Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre.

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2 weeks of cholecystectomy and group C-patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

'Single-Sitting' Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stone for Cholelithiasis and Choledocholithiasis: a Feasibility Study.

'Single-sitting' laparoscopic cholecystectomy followed by endoscopic common bile duct clearance is emerging as a viable option for management of cholelithiasis and concomitant choledocholithiasis. The only disadvantage of the procedure is logistical since it requires co-ordination between two teams-the surgeons and the endoscopists. This limitation can be overcome in centres where both the procedures are performed by one team. With a considerable experience in endoscopy, we conducted a prospective study in a select group of patients to assess the feasibility of this single-sitting approach. The study included 38 patients with a radiological diagnosis of choledocholithiasis or jaundice at presentation. After laparoscopic cholecystectomy, the patients were turned prone and subjected to endoscopic retrograde cholangiogram, sphincterotomy and extraction of the common bile duct stone. The procedure was successful in 33 (87 %) of patients. The mean procedure time and hospital stay were 2 h, 20 min and 2 days, respectively. None of the patients had any major complications. We conclude that in a select group of patients, single-sitting laparoscopic cholecystectomy followed by endoscopic clearance of the common bile duct stone is safe and effective.

Imaging findings in agenesis of the dorsal pancreas. Report of three cases.

CONTEXT: Agenesis of the dorsal pancreas is rare. The dorsal pancreatic agenesis is described in two forms, the partial and the complete form. PATIENTS: with this anomaly may be asymptomatic or may present with diabetes mellitus, epigastric pain, acute or chronic pancreatitis. CASE REPORT: We report the computed tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) findings in three cases with dorsal pancreatic agenesis, one with partial and the other two with complete form. Speckled calcification at pancreatic head was observed in one patient. Lateral contour lobulation of pancreatic head which is seen in one third of normal population is believed to be due to variation in fusion between ventral and dorsal pancreas. In contrast, we observed lateral contour lobulation of pancreatic head in a case of complete agenesis of the dorsal pancreas where structures derived from dorsal pancreas are undeveloped. The ventral and dorsal pancreatic duct lengths were measured on MRCP images and we observed that in partial agenesis, the duct of Wirsung was shorter in length, compared to the duct of Santorini. The duct of Wirsung was relatively longer in cases of complete agenesis of the dorsal pancreas. CONCLUSION: The CT, MRI and MRCP findings in dorsal pancreatic agenesis and the relationship between the length of ventral duct with the type of dorsal pancreatic agenesis will provide a new insight into this particular anomaly.

A rare presentation of mass abdomen.

An elderly male who had undergone inguinal hernia surgery eight years back presented with an intra-abdominal mass. Clinically and radiologically it was diagnosed as mesenteric cyst. Laparotomy revealed a thick walled cyst embedded in the omentum, containing brownish necrotic material and few 'linen thread knots'. On the basis of the latter finding the mass was thought to be a walled off hematoma, a complication of previous hernia surgery. Such a complication of inguinal surgery has not been reported earlier.

Biliary ascariasis--role of endoscopic intervention.

AIM: This study was undertaken to review the predisposing factors, presentation and management of patients diagnosed with biliary ascariasis while specifically emphasizing the role played by endoscopy. METHODS: We performed a retrospective analysis of nine patients diagnosed and admitted with biliary ascariasis at our center. The diagnosis was based on ultrasound findings and confirmed by detection of round worms in the biliary tract or the descending duodenum. The clinical presentation and management were reviewed. RESULTS: Five of the nine patients had prior biliary sphincter ablative/bypass procedures for choledocholithiasis; including endoscopic sphincterotomy in four and lateral choledochoduodenostomy in one patient. All but one patient presented with acute onset pain abdomen radiating to the back. One patient presented with features of acute cholecystitis. Ultrasound detected the presence of round worms in all the patients. Endoscopic retrograde cholangio-pancreatogram confirmed presence of worm in the biliary tree. Endoscopic extraction of the worm from the biliary tree or duodenum was successfully undertaken in all the patients and provided prompt relief. One patient had recurrence of infection after eight months which was re-treated by endoscopic extraction. Antihelminthics were instituted in all patients. CONCLUSION: Biliary ascariasis, should be considered in the differential diagnosis of acute abdomen, particularly in patients who have undergone prior biliary sphincter ablation/bypass procedures like sphincterotomy or choledochoduodenostomy. Ultrasonography is a reliable diagnostic modality. Endoscopic retrograde cholangiogram confirms the diagnosis and precedes endoscopic extraction of the worm. This offers prompt relief from symptoms.

