Continuous versus interrupted anastomotic technique for the hepaticojejunostomy: a prospective cohort study

Background

Interrupted sutures is the gold standard technique of hepaticojejunostomy (HJ) for bilioenteric anastomosis. This study compares the safety and early complications of continuous and interrupted suture HJ.

Methods

A prospective study involving all elective HJ between September 2019 and June 2021 was conducted. Patients with type IV or V biliary strictures, duct diameter less than 8 mm and/or associated vascular injury, and bilateral HJ were excluded. The study patients were divided into two random groups; interrupted and continuous anastomotic technique. Patient demographics, preoperative parameters including pathology (benign vs. malignant), HJ leak, suture time, and postoperative morbidity were recorded.

Results

Total 34 patients were enroled. Eighteen (52.9%) were into interrupted and 16 (47.1%) patients into the continuous group. Both the groups were comparable with regards to demographics, haemoglobin, serum albumin, preoperative cholangitis and biliary stenting. Total three (8.8%) patients in the entire study developed bile leak; interrupted-2 and continuous-1, which was not significant statistically (P=1.0). Similarly, total number of sutures used and the mean operating time to complete anastomosis in the continuous group was significantly lesser than the interrupted group (2.3±0.5 versus 9.6±1.6, P<0.001) and (16.2±3.1 versus 38.6±9.2 min, P<0.001), respectively. There were three (18.8%) re-exploration in the continuous anastomotic technique. Among them, only one re-operation was due to HJ anastomosis failure without mortality, remaining had re-exploration for bleeding (non-HJ).

Conclusions

Both the techniques is safe with comparable morbidity. Further, continuous has an added advantage of decreased anastomotic time and cost.

Failure to Rescue After Abdominal Surgery: an Audit on Incidence and Predictors

Introduction: Failure-to-rescue (FTR), defined as death after a surgical complication, is a quality metric that is an important variable affecting mortality rates in hospitals. This study aims to analyze complications, FTR rates, and its predictors at the index hospital setting. Methods: This was a retrospective cohort study performed at an academic  hospital from 2015 to 2020 in the Department of Surgical Gastroenterology. We included all patients who had major complications following elective major benign or malignant abdominal surgeries. The primary and secondary endpoint was FTR rates and the overall major complications and deaths, re-operation rate, and its predictors respectively. Results: Among 762 patients, the rate of any major complication was 14.9% . The overall mortality rate was 2.8%. However, the mortality rate among patients with complications was 27.4% (FTR). Twenty-seven (52.9%) patients underwent re-operation for complications, out of which 70% survived. Three (21.4%) patients had a delay in prompt diagnosis and interventions of complications and had FTR due to the anastomotic leak and bleeding. The ASA grade, co-morbidities,, re-operation, and nature of the disease (benign vs. malignant) did not predict the FTR. Conclusion: This study conducted at an academic, low-volume center had higher rates of FTR. It can be further reduced by both prompt and appropriate interventions of postoperative complications in a multidisciplinary setup.

Inflammatory cap polyp of the sigmoid colon: a case report

BACKGROUND

Inflammatory cap polyp is a very rare benign entity of the distal left colon, characterized by inflammatory polyp with a "cap" of fibrinopurulent exudates. They are usually multiple and commonly present with bleeding per rectum or mucoid discharge. Solitary polyp presenting with intermittent intussusceptions is rare.

CASE PRESENTATION

We report the case of a 45-year-old Nepalese male with a solitary inflammatory sigmoid colon polyp. The patient presented with a 1-month history of rectal bleeding, mucoid discharge, and severe colicky abdominal pain due to intussusceptions. On colonoscopy, there was an exophytic mass with surface exudates. Colonic resection and anastomosis were performed, due to recurring partial intestinal obstruction. At a 6-month follow-up, the patient was asymptomatic.

CONCLUSION

Inflammatory cap polyp is a benign entity, and it should be kept in mind as an important differential diagnosis of exophytic colonic mass with surface exudates.

Extended Total Mesorectal Excision (e-TME) for Locally Advanced Rectal Cancer

BACKGROUND

Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or multivisceral resection is a complex procedure associated with high morbidity, mortality, and R1 resection rates. However, e-TME in LARC with surrounding organ involvement is the only potential option for cure. The study aims to assess the clinical outcome of patients requiring e-TME for LARC.

METHODS

The study is a retrospective review of all patients with LARC requiring multivisceral resection (2013 to 2019). The database includes clinic-demographic profile, pelvic organ involved, operative details, resection margin status, morbidity, mortality, and survival.

RESULTS

Seven consecutive patients (9.2%) out of 76 LARC (median age 46 years; 5 females) required multivisceral resection. The organs involved were bladder (4); posterior wall of vagina (2); and uterus (1). The en bloc resection included total cystoprostatectomy - 1; partial cystectomy - 3; posterior vaginectomy - 2; and hysterectomy - 1. Additionally, four required abdominoperineal resection. All were adenocarcinoma: stage III, with R0 resection - 76%. The overall complications were seen in 60% of patients, majority being wound related. There was no operative mortality. The median survival was 32.2 months in the entire series, while one died with the disease at a 28-month follow-up.

CONCLUSION

e-TME with curative intent, though a complex procedure, is associated with high wound-related morbidity, R1 resection, but improved median survival benefit.

