Modified endocystectomy versus pericystectomy in echinococcus granulosus liver cysts: a randomized controlled study and the role of specific anti-hydatid iGG4 in detection of early recurrence

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries [level IV evidence, grade C recommendation]. So, there is a need for accurately designed randomized trials with precise goals to compare pericystes-tomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-opera-tive blood loss, complications and long term recurrence and to test the role of anti-hydatid IgG4 in diagnosis and detection of early recurrence. 60Patients with 131 liver cysts of E. granu-losus fulfilling the study criteria were randomly divided to two groups. G1: 32 patients with 69custs treated by modified endo-cystectomy and GII: 28 patients with 62cysts treated by closed total pericystectomy. GIa included 40cysts >5cm in diameter [mean 6.86, SD +/- 0.809] and GIb29cysts5cm in diame-ter [mean 7.01 SD +/- 0.79] and GIIb25cysts >/-cm in diameter [mean 4.04 SD +/- 0.93]. Preoperative evaluation inclyded histo-ry taking, clinical examination, blood tests, specific anti-hydat-id IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood trancfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early rasurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24-90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients [GII] had blood transfusion. The intraoperative bleeding in GI was <500ml/patient, and 18patients [GII] each bled >500ml. No intra-peritoneal seedling during the follow up. Five of 55patients [9%] were serologically suspected of relapse or incomplete cure. One [GII] showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.

New approach in surgical management of complicated umbilical hernia in the cirrhotic patient with ascites

A total of 23 consecutive patients operated upon on emergency basis for the treatment of complicated umbilical hernias associated with liver cirrhosis and ascites. The hernia was complicated by strangulation in 11 and ascitic fluid leak in twelve of the patients. Patients were assigned randomly in two groups. In the first group [GI, n = 12] peritoneal drainage at the conclusion of their surgery was done but no drainage was applied in the second group [Gil, n=12]. All patients were operated upon and when closed system peritoneal drainage was done, it was brought to outside of the abdomen through a separate stab. No negative pressure was applied. The main outcome measures were postoperative wound healing, control of ascites, complications, and hernia recurrence rate at follow up. The male/female ratio, Child's class, ascites severity, and mode of hernia complication were almost matched in both groups. Postoperative wound dehiscence occurred in four patients in G II [23.5%] but in none of GI. Control of ascites was achieved in all patients of GI. The overall mean hospital stay was significantly lower in-patient of GI than those of the G II [P < 0.0 1]. Recurrences of the hernia occurred in one patient only of the G I and in three of the G II on a mean follow- up of 19 +/- 3 months. So, postoperative closed peritoneal drainage in the management of complicated umbilical hernias associated with liver cirrhosis and ascites safe and effective in assuring postoperative wound healing, control of ascites and the prevention of hernia recurrence. It is specifically indicated in cases with bowel resection anastomosis and in patients with low preoperative serum albumin and history of rapid ascites re-accumulation under medical therapy

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

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