Biliary bypass surgery - Analysis of indications and outcome of different procedures

This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. This is a prospective observational study conducted over a period of 10 years [January 2001-december 2010]. A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct [CBD] stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy [both open and laproscopic] during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. Out of 1500 patients 83 [5.53%] required biliary bypass surgical procedures. The CBD stones were observed as the most common indication [25.3%], followed by CBD injuries after open [10.84%] or laproscopic-cholecystectomy [14.46%], carcinoma head of pancreas [12.05%] and CBD obstruction [14.46%] either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy [26.51%] was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy [i.e. 25.3% and 12.05% respectively]. Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases

Role of laparoscopy in peritonitis

Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. The conventional open surgery for peritonitis carries significant morbidity and mortality. The present study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients. This was a prospective study spanning over a period of four years. All those patients diagnosed as having peritonitis on clinical assessment and preoperative investigations and those who were stable enough haemodynamically were included in this study. After initial resuscitation for few hours, they underwent diagnostic and therapeutic laparoscopy to identify the cause of peritonitis and to confirm the pathology. All cases were done under general anesthesia, using three standard ports at appropriate sites according to pathology. Patients were treated by different procedures either laparoscopically or with laparoscopic assistance after diagnosis. Operative and post operative data was collected and analyzed. Ninety two cases of peritonitis underwent diagnostic and therapeutic laparoscopy. Mean age of patient was 46.5 years. 24 patients were diagnosed as perforated duodenal, in 14 [58.3%] patients laparoscopic suture repair was done and in 8 [33.3%] small upper midline incision was given and perforation was repaired. Out of 32 patients having perforated appendix, 25 [78.1%] patients laparoscopic appendectomy was done while in 7 [21.8%] perforation was dealt by laparoscopic assistance. Out of 14 patients of ileal perforation 6 [42.8%] with minimal contamination laparoscopic suture was applied, while in 8 [57.1%], perforated loop was brought out by making small window and perforation was closed. All 22 patients with pelvic sepsis needed only aspiration of pus and peritoneal lavage. Only one patient died post operatively and 2 [2.1%] patients developed fistula. 6 [6.5%] patients developed port site infection. Laparoscopic management is feasible, safe and effective surgical option for patients with peritonitis due to different abdominal emergencies in properly selected cases with higher diagnostic yield and a faster postoperative recovery

Laparoscopic management of hydatid cysts of the liver at a tertiary care hospital

To evaluate the feasibility and safety of laparoscopy in the management of hydatid cysts. All consecutive patients diagnosed with liver hydatid disease were offered laparoscopic management. We performed select conservative procedures using standard laparoscopic instruments after sterilization of the cysts with 20% hypertonic saline. Deroofing, evacuation and partial cystectomy were performed. Omentoplasty was performed, and a drain was placed in the cyst cavity. A total of 63 patients [M:F=48:15] with 75 cysts were managed successfully by laparoscopy. The mean age +/- SD of the patients was 38.59 +/- 11.46 years old. The mean operative time +/- SD was 88.24 +/- 23.52 minutes [range: 52-145 minutes]. The mean size of the cysts was 9.2 cm [range: 5.8-16.5cm]. The mean hospital stay +/- SD was 3.49 +/- 1.16 days [range: 1-7 days]. There was no disease or procedure related mortality. Recurrence of a cyst was observed in 3 [4.76%] cases. Open surgery had to be performed on four patients. There were no major complications; minor biliary leaks were observed in 7 cases and cavity infections in 5 cases. The mean follow-up +/- SD in 51 patients was recorded as 28.9 +/- 31 months. Laparoscopic treatment of hydatid cysts of the liver is safe and effective, with low morbidity and a low recurrence rate in uncomplicated cysts. Despite some of its limitations, the procedure is a good alternative to open surgery in select cases.

Post laparoscopic cholecystectomy exploration: an audit

This study was conducted to analyse the different causes and factors for exploration and their management after laparoscopic cholecystectomy in 1000 cases of cholelithiasis. This is a prospective study conducted in the department of surgery Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, from January 2003 to December 2010. Thousand cases of cholelithiasis were operated for laparoscopic cholecystectomy in eight years and were observed for their recovery and complications postoperatively. Those patients who developed major problems were assessed clinically and by different investigations like LFT, Ultrasound, CT scan and HIDA scan to find out the cause. They were operated once absolute indication of exploration was made. All patients were included in study after getting informed consent for first operation as well as for Re-do surgery if any one required exploration. Out of 1000 cases, 58 patients [5.8%] developed unidentified complications during laparoscopic cholecystectomy who required surgery for one or other reason. The problems which required exploration were bleeding in 2.2%, biliary leak in 1.9% and obstructive jaundice in 1.0% of cases as main reasons. The cases were managed by various open surgical procedures depending upon the pathology found on exploration. Laparoscopic cholecystectomy though proved as gold standard for cholelithiasis but still is not free of complications and can land up into major problems for patients who had either difficult cholecystectomy or over looked congenital anomalies of biliary tree

Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis

To compare the results of conventional open with laparoscopic cholecystectomy regarding their operative time and postoperative parameters. This is a comparative study of 400 patients of cholelithiasis operated for either open or Laparoscopic cholecystectomy during five years from January 2004 to December 2008. The cases were compared for operative time and various postoperative parameters in order to assess the advantages and disadvantages of each procedure. The patients were divided into two groups; group OC for open and group LC for laparoscopic cholecystectomy, each comprising of 200 cases. The operative time was longer in OC than LC patients with mean operative time of 54.16 +/- 11.94 minutes in OC and 46.89 +/- 14.83 minutes in LC group [P<0.001]. The overall frequency of postoperative complications was relatively high in OC group 50.5% as compared to LC [37%] including all minor and major problems with combined morbidity of 43.75% [P<0.001]. The mean hospital stay was shorter in LC group as compared to OC group i.e. 3.02 +/- 1.75 [range 1-5] days versus 5.56 +/- 9.8 [range 4-10] days respectively. Return to normal work was also significantly shorter in LC group i.e. 18.06 +/- 5.16days [range 1-4 weeks] as compared to 31.61 +/- 7.6 days [range 3-6 weeks] in OC group with p value <0.001. The laparoscopic cholecystectomy is superior to open cholecystectomy due to short operative time, early mobilization and fast recovery, less postoperative pain and complications, short hospital stay and early return to work

Early appendicectomy in appendicular mass - A Liaquat university hospital experience

Appendicular mass is a well-known complication of acute appendicitis. It is conventionally treated conservatively followed by interval appendectomy. This study aimed to determine the feasibility and safety of an early appendectomy in these cases. Descriptive and comparative. Department of Surgery Liaquat University Hospital, Jamshoro/Hyderabad from March 2003 to December 2007. One hundred and seventy six [176] patients with appendicular mass were included in this study. Patients were conveniently divided into two groups, A and B with equal distribution of cases [88 Patients each], regardless of age and sex. Immediate appendicectomy was performed in group A patients after preliminary investigations, where as patients in group B were initially treated conservatively followed by interval appendicectomy. A total 114 [64.8%] males and 62 [35.2%] females with a mean age of 25.09 years [Range 8-44 years] are included in the study population. Post-operative wound sepsis occurred in 17 [19.31%] patients in group A. Treatment failure, patient compliance, re-admission and overall expenses are main limitations in group B population. Early appendicectomy is a safe and superior option in patients with appendicular mass compared to conventional treatment

Laparoscopic cholecystectomy in the elderly patients. An experience at Liaquat University Hospital Jamshoro

Advancing age with its associated co-morbidities increases the likelihood of postoperative complications as well as conversion rate during laparoscopic cholecystectomy. Recent studies have also questioned efficacy of this procedure in geriatric patients. The present study assesses the safety and applicability of laparoscopic cholecystectomy in geriatric patients. The objective of the present study was to asses safety and applicability of laparoscopic cholecystectomy in the elderly patients of 65 years and above. This is a prospective analysis of 173 patients, over 65 years of age, who underwent laparoscopic cholecystectomy from December 2002 to November 2006 at Liaquat University Hospital, Jamshoro. Patients presenting with complicated and uncomplicated gallstone disease were included in the study population and all of them were operated laparoscopically. The data included demographic details, co-morbidities, underlying biliary pathology, indications for surgery, operative and postoperative complications, morbidity and mortality, and hospital stay. The statistical analysis of the data performed on SPSS version 10. Laparoscopic cholecystectomy undertaken in 173 elderly patients with a mean age of 69.72 years, out of whom 52 [30.05%] were males and 121 [69.94%] were females. Co-morbid conditions were identified in 53.17% [n=92] patients and included hypertension in 38 patients [21.96%], Diabetes Mellitus in 23 patients [13.29%], COPD in 19 [10.98%] patients, Coronary artery disease in 9 [5.20%] and cardiac arrhythmias in 3 [1.73%] patients. Indications for surgery included simple biliary colic in majority of patients [69.94%] and complicated stone disease in 52 [30.05%] subjects. There were 37 [21.38%] emergency laparoscopic cholecystectomies and 136 [78.61%] patients were operated electively. Mean operative time was 100 minutes with a SD 29.03. Fourteen [8.09%] patients required conversion to OC [Open Cholecystectomy] due to various reasons. Mean hospital stay was 6.28 days. Overall 23 [13.29%] patients developed postoperative complications. One patient died of acute MI on 2nd postoperative day. There is no undue risk in laparoscopic cholecystectomy in the elderly population and the procedure can be regarded as safe as in patients below 65 years of age

Synchronous bilateral testicular tumors

Synchronous bilateral testicular tumors are a rare entity. One such case of an elderly male is reported who presented with bilateral painless testicular swellings of 3 months duration. After clinical workup, provisional diagnosis of bilateral testicular tumors was made and bilateral orchidectomy was performed. Histopathology report revealed bilateral seminoma