Small bowel enterocutaneous fistulae: is waiting worth?

Background: Enterocutaneous fistula represents a group of complex intraperitoneal infectious processes. Even with recent advances in Para surgical management, critical care and nutritional support, enterocutaneous fistulas remain great challenges to the general surgeon. Mortality remains high largely due to frequent complications of sepsis and malnutrition. Most enterocutaneous fistulas occur following emergency abdominal surgeries and only 15-25% of spontaneous enterocutaneous fistulas are the result of underlying diseases such as Crohn’s diseases, radiation enteritis or diverticular disease. Expectant treatment consisting of octreotide, TPN, and antibiotics waiting for spontaneous closure is associated with high costs, high mortality and prolonged morbidity. In our country, there is need to abandon expectant lines of management for a more aggressive surgical approach once the fluid and electrolyte disturbance and sepsis have been corrected.Methods: The aim of the present study was to audit the result of an aggressive approach in patients with enterocutaneous fistulas and to identify the time of convalescence prior to restorative surgery thereby reducing the morbidity and mortality associated with them. The focus of this study was to determine whether, in patients with fistulae, early intervention resulted in low mortality and morbidity.Results: In the present study, 64 cases of small bowel enterocutaneous fistulas were taken, which were either operated in Patna medical college and hospital or outside in year 2011-13. Majority of patients were 60 years and in patients with preoperative albumin below 3.0g/dl (p value>0.05). Early surgical intervention resulted in good patient outcomes as compared to conservative treatment (p value-0.0418). Mortality was higher in patients with foregut fistulae (p value-0.0178) and high output fistulae (p value-0.0309).Conclusions: This study shows that early surgery can result in good patient outcomes. Initial emphasis should be on the treatment of septic foci, aim to improve to patient’s condition. Rather than following a prolonged conservative line of management, surgical repair should be performed when the patient is stable

Laparoscopic versus open pyelolithotomy: our experience of 40 patients

Background: The development of minimally invasive surgical techniques for the treatment of patients suffering from urinary lithiasis has been greatly dependent on technologic advances in the fields of fiberoptic, radiographic imaging, and lithotripsy (shockwave, ultrasonic, electrohydraulic, and laser). The objective of this study was to compare laparoscopic with open pyelolithotomy in relation to various indices and to ascertain whether laparoscopic surgery has superseded open surgery in modern era.Methods: The study was conducted in Department of Surgery, GSVM Medical College and associated Hospital, Kanpur, Lucknow, India from January 2012 to September 2013. 40 patients who were diagnosed with renal pelvic stones, between the age group of 6-70 years were included in this study. Patients were assigned to either laparoscopy group or open group by a computer generated random number. In present study, all the patients in the laparoscopy group were operated by retroperitoneal approach.Results: The male: female ratio was 2:1. The mean pain score was significantly less in laparoscopic group. Drain removal was done earlier in laparoscopic group. The patient in laparoscopic group stayed less as compared open groups. Of the total patients, who underwent surgery 6 sustained surgical complications in open group and only 1 in laparoscopic group. The patients who had undergone laparoscopic surgery returned to work earlier than those with open.Conclusions: Patients operated by laparoscopic surgery shown a better post-operative recovery course, complaints of less pain and thus required less analgesia, returned to normal routine activity earlier, intra-abdominal drain was removed at a much earlier period as compared to open group patient, this not only reduced morbidity but also because of this patient could be discharged earlier. The complication rates were more in the open group as compared to laparoscopic group in terms of surgical site infection, urine leakage and post-operative fever. Patient satisfaction with cosmesis was more in laparoscopic group as compared to open group (as assessed by visual analogue score)

Management of hepatic hydatidosis by laparoscopic approach in rural central India: a 3 year experience

Background: Hydatid disease is still a major health problem in the infested areas of world, mainly in sheep-raising areas. But owing to increased travel and tourism all over the world, it can be found anywhere, even in developed countries.1 Thus, surgeons in nonendemic areas encounter the disease and should be aware of its optimum treatment. A safe, new method of laparoscopic management of hepatic hydatidosis is described along with the review of relevant literature.Methods: From April 2011 to October 2013, Fifteen cases of hepatic hydatid disease were operated on laparoscopically using the Palanivelu hydatid system.Results: The majority of the patients presented in the 4th decade (43.3%) with female sex predisposition (70% females). Most common presenting feature was pain the in upper abdomen. Most of the patients had only a single cyst (76.6%). The right lobe of the liver was most commonly involved. Cysts were bilateral in 6 patients. In all the patients simple evacuation of the hydatid cyst by the palanivelu hydatid system was done. The remnant cavity was dealt with by omentoplasty. The average follow-up period is 6 months. There have been no recurrences to date.Conclusions: Minimal invasive management, using Palanivelu hydatid system for aspiration and laparoscopic intervention, is an alternative to open surgery because of its ability to prevent spillage and thus minimize recurrences.