Mirizzi syndrome.

Mirizzi syndrome is a complication of long standing cholelithiasis. In this, obstruction of the extrahepatic bile duct by stone/s in the Hartman's pouch or cystic duct (Mirrizi type I) may erode in to the bile duct forming cholecystobiliary fistula (Mirrizi type II). Altered biliary tract anatomy and the associated pathology make cholecystectomy, open or laparoscopic, a formidable undertaking. Awareness of this entity and its preoperative diagnosis is of paramount importance to avoid injury to the bile duct at surgery. Improper surgical procedures may lead to long-term stricture formation. The present article reviews the available literature on various aspect of this syndrome including its pathogenesis, diagnosis and recommended management guidelines.

Acute mesenteric venous thrombosis complicating endoscopic variceal sclerotherapy with absolute alcohol.

We report two patients, one with liver cirrhosis and another with extrahepatic portal vein obstruction, who developed acute mesenteric vein thrombosis following endoscopic variceal sclerotherapy with absolute alcohol. Both patients recovered after emergency laparotomy and resection of gangrenous bowel loop.

Abdominal tuberculosis: diagnosis by laparoscopy and colonoscopy.

BACKGROUND: Histopathological confirmation in abdominal tuberculosis is difficult due to suboptimal noninvasive access to the involved area. Peritoneoscopy and colonoscopy provide semi-invasive access to the peritoneum, large intestine and ileocecal area. Information on the diagnostic yield of these two investigation in abdominal tuberculosis is scarce. OBJECTIVE: To evaluate the role of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis. PATIENTS AND METHODS: Between January 1998 and July 2001, 34 patients were diagnosed to have abdominal tuberculosis on the basis of laparoscopy or colonoscopy. The case records of these patients were retrospectively reviewed to assess the usefulness of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis. RESULTS: Laparoscopy was performed in 23 patients. Peritoneal tuberculosis was diagnosed in 19 of them, characterized by presence of ascites, multiple whitish tubercles, fibrous bands and adhesions, hyperaemic edematous bowel loops or dense adhesions without ascites. Multiple jejunoileal hyperemic short segments with serosal neovascularization was noticed in three patients. One patient had cecal mass with pericecal inflammatory adhesions. In three patients, laparoscopy was converted to open laparotomy due to bowel injury, extensive adhesions, and difficulty in assessing lymph nodal mass in one patient each. Peritoneal biopsy confirmed the diagnosis in 10 of the 15 (67%) patients. In one patient pericecal tissue biopsy confirmed the diagnosis. The remaining patients received therapeutic trial with anti tuberculosis treatment. All patients showed good response. Thus laparoscopy provided positive diagnosis of tuberculosis in 20/23 (87%) and positive histology in 10 of the 15 (67%) patients with peritoneal lesions. Thirteen patients underwent colonoscopy. Mucosal lesions involving terminal ileum, cecum and colon was noted in 11 patients. Colonoscopic biopsy confirmed the diagnosis in six of the 11 patients (54%). Non of these patients had any complication related to colonoscopy. CONCLUSION: Laparoscopy was safe and helped in the diagnosis of peritoneal as well as intestinal tuberculosis in 87% of patients. Colonoscopy is useful for colonic and terminal ileal lesion with a positive diagnostic yield of 54%.