Laparoscopic cholecystectomy; early vs delayed acute cholecystitis

The role of laparoscopic cholecystectomy in treatment of acute cholecystitis is still controversial. The objective of this prospective randomized controlled trial was to evaluate the outcomes of early laparoscopic cholecystectomy for acute cholecystitis and to compare the results with delayed cholecystectomy. Sheikh Zayed Hospital, Lahore. 1[st] Feb, 2012 to 31[st] July 2012. 60 diagnosed patients of acute cholecystitis were randomly allocated to two groups, Group 1 underwent early laparoscopic cholecystectomy [Group 1, n = 30] and Group 2 to initial conservative treatment followed by delayed laparoscopic cholecystectomy, 6 to 12 weeks later [Group 2, n = 30]. The overall complication rate was 3.3% [01] in early group and 16.7% [05] in the delayed group. There was no common bile duct injury in both groups. The complications included wound infection and intraperitoneal collection. According to the results our study we concluded that early laparoscopic cholecystectomy can safely be carried out for acute cholecystitis as the complications for early laparoscopic cholecystectomy are less as compared to delayed laparoscopic cholecystectomy. Early laparoscopic cholecystectomy has also an edge over delayed because of single hospital stay

Psuedoaneurysm of the right hepatic artery: a rare cause of obscure GI bleeding

A 63 years old female with 1 month history of hematemesis and malena, severe weakness and lethargy, for which she had upper GI endoscopies multiple times, but the source of bleeding could not be identified. Base line investigations revealed Hb of 6.0g/dl. CT scan abdomen showed cholelithiasis with air inside the gallbladder. The selective celiac axis / Hepatic artery angiogram revealed a right hepatic artery aneurysm [pseudoaneurysm]. After resuscitation with blood transfusion and fluids, the patient under went surgical exploration, revealing an aberrant right hepatic artery aneurysm bleeding inside the gall bladder with a cholecystodeudenal fistula [Mirrizi type III] into the 1st part of the deudenum form where the blood was leaking into the gastrointestinal tract and causing severe hematemesis and malena. A cholecystectomy, dissection of sleeve of liver bed, ligation of the aneurysmal bleeding vessel, repair of the cholecystodendenal fistula and placement of the T-Tube done. Post operative the patient remained stable and was discharged on 7th post operative day. Biopsy revealed acute on chronic cholecystitis and cholelithiasis. Biopsy of the aneurysmal wall revealed inflamed granulation tissue

Mesh versus non-mesh repair, eleven years experience at Shaikh Zayed Hospital, Lahore

Ventral Incisional Hernias are a well known complication after abdominal surgery with a reported incidence of 10% - 20% and a recurrence rate of 30% - 50% after open suture repair and less than 10% after open mesh repair. To compare the outcome of two different methods of open repair of VIH [i.e. Mesh versus Non-mesh or Suture Repair in terms of morbidity, complications and recurrence. 11 years period [January 2000 - December 2010]. Shaikh Zayed Hospital, Lahore. The total number of patients who underwent surgery for repair of VIH during the study period was 321.There were only 33 patients in Group A [simple suture/Keel repair] while Group B had 288 patients. The most common early postoperative complications seen in both the groups were wound seroma and infection. Post-operative respiratory insufficiency was more common in the obese. Chronic pain and feeling of foreign body was more frequently seen in the mesh group. On the other hand, recurrence rates were far greater in the suture repair group. The overall mortality in the whole series was 3 patients [0.93%]. The rates of ventral incisional hernia recurrence and complications are significantly lower after open onlay mesh repair as compared to the open suture repair. However, these results require confirmation by prospective randomized clinical trials which should also include the results of laparoscopic ventral incisional hernia repair which is a new and emerging technique in Pakistan

Managing small intestinal obstruction: a Sheikh Zayed Hospital experience

Managing intestinal obstruction continuous to challenge surgeons all over the World. Between January 2001 to December, 2004, 54 patients with maw to female ratio of 1.8:1 and mean age of 51 presented with small bowel obstruction. They were divided in to two groups; group A and B. Group A comprised of 30 patients [55%] and were managed conservatively. Whereas group B had 24 patients [44%] who required surgery. Conservative management was observed for 12 to 36 hours and beyond this time patients were explored in the face of deterioration. In group a, 83% patients had history of previous surgery whereas 17% patients had no prior surgical intervention. In group B 38% patients had abdominal surgery in the past whereas 62% had no previous surgical intervention. Predominant symptoms of bowel obstruction were abdominal pain, [100%] constipation [60%] and vomiting [48%]. Common causes of obstruction were post-operative adhesions 38% [n=7] obstructed hernias 25% [n=6] ileoceacal tuberculosis 21% [n=3] intestinal ischemia 8% [n=2] and ceacal carcinoma 8% [n=2]. Two patients died to septicemia, subsequent to anastomotic leak. We conclude that adhesive bowel disease and obstructive external hernias are the commonest causes of small bowel obstruction. A good clinical acumen and repeated clinical examinations are necessary to avoid the stage of bowel gangrene while managing small intestinal obstruction

