Conversion of Laparoscopic to Open Cholecystectomy: Experience in A Tertiary Care Hospital

Now-a-days Laparoscopic cholecystectomy is regarded as the gold standard treatment for benign gallbladder disease but in certain situations conversion to open cholecystectomy is extremely important for the safety of the patient. The objective of this study was to evaluate the reason for conversion of this operation to open surgery. This prospective study was carried out on 392 patients in a single unit of Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh and in a private hospital from July 2013 to December 2018. Maximum (28.3%) patients were 31-40 years age group. Majority (75.3%) was female and 24.7% were male. It was observed that only 2.1% were converted due to dense adhesion (n=3), severe inflammation (n=2), difficult to define anatomy of Calot's triangle (n=2) and Mirizzi syndrome (n=1). Meticulous dissection and proper case selection can reduce the rate of conversion to open surgery.

Identification of bacterial isolates in neonatal sepsis and their antimicrobial susceptibility

A cross-sectional descriptive study was conducted in the Neonatal Intensive Care Unit (NICU) of Ad-din Medical College Hospital during the period of January to December 2011 to determine the pattern of bacterial agents causing neonatal sepsis and their susceptibility pattern to various antimicrobial agents. Blood cultures were performed on admitted newborn babies (0-28 days) to rule out sepsis. Antimicrobial susceptibility testing was done for all blood culture isolates according to the criteria of the National Committee for Clinical Laboratory Standards by disk diffusion method. Out of 1000 screened blood cultures, 87(8.7%) reported as positive and the gram positive and gram negative bacteria accounted for 21(24.1%) and 66(75.9%) respectively. The most common gram positive organisms were Coagulase Negative Staphylococcus Aureus (CONS) (18.4%) and Staphylococcus Aureus (4.6%) and gram negative organisms were Acinetobacter (34.4%), Pseudomonas (21.8%) and Klebsiella spp. (6.9%). The susceptibilities were remarkably low to Ampicillin (20%) and Cefotaxim (29.6%) for both gram positive & gram negative isolates. Gram positive group had susceptibilities of 71.1% to Gentamicin, 85.7% to Imipenem & 100% to Amikacin & Vancomycin. Gram negative isolates showed higher sensitivities to Colistin (96.9%), Piperacillin-Tazobactum (78.7%), Imipenem (74.2%), Levofloxacillin (71.2%), respectively. Gram-negative bacteria showed high level of resistance to commonly used antibiotics (Ampicillin, Ceftazidim and Cefotaxim). Gentamicin, Amikacin, Imipenem and Levofloxacin were the most effective drugs compared to others. Routine bacterial surveillance and their sensitivity patterns must be an essential component of neonatal care.

Primary closure of the Urinary Bladder, Urethra and Anterior Abdomen of Classical and Cloacal 39 Exstrophy - A Preliminary Experience of Three Consecutive Cases

A 4 years old female and 1.5 months old male with classical exstrophy and a 2 days old male child with cloacal exstrophy were admitted in Paediatric Surgery Department of Sher-e-Bangla Medical College Hospital (SBMCH), Barisal. The mothers of all children had complaints of protrusion of fleshy mass in lower abdomen from birth. They always remain wet producing smell of urine. The cloacal exstrophy case had a prolapsed ileum that was discharging stool. He had no anus too. All of the cases underwent one stage closure of urinary bladder and urethra and lower abdomen without osteotomy and patient was discharged. After 8 months of first operation the female patient underwent repair of the wound dehiscence. At the time of discharge her urinary bladder capacity was 10 ml and remained dry for 5 minute after manual evacuation. The male patient with classical exstrophy developed urethrocutaneous fistula on 15th post-operative day. The cloacal exstrophy case was discharged with end ileostomy on 10th post-operative day. DOI: http://dx.doi.org/10.3329/jss.v16i1.14447 Journal of Surgical Sciences (2012) Vol. 16 (1) : 39-43

