Anatomical appraisal of safe cholecystectomy: a prospective study.

BACKGROUND: Principles of safe cholecystectomy include dissection of the hepatocystic triangle and identification of the bilio-vascular structures to achieve critical view of safety. The aim of the present study was to document the variations in anatomical landmarks and bilio-vascular structures exposed during laparoscopic cholecystectomy. METHODS: All consecutive patients who underwent laparoscopic cholecystectomy were included in the study. Recommended techniques of safe cholecystectomy were followed. Rouviere's sulcus was classified into four types. Cystic duct was assessed for its length and diameter. A new classification was suggested for cystic artery. RESULTS: Five hundred patients were included in the study. Critical view of safety was achieved in 463 (92.6%) patients. Type1 Rouviere's sulcus was the most common variant found in 263 (52.6%). Normal cystic duct was present in 339 (67.8%). Wide cystic duct of normal length was the most common variant found in 71 (14.2%). Single cystic artery supero-medial to cystic duct (type1-s) was the most common variant found in 384 (76.8%). Inferior cystic artery i.e. artery infero-lateral to cystic duct (type-2) was the second most common variant, found in 40 (8%). Multiple cystic arteries in the hepatocystic triangle were due either to early division of single cystic artery (type-1m) or double cystic artery (type-3). Aberrant right hepatic artery giving off a small cystic artery (type-4) was seen in 12 (2.4%). CONCLUSION: Wide variation in the anatomical structures is noted when principles of safe laparoscopic cholecystectomy is followed. Awareness is paramount to avoid bilio-vascular injury during surgery.

Laparoscopic cholecystectomy for acute cholecystitis: Any time is a good time.

Backgrounds/Aims: Laparoscopic cholecystectomy within one week of acute cholecystitis is considered safe and advantageous. Surgery beyond first week is reserved for non-resolving attack or complications. To compare clinical outcomes of patients undergoing laparoscopic cholecystectomy in the first week and between two to six weeks of an attack of acute cholecystitis. Methods: In an analysis of a prospectively maintained database, all patients who underwent laparoscopic cholecystectomy for acute cholecystitis were divided into two groups: group A, operated within one week; and group B, operated between two to six weeks of an attack. Main variables studied were mean operative time, conversion to open cholecystectomy, morbidity profile, and duration of hospital stay. Results: A total of 116 patients (74 in group A and 42 in group B) were included. Mean interval between onset of symptoms & surgery was five days (range, 1-7 days) in group A and 12 days (range, 8-20 days) in group B. Operative time and incidence of subtotal cholecystectomy were higher in group B (statistically not significant). Mean postoperative stay was 2 days in group A and 3 days in group B. Laparoscopy was converted to open cholecystectomy in two patients in each group. There was no incidence of biliary injury. One patient in group B died during the postoperative period due to continued sepsis and multiorgan failure. Conclusions: In tertiary care setting, with adequate surgical expertise, laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis irrespective of the time of presentation.

Gallstone ileus of upper gastrointestinal tract: A case series.

Three patients with gallstone ileus are presented here. All of them were diagnosed on the basis of clinical presentation, endoscopy, and abdominal ultrasonography (USG) findings. We, therefore, propose that presence of the triad, i.e. cholecystoduodenal fistula on endoscopy, diseased gallbladder on USG, and clinical and radiological features of luminal obstruction should point to the diagnosis of gallstone ileus.

Large Intraperitoneal Loose Body.

We report a large, asymptomatic, intraperitoneal loose body in a 72-year-old male, presented with bilateral inguinal hernia.

The "Christmas Tree" Sign on MR Cholangiogram in Left-Sided Cholangiohepatitis.

We report the "Christmas tree" sign on the magnetic resonance cholangiogram in two patients with left-sided cholangiohepatitis.

Abdominal Cocoon: "Cauliflower Sign" on CT Scan.

A case of an abdominal cocoon that showed a characteristic "cauliflower sign" on CT scan has been presented.

Synchronous adenocarcinoma and neuroendocrine carcinoma of the colon: a case report.

