Routine or selective histopathology of gallbladder specimen after cholecystectomy for gallstone diseases

Objectives: To determine the incidence of incidental gallbladder cancer [IGBC] and to assess the need of routine histopathological examination of all gallbladder specimens after cholecystectomy for benign gallstone diseases Design: Retrospective study Setting: Department of Surgery, College of Medicine, King Saud University, KSA

Subjects: This study included all the patients who underwent elective or emergency cholecystectomy for gallstone disease at King Saud Medical City, Riyadh, Saudi Arabia between January 2012 and September 2015. Patients with preoperative suspicion of gallbladder cancer on imaging, or underwent cholecystectomy for gallbladder polyps or porcelain gallbladder were excluded from the study. Medical record of all the selected patients was reviewed and the data were collected. Interventions: Histopathological examination of gallbladder Main outcome measures: IGBC, routine histopathological examination of all gallbladder

Results: A total of 2396 patients underwent cholecystectomy for gallstones disease. All gallbladder specimens were sent for histopathological examination. IGBC was detected in nine gallbladder specimens [0.4%]. Out of 2396 patients, morphologic abnormalities were observed in 518 specimens [22.6%]. There was no reported case of IGBC with normal appearance of gallbladder specimen. Five patients underwent simple cholecystectomy for stage T1b, three patients of stage T2 tumor had further liver resection and one patient received only palliative care

Conclusions: The incidence of IGBC was 0.38%. All cases of IGBC were detected in abnormal looking thick wall gall bladder. Therefore, selective histopathology of abnormally looking specimen is recommended to reduce the cost and work load of pathologists

Comparison of harmless acute pancreatitis score with Ranson's score in predicting the severity of acute pancreatitis

Objective: To determine the predictability of harmless acute pancreatitis score [HAPS] in determining the severity of acute pancreatitis [AP] and compare it with Ranson's score

Study Design: Prospective cohort study

Place and Duration of Study: King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, between January 2012 and December 2015

Methodology: All patients admitted with AP at King Saud Medical City, Riyadh, during 2012 - 2015 were studied prospectively. Patients were assessed by HAPS and Ranson's score. Predictability values of the two systems were analysed and compared

Results: Out of 116 patients studied, 104 [89.6%] were HAPS positive and predicted to have mild disease. Pancreatitis was mild in 101 [87%] but severe in 3 [2.6%] patients who scored >/= 3 Ranson's criteria. Among 12 HAPS negative patients, 10 scored >/= 3 Ranson's criteria and developed severe pancreatitis while 2 [1.7%] with 2 positive Ranson's criteria developed mild pancreatitis. HAPS correctly predicted the disease severity in 101 [87%] patients, a sensitivity of 98% specificity of 77% and accuracy of 96%. Ranson's system predicted correctly in all but took 48 hours for assessment. Statistical analysis showed moderate agreement [Kappa = 0.776, p < 0.001], and positive relation [rs = 0.777, p < 0.001] between the two scores

Conclusion: HAPS is effective in rapid identification of patient who will run non-severe course of AP. Assessment can be completed within one hour from presentation. Ranson's score, although more accurate, takes 48 hours to complete

Metachronous metastatic renal cell carcinoma to the jejunum presenting with massive lower gastrointestinal bleeding

Metastatic renal cell carcinoma [MRCC] is a rare cause of massive lower gastrointestinal bleeding [LGIB]. We report a 51-year man who underwent left nephrectomy for renal cell carcinoma [RCC] 6 years ago. presenting with massive LGIB. Preoperative abdominal computed tomography [CT] revealed small bowel mass. Exploration of the abdomen revealed jejunal mass. Resection of the mass along with the jejunal segment with end-to-end anastomosis was performed. Histopathology of the jejunal mass confirmed MRCC. MRCC should be expected as a source of massive LGIB in a patient with history of RCC. Surgical intervention should not be delayed in a hemodynamically unstable patient and persistent bleeding

Intraoperative dilatation and air-tight testing of the hepaticojejunostomy: a new technique

