Introduction: Mortality rates after pancreaticoduodenectomy have decreased dramatically during the last two decades in high volume centers. However, despite a low mortality rate and improvements in perioperative care, morbidity rate is still high after pancreaticoduodenectomy. Studies defining the role of potential risk factors for the development of postoperative complications are few, and sometimes with conflicting results. There is need to identify potential risk factors for predicting complications after pancreatic resections. Aim: The aim of the present study was to assess the risk factors for morbidity after pancreatic resections, by utilizing a simple grading system and identify the factors affecting them. Material and Methods: This was a prospective study done in the Department of Surgical Gastroenterology between Feb 2007 to Jun 2009. All patients who underwent elective pancreatic surgeries were included in this study. Major Morbidity was defined as patients having grade III and above complications. The risk factors assessed were patient factors, disease factors, operative factors and postoperative factors. Risk factors were analyzed for morbidity and major morbidity separately. Results: One Hundred and Seven patients underwent elective pancreatic surgeries between Feb 2007 to Jun 2009. Pancreaticoduodenectomy was the commonest procedure. Three patients died after pancreatic surgeries. Mortality rate after pancreatic surgery was 2.8% (3/107) and that after Whipple's procedure was 4.68% (3/64).In our study a total of 58 of 107 (54.2%) patients developed complications after pancreatic surgery. Major morbidity defined as Grade III or more complication was seen in 24.2% (26/107). Complications after Whipple's procedure was seen in 49 of 64 (76%) patients. Major morbidity (Grade III and more) was seen in 22 of 64 patients (34.3%). All complications following pancreatic surgeries were graded. The mean postoperative duration was 12.4 days (6 -47 days).The significant risk factors for morbidity after pancreatic surgery were soft pancreas (OR 5.988; p=.007), SGPT > 73 U/L (OR 3.623; p = .054), age > 50yrs (OR 3.254; p = .053), and absence of chronic pancreatitis (OR 4.363, p = .016).The significant factors for major morbidity were soft pancreas (OR 6.557, p = .005), hypertension (OR 5.803, p = .037) and BMI >25(OR 4.052, p = .05). Conclusions 1. Independent factors predicting morbidity after pancreatic surgery were soft pancreas, age > 50yrs, SGPT > 73 U/L and absence of chronic pancreatitis. 2. Independent factors predicting major morbidity after pancreatic surgery were soft pancreas, hypertension and BMI > 25.
Background: Management of hollow viscus injury (HVI) due to blunt abdominal trauma (BAT) is a challenge to the clinicians even in the era of advanced imaging and enhanced critical care. Repeated clinical examination with appropriate imaging with multidisciplinary teamwork is the key for timely intervention in equivocal cases for successful outcomes. Aim of the study was to present our experience over last 4½ years.Methods: This is a retrospective study of prospectively collected data of patients treated at surgical gastroenterology department, Nizam’s Institute of Medical Sciences, Hyderabad, India over a period of 4½ years (2012-2016).Results: A total of 126 BAT Patients were treated in our unit as inpatients during the last 4½ years. Out of 126, twenty patients (15.87%) with HVI in whom surgical intervention was done formed the study group. Contrast enhanced CT Scan abdomen and chest was done in stable patients (13/20), in rest of the patients (7/20) the decision to operate was taken more on clinical grounds along with X-ray abdomen and USG abdomen features. 12 (60%) had jejunal and ileal injuries, 5 (25%) patients had colonic injuries (sigmoid 4, caecum 1). One (5%) patient had extra peritoneal rectal perforation with ascending retroperitoneal fascitis and 2 (10%) had duodenal injury. Two (10%)patients required relaparotomy. We had mortality in 3 (15%) patients and 17 (85%) patients had complete recovery.Conclusions: Hollow viscus injury should be suspected in all cases of blunt abdominal trauma. In equivocal cases careful repeat clinical examinations with close monitoring and repeat imaging is highly essential to prevent delay in intervention. Type of procedure is based on time of presentation, degree of contamination, associated injuries and general condition of the patient.
Primary ciliary dyskinesia (PCD) is a rare disorder with impaired ciliary function resulting in a spectrum of clinical manifestations of varying severity. PCD affects approximately one in every 20,000 individuals with a reported prevalence between 1:4000 and 1:50,000. Due to its nonspecific clinical features, the condition is usually diagnosed late in its course, unless situs inversus (SI) or organ laterality defects are discovered at imaging. A small subset of patients with PCD display associated organ laterality defects, different from the classical SI totalis. We present here, the clinical and imaging findings in a young female with PCD along with left-sided isomerism, a variant of heterotaxy syndromes.
