Laparoscopic-assisted enterolithotomy for gallstone ileus.

Gallstone ileus is a rare complication of cholelithiasis seen usually in elderly population with comorbidities. Most of the cases present as acute intestinal obstruction with the diagnosis being made intraoperatively. There exists controversy regarding appropriate emergency surgical treatment of gallstone ileus as to whether biliary tract surgery should be done during the first operation. Laparoscopy in recent years is also being used for management of such cases. We report a case of gallstone ileus diagnosed preoperatively and successfully treated by laparoscopic-assisted enterolithotomy.

Reuse of single-use devices: looking back, looking forward.

The reuse of medical devices marked as 'single use' by manufacturers has been going on for several decades. The process has been rationalized and legislated in the West as well as in Japan. However, the practice continues in an unregulated manner in India due to a paucity of guidance from the Food and Drug Administration in India. We trace the evolution of reuse policies, look at the prevalent practices in the Indian and international contexts, analyse the available Indian literature and address the ethical and economic implications of reuse. We also suggest some guidelines which may be adopted to formulate policies.

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BACKGROUND: Laparoscopic fundoplication (LF) has become the operation of choice for patients who need surgery for gastro esophageal reflux disease (GERD). Several studies have shown that the long-term results with surgery for GERD are better than medical therapy. In this retrospective study, we outline our experience with LF over an 8 year period. We analyzed factors that would affect the results of surgery and help in a better selection of patients for the operation. MATERIALS AND METHODS: From 1999 to 2007, 107 patients underwent a LF. Eighty five patients had surgery for GERD and form the basis of this article. The other 22 patients had paraesophageal hernias and were excluded from the study. Pre-operative evaluation consisted of endoscopy, a barium study, esophageal manometry and 24h pH monitoring. Patients were followed up every 3rd month for the 1st year, twice in the 2nd year and then annually. Follow up was by personal interview or telephonic conversation. At the last follow up the results of surgery were graded as good or poor as per a scoring system. Those with a poor result were evaluated and re-operation advised when an anatomical problem caused the poor result. Subjective, objective and technical variables were analyzed which could affect the outcome of surgery. RESULTS: In 84 patients, the operation was completed by laparoscopic access. One patient with bleeding was converted to open surgery. There were 5 intra-operative complications; 3 pnemothoracis, 1 esophageal perforation and 1 gastric fundus perforation. There was no mortality. Two patients underwent re-operation, 1 for delayed gastric emptying and 1 for dysphagia. Seventy four patients have been followed up from 7 months to 8 years. Eleven have been lost to follow up. Fifty seven patients (77%) have had a good result from surgery. Seventeen (23%) had a poor result; of these there were 4 wrap failures, 1 delayed gastric emptying and 1 excessive gas bloat as the cause. In 11 patients, there was no apparent cause of a poor result. Individual variables which predicted a good response to surgery (P<0.5); were a good response to proton pump inhibitors (PPis), volume reflux and a pH score of more than 14. CONCLUSION: LF gives good long-term relief of symptoms in patients with GERD. Strict selection criteria are necessary to optimize the results of surgery. Poor selection will result in a patient who is no better, or often worse than before surgery.

Laparoscopic-assisted ileo-colectomy for tuberculosis.

BACKGROUND: Laparoscopic-assisted colon resection (LACR) for benign disease has gained acceptance and has a lower morbidity than open surgery. Reports in Western literature have outlined the use of LACR for diverticulosis, ulcerative colitis, and Crohn's disease. We evaluated the use of LACR in patients with ileo-cecal tuberculosis (IC-TB) and describe our technique and results. METHODS: Twenty-six patients (20 F) between 16 and 45 years of age underwent a LACR for IC-TB over a 4-year period. Three access ports were used in 22 patients, four patients needed four ports. The cecum, ascending colon, proximal transverse colon, and terminal ileum were mobilized completely. The right colic vessels were divided intracorporeally. The specimen was delivered using a 5- to 6-cm incision. The ileo-colic pedicle and bowel were divided outside and an ileocolic anastomosis performed. After placing the bowel within the abdomen the pneumoperitoneum was recreated, saline irrigation done, and hemostasis achieved. RESULTS: No patient needed a formal laparotomy. Peristalsis returned within 48 h in 19 patients and after 72 h in the remaining seven. Oral liquids were started on all patients by the 3rd postoperative day (POD) and a soft diet by the 5th POD. Twenty patients had a bowel movement by the 4th POD and the rest by the 5th POD. Eighteen patients were discharged by the 5th day and the remaining by the 7th day. Three patients developed wound sepsis. Twenty-one patients could resume normal activity within 2 weeks, the rest within a month. CONCLUSION: Laparoscopic-assisted colon resection seems to be an ideal operation for patients with ileo-cecal tuberculosis. It has minimal morbidity and allows a quick return to normal activity.

Laparoscopic surgery for reflux esophagitis and paraesophageal hernia.

