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.

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.

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.

Clinico-pathological follow-up after total colectomy and straight ileo-anal anastomosis done for ulcerative colitis.

BACKGROUND: Restorative proctocolectomy is used as surgical treatment for ulcerative colitis. We have earlier documented adaptative changes in the terminal ileum after total colectomy, and straight ileo-anal anastomosis. AIM: To correlate the morphologic and functional changes in the ileal mucosa after total colectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis. METHODS: Thirty consecutive patients (age range 15-50 years, 24 men) who had undergone total colectomy, rectal mucosectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis were included in the study. These patients were followed up at 3-monthly intervals following surgery for two years and later once every year for a median duration of 9.5 (range 1-17) years. The clinical parameters studied were weight gain, frequency of stools, nature of stools, nocturnal stool frequency and need for antidiarrheal drugs. At each follow-up visit they were subjected to per rectal ileoscopy with ileal biopsy and barium enema. Ileal biopsy was analyzed histologically and histochemically. RESULTS: The clinical features improved over time, with average weight gain of 5 (range 1-7) Kg at one year. Frequency of stools decreased from 8-10 per day to 2-3 per day. The stools became semisolid and there was no need for antidiarrheal drug by the end of one year. All the patients showed adaptative changes in the ileum. The ileal mucosa was completely transformed into colonic type by the end of one year, colonoscopically (spacious lumen characteristic of colon), radiologically (disappearance of ileal characteristics with rectosigmoid-like appearance), histologically (blunting of villi with increase in goblet cells), and histochemically (sialomucin pattern to sulfomucin pattern). CONCLUSIONS: The ileum undergoes adaptative changes with corresponding improvement of clinical parameters over time, after proctocolectomy and ileoanal anastomosis for ulcerative colitis.

Nonfunctioning islet cell tumor presenting with ascites and portal hypertension.

Nonfunctioning islet cell tumors commonly cause no symptoms. A 22-year-old woman presented with lump in the left hypochondrium, refractory high-protein ascites and evidence of left-sided portal hypertension. At exploratory laparotomy, a 30 cm x 15 cm mass was seen at the splenic hilum, with large collateral vessels around. Distal pancreatectomy with splenectomy was done. Histology of the mass showed malignant islet cell tumor infiltrating the spleen. The patient died in the postoperative period.

Laparoscopic cholecystectomy in patient with portal cavernoma and portal hypertension.

Successful laparoscopic cholecystectomy has been reported in patients with cirrhosis of liver with portal hypertension; the procedure has, however, not been reported in patients with portal vein thrombosis, portal cavernoma and portal hypertension. We report an 18-year-old man with portal hypertension due to portal vein thrombosis and portal cavernoma who had symptomatic gallstone disease and was successfully treated with laparoscopic cholecystectomy.

Laparoscopic management of hydatid cyst of liver.

We describe the laparoscopic excision of a hydatid cyst in the liver. During the procedure, done after treatment with the scolicidal agents praziquantel and albendazole, care was taken to prevent spillage of scolices during evacuation of contents and to excise the entire germinal epithelium. The patient had no immediate or short-term complications and is asymptomatic 3 months later.

Mesenteric vasculopathy in intestinal tuberculosis.

BACKGROUND: Involvement of mesenteric vessels in intestinal tuberculosis and its role in the pathogenesis of the intestinal changes have not been studied histologically. AIM: To study mesenteric vessels in patients undergoing surgery for complications of intestinal tuberculosis. METHODS: Resected intestinal specimens from 68 patients presenting with intestinal perforation and intestinal obstruction were examined; involvement of the major mesenteric vessels was evaluated. RESULTS: Granulomas were seen in the vessel wall in one case and near the vessel wall in 11 cases, intraluminal thrombi were seen in 23 cases, and subintimal fibrosis in nine cases. Perivascular cuffing was seen in intramural and subserosal vessels in ten cases. CONCLUSIONS: Changes in the vessel wall may lead to gut ischemia, which may contribute to the development of strictures and stercoral perforation in intestinal tuberculosis.

Adult intrahepatic solitary choledochal cyst.

A 20-year-old woman presented with dull ache in the abdomen. Ultrasonography and CT scan showed a solitary liver cyst. Roux-en-Y cystojejunostomy was done since there was bile in the cyst. Histology of the cyst wall revealed it to be a choledochal cyst. Solitary intrahepatic choledochal cyst and presentation in adult life are rare.

Ksharsootra (medicated seton) treatment for fistula-in-ano.

BACKGROUND: Recurrence and incontinence are common after conventional surgery for fistula-in-ano. Medicated seton (ksharsootra) is a time-tested therapy. METHODS: Seton treatment was given to 114 patients with anal fistulae. The initial loose seton was changed weekly to achieve fistulotomy. RESULTS: Application of non-medicated seton did not show any cutting action; hence all patients were treated with ksharsootra after 3 weeks. Anal discharge (n = 114) and burning pain (35) were noted in the first 48-72 hours. The cut-out rate was around 1 cm/week, with mean cut-out time 8.3 weeks (range 3-18). All wounds healed well and patients remained ambulatory. Local induration developed in 18 patients; four had an abscess. There was no incontinence or recurrence over a follow-up of 6 months to 2 1/2 years. CONCLUSIONS: Ksharsootra treatment for anal fistulae is safe and effective, with low complication rates.

