Management of acute traumatic diaphragmatic rupture

The aim of this work is to describe the diagnostic and therapeutic work-up for the management of 13 blunt trauma cases with acute traumatic diaphragmatic rupture [TDR] in a single institution. This study was conducted at King Saud Hospital [350 beds], Al-Qassim Region, Saudia Arabia. All patients were resuscitated and underwent emergency chest x-ray examination, abdominal ultrasonography [US] and thoraco-abdominal CT. After hemodynamic stabilization, patients underwent exploratory lap-arotomy; through a midline incision to deal with injuries including repair of the diaphragmatic rupture. The study included 13 patients; 11 males and 2 females with a mean age of 38.6 +/- 7.6 years. Admission chest x-ray defined 5 cases with TDR; 4 left and one right rapture with a sensitivity rate o/38.5%. Preoperative CT scan was conclusive in 10 cases [including the five cases suggested by chest X-ray] with a sensitivity rate of 76.9%. There was a significant increase [X[2]=3.26, p<0.05] of diagnostic sensitivity with CT in comparison to chest x-ray. Concomitant injuries included liver laceration [n=2], splenic rupture [n=3], bowel injury [n=2], pelvic fractures [a = 4], rupture bladder [n=2], intracerebral hemorrhage [n=2]; and traumatic left below knee amputation in one case, either as a solitary injury or in combination. In all cases the diaphragmatic defect was identifed, herniated organs were gently reduced and the diaphragmatic defect was repaired using monofilament non-absorbable sutures and chest cavity was drained. Abdominal exploration showed isolated diaphragmatic tear without herniating viscera in 3 [23.1%] cases, herniated stomach in 6 [46.2%] cases, herniated omentam in 3 [23.1%] cases, herniated dome of the right lobe of the liver in one [7.7%] case, herniated spleen in 3 [23.1%] cases and herniated colon in one [7.7%] case, either alone or in combination. Nine cases had linear diaphragmatic defect, 2 cases had a V-shaped defect, one case had irregular laceration of the diaphragmatic copula and one case had a Y-shaped defect. Two patients died throughout the postoperative follow-up period with a mortality rate of 15.4%. It could be concluded that TDR should be suspected in all thoraco abdominal trauma and to be looked for during surgical exploration irrespective of the results of preoperative investigations. Chest radiographs and helical CT are the best screening tests for diagnosis of TDR

Mirizzi syndrome : a diagnostic and surgical problem

This study was conducted at King Saud Hospital [350 beds], Al-Qassim Region, Saudia Arabia; between December 2000 till May 2005. The aim of this work is to describe a series of 13 patients presented with obstructive jaundice and proved to have Mirizzi syndrome, at a single institution, submitted to surgical treatment and to comment on their aspects with emphasis on the diagnosis and treatment The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, type of Mirizzi syndrome according to the classification of Csendes et al, 1989, choice of operative procedures, and complications. The study comprised 13 patients [5 males and 8 females with mean age 58.2+9.3 years] with MS detected out of 1834 patients [0.7%] treated for cholelithiasis during the period of the study. Preoperative radiological examination succeeded in the diagnosis of MS in 6 cases; 2 cases by ultrasonography [15.4%], 4 cases by ERCP [30.8%], one out of 4 cases by CT [25%] and one out of 4 cases by MRCP [25%] and failed to diagnose 7 cases with a success rate of 46.2%. Surgical exploration through a right subcostal incision detected the presence of impacted stone in the infundibulum of the gallbladder or in the cystic duct of the all patients; there were 4 patients [30.8%] with MS type I, 3 patients [23.1%] had MS type II, 2 patients [15.4%] had MS type III and 4 patients [30.8%] had MS type IV. The surgical procedure done was cholecystectomy for patients with type I MS, Cholecystectomy, primary closure of the cholecysto biliary fistula and T- tube drainage of CHD for patients with MS type II. Patients with MS type III underwent cholecystectomy and choledochoduo denostomy, while cholecystectomy and Roux-en-Y hepatic jejunostomy were done for patients with MS type IV. Liver function tests returned to normal values in all patients within 43.8+20.7 days [range 30-70 days postoperatively] and the mean duration of post-operative and follow-up was 20.7+12.8 months [range: 6-48 months] with no postoperative major procedure-related complications or mortality. It could be concluded that MS is an uncommon form of benign obstructive jaundice identified with a frequency of 0.7% of patients with cholelithiasis. The preoperative diagnosis of Mirizzi syndrome is difficult and an awarded suspicion is necessary to avoid injuries of the biliary tree. The problem may only become evident during the operation due to firm adhesions around Calot's triangle. The success of the treatment is relate precocious recognition of the condition during surgery, and adapting the. management according to the individual characteristics of each case

Low-pressure pneumoperitoneum improves the outcome of laparoscopic cholecystectomy

Laparoscopic cholecystectomy [LC] is an advantageous procedure that widely replaced the traditional open cholecystectomy. However, highpressure pneumoperitoneum was accused for precipitating some intraoperative hemodynamic effects and postoperative shoulder-tip pain [STP]. The objectives of this study were to determine the influence of lowpressure pneumoperitoneum on the frequency and intensity of shouldertip pain and body hemodynamics in patients undergoing laparoscopic cholecystectomy. The study comprised 70 chronic calcular cholecystitis patients [25 men and 45 women]. Thirty-three patients [Group I] were assigned to undergo LC under high-pressure [13-15 mmHg] and 37 patients under low-pressure [7-9 mmHg] [Group II]. Intraoperative monitoring included measurement of heart rate [HR], systolic, diastolic blood pressure, and mean arterial blood pressure [MAP] was calculated. The frequency of postoperative STP was determined and its intensity was determined using visual analogue scale charts [VAS]. There was a significant [P<0.05] increase in MAP in both groups at 5 mm. after insufflation and after tilting the patient to reversed Trendelenberg position [RTP], but there was a significant decrease of MAP in Group II as compared to Group I [X[2]= 7.716, P<0.05]. There was a significant reduction of both frequency [13.5% vs. 33.3%] and intensity of STP in low-pressure group compared to high-pressure group. This difference was especially significant 6, 12, 24 hours postoperatively. Moreover there was a positive significant correlation between the insufflated pressure and the frequency [r=0.691. P<0.05] and intensity [r=0.612, P<0.05] of STP. There was a significant reduction of the amount consumed analgesic [declphenac potassium 75 mg/cc, amp.] in low-pressure group compared to high-pressure group. We can conclude that reduction of the pressure of the pneumoperitoneum to 7-9 mmHg results in a significant reduction of both the frequency and intensity of shoulder-tip pain and allows more stable hemodynamics of the patients through the duration of laparoscopic cholecystectomy. On the basis of these results, the widespread use of low-pressure pneumoperitoneum throughout most of a laparoscopic cholecystectomy procedure is recommended