CASE: Spontenous rupture of CDC and biliary peritonitis - CDC EXCISION AND ryhj^-www.drkeyurbhatt.in*

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.

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CASE: NCPF With recurrent bleeding and failed endotherapy^-www.drkeyurbhatt.in*

middle aged female with recurrent UGI bleed , more than 35 glue injection sessions

repeated episodes of gastric and duodenal varices bleeding

Surgery: splenectomy for decompression and liver BX

BX: NCPF, No evidence of cirrhosis of liver

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CASE: OPEN PANCREATIC NECROSECTOMY^-www.drkeyurbhatt.in*

Middle aged male with Acute Gall stone Necrotizing pancreatitis
day 35, not improving with conservative management

CECT: S/o organized infected pancreatic necrosis with air foci within the collection

SURGERY : OPEN pancreatic necrosectomy 

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CASE : Chronic pancreatitis - LPJ^-www.drkeyurbhatt.in*

young female with chronic abdominal pain for 8 yrs initially Type A pain now having type B pain for around  2 months
No endocrine or exocrine insufficiency..

SURGERY: LPJ (Lateral pancreatico jejunostomy with head coring )

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CASE: Unusual case of bowel ischemia^-www.drkeyurbhatt.in*

42 YRS male, non diabetic, non smoker, non Hypertensive
presented  with sepsis, shock, ARF (urea 91, Creat 2.1), P: 140, BP: 90/60 On inotrops..drowsy,

 ( p/h/o: pain in abdomen for 2 days and USG at that time s/o free fluid in abdomen (moderate) with non visulization of appendix / ? perforated appendix...and hence operated for open appendectomy, post op patient did well for 2-3 days , started having fever, distension, pain, low out put on POD 3....AND was referred on POD 7 night )

Abdominal drain was draining dirty , purulant fluid, after adequate rehydration, USG Done s/o dilated aperestaltic bowel loops with multiple pockets of collection through out the abdomen (on aspiration which drained feculant material )

ABG: WAS s/o over compensated alkaline pH.

Was taken up for surgery suspecting stump blow out / cecal perforation with peritonitis

OF SURPRISE:  It was TOTAL MESENTERIC ISCHEMIA WITH GANGRENE OF SMA region..with 1.5 liter of toxic fluid in abdomen...unfortunately ...we could not do much for the patient....

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CASE: Strange case of abdominal poly trauma^-www.drkeyurbhatt.in*

35 yrs female had high spike of fever, sever pain, agony, distension, shortness of breath, and constipation for 6 days..with swelling (irreducible) in rt flank, tachycardia, and low urine out put..

( Patient had h/o with fall from 4 feet height and sudden onset pain and appearance of swelling in rt flank..
USG: S/O liver laceration/hematoma with mild free fluid, and intermascular colonic hernia
CT SCAN ON day 4:s/o liver tare,hematoma, moderate free fluid perihepatic,para colics, and intermascular hernia of colon
was kept conservatively, with application of abdominal binder..and was discharged on day 6..)

after resuscitation USG/CT was done
s/o gross free fluid and on aspiration it was infected bile.

plan: ERC And stenting followed by surgery (lavage and drainage)

ERC: S/o total loss of biliary tree structure with p/o major CHD/CBD transection, stenting was done

SURGERY: Findings: 1. Trapped interperital hernia in rt hypochondrium with transverse colon
2. 1.5 liter biliary peritonitis
3. liver leceration,hematoma in seg 5,6,
4. TOTAL HILAR SEPARATION WITH 2 CM SEGMENT LOSS OF CHD

procedure : 1. lavage, drainage, reduction of hernia, intarnal mascular interupted absorbable sutures (no mesh) was done.
2. cholecystectomy, hilar exploration identification of ducts, CBD, "T" TUBE insertion from Right duct to CBD-Duodenum, left system 10 fr drainage tube placement, sub and supara hepatic,pelvic, paracolic drains.
3.  Feeding jejunostomy

patient recovered and was discharged with SUBHEPATIC DRAIN, BLOCKED T TUBE, open left duct stent, with refeeding of bile via FJ. on POD 16.

Planned for DEFINITIVE HJ After 2 months.

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CASE: Chronic idiopathic pancreatitis^-www.drkeyurbhatt.in*

Middle aged male with pain in abdomen central, with back radiation, for 4 yrs and wt loss and anorexia for 2-3 yrs

Evaluated and found to have Chronic calcific pancreatitis with dilated ducatal system and multiple stones.