Mitral stenosis in a girl of five years

Mitral stenosis(MS) detected below the age of 20 years is called juvenile mitral stenosis (JMS). JMS constitute 25-40 % of all cases of isolated mitral stenosis, though overall incidence of rheumatic fever and rheumatic heart disease (RHD) within mixed population is 7.5- 7.8 per thousand. The patient was 5 years old girl hailing from Modhupur, Tangail got herself admitted into CCU Mymensingh Medical College Hospital with the complaints of low grade fever, shortness of breath and also associated with failure to thrive. She was ill looking, mildly anaemic. Precordial examination revealed apex beat was in the left 5th intercostals space, tapping in nature, palpable P(2). There was left parasternal heave. 1st heart sound loud, pulmonary component of the 2nd heart sound was accentuated, opening snap with mid diastolic murmur with pre systolic accentuation. Routine blood examination reveals leucocytosis with raised ESR. C-reactive protein (CRP) and ASO titre were significantly raised. X-ray chest P/A view showing the features of mitral stenosis. Echocardiography showing MS (moderate) with pulmonary hypertension. She was treated with antibiotics and other relevant drugs and discharge with an advice for follow up and take preparation for cardiac intervention.

Effects of endotoxin on intestinal hemodynamics, glutamine metabolism, and function

The purpose of this study was to investigate the intestinal hemodynamics and gut glutamine metabolism during endotoxemia, and their correlation with altered intestinal absorptive capacity and permeability. Seventeen Sprague-Dawley rats were used in the study. The endotoxin group (ENDO) received endotoxin (10 mg/kg intraperitoneally, n = 9), while the control group (CONT, n = 8) received saline injection. Twelve hours later, D-xylose (0.5 g/kg) and fluorescein isothiocyanate-dextran (FITC-dextran, 750 mg/kg) were given by oral gavage. One hour later abdominal aortic (AA) blood flow, superior mesenteric venous (SMV) flow, mean arterial pressure (MAP), central venous pressure (CVP), and SMV pressure (SMVP) were also measured. The MAP, AA, and SMV blood flow decreased (P < 0.05), while the CVP and SMVP increased (P < 0.05) in the ENDO group as compared with the CONT group. The ENDO group showed significant decreases for both intestinal glutaminase activity and net intestinal glutamine uptake (P < 0.05). The D-xylose concentration in SMV decreased significantly (P < 0.05) in the ENDO group as compared with the CONT group. However, the plasma FITC-dextran concentration showed no significant difference between the groups. Endotoxin produced a hypodynamic effect in rats 12 h after intraperitoneal administration in association with both a decreased intestinal glutamine metabolism and an absorptive capacity.

Laparoscopic colpopoiesis using sigmoid colon

A new technique for colpopoiesis using sigmoid colon autograft by a laparoscopic surgery is introduced for the first time. This technique requires advanced skills perform and may be the choice in respect to naturalness and permanency of the neovagina with minimum invasion.

Laparoscopic reconstruction of vagina using sigmoid autograft

With the advent of advanced laparoscopic techniques in surgery, new applications have been found, which have expanded the role of laparoscopy in the gynecological field. The aim of this paper is to introduce our laparoscopic technique of taking a sigmoid colon autograft for colpopoiesis in a patient with congenital agenesis of the vagina. This technique is less invasive and is easy to perform, and it may be the best choice of operation in respect to the naturalness and the permanency of the vagina that results. The success of this laparoscopic technique of taking a sigmoid autograft for colpopoiesis suggests diverse possible applications in the future.

Influence of glutamine-supplemented parenteral nutrition on intestinal amino acid metabolism in rats after small bowel resection

Glutamine (Gln)-supplemented total parenteral nutrition (TPN) has been shown to improve mucosal adaptation after massive small bowel resection (SBR); however, its influences on intestinal amino acid metabolism remain unknown. In this study, intestinal amino acid flux, circulating plasma aminogram, mucosal glutaminase activity and protein, and DNA content were measured 7 days after massive SBR in rats receiving either standard (Std) or Gln-supplemented TPN. Sham-operated rats and rats fed chow after enterectomy served as controls. The uptake of Gln and the release of citrulline (Cit) by the remaining intestine was significantly decreased, with reduced mucosal glutaminase activity after SBR in the Chow and Std-TPN groups. Glutamine supplementation resulted in significantly increased gut Gln uptake compared with Std-TPN (P < 0.01). Mucosal glutaminase activity, mucosal protein, and DNA content was also increased by Gln; however, the gut release of Cit remained unchanged (P > 0.05). The subsequent decrease in circulating arginine (Arg) in the Gln-TPN group compared with the Std-TPN group (P < 0.05) was attributed to an insufficient exogenous supply. These findings show that Gln-supplemented TPN improves mucosal growth and gut Gln uptake after SBR. However, the intestinal production of Cit, which remained low in both TPN groups, may lead to an insufficiency of endogenous Arg synthesis. Thus, both Gln and Arg may be essential amino acids after SBR.

