Resection of pancreatic cystic neoplasms in recurrent acute pancreatitis prevents recurrent pancreatitis but does not identify more malignancies

BACKGROUNDRecurrent acute pancreatitis (RAP) may be a presenting feature of and an indication for resection of pancreatic cysts, including intra-ductal papillary mucinous neoplasm (IPMN). Few data are available regarding the prevalence of malignancy and post-operative RAP in this population.AIMTo study the role of resection to help prevent RAP and analyze if presentation as RAP would be a predictor for malignancy.METHODSThis retrospective study assessed 172 patients who underwent surgical resection of pancreatic cystic neoplasms at a university hospital between 2002 and 2016. The prevalence of preoperative high-risk cyst features, and of neoplasia was compared between patients with and without RAP. To identify the cause of pancreatitis, all the patients had a detailed history of alcohol, smoking, medications obtained, and had cross-sectional imaging (contrast-enhanced computed tomography/magnetic resonance imaging) and endoscopic ultrasound to look for gallstone etiology and other structural causes for pancreatitis. The incidence of RAP post-resection was the primary outcome.RESULTSIPMN accounted for 101 cases (58.7%) {[branch duct (BD) 59 (34.3%), main duct (MD) 42] (24.4%)}. Twenty-nine (16.9%) presented with RAP (mean 2.2 episodes): 15 had BD-IPMN, 8 MD-IPMN, 5 mucinous cystic neoplasm and 1 serous cystic neoplasm. Malignancy was similar among those with vs without RAP for all patients [6/29 (20.7%) vs 24/143 (16.8%)] and IPMN patients [6/23 (26.1%) vs 23/78 (29.5%)], although tended to be higher with RAP in BD-IPMN, [5/15 (33.3%) vs 3/44 (6.8%), P = 0.04]. At mean follow-up of 7.2 years, 1 (3.4%) RAP patient had post-resection RAP. The mean episodes of acute pancreatitis before vs after surgery were 3.4 vs 0.02 (P < 0.0001). CONCLUSIONMalignancy was not increased in patients with pancreatic cystic neoplasms who have RAP compared to those without RAP. In addition, specific cyst charac-teristics were not clearly associated with RAP. The incidence of RAP was markedly decreased in almost all patients following cyst resection.     

A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery

Postoperative hemorrhagic complications is still one of the major problems in cardiac surgeries. It may be caused by surgical issues, coagulopathy caused by the side effects of the intravenous fluids administered to produce plasma volume expansion such as hydroxyl ethyl starch (HES). In order to thwart this hemorrhagic issue, few agents are available. Fibrinolytic inhibitors like tranexamic acid (TA) may be effective modes to promote blood conservation; but the possible complications of thrombosis of coronary artery graft, precludes their generous use in coronary artery bypass graft surgery. The issue is a balance between agents that promote coagulation and those which oppose it. Therefore, in this study we have assessed the effects of concomitant use of HES and TA. Thromboelastogram (TEG) was used to assess the effect of the combination of HES and TA. With ethical committee approval and patient's consent, 100 consecutive patients were recruited for the study. Surgical and anesthetic techniques were standardized. Patients fulfilling our inclusion criteria were randomly allocated into 4 groups of 25 each. The patients in group A received 20 ml/kg of HES (130/0.4), 10 mg/kg of T.A over 30 minutes followed by infusion of 1 mg/kg/hr over the next 12 hrs. The patients in group B received Ringer's lactate + TA at same dose. The patients in the Group C received 20 ml/kg of HES. Group D patients received RL. Fluid therapy was goal directed. Total blood loss was assessed. Reaction time (r), α angle, maximum amplitude (MA) values of TEG were assessed at baseline, 12, 36 hrs. The possible perioperative myocardial infraction (MI) was assessed by electrocardiogram (ECG) and troponin T values at the baseline, postoperative day 1. Duration on ventilator, length of stay (LOS) in the intensive care unit (ICU) were also assessed. The demographical profile was similar among the groups. Use of HES increased blood loss significantly (P < 0.05). Concomitant use of TA reduced blood loss when used along with HES. r value was prolonged at 12 hours in all the groups and α angle was reduced at 12 hours in all the groups, where as MA value was reduced at 12 th hour in the HES group compared to the baseline and increased in TA + HES group. These findings were statistically significant. No significant change in Troponin T values/ECG, duration of ventilation and LOS ICU was observed. No adverse events was noticed in any of the four groups. HES (130/0.4) used at a dose of 20 ml/kg seems to produce coagulopathy causing increased blood loss perioperatively. Hemodilution produced by fluid therapy seems to produce Coagulopathy as observed by TEG parameters. Concomitant use of TA with HES appears to reverse these changes without causing any adverse effects in patients undergoing OPCAB surgery.     