Neuroendocrine tumors (NETs) originating from the gastrointestinal tract are considered to be relatively rare tumors with a poor prognosis. We describe a case of an 83-year-old male who presented with complains of bleeding per rectum. Colonoscopy revealed two ulceroproliferative tumors, one in the sigmoid colon and another in the descending colon. The patient underwent left hemicolectomy. Based on the immunohistochemistry, the sigmoid colon tumor was diagnosed as well-differentiated adenocarcinoma, whereas the descending colon tumor was diagnosed as NET. NET coexisted with adenocarcinoma occurring separately in the same segment of colon, as in the present case, is distinctly rare and has not been reported earlier. The coexistence of the NETs with other primary malignancies has been increasingly recognized. Therefore, we recommend that the patients with the diagnosis of NETs should undergo further screening for the associated primary malignancies to prevent late-stage diagnosis of synchronous malignancies.

Spilled Gallstone: Late Presentation.

Spilled gallstone, in a female patient, presented with an abscess 2 years after laparoscopic cholecystectomy. Computerized tomography scan of the abscess cavity containing the spilled stone that clinched the diagnosis has been presented.

Bouveret's syndrome--an unusual cause of spontaneous resolution of gastric outlet obstruction.

Gastric outlet obstruction due to a gallstone impacted in the duodenal bulb (Bouveret's syndrome) is a rare complication of gallstones. We report a 47-year-old man with this syndrome in whom the impacted stone migrated uneventfully.

Clinical profile of carcinoma stomach at a tertiary care hospital in south India.

Carcinoma of the stomach is an important cause of mortality due to cancer. Carcinoma of the stomach is common in the southern region of India. We conducted a retrospective study on the epidemiological, clinical and survival patterns among the patients with carcinoma of the stomach, attending our hospital from June 19, 1995 to 1st January 2003. All the patients had histopathological confirmation of malignancy. Patients with gastrooesophageal junction lesions were excluded. Surgery was performed with curative as well as palliative intent in suitable patients. Chemotherapy has been incorporated in to the combined modality treatment in our hospital since July 2000. Postoperative chemotherapy comprised commonly used intravenous chemotherapy regimens, while oral chemotherapy (etoposide) was given to patients with disease not amenable to surgery, and those having poor performance and nutritional status. Oral etoposide was given in a dose of 50 mg/day for 14 days, in a 28 day cycle. Quality of life was assessed in the oral chemotherapy group. Out of the 1749 cancer patients seen during the period, 151 had gastric malignancy (8.6%). The median age was 55 years (range 15-84 years). The male to female ratio was 4:1. Adenocarcinoma was found in 148 patients, 2 had stromal tumours and 1 had non-Hodgkin lymphoma. Stage disribution was as follows; stage 2-1 patient , stage 3a-25, stage3b-49, stage4-3 1, Metastatic-28. Staging was not completed in 17 patients. Eighty-nine patients underwent surgery. Fifty-nine patients (39%) did not have surgery. One patient underwent polypectomy. Curative gastrectomy was performed in 11 patients. Thirty-nine patients underwent palliative tumour resection. Palliative gastro-jejunostomy for relief of symptoms was performed in 26 patients and exploratory laparotomy alone was perforaied in 13. Thirty-eight patients received chemotherapy. Out of these, only 2 patients had prior complete resection of the tumour and 36 received palliative chemotherapy. Intravenous chemotherapy was given to 17 patients and oral chemotherapy to 19; All the patients who received oral etoposide did not experience any toxicity. Patients who received intravenous chemotherapy (n=17) had the following toxicities: grade 3 emesis in 4 (20%), discoloration of the skin and nails in 6(31%), alopecia in 8 (50%), grade 3 diarrhoea in 3 (15%) and neutropenic fever in 4 patients (20%). Median survival for the cohort was 10.4 months. Quality of life parameters, such as sleep, appetite, weight, pain, work and general sense of ill health showed improvement. In conclusion, 8.6% of all cancers at our hospital were due to cancer of stomach, in whom distal gastric tumor were more frequent and most were non-resectable. Median survival was 10.4 months. Oral etoposide was found to be safe, improved the quality of life and may play a role in the palliative management of advanced carcinoma of the stomach.