Biliary mishaps in laparoscopic cholecystectomy

AIM

To determine the incidence and types of biliary complications following laparoscopic cholecystectomy in our patients.

METHODS

The clinical records of one hundred and fifty-five patients undergoing laparoscopic cholecystectomy were reviewed.

RESULTS

Five patients developed biliary mishaps. The overall incidence of biliary complications was 3.2% (5/155). The incidence of major complications was 1.9% (3/155) and the incidence of minor biliary complications was 1.2% (2/155). In 3 out of 5 patients the mishap was attributed to developmental anomalies. Dense pericholecystic adhesions and cystic duct blow out were responsible for biliary complications in one patient each. Bilioenteric anastomosis was performed in two patients and restoration of continuity of the common hepatic duct over a T-tube was done in one patient. Side hole in an accessory duct was repaired over a T-tube and cystic duct blow out was managed with endoscopic biliary drainage alone.

CONCLUSIONS

A high index of suspicion of developmental anomalies, cautions approach in difficult cases and readiness to consider conversion to open cholecystectomy are recommended to reduce the incidence of biliary complications in laparoscopic cholecystectomy.

Pericholecystic adhesions in single v multiple gallstones and their consequences for laparoscopic cholecystectomy

BACKGROUND

Adhesions are amongst the common reasons for open conversion of laparoscopic cholecystectomy. It is not clear whether this problem is more common with single or multiple gallstones.

PATIENTS AND METHODS

The clinical records of 110 patients with chronic cholelithiasis harboring multiple stones in the gallbladder (multiple stone group; MSG) and 45 patients with single stones in the gallbladder (SSG) undergoing laparoscopic cholecystectomy were analyzed for differences in the clinical presentation and outcome with special reference to the incidence of pericholecystic adhesions, size of the stones, and their implications for conversion and complications.

RESULTS

Patients in the SSG had a significantly higher incidence of dense pericholecystic adhesions in the region of the porta hepatis (P = 0.003). Eleven patients in the SSG (24.4%) were converted to open cholecystectomy. Dense pericholecystic adhesions around the porta hepatis alone contributed to nine of these conversions (81.8%). The size of the stones was significantly greater (P < 0.001) in those patients of the SSG who required conversion to open cholecystectomy. Thirteen patients of the MSG (11.8%) required conversion to open cholecystectomy. Dense pericholecystic adhesions alone contributed to conversion in four cases (30.7%), and the size of the gallstones was not significantly different (P = 0.981) in patients with or without conversion to open cholecystectomy. There was no difference in the clinical presentation or complications in the two groups of patients.

CONCLUSION

Dense adhesions in the porta hepatis are significantly more common in patients with single stones and are the most common reason for open conversion.

Evaluation of the predictors of choledocholithiasis: comparative analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters

This prospective study was performed to assess the predictive ability of the various indicators of common bile duct (CBD) calculi, individually or in combination, by analyzing 88 patients with gallstone disease. The patients were classified into two groups according to the presence of 10 predefined criteria. Of 53 patients with one or more risk factors (group 2), 26 harbored CBD calculi; none of 35 patients with no risk factors (group 1) had CBD stones. Jaundice correlated best, with a sensitivity of 69%; and pancreatitis had the lowest sensitivity (12%). Elevated serum bilirubin and alkaline phosphatase levels correlated better than liver enzymes and serum amylase. The sensitivity and negative predictive value of cholescintigraphy scanning for diagnosing CBD calculi were better than those of ultrasonography, the sensitivity being 84% versus 50% and the negative predictive value 95% versus 82%. Endoscopic retrograde cholangiopancreaticography was successful in 94% of the patients, and CBD calculi were diagnosed in 74%. Moreover, peroperative cholangiography was 100% sensitive with no false-positive results. Ultimately, a palpable stone at surgery was the best predictor. When all the criteria were analyzed, it was found that as the number of criteria increased so did the percentage of patients harboring CBD calculi.

Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India

An outbreak of nosocomial fungemia due to the unusual yeast, Pichia anomala occurred in the pediatric wards of our hospital over a period of 23 months (April 1996 to February 1998). A total of 379 neonates and children (4.2% admissions) were infected. The probable index case was admitted to the pediatric emergency ward, with subsequent transmission to the premature nursery, pediatric intensive care units, and other children wards. Carriage on the hands of health care personnel was likely to be responsible for dissemination of the fungus. The outbreak could only be controlled after a health education campaign to improve hand-washing practices was instituted and after nystatin-fluconazole prophylaxis to all premature neonates and high-risk infants was introduced. In a case-control study, we identified a lower gestational age, a very low birth weight (<1,500 g), and a longer duration of hospital stay as significant risk factors associated with P. anomala fungemia in premature neonates. We conducted a culture prevalence survey of 50 consecutive premature neonates and found that 28% were colonized with P. anomala at a skin or mucosal site on the date of delivery and that 20% of these neonates subsequently developed P. anomala fungemia. We performed multilocus enzyme electrophoresis on 40 P. anomala outbreak isolates (including patient and health care workers' hand isolates), and the results suggested that these isolates were identical. Our study highlights the importance of P. anomala as an emerging nosocomial fungal pathogen.

