Influence of timing on performance of laparoscopic cholecystectomy for acute biliary pancreatitis.

AIM: Gallstone disease is the most common cause of acute pancreatitis. Cholecystectomy is mandatory to avoid recurrence of pancreatitis. Our objective was to evaluate the results of laparoscopic cholecystectomy (LC) in patients with gall-stone induced pancreatitis. METHODS: All patients presenting to us within the time frame from February 2004 to June 2008 with acute biliary pancreatitis were included in the study. The severity of pancreatitis was assessed by Ranson's criteria. ERCP and endoscopic sphincterotomy was performed when the common bile duct (CBD) was dilated (>6 mm) with either calculi or sludge as seen on imaging. Patients with successful ERCP with predicted demanding laparoscopic cholecystectomy were discharged instead for an elective LC, 4-6 weeks later. Patients with mild pancreatitis (with Ranson's score of 3 or less) and predicted uncomplicated LC underwent surgery at the same admission. The difficulty of the procedure was determined by the presence of adhesions in the gallbladder area, dissection in Calot's triangle, tackling the dilated cystic duct, intra-operative bleeding, and the need for a drain. RESULTS: A total of 26 patients (12 male and 14 female; age range 23-75 years) with acute biliary pancreatitis comprised the study group. Eleven patients with suspected choledocholithiasis underwent ERCP and clearance of the CBD was done in all of them. Nine patients (2 ERCP and 7 non-ERCP) underwent early LC in the same admission. Seventeen patients (9 ERCP and 8 non-ERCP) were predicted as difficult cases for LC and underwent delayed LC. No patient had recurrent pancreatitis in the interval period. CONCLUSION: There was no significant difference in the operative difficulty between early and delayed LC when patients were selected for timing of LC based on pre-defined criteria.

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis.

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Carcinoid tumor of bile duct.

We report a 38-year-old lady with carcinoid tumor of the extrahepatic biliary tract who presented with recurrent obstructive jaundice and previous surgery for suspected choledocholithiasis. MRCP revealed a large bile duct tumor extending from the confluence up to the superior aspect of the pancreas; this was completely excised, with bilio-enteric anastomosis. These tumors are characteristically slow growing and, therefore, are amenable to aggressive surgical excision, which offers the best chance of cure.

Laparoscopic splenectomy using conventional instruments.

INTRODUCTION: Laparoscopic splenectomy (LS) is an accepted procedure for elective splenectomy. Advancement in technology has extended the possibility of LS in massive splenomegaly [Choy et al., J Laparoendosc Adv Surg Tech A 14(4), 197-200 (2004)], trauma [Ren et al., Surg Endosc 15(3), 324 (2001); Mostafa et al., Surg Laparosc Endosc Percutan Tech 12(4), 283-286 (2002)], and cirrhosis with portal hypertension [Hashizume et al., Hepatogastroenterology 49(45), 847-852 (2002)]. In a developing country, these advanced gadgets may not be always available. We performed LS using conventional and reusable instruments in a public teaching the hospital without the use of the advanced technology. The technique of LS and the outcome in these patients is reported. MATERIALS AND METHODS: Patients undergoing LS for various hematological disorders from 1998 to 2004 were included. Electrocoagulation, clips, and intracorporeal knotting were the techniques used for tackling short-gastric vessels and splenic pedicle. Specimen was delivered through a Pfannensteil incision. RESULTS: A total of 26 patients underwent LS. Twenty-two (85%) of patients had spleen size more than 500 g (average weight being 942.55 g). Mean operative time was 214 min (45-390 min). The conversion rate was 11.5% (n = 3). Average duration of stay was 5.65 days (3-30 days). Accessory spleen was detected and successfully removed in two patients. One patient developed subphrenic abscess. There was no mortality. There was no recurrence of hematological disease. CONCLUSION: Laparoscopic splenectomy using conventional equipment and instruments is safe and effective. Advanced technology has a definite advantage but is not a deterrent to the practice of LS.

