Malignant gastrocolic fistula; A masquerading cause for fresh bleeding per rectum

Male diabetic, hypertensive patient, aged 55 yr presented with weight loss, epigastric pain and recurrent vomiting with anorexia, and anemia [Hb 7 gm]. He had one attack of melena followed by passage of fresh blood per rectum once. Patient looked anemic, loosing weight and somewhat toxic. Laboratory profile showed hypochromic microcytic anemia and elevated ESR. Tumor markers and LDH were within normal. Stool test for Helicobacter pylori antigen was negative with normal liver

Repeat endoscopic biliary sphincterotomy: indications and complications

Endoscopic biliary sphincterotomy [EBS] carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography [ERCP] and repeat EBS is safe and feasible. However, long term results of repeat ERCP and EBS and risk factors for late complications are largely unknown. The aim of this study was to investigate indications and early complications after repeat EBS compared to patients with initial EBS, as well as the long term outcome of repeat ERCP with or without EBS for recurrent bile duct stones. Risk factors predicting late choledochal complications will be identified. Two groups of patients were included. The first group included 28 patients underwent repeat ERCP combined with EBS in 24 for post-EBS recurrent choledocholithiasis. The second group included 25 patients with symptoms of biliary obstruction and underwent ERCP and initial EBS. Early complications were compared for both groups. Patients in group I were followed for long term outcomes of repeat ERCP and EBS were assessed by multivariate analysis. Complete stone clearance was achieved in all patients in both groups. 16 patients in group 1 had no visible evidence of prior sphincterotomy. Early complications occurred in 3 patients in group I and 4 patients in group II. During a follow up period of 0.9 - 2.3 years [mean 1.4 yrs.] for patients in group I, 8 of them [28.5%] developed late complications including stone recurrence [5 patients], acute acalculous cholangitis [2 patients], and acute cholecystitis [1 patient]. There were no deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial EBS and repeat ERCP and EBS /= 15 mm., and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP with or without EBS in 4 patients. Repeat EBS is a safe and effective procedure to manage recurrent biliary and pancreatic complications after initial EBS. The commonest early indications in our study included bleeding at the time of initial EBS, small length of EBS and failure to continue the procedure due to cholangitis, and multiple stones with variable sizes with inability to clear the bile ducts through the initial EBS. Late indications were mainly due to suspected recurrent bile duct stones as indicated by upper right quadrant abdominal pain with elevation of cholestatic enzymes or jaundice, cholangitis, and bile duct lithiasis and dilation proved by ultrasonography. Tight stenosis of biliary orifice which is one of the indications of repeat EBS was not found in our patients. Early complications of repeat EBS are less than initial one. However late choledochal complications after repeat EBS are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with dilated bile ducts, periampullary diverticulum, or early recurrence. Repeat ERCP with or without EBS is a reasonable treatment even for recurrent choledocholithiasis after initial EBS

Improvement in co-morbidities following weight loss by vertical banded gastroplasty in super obese individuals

Vertical banded gastroplasty [VBG] is a safe, and effective operation to treat obesity. The amount of excess weight that must be lost to improve the co-morbidities in the super obese patients remain unknown. Eighteen super obese patients [BMI > 50 kg /m[2]] underwent VBG and were followed up for I-2 years to evaluate the improvement in the pre-existing co-morbidities. The mean BMI decreased from 62.2 +/- 7.1 to 39.7 +/- 6.1. The weight loss was associated with resolution of 76% of co- morbidities and improvement of 21%, while 3% remained unchanged. VBG was associated with resolution or improvement of a significant number of co-morbidities associated with super obesity

Laparoscopic cholecystectomy for the management of acute calcular cholecystitis

Although laparoscopic cholecystectomy is well accepted as the golden standard for the management of symptomatic choleslithiasis yet acute cholecystitis is still challenging the technique. To study the role of laparoscopic cholecystectomy for the management of early acute cholecystitis [within seven days of onset]. Patients: Two groups [twenty patients each]. Group I included patients with acute calcular cholecystitis who underwent laparoscopic cholecystectomy within seven days of onset. Group II included patients with chronic calcular cholecystitis for whom laparoscopic cholecystectomy was done. Plan: All patients of both groups had proper clinical assessment, routine laboratory investigations, liver chemistry profile and abdominal ultrasound. The classical four-trocar method of laparoscopic cholecystectomy was employed in all patients and modifications required for group I of patients were noted. The operative data, the postoperative course and recovery as well as the postoperative morbidity were analyzed in both groups. All patients were followed for at least six months postoperatively. The diagnosis of acute calcular cholecystitis based on clinical, laboratory and ultrasound findings together with operative assessment. Right upper quadrant abdominal pain, fever, leucocytosis and ultrasound findings [ultrasound guided Murphy's sign, thickened gall bladder wall, gall bladder distension and increased size, presence of gall stones and presence of pericholecystic fluid] were the commonest and most importtant features of acute cholecystitis. Laparoscopic cholecystectomy could be performed successfully in all patients of group II and in [18] patients of group I [90%]. Modifications required to accomplish the procedure in group I of patients included mainly partial decompression of the gall bladder [85%], the use of toothed graspers [85%] and enlargement of the port of exit of the specimen [80%]. Two patients of group I [10%] required conversion to open surgery [because of the presence of tough difficult adhesions obscuring the anatomy]. The operative time for group I was longer than that for group II, [98 +/- 30.4] and [66.4 +/- 17.7] min respectively. Postoperative course and recovery was similar in successful laparoscopic procedures of both groups except for a longer hospital stay for group I of patients [55.3 +/- 8.4 hours and 30 +/- 6.2 hours respectively]. There was no major postoperative morbidity or mortality in both groups. Patients of group I operated upon within three days of onset of symptoms had less operative difficulties, less intraoperative complications and less operative time compared to those operated upon after three days of onset [4-7]. Follow up revealed no complications related to surgery in both groups. Conclusions: Laparoscopic cholecystectomy is technically feasible for the management of majority of cases of early acute calcular cholecystitis with no added risks. It is better performed within the first three days of onset of symptoms. The operation is technically demanding time and effort consuming so should only be offered by experienced surgeons and conversion to open surgery should be interpreted as a wise alternative to potential serious complications

Proximal bile duct obstruction: surgical approaches to a difficult problem

Over a period of 5 years [September 1998 to September 2003], forty one consecutive patients with proximal bile duct obstruction [either bening or malignant] were referred to our department, all presenting with obstructive jaundice. Surgery was offered to patients with pruritus, cholangitis or both associated with jaundice. Twenty four patients were operated upon. Fifteen patients were benign and nine had malignant obstruction. Segment III bypass or left duct hypass were offered to the patients. One patient had resection of a Klatskin tumor with bilateral hepaticojejunostomy. The disappearance of jaundice and pruritus were noted. The mortality and morbidity were analyzed