The role of endoscopic procedures in the management of postcholecystectomy and posttraumatic biliary leak

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool in the evaluation of the biliary system. It not only diagnoses the site of biliary leak following bile duct injury, but it also acts as a therapeutic modality to allow interventional procedures such as sphincterotomy, nasobiliary drainage, or stent placement to be performed. The present study was carried out to evaluate the role of endoscopic management of biliary leak, following either liver trauma or cholecystectomy. Of a total 21 patients with bile leak following liver trauma and biliary surgery, 20 were managed by various endoscopic procedures. In the postcholecystectomy group, ERCP revealed a cystic duct leak in 9 patients and common bile duct injury in 6 patients. These complications were managed by sphincterotomy alone in 2 patients, by nasobiliary drainage alone in 4 patients, by sphincterotomy and nasobiliary drainage in 8 patients, and by sphincterotomy and stent placement in 1 patient. Posttraumatic biliary fistula was successfully managed by performing sphincterotomy followed by the placement of nasobiliary drainage in all of five patients who had suffered trauma injury.

Anomalous bile duct injury during laparoscopic cholecystectomy

We report a patient in whom the common hepatic duct drained into the gall bladder body and the cystic duct continued as the bile duct into the duodenum. The anomalous duct was inadvertently injured during laparoscopic cholecystectomy. The injury was repaired and end-to-end anastomosis of the hepatic and cystic ducts was done through a subcostal incision.

Adjuvant interstitial brachytherapy in a case of anorectal melanoma

PURPOSE

A locally resectable case of anorectal melanoma is reported. In order to prevent local recurrence, interstitial brachytherapy was used.

METHOD

A 45 years old emaciated female presented with a 8 x 6 x 6 cm, hard, mobile, intraluminal mass in the anal canal and rectum, biopsy revealed malignant melanoma. As the mass was locally resectable, wide local excision of the tumour was carried out. She was subsequently given interstitial brachytherapy with Caesium--137 implants at tumour bed, not described so far in literature. Six months later her general condition had improved but abdomino-perineal resection was necessitated due to presence of extra-rectal metastasis.

RESULTS

Patient is in our follow-up for 36 months now and doing well.

CONCLUSION

Supplementation of interstitial brachytherapy after local resection of ano-rectal melanoma may help to prevent local recurrence.

Clinical significance of carcinoembryonic antigen in colorectal malignancy

Carcinoembryonic antigen (CEA) assay was performed in 40 patients of histologically proven colorectal carcinoma. The overall incidence of positivity was 72.5%. The incidence increased from 40% in Duke's A stage to 84.6% in Duke's C stage. Similarly the mean CEa levels also increased as the disease advanced i.e. 4.96 ng/ml, 8.07 ng/ml and 12.7 ng/ml in Duke's A, B and C respectively. Cancer with poor prognosis i.e. poorly differentiated and colloid carcinoma, had significantly less rise in CEA values (P < 0.05) as compared to well differentiated carcinoma. There was no relation of CEA values with the gross appearance of the tumour and lymph node involvement. CEA level came down in all the patients after surgery. Based on the postoperative CEA estimation, complete tumour clearance had been achieved in 86.2% of patients.

Comparative evaluation of the inflammatory mediators in patients undergoing laparoscopic versus conventional cholecystectomy

BACKGROUND

Injury induces systemic inflammatory response. The degree of response is proportionate to the trauma.

METHODS

Patients with ultrasound-proven gall stones posted for operation were randomized into two groups. Laparoscopic cholecystectomy was performed in one group while the other group underwent conventional cholecystectomy. Peripheral venous blood samples for inflammatory mediators, namely tumour necrosis factor, C-reactive protein, oxygen release from monocytes and polymorphonuclear leucocytes were drawn 1 day before surgery and repeated on the first and third days after surgery. Partial pressure of arterial oxygen was also measured in both groups. Only patients who met selection criteria and had uncomplicated postoperative courses were included in the study. There was a total of 40 patients for the final analysis, 20 in each group.