CECT: small pseudocyst in head of pancreas with multiples stones in MPD / dilated MPD. S/o chronic calcific pancreatitis


SURGERY: LPJ

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CASE: Massive lower GI bleed in CRF, Stercoral ulcers^-www.drkeyurbhatt.in*

Middle aged male with DM, HTN, CRF, on dialysis
had massive LOWER GI bleed,
h/o chronic constipation present.

COLONOSCOPY s/o large stercoral ulcers in entire rectum with profuse continues bleeding..and active spurting..

multiple sessions of endoscopy was done..over 3-4 days period., with more than 2 transfusion requirement of PCV per day..with all local, systemic measures applied, but bleeding was not controlled

Ultimately patient was taken up for rescue surgery: APR, With permanent colostomy.

pt recovered well in post op period and was discharged in due time..

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Efficacy of the Omental Roll-up Technique in Pancreaticojejunostomy as a Strategy to Prevent Pancreatic Fistula After Pancreaticoduodenectomy^-www.drkeyurbhatt.in*

Sae Byeol Choi, MD, PhD; Jin Suk Lee, MD; Wan Bae Kim, MD, PhD; Tae Jin Song, MD, PhD; Sung Ock Suh, MD, PhD;Sang Yong Choi, MD, PhD 

Arch Surg. 2012;147(2):145-150. doi:10.1001/archsurg.2011.865

Background  Most morbidity and mortality are caused by a pancreatic fistula after pancreaticoduodenectomy (PD), and its prevention is the major concern. We applied the omental roll-up technique around pancreaticojejunostomy and investigated the effectiveness of this technique to prevent a pancreatic fistula.

Design  Retrospective study.

Setting  Tertiary hepatobiliary and pancreas surgery clinic, Korea University Guro Hospital, Seoul.

Patients  Between March 1, 2009, and March 31, 2011, 68 patients underwent PD. The patients were divided into 2 groups according to the surgical application of the omental roll-up technique around the PJ site: group 1 (those who did not undergo the omental roll-up technique) compared with group 2 (those who did undergo the omental roll-up technique).

Main Outcome Measure  The occurrence of a pancreatic fistula.

Results  No differences were noted in the clinical characteristics, including patients' demographics and operation-related factors, between the 2 groups. A pancreatic fistula occurred in 23 of 39 patients in group 1 (59%) and in 6 of 29 patients in group 2 (20.7%). Group 2 had a significantly lower incidence of pancreatic fistula (P = .002), and these fistulas were classified as being grade A using the International Study Group on Pancreatic Fistula Definition showing a transient high amylase level in the drainage fluid without significantly affecting the patient's recovery. Drain removal was performed earlier in group 2 (P < .001). Mean postoperative hospital stay was 23.4 days in group 1 compared with 15.9 days in group 2 (P = .009). Overall mortality was 1.5%; however, no deaths were related to a pancreatic fistula.

Conclusions  The omental roll-up technique for the PJ site definitely reduced the occurrence of a pancreatic fistula. Therefore, the omental roll-up technique is a simple and effective strategy to prevent a pancreatic fistula.

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Randomized Clinical Trial of Total Extraperitoneal Inguinal Hernioplasty vs Lichtenstein Repair^-www.drkeyurbhatt.in*

A Long-term Follow-up Study

Hasan H. Eker, MD; Hester R. Langeveld, MD; Pieter J. Klitsie, MD; Martijne van't Riet, MD, PhD;Laurents P. S. Stassen, MD, PhD; Wibo F. Weidema, MD, PhD; Ewout W. Steyerberg, PhD; Johan F. Lange, MD, PhD;Hendrik J. Bonjer, MD, PhD; Johannes Jeekel, MD, PhD 

Arch Surg. 2012;147(3):256-260. doi:10.1001/archsurg.2011.2023

Hypothesis  Mesh repair is generally preferred for surgical correction of inguinal hernia, although the merits of endoscopic techniques over open surgery are still debated. Herein, minimally invasive total extraperitoneal inguinal hernioplasty (TEP) was compared with Lichtenstein repair to determine if one is associated with less postoperative pain, hypoesthesia, and hernia recurrence.

Design  Prospective multicenter randomized clinical trial.

Setting  Academic research.

Patients  Six hundred sixty patients were randomized to TEP or Lichtenstein repair.

Main Outcome Measures  The primary outcome was postoperative pain. Secondary end points were hernia recurrence, operative complications, operating time, length of hospital stay, time to complete recovery, quality of life, chronic pain, and operative costs.