Quantification of intestinal blood flow by ultrasonic transit time flowmetry in fed and endotoxaemic rats

OBJECTIVE

To compare the dye dilution method with ultrasonic transit time flowmetry (UTTF) for quantifying intestinal blood flow in the same experimental animals.

DESIGN

Open experimental study.

SETTING

University hospital, Osaka, Japan.

MATERIAL

11 (experiment 1) and 25 (experiment 2) adult male Sprague-Dawley rats.

INTERVENTIONS

In experiment 1, the rats were fasted overnight. In experiment 2, endotoxin, Escherichia coli lipopolysaccharide (endotoxin) or saline (sham) was injected intraperitoneally.

MAIN OUTCOME MEASURES

Superior mesenteric venous and abdominal aortic blood flow.

RESULTS

Experiment 1: intestinal blood flow measured by UTTF was significantly decreased by 17% (p < 0.05) and 56% (p < 0.05) after 30 minutes infusion through the tertiary branch of the mesenteric vein and during simultaneous drawing of blood samples from both the carotid artery and the superior mesenteric vein over a 1.5 minute period, respectively. The intestinal blood flow measurements obtained by UTTF at different intervals before simultaneous drawing of blood from the carotid artery and the superior mesenteric vein differed significantly (p < 0.05) from those obtained by the dye dilution method. Experiment 2: intestinal blood flow was also decreased by 21%-34% (p < 0.05) during similar simultaneous drawing of blood. Aortic blood flow in the endotoxin group was reduced by 66% (p < 0.05) compared with fed animals and 63% (p < 0.05) compared with sham animals. Simultaneously, intestinal blood flow in the endotoxin group was also reduced by 57% (p < 0.05) compared with fed or 48% (p < 0.05) compared with sham treated animals.

CONCLUSION

Real intestinal blood flow might not be measured by the procedure of simultaneously drawing blood from the carotid artery and the superior mesenteric vein in rats as is usually done in the dye dilution method. Intraperitoneal endotoxin reduced aortic as well as intestinal blood flow. We propose that UTTF is an alternative method for quantifying intestinal blood flow in fed and endotoxaemic animals.

Alanyl-glutamine dipeptide-supplemented parenteral nutrition improves intestinal metabolism and prevents increased permeability in rats

OBJECTIVE

The authors determined the effects of alanyl-glutamine-supplemented total parenteral nutrition (TPN) on mucosal metabolism, integrity, and permeability of the small intestine in rats.

METHODS

Male Sprague-Dawley rats were randomized to receive TPN supplemented with a conventional amino acids mixture (STD group) or the same solution supplemented with alanyl-glutamine; both solutions were isocaloric and isonitrogenous. On the seventh day of TPN, D-xylose and fluorescein isothiocyanate (FITC)-dextran were administered orally. One hour later, superior mesenteric vein (SMV) D-xylose and plasma FITC-dextran concentration were measured. Intestinal blood flow and calculated intestinal substrates flux were measured with ultrasonic transit time flowmetery.

RESULTS

Plasma FITC-dextran increased significantly in the STD group. Intestinal blood flow and SMV D-xylose concentration did not differ between the groups. Mucosa weight, villus height, mucosal wall thickness, mucosal protein, and DNA and RNA content in jejunal mucosa were significantly increased in the alanyl-glutamine group. Jejunal mucosal glutaminase activity and net intestinal uptake of glutamine (glutamine flux) were significantly higher in the alanyl-glutamine group as compared with the STD group.

CONCLUSION

Addition of alanyl-glutamine dipeptide to the TPN solution improves intestinal glutamine metabolism and prevents mucosal atrophy and deterioration of permeability.

Discoid Lupus Erythematosus Resembling Lupus Vulgaris

A case of discoid lupus erythematosus (DLE) in a 20 year old female patient is presented. The, case clinically resembled lupus causing bilateral ectropion and exposure keratitis in both eyes.