Composition of gallbladder bile in healthy individuals and patients with gallstone disease from north and South India.

BACKGROUND: Gallstones (GS) in south India (SI) are predominantly pure pigment or mixed, while in North India (NI), these are either pure cholesterol or mixed. While cholesterol rich gallbladder (GB) bile predicts cholesterol GS, constituent of bile in primary pigment GS is not known. We compared the composition of GB bile from healthy liver donors and patients with GS from north and south India. METHODS: Gallbladder bile from healthy liver donors from north (10) and south India (8) served as controls. Cases were patients from north (21) and south India (17) who underwent cholecystectomy for GS disease. Gallbladder bile from both cases and controls was analyzed for cholesterol, lecithin (phospholipid), and bile salts. Gallstones were classified as cholesterol, mixed, and pigment based on morphology and biochemical analysis. RESULTS: The median cholesterol concentration in control bile from north was significantly high compared to south (p<0.001) with no difference in lecithin and bile salts (p NS). Except for one sample each from north and south, the cholesterol solubility of controls was within the critical micellar zone. Mixed GS were most frequent in north India (61.9 %) while pigment GS dominated in south (61.9 %). The median cholesterol concentration in bile samples of cholecystectomy patients from north India was significantly high GS (p < 0.00001) with significant lowering of bile salts and lecithin (p < 0.00001). In south India, patients with mixed GS had high cholesterol content in bile compared to controls and patients with pigment GS; bile in latter had significantly higher concentration of bile salt compared to controls and mixed GS. The ternary plot confirmed the composition of GB bile from north and south India. CONCLUSIONS: Gallbladder bile in controls and patients with GS from north India had significantly high cholesterol concentration. In south India, patients with mixed GS had cholesterol rich bile while pigment GS had higher concentrations of bile salts.

Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India.

BACKGROUND: Bariatric surgeries are now redefined as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. Duodenojejunal bypass (DJB) is a novel metabolic surgery based on foregut hypothesis. Reports describe DJB as a stand-alone procedure for the treatment of diabetes in nonobese subjects. For obese subjects, DJB is combined with sleeve gastrectomy. This combination of DJB and sleeve gastrectomy is proposed as an ideal alternative to Roux-en-Y gastric bypass (RYGB) with these advantages: (1) easy postoperative endoscopic surveillance, (2) preservation of the pyloric mechanism, which prevents dumping syndrome, and (3) reduced alimentary limb tension. This study aimed to analyze the short-term outcomes of laparoscopic DJB with sleeve gastrectomy for morbidly obese patients. METHODS: At our institution, 38 patients who underwent laparoscopic DJB with sleeve gastrectomy were followed up. The inclusion criteria for the study were according to the Asian Pacific Bariatric Surgery Society guidelines. Sleeve gastrectomy was performed over a 36-Fr bougie, with the first part of the duodenum mobilized and transected. The jejunum was divided 50 cm distal to duodenojejunal flexure. A 75- to 150-cm alimentary limb was fashioned and brought in a retrocolic manner. End-to-end hand-sewn duodenojejunostomy was performed. Intestinal continuity was restored with a stapled jejunojejunostomy, and mesenteric rents were closed. RESULTS: The study population consisted of 38 patients (15 men and 23 women) ranging in age from 31 to 48 years. During a mean follow-up period of 17 months, the excess body weight loss was 72%, with a 92% resolution of diabetes. One patient presented with internal herniation through the retrocolic window 1 month after the operation and was managed surgically without any complication. No other minor or major complications occurred, and there was no mortality. CONCLUSION: Laparoscopic DJB with sleeve gastrectomy is safe and effective in achieving durable weight loss and excellent resolution of comorbidities. Long-term follow-up studies are needed.

Laparoendoscopic single-site lateral pancreaticojejunostomy.

