Internal herniation of the anterior gastric wall through an attenuated Nissen Fundoplication wrap: an unusual complication and its laparoscopic management.

Laparoscopic Nissen fundoplication is the treatment of choice for medically refractive gastro-oesophageal reflux disease as it is considered safe, cost efficient and effective. Unusual variants of internal abdominal herniation, however, have been reported after the procedure. Here, we present a case of a 38-year-old woman who presented 3 months after a successful laparoscopic Nissen Rossetti fundoplication, with abdominal pain and persistent vomiting. Abdominal X-ray at the time of admission was normal but CT suggested internal herniation of the stomach. Laparoscopy confirmed internal herniation of the anterior wall of the stomach through an attenuated fundoplication wrap. We show that a prompt diagnosis of this complication, which we have not found reported previously in the English literature, can be achieved by CT, permitting an early laparoscopic intervention to preserve the viability of the obstructed segment of stomach.

Outcome of gall bladder polypoidal lesions detected by transabdominal ultrasound scanning: a nine year experience.

AIM: To determine the outcome of polypoidal lesions within the gall bladder (PLG) diagnosed by trans-abdominal scanning. METHODS: A nine-year (1993-2002) retrospective case-note review of all patients who underwent ultrasound scanning after referral to a single Upper GI Surgeon at a District General Hospital was conducted. Patients who were diagnosed with a PLG were included in our study. A database was constructed and patient details, investigations including ultrasound scan (USS) findings, treatment and histology and final diagnosis were recorded. RESULTS: Twenty-three (out of 651) patients were diagnosed pre-operatively by USS to have a polyp-like gall bladder lesion (PLG). Post cholecystectomy histological examination revealed 12 gallstones, 7 cholesterol polyps, 3 adenocarcinomas within polyps and 1 normal gall bladder. The specificity of USS in the diagnosis of PLG was 92.3%. All the true polyps were malignant. Overall USS had 66.66% sensitivity and 100% specificity in the pre-operative suspicion of malignancy. Using size greater than 10 mm as measured on USS as a cut-off, we find 100% sensitivity and 86.95% specificity with a positive predictive value of 50% in the diagnosis of malignancy in PLG. CONCLUSION: A large number of PLG are in fact calculi within diseased gall bladder. In cases of gall bladder polyps more then 10 mm in size on USS further imaging (cross-sectional and/or EUS) is indicated prior to surgery. This will help in the optimal management of patients and avoid histological surprises.

Use of fistula director to enlarge the port site opening to retrieve a stone packed bulky gall bladder during laparoscopic cholecystectomy: a simple and safe technique.

Retrieval of the gall bladder through the port site opening is technically difficult and challenging when it is bulky either due to packed multiple calculi or a large solitary calculus. We describe in this article a simple technique that involves enlargement of the port site opening to facilitate the gall bladder removal in these difficult situations, using a scalpel and a fistula grooved director.

An evaluation of vesical urodynamics before renal transplantation and its effect on renal allograft function and survival.

This prospective study investigated the urodynamics of the urinary bladder prior to renal transplantation in 57 patients and related this to graft function and transplantation outcome. The study demonstrated a clear deterioration in the pretransplant urodynamic characteristics in all subgroups, with male patients in the hemodialysis group (HD) showing a more substantial decline: 1st sensation volume (ml) in male HD patients = 112 (120) vs. 171 (173) in male CAPD patients, P < 0.05; and corresponding average flow rate for same groups 3 (3) ml/sec vs. 5 (5) ml/sec, P < 0.05. Figures are median (interquartile range). We have identified a subgroup of patients with a small bladder capacity (less than 100 ml) who have a reduced graft survival (55% vs. 92% for bladders larger than 100 ml at 2 years) apparently unrelated to immunological processes.