Incidence of persistent symptoms after Laparoscopic Cholecystectomy

AIM: Laproscopic cholecytectomy has become mainstay of treatment for gallstone related pathologies. Many studies have reported varying results. This studies will strive to find the percentage and also symptom profiles suffered by patients after laparoscopic cholecystectomy MATERIALS AND METHODS: This study was done among 7o patients attending surgical department in kilpauk medical college,chennai.After consent and ethical commitee clearence,Patients were asked to fill Questionnaires regarding their symptoms 6 months before and after surgery. RESULTS: Only 58 patients completed the study.13 % of them suffered from their preoperative symptoms.6 of them were females. Colonic symptoms such as bloating and constipation showed poor cure rates. Dyspeptic symptoms showed better cure rates of around 90% suggesting that some of them could be due to gallstones whereas those noncured had other pathologies. Hence dyspepsia is not indication for cholecystectomy unless other pathologies are ruled out .Few of symptomatic patients had history of psychiatric treatment suggesting that it could be a contributive factor. CONCLUSION: The incidence of post cholecystectomy in this study which was 13% was similar to many studies reported before Two patients had persistent upper GI symptoms were found to have duodenal ulcer and upper gi symptoms showed cure rates around 80% suggesting some of upper GI symptoms could be due to biliary pathology that can be cleared by cholecystectomy. Hence Heartburn,Non specific dyspepsia are not adequate reason for cholecystectomy Colonic symptoms showed poor cure rates People with persistent colonic symptoms had history of psychiatric disorders like depression and history of drug intake such as antidepressants. Hence those who have used psychotropic drugs they may have asymptomatic gall bladder calculi and irritable bowel syndrome. Such patients are unlikely to benefit from laparoscopic cholecystectomy

A study of gallstone disease

INTRODUCTION: Calculus disease of biliary system is one of the most common disorders affecting the gastrointestinal tract constituting a major cause of morbidity. There has been a marked rise in the incidence of gall stone disease in the west during the past century. In the UK, USA and Australia, the prevalence rates varies from 15- 25%. In India, it is more common in North India than in South India. Similarly the incidence in Eastern India is higher than in the West. Incidence of gallstones increases with age. It is more common in females than males (M:F = 1:4) . About 50% of patients with gall stones are asymptomatic. 1 to 2% of asymptomatic patients will develop symptoms requiring cholecystectomy per year, making cholecystectomy one of the most common operations performed by surgeons. The etiopathogenesis of gallstones is multifactorial. It varies according to the type of gallstones. Primarily gallstones can be divided into two major groups. First is pure gallstones contributing to 10% of gallstones. Second is mixed and combined gallstones which accounts for 90% of gallstones. Mixed gallstones have increased preponderance for cholecystitis. Infection seems to be a major cause of gallstones formation. Moynihan’s aphorism that “gall stone is a tomb stone erected in the memory of the organism with in it” is true today. Evidence in favour of infection includes isolation of E. coli, klebsiella, bacterium typhosum, streptococcus from the bile within the gallbladder. Slow growing actinomyces also have been recovered from the bile. These organisms reach the gallbladder via blood stream from an infective focus elsewhere in the body and also by lymphatics. Brown pigment gallstones occur as a result of infection. Bacteria are found with in the calcium bilirubinate and protein matrix of brown pigment gallstones. Predisposing factors are obesity, dietary factors, liver disease, gallblader disease, haemolytic anaemia, gastric surgery and terminal ileal resection. Treatment varies from medical management to surgical management. Recently minimally invasive surgery improves the patient’s compliance and reduces the morbidity. Sequalae of gallstone disease contributes to most of the surgical problems in patients with the disease. OBJECTIVES: To study the age, sex incidence and various modalities of clinical presentation. Bacteriological analysis of the bile collected from all cases subjected to cholecystectomy in our study so as to identify the commonest type of organism associated with gall stones. METHODOLOY: Source of data : Patients admitted to Tirunelveli Medical College Hospital with the diagnosis of Gallstone disease were taken for this observational study from March 2011 to October 2012. Type of study: It is a prospective study. Inclusion Criteria: Patients of age >12 years and < 65 years. All proven cases of gallstone disease wh o got admitted to the hospitalfor cholecystectomy both open and laparoscopic cholecystectomy. Exclusion Criteria: Acute chole cystitis, Acute acalculus cholecystitis Emphyema gall bladder Mucocele of the gall bladder, Jaundice patients, Gallstones with multiple common bile duct stones (multiple CBD and intrahepatic stones), Patients who refused surgery. CONCLUSION: From observation of our prospective study of 50 cases, the following conclusions were derived: • Gallstone disease is common in females than in the males and the age group was 51 to 65 years. • All the cases presented with right hypochondriac pain. Nausea and vomiting were present in 18 cases and fever was present in 11 cases. • Ultrasound abdomen was the main investigation to detect gall stones and MRCP to know the anatomy of common bile duct. • In our study, 28 patients underwent open cholecystectomy, 17 patients underwent laparoscopic cholecystectomy and 5 patients underwent laparoscopy which was converted to open cholecystectomy for practical difficulties. • 21 cases showed organisms in bile culture –of which 17 were females and 4 were males. • The most common microorganism isolated from bile culture was Klebsiella in our study although E. Coli is the commonest organism as per standard text books.Our study revealed E.Coli growth only in 4 patients. • 34 cases in our study showed pigment stones and 16 cases were cholesterol stones. • Histopathological examination of gallbladder wall showed features of chronic calculus cholecystitis in all the cases