BACKGROUND: Laparoscopic surgery has become the standard for treatment of several abdominal diseases. We analyzed our data on laparoscopic treatment of reflux esophagitis and paraesophageal hernia. METHODS: Twenty patients (mean age 61 y; 14 men) - 18 with reflux esophagitis and sliding hiatus hernia, and two with paraesophageal and sliding hernia - were operated on using laparoscopy between March 1999 and March 2001. All patients were investigated by upper GI endoscopy, barium study and routine pre-operative work-up. Nineteen patients underwent a modified Nissen fundal wrap along with repair of the diaphragmatic crura; one patient had only crural repair with no fundal wrap. RESULTS: All procedures were completed laparoscopically. The mean operating time was 140 min (range 90 to 240). Eighteen patients were discharged on the third postoperative day and two on the fifth day. One patient had perforation of intrathoracic part of the esophagus during passage of an esophageal bougie; he presented with empyema 10 days after discharge and was treated by intercostal drainage. There were no other complications. All patients have been followed up on an outpatient basis for 3 months to 2 years. All are presently off acid-suppressive therapy. Seventeen patients are free of symptoms; two patients have gas bloat-like symptoms and one has occasional grade I dysphagia. CONCLUSIONS: Laparosopic surgery is a safe and effective method of treating esophagitis and paraesophageal hernia.

Complicated sigmoid diverticulosis.

BACKGROUND: To evaluate the outcome of patients treated for complications of sigmoid diverticular disease. METHODS: Fifteen patients (11 women; aged 54-80 years) were treated over a 6-year period in a community hospital. Five patients presented with perforation and peritonitis, 3 with colovesical fistula, 2 with colovaginal fistula, 2 with recurrent phlegmon and 3 with bleeding. Six patients (5 with perforation, 1 colovesical fistula with hematuria) underwent emergency surgery. Six patients (2 with colovesical fistula, 2 colovaginal fistula and 2 recurrent phlegmon) underwent planned sigmoid resection. All 3 patients with bleeding were treated conservatively. RESULTS: One patient with a colovesical fistula and severe hematuria died 72 hours later with septicemia. All 5 patients with peritonitis survived; two had an eventful post-operative period and were in hospital for nearly 3 months. All 5 developed wound sepsis. Six patients who had a planned procedure had uneventful recovery. The 3 patients who presented with bleeding recovered. CONCLUSION: Complicated diverticular disease carries a high morbidity and mortality especially when operated on as an emergency. Interval sigmoid resection should be offered to patients who have recovered from an acute complication.

Pseudoaneurysm of the hepatic artery along with common bile duct injury following laparoscopic cholecystectomy. A report of two cases.

Arterial injuries during laparoscopic cholecystectomy have been described frequently in literature. However, arterial injuries presenting in a delayed fashion as pseudoaneurysms are uncommon and the literature on the subject is also scant. Two patients are described here who developed pseudoaneurysms of the right branch of the hepatic artery following laparoscopic cholecystectomy along with lacerations of the common bile duct. One patient presented 7 days after the initial procedure with a bile fistula and bleeding from the drainage tube. The second presented as obstructive jaundice 4 months after the laparoscopic procedure. Both patients were operated upon after appropriate radiological evaluation. These are unusual complications but need to be kept in mind whenever patients present with bleeding or jaundice after laparoscopic cholecystectomy.

Endoscopic retrograde cholangiography in the era of laparoscopic cholecystectomy.

OBJECTIVE: To assess the value of endoscopic retrograde cholangiography (ERC) as an adjunct in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Four hundred and sixty consecutive patients with cholelithiasis were evaluated for LC over a four-year period (January 1991 to January 1995). Forty four (9.6%) patients underwent pre-operative ERC on a suspicion of harboring common bile duct (CBD) stones. Ten other patients who presented with acute gallstone pancreatitis also had pre-operative ERC as soon as the acute attack had settled. Endoscopic sphincterotomy (ES) and stone extraction were done if indicated. After LC, four patients underwent ERC for cystic or CBD related complications. RESULTS: Cannulation was possible in all patients undergoing ERC. Of 44 patients with suspected CBD stones, 33 (75%) actually had stones. In 30 patients the stones could be extracted. Three patients had large stones which could not be extracted. Of 10 patients with acute gallstone pancreatitis, CBD stones were found in only one. In the 4 patients who developed ductal complications, ERC was used to place stents in three and to extract a missed CBD stone in one. Three patients developed fever after ERC and three others had transient hyperamylasemia. There were no other ERC related problems. CONCLUSION: In patients undergoing LC, ERC is a useful adjunct both pre- and post-operatively.

Laparoscopic cholecystectomy: analysis of 100 cases.

OBJECTIVE: To study the efficacy and safety of laparoscopic cholecystectomy. METHODS: One hundred patients with symptomatic cholelithiasis were subjected to laparoscopic cholecystectomy. Preoperative ERCP and sphincterotomy were performed to detect and treat patients suspected to have associated common bile duct (CBD) stones on clinical, biochemical and imaging methods. RESULTS: Ninety patients underwent successful laparoscopic cholecystectomy. The mean operating time was 90 minutes. There were no deaths and morbidity was minimal (6%). Eighty five patients were discharged within 48 hours of surgery. In ten patients the procedure was converted to open surgery. Previous upper abdominal surgery; associated CBD stones; empyema gall bladder; and shrunken, non distensible gall bladder could make the laparoscopic procedure difficult and forewarn the surgeon about a possible conversion to open surgery. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective method of gall bladder removal.