Liver Segmentation and its Application to Hepatic Interventions

The thesis addresses the development of an intuitive and accurate liver segmentation approach, its integration into software prototypes for the planning of liver interventions, and research on liver regeneration. The developed liver segmentation approach is based on a combination of the live wire paradigm and shape-based interpolation. Extended with two correction modes and integrated into a user-friendly workflow, the method has been applied to more than 5000 data sets. The combination of the liver segmentation with image analysis of hepatic vessels and tumors allows for the computation of anatomical and functional remnant liver volumes. In several projects with clinical partners world-wide, the benefit of the computer-assisted planning was shown. New insights about the postoperative liver function and regeneration could be gained, and most recent investigations into the analysis of MRI data provide the option to further improve hepatic intervention planning

Case study of 100 cases of intestinal obstruction

INTRODUCTION: Intestinal obstruction is a common cause of acute abdomen handled by surgeons. Obstruction of inguinal hernias and adhesive obstructions make up a large number of these cases. The clinical presentation varies depending on the type, site, duration etc. Timely evaluation, diagnosis and management plays an important role in disease outcome. This study deals with epidemiology, etiology, clinical features, morbidity and mortality. AIM OF STUDY: 1. To study various causes of intestinal obstruction. 2. To study various presentations of the cases. 3. To study epidemiology of cases. 4. To study various surgical procedures and its outcome. 5. To study factors affecting morbidity and mortality. METHODOLOGY: The materials for the clinical study of intestinal obstruction were collected from cases admitted to various surgical wards of Tirunelveli medical college hospital, during the period from February 2011 to October 2012,hundred cases of intestinal obstruction have been studied. Patients belonged to the age groups ranging from 12 years to 88 years, paediatric age group is excluded from this study. The criteria for selection of cases was based on clinical history, physical findings, radiological and haematological investigations. Patients who were having sub acute intestinal obstruction treated conservatively,patients with a dynamic obstruction and paediatric patients were excluded from the study, and only those cases of acute intestinal obstruction which were managed surgically were studied to establish the aetiology of intestinal obstruction with an aim to know the mode of presentation, physical findings, radiological and haematological findings, operative findings and outcome of acute intestinal obstruction. After the admission of the patient, clinical data were recorded as per Proforma. The diagnosis mainly based on clinical examination and often supported by haematological and radiological examinations. Inclusion criteria: 1. All cases > 12 years age, 2. Both males and females, 3. Small bowel and large bowel obstruction, 4. Cases of acute intestinal obstruction. Exclusion criteria: 1. All cases < 12 years age, 2. Adynamicintestinalobstruction, 3. Sub acute cases. CONCLUSION: Acute intestinal obstruction remains an important surgical emergency in the surgical field Success in the treatment of acute intestinal obstruction depends largely upon early diagnosis skillful management and treating the pathological effects of the obstruction just as much as the cause itself. Erect abdomen X-ray is valuable investigation in the diagnosis of acute intestinal obstruction. 1. The study showed that inguinal hernias are the most common cause of intestinal obstruction. 2. Males were predominantly affected. 3. Age group between 41 – 70 years was the most commonly affected. 4. Patients taking mixed diet was predominantly affected. 5. Most common symptom was vomiting. 6. Most common sign was tachycardia. 7. Mortality was found to be highest with colonic obstruction due to growth. 8. Total number of Anastamotic leak and Wound infection were more in males, though a disproportionately higher incidence occurred in women inspite of their lower numbers. 9. Most common postoperative complication was wound infection. 10. Resection and anastomosis as well as release and herniorrhaphy were the most commonly done surgical procedures