A glance at gallstones in South Africa: a one year review of sonographic findings at a tertiary hospital

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in Internal Medicine. Johannesburg, June 2016Background. Gallstones (GS) have historically been thought to be uncommon in Sub-Saharan Africa. There are scanty data on the current prevalence of GS in South Africa despite a significant change in the GS risk factor prevalence. Objectives. To determine the prevalence and risk factors for GS among adult patients undergoing abdominal ultrasound scans at a tertiary institution. Methods. We conducted a retrospective cross sectional analysis of all adult abdominal ultrasound scan reports from the radiology department of the institution in the year 2009. Basic demographics, presence, symptoms and complications of gallstones were collected. Logistic regression was used to explore both dependent and independent risk factors for developing GS. Results. Of the 3 494 reports analysed, 284(8.1%) had GS [95% confidence interval 7.2 - 9.1], with 70% being female. Gallstone prevalence was 10.2% and 5.5% for females and males respectively with a symptomatic to asymptomatic GS ratio of 1:1.9. Complications were seen in 6.3% of all patients with GS, with cholecystitis being the commonest (61%). The GS prevalence by population group was significantly higher in the white population which was an independent risk factor [adjusted OR 2.44(1.86-3.20)]. Other independent risk factors for GS were female gender [adjusted OR 1.97(1.51-2.56)] and increasing age [adjusted OR 1.03(1.02-1.04)]. Conclusion. In this hospital based study, the prevalence of GS among adult patients was slightly higher than in other previous African studies. Independent risk factors for GS were increasing age, white race and female gender. Further community based surveys are necessary to determine the true prevalence of GS among adults in South Africa.MT201

Cholecystectomy Concomitant with Laparoscopic Gastric Bypass: A Trend Analysis of the Nationwide Inpatient Sample from 2001 to 2008

Background: Gallstone formation is common in obese patients, particularly during rapid weight loss. Whether a concomitant cholecystectomy should be performed during laparoscopic gastric bypass surgery is still contentious. We aimed to analyze trends in concomitant cholecystectomy and laparoscopic gastric bypass surgery (2001-2008), to identify factors associated with concomitant cholecystectomy, and to compare short-term outcomes after laparoscopic gastric bypass with and without concomitant cholecystectomy. Methods: We used data from adults undergoing laparoscopic gastric bypass for obesity from the Nationwide Inpatient Sample. The Cochran-Armitage trend test was used to assess changes over time. Unadjusted and risk-adjusted generalized linear models were performed to assess predictors of concomitant cholecystectomy and to assess postoperative short-term outcomes. Results: A total of 70,287 patients were included: mean age was 43.1years and 81.6% were female. Concomitant cholecystectomy was performed in 6,402 (9.1%) patients. The proportion of patients undergoing concomitant cholecystectomy decreased significantly from 26.3% in 2001 to 3.7% in 2008 (p for trend < 0.001). Patients who underwent concomitant cholecystectomy had higher rates of mortality (unadjusted odds ratios [OR], 2.16; p = 0.012), overall postoperative complications (risk-adjusted OR, 1.59; p = 0.001), and reinterventions (risk-adjusted OR, 3.83; p < 0.001), less frequent routine discharge (risk-adjusted OR, 0.70; p = 0.05), and longer adjusted hospital stay (median difference, 0.4days; p < 0.001). Conclusions: Concomitant cholecystectomy and laparoscopic gastric bypass surgery have decreased significantly over the last decade. Given the higher rates of postoperative complications, reinterventions, mortality, as well as longer hospital stay, concomitant cholecystectomy should only be considered in patients with symptomatic gallbladder diseas

