Sunday, September 23, 2012

CASE: Liver laceration with tare - Emergency left hepatectomy

young female with 6 weeks amenorrhoea and h/o fall from 3rd floor height
and hemoperitoneum
CECT: S/O LIVER left lobe with seg 8 extension hematoma and laceration with moderate free fluid in abdomen
however pt remained hemodynamically stable for 2 days, Hb remained stable around 10 after initial transfusion of two PCV.

Developed distension, fever, sepsis on day 3
repeat CT S/o gross free fluid with increased non enhancing liver paranchyma (on aspiration found to have blood and bile mixed peritonitis)

taken up for surgery and EMERGENCY LEFT HEPATECTOMY with ligation of left hepatic ducts was done (confirmed with intra op cholangiography) along with MTP.
post op pat had minor biliary lieak from paranchyma draining 20 mlbile/day..and was discharged with drain on normal diet on POD 11.





CASE: Chronic pancreatitis with obstructive jaundice - LPJ With CDD.

36 male with h/o  chronic alcohol intake
having chronic pancreatitis initially type A pain but now having type B
no endocrine or exocrine insufficiency
h/o jaundice for last 10 days

on CECT: found to have chronic calcific alcoholic pancreatitis with lower CBD long stricture and dilated proximal CBD AND IHBRD.

CA: 19.9 : NORMAL

surgery: LPJ With CDD. patient discharged on  POD 6. With normal diet.





CASE : Acute bowel gangrene of proximal jejunum

65 yrs male with pain in abdomen for 2 days sever, with sepsis, ARF, 
On evaluation with CT : found to have jejunal gangrene starting from DJ flexure to early ileal loops

surgery: Resection and primary anastomosis at DJ Flexure after mobilizing duodenum 4th part
patient diascharged on day 10 after surgery with normal diet





CASE: CA GALL BLADER

Middle aged female with with pain in abdomen in Rt flank
USG: S/o rt renal stag horn calculi, with mass in fundus of G.B.


CECT: s/o gundic mass in GB with RT renal Stag Horn calculi


surgery: Radical cholecystectomy with lymphadinectomy and Removal of Rt stag horn claculi and stenting.

pt discharged on day 10.




CASE: Gastric GIST, excision with wedge of stomach

middle aged male with pain in epigastric region, increase in size of lump in last 10-15 days
on evaluation found to have huge mass arising near greater curvature of stomach with close proximity to pancreas, spleen, stomach

CECT S/o likely GIST of stomach



Endo Sono: s/o GIST arising from the fourth layer of greater curvature of stomach.

surgery: excision of in toto tumor with gastric sleeve. discharged on POD 5.



BX With IHC s/o Gastric GIST, high grade, pt is now on the oral targeted therapy (gleevec)


CASE: APPENDICULAR PSEUDOMYXOMA

Young male with non specific pain in central and rt side of abdomen
P/A: soft no palpable mass, 
USG S/O : exophytic mass in abdomen of more than 10 x 8 cm.

CECT: S/o soft lump in RIF region surrounding appendix with calcification within
p/o  appendicular pseudomyxoma.


















Surgery: modified Sugabaker's procedure
( Extended Rt hemicolectomy, peritonectomy, cholecystectomy, omentectomy )


patient discharged on pod 6.

bx: s/o appendicular pseudomyxoma



CASE: Mallignangt melanoma of Ano-Rectum - APR

65 yrs male presented with mass protruding from the anus and bleeding per rectum
on evaluation found to have Malignant melanoma of rectum / anal canal
CECT: Chest and abdomen: No e/o metastatic disease apart from local tumor.

surgery: APR

pt discharged in time
Bx: Malignant melanoma of rectum growth limited to rectum, and 5/11 nodes positive.

CASE: CA HOP - Classical WPD

62 yrs female with SOJ, On evaluation found to have CA HOP with Dilated CBD And PD
After stenting re evaluated for resectablity

CECT: With doubtful plains near portal vein CA HOP.



SURGERY: Classical Whipple's pancreatico duodenectomy



pt was discharged on day 6 post op with normal diet. 

Sunday, September 9, 2012

CASES: CA colon with intestinal obstructions

CASE 1. 75 yrs female with pain in abdomen and distension and vomiting
CBC: Hb 6.5., suspected diagnosis was ca ascending colon
CECT: S/o  same findings

surgery: EXTENDED RT hemicolectomy with cholecystectomy and primary anastomosis of ileum to transverse colon and lymphadinectomy

patient was discharged on POD 9.

CASE 2. 70 Yrs female with pain in abdomen and constipation with distension...x ray s/o  dilated colon...and small bowel loops..

CECT: s/o pseudo obstruction...
patient detoriated and suddenly collapsed in conservative trial ...x ray : was done s/o free gas under diaphargm..immediately explored...and found to have colonic perforation with napkin ring structure growth in descending colon sigmoid  junction and ischemic whole colon with diameter of more than 10 cm...with multiple perforations....total colectomy was done with ileostomy but unfortunately pt did not make...

