Cholecystectomy is one of the commonest hepatobiliary procedures performed in general surgical practice. Both laparoscopic as well as open cholecystectomies have their place in modern-day surgical practice. Post cholecystectomy syndrome is a known entity affecting approximately 20% of patients who have undergone cholecystectomy. Post cholecystectomy pancreatitis is an uncommon and rare complication. A case of acute early post cholecystectomy pancreatitis is presented to create an awareness of this rare but misleading and morbid complication.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;manage...fiaz fazili
Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention--do no more harm-have low threshold for conversion;call for help of seniors or expertise or refer to higher center
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
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Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
Short bowel syndrome is one of the most complex sequel to resection of extensive lengths of the small intestine. The nutritional depletion caused exerts deleterious effects on every organ system of the body. Identifying and managing this complex problem is the biggest challenge to the clinician. The pathophysiology and therapeutic approach to short bowel syndrome is discussed
De Garengoet`s hernia is a femoral hernia containing the appendix. Awareness of this hernia is essential to prevent misdiagnosis and wrong choice of an operative procedure. The status of appendix dictates the choice of approach and nature of repair for the hernia. The pathophysiology, diagnosis and management of De Garengoet`s hernia is presented in this article to create an awareness of this rare hernia
BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;manage...fiaz fazili
Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention--do no more harm-have low threshold for conversion;call for help of seniors or expertise or refer to higher center
Bile duct injury:How safe is emergency laparoscopic cholecystectomy?KETAN VAGHOLKAR
laparoscopic cholecystectomy has become the gold standard . But its safety in acute cholecystitis is debatable. The traditional dictum to wait for 6 weeks before contemplating removal of the gall bladder still remains the safest option rather than removing the gall bladder on an emergency basis and heightening the chances of bile duuct injury leading to a surgical disaster.The presentation outlines the evaluation and management of bile duct injuries.
Bhaskar Health News and Medical Education is leading source for trustworthy health, medical, science and technology news and information. Providing world health information Medical Education.
Bhaskar Health News and Medical Education is dedicated to medical students, physiotherapists, doctors, nurses, paramedics, physician associates, dentists, pharmacists, midwives and other healthcare professionals.
We're committed to being your source for expert health guidance. Bhaskar Health and Medical Education.
Source : https://www.bhaskarhealth.com
Health Shop: https://www.bhaskarhealth.org
@drrohitbhaskar @bhaskarhealth
#DrRohitBhaskar #BhaskarHealth
#Health #Medical #News #Physiotherapy
Benign Billiary Stricture By Dr Dhaval Mangukiya
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
Short bowel syndrome is one of the most complex sequel to resection of extensive lengths of the small intestine. The nutritional depletion caused exerts deleterious effects on every organ system of the body. Identifying and managing this complex problem is the biggest challenge to the clinician. The pathophysiology and therapeutic approach to short bowel syndrome is discussed
De Garengoet`s hernia is a femoral hernia containing the appendix. Awareness of this hernia is essential to prevent misdiagnosis and wrong choice of an operative procedure. The status of appendix dictates the choice of approach and nature of repair for the hernia. The pathophysiology, diagnosis and management of De Garengoet`s hernia is presented in this article to create an awareness of this rare hernia
With increase in the number of laparoscopic procedures being performed, the incidence of port site complications has also increased proportionately. Infection and port site hernia are the commonest of the complications. Port site hernias are more prone to complications in view of the irregularity and narrowness of the defect. A case of an incarcerated umbilical port site hernia is presented to highlight the complexity of the problem and the surgical challenge that it poses.
Laparoscopic cholecystectomy is the gold standard for treating calculous cholecystitis. Many a times the procedure
may be associated with rupture of the gall bladder and spillage of gall stones and sludge into the peritoneal cavity.
The complication of spilled or dropped gall stones in the peritoneal cavity is not fully documented. This is because
majority of the cases go unreported. The possible natural history and management of dropped gall stones is discussed
in this article.
