence, pattern and outcome of stab injuries attending a North London Teaching Hospital over a 3-year (2006-2008) period. MATERIALS AND METHODS: A retrospective review of collected data from the Hospital database was conducted. The database contains comprehensive medical records for all patients attended by the trauma team for deliberate stab injuries. It is updated by the surgical team after each admission. All patients with deliberate penetrating injury who were attended by the service between 1 January 2006 and 31 December 2008 were identified. Patients who died in the prehospital phase, those managed exclusively by the emergency department and limb injuries without vascular compromise were excluded from the study. RESULTS: Six hundred and nineteen patients with stab injuries (following knife crime) from North London attended the Hospital in the above period. One hundred and thirty-seven paients required surgical admission. Two were cases of self-inflicted knife injuries. Over the 3-year period the percentage of victims below 20 years of age is increasing. Ninety-three percent of knife crime occured between 6 pm and 6 am; recently moving toward week days from weekend period. CONCLUSIONS: The overall rate of penetrating injuries (stab injuries) is slowly declining. Timely cardiothoracic support facility is vital in saving lives with major cardiac stab injuries. Although alcohol drinking restriction has been lifted, most cases of stabbings are still occurring out-of-hours when surgical personnel are limited.

Malignant gastro-colic fistula presenting with upper extremity deep vein thrombosis.

Locally invasive colonic carcinomas are seldom complicated by the formation of gastro-colic fistula. The authors present a case of a 52-year-old man with malignant gastro-colic fistula presenting with upper extremity deep vein thrombosis posing operative challenges.

An unusual complication encountered incidentally at laparoscopic cholecystectomy: a case series.

INTRODUCTION: This is a case series of erosion of the common bile duct by an in situ stent found incidentally during laparoscopic cholecystectomy (LC). To the best of our knowledge, this is one of the first reported incidences of this nature. METHOD: Four individual case reports. RESULTS: Thirty nine patients with an in situ CBD stent underwent LC for symptomatic gallstones in our institution over a 4-year time period (2005 to 2009). Four patients were found to have the stent eroding through the wall of the CBD. In these four patients, endoscopic retrograde cholangiopancreatography (ERCP) had previously been performed - extracting stone(s) - followed by sphincterotomy and insertion of a 7 Fr pigtail stent (measuring 4 cm). The operation was converted to open in two patients, and the procedure was abandoned in one of these cases. In the other two patients, the anatomy of Calots triangle was delineated well, and the operator was able to complete LC. The duration between initial pigtail stent insertion and LC ranged from 32 to 400 days. None of our patients required a definitive surgical repair of the CBD or T-tube placement. The stent was removed during surgery in one case, removed endoscopically at a later date in two patients, and passed spontaneously in one patient. All four patients made a good postoperative recovery. CONCLUSION: CBD erosion is a complication of plastic biliary stent insertion. CBD stent erosion will make surgery more hazardous especially if it remains in situ for a significant period of time. CBD erosion can generally be managed conservatively without the need for surgical repair. Awareness of this complication should prompt earlier surgery or earlier removal of plastic pigtail stents.