Pancreatic carcinoma

Pancreatic adenocarcinoma is recognized as one of the most lethal of all cancers. The disease is usually diagnosis when it is advanced for claiming cure. At the time of diagnosis, it is estimated that the tumour is confined to the pancreas in less than 10%, with 40% of patients have locally advanced disease, and 50% have distant spread. Most patients with this disease face a very poor prognosis, with only 17% will be alive one year after diagnosis. The median survival for resection alone is between 18 and 20 months. The current 15% to 22% 5 year-survival rate of patients with resected tumours is still poor. Improvements in surgical technique, preoperative staging, patient selection and perioperative management have substantially reduced the postioperative morbidity and mortality rate of patients with this malignancy. In this report we review the advances achieved at the various stages of management of patients with this diseases

Ventral hernias - a study of 77 patients

This report presents experience in the management of 77 patients with ventral hernias. The female to male ratio was 2.8:1, and the mean age of patients 44 years and 50 years for females and males respectively. Midline hernias were the commonest [80.5%] and the size of the defect was> 10cm in 37.7% of the cases. Previous general surgical procedures were recorded in 55.8% of the patients, and gynaecological operations in 37.7% of the cases. In 39% of the patients, the hernia was recurrent after one to three attempts at repair. Various possible predisposing factors to the development of incisional hernias were studied and evaluated. Among these were: 1] weight over 100 kg - [49.4%], 2] the use of absorbable sutures [45.5%], 3] multiple [more than 4] full-term pregnancies [31.2%], 4] history of wound infection [26%], and 5] history of more than one laparotomy [24.7%]. Emergency operations were carried out in 7.8% of the patients. Depending on the condition of the abdominal wall and the size of the hernial defect, 5 different repairs were performed. Additional operative procedures were carried out in 28.6% of the patients. There was no mortality; minor postoperative complications developed in 18.2% of the cases. An overall recurrence rate after a follow-up period of 2 to 6 years [mean 4 years] was 2.6%, or 6.9% for hernias> 10 cm in size. It was concluded that carefully dissected abdominal wall layers can be utilised in the majority of patients. Using the procedure of preoperative controlled reduction of large hernias will facilitate the repair with less postoperative complications. Synthetic material closure was only used in 3 patients

Maxon: a new synthetic monofilament absorbable suture for gastrointestinal anastomosis

In a controlled clinical trial, Maxon sutures were assessed in twenty five patients who required various gastrointestinal anastomosis. In another twenty five cases, Vicryl [R] and Silk sutures were used. In both groups of patients, there was no abnormaltiy, and post-operative complications developed in two cases of the Maxon [R] and control groups respectively. None of these complications were related to sutures or anastomotic dehiscence. The handling characteristics of Vicryl [R] and Silk were rated excellent. 3/0 Maxon [R] was rated excellent and in four out of nine patients in whom 2/0 Maxon [R] was used, it was rated acceptable, but improved to excellent in the other five cases, as adaptation to the handling of the suture improved

Clinical and bacteriological assessment in cholelithiasis

In a prospective study of 195 patients who underwent cholecystectomy, 184 [94.4%] cases had bile bacteriological studies. Positive cultures were found in 36 [19.6%] patients. E. Coli, Streptococcal strains, Klebsiella and Enterobactor were the commonest organisms isolated. The highest incidence of positive bile was in those patients who were over 60 years old [36.4%], those who had bilio-enteric fistulae [100%], acute cholecystitis [60%], and choledocholithiasis [50%]. Diabetic patients had a 28.6% incidence rate. Prophylactic antibiotics were given selectively to 39 [21.2%] high-risk patients. wound infection developed in 15 [8.2%] patients. Ten of these had positive bile, making up 27.8% of the total cases who had positive cultures. The other 5 cases had sterile bile, making up 3.4% of the total cases who had sterile bile. In the first group, wound and bile bacteria were the same in all cases except in one [90%] It was concluded that in patients with cholelithiasis, prophylactic antibiotics can be restricted to the high-risk group

Giant fibroadenoma of the breast

Two cases of giant fibroadenoma of the breast are presented. The pathology, diagnosis and treatment of these tumours are briefly discussed

Renal carbuncle

A case of renal carbuncle was diagnosed with ultrasonography and computed tomography. The case was successfully treated with surgical open drainage

Evaluation of per-operative cholangiography

In 264 consecutive cases with cholelithiasis undergoing cholecystectomy, per-operative cholangiography [POC] was performed in 227[86%]. There were 204 [89.9%] true nagatives and the common bile duct [CBD] was not explored. False positives were seen in 2 [0.9%] cases. The CBD exploration was negative and subsequent T-tube cholangiograms were satisfactory. In one further patient [0.44%], there was a false negative finding and in another 19 [8.4%], true positive findings were confirmed by positive CBD exploration. In 11 [4.8%] of them, CBD stones were unsuspected pre-operatively. The whole procedure time was from 5 to 20 minutes [10 minutes]. There was one mortality [0.44%] and wound infection was the only complication occurring in 13[5.57%] patients. We therefore advocate the routine use of POC since it can detect unsuspected CBD stones, and it shows clearly the anatomy of the biliary tract. It appears that it neither causes unnecessary delay in the operation time nor any increase in the complications