Volume 03, issue 2

The mission of CJS is to contribute to the effective continuing medical education of Canadian surgical specialists, using innovative techniques when feasible, and to provide surgeons with an effective vehicle for the dissemination of observations in the areas of clinical and basic science research. Visit the journal website at http://canjsurg.ca/ for more.https://ir.lib.uwo.ca/cjs/1049/thumbnail.jp

A Clinical study and Management of Cholelithiasis

INTRODUCTION: Among the many distinguished names in Hindu medicine is that of SUSHRUTA, The Father of Indian surger. He compiled the surgical knowledge of his time in his classic ―Sushrata Samhitha. It is believed that this classic was compiled between 800 B.C. and 400 A.D. He described jaundice as-pitta-ashmarijanya‖ meaning a jaundice caused by stone in bile.1It was also known that such jaundice could be caused by wrong diet. 6% of prevelance gall stone was found in India. Diagnosis of gallstone is by proper history and physical examination and combining it with appropriate investigations. With the help of ultrasound we can easily identify gall stones. Because of increase incident of Gall stones and its variable presentations in there is a need for study which can provide prevalence, clinical presentations and management outcomes. AIM OF THE STUDY: 1. To study the age and sex distribution. 2. To study the various modes of presentation. 3. To study safety and efficacy of laparoscopic cholecystectomy in patients of cholelithiasis by comparing with results of open cholecystectomy by comparing use of post-operative analgesia, post-operative hospital stay, wound infection. METHODOLOGY: This dissertation titled as “A clinical study and management of cholelithiasis” is going to conduct at Govt. Royapettah Hospital, KMCH, Chennai-10 for a period of January 2018 to June 2018. About 53 consecutive cases will admit, examine, investigate and operate during the period of January 2018 to June 2018. Detailed history of all the 53 cases will take according to the profoma approved by the guide. Detailed history and examination and relevant investigations done. Risk and complications of the condition as well as surgery has been explain to the patients, concern will take. Preoperative antibiotics will give. In this study sum of the patients undergone open cholecystectomy and some of the patients undergone lap cholecystectomy. Postoperative pain were assessed by VAS. Patients who undergone lap cholecystectomy discharge on the 7th day and open cholecystectomy discharge on the 11th day. Unless any complications. All Patients advise regarding diet, rest and to visit the surgical OPD for regular follow up. In the follow up period attention were given to subject to improvement of the patients with regard to symptoms as well as examination of the operative scar. OBSERVATION: The age incidence of cholelithiasis was more in the 3rd, 4th & 5th decade, with peak incidence in 4th decade of life. 60.4% (32 Patients) were female and 39.6 % (21 Patients) were male. The female to male ratio was 1.52:1. Pain was the commonest presenting symptom presenting in 98% patients. Tenderness in the right hypochondrium was the most common sign present in 100%. The most common complication of cholelithiasis was chronic cholecystitis 80% .LC versus OC (18 cases in open and 35 cases in lap) and found that the mean operating room time was 104 min for OC and 88 min for LC. The conversion rate was 10.5%. The mean duration of hospital stay was 11 days for OC and 8 days for LC. The amount and period of analgesia were significantly less in the LC group. Patients recovered significantly faster after LC. CONCLUSION: The highest age incidence of cholelithiasis was in the 4th decade, even though no age group was exempt from the disease process. The incidence of cholelithiasis was more in females. The commonest symptom was pain and commonest sign was tenderness. The most common complication presenting with symptomatic gall stones was chronic cholecystitis. Laparoscopic cholecystectomy is a safe and effective treatment for most patients with symptomatic gallstones

