Preoperative factors that determine technical difficulty during laparoscopic cholecystectomy for symptomatic calcular cholecystitis

The increasing experience in laparoscopic cholecystectomy has led to more difficult cases being performed The methods to identify a potentially difficult laparoscopic cholecystectomy would be a valuable indicator for good management policies with improvement of the outcome. The aim of this study was to determine the correlation between preoperative clinical and abdominal sonographic findings in patients undergoing laparoscopic cholecystectomy for symptomatic calcular cholecystitis and the technical difficulty at operation. All consecutive patients with calcular cholecystitis undergoing laparoscopic cholecystectomy for the last 8 years [531 patients] were reviewed. The clinical preoperative factors assessed involved patient's age, sex, body weight and body mass index, of the disease, associated diabetes mellitus, the occurrence of biliary colic within the last 3 weeks, the presence of symptoms and signs of acute cholecystitis at presentation and history of acute cholecystitis. The laboratory preoperative factors assessed involved, full blood picture including total leucocytic count, liver functions including serum transaminases, serum bilirubin and prothrombin time. The preoperative abdominal sonographic findings assessed involved gallbladder size, gallbladder wall thickness, peri-cholecystic fluid, gallstones number and size and the liver condition. Laparoscopic cholecystectomy was attempted in all patients. Operative data were compared to preoperative data of all patients and statistically analyzed. It was found that the following 7 parameters are independently predictive of a difficult operation: male sex [p<0.01], the presence acute cholecystitis [p<0.01], thickening of the gallbladder wall [p<0.01], shrunken gallbladder [p<0.01], mucocele of the gallbladder [p<0.05] and enlarged liver [p<0.05] or liver cirrhosis [p<0.05]. The above-mentioned factors are important and should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties

pharmacological approach to reverse portal hypertention and hepatic schistosomal fibrosis in Egypt, control experimental study

Schistosoma mansoni is the most prevalent cause of liver fibrosis in Egypt. It is characterized by hepatocyte damage, inflammation and chronic parasite egg-induced granuloma formation leading to fibrosis. Its management, particularly fibrosis, has focused primarily on treating and preventing the complications of portal hypertension. Unfortunately, there is no therapy that has been proved to prevent progressive hepatic fibrosis which is associated with a significant morbidity and mortality due to granulomatous hypersensitivity to parasite eggs. However, recent developments in understanding hepatic fibrogenesis confirm that recovery from advanced fibrosis is possible. There is a considerable imperative to develop anti-fibrotic strategies that are applicable to liver fibrosis. It was noted that a marked increase in the amount of different interstitial collagens types are associated with the development of fibrotic liver diseases. Mean while, it has been suggested that as long as the relative portions of liver collagen are still within the normal limits, the fibrosis may still be reversible. If it exceeds the normal limits fibrogenesis will proceed to its end stage, even if the etiological agent is removed. Collagen type IV and procollagen type III are two of the most accurate fibrosis markers which allow reliable non-invasive diagnosis. The T lymphocytes and the immuno-regulatory cytokines may be important in the host response to S. mansoni granuloma formation and fibrosis. Chronic parasite egg-induced granuloma formation can lead to fibrosis, which is immunologically characterized by the dominant Th2 response. Corticosteroids and prostaglandins interfere with both efferent and afferent mechanisms of immune function. These data indicate that this adjuvant therapy can be a candidate for therapeutic intervention in hepatic fibrosis through induction of a balance between Th1 and Th2 cells response as will be documented by the fibrosis markers One hundred S. mansoni infected hamsters [150-250 gm] were obtained from the BRPU-TBRI [5 groups, 20 hamsters each]. Treatment was started 10 weeks post infection. First G [20 hamsters] was neither infected nor treated, second G. was infected but untreated, third group infected and PZQ treated, fourth G. infected and PZQ and MP treated and fifth group infected and PZQ and PgE1 treated. Samples [liver and blood] were obtained 20 weeks post infection. The serum level of: liver functions, procollagen type III, collagen type IV and Th1 cytokine [IL-2] and Th2 cytokine [IL-b] were performed. Histopathology was performed to study live fibrosis, measuring the proliferate activity of the hepatocytes using cell image analyzer system and granuloma cells using the indirect immuno-histochemistry by monoclonal antibody proliferating cell nuclear antigen [PCNA]. In this study, G. V showed high significant reduction in granuloma size, type and percentage of fibrosis and significant elevation in percentage of degenerated ova compared to Gs. III and IV. The proliferation index measured using PCNA showed high proliferative activity of hepatocytes in non treated group which declined in the treated Gs. III, IV and V. The proliferation activity of hepatocytes and granuloma forming cells decreased significantly in G.V compared to G.IV. There was a significant reduction in liver function tests even tendency for normalization in G.V compared to group III and IV. Procollagen type III and collagen type IV were significantly low in the serum in G.V compared to Gs. III and IV. Th1 [IL-2] level was significantly high in G.V compared to Gs. III, IV and Th2 [IL-10] was significantly low in G.V compared to Gs III and IV indicating the low amount of fibrosis was in the group treated with PZQ and PgE1.PgE1 with PZQ to treat S. mansoni infected hamsters can modulate liver fibrosis and improves the liver function tests up to normalization. The balance between Th1 and Th2 cytokines level could be modulated to help reverse or decrease fibrosis in S. mansoni infected hamsters. This may pave the way for clinical application as combined therapy PZQ and PgE1 may by an effective approach to reverse hepatic fibrosis in schistosomiasis by the induction of dominant Th1 response

Surgical management of hydatid liver cysts; inra-operative pair, cysto-pericystectomy and omentoplasty

