Laparoscopic cholecystectomy in acute gallstone pancreatitis in index hospital admission: feasibility and safety.

BACKGROUND AND OBJECTIVE: Acute gallstone pancreatitis is quite common throughout the globe. Conventionally definitive cholecystectomy has been delayed in index hospital admission. Since the last decade timing of cholecystectomy is gradually shifting towards the earlier phase of disease and currently gallstone pancreatitis is being evaluated as a further indication for laparoscopic cholecystectomy. There is also great concern regarding compliance of patients for definitive surgery due to poverty, ignorance and illiteracy in developing countries. The aim of this study was to assess the feasibility and safety of laparoscopic cholecystectomy as a definitive treatment in patients with mild and resolving gall stone pancreatitis. METHODS: This was a prospective study from July 2009 to June 2012. Patients were diagnosed by clinical examination, biochemical tests, ultrasonography and contrast enhanced CT. Patients with mild form of the disease (Ranson Score ≤3) and who showed clinical improvement were offered laparoscopic cholecystectomy in index hospital admission. Those who were unfit for surgery were referred for endoscopic sphincterotomy. Common bile duct stones were excluded preoperatively. RESULTS: A total of 38 patients were admitted with acute gallstone pancreatitis in the study period. The mean age of patients was 46.3 years with male to female ratio of 11/27. 22 (57.8%) patients were selected for laparoscopic cholecystectomy and procedure was completed successfully. Ten (26.3%) patients were referred for ERCP and endoscopic sphincterotomy and 11 (28.9%) were managed by conservative treatment and went without any definitive treatment. Mean duration of time from onset of symptoms and laparoscopic cholecystectomy was 7 days (range 4-10). Mean duration of operative time was 45 minutes and hospital stay was 7 days. There was no operative mortality. No major intra-operative or post-operative complication was recorded. two patients (9%) had minor complications. CONCLUSION: Laparoscopic cholecystectomy can be safely performed in selected cases of mild gallstone pancreatitis in order to prevent further attacks of acute pancreatitis and other consequences of delayed treatment. Furthermore it resolves the problem of noncompliance of patients in third world countries where many patients are lost for definitive treatment.

The incidence, pattern and outcome of stray bullet injuries. A growing challenge for surgeons.

OBJECTIVE: To study the incidence, pattern of injuries, presentation and management of stray bullet injuries. METHODS: All patients presented and admitted with stray bullet injuries during a period of 4 years from January 2006 to December 2010 were included in this prospective study which was conducted at Liaquat University of Medical and Health Sciences Hospital Hyderabad/Jamshoro. All of the study subjects were admitted through casualty and were initially thoroughly examined and resuscitated. The pattern of injuries was noted and requisite investigations performed. Patients who sustained injuries demanding surgery were prepared accordingly and were submitted for laparotomy or other procedures depending upon the severity of injuries. The data collected on individual basis and variables studied including demographics, pattern of injuries, time since injury occurred and management. RESULTS: A total number of 165 patients with a mean age of 17.1 years, SD 13.807 and range of 74(2-76) presented with stray bullet injuries during study period. The study population comprised 117(70.90%) males and 48(29.09%) females. Majority of the patients were brought late because of delay in diagnosis or delay in transportation. The commonest victims were young children in their teens and comprised 78% of the study population. Haemothorax/ pneumothorax or peritonitis was the common presentations occurring in 11% and 61.81% of the study population respectively. Of the total number, 92 (55.75%) patients underwent laparotomy while remaining patients either had chest intubation or some other procedures done accordingly. Nine (5.45%) patients developed permanent disabilities while 13(7.87%) patients died either immediately after arrival or later on in the hospital during or after the operative treatment. Mortality was related to the time of arrival in hospital since the injury and thus was highest among those brought 4 or more hours after the shot (P<0.001). Patients who did not sustain major injuries were kept under observation and were subsequently discharged. CONCLUSION: Stray bullet injuries are an ever increasing challenge in our society. Unlawful and jubilant use of weapons in celebrations, weddings and similar occasions are causing a lot of morbidity and mortality in the society.

Biliary bypass surgery - Analysis of indications & outcome of different procedures.

OBJECTIVES: This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. METHODS: This is a prospective observational study conducted over a period of 10 years (January 2001-december 2010). A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct (CBD) stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy (both open & laproscopic) during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. RESULTS: Out of 1500 patients 83(5.53%) required biliary bypass surgical procedures. The CBD stones were observed as the most common indication (25.3%), followed by CBD injuries after open(10.84%) or laproscopic-cholecystectomy (14.46%), carcinoma head of pancreas (12.05%) and CBD obstruction(14.46%) either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy (26.51%) was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy (i.e. 25.3% and 12.05% respectively). Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. CONCLUSION: Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases.

