Tuesday, March 29, 2011

CASE: Sub Acute intestinal obstruction --- Ileal malignancy

73 yrs female with multiple episodes of intestinal sub acute obstruction
with nausea, constipation, distension of abdomen
ESR, Montoux, TB IgG/M/A : NEGATIVE

COLONOSCOPY: Normal colon except a small polyp in ascending colon, terminal ileum up-to 5 cm normal.

CECT: Terminal ileal stricture with proximal dilated bowel loops..
 


SURGERY : Laparotomy and EXTENDED Rt hemicolectomy and terminal ileal resection for ileal mass.




Histology : Ileal carcinoid spreaded upto serosa and 2/11 nodes positive.



CASE: DUODENO JEJUNAL INTUSSUSCEPTION

19 YR girl with acute abdominal pain and persistent vomiting
USG: S/o dilated stomach and duodenum
CECT S/O : Duodeno Jejunal Intussusception


 


SURGERY: Lap assisted reduction of Intussusception and resection & anastomosis of polyp baring segment of proximal jejunum.


Friday, March 18, 2011

CASE: NCPF + hypersplenism --> PSRS (Proxymal Spleno Renal Shunt)

35 yrs female with 5-6 yrs history of PORTAL hypertension (NCPF) non cirrhotic portal fibrosis
UGIE: S/O Grade 3 multiple columns of varices in GE junction, PGP+, IGV+.
DOPPLER : S/O Portal vein diameter 2 cm . splenic vein 12 mm. with multiple colaterals.& massive splenomegaly.Liver slightly bright in echotexture, left renal vein normal.

Clinically : pallor ++ with spleen reaching in RIF.

LFT : Normal
TLC : 2000./ cmm        Hb : 6 gm / dl
PLATELATE : 22,000 / cmm

SURGERY: SPLENECTOMY AND PROXIMAL SPLENO RENAL SHUNT.





CASE : Complete intestinal malrotation with Cecal Volvulus

38 yrs male
pain in abdomen for 3 days with differential abdominal distension more in LIF
Associated with constipation and nausea
p/h/o open appendectomy 15 yrs back from RIF incision..

USG : S/O volvulus of sigmoid colon
X RAY: S/O volvulus of colon arising from pelvis with few more air fluid levels
suspected diagnosis: Sigmoid Volvulus..

Sigmoidoscopy: normal...

CECT : Large bowel obstruction with ? p/o  Malrotation with kink midway ? cecal volvulus..with diameter of colon . >10 cm.. and dilated proximal bowel loops..



  



SURGERY:  (Exploratory Laparotomy): Derotation, untwisting and division of a LAD Band and repositioning of cecum in left iliac fossa (as this is a case of complete intestinal malrotation type 3) and decompression.






Thursday, March 10, 2011

CASE: CYSTO DUODENOSTOMY

21 Yr girl with h/o acute Idiopathic  pancreatitis 6 mths back
resolved with development of pseudocyst.

Significantly increasing in size and causing gastric outlet obstruction and visible lump..

CECT:




SURGERY: Cysto duodenostomy (the most Dependant portion of cyst)


Pt is now on oral diet and ready for discharge..

Tuesday, March 8, 2011

CASE: ACUTE MESENTERIC VENOUS THROMBOSIS & BOWEL GANGRENE

28 yrs male with pain in abdomen for 3 days
distension, nausea, Melena
Rising TLC and agony

CECT:

SURGERY: Laparotomy and resection of gangrenous segment of jejunum (as stated in scan with venous thrombosis) and stoma.
(1.5 liters of toxic fluid and gangrenous distal jejunum)





Pt about to go home... with distal mucus fistula feeding....

CASE: LAP. RETROPERITONEAL NECROSECTOMY

Monday, March 7, 2011

CASE: LAP. RETROPERITONEAL NECROSECTOMY

38 yrs male with Acute Necrotising pancreatitis
 TLC ; > 18,000, & Fever...Pain in abdomen with distension and discomfort...

S/O Infected Pancreatic necrosis.

CECT:
Infected pancreatic necrosis inlasser saac, and retroperitoneum
going in mesentery and behind descending colon


SURGERY: Total Retroperitoneoscopic necrosectomy
TIME : 3 hrs. BLOOD LOSS: 50 ML
1 Tray full necrosis & 500 ml of pus.
ICU STAY: 1 DAY  ORAL DIET : From day 2.

