Biliary mishaps in laparoscopic cholecystectomy.

AIM: To determine the incidence and types of biliary complications following laparoscopic cholecystectomy in our patients. METHODS: The clinical records of one hundred and fifty-five patients undergoing laparoscopic cholecystectomy were reviewed. RESULTS: Five patients developed biliary mishaps. The overall incidence of biliary complications was 3.2% (5/155). The incidence of major complications was 1.9% (3/155) and the incidence of minor biliary complications was 1.2% (2/155). In 3 out of 5 patients the mishap was attributed to developmental anomalies. Dense pericholecystic adhesions and cystic duct blow out were responsible for biliary complications in one patient each. Bilioenteric anastomosis was performed in two patients and restoration of continuity of the common hepatic duct over a T-tube was done in one patient. Side hole in an accessory duct was repaired over a T-tube and cystic duct blow out was managed with endoscopic biliary drainage alone. CONCLUSIONS: A high index of suspicion of developmental anomalies, cautions approach in difficult cases and readiness to consider conversion to open cholecystectomy are recommended to reduce the incidence of biliary complications in laparoscopic cholecystectomy.

Anomalous bile duct injury during laparoscopic cholecystectomy.

We report a patient in whom the common hepatic duct drained into the gall bladder body and the cystic duct continued as the bile duct into the duodenum. The anomalous duct was inadvertently injured during laparoscopic cholecystectomy. The injury was repaired and end-to-end anastomosis of the hepatic and cystic ducts was done through a subcostal incision.

Adjuvant interstitial brachytherapy in a case of anorectal melanoma.

PURPOSE: A locally resectable case of anorectal melanoma is reported. In order to prevent local recurrence, interstitial brachytherapy was used. METHOD: A 45 years old emaciated female presented with a 8 x 6 x 6 cm, hard, mobile, intraluminal mass in the anal canal and rectum, biopsy revealed malignant melanoma. As the mass was locally resectable, wide local excision of the tumour was carried out. She was subsequently given interstitial brachytherapy with Caesium--137 implants at tumour bed, not described so far in literature. Six months later her general condition had improved but abdomino-perineal resection was necessitated due to presence of extra-rectal metastasis. RESULTS: Patient is in our follow-up for 36 months now and doing well. CONCLUSION: Supplementation of interstitial brachytherapy after local resection of ano-rectal melanoma may help to prevent local recurrence.

Clinical significance of carcinoembryonic antigen in colorectal malignancy.

Carcinoembryonic antigen (CEA) assay was performed in 40 patients of histologically proven colorectal carcinoma. The overall incidence of positivity was 72.5%. The incidence increased from 40% in Duke's A stage to 84.6% in Duke's C stage. Similarly the mean CEa levels also increased as the disease advanced i.e. 4.96 ng/ml, 8.07 ng/ml and 12.7 ng/ml in Duke's A, B and C respectively. Cancer with poor prognosis i.e. poorly differentiated and colloid carcinoma, had significantly less rise in CEA values (P < 0.05) as compared to well differentiated carcinoma. There was no relation of CEA values with the gross appearance of the tumour and lymph node involvement. CEA level came down in all the patients after surgery. Based on the postoperative CEA estimation, complete tumour clearance had been achieved in 86.2% of patients.

Correlation of the growth fraction, nucleolar organizer region counts and epidermal growth factor receptor with histomorphological prognostic criteria in breast cancer.

A total of 60 cases of breast cancer were studied to find the correlation between newer parameters of prognosis viz growth fraction (GF), nucleolar organizer region (AgNOR) counts and epidermal growth factor receptor (EGFR) positivity with the various histomorphological factors such as tumour size, nuclear grade, histological grade and mitoses. Growth fraction measured by Ki67 monoclonal antibody varied from 3.6 to 73.7 percent. AgNOR counts ranged from 1.2 to 16.9 dots per tumour cell nucleus with a mean of 6.26 dots. EGFR positivity was seen in 66.7% of cases. Ki67 score correlated with all prognostic variables studied except the presence of axillary metastases. AgNOR counts correlated with size of tumour, axillary lymph-node metastases and Ki67 score but no correlation was seen with histologic or nuclear grade. EGFR positivity correlated strongly with size of the tumour and weakly with Ki67 score, AgNOR counts and mitoses.

Disseminated mucormycosis in healthy adults.

Three patients of disseminated mucormycosis are described. None had predisposing factors. Two of them presented with nonspecific symptoms along with acute renal failure and peritonitis. Third patient had fulminating primary cutaneous mucormycosis which disseminated later. Development of acute renal failure with smooth enlargement of both kidneys in an apparently healthy individual or appearance of mould in a wound should raise the suspicion of mucormycosis. The hallmark of the infection was vascular invasion and thrombosis. Antemortem diagnosis could be made in one patient only. All patients had progressive downhill course despite supportive treatment, antibiotic and amphotericin in-B in one patient.