Paraesophageal mediastinal drainage with diversion for delayed presentation of esophageal perforation.

Esophageal perforation is a serious condition; a delay of more than 48 hours in initiation of treatment leads to increased morbidity and mortality. Management of such patients is a surgical dilemma. We successfully managed 4 patients (2-iatrogenic, 1-tuberculous, 1-Boerhaave's syndrome) with delayed presentation of esophageal perforation by esophageal exclusion and paraesophageal mediastinal drainage, achieving good control of mediastinal sepsis, healing of perforation and at the same time avoiding thoracotomy and subsequent second surgery.

Varied presentations of gastrointestinal stromal tumour.

Gastrointestinal stromal tumours (GIST) are soft tissue tumours arising from the mesenchyma in the gastrointestinal tract. These are rare tumours. However, over the past few years with the better understanding of the pathogenesis of GIST and better imaging facilities, the diagnosis is made more frequently. The characteristic diagnostic feature of GIST is the expression of CD34 and receptor tyrosine kinase KIT, CD117 by these tumours. The use of tyrosine kinase inhibitor imatinib mesylate has led to improved outcome. The presentation of GIST however remains non-specific, and varies depending upon the size and the organ of origin. We present a series of four cases of GIST with varied presentation.

Laparoscopic orchidectomy for undescended testis in adults.

BACKGROUND: Impalpable testis is a significant diagnostic and therapeutic challenge in adults, for both radiologist and surgeons, with few reports in literature addressing this problem in adults. Laparoscopy is a reliable and definitive procedure obviating the necessity of advance investigation and subsequent inguinal exploration in adults. AIMS: To study the utility of laparoscopy as combined diagnostic and therapeutic modality for undescended testis in adults. SETTINGS AND DESIGN: Prospective study from a single surgical unit of a large tertiary referral centre during August 2000 to January 2002. METHODS AND MATERIAL: Nine patients of unilateral undescended testis with average age 22.7 years (range 13-31 years) underwent diagnostic laparoscopy and orchidectomy subsequent to detailed clinical, ultrasound and examination under anaesthesia (EUA) procedure. All patients were operated with one 10 mm umbilical camera port, one suprapubic port and 1 lateral port. RESULTS: None of the patients had palpable testis or an inguinal cough impulse on clinical examination and during EUA. In only 3(33.3%) patients, the ultrasound could locate the testis situated at the deep ring. On laparoscopy all testes were identified, 4 were present at the deep ring, 3 were intra-abdominal and 2 had blind ending vas entering the deep ring. Mesh plug was inserted in the internal ring in these 2 patients, after dissecting the peritoneum. None of the patients had intra or post-operative complications and all were discharged on the next day. CONCLUSION: Laparoscopy is one of the most satisfactory methods for the diagnosis and management of non-palpable testis in adult cryptorchid patients.

Role of computed tomography in the diagnosis of rib and lung involvement in tuberculous retromammary abscesses.

OBJECTIVE: To assess the role of computed tomography (CT) in the diagnosis of rib and lung involvement in tuberculous abscess in the retromammary region. DESIGN AND PATIENTS: Eight patients with tuberculous retromammary abscess were examined by CT and the findings were evaluated. A cold abscess (purulent collection with absence of acute inflammation) was aspirated in all cases. Diagnosis was confirmed by acid-fast bacillus culture, or histologic examination. RESULTS: CT showed a relatively well marginated, inhomogeneous, hypodense lesions in all eight cases. Following administration of intravenous contrast medium, these lesions showed enhancing walls, suggestive of an infective collection. Lung involvement was seen in one patient. A direct communication from the retromammary lesion through the thoracic wall into the pleura was seen in five cases. In four cases destroyed rib fragments within the abscess were noted. CONCLUSION: A tuberculous abscess in the retromammary region is usually shown on CT as a focal, well-marginated, inhomogeneous, hypodense lesion with a surrounding enhancing rim. A direct communication with the pleura, a destroyed rib fragment in the abscess, and associated lung involvement may be revealed by CT.