Management of intestinal obstruction following laparoscopic donor nephrectomy

Internal hernias are a rare cause of small bowel obstruction. Following laparoscopic bariatric surgery, specifically gastric bypass and laparoscopic colonic resections, there has been an increase in the incidence of internal hernias. This has been due to either a mesenteric or mesocolic defect being not closed or completely missed. Small bowel loops usually herniate through these defects and present as intestinal obstruction. Internal hernia following laparoscopic donor nephrectomy is a rare complication. The need for presenting this case is the rarity of its occurrence, to stress the fact that following major abdominal laparoscopic surgery the mesenteric or mesocolic defects should be closed, and that this complication was managed laparoscopically, through the same port sites as used earlier for the donor nephrectomy

Role of water-soluble contrast study in adhesive small bowel obstruction: A randomized controlled study

Background : Oral Gastrografin \uae has been used to differentiate partial from complete small bowel obstruction. It may also have a therapeutic effect and predict the need for early surgery in adhesive intestinal obstruction. Aim : To assess the accuracy of Gastrografin \uae contrast in predicting the necessity of operative intervention in patients with adhesive intestinal obstruction and to decide on optimum period of observation in patients with adhesive intestinal obstruction. Materials and Methods : This prospective randomized controlled trial was performed on 32 patients with adhesive intestinal obstruction admitted in the Department of Surgery of a tertiary hospital. All patients were diagnosed with adhesive intestinal obstruction and were randomized into two groups, a Control group and a Gastrografin \uae group. Patients in the control group were treated conservatively. If symptoms of strangulation developed or if the obstruction did not resolve spontaneously after 48 hours of admission, a laparotomy was performed. Patients in the Gastrografin \uae group received 60 ml of Gastrografin \uae mixed with 40 ml of distilled water after two hours of gastric tube aspiration following admission. Those in whom the contrast medium reached the colon in 22 hours were considered to have partial intestinal obstruction and were fed orally. Any patient who did not tolerate feeds was surgically explored for persistent obstruction. All patients in whom Gastrografin \uae failed to empty into the ceacum within 22 hours of administration, were operated. Findings were analyzed by standard statistical tests. Qualitative data was analyzed by either Chi-square or Fisher Exact test. For the quantitative data, the means were compared by ANOVA-F test in the case of four groups whereas for two groups it was compared by using student\u2032s t test. Results : Oral Gastrografin \uae contrast study is safe and can facilitate the prediction of the necessity of early operative intervention compared to a plain radiograph. Oral Gastrografin \uae study was found to have an overall accuracy of 82.35% in predicting the need for operative intervention in patients with adhesive small bowel obstruction. Also it was seen that it was sufficient to study the patients for 18 hours after administration of oral Gastrografin rather than 24 hours. Conclusion : Oral Gastrografin \uae helps in the management of patients with adhesive intestinal obstruction

Precholecystectomy ERCP in follow up cases of gallstone pancreatitis. Is it necessary?

Background/Objective: The need for a routine ERCP prior to cholecystectomy in all follow up cases of gallstone pancreatitis; the incidence of choledocholithiasis in these cases and to define radiological and biochemical criteria that would necessitate a precholecystectomy ERCP. Materials and Methods: 42 patients of severe gallstone pancreatitis were treated in the hospital during the period 1st January - December 31st 2001. The severity of acute pancreatitis was based on Ranson's scoring system. All were conservatively managed during the initial phase of hospitalization, which ranged from 11-31 days. Standard radiological and biochemical investigations for acute pancreatitis were done in all cases. They were advised to undergo ERCP followed by cholecystectomy within 3-4 weeks. However only 36 patients came back for follow up and they form the study group. Ultrasound of abdomen and liver function tests were repeated in all of them prior to ERCP. All of them subsequently underwent cholecystectomy, 34 of them laparoscopically. Results: Only 3(8.3%) had choledocholithiasis on ERCP. The CBD was cleared of stones during the same procedure and patients underwent cholecystectomy subsequently. Ultrasound showed choledocholithiasis in 2 and the alkaline phosphatase (AKP) and aspartate transaminases (AST) were raised in 2 patients. Conclusion: A precholecystectomy ERCP should be performed in follow up cases of gallstone pancreatitis only if there are sonological features suggestive of choledocholithiasis and/or an elevation specifically of alkaline phosphatase and aspartate transaminase in the liver function tests

