role of CCK-HIDA scan and cholecystectomy in patients with biliary symptoms and normal ultrasound

Laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstones. "Biliary dyskinesia" refers to postprandial right upper abdominal pain, fatty food intolerance, nausea or bloating without cholelithiasis. There is a striking increase in number of cholecystectomies performed for dyskinesia. Cholecystokinin stimulated hepatobiliary 99m- Tc iminodiacetic acid scintigraphy [CCK-HIDA] has been suggested as an objective diagnostic tool and predictor of outcome. Over a period of 3 years [July 200/ to June 2004] patients between 18 and 90 years with symptoms of gallbladder disease and no stones on ultrasound were evaluated with CCK-HIDA scan. Other appropriate tests were done to exclude potential causes of each patient symptom. Cholecystectomy was performed when no cause was found to explain the complaint. Patients were divided into 2 groups, group A with EF 35% or less and group B with EF> 35%. Success was considered if symptoms improved, patients were satisfied and would agree to go for surgery again f time goes back. Improvement was correlated with degree of dyskinesia, type of symptom, reproduction of pain during CCK-HIDA, age, sex and pathology findings. 57 patients were included. Mean age was 42.6 years with 46 female and 5 males. 49 patients had recurrent symptoms. 43 patients had classic gallbladder pain. 69 US, 32 CT scan, 33 EGD, 9 colonoscopies, 6 ERCP 's, 9 barium meal fallow through. 6 HIDA scans, 3 gastric emptying studies, I MRCP, I barium enema and I endoscopic US have been performed without being able to explain the patients symptom. All patients had CCK-HIDA scan, EF was 35% or less in 31 patients [group A] and >35% in 20 patients [group B]. Groups were similar in other aspects. All patients had cholecystectomy. Mean follow up was 17.4 months [range 3-36]. Most common,morbidity was diarrhea [23/51]. Most common pathology was chronic cholecystitis [39/51]. The overall success was 67%, similar results were found in groups A and B [68% and 65% respectively,] with no correlation found between the result of surgery and EF. In addition reproduction of pain during CCK administration and patient age did not predict the outcome. Patients with typical symptoms had better results [70% success] when compared to patients with atypical symptoms [50% success,] [p=0.42,]. Females showed more favorable outcome [70% success] when compared to males [40% success] [p=0.32] Only 67% of patients with pathologic evidence of chronic cholecystitis improved after surgery. The 3 patients with stones did not improve. Biliary Dyskinesia remains a challenge. Cholecystectomy is safe and provides improvement in 70% of patients with typical symptoms after exclusion of other possible causes of pain by appropriate investigations. Patients with atypical symptoms and males tend to have less favorable outcome [50% success]. Clinical evaluation is the best predictor of outcome and careful patient selection is important to assure good results

Evaluation of the usefulness of quadruple test in preoperative diagnosis of indeterminate breast masses

It is always a challenge to the physician to diagnose clinically the nature of a breast mass; especially with the increasing desire among patients to avoid surgery just for accurate diagnosis. Clinical examination of the breast, mammography, ultrasound supported by FNAC, provide a high level of diagnostic accuracy. This study included 45 female patients with 50 indeterminate breast lumps [40 patients had single lesion and 5 patients had 2 synchronous lesions]. The sensitivity and specificity of the individual tests were as follows: 87.5% and 53.84%, respectively for physical examination, 95.83% and 84.61% for FNAC, 83.3% and 92.3% for mammography, 91.66% and 88.46% for ultrsonography. The quadruple test was 100% sensitive and 100% specific when all the tests were positive or negative, and 100% sensitive and 46.15% specific when at least one test is positive. To conclude, the quadruple test is reliable and very helpful to the surgeon and the patient in determining nature of palpable breast mass

Radiofrequency venous closure: a new approach for the treatment of varicose veins

Over a period of 1 year [May 2003-May 2004] patients with primary varicose veins with documented reflux of saphenofemoral junction [SFJ] were included in this study. Patients with age <18 or >60 years, recurrent varicose veins, postphlebitic veins, mega saphenous vein [>12mm] or significant dilation of the proximal saphenous vein with an "aneurysmal" SFJ were excluded. Patients were divided into 2 groups. Group "A" had undergone venous closure using the radiofrequency [RF] technique at Fairview Hospital. Cleveland, Ohio, USA while group "B" had the standard open high ligation with stripping of upper part of GSV at Kasr El Aini, Cairo University Hospitals, Faculty of Medicine, Cairo, Egypt. In both groups resection of other smaller varicose veins was done as needed by "stab avulsion" technique. Demographics, clinical, operative, postoperative and follow up data were recorded. Results were evaluated using a Chi-square test, with P<0.05 of statistical significance. Groups were compared with respect to patient age, sex, medical co-morbidities, operative, postoperative course and outcome. Each group consisted of 22 patients [22 limbs] with similar demographics and preoperative presentation. Intra-operative duration was comparable. Mean follow up was 12 and 14 months for groups A and B respectively. No mortality or significant morbidity occurred. Both techniques were similarly effective in relieving pain related to reflux. In group A 68.1% of patients did not use pain medications postoperatively versus 31.8% in group B [P=0.035; significant]. Mean duration to return to normal activity and work was 5.5 days in group A, 2 days earlier than group B patients. Over all 95.4% of patients in group A were satisfied versus 72.7% in group B. RF venous closure is a safe minimally invasive technique for the treatment of primary varicose veins. It is as effective as the standard high ligation and stripping. Advantages of RF venous closure include significant less postoperative pain, quicker recovery, early return to normal activities, improved cosmetic results with more patient satisfaction. Cost and technology availability are some limitations

Safety, pitfalls and early complications of laparoscopic ventral hernia repair

Ventral hernia repair, particularly with large defects are plagued by high recurrence and frequent wound complications. Laparoscopic ventral hernia repair [LVHR] potentially offers a tension-free technique with less morbidity and fewer recurrences. This study addresses safety, pitfalls and early complications associated with LVHR. Patients underwent LVHR in the period between January 2002 and May 2003 Preoperative, Intraoperative and postoperative as well as follow up data is presented. Thirty-six patients [41 hernias] had attempted LVHR. Hernias were 27 incisional, 7 recurrent incisional, 6 primary and 1 iatrogenic. Mean operative time was 2 hours [range 1-4]. Mean hospital stay was 2.4 days [range 1-10]. Two cases underwent concomitant additional procedures. Two cases [5.5%] were converted to open procedure; 2 others needed open re-exploration. Complications included 3 cases [8.3%] of inadvertent bowel injury. Twenty-two cases [68.7%] had wound complications; none needed operative intervention. Pain was the most common reason delaying patient discharge. Mean follow-up was 22 months [range /2-28 months] with 2 [7.14%] recurrences. LVHR is safe however, it may be associated with significant morbidity, in part preventable by proper patient selection, meticulous technique and liberal conversion to open technique. Benefits for LVHR include proper repair of all defects, without long incision or extensive abdominal wall dissection. Although wound morbidity seems common, most are minor and resolve spontaneously