RESULTS

There was no significant difference (P > 0.1) in age, sex or body mass index in both groups of patients. The level of all of the inflammatory mediators was elevated on the first postoperative day; however, the elevation was significantly less following laparoscopic cholecystectomy compared to conventional cholecystectomy (P < 0.01). Although the values came down on the third postoperative day, they remained above the respective controls. Postoperative hypoxaemia was significantly more in patients of conventional than laparoscopic cholecystectomy (P < 0.001).

CONCLUSIONS

Trauma-induced inflammatory response is significantly less following laparoscopic cholecystectomy compared to conventional cholecystectomy. It appears to be related to degree of trauma.

Expectant management of haemoperitoneum

Nonoperative management was successful in 81 of the 90 patients including two patients with penetrating injury. Nine patients were operated on after an initial period of observation, eight because of continued bleeding and one because of features of peritonitis. There were four deaths. These were due to multisystem injuries and not directly related to haemoperitoneum alone. Nonoperative management is a relatively safe and effective method in management of selected cases of haemoperitoneum.

Laparoscopic treatment of hepatic hydatid cyst

A case of hydatid cyst treated by laparoscopic surgery is described. The principles of conventional surgery in hydatid disease were achieved. The role of laparoscopic surgery is reemphasized.

Role of ultrasonography in blunt abdominal trauma

Patients with blunt abdominal trauma (BAT) often have equivocal signs of intra-abdominal injury. Diagnostic peritoneal lavage (DPL) has been the 'gold standard' for evaluating these patients, the use of ultrasound (US) being a recent phenomenon. Seventy-three patients with BAT and equivocal physical signs were subjected to both DPL and US for detection of intra-abdominal injury. Based on clinical status, DPL and US findings, the patients underwent laparotomy or non-operative management. DPL was positive in 35 patients. There was one false positive and one false negative result (sensitivity 97.1%, specificity 97.4%, accuracy 97.3%). US was positive in 31 patients. There were 5 false positive and 4 false negative results (sensitivity 86.7%, specificity 88.4%, accuracy 87.7%). Solid viscus injury was documented at laparotomy in 24 patients. DPL failed to detect one pancreatic injury, while US failed to detect 4 splenic and 2 liver injuries. US additionally detected a single case of haemopericardium. Although DPL outperformed US in this study, US can complement DPL in defining the organs injured and in follow up of patients undergoing non-operative management for BAT.

Correlation of the growth fraction, nucleolar organizer region counts and epidermal growth factor receptor with histomorphological prognostic criteria in breast cancer

A total of 60 cases of breast cancer were studied to find the correlation between newer parameters of prognosis viz growth fraction (GF), nucleolar organizer region (AgNOR) counts and epidermal growth factor receptor (EGFR) positivity with the various histomorphological factors such as tumour size, nuclear grade, histological grade and mitoses. Growth fraction measured by Ki67 monoclonal antibody varied from 3.6 to 73.7 percent. AgNOR counts ranged from 1.2 to 16.9 dots per tumour cell nucleus with a mean of 6.26 dots. EGFR positivity was seen in 66.7% of cases. Ki67 score correlated with all prognostic variables studied except the presence of axillary metastases. AgNOR counts correlated with size of tumour, axillary lymph-node metastases and Ki67 score but no correlation was seen with histologic or nuclear grade. EGFR positivity correlated strongly with size of the tumour and weakly with Ki67 score, AgNOR counts and mitoses.

Disseminated mucormycosis in healthy adults

Three patients of disseminated mucormycosis are described. None had predisposing factors. Two of them presented with nonspecific symptoms along with acute renal failure and peritonitis. Third patient had fulminating primary cutaneous mucormycosis which disseminated later. Development of acute renal failure with smooth enlargement of both kidneys in an apparently healthy individual or appearance of mould in a wound should raise the suspicion of mucormycosis. The hallmark of the infection was vascular invasion and thrombosis. Antemortem diagnosis could be made in one patient only. All patients had progressive downhill course despite supportive treatment, antibiotic and amphotericin in-B in one patient.

Management of duodenal trauma

The surgical management of fifteen cases of duodenal trauma is reported. Blunt injury of the abdomen was the commonest mode of injury. Thirteen patients (86.6%) had associated intra-abdominal and/or extra-abdominal injuries. Diagnosis of duodenal injury was made at laparotomy in all patients. In the majority of patients (n = 11), either duodenal repair, or anastomosis with the pylorus or jejunum was done. Duodenal diverticulization or pancreaticoduodenectomy were undertaken in 2 patients each. Feeding jejunostomy was an important adjunct for nutritional support. Septicemia with multisystem organ failure and duodenal fistula were lethal complications. Mortality in the present series was 46.6%.

