Spontaneous Free Peritoneal Perforation of an Infected Pancreatic Fluid Collection Managed with Laparoscopic Drainage and Necrosectomy.

INTRODUCTION: Free peritoneal perforation of pancreatic fluid collections is extremely rare and only few case reports exist in the literature. Many of these patients undergo emergency exploratory laparotomy due to sepsis and haemodynamic instability requiring sepsis control. The use of laparoscopic techniques in this circumstance is limited by the haemodynamic stability of the patient and the technical challenges. But effective laparoscopic management is associated with less morbidity to the patient. Case Presentation. A 28-year-old patient presented with worsening generalized abdominal pain with increased inflammatory markers. She required persistent inotropic support despite adequate fluid resuscitation. She had transient acute renal impairment and acute respiratory distress, which improved with noninvasive support. CECT (contrast-enhanced computed tomography) showed an infected pancreatic fluid collection with peritoneal free fluid. Aspiration of pelvic collection showed purulent fluid. Based on these clinical and imaging findings, she was diagnosed with a free peritoneal perforation of an infected pancreatic fluid collection. She underwent a laparoscopic drainage and necrosectomy of the infected pancreatic collection and peritoneal washout. She had a gradual recovery. All inotropes were omitted on the second day following surgery. She was sent to the ward from the ICU (intensive care unit) on the 4th postoperative day. CONCLUSION: The laparoscopic approach is a viable option in managing ruptured pancreatic fluid collections when patient and technical factors are supportive. It reduces surgical morbidity, thereby reducing the overall strain on physiological reserves. When opted for laparoscopic drainage, the procedure must be guided by imaging findings. Multidisciplinary participation is critical in the overall management.

Laparoscopic Bilateral Adrenalectomy in a Young Female Patient with Recurrent Cushing's Disease.

INTRODUCTION: Synchronous bilateral adrenalectomy is undertaken less often due to numerous perioperative challenges and rare circumstances of patients needing this procedure. Bilateral adrenalectomy is an important second-line option for patients with persistent or recurrent hypercortisolism following transsphenoidal surgery for Cushing's disease. Here, we present a challenging case of synchronous laparoscopic bilateral adrenalectomy for a young female patient with recurrent Cushing's disease and fertility wishes. Case Presentation. A 21-year-old recently married patient who was diagnosed with Cushing's disease with a pituitary microadenoma had undergone two attempts of transsphenoidal excision of the pituitary tumour. Follow-up evaluation showed an unresectable residual tumour with invasion of the intracavernous part of the left internal carotid artery. As the patient had the hypothalamic-pituitary-ovarian axis intact with strong fertility wishes, she was offered bilateral adrenalectomy instead of radiotherapy. She was prepared for the surgery with close perioperative support from the endocrinology and anaesthesia teams. Intravenous hydrocortisone infusion was started at the induction of anaesthesia. Transperitoneal approach was used with the patient positioned in left and right lateral positions for right and left glands, respectively. A meticulous surgical technique was used for the identification of adrenal veins to clip them before division followed by handling of the glands. The patient had minimal haemodynamic disturbances during surgery. Intraoperative blood loss was less than 100 ml, and operative time was 220 minutes. She had a gradual recovery following postoperative respiratory distress due to basal atelectasis and consolidation. Cortisol levels were less than 20 nmol/L postoperatively, suggesting successful surgical intervention. Two months after surgery, she continued on maintenance therapy of oral hydrocortisone and fludrocortisone and was encouraged to go ahead with pregnancy. CONCLUSION: Although bilateral adrenalectomy is considered a high-risk procedure, these risks can be mitigated and performed safely while maintaining close multidisciplinary perioperative support.

Epidemiology and clinical course of inflammatory bowel disease in the Central Province of Sri Lanka: A hospital-based study.