Perforation of Jejunal Diverticula in Steroids and Nonsteroidal Anti-Inflammatory Drug Abusers: A Case Series

INTRODUCTION: Jejunal diverticula are rare lesions, and when complications arise, they pose diagnostic difficulties. Perforation is a common complication resulting in an acute abdomen, although preoperative diagnosis is usually not possible. The "gold standard" for management for patients with complications is surgery. We present a series of patients with perforated jejunal diverticula who were on prolonged treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids for Chikungunya fever. METHODS: There were a total of six patients, all of them presenting with perforative peritonitis, with or without shock. Plain abdominal radiogram and ultrasonogram confirmed this, although the exact site of the perforation was not diagnosed preoperatively. All patients underwent exploratory laparotomy and perforated jejunal diverticulum was found. Resection and anastomosis was performed in all cases. RESULTS: The mean operating time was 113.5 minutes, and the blood loss was not significant. Postoperative course was uneventful except wound infection in two patients. There was no mortality. CONCLUSIONS: Prolonged NSAID and steroid use are known to cause ulceration/perforation of the upper digestive tract and colonic diverticula. This seems to be the most likely cause for the perforation of jejunal diverticula in our series of patients. This view is supported by the absence of inflammation and infiltration of neutrophils on histopathological examination of the diverticula.     

Laparoscopic right hemicolectomy for mucocele due to a low-grade appendiceal mucinous neoplasm.

Tumors of the appendix are rare entities causing mucoceles. The majority of them are discovered incidentally during investigation for other conditions. Laparoscopic surgery for appendiceal tumors is still controversial, as inadvertent rupture of the lesion due to improper handling will cause pseudomyxoma peritonei. The patient was incidentally discovered to have an appendiceal tumor and referred to us for laparoscopy. Because the tumor involved the entire appendix, a laparoscopic right hemicolectomy was performed without directly handling the tumor. Postoperative recovery was uneventful. Pathological diagnosis was low-grade appendiceal mucinous neoplasm. The safety of laparoscopic appendectomy for the management of incidentally discovered appendiceal tumors has not yet been established. Several reports in the literature support both laparoscopic and open surgery. The main concerns to be addressed are the adequacy of resection and intraperitoneal rupture of the tumor. Our patient successfully underwent laparoscopic surgery without any complications. A formal right hemicolectomy was performed because the tumor involved the entire appendix. We now think laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial.     

Laparoscopic Management of a Retroperitoneal Duodenal Perforation Following ERCP for Periampullary Cancer

Introduction:

Endoscopic retrograde cholangiopancreatography (ERCP) is a fairly common procedure being performed in several centers worldwide. Although it is proven to be efficient and relatively safe, complications do occur (1.8%). We present a patient with ERCP-induced retroperitoneal perforation of the duodenum treated laparoscopically at our institution.

Case Report:

The patient is a 60-year-old female who underwent ERCP for obstructive jaundice due to periampullary carcinoma, during which the perforation occurred. Laparoscopy was performed 5 hours later and the perforation sutured primarily.

Results:

The operating time was 125 minutes. On the fourth postoperative day, the patient developed a retroperitoneal collection, confirmed by computed tomographic scan. Re-look laparoscopy was performed and the fluid drained. She recovered completely and was discharged on the eighth postoperative day.

Conclusion:

Duodenal perforation following ERCP is rare, with an incidence of 1.8%. Both surgical and non-surgical management have been reported, each with its specific indications. Our patient needed surgery, because the perforation was large and a retroperitoneal collection was present. Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.     

