Complications in laparoscopic cholecystectomy

Objective: to list and understand the types and the rate of complications associated with laparoscopic cholecystectomy done by a small group of surgeons over a decade at four military hospitals PNS Shifa Karachi, CMH Rawalpindi, MH Rawalpindi and PNS Hafeez Islamabad

Study Design: observational and descriptive study

Place and Period of study: CMH Rawalpindi from January 2003 to December 2012 [10 years]

Patients and Methods: case records of all patients [both genders and all age groups] undergoing laparoscopic cholecystectomy over a period of ten years were reviewed. Fifteen hundred patients with a clinical follow up record of at least six months were included in the study. Complications were grouped into three main categories, per operative, early post-operative and late post-operative. They were further sub-grouped into major and minor categories. A major complication was regarded as one causing significant morbidity or likely to be potentially fatal if not treated expeditiously. Data analysis included calculation of the number of patients, rate and percentage of different types of complications

Results: complications occurred in 495 [33%] cases. Major complications occurred in 199 [13.27%] cases. In the remaining 296 [19.73%], the complications were labeled as minor. Conversion to open surgery occurred in 147 [9.8%]. Post-cholecystectomy laparoscopic re-intervention within 48 hours was done in 3 [0.2%] cases. There was one mortality due to septicemia following bowel injury

Conclusion: the risk of complications is a possibility in any patient undergoing laparoscopic cholecystectomy despite remarkable advances in instrumentation and video systems. Most common complication is hemorrhage [1.3%] followed by CBD injuries [.13%]. Due attention to risk assessment, patient and family counseling, importance of valid consent and a flexible approach to conversion to open surgery is stressed

Surgical palliation for unresectable pancreatic carcinoma

To review the results of surgical palliation for unresectable pancreatic carcinoma, and to analyze the morbidity and mortality associated with the surgical procedure. The reasons for readmission after discharge from the hospital were also analyzed. A retrospective study from 1995 to 2001 was done on 30 patients with pancreatic cancer operated with palliative intent, or those explored with curative intent but histopathology revealed positive resection margins or lymph node metastasis. Twenty-five [83.25%] patients were above 50 years of age. There were 16 [53.28%] male, and 14 [46.62%] females, 8 [26.64%] had diabetes mellitus, 2 [6.66%] chronic pancreatitis and 4 [13.32%] had smoking as risk factors. Twenty-three [76.59%] patients presented with jaundice, 18 [59.94%] with weight loss, 17 [56.61%] with epigastric pain, 15 [49.95%] with anorexia and 14 [46.62%] with vomiting. Whipple's procedure was performed in 9 [29.97%] patients, triple bypass in 13 [43.29%], choledochojejunostomy and gastrojejunostomy in 3 [9.99%] and gastrojejunostomy alone in 5 [16.65%] patients. Seven [23.31%] patients had preoperative ultrasonography, while CT Scan was done in 24 [79.92%] and ERCP in 8 [26.64%] patients. Histopathology showed positive resection margins in 9 [29.97%] patients and lymph node metastasis in 5 [16.65%] patients. Seventeen [56.61%] patients received less than 2 units of pack cells transfusion. Most of the patients remained admitted in the hospital between 20 to 30 days. Post-operatively, delayed gastric emptying was detected in 6 [19.98%] patients, cholangitis in 2 [6.66%], wound infection in 3 [9.99%], anastomotic leak in 2 [6.66%] and line sepsis in 2 [6.66%] patients. Three [9.99%] patients expired in hospital post operatively. The reasons for re-admission after discharge included abdominal pain in 9 [29.97%] patients, anemia in 3 [9.99%], intestinal obstruction in 3 [9.99%] and urinary tract infection in 2 [6.66%] patients. Follow up record was available for 22 [73.26%] patients. Six [19.98%] patients survived for 5 to 6 months and 9 [29.97%] had a survival between 7 to10 months. A single surgical procedure can palliate all three symptoms associated with unresectable pancreatic carcinoma, and can be carried out with reasonable safety in selected patients. The commonest indication for re-admission is severe abdominal pain associated with advanced malignancy, hence chemical splanchiectomy may also be considered at the time of surgical exploration

audit of laparoscopic cholecysstectomies performed at PNS Shifa

Open cholecystectomy used to be the gold standard for more than 100 years, now this has been taken over by laparoscopic cholecystectomy. The operation has proved its worth because of little post operative pain, minimal scar, reduced hospital stay [1-2 days] and convalescence 1 to 2 weeks as compared to open cholecystectomy. The only problem seems to be the proper training of surgeons for safety of the patient to avoid common bile duct [CBD] and other injuries