Costs of management of bile duct injuries.

Background: Only a few studies address the financial impact of the management of bile duct injuries (BDI). This study was aimed to assess the cost of BDI sustained during cholecystectomy. Methods: Patients who underwent surgical repair for post cholecystectomy BDI and due for routine follow up between August 2006 and September 2007 were called for an interview. Results: 47 patients were interviewed. There were 39 (83%) women and 8 (17%) men. The median direct cost was US$ 1626 (451-11,009); ` 73,983 (20,521-500,910). The median indirect cost was US$ 312 (26-2,708); ` 14,196 (1,183-123,214). Total median cost was US$ 2,045 (488- 12,369); ` 93,046 (22,204-562,790). The median total costs of management of BDI was 9.98 times the costs of a cholecystectomy at our centre (US$ 205); (` 9,328) and was 8.41 times the median monthly income of the patients (US$ 243); (` 11,057). Conclusions: Our results will help the hospital administrators and the insurance agencies to calculate and revise the packages and premium for cholecystectomy so that the extra cost of a possible BDI is evenly distributed.

Salvage surgery in variceal bleeding due to portal hypertension.

BACKGROUND: A proportion (10%-15%) of patients with variceal bleeding do not respond to medical management and require surgical intervention. METHODS: Retrospective analysis of 82 consecutive patients (median age 31 years, range 3-71; 60 male) who underwent salvage surgery for variceal bleeding between 1989 and 2005. RESULTS: Immediate control of variceal bleeding was achieved in 78 (95%) patients. Four patients (cirrhosis 3, portal vein block 1) continued to bleed in the postoperative period following gastro-esophageal devascularization (3) or portacaval shunt (1). Twelve (15%) patients died in hospital; the commonest cause of death (n=7) was liver failure and sepsis leading to multi-system organ failure. The mortality rate was higher among patients who had undergone emergency surgery for active bleeding than among those who had been adequately resuscitated and evaluated prior to surgery (12/45 vs. 0/37; p< 0.001). Mortality rate tended to be higher in patients with cirrhosis (overall 10/45 [22%]; Child A 1/9 [11%], Child B 4/20 [20%], Child C 5/16 [31%]) than in those with non-cirrhotic portal hypertension (3/37 [8%]; p=ns). CONCLUSIONS: Our data suggest that salvage surgery is justified in patients with variceal bleed in whom non-surgical measures fail.

Xanthogranulomatous cholecystitis: differentiation from associated gall bladder carcinoma.

Xanthogranulomatous cholecystitis (XGC) is a destructive form of chronic cholecystitis. In some patients it coexists with gall bladder carcinoma (GBC) and is often difficult to differentiate between the two. Present study was performed with an aim to identify differentiating features of XGC and those of XGC with associated Gall bladder carcinoma (XGC ass. GBC). A retrospective analysis of prospectively maintained data of 4800 cholecystectomies performed from January 1988 to December 2003 was carried out. On histopathology 453 cholecystectomy specimens revealed XGC. These patients were divided into two groups, those with associated GBC (n=26) and those without GBC (n=427). Clinical, radiological and operative findings were compared in these two groups. P value of < 0.05 was considered statistically significant. The incidence of associated GBC in present series was 6%. XGC patients with associated GBC, at presentation were older than those with XGC alone and there was male preponderance. XGC patients with associated GBC were more likely to present with anorexia, weight loss, palpable lump and jaundice. Gall stones were present in majority of patients in both the groups. GB wall thickening, GB mass, enlarged abdominal lymph nodes may be found on imaging in both the groups but more so in patients with associated GBC. Both preoperative FNAC and peroperative FNAC/imprint cytology failed to reveal the associated GBC with XGC in some patients.

Surgical management of corrosive strictures of stomach.

BACKGROUND: Corrosive injuries of the upper aero-digestive tract are a frequent cause of morbidity in India. We report here our institution's experience in managing patients with corrosive strictures of the stomach. METHODS: Records of 28 patients who underwent definitive surgery for corrosive strictures of the stomach in our institution over a 15-year period were reviewed. RESULTS: The main presenting complaints were vomiting (75%), dysphagia (46%) and significant weight loss (100%). Pre-operative evaluation included barium and endoscopic studies. Most patients had antro-pyloric strictures (n=22); in 6 patients, however, near-total or total gastric involvement was observed. Thirteen (46%) patients had associated strictures of the esophagus; of these, 7 responded to esophageal dilation. Strictures of the stomach were managed with resectional procedures like distal gastrectomy (n=16), subtotal gastrectomy (1) or total gastrectomy (3) and esophagogastrectomy (1) in 21 (75%) patients. The remaining 7 patients underwent bypass procedures like gastrojejunostomy (5), stricturoplasty (1), and colonic bypass of esophagus and stomach (1). Three patients had entero-cutaneous fistulae in the postoperative period. One patient died in hospital of septicemia and malnutrition. CONCLUSIONS: In patients with corrosive strictures of the stomach, surgery, tailored according to the extent of gastric involvement and presence of associated esophageal strictures, gives excellent results.

Morphological changes in bile ducts following preoperative biliary stenting.

OBJECTIVES: To analyze the morphological changes in bile ducts following endobiliary stent insertion, and consequent technical problems encountered at surgery. METHODS: Data on bile duct morphology--gross (luminal diameter and wall thickness) and microscopic (histological changes in bile duct wall graded semiquantitatively)--and operative parameters related to bile duct dissection (grade of difficulty in dissection) were collected prospectively in 31 consecutive patients undergoing pancreatico-duodenectomy. These data were compared between patients who had undergone preoperative endoscopic biliary stent placement (n=17) and those who had not (n=14). RESULTS: Mean duration of stenting before surgery was 34 (range 10-120) days. Stented ducts were significantly narrower (luminal diameter 9 [7-12] mm vs. 17.5 [8-23] mm; p=0.0001) and had thicker walls (2.3 [1.3-3.5] mm vs. 1.85 [0.8-2.2] mm; p=0.004) compared to non-stented ones. On microscopy, stented ducts had advanced grades of submucosal gland hypertrophy, fibrosis and inflammatory cell infiltrate. Difficulty in bile duct dissection was encountered more often in patients who had been stented than in those without stents, though the difference was not statistically significant. CONCLUSION: Endobiliary stent placement results in significant morphological and fibroproliferative inflammatory changes in bile ducts, making dissection difficult.

Large Brunneroma presenting with bleeding.

Brunner's gland adenoma (Brunneroma) is a rare entity. We report a patient who presented with severe anemia due to bleed from a large Brunneroma arising from the duodenal bulb, and was managed successfully by surgical excision of the tumor.