Comparison of continuous versus interrupted method of abdominal fascia closure using non - absorbable suture in the patients of acute peritonitis: our experience of 60 cases

Background: The best method of wound closure would be one that provides adequate tensile strength to the incision until the wound heals and approximates the tissue in a way that normal healing mechanism can occur under optimal circumstance. The suture should remain secure even in the presence of local or systemic infection. The continuous suture has the advantage of an evenly distributed tension across the suture line and being more expedient. It also has the advantage of having a single suture line holding the fascia together. The interrupted suturing technique has the disadvantage of being time consuming.Methods: All the patients of peritonitis were taken up for emergency laparotomy fulfilling the inclusion criteria will be included in the study. They were divided into two groups A and B by randomization technique. Each group contained 30 patients each. Patients included in group A underwent continuous method of abdominal fascia closure post laparotomy. Patients included in group B underwent interrupted method of abdominal fascia closure post laparotomy.Results: In the present study, 60 cases of peritonitis were taken up, out of these mean age in the two groups were 34.03 years and 35.03 years respectively, majority of the patients were male 50 (83.3%); Most common diagnosis was of duodenal perforation peritonitis with 22 patient (36.7%), with Ileal perforation peritonitis 15 patients (25.0%), Kochs perforation peritonitis 13 patient (21.7%); Mean time taken for closure in continuous group was 13.10 minutes as compared to 16.00 minutes in interrupted group, This difference was statistically significant. Wound infection rate in two group were 26.7% and 33.3% respectively, wound infection was present in 30%of total patient. Burst abdomen was present in 20% in both the group.Conclusions: Continuous suturing with polypropylene is comparable to interrupted suturing in terms of wound infection, frequency of burst abdomen. Although continuous suturing is better than interrupted suturing as it is faster, take less time in closure than interrupted closure. Continuous polypropylene thus becomes the preferred material and method of closure for abdominal fascia for acute peritonitis

Management of hepatic hydatidosis by open versus laparoscopic surgery

Background:Aim of current study was to compare between laparoscopic versus open management of the hydatid cyst of liver regarding complication rate, post-operative recovery course with different modality of treatment and hospital stay. This study shows our results of surgical treatment of liver hydatid cysts during a 2.5 years period.Methods:A prospective study of 30 patients operated on in a 2.5 year period (April 2011 to October 2013) in department of general surgery of J.N. medical college, Sawangi (Meghe), Wardha, Maharashtra, with hepatic hydatid cyst. All patients were preoperatively treated with albendazole. 15 patients were tackled by laparoscopic technique (using Palanivelu hydatid system) and rest 15 underwent Open procedure as surgical approach.Results:Patients operated by laparoscopic surgery shown a better post-operative recovery course, required less analgesia, mobilized and started on oral feed early, intra-abdominal drain was removed at a much earlier period as compared to open group patient, this not only reduced morbidity but also because of this patient could be discharged earlier.Conclusion:Minimal invasive management, using Palanivelu hydatid system for aspiration and laparoscopic intervention, is an alternative to open surgery because of its ability to prevent spillage and thus minimize recurrences. It is better and safe to use laparoscopy in treatment of hydatid liver with less morbidity, mortality and recurrence rate in comparison with open technique.

Maternal and fetal outcome among abruptio placentae cases at a rural tertiary hospital in Karnataka, India: a retrospective analysis

Background: Placental abruption complicates about 1% of pregnancies and is a leading cause of vaginal bleeding in the latter half of pregnancy. It is also an important cause of perinatal mortality and morbidity. The maternal effect of abruption depends primarily on its severity, whereas its effect on the fetus is determined both by its severity and the gestational age at which it occurs. The Diagnosis was confirmed on the presence of retroplacental clot, which was used to estimate the amount of bleeding and severity of abruption. Patients were managed according to the fetal and maternal conditions and ultrasonography.Methods: The study was carried out for a period of two years from 1st July 2012 to 30th June 2014. The study population included all cases presenting with ante partum hemorrhage to the Department of Obstetrics and Gynecology during the study period. Subjects selected for the study were all cases diagnosed as having abruptio placentae.Results: Total number of women admitted in labor ward between 1st July 2012 to 30th June 2014 was 4956. Among these 138 had abruption placenta. Majority of patients were in the age group 25-30 years. Incidence was higher in multi-parous. Spontaneous vaginal delivery was the mode in most patients (~74%). Major maternal complication seen was Shock, followed by postpartum hemorrhage, altered coagulation profile and renal failure. Eighty four (62.3%) women delivered alive babies while 52(37.7%) were stillborn. Out of these 86 alive born babies four died in early neonatal period due to prematurity. Overall perinatal mortality was 40.5%.Conclusion: In our setup, frequency of abruptio placenta is comparable with local and international literature. Abruptio placenta is associated with high rate of maternal and fetal morbidity and mortality, Because of this association, the conditions predisposing it should be carefully evaluated in order to reduce the occurrence of placental abruption. Unfortunately neither accurate prediction nor prevention of abruption is possible at the present time. Despite advances in medical technology, the diagnosis of abruption is still a clinical one.

