Simple repair is sufficient for most injuries to the duodenum - a case series of 23 patients

Duodenal injury is the most important hollow viscus injury in the abdomen. The study analysed the outcome of duodenal injuries at the unit. Prospectively collected data on a case series involving 23 patients over 3 years. It involved demographic details, part of duodenum injured, injury severity according to the AAST, injury-operation time lag, mode of repair, and the extent of significant associated injuries. M:F ratio was 4.75:1. Mean age 33yrs. Patients with non-perforating injury were excluded. All were operated by a senior registrar or senior. 7/23 were blunt, 13/23 firearm and 3/23 stab injuries. D2 was involved in 87%. Injury severity was graded according to AAST [American Association for Surgery of Trauma]. 17/23 were Grade II/III, 3 Grade IV and 3 Grade V injuries. Four had injury-operation lag of >18hrs. Two injuries were missed. All injuries up to Grade IV had simple repair. Two of them had T-tube duodenostomy. None had pyloric exclusion. Complex repairs wer e required for 3/23 patients. Five patients died, as a result of associated insults. One delayed repair developed duodenal fistula. Intra-abdominal abscess, septicaemia and wound dehiscence were seen in two patients each. Duodenum-related mortality was zero. Adverse prognostic factors towards morbidity were injury severity >GIII and injury-operation lag >18hrs. The mortality was related to associated injuries. Primary repair is sufficient for most non-resectional duodenal injuries

Day case laparoscopic cholecystectomy

Day case laparoscopic cholecystectomy [DC-LC] is being practised in the USA and at sporadic centres in the UK including our department. The aim was to evaluate the initial experience of DC-LC at the unit. Prospectively collected data was analysed retrospectively. The case notes of all patients were retrieved from the medical records and reviewed individually. Standard laparoscopic cholecystectomy was performed. All patients had anti-DVT prophylaxis [pneumatic compression and enoxaparin], per-operative antibiotic, oro-gastric tube, paracetamol suppository and local anaesthetic to all wounds. They were discharged the same day. The end point was 6-week follow-up [86% overall]. Over a 32-month period, 164 consecutive patients with symptomatic cholelithiasis and ASA score of III or less were included. M:F was 1:5 and median age 43y. There were two conversions. The direct admission rate [DAR] was 26/164 [14%]. The indication for direct admission included observation alone [7/26], wound pain [6/26], nausea [3/26], suction drain [2/26] and operation in the afternoon [2/26]. Six [3.6%] required re-admission. One had a cystic artery pseudo-aneurysm presenting with colonic bleeding and anot her with an injury to CBD. One had post-op mild pancreatitis and three had wound pain and bruising. DC-LC is safe and feasible in non-acute patients with symptomatic cholelithiasis

Adult intussusception - asurgical dilemma

Adult intussusception is rare. It is expected to be found in 1/30,000 of all hospital admissions, 1/1300 of all abdominal operations, 1/30'1/100 of all cases operated for intestinal obstruction and one case of adult intussusception for every 20 childhood ones. The authors encountered 4 cases of adult intussusception. M:F ratio was 1:1. Mean age was 47years. Small bowel obstruction was documented in all. They were investigated by radiographs, ultrasound exam, barium studies, endoscopy and CT scan. All however were diagnosed at operation although some pre-operative suspicion was raised in one case. All had a laparotomy. Two were ileo-ileal and two ileo-caecal intussusceptions. One was chronic intussusceptions and three sub-acute. One intussusception had a malignancy [lymphoma] as a lead point. Two had a submucous lipoma at the apex. In an interesting case the suture knot from a recent small bowel anastomosis [2-3 weeks prior] was forming the lead point of the intussusception! The 2 ileo-ileal intussusceptions had segmental resection. Right hemicolectomy was done for the 2 ileo-caecal cases. 'Target lesion' and leumen-within-leumen were the CT hallmarks on review. Retrospective barium enema review failed to show the intussusception. This may suggest the intussusception may have been recurrent or chronic. All 4 recovered uneventfully and remained well. One patient was referred for chemotherapy for intestinal lymphoma. Adult intussusception remains a rare cause of abdominal pain. The treatment almost always is surgical

Role of thyroid scan and FNAC in evaluation of solitary thyroid nodule

The study was carried out from May 1990 to November 1995 in the departments of surgery and pathology of a teaching hospital. The role of thyroid radioisotope scan and fine needle aspiration and cytology [FNAC] was studied in 172 patients with clinically solitary thyroid nodule [STN], all of whom underwent surgery. These patients were divided into two groups, Group A [72 patients] which underwent thyroid scan without FNAC and Group B[100 patients] which was subjected to both. Thyroid scan turned out to be dispensable except in hyperthyroidism where it had 100% sensitivity, specificity and accuracy in diagnosing hyperfunctioning thyroid adenoma. FNAC reaffirmed its superior value by low false negative [1.4%], high specificity [97.5%] and accuracy [96.5%]. FNAC however is liable to be overruled by clinical data especially when dealing with the cytologically "indeterminate" subgroup

Surgical affections of the duodenum

From April, 1995 to July, 1997, 18 consecutive patients with surgical diseases of the duodenum excluding perforated duodenal ulcer requiring an omental patch were managed in West Surgical Unit of Mayo Hospital, Lahore. Trauma [blunt or penetrating] was the most common affection. Time lag between injury and operation was the most important factor prognostically followed by the severity of injury. There was a random mortality of 33% rising to 65% after formation of duodenal fistula. T-tube duodenostomy, sump drainage and TPN may be the pillars of management of late, extensive or complicated duodenal surgery. Of the six patients who died in all, five of them did so due to trauma. "Treatment policies" should be overruled by individual case assessment where required