Acute Kidney Injury among Post Cardiac Surgery Patients : A Retrospective Study

Background : Acute Kidney Injury (AKI) is a common complication Post Cardiac Surgery with reported incidence of 20-70%. Various studies have been conducted worldwide on risk factors contributing to the etiology of AKI in Cardiac surgery patients. We undertook similar study to understand the etiology and risk factors associated with AKI at Goa Medical College hence we undertook this study. Methodology : A retrospective record based observational study was conducted at Goa Medical College; wherein records of 419 patients who underwent Cardiac Surgery during the study period were analyzed for pre-operative, intra-operative and postoperative variables. Kidney Disease Improving Global Outcomes criteria were used to study the incidence of AKI. The Data was entered in Microsoft Excel and analysed using SPSS version 22.0. Chi-square test and Student t test were used as a test of significance. Results : Out of 419 patient records reviewed; 40.3% patients developed AKI after Cardiac Surgery. Age, Sex, h/o previous Cardiac Surgery, CPB duration, Aortic Cross Clamp Time, addition of vasopressor etc. were some of the significant risk factors associated. AKI associated with Cardiac Surgery was associated with a mortality of 8.3%. Mean duration of ventilation 38.48�.27 hrs. and ICU stay 6.12�15 days was comparatively longer than patients without AKI (P<0.001). Conclusion : We concur that AKI is a serious complication in patients undergoing Cardiac Surgery and has significant impact on the outcome of the patients in terms of duration of ICU stay, duration of ventilation and mortality. There is need to identify modifiable risk factors at the earliest and develop approaches to improve the outcome and decrease the AKI associated morbidity and mortality

Sleep deprivation, stress and anxiety among pre-university college students of Mangaluru city, India

Background: Adequate sleep is extremely important for appropriate physical growth, emotional stability, behavior, and maintenance of cognitive function. Good quality of night sleep will reflect in better school performance and increased motivation to study. The aim of this study is to determine the level of sleep deprivation, daytime sleepiness, stress and anxiety and to associate stress, anxiety with sleep pattern.Methods: A college based, cross-sectional study was conducted in Mangaluru City, Karnataka. The study has been conducted among 5 pre–university colleges (2 from Aided, 2 from private and 1 from government). A total of 634 participants were enrolled from grade 11th and 12th irrespective of their stream and responded to a questionnaire that included socio-demographic characteristics, sleep pattern, daytime sleepiness by using Epworth sleepiness scale, level of stress using Perceived stress scale-10, level of examination anxiety and general anxiety by using Westside Anxiety scale and Anxiety Self-Rating scale. Descriptive statistics, chi square or likelihood ratio test were used. The data was entered and analysed using SPSS 16v.Results: Among 634 students the mean age was found to be 16 years. Prevalence of sleep deprivation was found to be 39%, daytime sleepiness was 66.6%, 77.8% had moderate stress and 9.1% had high stress. Moderately high-test anxiety was observed among 22.6% of the respondents and 1.4% with extreme anxiety.Conclusions: The study showed that 1/3rd of the respondents had sleep deprivation and 2/3rd had daytime sleepiness and the prevalence of general anxiety was higher than examination anxiety and most of the respondents had moderate stress.

Initial experience with hyperthermic intra peritoneal chemotherapy and cytoreductivesurgery.

BACKGROUND: Promising results were reported with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal carcinomatosis. Experiences in India are not published. This is a preliminary report. MATERIALS AND METHODS: From eight patients with peritoneal metastasis, six patients (5 M, 1 F), aged (40‑62 years) were treated with CRS and HIPEC between May 2010 and August 2011 from a single institution. Three had Mucinous Adenocarcinoma of Appendix and one each with Mesothelioma, Ovarian Cancer and Colonic Cancer. Four were earlier treated with systemic chemotherapy and recurred. Pre‑operative peritoneal cancer index (PCI) was calculated based on recent computerized tomography or positron emission tomography scans. Surgical completeness cytoreduction score (CCS) was classified as macroscopically complete (CCS‑0); optimal residual disease ≤2.5 mm in any region (CCS‑1); or grossly incomplete: Residual disease >2.5 mm (CCS‑2) or >25 mm (CCS‑3). They were treated by closed perfusion technique with mitomycin‑C (MCC) and cisplatin at 41‑42°C, for 60 min. RESULTS: Optimal cytoreduction (residual tumor nodules <2.5 mm i.e. CC0 and CC1) was performed in four patients (66.67%). There was no operative mortality or Grade 3 and 4 toxicity. Patients with PCI <11 are alive without recurrence with overall survival of 26‑31 months. Those with PCI >11 had recurrence with overall survival of 3‑19 months. Two patients died at 3 and 9 months. CONCLUSION: CRS and HIPEC is a promising therapeutic option in selected patients with peritoneal carcinomatosis. These results in six patients are preliminary but encouraging. Patient with low PCI had better disease free survival.

Postoperative deep vein thrombosis in patients with colorectal cancer.

Deep vein thrombosis (DVT) is reported to be common among patients undergoing surgery for colorectal cancer. This randomized controlled trial was aimed to determine the efficacy of low molecular-weight heparin in the prophylaxis of DVT in this high-risk group and was truncated early in view of an unexpectedly low incidence of DVT. Between March 2002 and January 2004, a total of 99 patients with colorectal cancer - selected for surgery in the lithotomy position - were randomized before surgery to either receive dalteparin or no drug (51 and 48 patients, respectively) during the perioperative period. Duplex ultrasonography was performed before and after the surgery. We also looked for distal venous thrombosis, pulmonary embolism, hemorrhage and any mortality. No episode of DVT occurred in either the drug arm or the observation arm. There was no death following surgery. The incidence of DVT in Indian patients operated for colorectal cancer in the lithotomy position was negligible.

