CASE: Transgastric necrosectomy (alcoholic infected pancreatic necrosis)^-www.drkeyurbhatt.in*

young male with acute necrotizing pancreatitis before 2 months
with recurrent fever and abdominal pain, nausea, vomiting, weight loss, sepsis

CECT: S/o infected pancreatic multiloculated necrosis.

SURGERY: Transgastric pancreatic necrosectomy

patient discharged uneventfully after 7 days..

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CASE: A rare case of Isolated amoebic abscess of spleen^-www.drkeyurbhatt.in*

Old yrs female with DM,HTN,IHD., And ARF.
Presented with Symptoms of UTI
Later evaluated and found to have splenic abscess... was treated conservatively initially..in view of medical risk factors..but did not responded and was referred for surgery

CECT:

SURGERY: open splenectomy

BX: S/O Amoebic splenic abscess .www.gisurgerysurat.com

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Two staged hepatectomy in marginally resectable liver tumors^-www.drkeyurbhatt.in*

Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings

Schnitzbauer, Andreas A.; Lang, Sven A.; Goessmann, Holger; Nadalin, Silvio; Baumgart, Janine; Farkas, Stefan A.; Fichtner-Feigl, Stefan; Lorf, Thomas; Goralcyk, Armin; Hörbelt, Rüdiger; Kroemer, Alexander; Loss, Martin; Rümmele, Petra; Scherer, Marcus N.; Padberg, Winfried; Königsrainer, Alfred; Lang, Hauke; Obed, Aiman; Schlitt, Hans J.

Annals of Surgery. 255(3):405-414, March 2012.

doi: 10.1097/SLA.0b013e31824856f5

Purchase AccessDF (723 K

Abstract

Objective: To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.

Background: Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.

Methods: Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery.

Results: The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197–444 mL). After a median waiting period of 9 days (range = 5–28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273–881 mL), representing a median volume increase of 74% (range = 21%–192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%–0.49%) to 0.61% (range = 0.35–0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60–776 days) with an estimated overall survival of 86% at 6 months after resection.

Conclusions: Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.

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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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