A study on the surgical management of acute intestinal obstruction in adults

BACKGROUND AND OBJECTIVES: Intestinal obstruction remains as one of the most common intra-abdominal pathologies encountered by surgeons whether it is caused by hernia, neoplasm, adhesions or any biochemical disturbances. Intestinal obstruction of the small or large bowel continues to be an important cause of morbidity and mortality. The objective of this study is to analyse the clinical features, treatment and outcome of patients with acute intestinal obstruction along with the cause of obstruction and causes of bowel ischaemia, necrosis and perforation. The following are the objectives of the study: 1. To study various patterns of presentation, various causes, significance of early recognition, diagnosis and treatment. 2.To study various influencing factors like age, sex, diet and socio-economic status in the pathogenesis of acute bowel obstruction. 3. To study morbidity and mortality rates in acute intestinal obstruction. METHODS: The materials for the clinical study of bowel obstruction were collected from various Cases getting admitted to various surgical wards. 50 cases of acute intestinal obstruction have been studied. Patients were belonging to the age groups from 12 years to 85 years, paediatric age group (<12 yrs) is excluded from this study. The case selection criteria was based on history, physical findings, radiological findings and haematological parameters. The study has been divided into Clinical study, Investigations and Treatment. Postoperative Follow-up was done in majority of the patients upto six months after the discharge of patients. The results have been tabulated stressing on following points: age, sex, symptoms, clinical findings, investigations, abnormalities, possible causative factors, operative findings and operative procedure done and complications if any occurred. RESULTS: The study group had 50 cases of acute bowel obstruction in the adult age group from 12 years to 85 years. The prevalent age groups are 31-40 and 51-60 age group with around 20% each in the total study. The most common cause of acute intestinal obstruction in the adults in this study series has been post-operative Adhesions (40%) and the next being obstructed Hernia (30%). The clinical features of abdominal pain, vomiting, constipation have been the main symptoms in this study. Abdominal Tenderness, guarding, rigidity, rebound tenderness and shock have been the cardinal features of strangulated obstruction. The commonest type of obstruction has been due to adhesions or band arising from the previous surgeries. This has constituted to about 40% of the cases of the study group. The second most common type of bowel obstruction is due to obstructed/strangulated external hernia. Salient features had been pain in the groin swelling, acute onset of swelling which is tender, not reducible and without cough impulse. Obstructed hernia constituted about 30% of the total cases studied. Volvulus of the sigmoid colon was 4% in this series. Conservative measures included insertion of ryle’s tube and iv fluids but all the cases underwent laparotomy due to failure of the recovery of symptoms. Derotation of the volvulus and sigmoidopexy was done in one case and in one case with vascular compromise, resection and anastamosis was done. Malignancy of the colon was seen in 7 patients constituting 14% of cases. 65% of the malignancies were in the age group of 35-75 years. Of these 2 patients have been managed with Hartman’s procedure. One case has been managed with loop transverse colostomy and remaining patients were managed with resection and anastamosis. Most of the deaths occurred those with malignancy. Although pulmonary tuberculosis is more prevalent in India, due to the use of antitubercular drugs, abdominal tuberculosis is becoming less prevalent. In this study incidence of ileocaecal tuberculosis was 4% and both patients were managed with resection and anastamosis. In this study intussusception causing intestinal obstruction was 6%. One case was managed with simple reduction and the remaining two patients underwent resection and anastamosis. One case of mesenteric ischaemia was recorded is our study. This patient was managed with resection and anastamosis but patient expired due to septicemia. The complication rate in this study was 18%. Overall mortality of this study was 14%. The results obtained from this study was comparable to various other studies. Malignancy and mesenteric ischemia had more mortality than simple obstruction due to postoperative adhesions. The poor prognosis of the disease was because of late presentation to the hospital with a high incidence of bowel damage with associated faecal peritonitis. The morality in the postoperative period was mostly due to faecal peritonitis, pneumonia and respiratory tract infection. INTERPRETATION AND CONCLUSION: Acute intestinal obstruction remains to be an important surgical emergency in the surgical field. Success in the treatment of acute bowel obstruction depends mainly on the early diagnosis and efficient management and treating the pathological effects of the obstruction as much as the treatment of the cause itself. Erect abdomen X-ray is a valuable tool in the diagnosis of acute intestinal obstruction. Postoperative adhesions have been the most common cause to produce bowel obstruction. Clinical, radiological and operative findings when put together can diagnose the intestinal obstruction. Mortality is still significantly high in acute intestinal obstruction in adults

A study on raised serum LDH level in acute intestinal Obstruction: A marker of bowel gangrene Coimbatore Medical College Hospital