Omental torsion: a rare cause of acute abdomenKETAN VAGHOLKAR
Torsion of the greater omentum is one of the rare causes of acute abdomen. However with an increase in the incidence of obesity in urban population there is a steady increase in the incidence of this rare and deceptive abdominal condition. The attending surgeon needs to be aware of this condition especially when confronted with an obese patient presenting as an acute abdomen. The paper reviews the etiopathogenesis and management of this rare condition.
Sub phrenic collections are a common sequel to hepatobiliary surgery. Prompt diagnosis and treatment are necessary to reduce the morbidity and mortality to a bare minimum. Contrast enhanced CT (CECT) scan is the best imaging modality to identify the location and approximate size of the collection. Laparoscopic drainage is the best option for treating sub phrenic abscesses. A case of a sub phrenic abscess drained laparoscopically is presented to highlight the efficacy of this approach.
Posttraumatic hematuria with pseudorenal failure: A Diagnostic lead for Intra...KETAN VAGHOLKAR
Bladder rupture is a very morbid injury following blunt or penetrating lower abdominal trauma. Prompt diagnosis is crucial to initiate optimal treatment. Intraperitoneal bladder rupture is associated with haematuria and biochemical features of renal failure.
Cystogram is diagnostic. Immediate open surgical repair is the main stay of treatment. A case of intraperitoneal rupture diagnosed preoperatively by the presence of haematuria and pseudorenal failure is presented to highlight the association of posttraumatic
haematuria and pseudorenal failure in such injuries.
Surgical Complications of Roundworm InfestationKETAN VAGHOLKAR
Round worm infestation is common in the tropical countries. Ascaris lumbricoides can cause a variety of complications in the abdomen ranging from colic to perforative peritonitis. As majority of abdominal complications require surgical intervention awareness of the complications is pivotal to the attending surgeon. The surgical complications of roundworm infestation are discussed in this article.
Chronic Salmonella typhi carrier state: a precursor to gall bladder cancer KETAN VAGHOLKAR
Typhoid fever is one of the commonest infections of the gastrointestinal tract seen in the Indian subcontinent. Association with gall stones can lead to a chronic carrier state. This is a dangerous situation as it can strongly predispose to the development of carcinoma of the gall bladder which is known to have a very poor prognosis. The pathophysiology of this carcinogenic change and its clinical implications are discussed in this paper.
Surgical management of hepatic hydatid diseaseKETAN VAGHOLKAR
Hydatidosis is strictly a zoonosis. Humans are an accidental host. The disease is endemic in rural agricultural areas. However if acquired by humans, it can cause extensive spread affecting a wide range of organs with predilection for the liver. Managing such cases requires a sound fundamental knowledge of the parasite and its pathogenicity. It is essential that surgeons who deal with such cases have a good working knowledge of the disease. The approaches to hepatic hydatids with respect to the principles of surgical treatment are presented in this article.
Anatomical principles of intraperitoneal drain placementKETAN VAGHOLKAR
Drain placement after abdominal surgery continues to be a standard practice. However in recent years there has been reluctance amongst surgeons to drain the peritoneal cavity liberally thereby leading to a multitude of septic complications. A brief review of the physical dynamics of intraperitoneal spaces is presented with a view to improve the practice of optimum drain placement
Anastomotic dehiscence after colorectal surgeryKETAN VAGHOLKAR
Anastomotic dehiscence after colorectal surgery can have disastrous consequences. Various factors determine the
chances of anastomotic failure. The technical and systemic factors which a surgeon needs to be aware of are presented
in this article.
Inflammatory fibroid polyp (Vanek’s tumour) of the bowel KETAN VAGHOLKAR
Inflammatory fibroid polyp (IFP) or Vanek’s tumour is a rare benign tumour of the gastrointestinal tract. Lower gastrointestinal IFP’s may present as an acute abdomen in the form of an intussusception in an adult. The surgeon needs to be aware of this entity to avert misdiagnosis. An abdominal CT or an MRI is helpful in diagnosing an acute abdomen due to IFP in an adult. Surgery is the mainstay of treatment. The etiopathology and management of this rare tumour is discussed.
