Long-term results of choledochoduodenostomy in benign biliary obstruction

AIM:To determine the long-term results of choledochodudenostomy in patients with benign billiary obstruction.METHODS:This prospective study was conducted at Sheri Kashmir Institute of Medical Sciences Srinagar Kashmir,India over a period of 10 years from January 1997 to December 2007.The total number of patients who underwent choledochoduodenostomy during this period was 270.On the basis of etiology of biliary tract obstruction,patients were divided into a calculus group,an oriental cholangiohepatitis group,a benign biliary stricture group and others.Patients were followed for a variable period of 13 mo to 15 years.RESULTS:Choledochoduodenostomy(CDD) with duodenotomy was performend in four patients.CDD with removal of T-tube,CDD with left hepatic lobectomy and CDD with removal of intra biliary ruptured hydatid was performed in three patients each.In the remaining patients only CDD was performed.Immediate post operative complications were seen in 63(23%) patients,while long-term complications were seen in 28(11%) patients,which were statistically significant.Three patients died during hospitalization while four patients died in the late post-operative period.CONCLUSION:Our conclusion is that CDD is safe and produces good long term results when a permanent biliary drainage procedure is required.

Drainage vs no drainage in secondary peritonitis with sepsis following complicated appendicitis in adults in the modern era of antibiotics

AIM: To compare the profile of postoperative outcome in secondary peritonitis with sepsis due to complicated appendicitis in two cohorts(drainage vs no-drainage) after appendicectomy in adults in the modern era of effective antibiotics. METHODS: A retrospective review of all adult patients who were operated for secondary peritonitis with sepsis due to complicated appendicitis was carried out. Total of 209 patients were identified from May 2005 to April 2009 with operative findings of gangrenous or perforated appendix. The patients were divided into two cohorts, those where prophylactic drainage was established(n = 88) and those where no drain was used(n = 121). Abdominal drain was removed oncethe drainage ceased or decreased(< 10-20 mL/d in closed system of drainage or when once daily dressing was minimally soaked in open system). Broad spectrum antibiotics to cover the gut flora were started in both cohorts at diagnosis and were stopped once septic features resolved. Peritoneal fluid for aerobic culture and sensitivity were routinely obtained intra operatively; however antibiotic regimens were not changed unless patient failed to respond to the antibiotics based on the institutional protocol. The co-morbidities and their influence on primary end points were noted. Immunocompromised patients, appendicitis complicated by inflammatory bowel disorder and tumors were excluded from the study. RESULTS: Disease stratification and other demographic features were comparable in both cohorts. There was zero mortality in drainage group while as one patient(0.82%) died in the non-drainage group. The median duration(in days) of hospital stay(6.5 vs 4); antibiotic use(5 vs 3.5); regular parental analgesic use(5 vs 3.5) and paralytic ileus(2.5 vs 2) was more common in the drainage group. Incidence of major wound infection in patients 14(15.9%) vs 22(18.18%) and residual intraabdominal sepsis(inter loop collection/abscess)-7(8%) vs 13(10.74%) requiring secondary intervention was not significantly different in drainage and non-drainage cohorts respectively. One patient in the drainage cohort had faecal fistula(1.1%). CONCLUSION: The complicated appendicitis in the modern era of antibiotics does not necessitate the use of prophylactic drain placement which at times may even prove counterproductive.

Pyogenic liver abscess: Changing patterns in approach

AIM: To define optimum management of the pyogenic liver abscess and assess new trends in treatment. METHODS: One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir In- stitute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment. RESULTS: Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.CONCLUSION: Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.

Surgical management of complicated hydatid cysts of the liver

AIM: To review the clinical presentation and surgical management of complicated hydatid cysts of the liver and to assess whether conservative surgery is adequate in the management of complicated hydatid cysts of liver.METHODS:The study was carried out at Sher-i-Kashmir Institute of Medical Science,Srinagar,Kashmir,India.Sixty nine patients with hydatid disease of the liver were surgically managed from April 2004 to October 2005 with a follow up period of three years.It included 27 men and 42 women with a median age of 35 years.An abdominal ultrasound,computed tomography and serology established diagnosis.Patients with jaundice and high suspicion of intrabiliary rupture were subjected to preoperative endoscopic retrograde cholangiography.Cysts with infection,rupture into the biliary tract and peritoneal cavity were categorized as complicated cysts.Eighteen patients(26%)had complicated cysts and formed the basis for this study.RESULTS:Common complications were infection(14%),intrabiliary rupture(9%)and intraperitoneal rupture(3%).All the patients with infected cysts presented with pain and fever.All the patients with intrabiliary rupture had jaundice,while only four with intrabiliary rupture had pain and only two had fever.Surgical procedures performed in complicated cysts were:infection-omentoplasty in three and external drainage in seven;intrabiliary rupture-omentoplasty in two and internal drainage in four patients.Two patients with intraperitoneal rupture underwent external drainage.There was no mortality.The postoperative morbidity was 50%in complicated cysts and 16%in uncomplicated cysts.CONCLUSION:Complicated hydatid cyst of the liver can be successfully managed surgically with good long term results.