Laparoscopic versus inguinal (Ivanissevich) varicocelectomy.

OBJECTIVE: To compare the postsurgical outcome of laparoscopic and open inguinal varicocelectomy. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, from July 2003 to June 2007. METHODOLOGY: One hundred seven patients underwent either open inguinal or laparoscopic varicocelectomy. Diagnosis was made by clinical examination and color Doppler scan in doubtful cases. Pre-operative semen analysis was done in all patients. Operative time, postoperative analgesic requirement in number of tablets, hospital stay in days, improvement in semen parameters in subfertile subjects, pain on visual analog score. and postoperative complications were recorded and compared between the two groups. RESULTS: There were 50 patients in each group, with age ranging from 12-50 years (26.9+/-7.67 in open inguinal and 26.2+/-7.08 in laparoscopic group). Average operative time was 34.8+/-7.89 minutes for open inguinal and 43.8+/-8.95 minutes for laparoscopic group. The analgesic requirement was 16.3+/-1.58 tablets in the open inguinal and 11.3+/-2.23 in the laparoscopic group. Postoperative pain was significantly less in the laparoscopic group. There was statistically significant (p < 0.001) improvement in sperm count as well as motility in both groups irrespective of procedure. CONCLUSION: The open inguinal (Ivanissevich) procedure and laparoscopic varicocelectomy had almost equivalent postoperative outcomes regarding improvement in semen parameters and postoperative complications. Open inguinal procedure had a shorter operating time while laparoscopic varicocelectomy had the advantage of less analgesic requirement and short hospital stay. On the whole, open inguinal (loupe magnified) varicocelectomy is an effective procedure where availability and costs of laparoscopic instruments are barriers.

A comparative analysis between non-mesh (Bassini's) and mesh (Lichtenstein) repair of primary inguinal hernia.

BACKGROUND: The groin hernia repair is one of the common operations in general surgery. The optimum repair method is under debate and the best mode of repair is yet to be decided. This study is conducted to compare the results of open non-mesh (Modified Bassini's) and Lichtenstein's mesh repair of primary inguinal hernia in terms of recurrence, postoperative complications and quality of life in the long-term. METHODS: This retrospective comparative analytical study includes 840 patients of which 40 patients were excluded from the study due to various reasons. The remaining 800 patients with unilateral primary inguinal hernia, above 16 years of age, operated during January 2000 to December 2007 in a teaching hospital are included in the study. Of the total number, 392 patients (49%) underwent Lichtenstein mesh repair, while remaining 408 patients (51%) were operated by modified Bassini's suture technique. Follow up was conducted 1, 5, 8 and 15 days; 1, 2, 6, 24 and 36 months. RESULTS: The recurrence rate and postoperative pain were significantly low in Lichtenstein mesh repair compared to open non-mesh repair by modified Bassini's technique (p < 0.001). Recurrence occurred in 8 (2.0%) out of 392 patients those with Lichtenstein mesh repair. On the other hand 29 (7.1%) patients with Bassini's repair reported recurrence within 3 years time. CONCLUSION: Mesh repair of inguinal hernia is much superior to non-mesh repair in terms of recurrence and postoperative chronic pain.

Early appendicectomy in appendicular mass--a Liaquat University Hospital experience.

OBJECTIVES: Appendicular mass is a well-known complication of acute appendicitis. It is conventionally treated conservatively followed by interval appendectomy. This study aimed to determine the feasibility and safety of an early appendectomy in these cases. STUDY DESIGN: Descriptive and comparative. PLACE AND DURATION: Department of Surgery Liaquat University Hospital, Jamshoro/Hyderabad from March 2003 to December 2007. METHODS: One hundred and seventy six (176) patients with appendicular mass were included in this study. Patients were conveniently divided into two groups, A and B with equal distribution of cases (88 Patients each), regardless of age and sex. Immediate appendicectomy was performed in group A patients after preliminary investigations, where as patients in group B were initially treated conservatively followed by interval appendicectomy. RESULTS: A total 114 (64.8%) males and 62 (35.2%) females with a mean age of 25.09 years (Range 8-44 years) are included in the study population. Post-operative wound sepsis occurred in 17 (19.31%) patients in group A. Treatment failure, patient compliance, re-admission and overall expenses are main limitations in group B population. CONCLUSION: Early appendicectomy is a safe and superior option in patients with appendicular mass compared to conventional treatment.