BACKGROUND AND AIM: There is increasing prevalence of inflammatory bowel disease (IBD) in Asia, but Sri Lankan data on the state of epidemiology and clinical course of IBD are scarce. METHODS: A hospital-based study was done by recruiting IBD patients who permanently reside in the Central Province (population 2.57 million, 12.6% of Sri Lankan population) of Sri Lanka. Cases were confirmed by standard criteria and data were collected from health records and patient interviews at clinic visits and hospital admissions. RESULTS: There were 200 cases of IBD; (ulcerative colitis [UC]-140, Crohn's disease [CD]-60, microscopic colitis-7). The crude prevalence rate of UC was 5.44/100 000 (95% CI 5.41-5.47/100 000) and CD was 2.33/100 000 (95% CI 2.31-2.35/100 000). Female to male ratios were 1:0.8 for UC but 1:1.5 for CD.Mean age at diagnosis was 42.0 and 31.9 years for UC and CD, respectively. One UC and one CD patient had positive family history of IBD. Among the UC patients, 60.7%, 24.3%, and 15% had proctitis, left sided, and extensive disease, respectively. At presentation, 62.1% of the UC patients have had moderately severe disease. 60% of the CD patients had only large bowel involvement and 80% had nonstricturing and nonpenetrating disease. Extra intestinal manifestations were present in 45.7% and 60.0% of UC and CD patients, respectively, in which peripheral arthralgia and arthritis being the commonest. 6.4% of UC and 23.3% of the CD patients (total of 23) required infliximab for induction of remission. CONCLUSION: The prevalence of IBD in the Central Province of Sri Lanka is lower than other Asian and Western populations. There is a predominance of male gender and isolated colonic disease in CD patients. UC patients have an equal gender distribution and a higher proportion of proctitis. CD needed induction with infliximab than UC.

Laparoscopic Resection of Pancreatic Tail Solid Pseudopapillary Tumour in a Young Male.

Background. Solid Pseudopapillary Tumours of the pancreas are a rare entity and more commonly seen in women than in men. These tumours have typically reached large sizes when clinically detected. Case Description. A 21-year-old male was found to have a left hypochondrial mass on physical examination following a trivial soft tissue injury. Contrast-enhanced computed topography (CT) of the abdomen showed a 10.3 × 7.6 × 10.3 cm size arising from the body and the tail of the pancreas. He underwent laparoscopic resection of distal pancreatic tumour en bloc with spleen. Large tumour was noted originating from the body and tail of the pancreas with dilated veins surrounding the tumour. Histology revealed a clear cell variant of solid pseudopapillary neoplasm with steatotic pattern. Resection margin was free of tumour. Discussion. Several studies have shown significant short term advantages using laparoscopic approach compared to open surgery, in terms of lower blood loss, resumption of oral intake, and hospital stay. This case and few other case reports published in world literature have shown that laparoscopic approach is safe and oncologically adequate.

Pattern of clinical benign euthyroid goitre in a tertiary care center in the Central Province of Sri Lanka from 1981-2011

Objectives: To describe the pattern of clinical euthyroidgoitre in a tertiary care unit in Sri Lanka before and after iodination of salt in Sri Lanka. Methods: We reviewed our thirty-one year computerised database of patients with goitres, spanning iodination in 1995. Results: Prevalence of euthyroid clinical simple diffuse goitre did not reduce during the first thirteen years (p=0.822). However, it reduced in the latter four years from 2008 to 2011. There is significant reduction of prevalence in the younger age groups (p<0.001). A significant reduction of nodular change was observed in all groups within seven years after iodination (p<0.001). Conclusions: There was a significant reduction in the prevalence of clinical nodularity in the post-iodination era in all age groups. Reduction in prevalence of clinical euthyroid simple diffuse goitre was observed only during the period 2008-2011.

A low cost rapid urease test to detect Helicobacter pylori infection in resource limited settings.

The aim of the study was to evaluate the suitability of a modified one minute rapid urease test (one day rapid urease test) as a low cost H. pylori detection method. A sample of 205 patients clinically suspected of having H. pylori infection was tested. One day rapid urease test and histology based H. pylori tests (the gold standard) were performed on endoscopic antral biopsies. There were 6 true positives, 191 true negatives, 8 false positives and zero false negatives. The sensitivity, specificity and positive (PPV) and negative predictive values (NPV) of the test were 100%, 96%, 42.9%, and 100% respectively. The cost per patient was 0.3US$. High sensitivity, specificity and NPV, low cost and simplicity of method were the advantages of the test and the main limitation was low PPV. Hence, one day rapid urease test can be considered as a suitable low cost method to detect H. pylori infection in resource limited settings.

Prevalence of Helicobacter pylori in benign gastric ulcers in a cohort of Sri Lankan patients.

Helicobacter pylori prevalence is decreasing globally and prevalence of non H. pylori gastric ulcers is increasing. The following study was conducted to assess the prevalence of H. pylori in benign gastric ulcers in a sample of Sri Lankan patients. This was a cross-sectional study of 59 dyspeptic patients with benign gastric ulcers. Multiple endoscopic gastric biopsies were obtained and histology, immunohistochemistry and polymerase chain reaction were performed for H. pylori detection. An immunochromatography assay was performed to detect blood anti H. pylori antibodies. Four (6.8%) were positive for H. pylori. Therefore, it is likely that most benign gastric ulcers are of non-H. pylori aetiology.