POST LAP - BILE DUCT INJURY^-www.drkeyurbhatt.in*

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.

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CASE: Segmental Mesenteric vascular Gangrene^-www.drkeyurbhatt.in*

54 yr male with HTN
C/O pain in abdomen for 2 days with distension and agony
No h/o constipation, diarrhoea , Vomiting, fever
CECT S/o:                                          

Pt explored &
Similar findings intra op:

Gangrenous segment resected and Double Barrel loop Ileostomy made..
Pt now out of sepsis and on oral diet in discharge line....

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CASE: INSULINOMA a rare endocrine tumor of pancreas^-www.drkeyurbhatt.in*

47 yrs female with multiple episodes of unconciousness....every time found to be hypoglycemic..
finally diagnosed to have Insulunoma.....by an Eminent physician.

Random Insulin level : 198 (normal is <5)  Parathormone:  Normal ;   Ca ++ : normal
(no e/o MEN1 or MEN 2B)

MRI s/o

surrounded by vital structures

CECT S/o:

just few mm away from main pancreatic duct

SURGERY: Enucleation of tumor....

Intra Op: 10 % dextrose infusion was given @ 100 ml / hr to prevent hypoglycemia...and thanks to anesthetist who kept pt stable through out surgery and was hardly 50 ml blood loss...

post operatively pt doing well... started on oral diet...sugars are normal...
shifted to General ward (POD - 3)

http://drkeyurbhatt.blogspot.com/2011/02/insulinoma.html

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CASE : Acute on chronic Mesenteric Ischemia with multiple abdominal visceral involvement^-www.drkeyurbhatt.in*

52 yrs female with HTN had agonising abdominal pain for a day...Admitted to a surgeon's place....X-ray , USG: Did not show any abnormality and TLC was near normal..
but severe pain in abdomen----surgeon Doctor promptly advised for CECT abdomen suspecting MAT(Mesenteric Arterial thrombosis)..
And was right in Diagnosis

pt had a very bad CECT Picture:

Immediately underwent Mesenteric angio and Inj Heparin was started in infusion...
Fortunately by angiography Hepatic artery, spleenic artery, IMA and celiac was opened...pulse injection of PAPAVERIN Was given in vessels...and catheter was left in SMA for cont infusion...

Next day pt had relief in Pain but started developing metabolic acidosis in ABG (FIRST MARKER OF BOWEL ISCHEMIA --Even before pulse and BP Alteration )
Repeat ABG in afternoon showed marked drop in Ph and severe metabolic acidosis...

Heparin stopped, Protamine given and taken up for surgery...

fortunately she is saved of LIVER, SPLEEN,KIDNEY PROXYMAL 2 FEET OF SMALL BOWEL AND ASCENDING COLON ONWARDS LARGE BOWEL....

ALL BECAUSE OF EARLY SUSPECTING , CECT ( by primary consultant within 12hrs ) &  INTERVENTION (by Intervention radiologist) AND TIMELY ACTION (surgery) WHICH IS REALLY DIFFICULT AND VERY LESS OFTEN POSSIBLE...but a team effort made it possible...

Pt was saved going into septecemia and shock and now on re-feeding of stoma contents with oral diet and antico-agulants....ambulant in ward  ..(POD -7)

now will require high nutritional supplimentation....and close observations...fingers are still crossed !!! lets hope for full recovery.....

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CASE: Unusual case^-www.drkeyurbhatt.in*

74 yrs male + DM + HTN + IHD + COPD

with 1 month history of on and off fever...initially treated as Malaria...later as Typhoid..
cont. diarrhoea...c/o distension and abdominal discomfort for 2 days...
rising bilirubin..., constipation..No..nausea/vomiting...

USG : s/o gross peritonitis CBD 7mm, GB partially distended....rest all WNL... TLC: 21,000. Pt Disoriented with electrolyte imbalance...

Suspected Enteric perforation...... and found to have PERFORATED GB with gross (4 liters) biliary peritonitis...No Gall Stones...CBD normal...

? typhoid induced GB perforation...? lower end block / impacted small stone / stricture

Surgery (lavage, Cholecystectomy, drainage) done in Epidural anesthesia in view of multiple risks...and post op patient is doing well...

later develop bile leak...in drain...Suspected Cystic duct stump blown out...USG: repeated : s/o lower end Small 7 mm impected stone...dilated CBD and IHBRD....

Pt underwent ERC & removal of ampulary impected stone and stenting.....
doing well now...

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