Tuesday, February 18, 2020

JP drain migrated into stomach

We operate a number of pancreatic necrotic patient and we used to put JP drain in cavity for a long duration of time, for that JP drain was most comfortable and effective in form of drainage with its negative suction capacity, long durability, and less pain for the patient as it is made up of soft PTFE material. But in our 3 operated patient of necrosectomy, we found that the JP drain was migrated in the stomach. on average, the patients presented after 4-6 months of necrosectomy with complain of gastric content was coming out of JP drain. On investigation, (upper GI scopy) found to have migrated JP drain in the stomach.

All 3 cases were managed by simple one stage pulling out of drain (in view of 6 months following native surgery, which would have lead to tract formation).

*Always listen to patients' complaints.
*Even PTFE/soft drain can also ultimately perforate/migrate in the hollow viscus.
*Any gastric drain/tubes can be pulled out in single-stage after 4-6 months.
*Same is the story with the small intestine.
*At most care should be taken if the same happens with the colon.

Wednesday, January 8, 2020

Sleeve Gastrectomy leak with secondary peritonitis

A 19 years old boy suffering from obesity, BMI of 42, underwent laparoscopic sleeve gastrectomy, he had a complaint of abdominal pain and fever after discharge (POD 2), hence he was readmitted, & the investigations were done, showed near-normal reports of blood counts. The patient had pain and tachypnoea, he did not have any other symptoms. On day 7 found to have sleeve gastrectomy leak (distension, low urine output and X-ray showing free gas under diaphragm) hence re-exploration laparoscopic primary repair of an ischemic leak from near fundus with SASI bypass was done, by the same primary pairs of surgeons. After 3-4days. again he had complained of abdominal pain and discomfort, associated with uneasiness, weakness, and constipation.
The patient was shifted to our institute, On examination fever,  severe tachycardia- Pulse- 170/min, hypotension- 70 systolic, SpO2- 93%,  P/A- distension, blood and bile from all drains. was found
CT scan abdomen with on table positive oral contrast was done which showed a large collection with hemorrhage and air foci seen in peritoneal cavity extending into the anterior abdominal wall, leak of oral contrast from the anastomotic region into a large collection seen in the abdomen.  In View of anastomotic leak and peritonitis, he was explored.

Findings were as expected, the SASI Bypass was almost completely open, and gross leak from fundic area of the sleeve. Extensive hematoma approx 1 liter with biliary peritonitis.

Laparotomy, antrectomy, draining gastrostomy, feeding jejunostomy, proximal end jejunostomy, distal end jejunostomy was done. 

FJ feeding was started and refeed gastric content into the Feeding tube. Gradually patient improved and discharged on day 22 with 2 drains and one feeding pipe in situ. The patient was then lost to follow up.

*Though sleeve gastrectomy is a relatively simple surgery it still carries complications, the commonest surgical immediate complication is a leak near fundic/cardia region.
*Leak detected within 3 days, without peritonitis, without signs of sepsis and purely mechanical-can be tackled with either resuturing or restapling along with +/-NJ, +/- covered mega stent placement.
*Anything beyond 72 hrs with peritonitis, with sepsis, should be treated like any other GI surgical leak. No reinforcement/staple/anastomosis should be attempted in the presence of peritonitis.
*Basic principle of any leak management in GI system should be a) Diversion, b) lateral fistulization, c) relief of distal obstruction, d) maintenance of nutrition.
*TPN does not provide any aid in fistula healing/it only provides supplement nutrition.
*Primary source control is at most things in the management of fistula.

MGB (Bariatric surgery) Perforation after 6 months

A middle-aged female with a BMI of  55 underwent laparoscopic MGB surgery for weight reduction purpose and everything went uneventful, she maintained a steady course of weight loss.
6 months following surgery patient came with complaints of fever and abdominal pain, she consulted general physician and he gave symptomatic medicine and next-day pain increased and urine output was low, she was consulted by a physician, USG was done which showed mild free fluid in the abdomen. 
In view of low urine output, she was managed conservatively and kept hospitalized for observation without CT Scan. The next day she was found to have severe tachycardia, tachypnea, and hypotension and persistent fever. She was subjected to CT scan of the abdomen, which showed free intraperitoneal gas as well as free fluid in pelvis and peritoneal cavity. 