Wednesday, September 5, 2012

CASE: COROSSIVE INGESTION , GASTRIC NECROSIS, WITH SITUS INVERTUS IN 3 YR OLD CHILD

with Respected DR. YATINBHAI THAKAR (M.S.,M.S., Pediatric surgeon)

3 YR OLD MALE (SITUS INVERTUS) child presented in emergency with distension, hemetemesis after corossive ingestion

1.  lavage and multiple drains were kept in abdomen (as the patient's G/C was very poor) to sustain a major surgery
2. after 6 days he improved and was even extubated on day 3 of index surgery...taken up for definative phase one surgery
   
Total gastrectomy (as 80 % of stomach of necrosed)  and duodenal stump closure, along with lower esophageal end closure..and feeding jejunostomy

3. after successful recovery from 2nd surgery was discharged on FJ Feeds...gained 4 kg weight in 3.5 months...was re-evaluated for esophageal status..and found to have a single short segment small stricture in upper esophagus which was negotiable with endoscope...and was taken up for definitive surgery

ROUX EN Y , J POUCH DOUBLE STAPLE ESOPHAGO JEJUNOSTOMMY and FJ

recovered well started tolerating FJ From day 3 and dye study from oral route did not show any anastomosis  leak..but unfortunately had a kink at the NEW FJ site..and was having recurrent bilious vomiting...

4. was taken up once again and kink was taken care of  along with removal of FJ...Patient was happily discharged on day 4 with normal diet...without any complication..child is play full..taking oral diet....


CASES: DISTATL PANCREATECTOMIES

1. CASE: young male with chronic calcific pancreatitis with mass in distal body of pancreas..with recurrent episodes of acute pancreatitis...

on evaluation found to have multiple stones in head of pancreas with dilated duct 12mm and inhomogenous mass and distorted pancreas in distal tail with multiple dilated side branching..

SURGERY: Distal pancreatectomy  with splenectomy and PANCREATICO JEJUNOSTOMY





Bx: benign chronic inflamation of pancreas..pt was discharged on day 10.


case 2: 13 yrs old girl with h/o blunt trauma abdomen..
detected to have totally transected pancreas at body tail junction
presented within 12 hrs of injury...was explained the need of surgical intervention..unfortunately..did not got ready...but presented again 48 hrs later with distension and vomiting, tachycardia, hypotension...

fortunately spleen preserving distal pancreatectomy was done on day 3 of trauma

IMAGES: 



patient discharged home uneventfully  on day 6.

CAS: RE DO RYHJ -Status stricture RYHJ FOR BDI

Young female with h/o BDI during lap chole 6 yrs back and intra op HJ Was done

h/o recurrent cholangitis for last 1.5 yrs 

on evaluation found to have dilated IHBRD with strictured anastomosis of HJ
MRCP:


SURGERY: RE DO RYHJ (3.2 CM anastomosis)





patient was discharged on POD 5 without any complications..



CASES: PANCREATIC NECROSECTOMIES

case 1:  acute necrotizing pancreatitis with localized necrosis in lesser sac day 38.. with air foci ( infected )  and majority component in liquid form..

taken up for endoscopic transgastric necroesctomy and was done successfully ( more than 2 liter of pus was drained ) and pt was shifted to icu for observation
for day or so pt improved clinically but again in 3 days had a similar distension, respiratory distress, tachycardia..and rise in count

CECT was done and was s/o again collection  ( gross) almost similar to pre endoscopy and free intra peritoneal gas as well..along with more necrotic solid area

was timely taken up for open necrosectomy...and discharged with left sided drain in situ on day 12..with oral diet..


CASE 2: Young female with ideopathic acute necrotizing pancreatitis with severe infected necrosis..
with worsining G/C and daily persistant spikes of fever , respiratory distress and distension, low out put on DAY 29 Of illness was taken up for open necrosectomy

had very severe wound infection ...treated with dressing and secondary suturing...doing well now all drains out by now..patient at home and taking normal diet, ambulant.



CASE: CA SIGMOID With LGI bleed

elderly (86 yrs) female with LGI Bleed for last one year
on evaluation found to have CA SIGMOID.

PLANNED FOR ANTERIOR RESECTION AND primary anastomosis..

successfully discharged with normal diet on day 7.
 BX. : S/O adenocarcinoma with all nodes negative and T3 lesion.. all margins free


CASE: CA COLON With adjacent liver infiltration

middle aged male with constipation and anemia, CABG was done six months ago
evaluated and worked up ..found to have CA hepatic flexure with adjacent liver infiltration

CECT:



SURGERY: Extended rt hemicolectomy and in toto segment 6 resection of liver

all margins clear..adeno ca with free liver margin.... 6/12 lymph nodes positive..

pt schedule for chemotherapy

CASE: Corossive esophagial and gastric injury

young female with ingestion of acid 5 months ago
on FJ Feeds

dysphagia grade 4
barium s/o long standing lower 1/3 esophagila stricture with pyloric stricture

surgery: esophago coloplasty with pyloroplasty



CASE: Spontenous rupture of CDC and biliary peritonitis - CDC EXCISION AND ryhj

3 yrs old child with abdominal pain and distension with fever
initially diagnosed as perforated appendix and peritonitis
laparoscopy was done by Dr. Ashok Jagani and immediately found to have biliary peritonitis and there was bile leaking near hilum..was confirmed...drain kept and closed
next day opened at institute..

Diagnosis confirmed by doing intra op cholengiography


CDC was excised and end to side hepatico jejunostomy was done
child was discharged on DAY 6  uneventfully.