INTRODUCTION: Intestinal obstruction accounts for 20% of all surgical emergencies around the world. Intestinal obstruction can result from variety of causes. When strangulation superimposes and blood supply to the bowel is compromised , it may lead to bowel gangrene. The most common cause of bowel gangrene secondary to mechanical obstruction is strangulated hernia in India and post operative adhesions in developed countries. Lactate dehydrogenase is an enzyme found abundant in intestinal mucosa and when the intestinal mucosa undergoes tissue hypoxia/ischemia, it is released into the serum and its serum level increases. Hence serial estimation of the serum LDH helps us to identify whether the obstruction goes on for gangrene or not. This study was conducted to emphasise the significance of early estimation of rise in LDH levels followed by early intervention which helps in reducing the morbidity and mortality caused by bowel gangrene following obstruction. OBJECTIVE OF THE STUDY: 1. To estimate the levels of serum LDH in patients presenting with symptoms of intestinal obstruction 2. To identify the patients with elevated levels of serum LDH and correlate the elevated levels of LDH with viability of the bowel. MATERIALS AND METHODS: In this study, the estimation of serum LDH was conducted in 45 cases of acute intestinal obstruction who were admitted in surgical wards of CMCH during the period of September 2014 to August 2015. LDH was estimated in all the cases preoperatively on the day of admission. Serum LDH was estimated in all the patients at the time of admission and the estimated value of serum LDH is compared with the viability of the bowel intra operatively. RESULTS: Among 45 patients presented with obstruction 20 patients had LDH level between 50 to 200 and all the 20 patients had normal bowel viability and 3 patients had LDH level between 200 to 400 and all the three patients had normal bowel viability. 4 Patients had LDH level between 400 to 800 and two of them had normal bowel viability and two others had bowel gangrene. 8 Patients had LDH level between 800 to 1200 and all of them had bowel gangrene. 10 Patients had LDH level more than 1200 and all of them had bowel gangrene. DISCUSSION: The normal level of serum LDH is 50 to 200 IU/L. Out of 45 patients 25 patients had elevated serum LDH which is about 55.56% and among those 25 patients, 20 patients found to have bowel gangrene which is about 80% . In our study the mean value of elevated serum LDH in bowel gangrene patients is 1037 IU/L. The incidence of bowel obstruction and gangrene is more common in males(72%) than females(28%). According to Muchas, an elevated level of LDH is found in 86% of patients who had bowel gangrene. “Lactate dehydrogenase is one of the markers of intestinal ischemia”. - Thompson. A study conducted by Lange.H, Jackel.R revealed an inference of 100% sensitivity and 42% specificity for increased LDH in patients presenting with acute abdomen who later are found to have intestinal ischemia and gangrene(34). Dr Neil R Feins suggested that the level of LDH can be taken as a criteria for intestinal obstruction. CONCLUSION: From this study it is evident that ischemic changes in any part of the bowel can cause elevation in the serum levels of LDH and a higher value of >1000 IU/L strongly indicates an underlying gangrenous change. It is a less invasive , cost effective and easily available diagnostic tool to diagnose bowel ischemia/gangrene. Hence it is more useful in centres where the diagnostic facilities are limited. The pre operative estimation of serum LDH levels in patients presenting with features of acute intestinal obstruction helps in identifying the patients who undergo intestinal ischemia and gangrene at the earliest which makes an early intervention possible and helps in reducing the morbidity and mortality due to bowel gangrene. Early diagnosis and early intervention is the key to reduce the mortality rate due to bowel gangrene. This study was conducted in Coimbatore medical college hospital and the results are similar and comparable to the other studies

Two Independent Networks of Interstitial Cells of Cajal Work Cooperatively with the Enteric Nervous System to Create Colonic Motor Patterns

Normal motility of the colon is critical for quality of life and efforts to normalize abnormal colon function have had limited success. A better understanding of control systems of colonic motility is therefore essential. We report here a hypothesis with supporting experimental data to explain the origin of rhythmic propulsive colonic motor activity induced by general distention. The theory holds that both networks of interstitial cells of Cajal (ICC), those associated with the submuscular plexus (ICC–SMP) and those associated with the myenteric plexus (ICC–MP), orchestrate propagating contractions as pacemaker cells in concert with the enteric nervous system (ENS). ICC–SMP generate an omnipresent slow wave activity that causes propagating but non-propulsive contractions (“rhythmic propagating ripples”) enhancing absorption. The ICC–MP generate stimulus-dependent cyclic depolarizations propagating anally and directing propulsive activity (“rhythmic propulsive motor complexes”). The ENS is not essential for both rhythmic motor patterns since distention and pharmacological means can produce the motor patterns after blocking neural activity, but it supplies the primary stimulus in vivo. Supporting data come from studies on segments of the rat colon, simultaneously measuring motility through spatiotemporal mapping of video recordings, intraluminal pressure, and outflow measurements

MODELLING GASTROINTESTINAL SMOOTH MUSCLE MECHANICS

Ph.DDOCTOR OF PHILOSOPH

A clinical study of the factors affecting the outcome of intestinal resection and anastomosis

INTRODUCTION: Resection and anastomosis is the surgical procedure involving excision of a diseased organ with adequate margins and joining the cut ends so as to maintain anatomical continuity. Most commonly performed resection and anastomosis is that involving the intestines. The above mentioned study is a humble attempt to understand the various factors which influence the outcome of an intestinal anastomosis in order to bring forth successful anastomosis healing. BODY: The above mentioned study has been conducted under the Department of General Surgery, Tirunelveli Medical College, with Institutional Ethical Committee approval. 50 cases of intestinal resection and anastomosis due various causes have been studied. Various factors – patient related, surgery related and post operative were analysed and compared. Patient related factors include Age, Cause for resection, Diabetes, Hypertension, biochemical parameters. Surgery related includes presence of gangrene, volume of bowel resected, type of anastomosis, and contamination of peritoneum. Post operative includes transfusion of blood and blood products, TPN. The presence or absence of these factors in the 50 patients were followed and analysed. Outcomes taken into consideration were a successful anastomotic healing, anastomotic leak and death. Factors which were found to directly influence the outcomes were age, sex, cause of resection, diabetes, low serum proteins, anaemia, presence of gangrene and TPN. CONCLUSION: Outcome of intestinal resection and anastomosis is multi-factorial. A successful anastomosis healing is an outcome of a wholesome approach. Correction of metabolic abnormalities and supplementation of nutrients goes a long way in proper healing of the anastomotic site