Reference was given to the surgeon, he expected to have an enteric fever and enteric perforation considering the history of the patient.

A midline laparotomy was done. Her BMI was 42 at the time of surgery, the intraoperative finding showed a normal small bowel, but the MGB site was  80 % open, probably because of perforation of ulcer that has occurred at MGB site. with more than 3.5 liters of peritonitis.

The patient was in extremely septic condition, during surgery call was received. when we joined surgery, the patient was anuric for more than 12 hrs, her blood pressure was below 70 systolic with inotropic supports and she didn't hand any of the invasive lines or neither a value of ABG & LFT.

MGB site was dismantled and both ends of jejunum brought externally as stoma, feeding tube inserted in distal jejunal loop. Drains kept near the gastric open residual area. RT was kept in gastric pouch, abdomen closed after putting multiple drains. (The patient was lost on day 2).

*All bariatric patients for any complication or any symptom following bariatric surgery must consult a primary surgeon.
*No symptom is a minor symptom in obese patients.
*Ultrasonography should never be done in extremely or morbidly obese patients because it will always mislead.
*Primary investigation of choice in any obese patient is a CT scan abdomen.
*MGB can lead to an ulcer at the stomal site and that should be suspected in any case of MGB even 6 months or 1 year following surgery.
*If expertise is available then laparoscopy should be tried especially in the patient whose BMI is more than 40 in order to reduce postoperative morbidity.
*No anastomosis generally holds in any septic situation especially when then urine output is nil, noradrenaline support is on a higher rate, so one must not attempt to do any anastomosis, one should always try to divert things.

Friday, January 3, 2020

Denture sailed an old lady into trouble - Managed with surgery

A 60 years old lady presented with a history of accidental ingestion of denture 7 days ago. She had a complaint of dysphagia since the day of ingestion. She tried home remedies for the same for a couple of days. Two attempts of endoscopic removal of denture were done at 2 days interval at different places. The denture could not be removed hence the patient was referred to our Hospital.

CT scan abdomen was done which showed suspiciously poorly radio-opaque foreign body is seen in the retrocardiac esophagus with thickening of esophageal wall in the retrocardiac region, no leak of oral contrast from esophagus was seen, however, flanges of denture could be seen intramurally.

In view of the current situation one more trial of endoscopic removal was attempted, which showed denture at 33 cm with impacted lateral flanges in muscular of the esophagus which could not be removed by endoscopy. 

The decision of thoracoscopic removal of the esophageal foreign body was taken and executed with the repair of the esophagus and feeding jejunostomy on  2/11/2018. During surgery 3-4 cm of vertical incision taken over the esophagus, foreign body (denture ) removed. Esophagus repaired using vicryl 2-0 by endo stitch in a continuous manner in 2 layers, the pleural flap created and suture line covered by flap by vicryl 2-0 in an interrupted manner,  one of the ports incision extended and denture delivered out through same. 

On a postoperative day 7,  CT Dye study was done which did not show any leakage of contrast. ICD was removed and the patient discharged on day 9 with feeding jejunostomy in situ. On follow up after 15 days patient gradually liquid to soft diet started.

*Any stuck foreign body in upper airway/upper digestive tract should be dealt with immediately by expert-because this can lead to death.
*An endoscopist attempt should always be made for the retrieval of any foreign body under sedation/anesthesia, preferably with flexible endoscopic instrument(rigid scope tend to create more complication by instrumentation).
*CT scan should always be ordered before any attempt to remove the foreign body after 48 hrs.

Self-Knotting of Feeding Jejunostomy Tube: An Extremely Rare Complication

A 25-year-old female with corrosive ingestion underwent reconstructive surgery and FJ on. One and a half months later, she presented with the complaint of difficulty and inability to feed through FJ tube. On examination, the outer part of the FJ tube found to be normal but even by force water could not be instilled. 
Hence, she was subjected to X-Ray (fig.1 (A)) and gastro graffine study which revealed knotting and kinking of FJ tube. On the same day, laparotomy was performed to remove the tube and new FJ was made. The patient is on follow-up at the outpatient department without any further issues. 

