Endoscopic Sphincterotomy for Cholecysto-Choledocholithiasis Complicates Subsequent Laparoscopic Cholecystectomy: A Retrospective Report From Sri Lanka.

OBJECTIVE: Published literature so far has supported the fact that patients who underwent endoscopic retrograde cholangio-pancreatography and sphincterotomy (ERCPS) had a difficult perioperative course after subsequent laparoscopic cholecystectomy. Through a retrospective study, this original report mentions statistics in a Southeast Asian population comparing the effect on conversion to open surgery in patients undergoing laparoscopic cholecystectomy after ERCPS in a university hospital in Sri Lanka. METHODS: The results of 205 patients who underwent laparoscopic cholecystectomy and 85 patients who were converted to open surgery between 2016 and 2018 were analyzed to find out whether ERCPS is a risk factor for conversion or subsequent perioperative morbidity. RESULTS: Demographics like age, gender and previous abdominal surgeries were comparable between the two groups. Cholecysto-choledocholithiasis and undergoing ERCPS for it were significant factors associated with conversion to open cholecystectomy. CONCLUSION: Performing laparoscopic cholecystectomy after ERCPS for cholecysto-choledocholithiasis is a significant challenge and preferably should be often handled by a more experienced surgeon.

Hospital-Based Case Series Analysis of Road Traffic Trauma Patients in Sri Lanka.

Road traffic accidents claim many lives each year worldwide and cause significant disability among survivors. Resulting socioeconomic burden is severe in low- and middle-income countries. Global emphasis currently focuses on trauma education and prevention in addition to improving post-injury care. Sri Lankan government recently made compulsory legislation to improve the safety standards of imported motor vehicles. Such regulations would not directly protect vulnerable road users (VRUs) who form the main bulk of Sri Lankan and South Asian automobile trauma casualties. With the objective of reviewing the management outcome of automobile trauma in order to correlate the potential impact of new legislation on injury prevention, data of all admitted road traffic injury victims were audited for 2 months. Out of 473 eligible cases (332 (70.2%)-males; mean age 37.2 years), there were 14 (3%) fatalities. Of 459 (97%) survivors, 77 (16%) suffered major injuries. Twelve out of 14 (85.7%) fatalities, 64 of 77 (83.1%) survivors with major injuries and 263 of 382 (68.8%) cases of lesser injuries were VRUs (p value = 0.02: chi-square). VRUs had a significantly higher mean Injury Severity Score (ISS) of 10.96 ± 8.43 SD than non-VRUs who had a mean ISS of 8.14 ± 6.04 SD (p = 0.003: t test). Among all survivors, 33/39 (84.6%) with permanent disability, 95/110 (86.4%) with temporary disability and 199/310 (64.2%) with no residual disability were VRUs (p value < 0.0001: chi-square). Of 222 drivers/riders, 45 (20.3%) had consumed alcohol prior to the incident and 20 (9%) were driving without a valid licence. Thirty-four out of 162 (21%) motor bike travellers were not wearing a protecting helmet. Results denote that VRUs suffer significant majority of the fatalities and major injuries after road traffic trauma and to have higher residual temporary/permanent disability among survivors. Recent compulsory motor vehicle safety measures are unlikely to directly protect majority of automobile trauma victims in Sri Lanka. To obtain a higher impact on road traffic injury prevention, main emphasis has to be given to improve the safety standards of VRUs in developing countries.

Extra-ampullary Peutz-Jeghers polyp causing duodenal intussusception leading to biliary obstruction: a case report.

BACKGROUND: Duodenal Peutz-Jeghers polyp is a rare cause of duodenal or biliary obstruction. However, a sporadic Peutz-Jeghers polyp leading to simultaneous biliary and duodenal obstruction has not been reported. CASE PRESENTATION: We report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical "Peutz-Jeghers polyp". As there was not enough evidence to diagnose Peutz-Jeghers syndrome this was considered to be a sporadic Peutz-Jeghers polyp. CONCLUSION: Rare benign causes such as a duodenal polyp should be considered and looked for in initial imaging, when the cause for concurrent biliary and intestinal obstruction is uncertain, particularly in young individuals.

Management and outcome of residual bile duct stones following cholecystectomy at a tertiary referral centre in Sri Lanka.

BACKGROUND: In spite of the advent of pre- and per-operative imaging techniques, the problem of residual bile duct stones following laparoscopic or open cholecystectomy still exists with a reported frequency of 2-10%. Endoscopic stone extraction is a minimally invasive technique which is fast becoming popular in the management of residual ductal stones. OBJECTIVE: To review the experience in our unit with regard to clinical presentation and the outcome following endoscopic management of residual bile duct stones. DESIGN: Retrospective descriptive study. SETTING: Patients referred to a tertiary referral centre with suspected residual bile duct stones following open or laparoscopic cholecystectomy from 5 March 2002 to 31 December 2006. PATIENTS AND METHOD: 56 patients with suspected residual bile duct stones were reviewed with regard to clinical presentation, stone profile, success rate and outcome. RESULTS: Mean age of the sample was 43.2 years. Female to male ratio was 34/22. 4 (73.3%). Main presenting symptom was epigastric or right hypochondrial pain (39.2%). Presence of residual stones or gravel noted in 91% (51) during ERCP. Complete stone extraction was achieved in 83.9% (47). All these patients became completely asymptomatic. Four patients had ERCP related morbidity. There were no deaths. Longest follow up was 38 months and the shortest 1.5 months. CONCLUSIONS: Endoscopic approach is a safe and effective method in the diagnosis and treatment of residual bile duct stones.