Serum beta-N-acetylhexosaminidase, carcinoembryonic antigen & sialic acid in benign & malignant extrahepatic biliary obstruction

Study of tumour markers to differentiate benign and malignant extra hepatic biliary obstructions showed that levels fo serum beta-N-acetylhexosaminidase and lipid associated sialic acid were not different in the two groups. The levels of carcinoembryonic antigen (CEA) and total sialic acid (TSA), on the other hand, were significantly higher in patients with the malignant biliary obstruction. At a cut-off value of 6.4 ng/ml (mean + 2SD) CEA had 66.7 per cent true positivity in malignancy 100 per cent true negativity in control and 78 per cent true negativity in the benign group. Similarly, TSA at a cut off value of 60 mg/dl had 61 per cent true positivity in malignancy, 90 per cent true negativity in controls and 70 per cent true negativity in the benign group. These two tumour markers appear to have similar diagnostic potential for malignant extrahepatic biliary obstruction. Surgical management of the malignant obstruction did not result in a decline in the elevated levels of these two markers during the post-surgical period of 7 days.

Bile duct cysts: presentation in adults

Bile duct or choledochal cysts are rare congenital anomalies and presentation in adult is infrequent. Seven cases of type I/IV bile duct cysts presenting in adult life have been treated by the authors during the past 2 years. The diagnosis was made using a combination of ultrasound and cholangiography (endoscopic retrograde cholangiopancreatography/percutaneous transhepatic cholangiography). All cases underwent total cyst excision and Roux-en-Y hepaticojejunostomy. There were no operative complications and all patients were asymptomatic in the follow-up period, which ranged from 3 to 23 months.

Effect of blockade of transdiaphragmatic absorption of bacteria on survival in peritonitis: an experimental study in rats

An experimental rat model of established peritonitis was used to test the effect of intraperitoneal injection of platelet rich plasma (PRP) on blood and peritoneal fluid culture positivity and survival rates. Thirty animals divided into two groups of 15 each were studied. The first group served as control while animals in the second group received intraperitoneal injection of PRP. The use of PRP in established. Peritonitis was of no significant benefit.

Intestinal endometriosis

Two cases with intestinal endometriosis, one with a right iliac fossa mass and the other with subacute intestinal obstruction, are presented. In both the cases, the diagnosis was not suspected clinically and was reached only on histological examination of the resected specimens.

Multiple neoplasia in a patient with pituitary acromegaly

A case of pituitary acromegaly with multiple nonendocrine neoplasia is reported. The tumorogenic potential of growth hormone, prolactin and other growth factors is discussed.

A clinical study of intubating conditions under vecuronium bromide

The drug vecuronium bromide, a short acting, non-depolarising agent with little side-effects, has brought much promise in the field of muscle relaxants. Fifth healthy patients were induced with injection thiopentone sodium 4 mg/kg and vecuronium bromide, 0.1 mg/kg was given IV. The earliest time at which the largest percentage of patients could be intubated satisfactorily was noted. The intubating conditions were estimated by scoring method. The duration of clinical relaxation was decided from the time of IV injection of vecuronium bromide to the return of muscle power of the non-respiratory muscles requiring repeat dose of the drug. The ideal intubating condition was achieved at 120 seconds and the duration of clinical relaxation ranged from 11-15 minutes.

Open management of septic abdomen by Marlex mesh zipper

Marlex mesh with zipper was used for abdominal closure in 5 of 147 patients with generalized peritonitis seen during a period of 2 years. Residual/recurrent intra-abdominal sepsis necessitating repeated explorations prompted use of this technique followed by frequent peritoneal lavages. Abdominal sepsis was successfully controlled in 4 of 5 patients, although we lost 3 of 5 patients due to multiple factors.

Giant perforations of duodenal ulcer

Over a period of eleven years, eight patients were treated for duodenal ulcer perforation measuring more than one centimetre in diameter. In five of these patients, the perforation was sealed using a jejunal loop as serosal onlay patch; one patient underwent gastrectomy and in two patients catheter duodenostomy was done. Two patients died, both due to renal failure. The six surviving patients were discharged with the advice for a subsequent 'ulcer-curing' operation after six months. Two patients developed life threatening complications during this waiting period and one of these died. Giant perforations of duodenal ulcer can safely be closed using a jejunal loop as serosal patch. Delay in doing the second stage definitive surgery for the ulcer may be dangerous.

Isolated splenic vein thrombosis with natural shunt caused by jejunal tuberculosis

A case of jejunal tuberculosis causing isolated splenic vein thrombosis with natural shunt is reported, for the first time. The patient, presented with upper small bowel obstruction and massive upper gastrointestinal bleeding, was treated successfully with splenectomy, jejunal resection and antituberculous drugs.