Abdominal tuberculosis

This is a report of 19 patients with abdominal tuberculosis. Nine patients presented with intestinal obstruction due to ileocaecal involvement, 3 had widespread disease with ascites, 2 presented with features similar to appendicular mass, 2 had ileal and extensive colonic involvement with ascites, 2 had colonic stenosis after completely healed lesions, and one patient presented with generalised peritonitis as a result of perforation from an ileocaecal lesion. Seventeen patients had laparotomies [15 resections and 2 biopsies], and the condition in the other 2 cases was controlled medically. There were no deaths or complications and post-operative anti-tuberculous treatment continued for one year

Carcinoma of the thyroid gland with unexpected rare complications

According to the Kuwait Cancer Registry [1971- 1982], thyroid cancer is the second most common cancer in females and the sixth in males. In this condition surgery is the main line of treatment which is usually followed by a good recovery and the least complications. In this report we are presenting the servere metabolic changes which developed in one of our cases who needed postoperative irradiation. The various factors contributing to the condition and their management are also discussed

Experience in peptic ulcer surgery

In a review of 218 patients with different peptic ulcer disease treated surgically over a nine year period, the occurence in males was found to be 3.7 times more than in females. The patients had a mean age of 41.6 years and a mean duration of symptoms of 9.8 years. Seventy-eight cases [35.8%] presented with ulcer complications [obstruction, perforation and bleeding] and 44 patients [20.2%] had emergency operations. Although the clinical features were suggestive, gastric secretion studies, barium meal and endoscopy were confirmative investigations to diagnosis. Duodenal ulcers were found in 88.6% of patients, gastric ulcers in 6.4%, oesophageal ulcers in 3.2% and stomal [jejunal] ulcers in another 1.8% of cases. Sixteen patients [7.3%] had previous operations for the same disease. Various operations were performed on all cases, and in 32 patients [14.7%], appendectomy and cholecystectomy were additional procedures to the surgery of the ulcer. There were 3 operative deaths [1.4%] all from the emergency operations group, and postoperative complications developed in 18 [8.3%] cases. Successful results were achieved in 200 patients [91.7%] and there were 18 failures

case of xanthogranulomatous pyelonephritis, portal hypertension and chronic calcular cholecystitis

Xanthogranulomatous Pyelonephritis is an uncommon and atypical form of chronic pyelonephritis with segmental or diffuse changes of the renal parenchyma[1,2]. These changes may involve the perinephric fat and may extend to other retroperitoneal organs[3]. Here we present another case. The patient admitted with massive hematemesis due to portal hypertension, was also discovered to have calcular cholecystitis, while the diagnosis of the renal condition was only confirmed after surgical exploration

Acute appendicitis

In a prospectie study of 132 patients with operative and histological proof of acute appendicitis, details of clinical features, and many laboratory and radiological investigations were made. The disease was found to be predominant among males in their twenties, who usually presented with central abdominal pain which then referred to the right iliac fossa. Only half of the patients had fever and tachycardia and the minority were constipated, while the abdominal findings were remarkable. Rectal examination was informative in more than half of the cases, and leucocytosis was present in 72.7% of the patients. Positive radiological findings directly related to acute appendicitis were detected in 55% of the cases. Drainage of the operative field even in gross soiling was not necessary, and antibiotics were only used in 36% of the patients. There was no mortality, but postoperative complications occured in 22 patients [16.6%]. Wound sepsis, which occured in 20 cases [15%], had a significant relationship to the pathological status of the appendix. Those who had gangrenous-perforated appendix had about a 7 times greater chance of developing wound infection than others

Bilharzial anuria

In a series of 451 patients affected with bilharzial ureteric strictures, anuria developed in 24 cases [5.3%]. All patients were males with a mean age of 35 years. Five of the cases had preious unilateral nephrectomy. Two had middle third ureteric strictures, while all others had lower third strictures. On admission all patients appeared ill and had their blood urea and serum creatinine around 300mg/100 ml and 12.5 mg/100 ml respectively. Nephrostomy was performed in all cases. Following this, one patient died, 3 had complications and 8 out of 19 cases who had bilateral nephrostomy were discovered to have a unilateral functioning kidney. After an average period of two weeks, their general condition was improved and all 23 patients were operated on to rectify their ureteric strictures. Following this, 3 cases developed wound infection and there was no mortality. When they were discharged, all patients had improvement in their renal function. Within one month 2 cases had normal levels of their blood urea and serum creatinine, which remained so over two years follow up. While in all other patients, after an initial improvement in their blood urea and serum creatinine, continuation of these tests showed above normal levels during the period of follow up. It was observed that preliminary percutaneous nephrostomy in anuric bilharzial patients improves renal function significantly. Surgery should always be attempted and long term results depend on the quality of preserved renal tissues