Diagnosing gastric volvulus in chest X-ray: report of three cases

Gastric volvulus is a rare abnormal rotation of the stomach along its axis. It is a surgical emergency, hence requires prompt diagnosis and treatment to prevent life-threatening gangrenous changes. Hence, a high index of suspicion is required in any patients presenting with an acute abdomen in emergency. The entity can present acutely with pain abdomen and vomiting, or as chronic with non-specific symptoms. Chest X-ray findings to diagnose it may be overlooked in patients with acute abdomen. Here, we report three patients with gastric volvulus, where the diagnosis was based on the chest X-ray findings, confirmed with computed tomography, and managed successfully with surgery.

Triple tubostomy and its outcome for blunt duodenal injury

Introduction: Blunt duodenal injury in an uncommon form of abdominal injuries, which comprises less than 5% of all injuries. The diagnosis and management are challenging, because of delays in diagnosis due to subtle signs and symptoms in its early stage of presentation. Primary repair along with triple tubostomy (gastrostomy, retrograde duodenostomy and feeding jejunostomy) is a simple and safe method of damage control surgery in this group of patients. This study aims to report our experience in the management of this uncommon procedure. Methods: This is a retrospective analysis of the patients undergoing triple tubostomy (TT) for blunt duodenal injury at the Department of Surgery, B.P.Koirala Institute of Health Sciences (BPKIHS), Dharan, over a three and half years. The study included demographics, clinical profile, length of hospital stay, postoperative morbidity (duodenal fistula), rate and timing of spontaneous closure of fistula and mortality. Results: Eleven (6.7%) patients out of 164 blunt trauma abdomen had sustained a duodenal injury. Eight patients who underwent TT were included in the study. The mean age of the patient was 31.8 years (range: 18-67), with a male: female ratio of 3:1. The mean time to trauma and presentation was 4.25 days. The most common site of injury was the second part of the duodenum (87.5%), AAST grade III was seen in 62.5%, two (25%) patients were in shock at presentation. Eight patients required primary closure with triple tubostomy. Postoperatively, all patients had a duodenal fistula, which closed spontaneously in 6 (75%) patients at a mean duration of 17 days, with a mean postoperative length of hospital stay of 33.5 days. The remaining two (25%) patients died of an active fistula. Conclusion: Blunt duodenal trauma, when presented late can be managed with primary closure and triple tubostomy with acceptable postoperative outcomes.  

Incarcerated complete rectal prolapse managed by Altemeier's procedure

Rectal prolapse is a complete protrusion of the rectum through the anal canal, which usually occurs in elderly women. Incarceration is a rare event and can be the first presentation of a rectal prolapse. We present the case of a 54-year-old male patient who presented with incarceration and was managed successfully with Altemeier's procedure.

IMFT of the sigmoid colon: a case report

Inflammatory myofibroblastic tumor (IMFT) of the colon is a very rare entity, characterized by proliferation of myofibroblast cells admixed with inflammatory infiltrates. The entity was first described in the late 1990s, and since then less than 30 cases have been described. It frequently mimics other neoplasm of the colon, such as adenocarcinoma, lymphoma and stromal tumor, and is very difficult to clinch the diagnosis preoperatively based on the clinical and radiological findings. Here, we discuss an uncommon case of sigmoid IMFT in a 35-year old male, presenting with bleeding per rectum and managed successfully by colectomy.

Comparison of oral hygiene status among 6-14 year old students of public and private schools of Rajbiraj, Saptari, Nepal

Aim To determine the oral hygiene status of 6-14 years old school children in Rajbiraj, Nepal. Materials and Methods Three hundred school children from public and private schools were examined for oral hygiene status using OHI(S). Descriptive statistics and independent sample t-tests were done. Results There was no significant difference in the oral hygiene status among gender, but the oral hygiene status of the children in private schools was better than that of the public school. Conclusion Large number of public school children had poor oral hygiene compared to private school children. Hence, oral health education programs should be conducted on a frequent basis to improve their oral hygiene status. DOI: http://dx.doi.org/10.3126/jcmsn.v10i1.12763 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(1); 17-21

Ab initio studies of molecular structures, conformers and vibrational spectra of heterocyclic organics: I. Nicotinamide and its N-oxide

FTIR spectra of nicotinamide and its N-oxide have been recorded and analyzed in the range 400-4000 cm(-1). The stabilities, optimized molecular geometries, APT charges and vibrational characteristics for the two possible conformers of nicotinamide and its N-oxide have been studied theoretically using restricted Hartree-Fock (RHF) and density functional theory (DFT) methods. The E (trans) conformers of nicotinamide and its N-oxide are found to be more stable and less polar than their respective Z (cis) conformers. Due to addition of an O atom at the N(1) site in the NA molecule the magnitudes of atomic charges on all the H atomic sites are found to increase. For all the studied molecules, magnitude of the wagging mode of the NH(2) group is found to be higher than its torsion mode, which is in the reverse order as compared to that for the aniline molecule. Most of the vibrational frequencies have nearly the same magnitude for the two conformers of nicotinamide and its N-oxide, however, significant changes are noticed in their IR intensities, Raman activities and depolarization ratios of the Raman bands. The frequency of the ring breathing mode for the NA molecule is found to decrease by 100 cm(-1) in going to the NANO molecule for both the conformers. The IR intensity for the scissoring mode of the CON(H(2)) group is found to decrease significantly for the NA-II conformer as compared to that for the NA-I conformer.