Prediction of difficult laparoscopic cholecystectomy on the basis of gallbladder wall thickness

To identify if gallbladder wall thickness is associated with technical difficulty during laparoscopic surgery and whether conversion to open cholecystectomy is more frequent in such patients. This prospective, non-randomized and descriptive study was conducted in Department of Surgery, Unit IV of Civil Hospital Karachi from December, 2010 to November 2012. Sixty four patients who underwent laparoscopic cholecystectomy were included. A fresh ultrasound was performed one day prior to surgery and gall bladder wall thickness of 3 mm was taken as predictor for difficult surgery. Various intraoperative parameters were recorded including total time taken, time taken to clear calots triangle and conversion to open cholecystectomy. Out of 64 patients, 4 [6.3%] were males and 60 [93.8%] were females. Age ranged from 22-65 years with a mean of 40.45 +/- 12.43 years. Gall bladder wall thickness ranged from 1-4.2 mm with a mean of 1.78 +/- 0.80 mm. Difficult laparoscopic cholecystectomy was encountered in 13 [20.3%]. In patients with difficult laparoscopic cholecystectomy the mean gallbladder wall thickness was 2.40 +/- 0.87 mm [p=0.001]. The mean age of patients with difficult surgery was 40.54 +/- 13.80 years. Mean operating time in patients with difficult laparoscopic cholecystectomy was 90.77 +/- 30.81 minutes as compared to 57.02 +/- 20.63 minutes in normal laparoscopic cholecystectomy [p<0.001] This study identifies and corroborates with the international literature that gallbladder wall thickness of 3 mm is associated with difficult cholecystectomy and higher rate of conversion to open cholecystectomy

Anatomical Variations Of Cystic Artery: Telescopic Facts

The introduction of laparoscopic cholecystectomy has stimulated a renewed interest in the anatomy of Calot’s triangle 1. This triangle is a focal area of anatomical importance in cholecystectomy and a good knowledge of its anatomy is essential for both open and laparoscopic cholecystectomy 2, 3. This triangle was described by Calot in 1891 as bounded by the cystic duct, the right hepatic duct and lower edge of liver 4. In its present interpretation the upper border is formed by the inferior surface of the liver with the other two boundaries being the cystic duct and the common hepatic duct 2,5. Its contents usually include the right hepatic artery (RHA), the cystic artery, the cystic lymph node (of Lund), connective tissue and lymphatics 5,6. The cystic artery is a branch of the RHA and is usually given off in Calot’s triangle 7. Anatomic variations in Calot’s triangle are common. Variations in cystic artery anatomy, based on its origin, position and number are well described 3, 8 because of its importance in avoiding inadvertent bleeding and its consequences. The reported incidence of these variations is from 25 to 50 % in various studies 3,9 with the magnified laparoscopic view having increased the frequency of recognition of these variations. The methods of retraction used in the laparoscopic procedure gives a different view of the area, thus introducing the term ‘laparoscopic anatomy’7. Accurate knowledge of cystic artery anatomy and its variations can reduce the likelihood of uncontrolled intraoperative bleeding, an important cause of iatrogenic extra hepatic biliary injury and conversion to open cholecystectomy 3, 7, 8. The incidence of conversion to open surgery due to vascular injury is reported to be 0-1.9% and its mortality 0.02% 3, hence these variations should stay in surgical conscience to prevent procedure related morbidity. We aim to present the variations in cystic artery seen in laparoscopic cholecystectomy in our patient population.

Triple hepatitis: frequency and treatment outcome of co/super-infection of hepatitis C and D among patients of hepatitis B

To determine the frequency of hepatitis C and D in patients of chronic hepatitis B and the treatment response of hepatitis B in such patients. Case series. Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005. All patients of hepatitis B presenting during the study period were screened for triple infection by carrying out anti-HBc [IgG], anti-HCV and anti-HDV. Patients who were positive to all three were included in the study. Complete Blood Count [CBC]; HBsAg; HBeAg; anti-HBc IgM; anti-HDV; anti-HCV; HBV DNA PCR; HCV RNA PCR; serum albumin; SGPT; serum bilirubin and ultrasound abdomen were acquired in all patients. All patients received pegylated interferon-alpha 2a 180 mcg sc weekly x 48 weeks. Patients who were also positive for HCV RNA also received ribavirin 1000-1200 mg/d po x 24 weeks for genotype 3 and 48 weeks for genotype 1. Descriptive statistics were used for describing the data. Out of the 246 patients of HBV, 29 [11.8%] patients were also positive for anti-HBc IgG, anti-HDV and anti-HCV. After 48 weeks of therapy, the respective viral undetection by PCR was 4 [13.8%] in patients having only HBV DNA, 3 [10.3%] in patients with only HCV RNA and in patients who had both HBV DNA and HCV RNA positive, simultaneously HCV was cleared in 2 [6.9%] while HBV was not cleared in any case. In patients coming with one hepatic infection, other infections should be sought as they share a common mode of spread and may affect the overall response to treatment

Treatment outcome in patients of hepatitis B with hepatitis D: experience of 4 years at a tertiary care centre in Pakistan

To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MID of interferon-a 2b. Quasi experimental study. Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005. All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DMA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-a 10.0 MID sc t.i.w. for 48 weeks. HBeAg and quantitative HBV DNA was done at week 0, 24 and 48 while CBC and SGPT were done monthly. HBV suppression was defined as levels <400 copies/ml. Fifty-two patients were selected for intervention, including 34 males and 18 females. At the end of therapy after 48 weeks, HBV DNA suppression was achieved in 51.9% and HBeAg became undetectable in 53.8% of patients. Twenty -one patients with HBV suppression still had raised SGPT. HDV should be screened in all patients eligible for HBV treatment

Frequency and comparative analysis of hepatitis in patients seeking treatment for hepatitis B

To find the frequency of hepatitis 'D' in patients of hepatitis 'B' seeking treatment and to compare clinical and biochemical features in patients harboring HDV with those who are not. Cross-sectional study. Medical Unit-IV, Civil Hospital Karachi, Medical Unit-VI and Surgical Unit-VII, Lyari General Hospital, Dow University of Health Sciences, Karachi; from July 2003 to June 2005. HBsAg positive patients seeking treatment were enrolled in the study. Anti-HDV was done in all. Patients were split into two groups according to their anti-HDV status into HDV positive and HDV negative groups. Liver biochemistries and viral profile for HCV, anti-HBc IgM and HBeAg were done and compared between the two groups. A total of 246 patients were selected. HDV was positive in 66 [26.8%] patients. No significant difference was observed in the frequency and stages of cirrhosis between the two groups while significant differences were observed in the mean SGPT [95% CI: -381.09 to -110.74; P = 0.001] and albumin levels [95% CI: 1.87 to 7.73; P = 0.007] and in the frequency of HBeAg [P = 0.001], anti- HBc IgM [P = 0.02] and HBV DNA [P < 0.001]. HDV infection was common in patients with HBV in this cohort of patients. All patients of HBV should be screened for HDV before treatment decision for the former is taken

Idiopathic gastroparesis

This case report describes a young female with idiopathic gastroparesis, who presented with persistent vomiting and weight loss. Treatment with erythromycin and tegaserod led to the recovery from symptoms and weight gain