Oriental cholangiohepatitis - is our surgery appropriate?

Oriental cholangiohepatitis, or recurrent pyogenic cholangitis is only noted in certain parts of the world, especially South East Asia. Due to increasing immigration the disease is now being seen in western countries also. Treating physicians may face difficulty in managing such cases due to lack of exposure. Furthermore management of such cases is not standardized because of lack of a universally accepted classification system. Here we review the disease and share our long experience with management of these patients.

Emergency pancreaticoduodenectomy in duodenal paraganglioma: case report.

Duodenal gangliocytic paraganglioma (DGP) is a rare tumor that characteristically occurs in the second part of duodenum. These appear as submucosal masses that protrude into the lumen of a duodenum. Gastrointestinal bleeding is the commonest manifestation of DGP. Metastatic spread to regional lymph nodes occurs rarely. Surgical resection is the treatment of choice for DGP. A case of a DGP is reported in young female who presented with a recurrent upper gastrointestinal bleeding. Upper gastrointestinal endoscopy (UGIE) documented a mass in the ampullary region with ulceration in its middle which was bleeding. Recurrent gastrointestinal bleeding necessitated an emergency pancreaticoduodenectomy. Histopathology of specimen documented gangliocytic paraganglioma.

Closure of the Common Duct -Endonasobiliary Drainage Tubes vs. T Tube: A Comparative Study.

For the last century T tube drainage of the bile duct has remained standard practice following choledochlithotomy. It vents the biliary tree, provides route for cholangiography and management of residual stones. However, T tubes are associated with significant complications. This retrospective study compared the use of Endonasobiliary drainage tubes and the T tube in 66 patients who underwent open choledocholithotomy for effectiveness and complications. Both groups were statistically comparable. Only 15.15% patients in the Endonasobiliary drainage group, while 45.45% patients in the T tube group developed complications. Severe complications such as biliary peritonitis and intraperitoneal collections were noted only in the T tube group. The Endonasobiliary drainage tube was removed significantly earlier and patients from this group were discharged earlier as compared to those in the T tube. The Endonasobiliary drainage tube is as effective as the T tube in postoperative biliary drainage and allows cholangiograms to be performed. Its use is associated with less complications and it can be removed safely earlier than the T tube. Thus patients have a shorter time with tubes and can be discharged home earlier.

Idiopathic massive spontaneous hemothorax: adhesion disruption.

BACKGROUND: Hemothorax has been reported to occur along with spontaneous pneumothorax due to adhesion disruption. Rupture of pleural adhesions spontaneously or after unnoticeable trivial trauma causing massive hemothorax alone is rare. METHODS: We present a series of seven cases of idiopathic massive spontaneous hemothorax due to adhesion disruption, of which all required emergency thoracotomy with ligation or cauterization of bleeding adhesions. RESULTS: Six patients had bleeding pleural lung adhesions of which five involved the upper lobes. Another had bleeding from pleuropericardial adhesions. All patients are doing well on follow-up. CONCLUSIONS: Disruption of pleural adhesions may cause massive hemothorax, requiring early surgical intervention. After thoracotomy the outcome in these patients is excellent.

Is any surgical procedure ideal for chronic pancreatitis?

Chronic pancreatitis continues to be a major therapeutic challenge for all pancreatic surgeons. This article is written with a purpose to review various surgical procedures developed from time to time for the relief of pain in these patients. Since no single procedure can be labeled as "ideal" because of the problems of the inability to address the whole pathology at the initial procedure, failure or recurrence of the pain; most of the pancreatic and practicing surgeons may benefit from knowledge of the various procedures being performed, even though the personal experience of the surgeon most of the time ultimately dictates the final choice of the procedure for the patient.

Nontraumatic terminal ileal perforation.

BACKGROUND: There is still confusion and controversy over the diagnosis and optimal surgical treatment of non traumatic terminal ileal perforation-a cause of obscure peritonitis. METHODS: This study was a prospective study aimed at evaluating the clinical profile, etiology and optimal surgical management of patients with nontraumatic terminal ileal perforation. RESULTS: There were 79 cases of nontraumatic terminal ileal perforation; the causes for perforation were enteric fever(62%), nonspecific inflammation(26%), obstruction(6%), tuberculosis(4%) and radiation enteritis (1%). Simple closure of the perforation (49%) and end to side ileotransverse anastomosis(42%) were the mainstay of the surgical management. CONCLUSION: Terminal ileal perforation should be suspected in all cases of peritonitis especially in developing countries and surgical treatment should be optimized taking various accounts like etiology, delay in surgery and operative findings into consideration to reduce the incidence of deadly complications like fecal fistula.

Primary closure of the common duct over endonasobiliary drainage tubes.

The T-tube remains the standard method of intraductal drainage after open choledochotomy for choledocholithiasis. We studied the use of an endonasobiliary drainage (ENBD) tube as an alternative to the T-tube for postoperative intraductal drainage. A series of 20 patients with documented choledocholithiasis in whom endoscopic methods of stone retrieval failed to clear the common bile duct (CBD) were selected for the study. All patients had ENBD tubes placed preoperatively at endoscopic retrograde cholangiopancreaticography and then were subjected to open choledocholithotomy with primary closure of the choledochotomy over the ENBD. The age of the patients in the study group ranged from 18 to 75 years. Three patients (15%) had acute cholangitis at the time of surgery. Stones were confirmed at surgery in 85% of the patients, and the size of the CBD was found to range from 1.0 to 2.3 cm. All 20 patients underwent closure of the common duct over an ENBD tube without any difficulty. None of the patients experienced biliary complications such as bile leaks, biliary peritonitis, biliary fistula, pancreatitis, or cholangitis. No patient had any residual stone as documented by postoperative cholangiograms. Abdominal drains remained in place for 2 to 4 days, and the ENBD tubes were removed between days 6 and 8. The length of the postoperative hospital stay varied from 7 to 15 days, with 65% of the patients going home before postoperative day 8.