Management of duodenal trauma.

The surgical management of fifteen cases of duodenal trauma is reported. Blunt injury of the abdomen was the commonest mode of injury. Thirteen patients (86.6%) had associated intra-abdominal and/or extra-abdominal injuries. Diagnosis of duodenal injury was made at laparotomy in all patients. In the majority of patients (n = 11), either duodenal repair, or anastomosis with the pylorus or jejunum was done. Duodenal diverticulization or pancreaticoduodenectomy were undertaken in 2 patients each. Feeding jejunostomy was an important adjunct for nutritional support. Septicemia with multisystem organ failure and duodenal fistula were lethal complications. Mortality in the present series was 46.6%.

Serum beta-N-acetylhexosaminidase, carcinoembryonic antigen & sialic acid in benign & malignant extrahepatic biliary obstruction.

Study of tumour markers to differentiate benign and malignant extra hepatic biliary obstructions showed that levels fo serum beta-N-acetylhexosaminidase and lipid associated sialic acid were not different in the two groups. The levels of carcinoembryonic antigen (CEA) and total sialic acid (TSA), on the other hand, were significantly higher in patients with the malignant biliary obstruction. At a cut-off value of 6.4 ng/ml (mean + 2SD) CEA had 66.7 per cent true positivity in malignancy 100 per cent true negativity in control and 78 per cent true negativity in the benign group. Similarly, TSA at a cut off value of 60 mg/dl had 61 per cent true positivity in malignancy, 90 per cent true negativity in controls and 70 per cent true negativity in the benign group. These two tumour markers appear to have similar diagnostic potential for malignant extrahepatic biliary obstruction. Surgical management of the malignant obstruction did not result in a decline in the elevated levels of these two markers during the post-surgical period of 7 days.

Effect of blockade of transdiaphragmatic absorption of bacteria on survival in peritonitis: an experimental study in rats.

An experimental rat model of established peritonitis was used to test the effect of intraperitoneal injection of platelet rich plasma (PRP) on blood and peritoneal fluid culture positivity and survival rates. Thirty animals divided into two groups of 15 each were studied. The first group served as control while animals in the second group received intraperitoneal injection of PRP. The use of PRP in established. Peritonitis was of no significant benefit.

Multiple neoplasia in a patient with pituitary acromegaly.

A case of pituitary acromegaly with multiple nonendocrine neoplasia is reported. The tumorogenic potential of growth hormone, prolactin and other growth factors is discussed.

Intestinal endometriosis.

Two cases with intestinal endometriosis, one with a right iliac fossa mass and the other with subacute intestinal obstruction, are presented. In both the cases, the diagnosis was not suspected clinically and was reached only on histological examination of the resected specimens.

A clinical study of intubating conditions under vecuronium bromide.

The drug vecuronium bromide, a short acting, non-depolarising agent with little side-effects, has brought much promise in the field of muscle relaxants. Fifth healthy patients were induced with injection thiopentone sodium 4 mg/kg and vecuronium bromide, 0.1 mg/kg was given IV. The earliest time at which the largest percentage of patients could be intubated satisfactorily was noted. The intubating conditions were estimated by scoring method. The duration of clinical relaxation was decided from the time of IV injection of vecuronium bromide to the return of muscle power of the non-respiratory muscles requiring repeat dose of the drug. The ideal intubating condition was achieved at 120 seconds and the duration of clinical relaxation ranged from 11-15 minutes.

Giant perforations of duodenal ulcer.

Over a period of eleven years, eight patients were treated for duodenal ulcer perforation measuring more than one centimetre in diameter. In five of these patients, the perforation was sealed using a jejunal loop as serosal onlay patch; one patient underwent gastrectomy and in two patients catheter duodenostomy was done. Two patients died, both due to renal failure. The six surviving patients were discharged with the advice for a subsequent 'ulcer-curing' operation after six months. Two patients developed life threatening complications during this waiting period and one of these died. Giant perforations of duodenal ulcer can safely be closed using a jejunal loop as serosal patch. Delay in doing the second stage definitive surgery for the ulcer may be dangerous.

Isolated splenic vein thrombosis with natural shunt caused by jejunal tuberculosis.

A case of jejunal tuberculosis causing isolated splenic vein thrombosis with natural shunt is reported, for the first time. The patient, presented with upper small bowel obstruction and massive upper gastrointestinal bleeding, was treated successfully with splenectomy, jejunal resection and antituberculous drugs.