Liver hydatid cysts caused by Echinococcus granulosus presents medical, veterinary and economic problems worldwide. In an attempt to eradicate liver hydatid cysts by eliminating the parasite, disappearance of the residual cavity, preventing complications and recurrence, the present study was done in Theodore Bilharz Research Institute on 36 patients. They were 11 females and 25 males with age ranging between 18-55 years old. All patients were sub to a full history taking and clinical examination, a full battery of hematological, biochemical, immunological and radiological investigations. Intra-operative Puncture Aspiration Injection and Re-aspiration [PAIR] was performed to all cysts before surgical intervention. Total cysto-pericystectomy [CPC] was done in 25 patients with both open and closed technique. Partial cysto-pericystectomy was done in 11 patients due to firm adherence of the cyst to the liver structures. Omentoplasty [OP] was performed to fill all cavities accompanied with external open system drainage tube. There were no mortalities in this study. Post operative complications were found in 7 patients. Cystectomy and omentoplasty related complication were found in 3 patients, General surgical complications were found in 1 patient. Biliary related complications occurred in 3 patients in the form of biliary leak in 2 patients and biliary fistulae in 1 patients. All these complications responded well to conservative management. A combination of different radical and conservative surgical modalities in the same sitting in the form of intra-operative Puncture Aspiration Injection and Re-aspiration, cystopericystectomy and omentoplasty could be considered the surgical method of choice with no mortality

Effect of preoperative endoscopic biliary drainage and stenting on postoperative infection and the outcome of surgery for benign obstructive jaundice

The effect of preoperative endoscopic biliary drainage on the outcome of surgery for patients presenting with obstructive jaundice [OJ] has been studied; increase the risk of morbidity, and mortality. This work aim to studying the bile samples from those patients before and after endoscopic retrograde cholangiopancreatography [ERCP] with biliary stenting and its possible association with postoperative septic complications. The study involved 79 patients with surgically corrected benign obstructive jaundice at Thodor Bilharze Research Institute. Preoperative [ERCP] was done for all of the patients and stent insertion was made in 60 of them. Bile specimens were obtained during endoscopic cholangiography by flushing technique and intra-operatively by puncture before incising the common bile duct. Bile samples were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant postoperative septic complications such as wound infection and cholangitis were also assessed. Bile culture of intra-operatively obtained specimens was positive in 39/60 [65.0%] of the patients in Group II [ERGP+ biliary stent], a significantly higher incidence than that observed in group I [ERCP only], in which 7/19 [36.8%] of the patients presented positive cultures [p=0.001]. There was no significant difference in general postoperative morbidity between groups. When infective complications [cholangitis, pneumonia, wound infection] were analyzed separately, a higher incidence, although without significance was found in Group II than in Group I. Preoperative biliary drainage using the endoscopic retrograde cholangiopancreatography [ERCP] and stent insertion in patients subjected to surgery for benign obstructive jaundice could provoke biliary bacterial colonization with a possible appearance of infective complications during the postoperative period

Fiberendoscopy with mucosal biopsy in the diagnosis of gastroduodenal dyspepsia

Multiple biopsies were taken from the body and pyloric antrum of the stomach, duodenum and esophagus, and from any lesion from 50 patients with gastroduodenal dyspepsia an endoscopy was visualized. The biopsies were stained and examined and a comparison between the clinical impression, radiological, endoscopic diagnosis was done. The commonest cause of dyspepsia was gastritis proven by duodenal ulcer and gastric cancer

Gastric motility following selective and proximal gastric vagotomy: an experimental study

The different branches of the vagus were electrically stimulated and the antral contractions recorded before and following selective and proximal gastric vagotomy, in 20 mongrel dogs. The antral contractions diminished markedly following selective vagotomy. The motor function of the antropyloric segment was preserved in proximal gastric vagotomy

value of fibre endoscopy in the diagnosis of gastro-duodenal dyspepsia

150 patients with gastroduodenal dyspepsia were examined endoscopically, the additional information obtained by endoscopy in patients already examined by barium studies was assessed. In duodenal ulcers 73% were diagnosed by barium studies, the accuracy of endoscopy was 98%. Most cases of advanced carcinoma of the stomach were diagnosed radiologically. However, endoscopy yielded two patients with early mucosal carcinoma. Endoscopy was essential in the diagnosis of chronic gastritis. A large percent [22%] of patients had negative radiological and endoscopic findings inspite of persistent dyspepsia

patterns of acute abdomen seen in the university of Alexandria hospital emergency department

This is a prospective study that covered a six months period started from February to July 1977, in the emergency department of Alexandria University Hospitals to study the different patterns of acute abdomen. 1660 patients with the diagnosis of acute abdomen were studied. Acute appendicitis headed the cases, followed by intestinal obstruction then peritonitis. Different gynecological conditions caused acute abdomen. Four patients had acute pancreatitis. Abdominal trauma caused 2% of acute abdomen with mortality rate of 39%

Proximal gastric vagotomy versus truncal and selective vagotomy: a controlled clinical trial

A randomised controlled clinical trial was carried out on sixty patients with chronic duodenal ulcer. Twenty patients were allocated to one of three types of vagotomy. Proximal gastric vagotomy [PGV]; truhcal vagotomy with gastro-jejenosto my [TV + GJ] and selective vagotomy with gastrojejenostcmy [SV + GJ]. Proximal gastric vagotomy [PGV] was found to be as effective as TV and SV in reducing basal acid output [BAO] and peak acid output [PAO] to a safe level which was found to remain low after 24 months follow-up with no recurrent ulceration. Post-vagotomy complications and complications attributed to loss of the antropyloroduodenal emptying system were reduced significantly