Critical study of latrogenic bile duct injuries

latrogenic bile duct injury remains a serious and challenging complication following surgeries of the biliary tract, specially cholecystectomies. Numerous factors influence the outcome of repair of bile duct injuries. This prospective research was performed on 20 patients we received between May 1998 and March 2001, aiming to study different bile duct injuries following open or laparoscopic cholecystectomy as regards the type of injury. aiming of identification, the clinical presentation, methods of investigations and various modalities of correction and follow up. We received 14 cases after open cholecystectomy and 6 patients after laparoscopic cholecystectomy. 4 of them were recurrent after previous repair. One case was detected intraoperatively and primary repair was done while the time of presentation of the other cases ranged between days and 18 months. The main presentations were or biliary peritonitis. ERCP succeeded in treatment of 4 cases and one case was treated by percutaneous transhepatic dilatation and stenting. The other cases were treated either by primary repair in one case, delayed primary in one case, choledecro-doodenostomy in one case, cholectecro-jejunostomy in one case and 12 cases were treated by either Rouxen-Y or simple loops hepatico-jejunostomy. We had only one recurrence in a redo case which was treated by PTC dilatation and stenting. High or left duct approach offers good results in complicated or recurrent cases. Percutaneous transhepatic dilaration and stenting has to be considered first in recurrent cases

comparative study of clean surgical wound management with and without dressings

The covering of the primarily sutured surgical wound with a sterile dressing is ordinarily considered to be a routine conclusion to aseptic operations. Routine treatment of sutured clean surgical wounds with dressings is based on tradition and not scientifically supported. This prospective study has been completed on 40 patients. Their ages ranged from 25-46 years with an average of 34 years. The total number of exposed wounds showing colonization was 15 out of 20, only one case needed to be drained compared to 5 out of 20 cases of dressed wounds where also one case needed to be drained. The two cases which showed post-operative infection and needed to be drained were incision hernias, in which the operative time was long and the dissection was extensive. The study showed that routine covering of a primarily sutured clean surgical wound and a sterile dressing is not superior to the technique of keeping these wounds after the first post-operative day in the prevention of wound infection and must be reserved for badly sutured clean or clean contaminated wounds. Keeping the wound undressed has many advantages, the wound can be easily examined, patients are more easily able to carryout their personal hygiene, adhesive tap irritation is avoided and the wound without dressing appeared to heal more rapidly and with less local inflammatory reaction

Tumor necrosis factor in malignant tumours and endotoxemia

Tumor necrosis factor [TNF], also called cachectin, has been estimated using Enzyme Amplified Sensitivity Immuno Assay [EASIA] technique in the serum of ten controls [mean 11.3 pg/ml]. It was estimated also in 20 malignant patients: 10 of them with breast cancer and the other 10 with bladder cancer. The preoperative level mean was 28.73 and 38.06 pg/ml and the postoperative one was 29.2 and 40.68 pg/ml respectively. TNF level was found high in the malignant patients in the preoperative and postoperative samples in comparison with the control group and the difference was statistically significant [P <0.05]. The difference between the preoperative level and the postoperative one was not statistically significant. TNF was estimated also in 20 patients with sepsis syndrome, 10 of them have been subjected to indomethacin treatment and TNF level was estimated before and after its injection. TNF was found higher in septicemic patients compared to the control group and this increase was statistically highly significant [P <0.005]. TNF level decreased after indomethacin injection but this decrease was not statistically significant

Risk factors for wound infection after cholecystectomy

Biliary surgery in general, with cholecystectomy in particular, is a common major elective abdominal operation world wide. Wound sepsis after biliary surgery is an extraburden to patients, surgeon and nation. This prospective study completed on 160 patients [105 females and 55 males] undergoing biliary surgery at Kasr El-Aini Hospital. Their ages ranged from 30 to 70 years with an average of 44 years. The overall incidence of postoperative wound infection was 15%. Three major risk factors were detected for wound infection: Age patients above 60, other operative procedures added to cholecystectomy and contaminated bile. Bactibillia was an important endogenous source of postoperative wound infection which was detected in all cases of acute cholecystitis and in 7.5% of cases with calcular obstructive jaundice and in 60% of patients with stones in the common bile duct and have no jaundice. In 21 out of 24 of infected cases, the organisms isolated from wounds were the same as from the corresponding bile samples. Prophylactic antibiotic is recommended in patients with risk factors detected in this study, while routine antibiotic prophylaxis in simple cholecystectomy is probably unjustified