Serological markers of gluten sensitivity in Border terriers with gall bladder mucocoeles

Objectives To evaluate serological markers of gluten sensitivity in conjunction with cholecystokinin measurement in Border terriers with gall bladder mucocoeles. Materials and Methods Medical records from two referral hospitals were obtained between 2011 and 2019 to identify Border terriers with gall bladder mucocoeles, non‐Border terriers with gall bladder mucocoeles and control Border terriers with non‐biliary diseases. Enzyme‐linked immunosorbent assays were performed on stored fasted serum samples for anti‐gliadin IgG, anti‐canine transglutaminase‐2‐IgA autoantibodies and cholecystokinin. Statistical analysis was performed using the Kruskall‐Wallis test to identify differences between the groups. Results Fifteen Border terriers with gall bladder mucocoeles, 17 non‐Border terriers with gall bladder mucocoeles and 14 control Border terriers with non‐biliary diseases were recruited. Median transglutaminase‐2‐IgA autoantibodies in Border terriers with gall bladder mucocoeles was 0.73 (range: 0.18 to 1.67), which was significantly greater than in control Border terriers at 0.41 (0.07 to 1.14). Median cholecystokinin concentration in Border terriers with gall bladder mucocoeles was 13 pg/mL (6 to 45 pg/mL), which was significantly lower than in control Border terriers at 103 pg/mL (9 to 397 pg/mL). There was no difference in the anti‐gliadin IgG between these groups. There was no difference observed in the non‐Border terriers with gall bladder mucocoeles with either of the other groups. Clinical Significance Reduced cholecystokinin and increased transglutaminase‐2‐IgA autoantibodies was detected in Border terriers with gall bladder mucocoeles; which is in part homologous to gall bladder disease identified in human coeliac disease. The results suggest an immunological disease with impaired cholecystokinin release may be affecting gall bladder motility and possibly contributing to mucocoele formation in Border terriers

A comparitive study of open cholecystectomy versus laparoscopic cholecystectomy

INTRODUCTION: Gall bladder disease is the most common curable disease in female of middle age. Laparoscopic cholecystectomy has rapidly become the choice of elective surgery for the treatment of Cholecystitis even though Open Cholecystectomy remains the main modality of surgery in many centres in India. But to become an alternative to open method, it should be safe, less morbid and it should have the possibility of early return to work better than that of open the procedure. This study compares the open cholecystectomy and laparoscopic cholecystectomy with respect to duration of procedure post operative pain, wound infection, requirement of antibiotics and analgesics period of stay in hospital and return to work. In this study we selected 65 patients with gall bladder diseases and divided in to two groups as Group A and Group B in a random wise 33 in former and 32 in later group. The source of cases were obtained from Govt. Kilpauk Medical College, Chennai & Govt. Royapettah Hospitals, Chennai, department of general surgery. All the patients were subjected for USG abdomen, Complete blood count, renal function test, CXR, liver function test and MRCP in selected cases. Group a subjected for open cholecystectomy and Group B for laparoscopic cholecystectomy and the above mentioned datas were compared. Pre operative antibiotic given half an hour prior to surgery is more enough to prevent infection except in conditions like diabetes mellitus association with it. Per rectal Paracetamol suppository is enough to relieve in both the groups. Time taken for laparoscopic surgery is lesser than that for open procedure and the period of hospital stay is also less in laparoscopic surgery

The Icterus index of the blood serum as an aid to diagnosis, treatment, and prognosis