Modified Partington's procedure for pancreaticojejunostomy in chronic pancreatitis.

BACKGROUND: Various techniques have been described for pancreaticojejunostomy for chronic pancreatitis. We prospectively evaluated a modification of Partington's procedure with Roux-en-Y anastomosis for chronic calculous pancreatitis. METHODS: From 1980 to 1994, 53 patients with chronic calculous pancreatitis (46 men, 7 women; aged 14-70 years, mean 38) underwent surgery by the modified technique and were followed up for 1-14 years. The inclusion criterion for this procedure was pancreatic duct dilated to greater than 7 mm. End-to-side pancreaticojejunostomy was done by fishmouthing the jejunal end to a required length and anastomosing it to the pancreatic duct which is opened along its whole length. The procedure was evaluated in terms of feasibility of anastomosis, time required for surgery, perioperative complications and postoperative results. RESULTS: There were no anastomotic leaks or obstructive bowel symptoms in the immediate postoperative period. Excellent pain relief was seen in 81% of cases, and substantial relief in 12.8%. Average weight gain in the postoperative period was 4.2 Kg. Endoscopic retrograde pancreatography six months after surgery showed patency of anastomosis with free flow of dye into the jejunal loop across the anastomosis. CONCLUSION: The modified Partington's procedure is easy to perform and functions well without any complications. Pain is relieved successfully in a majority of cases.

Biliary sepsis: an ascending infection.

AIM: To study the bacteriology of normal and obstructed biliary tree and determine the mode of biliary infection. METHODS: Fifty seven patients undergoing elective biliary surgery for calculous biliary disease cholecystitis 45, obstructive jaundice 12) were studied. Bile samples collected separately from gall bladder, common bile duct and duodenum at the time of surgery were processed for aerobic and anaerobic cultures and antibiotic assays. To locate endogenous foci of infection, urine, nasal swab and throat swab cultures were done. Isolates from/biliary tract were compared with those from other sites. RESULTS: Thirty eight patients (66.7%) had bactobilia. The prevalence was higher in patients with obstructive jaundice (10/12, 83.3%) than (p = 0.5) in those with non-obstructed biliary tree. Single bacterial infection (31 cases, 81 %) was more common than mixed infection (7 cases, 19%). Colonization of more than one segment of the biliary tree was seen in 30 patients (79%). E coli was the most frequently isolated organism. In 24 cases (63.2%), strains of organisms from the common bile duct and gall bladder were similar to those from the duodenum, and in only 10 cases (23.2%) were similar to those found in the nose, throat and urine. The antibiotic concentrations in the common bile duct after single doses of preoperative antibiotic (gentamicin and cephazolin) were lower in the obstructed biliary tree (1.5 +/- 0.4 milligrams/mL and 2.8 milligrams/mL respectively) than in the non-obstructed system (3.9 +/- 1.7 milligrams and 12.6 milligrams/mL/mL respectively) (p = 0.5 for both antibiotics). CONCLUSION: Ascending infection forms the mode of biliary sepsis in a majority of cases. Prophylactic antibiotics give low levels in the bile in an obstructed biliary tree.

Bleeding ileal schwannoma.

We report a case of ileal schwannoma who presented with bleeding per rectum. Three-vessel angiogram was the only diagnostic investigation, and revealed tumor blush in the mid-ileal region. On exploration, an intraluminal mass was found in the mid-ileal region along with a feeding vessel in the mesentery. Resection of the involved ileum with end-to-end anastomosis was done. Histopathology showed benign schwannoma of ileum involving the submucosa, muscularis propria and serosa.

Laparoscopic versus mini-lap cholecystectomy for gallstone disease.

AIM: To compare the outcome of laparoscopic cholecystectomy (LC) and mini-lap cholecystectomy (MC) in patients with symptomatic gallstone disease. METHOD: One hundred patients undergoing LC (50) or MC (50) were evaluated for duration of surgery, morbidity, need for analgesia, duration of hospitalization and interval to return to normal work. RESULTS: The mean operative time was significantly longer in the LC group (94 +/- 17 vs 129 +/- 33 min; p < 0.05). The rate of morbidity and conversion to open surgery were similar in the two groups. Patients in the MC group required more oral analgesia (p = ns). The mean post-operative hospital stay in this group was 3.3 +/- 1.5 days as compared to 3.3 +/- 2.7 days in the LC group (p = ns). Patients in the LC group took the same time to return to normal work (19.1 +/- 3.2 days) as those in the MC group 19.5 +/- 5.4 days (p = ns). CONCLUSION: MC and LC are comparable procedures for treatment of gallstone disease in our country.

The influence of surgical stress on the psychoneuro-endocrine-immune axis.

