Management of choledochal cyst: 30 years of experience and results in a single center^-www.drkeyurbhatt.in*

She WH, Chung HY, Lan LC, Wong KK, Saing H, Tam PK.

Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong.

BACKGROUND: Choledochal cyst is usually diagnosed in childhood. Early treatment can prevent further complication. We report on our series of patients over the past 30 years.

METHODS: A retrospective study was performed on all pediatric patients who presented with choledochal cyst from January 1978 to December 2008. The main outcome measures recorded were the clinical presentation, management, and long-term outcome of the patients.

RESULTS: Eighty-three patients presented to us during the caption period with a mean age at diagnosis of 45 months (0 month to 16 years). Diagnoses were made antenatally in 15 patients. The most common symptoms were abdominal pain (n = 39) and jaundice (n = 35). Seventy-five patients had surgery, in which 72 patients had resection of the cyst and Roux-en-Y hepaticojejunostomy. Ten were performed by laparoscopic means. We categorized the cysts based on the Todani classification. There was no mortality. No malignant change was documented. For those 4 who had Caroli disease, 2 underwent liver transplantation and 2 had hepatectomy. Overall early complication rate was 5.3% (4/75).

CONCLUSIONS: Complete excision of cyst with Roux-en-Y hepaticojejunostomy is the treatment of choice, and the late result is good. Laparoscopic surgery is feasible. Long-term follow-up is necessary. There is no evidence to suggest that some type IV cysts are the result of disease progression from type I cysts.

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Hilar cholangiocarcinoma: current management^-www.drkeyurbhatt.in*

Hilar cholangiocarcinoma: current management.

Ann Surg. 2009 Aug;250(2):210-8

OBJECTIVE: To review the literature with regard to outcome of surgical management for hilar cholangiocarcinoma (Klatskin tumor). 

BACKGROUND: Hilar cholangiocarcinoma is a rare tumor with a poor prognosis. Surgical resection provides the only possibility for cure. Advances in hepatobiliary imaging and surgical strategies to treat this disease have resulted in improved postoperative outcomes. 

METHODS: We performed a review of the English literature on hilar cholangiocarcinoma from 1990 to 2007. This review included preoperative evaluation, surgical techniques, issues and controversies in management, prognostic variables, and considerations for future directions. 

RESULTS: Complete resection remains the most effective and only potentially curative therapy for hilar cholangiocarcinoma. Negative resection margins are associated with improved outcomes, and major hepatic resections have enhanced the likelihood of R0 resection. Portal vein embolization may be indicated in selected patients before extensive hepatic resection. Staging laparoscopy should be considered to detect occult metastatic disease. Orthotopic liver transplantation might be applicable for a highly selected subgroup. 

CONCLUSIONS: Surgical resection including major hepatic resection remains the mainstay of treatment of hilar cholangiocarcinoma. Additional evidence is needed to fully define the role of orthotopic liver transplantation. Improvements in adjuvant therapy are essential for improving long-term outcome.

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single port lap cholecystectomy^-www.drkeyurbhatt.in*

Single-port laparoscopic cholecystectomy: initial experience

Abstract

Background As surgeons embrace the concept of increasingly less invasive surgery, techniques using only a

single small incision have begun to gain traction. Several commercially available products have emerged recently. The TriPortTM system and the SILSTM Port are single-port devices that allow the surgeon to perform laparoscopic surgery through a 2- to 3-cm periumbilical incision. This study aimed to ascertain whether these devices allow safe and reliable access for laparoscopic cholecystectomy. Methods From March 2008 to June 2009, single-port laparoscopic cholecystectomy was attempted for 22 patients with an average age of 40 years (range, 23– 73 years). The data collected prospectively after institutional review board approval included demographics, operative time, complications, and reasons for conversion to standard four-port laparoscopic surgery.

Results The operation was completed successfully for 21 of the 22 patients (15 women and 7 men) using five different techniques. The mean body mass index (BMI) of the patients was 32.7 kg/cm2 (range, 22.3–46.1 kg/cm2). Three of the patients had previously undergone laparoscopic Roux-en-Y

gastric bypass. The mean operative time was 80.8 min (range, 51–156 min). One patient experienced a Richter’s hernia postoperatively, which required a reoperation and subsequent bowel resection. One patient required conversion to a standard four-port laparoscopic cholecystectomy because the articulating instrument could not reach the gallbladder from the umbilicus.

Conclusion The results from the current series show single-port laparoscopic cholecystectomy to be a promising technique. A variety of patient demographics appear suited to this approach. The operative time in this series compares favorably with that for the standard four-port operation. The feasibility of single-port laparoscopic cholecystectomy is now established. However, routine application of this

novel technique requires an evaluation of its safety and cost effectiveness in larger studies. In addition, its superiority over standard laparoscopic cholecystectomy in terms of postoperative pain, cosmesis, and overall patient satisfaction requires further study. Refinements in instrumentation will enable wider use of this novel minimally invasive approach.

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CASE : Eventration of diaphragm with Gastric Volvulus (stomach and spleen herniated via defect )^-www.drkeyurbhatt.in*

40 yrs female
with chronic epigastric pain and full ness.
Unfortunately got operated before 2 days for Lap. Appendectomy.
presented with persistent vomiting and severe epigastric pain

CECT reveled : Eventration of diaphragm with Gastric Volvulus (stomach and spleen herniated via defect )

1. De rotation of stomach.

2.  Plication of diaphargm

3. Seromascular GJ ( Pseudo GJ: for fixation was done)

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Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis^-www.drkeyurbhatt.in*

Hepatobiliary Surgical Unit, †Department of Radiology, and ‡Critical

Care Unit, Manchester Royal Infirmary, Manchester, United Kingdom.

Objective: To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis. Background Information: The last decade has witnessed major developments

in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade.

Methods: During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twentyfour (86%) were tertiary referral patients.

Results: The median APACHE II score on admission was 10.5 (5–26). Median logistic organ dysfunction score on admission was 3 (0–10). Median LODS score after surgery was 2 (0–8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths.

Conclusions: Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

    (Ann Surg 2010;251: 783–786)

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