Pheochromocytoma: a clinical and operative study

Ten patients with pheochromocytoma were studied as regards clinical presentations, laboratory and radiographic investigations, preoperative preparation, anaesthesia, operative details and operative and postoperative complications.The results showed that the most common site of pheochromocytoma is the suprarenal medulla, the most commonpresentation is hypertension that the 24 hours urinary catecholamines was constantly raised in all patients. CT scan of the abdomen is the most accurate method of localization of the tumour, especially if it is of suprarenal origin.Preoperative preparation with alpha adrenergic receptor blockers is mandatory. Beta adrenergic receptor blockers may or may not be used. Surgical treatment is the ideal method in all patients. The most important operative hazards include hypertensive attacks during tumourmanipulation and hypertension following tumour removal. Persistent hypertention is the most important postoperative complication

study of the complications of thyroid surgery

This study included 250 consecutive cases undergoing thyroidectomy. The chief indications were nodular goitre [67.6%] and secondary toxic goitre [10%]. There were 132 males and 118 females whose ages ranged from 19 to 68 years. The routine technique involved cutting the strap muscles without exposure of the recurrent laryngeal nerves [RLN]. The majorcomplicationswereinjury to the RLN [2%], hypoparathyroidism [1.2%], reactionary hemorrhage [0.8%] and tracheal instability [0.4%]. The commonest minor complications were wound infection [8%], brawny edema of the upper skin flap [4%], laryngeal edema [2%], injury of the superior laryngeal nerve branches [1.6%] and adherent scar. The overall incidence of complication was 24.4%. Major complications occurred in 4.4% and 6.8% of patients suffered from more than one complication. There was a significantly higher incidence of major and multiple complications among the malignant, toxic and recurrent cases

Spontaneous healing of appendectomy wounds versus primary skin closure

Thirty patients with severely inflame dappendices under went appendicectomy were divided into two identical groups. In the first [control] group, all layers of the wound were primarily closed, while skin and subcutaneous tissues were left open for spontaneous healings in the second group.The wound was considered septic when pus discharged spontaneously and complete healing was considered when the scab separated leaving healthy epithelium

new method of staging bilharzial liver disease based on clinical, histochemical and 8-glutamyl transferase activity

The histochemical enzymatic activity in liver biopsies and gamma - glutamyl transferase activity were studied in 10 normal and 20 bilharzial cases. The hepatic tissue alkaline phosphatases were found to be slightly affected in the hepatocytes in the first and second stages of bilharzial liver fibrosis, while the sinusoidal reaction was augmented, but in the third and fourth stages, the activity was markedly diminished at both sites. The gamma -glutamyl transferase activity increased steeply with the progress of the disease. Upon clinical, biochemical, histochemical and gamma -glutamyl transferase changes a new more elaborate staging of the disease is suggested

Evaluation of three systems for preoperative hair removal in clean operations

Seventy five male patients were subjected to inguinal herniorraphy. The hair was removed preoperatively by 3 different system each applied to 25 patients. Group A patients were shaved the night before operation, group B were shaved the morning of operation and group C were subjected to depilatory cream the night before operation. Purbulent wound infection occurred in 16%, 4% and 4% in group A, B and C respectively. The mean preoperative bacterial count was 128, 28 and 32/cm[2] in group A, B and C in this orer. All wound infections of group A and B were caused by Staph. aureus that were present preoperatively [auto-infection], while the sngle infection in group C was caused by E. coli not present preoperatively and hence unrelated to the method of skin preparation. 36% of group A and 40% of group B patients complained of discomfort and itching due to hair regrowth; while 28% of group C patients, being males, did not welcome the use of cream as a method of hair removal

mutual interrelation between major surgical trauma and the immunological response as measured by spontaneous rosette formation

The cell mediated immune response was studied by rosette formation in 24 patients before and after major surgery. Nine patients [37.5%] showed preoperative reduction in the number of T lymphocytes, and these patients continued to be suppressed postoperatively. Out of the other 15 patients, nine cases [60%] developed a de novo postoperative fall in their T lymphocyte population; this can be attributed to operative trauma. Among the overall 18 immunosuppressed patients in the postoperative period, 12 developed infection, 5 had other complication, while one died. This last patient had both preoperative and postoperative reduction of T lymphocytes. Infection was encountered in all the 9 patients with preoperative immunodepression, but only in 3 out of the 9 patient who developed postoperative suppression; a finding that may point to greater role of preoperative reduction of T lymphocytes than surgical trauma in the pathogenesis of postoperative morbidity