Surgery:

pre op left flank buldge
main lesser sac cavity
Infected necrosis

Total baring of mesenteric vessels and removal
of necrosis
drain placement
necrotic material

post op with just two drains


LAP SPLENECTOMY IN ITP with platelate of 8000

lap splenectomy video link........




Thursday, March 3, 2011

Bariatric Surgery

Long-term Prevention of Mortality in Morbid Obesity Through
Bariatric Surgery. A Systematic Review and Meta-analysis of
Trials Performed With Gastric Banding and Gastric Bypass

Antonio E. Pontiroli, MD, and Alberto Morabito, PhD

(Ann Surg 2011;253:484–487)

Background: Bariatric surgery has been reported to reduce long-term mortality in operated participants in comparison with nonoperated participants.
Methods: We performed a systematic review and meta-analysis of clinical trials published as full articles dealing with cardiovascular (CV) mortality, all-cause mortality (noncardiovascular), and global mortality (sum of CV and all-cause mortality). Pooled-fixed effects of estimates of the risk of mortality in participants undergoing surgery were calculated compared with controls.
Results: Of 44,022 participants from 8 trials (14,052 undergoing surgery and 29,970 controls), death occurred in 3317 participants (400 in surgery, 2917 in controls);when the kind of deathwas specified, 321 CV deaths (118 in surgery, 203 in controls), and 523 all-cause deaths (218 in surgery, 305 in controls) occurred. Compared with controls, surgery was associated with a reduced risk of global mortality (OR = 0.55, CI, 0.49–0.63), of CV mortality (OR = 0.58, CI, 0.46–0.73), and of all-cause mortality (OR = 0.70, CI, 0.59–0.84). Data of all-cause mortality were not heterogeneous; heterogeneity of data of
CV mortality decreased when studies were grouped according to size (large vs small studies). The reduction of risk was smaller in large than in small studies (OR = 0.61 vs 0.21, 0.63 vs 0.16, 0.74 vs 0.35 for global, CV, and all-cause mortality, respectively). The effect of gastric banding and gastric by-pass (3797 vs 10,255 interventions) was similar for global and all-cause mortality (OR = 0.57 vs 0.55, and 0.66 vs 0.70, respectively), different for CV mortality (OR = 0.71 vs 0.48). At meta-regression analysis, a trend for a
decrease of global mortality (Log OR) linked to increasing BMI appeared.
Conclusion: This meta-analysis indicates that (1) bariatric surgery reduces long-termmortality; (2) risk reduction is smaller in large than in small studies; and (3) both gastric banding and gastric by-pass reducemortality with a greater effect of the latter on CV mortality.

POST LAP - BILE DUCT INJURY


Specialist Early and Immediate Repair of Post-laparoscopic
Cholecystectomy Bile Duct Injuries Is Associated With an
Improved Long-term Outcome

(Ann Surg 2011;253:553–560)

The Liver Unit, University Hospital Birmingham, Queen Elizabeth Hospital,
Birmingham, United Kingdom.

Introduction: A majority of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy require formal surgical reconstruction, and traditionally this repair is performed late.We aimed to assess long-term outcomes after repair, focusing on our preferred early approach.
Methods: A total of 200 BDI patients [age 54(20–83); 64 male], followed up for median 60 (5–212) months were assessed for morbidity. Factors contributing to this were analyzed with a univariate and multivariate analysis.
Results: A total of 112 (56%) patients were repaired by specialist hepatobiliary surgeons [timing of repair: immediate, n = 28; early (<21 days), n = 43; and late (>21 days) n = 41], whereas 45 (22%) underwent repair by nonspecialist surgeons before specialist referral [immediate, n = 16; early, n = 26 and late, n = 03]. Outcomes after immediate and early repairs were comparable to late repairs when performed by specialists [recurrent cholangitis:11%, 12%, and 10%; P = 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01; nonsurgical intervention: 14%, 5%, and 24%; P<0.03; redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall morbidity: 21%, 14%, and 39%; P<0.02]. On multivariate analysis, immediate and early repairs done by
nonspecialist surgeons were independent risk factors (P < 0.05) for recurrent cholangitis [50% and 27%], re-stricturing (75% and 61%), redo reconstructions (31% and 61%), and overall morbidity (75% and 84%).
Conclusion: Immediate and early repair after BDI results in comparable, if not better long-term outcomes compared to late repair when performed by specialists.