Role of water-soluble contrast study in adhesive small bowel obstruction: A randomized controlled study

Background : Oral Gastrografin ® has been used to differentiate partial from complete small bowel obstruction. It may also have a therapeutic effect and predict the need for early surgery in adhesive intestinal obstruction. Aim : To assess the accuracy of Gastrografin ® contrast in predicting the necessity of operative intervention in patients with adhesive intestinal obstruction and to decide on optimum period of observation in patients with adhesive intestinal obstruction. Materials and Methods : This prospective randomized controlled trial was performed on 32 patients with adhesive intestinal obstruction admitted in the Department of Surgery of a tertiary hospital. All patients were diagnosed with adhesive intestinal obstruction and were randomized into two groups, a Control group and a Gastrografin ® group. Patients in the control group were treated conservatively. If symptoms of strangulation developed or if the obstruction did not resolve spontaneously after 48 hours of admission, a laparotomy was performed. Patients in the Gastrografin ® group received 60 ml of Gastrografin ® mixed with 40 ml of distilled water after two hours of gastric tube aspiration following admission. Those in whom the contrast medium reached the colon in 22 hours were considered to have partial intestinal obstruction and were fed orally. Any patient who did not tolerate feeds was surgically explored for persistent obstruction. All patients in whom Gastrografin ® failed to empty into the ceacum within 22 hours of administration, were operated. Findings were analyzed by standard statistical tests. Qualitative data was analyzed by either Chi-square or Fisher Exact test. For the quantitative data, the means were compared by ANOVA-F test in the case of four groups whereas for two groups it was compared by using student′s t test. Results : Oral Gastrografin ® contrast study is safe and can facilitate the prediction of the necessity of early operative intervention compared to a plain radiograph. Oral Gastrografin ® study was found to have an overall accuracy of 82.35% in predicting the need for operative intervention in patients with adhesive small bowel obstruction. Also it was seen that it was sufficient to study the patients for 18 hours after administration of oral Gastrografin rather than 24 hours. Conclusion : Oral Gastrografin ® helps in the management of patients with adhesive intestinal obstruction

Precholecystectomy ERCP in follow up cases of gallstone pancreatitis. Is it necessary?

Background/Objective: The need for a routine ERCP prior to cholecystectomy in all follow up cases of gallstone pancreatitis; the incidence of choledocholithiasis in these cases and to define radiological and biochemical criteria that would necessitate a precholecystectomy ERCP. Materials and Methods: 42 patients of severe gallstone pancreatitis were treated in the hospital during the period 1st January - December 31st 2001. The severity of acute pancreatitis was based on Ranson's scoring system. All were conservatively managed during the initial phase of hospitalization, which ranged from 11-31 days. Standard radiological and biochemical investigations for acute pancreatitis were done in all cases. They were advised to undergo ERCP followed by cholecystectomy within 3-4 weeks. However only 36 patients came back for follow up and they form the study group. Ultrasound of abdomen and liver function tests were repeated in all of them prior to ERCP. All of them subsequently underwent cholecystectomy, 34 of them laparoscopically. Results: Only 3(8.3%) had choledocholithiasis on ERCP. The CBD was cleared of stones during the same procedure and patients underwent cholecystectomy subsequently. Ultrasound showed choledocholithiasis in 2 and the alkaline phosphatase (AKP) and aspartate transaminases (AST) were raised in 2 patients. Conclusion: A precholecystectomy ERCP should be performed in follow up cases of gallstone pancreatitis only if there are sonological features suggestive of choledocholithiasis and/or an elevation specifically of alkaline phosphatase and aspartate transaminase in the liver function tests

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways