Cystic duct anomalies and their surgical implications in patients undergoing laparoscopic cholecystectomy

Background: During cholecystectomy, to avoid common bile duct injury or other per operative complication, the knowledge of cystic cyst anomalies is imperative. This study aimed to highlight cystic duct anomalies identified during laparoscopic cholecystectomy and report their implications

Methods: This prospective study was conducted at Liaquat University of Medical and Health Sciences, Jamshoro over a period of six years [2009-2014] in the department of Surgery. Over this specified period a total of 775 patients underwent cholecystectomy and were included in this study

Results: Among 775 patients who underwent laparoscopic cholecystectomy, abnormal confluence was found in 7.22%, short cystic duct in 26.78%, long cystic duct in 17.86% and double cystic duct in 12.50%. Surgical problems encountered due to these variations were cystic duct avulsion, common bile duct injury, bleeding and bile leak

Conclusion: During laparoscopic cholecystectomy, unidentified anatomical variations of cystic duct may cause drastic complications including ductal injuries which significantly increase morbidity and may raise mortality

incidence, pattern and outcome of stray bullet injuries: a growing challenge for surgeons

Objective: To study the incidence, pattern of injuries, presentation and management of stray bullet injuries

Methods: All patients presented and admitted with stray bullet injuries during a period of 4 years from January 2006 to December 2010 were included in this prospective study which was conducted at Liaquat University of Medical and Health Sciences Hospital Hyderabad/Jamshoro. All of the study subjects were admitted through casualty and were initially thoroughly examined and resuscitated. The pattern of injuries was noted and requisite investigations performed. Patients who sustained injuries demanding surgery were prepared accordingly and were submitted for laparotomy or other procedures depending upon the severity of injuries. The data collected on individual basis and variables studied including demographics, pattern of injuries, time since injury occurred and management

Results: A total number of 165 patients with a mean age of 17.1 years, SD 13.807 and range of 74[2-76] presented with stray bullet injuries during study period. The study population comprised 117[70.90%] males and 48[29.09%] females. Majority of the patients were brought late because of delay in diagnosis or delay in transportation. The commonest victims were young children in their teens and comprised 78% of the study population. Haemothorax/ pneumothorax or peritonitis was the common presentations occurring in 11% and 61.81% of the study population respectively. Of the total number, 92 [55.75%] patients underwent laparotomy while remaining patients either had chest intubation or some other procedures done accordingly. Nine [5.45%] patients developed permanent disabilities while 13[7.87%] patients died either immediately after arrival or later on in the hospital during or after the operative treatment. Mortality was related to the time of arrival in hospital since the injury and thus was highest among those brought 4 or more hours after the shot [P < 0.001]. Patients who did not sustain major injuries were kept under observation and were subsequently discharged

Conclusion: Stray bullet injuries are an ever increasing challenge in our society. Unlawful and jubilant use of weapons in celebrations, weddings and similar occasions are causing a lot of morbidity and mortality in the society

Laparoscopic cholecystectomy in complicated gallstone disease

Objective: To assess the role of laparoscopic cholecystectomy [LC] in gallstone disease with its complicated problems. Design: Prospective observational study. Setting: Surgical Department of Liaquat University of Medical and Health Sciences, Jamshoro and Private Hospitals of Hyderabad, Sindh-Pakistan; from May 2001 to April 2005

Methods: The patients were categorized as cases of complicated gallstone disease on the basis of clinical assessment, investigations especially ultrasound abdomen and operative findings noted during laparoscopic cholecystectomy. All patients were explained for advantages and disadvantages of early LC with their difficult disease problem and willing taken for study. Sampling strategy was convenient. The patients with uncomplicated gallstones, obstructive jaundice, acute pancreatitis and carcinoma of gall bladder were excluded from this series

Results: 120 out of 400 patients presented with one of the known complication of cholelithiasis such as chronic cholecystitis 50%, acute cholecystitis 12.5%, empyma 18.33%, mucocele 10% and fibrosed gall bladder in 9.17% of cases as assessed on clinical examination, ultrasound and laparoscopic findings. Majority [75%] of cases were having adhesions around gall bladder and 25% without adhesions. Problems encountered during LC were difficult separation of tight adhesions around gallbladder [50.0%], grasping and holding of thick walled and distended gallbladder [41.67%], dissection and identification of structures in Calot's triangle [29.17%], haemorrhage from main cystic artery and gall bladder bed 20.83% and delivery of large and thick wall gallbladder in 25% of cases. Intra operative complications seen during procedure were haemorrhage in 20.83% cases, perforation of gallbladder by instrumentation in 12.5% and avulsion of cyctic duct in 1.67% of cases. Two patients [1.67%] were converted to open cholecystectomy due to bleeding. Postoperatively 12.5% of patients developed biliary leak, out of which 3 cases [2.5%] were due to actual common bile duct injury, 2.5% of cases developed port-site sepsis as main postoperative complications. Cases with bile duct injury were re-explored and managed accordingly. Hospital stay varied from 2-7 days but majority of patients were discharged [70.83%], within 2-3 days, no mortality was seen in this series

Conclusion: Laparoscopic cholecystectomy like uncomplicated biliary stone disease is equally effective procedure for complicated cholelithiasis. Its applicability is almost 95% in experienced hands

Carcinoma of caecum with subcutaneous metastasis

In colorectal cancer, subcutaneous/osseous metastasis without liver involvement is very rare. We present a case of 40 years old man who had carcinoma of caecum with a subcutaneous nodule in right upper arm. Preoperatively, he was diagnosed as a case of tuberculosis of ileocaecal junction or appendicular mass with rectal polyps along with calcified lipoma in right upper arm. On exploratory laparotomy, ileocaecal mass with mesenteric lymphadenopathy was seen. Specimen were sent for histopathology after right hemicolectomy and excision of subcutaneous lump which revealed adeno-carcinoma caecum with metastatic nodule in right upper arm