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Residual gall bladder: An emerging disease after safe cholecystectomy
Vikas Gupta,Anil Kumar Sharma,Pradeep Kumar,Mantavya Gupta,Ajay Gulati,Saroj Kant Sinha,Rakesh Kochhar 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.4
Backgrounds/Aims: Residual gallbladder mucosa left after subtotal/partial cholecystectomy is prone to develop recurrent lithiasis and become symptomatic, which mandates surgical removal. Methods: we retrospectively evaluated the patients with residual gallbladder referred to us from January 2011 to December 2017. Based on MRCP we classified calot’s anatomy to – type I where cystic duct was seen and type II where sessile GB stump was seen. Results: 21 patients with median age 38 years and M:F::1:9.5, had undergone cholecystectomy (3 months-20 years) prior, presented with recurrent biliary pain. 3 had jaundice (CBD stone, Mirizzi and biliary stricture), 1 had pancreatitis and one had malignancy of the GB. Imaging revealed type I anatomy in 14 (67%) and type II in 7 (33%). All underwent completion cholecystectomy – open in 18 and laparoscopic in 3 (one converted to open). Additional procedure was required in 5 patients – CBD exploration in 2 (10%) and one each Hepatico-jejunostomy, extended cholecystectomy and splenectomy. Median hospital stay was 1 day. There was no mortality and 10% morbidity. One patient with malignancy died at 2 years, two died of unrelated cause, one developed incisional hernia and the remaining were well at a median follow up of 29 months. Conclusions: Residual GB lithiasis should be suspected if there are recurrent symptoms after cholecystectomy. MRCP based proposed classification can guide the management strategy. Completion cholecystectomy is curative.
Post-cholecystectomy acute injury: What can go wrong?
Vikas Gupta,Ashish Gupta,Thakur Deen Yadav,Bhagwant Rai Mittal,Rakesh Kochhar 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.2
Backgrounds/Aims: Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries. Methods: We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management. Results: Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy. Conclusions: Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.
Hemorrhage complicating the course of severe acute pancreatitis
Vikas Gupta,Pradeep Krishna,Rakesh Kochhar,Thakur Deen Yadav,Venu Bargav,Asheesh Bhalla,Naveen Kalra,Jai Dev Wig 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.3
Backgrounds/Aims: The course of severe acute pancreatitis (SAP) complicated by hemorrhage is associated with poor outcome. Methods: Twenty-four (13%) out of 183 cases of SAP had hemorrhagic complications- 12 intraabdominal & 12 intraluminal, 13 had major & 11 had minor and 16 had de-novo & 8 post-surgical bleeding. The mean duration of pancreatitis prior to bleeding was 27±27.2 days. Results: Predictors of haemorrhage on univariate analysis were delayed admission (0.037), more than one organ failure (p=0.008), presence of venous thrombosis (p=0.033), infective necrosis (0.001) and systemic sepsis – bacterial (0.037) & fungal (p=0.032). On multivariate analysis infected necrosis (OR=11.82) and presence of fungal sepsis (OR=3.73) were the significant factors. Patients presenting with more than one organ failure and bacterial sepsis had borderline significance on multivariate analysis. Need for surgery (50% vs. 12.6%), intensive care stay (7.4±7.9 vs. 5.4±5.2 days) and mortality (41.7% vs. 10.7%) were significantly higher in patients who suffered haemorrhage. Seven of the 13 with major bleeding had pseudoaneurysms-4 were embolized, 4 needed surgery including 1 embolization failure. Seven with intraabdominal bleeding required surgical intervention, 2 had successful embolization and 3 had expectant management. CT severity index and surgical intervention, were significantly associated with intraabdominal bleeding. Organ failure, presence of pseudoaneurysm and surgical intervention were associated with major bleeding. Conclusions: Hemorrhage in SAP was associated with increased morbidity and mortality. Infected necrosis accentuated the degradation of the vessel wall, which predispose to hemorrhage. Luminal bleeding may be indicative of erosion into the adjacent viscera by the pseudoaneurysm.