Lupus enteritis as a lone manifestation of SLE: rare but possible

A 28-year-old Southeast Asian non-pregnant woman with asthma and prior cholecystectomy presented to the emergency department with acute watery diarrhoea, intermittent abdominal pain and vomiting. Apart from abdominal tenderness, the rest of the physical examination was unremarkable. She had leucocytosis, alkaline phosphatase elevation and exudative ascites. Radiological imaging ruled out biliary leak and was only significant for circumferential small and large bowel thickening. Upper endoscopy and colonoscopy showed normal duodenal and colonic mucosae. Both infectious and malignancy workup were also unremarkable. Bereft of other systemic symptoms, autoimmune pathology was initially deemed unlikely; however, autoimmune workup revealed positive antinuclear antibody, double-stranded DNA, anti-Smith antibody, antinuclear ribonucleoprotein and hypocomplementaemia. With multidisciplinary collaboration, the patient was initiated on high-dose steroids, which dramatically improved her symptoms. She was discharged home with a steroid taper, and at 3 months of follow-up with her rheumatologist, she was continued on steroids and hydroxychloroquine.

Complications following T-tube & C-tube Drainage of the Common Bile Duct

The aim of this study is to assess the complications of T-tube (Kehr) and C- tube (Cystic) drainage used for biliary drainage, following biliary surgery. We evaluate all possible complications, related to the tube in situ, during cholangiography and following t- tube removal retrospectively, during a 4- year period 2016-2019. T-tubes were inserted in 48 patients, with 11 (22.8%) patients experiencing complications related to T-tube. A broad spectrum of complications was found, ranging from biliary-specific complications such as a biliary leak, biliary peritonitis, and retained stones, to systemic general complications as wound infection, pulmonary thromboembolism, and internal hemorrhage. Although this retrospective study has underestimated the incidence of T-tube complications, it has demonstrated significant morbidity related to T-tube use, which poses the need for replacement by minimally invasive surgical techniques.

Comparative study to evaluate ultrasonic verses monopolar electrocautery dissection of gall bladder in laparoscopic cholecystectomy

Background: Gallstones are one of the most common routinely encountered surgical problem in the developed world. Laparoscopic cholecystectomy being the gold standard surgery for gall stones has been modified various times using different instruments in order to improve intraoperative and postoperative outcomes. The aim of the study was to see clinical outcomes of ultrasonic scalpel verses monopolar electrocautery in dissection of gall bladder in laparoscopic cholecystectomy.Methods: A prospective randomized controlled study was done with total 100 patients in which 50 patients underwent laparoscopic cholecystectomy via ultrasonic scalpel while rest 50 patients were operated using monopolar electrocautery. The study was conducted for a period of eighteen months and clinical outcomes were studied in terms of operative time, frequency of lens cleaning, gall bladder perforation, biliary leak, common bile duct injury, bowel perforation and postoperative hospital stay.Results: The two groups were comparable in terms of demographic profile considering age and sex distribution. However, there was a statistically significant reduction in operative time, frequency of lens cleaning and gall bladder perforation in group A (harmonic scalpel) as compared to group B (electrocautery).Conclusions: Harmonic scalpel is not only a safe and effective instrument but also a reliable alternative to electrocautery. Even though the study revealed no significant difference in biliary leak, common bile duct injury, bowel perforation and postoperative hospital stay but it can significantly reduce operative time and incidence of gall bladder perforation. Thus, it can improve the operative course in laparoscopic cholecystectomy.

Anaesthesia for liver transplantation at King Hussein medical centre: an overview of 70 cases

Background: To review the indications, patients' demographics, and anaesthetic protocol and to analyze perioperative complications of liver transplantation surgery.Methods: Retrospective analysis of 70 cases of LT in the period between June 2004 and October 2020 at King Hussein medical centre. Preoperative factors such as patients' demographics, age, gender, etiology of hepatic pathology, laboratory investigations, model for end-stage liver disease scores, duration of surgery and type of liver donation were recorded. Intraoperative factors such as anaesthetic and surgical protocols, need of blood product transfusions and haemodynamic monitoring were analyzed. Postoperative tracking of patients' complications and outcomes was done.Results: 68 living donor and two cadaveric LT procedures. Male to female ratio was 2.9:1.The age of LT recipients ranged from 3 to 62 years with an average age of 38.45 years. Their body weights ranged from 13 to 100 kg with mean body weight of 67.03 kg. Most common indication was cryptogenic liver cirrhosis (21.4%), followed by cirrhosis due to viral hepatitis B (15.7%). Autoimmune hepatitis was an indication in 11.4% and hepatitis C liver cirrhosis in 10%. All living donors were closely related. Right hepatic lobe graft was used in 85.7% of transplantations. Average red cells concentrate (RCC) transfused (units) was 3.1±3.97 (mean±SD). Duration of surgery (hours) was 12.5±2.4 (mean±SD). Fast track LT with extubation in theatre was done in 37 LT recipients (52.9%). Readmission to operative theatre was needed in 5 recipients (7.14%). Most common long term complications were biliary leak (20%), biliary stenosis (14.2%) and recurrence of primary disease (12.9%).Conclusions: Transplantation from living donors was by far more common in our study population. Majority of recipients were male and cryptogenic liver cirrhosis was the most common indication. Right hepatic lobe graft was used mostly. Biliary leak was the most common postoperative complication. Surgical time duration and blood products transfusion decreased significantly over years since the start of LT program.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

AngelChik Device Removal and Revisional Fundoplication

Gastro-oesophageal reflux disease (GORD) is a common condition in developed countries with an increasing incidence in the UK, currently estimated at 5 per 1000 person-years. Risk factors for GORD include Helicobacter pylori infection, obesity, alcohol consumption, smoking and genetic predisposition. Surgical management is performed in chronic, severe cases of GORD, refractory to medical management. There are a variety of interventional surgical techniques available and the patient in this case had placement of an AngelChik Device (AD) 30 years ago. This is now a historic device due to associated complications and this patient had it removed with revisional treatment of the patient’s GORD with Nissen Fundoplication. The patient experienced multiple post-surgical complications, namely biliary leak from the central port, pulmonary embolism and pneumonia. Following description of the case, this report will discuss the increasing incidence of late complications of AD and propose a proactive approach to these patients going forwards. It will also discuss the current uncertain evidence of a new surgical intervention called magnetic sphincter augmentation (MSA) of the lower oesophagus that has similar principles to the mechanism of an AD. From this it will emphasise that more stringent and worldwide collaboration is required when bringing a new medical device into clinical care.

Full-split liver transplantation. The first experience in Russian Federation

Aim. To present the first successful full-split liver transplantation for two adults recipients in Russia.Materials and methods. The first successful full-split liver transplantation for two adults in ex situ way in Russia was made on 26th of September 2014 in the Burnasyan Federal Medical Biophysical Center of FMBA. The deceased donor was inside UNOS, Lee. The GRWR index in both recipients was near 1. The first recipient had been in a waiting list for 1 year, the second for 4 months. Both recipients had got liver cirrhosis in terminal stage.Results. The surgical procedure length was 650 and 660 min. The overall time of cold ischemia was 510 min. We observed a primary function of each graft. ISGLS B and Clavien-Dindo 3A biliary leak complications were observed in both recipients. Both patients were discharged after 33 and 34 days. Overall survival for this moment is 68 months.Conclusion. Full-split liver transplantation for two adults in ex situ way seems to be a complicated procedure both from the technical and organizing points of view. It demanding good mastership and coordination between surgical team members. At the same time, that treatment method has to be spread widely to improve treatment of patients with end-stage cirrhosis results.