Biliary cystadenoma is a very rare cystic neoplasm of the liver that usually occurs almost exclusively in middle-aged women. These are slowly progressive tumours and cannot be safely differentiated from cystadenocarcinomas on preoperative imaging and hence should always be considered for resection. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, partial resection resulting in high rates of recurrence. In addition biliary cystadenoma is a premalignant lesion and only surgical excision can differentiate it from its malignant counterpart, biliary cystadenocarcinoma.
Background: Pancreatic ascites is a challenging problem faced by clinicians. The management requires a multidisciplinary approach. Timely surgical intervention is the key especially in patients with chronic pancreatitis and pancreatic ascites where conservative and endoscopic treatments were not successful.Methods: The data was retrieved from a prospectively maintained database for a period of 4 years. A total of 14 patients were included. They were initially optimized with ascitic fluid drainage, nutritional supplementation either enteral or parenteral. Endoscopic retrograde cholangio pancreatography (ERCP) was done in patients with failed conservative treatment after 2 weeks. Endoscopic pancreatic stenting was attempted in proximal ductal disruptions. Nonresponders were taken up for surgery. The type of surgery was based on the site of leak and associated pancreatic pathology like pseudocyst.Results: Initially three patients were responded to conservative management. ERCP was done in 9/14 patients. ERCP demonstrated leak of contrast into peritoneal cavity in 3 (3/9), leaking pancreatic pseudocyst in 3 (3/9) and non-visualisation of distal duct in 2 (2/9). ERCP and stenting of pancreatic duct was attempted in three patients and was successful in resolution of symptoms in one. Nine out of fourteen needed surgical intervention. Surgery was based on site of leak and presence of pseudocyst.Conclusions: Majority of the patients in our study were ethanolics and a change in life style early in the course can prevent this morbid disease. Nasojejunal tube feeding with blendarized home feeds will improve the nutritional status. CECT abdomen and ERCP will give a road map in deciding the type of intervention. For proximal ductal disruption endoscopic stenting should be tried before going for a major surgical intervention. Surgery provides definitive cure.
The POSSUM is a scoring system which is used for estimating mortality and morbidity risk in major operations. Its reliability on predicting and quantifying the impact of complications was proven in previous studies. P-POSSUM is better in predicting mortality after major surgery. The use of POSSUM and PPOSSUM after pancreatic surgery was evaluated previously with varied results. Aim: The aim of the study was to evaluate the use of POSSUM and Portsmouth (P) POSSUM scoring systems to predict postoperative mortality after pancreatic surgery. POSSUM was also evaluated for predicting morbidity and major morbidity after pancreatic surgery.
the Hannover classification. The pre-operative MELD score was obtained and correlated with the following: patient characteristics, perioperative variables and postoperative outcomes, including mortality rates. Results: Out of 25 patients, 13 (52%) had open and 12 (48%) had laparoscopic cholecystectomy. 17 patients (68%) were referred to our center within 6 weeks from the time of injury. 14 (56%) were managed by endoscopic stenting, while 7 (28%) had definitive surgical reconstruction. There were no mortalities for patients with MELD score < 20. However, for those patients with MELD scores of 20-29 and 30, the mortality rate was 50% and 100%, respectively. Conclusion: MELD score is a potential prognostic tool for patients with iatrogenic bile duct injury sustained during cholecystectomy.
patients with gastrinoma have multiple endocrine neoplasia type 1 (MEN-1). We experienced two cases of gastrinomas associated with MEN-1 syndrome. 42 and 56-year-old man was admitted for abdominal pain and diarrhea. The endoscopic findings revealed severe reflux esophagitis and multiple ulcers at the bulb and second portion of the duodenum. They were diagnosed as ZES based on typical clinical features such as markedly elevated fasting gastrin level (1,000 pg/mL) and findings from a CT scan and somatostatin receptor scan. Pathologic findings after the operation revealed malignant gastrinoma. He was confirmed to have parathyroid adenoma and MEN-1. We diagnosed this patient using immunohistochemical studies and treated the patients by tumor resection with distal pancreatectomy. The patients are alive and in a good condition without recurrence for 10 months and 9 years. MEN-1 syndrome should always be considered in pts with ZES. A precise preoperative localization of all pancreaticoduodenal lesions, in combination with a surgical exploration and management by experienced surgeons, seems to be curative in patients.
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