Objective: To evaluate the effect of creating an air-tight anastomosis and intraoperative dilatation of the hepaticojejunostomy [HJ] in reducing the early and long-term complications. Study Design: Interventional study. Place and Duration of Study: Department of Surgery, King Saud University, Riyadh, between March 2008 and January 2016

Methodology: After completion of HJ, the anastomosis was tested for air-tightness, and dilated with Kelly clamp in all patients undergoing the procedure. The anastomosis was reinforced with extra suture in cases of air leak. Comparison was performed between the patients who underwent HJ by the same surgeon, after and before the new technique

Results: Sixty-seven patients underwent HJ during the study period. Air leaks from HJ were observed in 3 patients before anastomotic dilatation. The anastomosis was reinforced in these patients. No air leak was observed after dilatation of the anastomosis. There was no postoperative bile leak in any patient. However, during the follow-up 3 patients presented with recurrent cholangitis and stricture formation at the HJ site required surgical revision. The new technique had significantly reduced the rate of bile leak [p=0.029] and stricture [p=0.037] at the site of HJ when compared with patients who underwent HJ without the new technique

Conclusion: Creation of air-tight HJ anastomosis has completely eliminated the postoperative bile leak and reduced the rate of HJ stricture formation. The addition technique resulted in insignificant prolongation of operative time. There was no technique related complication

Early versus interval cholecystectomy after mild acute gallstone pancreatitis: a 10 year experience in central Saudi Arabia

To study the safety of early cholecystectomy [EC] during the index admission following acute mild gallstone pancreatitis, focusing on conversion rate, biliary injuries, length of hospital stay and recurrent gallstone related events. Medical records of all patients who were admitted with a diagnosis of acute mild gallstone pancreatitis at King Saud Medical City, Riyadh, Kingdom of Saudi Arabia between January 2003 and December 2012 were studied retrospectively and reviewed in relation to age, gender, presenting symptoms, laboratory findings, imaging studies, timing of cholecystectomy, biliary injury, intraoperative bleeding, conversion to open surgery, duration of surgery, operating surgeons, hospital stay, recurrent gallstone related events and mortality. Out of 386 patients admitted with acute mild gallstone pancreatitis, 267 patients underwent EC which was successfully performed in 256 cases. Conversion to open cholecystectomy was needed in 11 cases. The rest of the patients [n = 119] were discharged after successful conservative treatment for interval cholecystectomy [IC] after 6-12 weeks. IC was performed on 83 patients, two were converted to open cholecystectomy. Hospital stay was significantly shorter in the EC [P < 0.0001] while the recurrent gallstone related events were significantly higher in IC [P < 0.0001]. There was no significant difference in conversion rate [P = 0.567], and biliary complications [P = 0.663]. EC following acute mild gallstone pancreatitis was found to be a safe procedure when performed during the index admission. There was no significant increase in conversion rate or bile duct injuries. In fact, EC resulted in significant reduction in the hospital stay as well as in the recurrent gallstone related events

Rupture of the common bile duct; a rare cause of biliary peritonitis

A 17-year-old unmarried female complained some pain in the right iliac fossa with associated nausea, vomiting and anorexia. Her examination revealed a conscious and febrile[38[degree sign] C] patient with tenderness in right half. The laboratory findings showed leukocytosis at the time of admission. The patient was admitted to the surgical ward with provisional diagnosis of acute appendicitis. Laparoscopic appendicectomy was planned for the patient on the same day. When we introduced the camera, a sufficient amount of bile was noted in the peritoneal cavity. All other organs including appendix were examined and were found to be normal. Consequently, a diagnosis of perforation in the hepatobiliary system was made and the procedure was converted to open through a mid line laparotomy incision. Gall bladder was collapsed and there was 0.5 cm irregular perforation in the common bile duct. Per operative cholangiogram was unremarkable. A T tube was inserted and peritoneal cavity was washed with normal saline. A drain was placed down to the common bile duct and abdomen closed. The patient made uneventful recovery and was discharged home in a stable condition. Spontaneous Common Bile Duct Injury is extremely rare which should be considered by all physicians dealing with the patients with acute abdomen