Transumbilical endoscopic appendectomy in humans: on the road to NOTES: a prospective study

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is the newest technique emerging in the field of surgery. There are several techniques described in the literature, though there is no standardization yet. In this paper, we describe a transumbilical approach for the endoscopic appendectomy in humans. MATERIALS AND METHODS: Eight of 12 patients with uncomplicated appendicitis successfully underwent a transumbilical endoscopic appendectomy. Patients with a mass, abscessed or perforated appendix, previous lower abdominal surgeries, and conversion to laparoscopy (4 patients) were excluded. RESULTS: The average age of the patients was 32.5 years. The mean operating time was 95 minutes, and the conversion rate was 33.3%. Only 1 dose of intravenous analgesics was administered postoperatively. Hospital stay was 1-3 days. The follow-ups were scheduled at 7, 30, and 90 days and 8 months. Six patients completed all the follow-ups and experienced no problems. DISCUSSION: So far, this transumbilical approach to the appendectomy in humans has not been reported. We think that this method of approach is an effective technique by itself and an ideal "stepping stone" to NOTES, as well as helpful to train laparoscopic surgeons to make the transition to full-fledged NOTES. Unlike the transgastric or transvaginal approaches, the umbilical approach allows an easy maneuverability of the endoscope, though at the cost of an umbilical scar. The technical ease of the procedure and early outcome seem satisfactory. This technique may be considered as a "precursor" to NOTES.     

Laparoscopic and perineal excision of an infected "dumb-bell" shaped retrorectal epidermoid cyst

INTRODUCTION: Extraperitoneal cysts in the pelvis adjacent to the rectum are rare entities. They are of vague etiology, and the pathologic types of the acquired variety are dermoid, epidermoid, and teratoma. As far as we know, laparoscopic excision of a retrorectal epidermoid cyst has never before been reported. CASE REPORT: The patient was an elderly lady with a large pelvic cyst and another large cyst in the perineum, which displaced the vagina and the anus. Laparoscopy was performed; the pelvic cyst was punctured and then dissected out. The perineal extension of the cyst was excised via a perineal approach. The patient had an uneventful recovery and was discharged on the 4th postoperative day. Histopathologically, the cyst was of the epidermoid type. Follow-up after 26 months revealed no recurrence. DISCUSSION: Our case presented a diagnostic dilemma. Laparoscopic excision was tedious, though we completed the procedure successfully. Precaution was taken to avoid spillage of the contents and also to avoid injury to vital structures nearby, such as the iliac vessels and ureter. It is feasible to laparoscopically excise retrorectal cysts with a careful and meticulous dissection. CONCLUSIONS: The major advantages are rapid recovery with minimal morbidity and excellent cosmesis.     

Laparoscopic management of drain-site incisional hernias following laparotomies--a simple suture technique

BACKGROUND: Herniation through drain sites is a rare but recognized complication of surgical drainage and are actually considered to be a type of incisional hernia. Incisional hernias form following surgery through the incision site or previous drain sites, or through laparoscopic trocar insertion sites. PATIENTS AND METHODS: In this paper, we present 13 such patients with incisional hernia of the main laparotomy wound and at the drain site, and 1 patient with an isolated drain-site hernia. A laparoscopic meshplasty with a simple suturing of the drain-site defect was performed. DISCUSSION: Incisional hernias are reported to occur in approximately 4%-10% of patients following open surgical procedures. There are several studies that have proven the efficacy of laparoscopic repair of incisional hernias, when compared to open procedures. The main predisposing factor regarding incisional hernias is probably the presence of a sepsis during the previous laparotomy, which was why the drainage tube was kept in the first place. CONCLUSIONS: The laparoscopic approach is useful for repairing the main incisional hernia, as well as drain-site hernias, simultaneously. We cut costs by avoiding tacking devices and use intracorporeal suturing instead.     

Abdominal cocoon: sonographic features.

An abdominal cocoon is a rare condition in which the small bowel is encased in a membrane. The diagnosis is usually established at surgery. Here we describe the sonographic features of this condition.