Intussusception in adult population is quite uncommon. It is usually seen in the pediatric age group. A wide range of causes can predispose to intussusception in adults. Majority of them are benign especially in cases of small bowel intussusception. However malignancy is quite often encountered in cases of colonic intussusception. Diagnosis in adults is difficult due to vague symptoms and intermittent nature. Computerized tomography is diagnostic. However majority of cases in adults are diagnosed at laparotomy. Surgical resection assuming the lesion to be malignant is the treatment of choice.
Mesh infection is one of most disastrous complication following hernia surgery. The consequences are more complex especially following a laparoscopic hernia repair operation. Understanding the pathophysiology of mesh infections is pivotal in adopting preventive strategies. Once infected, exact determination of the extent of the septic complication by CECT is essential. A two staged surgical intervention yields excellent results. A case of infected laparoscopic mesh repair treated by a two staged operation is presented along with a brief review of literature to highlight the safety and efficacy of this approach.
Surgery for intra abdominal hydatid disease a single centre experienceKETAN VAGHOLKAR
Background: Hydatid cyst is one of the commonly encountered parasitic disease in agricultural countries. Man is an accidental host. However the parasite can cause cystic lesions in various organ systems of the body. Intra-abdominal hydatid cyst continues to be a challenging problem. Methods: Case records of patients diagnosed and surgically treated for intra-abdominal hydatid disease were studied. Demographic details, diagnostic modalities and surgical approach to each patient was studied. Results: Ten cases of intra-abdominal hydatid disease diagnosed and managed in a single surgical centre were studied. Eight patients had hepatic disease, one had splenic disease and one had disseminated disease which included both hepatic and peritoneal disease. All were treated surgically. Conclusions: Males involved in livestock industry are commonly affected. Liver is the commonest intra-abdominal site for hydatid disease. CT scan is diagnostic. Open surgery still continues to be the safest option for treating this condition.
Ascaris lumbricoides is one of the commonest parasite seen in the developing world. A multitude of complications can be caused by this parasite. Hepatobiliary ascariasis (HBA) can be very deceptive in its presentation. A high index of suspicion is therefore necessary to diagnose biliary infestation presenting as jaundice. A case of obstructive jaundice due to biliary ascariasis is presented to highlight this deceptive cause for jaundice.
Laparoscopic cholecystectomy is one of the commonest operations performed on the biliary system. Acute
pancreatitis following Lap-chole is quite uncommon. Whether pancreatitis is a complication or a sequalae to surgical
treatment of gall stone disease continues to be a debatable issue. A 37-year-old lady underwent laparoscopic
cholecystectomy for incidentally diagnosed gall stones. Early post-operative course was uneventful. The patient
presented 3 weeks after surgery with severe excruciating abdominal pain and was diagnosed as acute pancreatitis by
ultrasound evaluation. Liver function tests were altered with raised bilirubin, serum lipase and amylase. MRCP
revealed a normal biliary tract. Pancreas showed changes of acute interstitial pancreatitis. Patient responded to
conservative line of treatment. Acute pancreatitis could be a known complication following laparoscopic
cholecystectomy. What causes pancreatitis continues to be a matter for debate. MRCP is the investigation of choice.
Interventional endoscopy (ERCP) is indicated in cases of impacted gallstone in the CBD. While if the CBD is clear of
stones, aggressive conservative management will suffice.
Laparoscopic cholecystectomy is one of the commonest operations performed on the biliary system. Acute
pancreatitis following Lap-chole is quite uncommon. Whether pancreatitis is a complication or a sequalae to surgical
treatment of gall stone disease continues to be a debatable issue. A 37-year-old lady underwent laparoscopic
cholecystectomy for incidentally diagnosed gall stones. Early post-operative course was uneventful. The patient
presented 3 weeks after surgery with severe excruciating abdominal pain and was diagnosed as acute pancreatitis by
ultrasound evaluation. Liver function tests were altered with raised bilirubin, serum lipase and amylase. MRCP
revealed a normal biliary tract. Pancreas showed changes of acute interstitial pancreatitis. Patient responded to
conservative line of treatment. Acute pancreatitis could be a known complication following laparoscopic
cholecystectomy. What causes pancreatitis continues to be a matter for debate. MRCP is the investigation of choice.
Interventional endoscopy (ERCP) is indicated in cases of impacted gallstone in the CBD. While if the CBD is clear of
stones, aggressive conservative management will suffice.
Annular pancreas is an uncommon condition in adults.
The ring formation generally originates from the failure of
normal clockwise rotation of ventral pancreas. First
described by Tiedmann in 1818, its incidence is
1:20,000 population. It has bimodal presentation i.e is seen
either in Infants or in 4th & 5th decade of life.
Spontaneous Gall Bladder Perforation: A rare clinical entity, a diagnostic an...Crimsonpublisherssmoaj
Gallbladder perforation requiring an emergent treatment is usually a complication of cholecystitis [1]. Acute cholecystitis develops in up to 2% of patients affected by asymptomatic cholelithiasis. Gallbladder perforation occurs in 2 to 11% of acute cholecystitis cases. Due to the high mortality that can be caused by a delay in the correct diagnosis and following adequate surgical treatment, gallbladder perforation represents a special diagnostic and surgical challenge [2].
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Drs. Brooks, Hambright, Holland, and Lorenz’s CMC Abdominal Imaging Mastery P...Sean M. Fox
Drs. Kylee Brooks and Parker Hambright are Emergency Medicine Residents and Drs. Alexis Holland and William Lorenz are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham, Brent Matthews, and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s cases include:
- Pyogenic Liver Abscess
- Bladder Rupture
- Sigmoid Volvulus
Laparoscopic surgery has undergone rapid development in recent years. Laparoscopic cholecystectomy was first performed in 1985. Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery.
Comments Excellent paper. It’s obvious that you put quite a bit of .docxdrandy1
Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
Similar to Post cholecystectomy pancreatitis: a misleading entity (20)
Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis
is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is
a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the
diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along
with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma
of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is
invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum
prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for
other age groups is advisable.
Hyperbaric oxygen therapy a boon for complex post traumatic woundsKETAN VAGHOLKAR
Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.
Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral
veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein
thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the
cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management
thereby reducing the morbidity and mortality associated with the disease.
Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...KETAN VAGHOLKAR
Background: Fluid collection in a femoral hernia sac designated as a femorocele is an
extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and
one case of bilateral femorocele have been reported in English literature. Objective: Thus
making the case presented the second case of bilateral femorocele in English literature.
Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease
who had undergone dual valvular replacement with ascites due to cardiac cirrhosis
is presented to highlight the surgical challenges in management of such a rare case. Discussion:
Pathophysiology, clinical features, investigations and managemeny of femorocele
are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is
diagnostic. Open surgery in the form of dissection of sac with high ligation followed by
obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.
Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a
dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential
for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal
hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding
hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia.
Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.
Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.
Fournier’s gangrene of the scrotum after inguinal hernia repair: case reportKETAN VAGHOLKAR
Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.
Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a
great challenge to the attending surgeon. There are various variants of embryological abnormality of the
processes vaginalis manifesting in different forms. Understanding the embryological development of the
processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical
option for treating these rare cases.
Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple
sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to
hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities
such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical
intervention in the form of debridement and desloughing followed by wound care is the next line of
management. Patient education at the time of discharge is necessary for prevention of recurrence.
Foreign body in the male urethra: case reportKETAN VAGHOLKAR
Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.
Morel-Lavallée Lesion: Uncommon Injury often MissedKETAN VAGHOLKAR
Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have
been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to
the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is
to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma
patients.
Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over
accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid
in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to
induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage.
Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early
diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along
with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.
Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such
an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case
report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced
CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete
excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair.
Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the
mainstay of surgical treatment.
Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...KETAN VAGHOLKAR
Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle
in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes
fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case
report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar
hernia. He had a severe two wheeler accident. Following the accident he had undergone
various surgical interventions for a fractured pelvis with a deglowing injury involving the
right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia
for which he had undergone open mesh repair. Subsequently he developed recurrence of
the post traumatic right-sided lumbar hernia. After complete investigation he underwent
open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and
was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with
bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes
drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles.
They were double-breasted to cover the mesh. Postoperative outcome was excellent
with no recurrence for the last six months. Discussion: The various anatomical and technical
considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion:
Bone fixation of the mesh with bone anchors is a viable option especially in cases where
there is severe attenuation of adjacent muscles for mesh fixation.
LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...KETAN VAGHOLKAR
Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of
laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention.
As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to
evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and
safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients
who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied
prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right
hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes.
In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure.
10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic
cholecystectomy is a safe and viable option for treating acute calculous cholecystitis
Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.
LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)KETAN VAGHOLKAR
Background: Appendicectomy is one of the common procedures performed by a general surgeon. However,
the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore
there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The
study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and
postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised
into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised
25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative
findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced
need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed
in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure
for appendicectomy.
Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to
be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation
and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ
involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal
tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various
surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was
commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia
were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early
histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant
adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis
Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or
contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly
suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical
intervention for complications is the mainstay of treatment.
PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...KETAN VAGHOLKAR
Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending
surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both
morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify
these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to
identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials
and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed
by clinical and radiological investigations were included in the study and studied prospectively. On admission to the
hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients
subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated
and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented
in an advanced stage developed complications. The majority of patients were males. The interval between the onset
of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was
the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most
common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process,
were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by
perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication.
Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination
found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the
complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria
and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the
diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher
complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early
meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.
COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...KETAN VAGHOLKAR
Background: Skin approximation is a very important step in a surgical operation. The quality of skin
approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications.
Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare
traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound
complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients
are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation).
The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation)
had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction.
Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Vagholkar K et al. Int Surg J. 2016 May;3(2):941-943
International Surgery Journal | April-June 2016 | Vol 3 | Issue 2 Page 942
120/70 mmHg. The patient was icteric. Per abdominal
examination revealed mild fullness in the upper abdomen.
There was tenderness in the epigastrium. However there
was no rebound tenderness, guarding or rigidity.
Figure 1: Preoperative MRCP showing a clear
common bile duct and pancreatic duct.
Figure 2: Specimen of the gall bladder which has been
opened shows thick bile, sludge and soft stones.
Figure 3: Post cholecystectomy MRCP showing
normal CBD but plenty of fluid in the abdominal
cavity marked by black arrows. The head of the
pancreas is enlarged.
Figure 4: Post cholecystectomy MRCP showing an
enlarged head of and body of the pancreas with fat
stranding.
Hematological investigations were carried out. CBC was
normal. However liver function tests were grossly
deranged. Total bilirubin was 7.5% mg, Direct bilirubin:
5.5% mg, SGOT: 75 IU, SGPT: 80 IU, Alkaline
phosphatase: 430 IU, Serum Amylase: 500 IU, Serum
lipase: 1190 IU. An MRCP was done immediately which
revealed a normal CBD, common hepatic duct and
intrahepatic biliary radicals. There was no evidence of
any filling defect nor was there dilatation of any portion
(Figure 3). Head and body of pancreas were bulky with
presence of fat stranding (Figure 4). There were extensive
fluid collection in peri pancreatic area and sub hepatic
region (Figure 3). A diagnosis of acute pancreatitis was
therefore made and aggressive conservative treatment
commenced. Patient responded to this treatment within 2
days. By fifth post-operative day, the total bilirubin was
2.5% mgm, alkaline phosphatase was 180 IU. The drain
output however increased and drained approximately
750cc of blood stained fluid which later cleared and
stopped draining within 2 days. Patient passed flatus and
stools by the seventh post-operative day. Oral feeds were
commenced a day after. Liver function tests were
performed on seventh post-operative day and were within
the normal range. Drain was removed on seventh post-
operative day. Complete suture removal was done on
tenth post-operative day. Patient has been following up
for the last 1 month with no symptoms.