The proposed mechanism for the knotting of the FJ tube would be the reverse direction of tube placement. In such a scenario when feeding is given every time with peristalsis the tube is forced to go in the forward direction of peristalsis and in resting position because of the broad base technique of FJ, it will come and aligned in the proximal direction leading to intraluminal knotting. The knotting of the FJ tube may be prevented by performing FJ with a proper broad base manner (Witzel) and the direction of the tube should be distally towards the ileum and taking care of the direction of the FJ tube with the direction of peristalsis. Although knot formation is relatively rare from a vast majority of complications; it could require another surgery to resolve the problem.  Most of the time it happens during a surgical procedure, that placement of FJ tube and abdominal closure is allocated to resident doctors after tiring long surgery. 

* Care should be taken in every case to prevent such kind of complications and every FJ tube placement should be monitored.
* Reverse direction of feeding jejunostomy can lead to such a disaster.

Tuesday, December 31, 2019

Bile duct injury - A strange and unique case!

The middle-aged patient had gall stone and CBD stone, the patient underwent ERCP and clearance of CBD with plastic stenting followed by laparoscopic cholecystectomy after 3 days. The patient was asymptomatic on day 1  and had gradually developed pain and distension on day 2, on day 3 drain started draining bile, the patient developed tachycardia, and hypotension. 

On day 4, the condition deteriorated and the patient was transferred to tertiary care hospital, CT scan was done which showed the cut end of stent migrated proximally within the liver and cut end of the distal end of stent migrated distally into duodenum with moderate amount of free fluid which was echogenic in nature in peritoneal cavity.

The patient was taken up for laparoscopy and found to have a complete division of bile duct along with the stent which was divided. Proximally migrated cut end of the stent was removed from the bile duct. Thorough lavage was given. Large bore ADK kept in Morrison pouch. 2 Biliary stents kept on right and left side laparoscopically. A few anchoring stitch (end to end on bile duct) was taken in order to create a controlled fistula. 

Gradually the patent recovered and discharge with drain in situ on day 8. Biliary external fistula healed over a period of 2-3 weeks. The drain was removed. 

After 2.5 months later following injury, final definitive surgery hepaticojejunostomy was done and both stents were removed. The patient is doing well following surgery.

*CBD stenting with a stent in situ does not make the surgeon immune from doing bile duct injury.
*Almost care should be taken while dissecting calot's triangle, one should always have at least  feeling of cutting of stent!!!
*Whenever in doubt one must always call for help.
*Whenever gall bladder is inflamed and calot's triangle is frozen, it is always recommended to do subtotal cholecystectomy

Insertion of ICD in liver instead of in pleural cavity for pleural effusion and a missed liver abscess!

A young male presented with complaints of difficulty in breathing, on examination he had hypoxia (SpO2-85 %). His CBC was11.5/18,500/3.2L (working diagnosis of pneumonia with Right-sided effusion was made!)

On chest x-ray found to have right-side gross pleural effusion so he was subjected for ICD insertion. ICD was inserted in the 6th intercostal space in the midaxillary line. ICD output was somewhat bloody in nature and hardly around 10 ml. 
Post ICD insertion x-ray chest showed ICD in situ with gross similar pleural effusion, & the patient did not improve in fact symptom increased, hypoxia was persistent.

He was subjected to CT scan chest was done which showed ICD was inserted in the liver with gross pleural effusion and a large liquified posteriorly ruptured liver abscess in right posterior segments. 

The patient was subjected to laparostomy, lavage and drainage of the abscess were, ICD was removed and replaced in the right chest. Diaphragmatic repair was done. The patient gradually improved and discharged on postoperative day 10th.

* Thorough diagnosis is the key and history is very important
* One must think of subdiaphragmatic pathology in Right lower zone lung issues.
* A simple Ultrasound of the abdomen can save the disaster.
* ICD should always be inserted in the 4th or 5th intercostal line and the presence should be confirmed immediately.
* If accidentally inserted in the liver than it should not be pulled without any guidance because it can lead to massive bleed!