Critical factors effecting morbidity and mortality in patients operated for typhoid ileal perforation

Typhoid perforation is the most important surgical complication of typhoid enteritis and is associated with a significant morbidity and mortality. To determine the factors affecting morbidity and mortality in patients with typhoid intestinal perforation, the complete medical records of a pool of patients from two major teaching hospitals of Lahore were reviewed. A total of 39 patients diagnosed to have typhoid Heal perforation at operation included 27 patients operated in the emergency of South Surgical Ward. Mayo Hospital Lahore from January 1998 to Dec 2000, and 12 consecutive patients operated by the surgical team of Surgical Unit II. Shaikh Zayed Medical Complex. Lahore between December 2000 to May 2005. The average age was 26 years, the male-to-female ratio 4/1. The mean interval from admission to operation was 09 hours [range 05 hours - 03 days]. Eight patients had more than one perforation at the time of operation. Primary repair of the perforation was performed in 22% of the patients, ileostomy [primary repair and proximal loop ileostomy or exteriorization of perforation as a loop ileostomy] in 46%. and resection with end ileostomy and mucous fistula in 32%. No primary end-to-end anastomosis after resection was performed. Postoperative complications occurred more commonly in patients with delayed admission and/or severe peritonitis. Hospitalization was shorter and the postoperative complication rate lower in patients who underwent ileostomy. Three patients developed an enter cutaneous fistula requiring re-operation. The four deaths [10.25% mortality] resulted from overwhelming sepsis. The most significant factors affecting morbidity were prolongation of perforation-operation interval and severe peritonitis. No single operative procedure is best in all cases: therapy should be individualized and tailor made for every patient. Ileostomy appears to be an effective and safe procedure, particularly in patients with severe abdominal contamination and delayed presentation. Early diagnosis, aggressive resuscitates tion with fluid and electrolyte optimization and prompt operation may result in improved survival in these seriously ill patients

Delorme procedure for complete Rectal Prolapse in young adults - an analysis of 7 cases

The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures. Delorme operation is a suitable procedure for elderly and/or medically unfit patients with rectal prolapse. However, good results have also been demonstrated for younger patients, suggesting that the operation may have wider application. From January 2001 to September 2003, 07 young adult patients underwent the Delorme repair of rectal prolapse in our unit with good results. The main outcomes measured were method of anesthesia, morbidity, mortality, recurrence rates, length of follow-up, and incontinence. In the 07 patients, the mean age of the patients was 24 years. The mean operating time was 55 minutes. Four patients were administered general anesthesia and 03 were administered spinal anesthesia. The mean postoperative stay was 05 days. No patients died as a result of th e procedure. Patients were followed up for 3 - 33 months. Preoperative incontinence was present in 02 patients, both of whom improved after the procedure. Postoperative incontinence was seen in only one of these patients but that too seemed to improve with time. No recurrent postoperative prolapse has yet been seen. None of the patients had complications that required operative intervention in the postoperative period. Although, the best operation for rectal prolapse remains a controversial subject, we believe that the Delorme Operation offers a promising option for the treatment of rectal prolapse even in young adults

Transduodenal Sphincteroplasty - still an effective biliary drainage procedure in the Laparoscopic era

With the advent of interventional endoscopic procedures and with growing experience with laparoscopic surgery, the indications for open biliary procedures have become limited. This prospective study reviews the changing trends in the indications of transduodenal sphincteroplasty and presents the short-term and long-term outcomes of this procedure in the present minimally invasive surgical era. Transduodenal sphincteroplasty was performed for various benign obstructive biliary pathologies. Various parameters recorded were the demographic data, indications for surgery, early and late complications and long-term outcome of the procedure. The changing trend in the current indications of the procedure was reviewed. Results of transduodenal sphincteroplasty on 49 consecutive patients over 9 years period are presented. Mean age was 48.4 years with male to female ratio of 1:3.4. Twenty-six [53.0%] patients presented with obstructive jaundice and 36.7% had cholangitis. Common indications of surgery included multiple common duct calculi [44.8%], impacted ampullary stones [36.6%] and ampullary stenosis [10.2%]. Overall hospital morbidity was 12.2% with zero mortality. After a mean follow up of 9.3 years, 95.9% patients had "good" or "fair" and 4.1% reported "poor" results. Most of the biliary pathologies may be dealt with laparoscopic and endoscopic procedures; open drainage procedures may still be indicated in selected patients. Transduodenal sphincteroplasty remains an effective biliary drainage procedure with acceptable morbidity and mortality. The procedure should be regarded as an essential in the general surgical knowledge and training