DISCUSSION
Early post cholecystectomy pain can be attributed to a
wide variety of causes.1
A missed stone or a sludge ball
in the CBD could possibly pass across the ampulla of
Vater giving rise to temporary obstruction with
accompanying pain. This can also cause transient
jaundice which will resolve after passage of stone or
sludge ball into the duodenum. It can also cause back
pressure changes in the CBD leading to blow out of the
cystic duct stump with leakage of bile. The leaking bile
may give rise to clinical features of peritonitis. However,
this process may take some time approximately 2-3 days
to evolve fully with typical clinical features. In the case
presented the gall bladder was severely thickened and
3. Vagholkar K et al. Int Surg J. 2016 May;3(2):941-943
International Surgery Journal | April-June 2016 | Vol 3 | Issue 2 Page 943
fibrotic. Pre-operative MRCP was normal with no
evidence of any CBD calculi or sludge. Microliths can
also cause or precipitate severe pancreatitis.2
Microliths
cannot be picked up by routine MRCP or CT scanning. It
is therefore possible that microliths in the CBD bile may
have passed and crossed the sphincter of Oddi causing
temporary obstruction with precipitation of an attack of
acute pancreatitis.3
This was evidenced by enlargement of
pancreatic head and body as seen on the post-operative
MRCP. Typical fluid collections in peri pancreatic area
with fat stranding are diagnostic of pancreatitis. Prompt
and aggressive supportive care can lead to early
resolution of pancreatic inflammation. Post
cholecystectomy acute pancreatitis therefore can be a
misleading complication after cholecystectomy.4
Any
post-operative sequel after cholecystectomy therefore
warrants an urgent MRCP. MRCP provides an excellent
road map to plan the course of further treatment. In the
case presented, as the diagnosis of acute pancreatitis was
confirmed and the CBD was normal, conservative
treatment was the mainstay of management. However if
there happens to be a stone or sludge ball impacted in the
lower end of the CBD then ERCP with sphincterotomy
and stenting is essential.
CONCLUSION
Early acute post cholecystectomy pancreatitis is a rare
entity. Immediately MRCP accompanied with altered
enzymes (lipase and amylase) and liver function tests is
diagnostic. Aggressive supportive care is the mainstay of
treatment in cases where there is no obstruction in the
CBD. However if there is an impacted stone or sludge
ball seen on MRCP then endoscopic intervention is
mandatory.
ACKNOWLEDGEMENTS
We would like to thank the Dean of D.Y. Patil University
School of Medicine, Navi Mumbai, India for allowing us
to publish this case report.
We would also like to thank Parth Vagholkar for his help
in type setting the manuscript.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
REFERENCES
1. Shaffer E. Acalculous biliary pain; new concepts for
an old entity. Dig Liver Dis. 2003;35(3):20-5.
2. Ros E, Navarro S, Bru C, Garcia Puges A,
Valderrama R. Occult microlithiasis in idiopathic
acute pancreatitis; prevention of relapses by
cholecystectomy or ursodeoxycholic acid therapy.
Gastroenterology. 1991;10(6):1701-9.
3. Abeysriya V, Deen KI, Navarathne NM. Biliary
microlithiasis, sludge, crystals, microcrystallization,
and usefulness of assessment of nucleation time.
Hepatobiliary Pancreat Dis Int. 2010;9(3):248-53.
4. Quallich LG, Stern MA, Rich M, Chey WD, Barnett
JL, Elta GH. Bile duct crystals do not contribute to
sphincter of Oddi Dysfunction. Gastrointest Endosc.
2002;55(2):163-6.
Cite this article as: Vagholkar K, Pawanarkar A,
Vagholkar S, Pathan S, Desai R. Post
cholecystectomy pancreatitis: a misleading entity.
Int Surg J 2016;3:941-3.