ABSTRACT
Pancreatic ascites or internal pancreatic fistula is a known complication of chronic pancreatitis. This condition is associated with considerable morbidity and mortality. The management approach of pancreatic ascites in tropical calcific pancreatitis is infrequently reported owing to the low incidence of this condition. Between December 2005 and June 2007, 11 patients with pancreatic ascites with tropical calcific pancreatitis (male:female 7:4, mean age 29.5 [14.2] years) were treated. A retrospective analysis of patients who underwent endotherapy and surgery for this condition based on an institutional protocol was performed. The end point was resolution of pancreatic ascites and relief of symptoms. All patients had pancreatic ascites, and one patient also had pancreatic pleural effusion. Endoscopic transpapillary stenting was possible in nine patients (81 ). Identification of site of leak and placement of an endoscopic stent across the PD disruption was possible in five (45 ) patients. All these patients had relief of ascites. Mean number of endotherapy sessions required before control of ascites was 1.8. Among the remaining four (36.6 ) patients who had ERCP, placement of stent across the leak was unsuccessful; however stenting helped stabilize the general condition and nutritional status. These four patients and two patients who failed ERP underwent lateral pancreatojejunostomy surgery. Morbidity was observed in three patients who underwent surgery and one patient died due to sepsis and hemorrhage. All patients who had surgical drainage had complete relief of ascites and symptoms. In patients with pancreatic ascites in tropical calcific pancreatitis endotherapy and transpapillary stenting helps in resolution of ascites in nearly half of the patients. In the remaining patients preliminary conservative management followed by surgical pancreatic ductal drainage provides good relief of symptoms.
ABSTRACT
BACKGROUND: Crohn's disease is increasingly encountered in India. This paper reviews our experience with surgery for small bowel involvement in Crohn's disease. METHODS: Retrospective analysis of prospectively collected data of patients who underwent surgical resection for Crohn's disease during a period of 8.8 years from 1997-2006 at a tertiary care center. RESULTS: Twenty-eight patients (mean age 31.2 years; 18 men) underwent surgical treatment for Crohn's disease. The diagnosis was made only after surgery in 17 patients; 5 of them were receiving anti-tuberculosis treatment. The most common indication for elective surgery was subacute intestinal obstruction (n=15) followed by enterocutaneous fistula (3) and protein-losing enteropathy (2). Emergency surgery was performed in 4 patients who presented with perforation and peritonitis. Resection of the maximally involved segment and primary anastomosis was done in all elective cases. Resection and exteriorization of resected ends was done in patients who presented with peritonitis. Multiple strictureplasties combined with resection were done in 9 patients. Predominant colonic involvement was observed in 2 patients. The type of small bowel involvement included strictures (n=25), fistulizing disease (8) and perforation (6); 11 patients had more than one pathology. Postoperative morbidity was observed in nine patients; 6 patients underwent re-operation for anastomotic leak. Stoma had to be created in 11 patients either primarily or at re-operation, which could be closed after a median interval of 3.2 months. During a median follow up of 29 months, 3 patients required more than one hospital admission for abdominal symptoms. Pre-operative anemia, malabsorption and/or growth retardation, steroid and/or immunosuppressant therapy and mid small bowel resection had a negative impact on anastomotic integrity leading to anastomotic dehiscence. Indication for surgery, the type or extent of disease did not have any impact on postoperative morbidity. CONCLUSION: This retrospective analysis from a tertiary referral center indicates that sub-acute intestinal obstruction and perforation-peritonitis were the most common indications for surgery in Crohn's disease. Pre-operative anemia, malabsorption state, steroid/immunosuppressant and mid small bowel resection were associated with higher postoperative morbidity.