1. That we have in the Icterus Index a delicate clinical test for hyperbilirubinaemia, which, if used in correlation with the clinical findings, will in certain diseases be of value in diagnosis, treatment, and prognosis. 2. That the technique is a simple one, requiring no specialized laboratory experience. Some of the more recent modifications of the technique are especially simple, and while not so accurate as Bernheim's method, are perhaps sufficiently so for general purposes. 3. That normal persons show an Icterus Index which lies between 3.0 and 8.0 4. That an Icterus Index of over 8.0 may be considered as denoting a pathological hyperbili_ rubinaemia. 5. That with an Icterus Index of 15.0 or over there is almost invariably clinical jaundice present. 6. That the Icterus Index varies directly in proportion to the degree of jaundice. In this connection it has been found that the Icterus Index follows very closely any variations in the jaundice, and may be taken as a means of recording recording increase or decrease of the latter, It is as a means of following up cases of jaundice that the Index has been found especially useful. 7. That in cases of cholecystitis and cholelithiasi by means of variations in the Icterus Index, taken in conjunction with the clinical findings, the former are of value in the placing of operative indications. 8. That the Icterus Index is of value in the post operative prognosis in cases of gallbladder disease. 9. That the mere presence of gallstones, without obstructive symptoms or associated cholecystitis will not cause a hyperbilirubinaemia with a resultant raised Icterus Index. 10. That the mere height to which the Icterus Index is raised in a case of jaundice is not evidence for or against malignancy, but a steadily rising Index points to malignant obstruction of the common bile duct. In this connection the possibility of a simple tightly impacted stone, completely occluding the duct, must not be forgotten. 11. That the Icterus Index may be used to differentiate between renal and biliary conditions, the former giving normal figures. 12. That while a raised Index may be caused either by effects on the liver or by haemolytic processes, the figures obtained are usually higher in the former. 13. That the Icterus Index is of no value in the diagnosis of early secondary malignant deposits in the liver. 14. That as duodenal ulcer commonly causes a raised Index, while gastric ulcer gives normal figures, the Icterus Index may be of use in the differential diagnosis of these conditions. 15. That confusion may arise owing to the fact that both biliary dysfunction and duodenal ulcer caus a raised Icterus Index. It is sometimes difficult to make a positive diagnosis between then two conditions, but the clinical findings and the fact that biliary disorders almost invariabl give higher figures than duodenal ulcer should enable one to decide the diagnosis in the majority of cases. 16. That though a raised Icterus Index is sometimes obtained in cases of acute appendicitis, this is uncertain, and cannot be considered as of value in diagnosis. 17. That cases of chronic appendicitis do not raise the Icterus Index. 18. That the Icterus Index is raised in pernicious anaemia, and that variations in the Index are of prognostic value in that disease. 19. That the Icterus Index is of value in the differential diagnosis between pernicious anaemia and carcinoma of the stomach, the latter giving a normal Index. 20. That cases of secondary anaemia show a subnormal Icterus Index, and that therefore this test may be used to differentiate primary and secondary anaemias. 21. That there seems to be small ground for supposing that the Icterus Index may be used ás a means of deciding for or against splenectomy in Banti' disease. 22. That the low Icterus Index caused by secondary anaemia may mask a raised Index due to disease. This fallacy must be kept in mind when interpret ing results of Icterus Index readings in anaemic patients. 23. That the Icterus Index is raised in cases showing cardiac decompensation, and that this rise is directly proportional to the degree of decompensation. 24. That repeated Icterus Index readings in cardiac cases are of value in following the progress of the case, and in forming one's prognosis. 25. That mere valvular disease or any other cardiac disease without decompensation will not raise the Icterus Index. 26. That cases of arsenical hepatitis and dermatitis cause a raised Icterus Index. 27. That venereal disease in general, and syphilis in particular, does not raise the Icterus Index, but the intravenous administration of arsenic for syphilis often causes a preliminary rise in the Index at the start of treatment. This rise disappears as treatment is continued and does not contraindicate further arsenical medication. 28. That in a case receiving arsenical treatment an Icterus Index rising steadily through the period of latent jaundice is a danger signal of oncoming intolerance. 29. That until the Icterus Index has returned to normal in a case of arsenical hepatitis, further arsenical treatment is contraindicated. 30. That we have in the Icterus Index a convenient 'tolerance' test for patients receiving intra_ venous arsenic, which, if performed at regular intervals, should prove of great value in the anticipation and prevention of such complication as hepatitis and dermatitis. 31. That any rise in the Icterus Index in cases receiving arsenic is not in any way proportional to the amount of arsenic given. 32. That a high Icterus Index in pneumonia is a bad prognostic sign, 33. That in the majority of cases of diabetes, the Icterus Index is not raised, and that the high figures obtained in some cases is probably due to carotinaemia. 34. That the Icterus Index is raised in cases of hyperemesis gravidarum. Opportunities for investigating the possible prognostic value of this rise have not, however, presented themselve , and no definite statement ca n at present be made