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OBJECTIVE: To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy. MATERIALS AND METHODS: This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related. RESULTS: The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calot's triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series. CONCLUSION: Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.

Laparoscopic cholecystectomy in the elderly patients. An experience at Liaquat University Hospital Jamshoro.

BACKGROUND: Advancing age with its associated co-morbidities increases the likelihood of postoperative complications as well as conversion rate during laparoscopic cholecystectomy. Recent studies have also questioned efficacy of this procedure in geriatric patients. The present study assesses the safety and applicability of laparoscopic cholecystectomy in geriatric patients. The objective of the present study was to asses safety and applicability of laparoscopic cholecystectomy in the elderly patients of 65 years and above. METHODS: This is a prospective analysis of 173 patients, over 65 years of age, who underwent laparoscopic cholecystectomy from December 2002 to November 2006 at Liaquat University Hospital, Jamshoro. Patients presenting with complicated and uncomplicated gallstone disease were included in the study population and all of them were operated laparoscopically. The data included demographic details, co-morbidities, underlying biliary pathology, indications for surgery, operative and postoperative complications, morbidity and mortality, and hospital stay. The statistical analysis of the data performed on SPSS version 10. RESULTS: Laparoscopic cholecystectomy undertaken in 173 elderly patients with a mean age of 69.72 years, out of whom 52 (30.05%) were males and 121 (69.94%) were females. Co-morbid conditions were identified in 53.17% (n = 92) patients and included hypertension in 38 patients (21.96%), Diabetes Mellitus in 23 patients (13.29%), COPD in 19 (10.98%) patients, Coronary artery disease in 9 (5.20%) and cardiac arrhythmias in 3 (1.73%) patients. Indications for surgery included simple biliary colic in majority of patients (69.94%) and complicated stone disease in 52 (30.05%) subjects. There were 37 (21.38%) emergency laparoscopic cholecystectomies and 136 (78.61%) patients were operated electively. Mean operative time was 100 minutes with a SD 29.03. Fourteen (8.09%) patients required conversion to OC (Open Cholecystectomy) due to various reasons. Mean hospital stay was 6.28 days. Overall 23 (13.29%) patients developed postoperative complications. One patient died of acute MI on 2nd postoperative day. CONCLUSION: There is no undue risk in laparoscopic cholecystectomy in the elderly population and the procedure can be regarded as safe as in patients below 65 years of age.

Laparoscopic cholecystectomy in empyema of gall bladder: An experience at Liaquat University Hospital, Jamshoro, Pakistan.

OBJECTIVE: To find out the safety profile of laparoscopic cholecystectomy in empyema of gallbladder. BACKGROUND: Empyema of gall bladder is a severe form of acute cholecystitis with superadded suppuration. It has been considered a contraindication for the laparoscopic cholecystectomy (LC) because of fear of life-threatening complications. This study aimed to determine the safety and feasibility of LC in empyema of gallbladder. MATERIALS AND METHODS: LC was attempted in 67 patients of empyema of gallbladder within 24h. However in few cases there was a delay because of reluctance for surgery or delay in giving consent etc. The procedure was performed by standard four-port technique with few changes made to facilitate dissection according to situation. RESULTS: Between April 2003 to June 2006, 970 LC performed for gallstone disease at surgical unit-1 of LUMHS by the same surgical team. Among these, 67 (6.90%) patients were diagnosed to have empyema gall bladder. LC successfully completed in 54 (80.59%) patients. In 13 (19.40%) patients the procedure was converted to open cholecystectomy (OC) due to various operative difficulties of which the most serious injuries included bleeding from cystic artery (four cases), common bile duct injury (two cases) and duodenal injury in one case. Maximum operating time was up to 160 minutes (one case). Postoperative complications occurred in 10 (18.51%) successfully operated patients. Maximum patients (n=45, 83.33%) were discharged in 48-96 hours while three patients were discharged after two weeks. CONCLUSION: Laparoscopic cholecystectomy can be performed in empyema of gallbladder keeping in mind a slightly increased risk of complications even in the best hands. However, the experience of the surgeon plays a key role in the overall outcome.

Synchronous bilateral testicular tumors.

Synchronous bilateral testicular tumors are a rare entity. One such case of an elderly male is reported who presented with bilateral painless testicular swellings of 3 months duration. After clinical workup, provisional diagnosis of bilateral testicular tumors was made and bilateral orchidectomy was performed. Histopathology report revealed bilateral seminoma.