Results  At 5 years after surgery, TEP was associated with less chronic pain (P = .004). Impairment of inguinal sensibility was less frequently seen after TEP vs Lichtenstein repair (1% vs 22%, P < .001). Operative complications were more frequent after TEP vs Lichtenstein repair (6% vs 2%, P < .001), while no difference was noted in length of hospital stay. After TEP, patients had faster time to return to daily activities (P < .002) and less absence from work (P = .001). Although operative costs were higher for TEP, total costs were comparable for the 2 procedures, as were overall hernia recurrences at 5 years after surgery. However, among experienced surgeons, significantly lower hernia recurrence rates were seen after TEP (P < .001).

Conclusions  In the short term, TEP was associated with more operative complications, longer operating time, and higher operative costs; however, total costs were comparable for the 2 procedures. Chronic pain and impairment of inguinal sensibility were more frequent after Lichtenstein repair. Although overall hernia recurrence rates were comparable for both procedures, hernia recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was also significantly higher after TEP. Therefore, TEP should be recommended in experienced hands.

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A Meta-Analysis of Surgical Morbidity and Recurrence After Laparoscopic and Open Repair of Primary Unilateral Inguinal Hernia^-www.drkeyurbhatt.in*

Annals of Surgery:

May 2012 - Volume 255 - Issue 5 - p 846–853

doi: 10.1097/SLA.0b013e31824e96cf

Meta-Analyses

O'Reilly, Elma A. MB, BCh; Burke, John P. PhD, MRCSI; O'Connell, P. Ronan MD, FRCSI

Abstract

Background: Laparoscopic inguinal hernia repair (LIHR), using a transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) technique, is an alternative to conventional open inguinal hernia repair (OIHR). A consensus on outcomes of LIHR when compared with OIHR for primary, unilateral, inguinal hernia has not been reached.

Objectives: Perform a meta-analysis of all randomized controlled trials (RCTs) comparing OIHR and LIHR for primary unilateral inguinal hernia. Outcomes were hernia recurrence and surgery-related morbidity.

Methods: A comprehensive search for published RCTs comparing LIHR with OIHR for primary, unilateral, and inguinal hernia was performed. Reviews of each study were conducted and data were extracted. Random effect methods were used to combine data.

Results: Data were retrieved from 27 RCTs describing 7161 patients. An increased risk in hernia recurrence existed when LIHR was compared with OIHR (relative risk [RR] = 2.06, 95% confidence interval [CI] = 1.26–3.37, P = 0.004). TAPP had equivalent recurrence (RR = 1.14, 95% CI = 0.78–1.68, P = 0.491) but TEP had increased recurrence of risk (RR = 3.72, 95% CI = 1.66–8.35, P = 0.001) relative to OIHR. LIHR was associated with greater perioperative complication risk than OIHR (RR = 1.22, 95% CI = 1.04–1.42, P = 0.015). TAPP (RR = 1.47, 95% CI = 1.18–1.84, P < 0.001) but not TEP (RR = 1.05, 95% CI = 0.85–1.30, P = 0.667) was associated with this increased complication risk. LIHR was associated with reduced risk of chronic pain (RR = 0.66, 95% CI = 0.51–0.87, P = 0.003) and chronic numbness (RR = 0.27, 95% CI = 0.12–0.58, P < 0.001) relative to OIHR.

Conclusions: For primary unilateral inguinal hernia, TEP is associated with an increased risk of recurrence relative to OIHR but TAPP is not. TAPP is associated with increased risk of perioperative complications relative to OIHR. LIHR has a reduced risk of chronic pain and numbness relative to OIHR

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CASE: Strange case of duodenal third part perforation - close loop obstruction^-www.drkeyurbhatt.in*

22 yrs male with h/o corrosive ingestion 3 months back
with residual gastric and esophagial scaring

FJ was done for the same 3 months back..

patient presented with sever agonizing pain in abdomen for last 2 days with shock

P: 170/min BP: 70 systolic
resuscitation and
CT SCAN S/O : Retro peritoneal collection with free gas..and dilated duodenum and proximal jejunum till FJ site..distal loops collapsed   ? duodenal perforation

exploration: reveled the same a large perforation in D 3 Bellow the vessels with retroperitoneal sepsis.

primary closure , detwisting of jejunal loop , and a new feeding jejunostomy and drainage was done.

Fortunately pt survived..

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CASE: Chronic alcoholic pancreatitis with pseudocyst in head^-www.drkeyurbhatt.in*

Middle aged male with severe pain in central abdominal pain severe in intensity ,  for 6 months and 25 kg wt loss. DM II For last 6 months..

evaluated and diagnosed as Chronic alcoholic calcific pancreatitis with pseudo cyst in uncinate process of pancreas..

CECT:

SURGERY: LPJ With head coring...

Patient discharged on POD 6. without pain.

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