BACKGROUND: Chronic pancreatitis is mainly managed with drugs, but surgery is required in selected groups of patients. The Partington procedure is still the procedure of choice for patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass. The same equivalent can be achieved by laparoscopic approach. Laparoendoscopic single-site surgery gained tremendous attention in the past few years. Complex surgeries are being reported using this technique. We report in this paper the first laparoendoscopic single-site lateral pancreaticojejunostomy (LPJ) for chronic calcific pancreatitis with dilated pancreatic duct. PATIENT AND METHOD: The procedure was performed on a 32-year-old female diagnosed to have chronic calcific pancreatitis. A single vertical 2.5-cm umbilical incision and one 10-mm and two 5-mm ports were made. The procedure was completed in 220 min without any intraoperative complication. There were no postoperative complications, and the patient was discharged on day 5 when she started taking routine diet. CONCLUSION: This preliminary experience suggests that single-incision laparoscopic LPJ is feasible and safe when performed by an experienced laparoscopic surgeon. It has a cosmetic advantage over laparoscopic LPJ. However, it remains to be determined if this technique offers additional advantages of decreased analgesia, decreased hospital stay or cost effectiveness. Further studies are required to analyze these factors.

Minimally invasive oesophagectomy for carcinoma oesophagus--approaches and options in a high volume tertiary centre.

Minimally invasive oesophagectomy is being increasingly performed for treatment of carcinoma oesophagus. In this article, we overview the different types of minimally invasive oesophagectomies we used in our experience. To present an overview of the different types of minimally invasive oesophagectomies used to treat carcinoma oesophagus and to propose a simple working algorithm for surgical management of carcinoma oesophagus, a retrospective review of patients with carcinoma oesophagus who were operated at this centre during the period 1997-2009 was made. Data regarding type of surgery, level of growth, type of carcinoma, and complications were reviewed. A total of 463 patients underwent minimally invasive oesophagectomy for carcinoma oesophagus. Of these, 121 patients (26%) were female. There were no conversions. The mean age of patients was 61.6 years (range 36 years-77 years). Most patients (n = 330; 71%) had squamous cell carcinoma while 133 patients (29%) had adenocarcinoma. Overall mortality was 0.9%. Overall morbidity was 16%. Minimally invasive approaches to oesophagectomy are safe and the type of approach has to be tailored for the histology, level and stage of growth.

Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center.

BACKGROUND: Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years. METHODS: Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed. RESULTS: There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22). CONCLUSION: Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.

Effect of early enteral feeding after upper gastrointestinal surgery.

BACKGROUND AND AIMS: The impact of early enteral nutrition in elective upper gastrointestinal surgery was the focus of this study, with particular reference to its feasibility and benefits. METHOD: This prospective study was carried out over 2 years. The study group included 30 patients and the control group had 31patients. Twenty-two patients in each group underwent truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer and gastric outlet obstruction. Eight patients in the study group and nine in the control group underwent gastrectomy for carcinoma stomach. A standard milk-based diet was initiated 12 hours after surgery through a nasojejunal tube. The patients were monitored for side effects of enteral feeding and postoperative infective complications. Nitrogen balance and nutritional parameters like the body weight, serum albumin, and serum transferrin were measured pre and postoperatively. RESULTS: The groups were comparable with respect to age, sex, and preoperative nutritional factors like body weight, serum albumin, and serum transferrin. The return of bowel sounds and passage of flatus took place significantly earlier in the study group (1.43 vs. 2.81 days). Diarrhoea and abdominal cramps were the significant complications noted in the study group in relation to early enteral feeding. No patient required withdrawal of enteral feeds. They showed a positive nitrogen balance on the fourth postoperative day. The patients in the study group showed significant increase in the serum transferrin level compared with the preoperative level but the serum albumin level was not significantly altered. CONCLUSION: Early enteral feeding through the nasojejunal tube following elective upper gastrointestinal surgery is feasible, safe and improves the nutritional status.

Postoperative intussusception in the adult: a case report.

We report the case of a 40-year-old man who presented with a history of sudden onset abdominal pain and obstipation of 1 day's duration. During laparatomy, a 5mm perforation was seen in the anterior wall of the first part of the duodenum, which was closed by a Graham patch and the abdomen was closed after peritoneal lavage. Postoperatively, the patient's condition worsened and he was posted for a laparatomy with a diagnosis of postoperative obstruction. During the laparatomy, an ileocolic was seen which could be easily reduced. After the second surgery, the patient made an uneventful recover.