Stress is known to depress the immune system severely. This study was done to evaluate whether surgical stress influenced polymorphonuclear (PMN) and monocyte functions in association with serum cortisol and the anxiety score as measured on the HARS Rating Scale. We found that surgery (irrespective of whether it was major or minor) significantly depressed PMN and monocyte functions and increased serum cortisol levels. PMN phagocytosis correlated significantly (p < 0.05) with the rise in serum cortisol. In spite of these changes, postoperative clinical recovery was uneventful. No major alterations in the HARS scores were noted pre and post operatively. This study demonstrates that surgical stress depresses the immune system with a concomitant rise in cortisol.

Lymphangioma of the chest wall.

A lymphangioma of the chest wall, hitherto unreported is described here.

Can we do away with PTBD?

Percutaneous Transhepatic Biliary Drainage (PTBD) is performed in surgical jaundice to decompress the biliary tree and improve hepatic functions. However, the risk of sepsis is high in these patients due to immunosuppression and surgical outcome remains poor. This raises a question--can we do away with PTBD? To answer this query a study was carried out in 4 groups of patients bearing in mind the high incidence of sepsis and our earlier studies, which have demonstrated immunotherapeutic potential of Tinospora cordifolia (TC): (A) those undergoing surgery without PTBD (n = 14), (B) those undergoing surgery after PTBD (n = 13). The mortality was 57.14% in Group A as compared to 61.54% in Group B. Serial estimations of bilirubin levels carried out during the course of drainage (3 Wks) revealed a gradual and significant decrease from 12.52 +/- 8.3 mg% to 5.85 +/- 3.0 mg%. Antipyrine half-life did not change significantly (18.35 +/- 4.2 hrs compared to basal values 21.96 +/- 3.78 hrs). The phagocytic and intracellular killing (ICK) capacities of PMN remained suppressed (Basal: 22.13 +/- 3.68% phago. and 19.1 +/- 4.49% ICK; Post drainage: 20 +/- 8.48% Phago and 11.15 +/- 3.05% ICK). Thus PTBD did not improve the metabolic capacity of the liver and mortality was higher due to sepsis. Group (C) patients received TC during PTBD (n = 16) and Group (D) patients received TC without PTBD (n = 14). A significant improvement in PMN functions occurred by 3 weeks in both groups (30.29 +/- 4.68% phago, 30 +/- 4.84% ICK in Group C and 30.4 +/- 2.99% phago, 27.15 +/- 6.19% ICK in Group D). The mortality in Groups C and D was 25% and 14.2% respectively during the preoperative period. There was no mortality after surgery. It appears from this study that host defenses as reflected by PMN functions play an important role in influencing prognosis. Further decompression of the biliary tree by PTBD seems unwarranted.

Emblica officinalis: a novel therapy for acute pancreatitis--an experimental study.

Acute necrotising pancreatitis is associated with an unacceptably high mortality for which no satisfactory remedy exists. Emblica officinalis (E.o.) is a plant prescribed in Ayurveda, the Indian traditional system of medicine, for pancreas-related disorders. This study was carried out to evaluate the protective effect of E.o. against acute necrotising pancreatitis in dogs. Pancreatitis was induced by injecting a mixture of trypsin, bile and blood into the duodenal opening of the pancreatic duct. Twenty eight dogs were divided into 4 groups (n = 6-8 each): GpI--control, GpII--acute pancreatitis, GpIII--sham-operated, GpIV--pretreatment with 28 mg E.o./kg/day for 15 days before inducing pancreatitis. Serum amylase increased from 541.99 +/- 129.13 IU/ml to 1592.63 +/- 327.83 IU (p <0.02) 2 hrs after the induction of pancreatitis in GpII. The rise in serum amylase in both GpIII and GpIV was not significant. On light microscopic examination, acinar cell damage was less and the total inflammatory score was significantly lower in the E.o. treated group as compared to GpII. Electron microscopy confirmed this and showed an increased amount of smooth endoplasmic reticulum and small, condensed granules embedded in a vacuole. More studies are needed to explore the clinical potential of E.o. and its mechanism of action.

Leiomyosarcoma of the duodenum.

Leiomyosarcoma of the duodenum is a rare tumor. These tumors manifest with unexplained melena, anemia and sometimes partial duodenal obstruction. Diagnosis is difficult on account of inaccessibility for biopsy. Treatment involves excision of the duodenum with reconstruction, a difficult task with high morbidity and mortality. However, if the tumor is successfully treated, its prognosis is usually good because of its non-aggressive nature.

Non-specific granulomatous inflammatory lesions of small bowel.

The entity of nonspecific granulomatous inflammatory lesions(NSGIL) of the small bowel is a diagnostic and therapeutic dilemma. Data of 52 histopathologically proven cases of NSGIL seen by us between 1986 and 1991 were analysed. All these patients presented with either intestinal obstruction or perforation. They were thoroughly evaluated and investigated for tuberculosis. Of the 52 patients, 6 patients received antitubercular therapy (ATT) before and after surgery and 32 patients only after surgery. Fourteen patients did not receive ATT. Surgical procedures undertaken included stricturoplasty, resection/anastomosis and simple suturing of perforation. No complications were seen in patients who received ATT; however, six of 14 patients who did not receive ATT developed wound sepsis and 2 developed partial wound dehiscence. Many of these NSGIL lesions could be tuberculous in etiology though typical caseating granulomas were not seen.