A Study on Variations of Branching Pattern of Hepatic Arteries with its Clinical Significance

Background Variation of hepatic artery is very frequent and may predispose the patients to inadvertent injury to the vessels during hepato-billiary surgery. With the advancement of new diagnostic, therapeutic and operative techniques for abdomen, the sound knowledge of variations of hepatic arterial system have become increasingly important for dealing clinicians, surgeons and interventional radiologists. Objective To study the variations of hepatic artery and to evaluate the possible clinical significances. Method A total of 104 images of abdominal computed tomography scans were used for this study. The origin and branching patterns of hepatic artery were recorded. After collecting the data, statistical analysis was done. Result The present study concluded that normal branching pattern of hepatic artery was seen in 86.54% cases, whereas 13.46% cases showed different types of variations. Among them, type II and IV pattern were seen in 0.96% in each, type VI in 1.93%, type VII in 2.87% and the most common variation type IX was seen in 3.85%. There were not a single case of type III, V, VIII and X recorded in this study. Addition to these, one of the variants was common hepatic artery originating from abdominal aorta, was seen in 1.93% of cases while the other variant is unnamed artery arising from superior mesenteric artery, was seen in 0.96% of cases. Conclusion The knowledge of the branching pattern of hepatic artery might be helpful for clinicians to the better understanding of the arterial supply of the liver and may reduce the risk of complications.

Experience with common bile duct exploration at Lumbini Medical College

Common bile duct stones represent a significant danger to patients, because they can lead to biliary colic, obstructive jaundice, cholangitis, or pancreatitis. Common bile duct stones either migrate from the gallbladder or form primarily within the bile ducts themselves. Primary stones are more common in South Asia and are usually sequelae of biliary infection and stasis. In the United States and other Western countries, common bile duct stones are predominantly secondary stones, having formed in the gallbladder. In patients who have gallstones, and in whom a cholecystectomy is considered, common bile duct stones can be found preoperatively, intraoperatively, or postoperatively. Ten percent to 15% of patients undergoing a cholecystectomy will be found to have choledocholithiasis at some point during their treatment. We present our case of 16 patients of common bile duct stones with or without cholelithiasis from April 2011 to March 2012. To review the treatment and outcome of patients with common bile duct (CBD) stones who underwent cholecystecomy with open common bile exploration (CBDE). We analysed the fact that cholecystectomy with commonbile duct exploration still holds as a good modality of treatment where ERCP (Endoscopic Retrograde cholangio pancreaticogram) is not available. All 16 persons in age group of 20-65 years, all females with body weight in the range of 45-60 kgs undergoing inpatient common bile duct exploration during April 2011- March 2012 were included. Common bile duct exploration was successful in all patients. Mean operating time was 120 +/- 40 minutes and length of hospital stay was 13 +/- 3days. 3 complications (18.75%) were recorded, 2 cases of retained stone (12.5%) who underwent choledochoduodenostomy. In 16 patients undergoing common bile duct exploration, CBD stones were discovered with flexible choledochoscope and intraoperative cholangiography. None of the Gallbladder specimen revealed any feature of malignancy in final histopatholgical report. All patients are doing fine till date. Open common bile duct exploration can still be a gold standard technique in set up where ERCP is not available. The results of common bile duct exploration are good with less complications in experienced hands.

Acute appendicitis in elderly patients: a challenge for surgeons

The classic symptoms of acute appendicitis are seldom seen in the elderly patient. More subtle symptoms and the more virulent pathologic course allow the disease to progress rapidly and insidiously. This leads to delayed hospitalization, diagnosis and treatment. The high incidence of concomitant diseases and the multiplicity of differential diagnostic possibilities in this age group are also factors. The aim of this study is to compare the results of appendicitis operated at Lumbini Medical College, Pravas, in patients younger than 60 and patient elder than 60 years of age. All patients aged 60 years and older who underwent appendectomy for appendicitis between January 2008, and December 2011, were studied and compared with the patients who were younger than 60 years of age. All the operations were performed by consultant surgeons at Lumbini Medical College, Pravas, Tansen. Preoperative USG was done in all the cases. Preoperative antibiotics were given in all the cases. All patients underwent appendectomy as an emergency basis. The results were compared with regard to age, sex, pre-operative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. There were 50 patients in group 1 and 150 patients in group 2 who met the inclusion criteria. The mean age (64 years for group 1 and 28 years for group 2), sex, preoperative suggestion of appendicitis (group 1, 35 [70%] of 50 patients; group 2, 135 [90%] of 150 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 1 patients [20%]; group 2, 30 patients [20%]) were similar in both groups. Laparoscopy was used in (group 1, 5 patients [10%]; group 2, 6 patients [4%] and associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time was more in the first group. The mean hospital stay was 5.3 in group 1 and 2.2 in group 2 (p < 0.05). Also duration of Hospital stay was 9.5 days for perforated appendicitis and 5.4 for non perforated appendicitis in both group (p < 0.05). Advanced age adversely affects clinical diagnosis, the stage of the disease and the outcomes. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with poor outcome from surgery.