Abdominal tuberculosis: a study of 50 cases

Background: The main type of tuberculosis of interest to any hospital- based surgeon is intestinal, the clinical presentation of which varies from one of an acute abdomen to one of a protracted cause of ill health and morbidity with a notorious reputation for poor response to therapy, both conservative as well as surgical. Low socio- economic status and malnutrition in our country are very important causes of the high prevalence of pulmonary tuberculosis, and with superadded problems of overcrowding and poor access to good sanitation and neglect for medical attention, extra pulmonary forms of tuberculosis also form a sizeable proportion of the case load of tuberculosis. The major source of infection is the open untreated case of pulmonary tuberculosis.Methods: Presented here is a brief account of hospital- based study of the presentation of 50 cases of abdominal tuberculosis and its management in both the acute as well as chronic setting, carried out at the B. Y. L. Nair Municipal Hospital Mumbai.Results: In our study 40% patients presented with signs of intestinal obstruction, 6% with perforative peritonitis, 34% with diffuse or well defined lump and 54% with ascites. All these patients underwent biochemical, radiological and endoscopic investigations.All the cases in this study were put on antitubercular four drug regime. Isoniazid (5mg / kg), Rifampicin (5-10mg/kg), Ethambutol (15mg/kg) and Pyrazinamide (20-25mg/kg) for two months followed by Isoniazid and Rifampicin for seven months. None of the patients developed drug toxicity during treatment. In our study out of 50 patients, 24 patients were treated conservatively. These includes 12 with tuberculous peritonitis (2 of the 12 had associated paraortic lymphadenopathy), 6 with subacute intestinal obstruction, 4 with RIF lump and 2 with colonic pathology) were treated conservatively. 26 patients underwent surgical treatment. Out of these 26 patients, 14 were operated in emergency and 12 were operated electively. Emergency surgeries were performed after correction of fluid electrolyte imbalance. Of the 14 emergency cases, 3 patients underwent resection anastomosis of small bowel, 6 patients underwent right hemicolectomy for iieocaecal tuberculosis. One patient had a stricturoplasty for ileal stricture in addition to right hemicolectomy. One patient underwent a stricturoplasty for ileal stricture and one unstable patient underwent drain insertion under local anaesthesia to drain out contaminated peritoneal fluid. Remaining two patients underwent adhesiolysis.Conclusions: In this study 60% patients had an acute and subacute presentation and 40% patients had a chronic presentation.

Malignant retroperitoneal teratoma in a young girl: a rare case report

Of all primary retroperitoneal teratomas, less than four percent occur in children and 90% are benign. Here we report a case of malignant retroperitoneal teratoma (dermoid) in a 15 year old girl who presented to our hospital - Acharya Vinoba Bhave Rural Hospital (AVBRH). She presented with a tender, large, irregular mass with variegated consistency in the entire left side of abdomen crossing midline. Ultrasound of abdomen suggested a complex intra-abdominal mass with septations and lobulations. It was not feasible to use other imaging modalities for evaluation due to poor socio-economic status and illiteracy. Patient underwent exploratory laparotomy with tumor resection along with left kidney and part of the descending colon which was densely adhered to tumor. Histopathological examination of tumor was suggestive of immature teratoma. Post operative recovery was uneventful and patient was discharged from the institution. Tissue adherence which can be observed in both benign and malignant form of teratomas, requires extended surgery for removal of adhered organ for the completeness of surgery and good prognosis

Predicting Morbidity and Mortality using POSSUM Scoring in Patients Undergoing Emergency Laparotomy –An Observational Study

Background: Emergency laparotomy is a lifesaving procedure with a significant risk of mortality and morbidity. Scoring system should be easy to calculate, reliable and applicable to all people undergoing emergency surgery. An accurate prediction of outcome could then be made, allowing the surgical team to present a more informed choice to the patient on treatment options and their likely outcome. This study was conducted to assess the validity of POSSUM scoring in predicting mortality and morbidity in patients undergoing emergency laparotomy. Objective: To evaluate the effectiveness of POSSUM scoring for prediction of mortality and morbidity after emergency laparotomy. Material and methods: The present study was conducted in the Department of General Surgery, Rohilkhand Medical College and Hospital, Bareilly. This was an observational study comprising of 74 patients of 18-65 years of age undergoing emergency laparotomy. Parameters for calculating POSSUM score were retrieved and O:E ratio for Mortality and Morbidity calculated using linear and exponential analysis. Results: The observed and expected morbidity was 37.8% and 39.2% respectively with observed by expected morbidity ratio (O:E) of 0.97. The observed and expected mortality was 14.9% and 47.3% respectively with observed by expected mortality ratio (O:E) of 0.31.Conclusion: POSSUM scoring system has an undeniable advantage in the set up for better patient counselling, improving the surgical outcomes in emergency setting and for better management of limited resources and manpower