Neoadjuvant chemotherapy before surgery of hepatoblastoma.

Though surgical resection is the main stay of treatment for childhood hepatoblastoma (HB), many are unsuitable for radical surgery at diagnosis due to extensive intrahepatic and/or extra hepatic disease. We report experience in five patients of HB from a single institution (2001-2005) with preoperative Neoadjuvant chemotherapy (NACT) followed by surgery. Three patients received cisplatin, doxorubicin; and two cisplatin / vincristine /5-fluorouracil. All showed more than 50% reduction in tumor size confirmed by CT scan. Hepatic resection R0 was performed in all. There was no chemotherapy related toxicity nor post surgical morbidity or mortality. All are disease free at median follow up of 4 years. NACT produces adequate down staging of the HB with acceptable toxicity. Though cisplatin with doxorubicin produced good results, new protocol with cisplatin, vincristine and 5FU is promising without cardiotoxicity.

Radiofrequency ablation of liver tumors: experience with open and percutaneous approach.

BACKGROUND: Radiofrequency ablation (RFA), a thermal coagulation technique, has been used for ablation of primary and secondary liver tumors. METHODS: Over a 24-month period, 41 patients, including 20 with hepatocellular cancer (HCC), 14 with liver metastases from colorectal tumors and 7 with metastases from other tumors, underwent RFA in our institution. Ablation was done using intra-operative (n=27) or percutaneous ultrasonographic (n=14) guidance. A zone of ablation larger than the size of the lesion on CT scan indicated successful RFA. RESULTS: The mean size of lesions was 4.9 cm for HCC and 3.1 cm for metastases. Among 20 patients with HCC, 16 had complete tumor ablation and one had failure of localization. All patients with liver metastases had successful tumor ablation. There was no procedure-related death. Two patients had hemoperitoneum and one experienced skin burn. During a median follow up of 16 months, five patients with HCC and two with colorectal metastases died. One patient had tumor recurrence at the ablation site and two developed fresh solitary metastatic lesions; all three are disease-free after repeat ablation treatment. CONCLUSIONS: RFA is a safe and promising technique for the treatment of non-resectable HCC and liver metastases, in the short term.

Bile cultures and sensitivity patterns in malignant obstructive jaundice.

BACKGROUND: Bactibilia is one of the important factors in the development of postoperative septic complications. We undertook this retrospective analysis to identify the organisms present in bile and their antibiotic susceptibility patterns in patients with malignant obstructive jaundice. METHODS: Bile specimens were obtained during endoscopic cholangiography (ERC; n=65), by flushing biliary stents (n=15), intra-operatively before incising the common bile duct (n=7) or during percutaneous transhepatic biliary drainage (PTBD; n=1). Eighty-eight samples from 65 consecutive patients were analyzed for their bacterial spectrum and sensitivity to antibiotics. Concomitant septic complications such as wound infection and cholangitis were also assessed. RESULTS: Of 65 patients (hilar block 39, distal block 26), 17 (26.1%) had bactibilia at initial ERCP; in addition, 3 of 7 bile specimens obtained during surgery, one collected during PTBD, and 13 of 15 stent flushings grew bacterial organisms. Cholangitis developed in 15 patients (12 with hilar block, 3 with distal block). Blood cultures were positive in 3 cases, and initial bile culture was positive in four patients with cholangitis. The most commonly found organisms were Escherichia coli (36.6%), Klebsiella pneumonia (18.3%), Pseudomonas aeruginosa (8.3%), Proteus vulgaris (8.3%) and coagulase-negative staphylococci (8.3%). The organisms found on ERC were similar to those found at wound cultures in 3 of the 4 cases who developed wound infection. Amikacin, gentamicin, cefotaxime, ceftazidime, and cefoperazone-sulbactam combination showed good activity against E. coli and K. pneumonia. CONCLUSION: Approximately one-fourth of patients with malignant obstructive jaundice have positive bile cultures at initial ERC. Post-ERC cholangitis is common in hilar blocks.

Pancreatic tuberculosis.

Tuberculosis infrequently involves pancreas. The clinical features in patients with pancreatic tuberculosis are usually non-specific. The radiological features mimic pancreatic malignancy or pancreatitis. Ultrasound or CT scan guided fine needle aspiration cytology or biopsy may show caseating granulomatous inflammation. The present report includes two cases of pancreatic tuberculosis and review of relevant literature. One of our patients was diagnosed at laparotomy and the other with a CT scan guided fine needle aspiration cytology. Both patients responded well to anti tubercular chemotherapy and are now asymptomatic.

Epidemiology of digestive tract cancers in India. VI. Projected burden in the new millennium and the need for primary prevention.

The incidence rates of most digestive cancers in India are moderate or low. The highest rates are recorded in the urban population of Mumbai and the lowest in the rural population of Barshi in Maharashtra state. The rates will rise as the life expectancy of Indians increases along with urbanization and, within the next few decades, may reach those recorded in Indians living abroad. Based on available population data, we estimate that in the year 2001 there will be approximately 145,000 new cases of digestive cancers in India. In men, the esophagus would be the commonest site (n = 24,925), followed by the stomach (23,100), rectum (10,462), liver (8812), colon (8004), pancreas (5757) and gall bladder (3967). In women, the esophagus would be the commonest site (n = 18,608), followed by the stomach (11,890), gall bladder (7360), rectum (6983), colon (6115), liver (4227) and pancreas (3435). The incidence of cancers of the esophagus and stomach is declining spontaneously in India. It may be possible to accelerate this by reducing the use of tobacco and improving the diet. At the same time the incidence of cancers of the colon, pancreas, liver and gall bladder is rising, largely due to urbanization that leads to major changes in the diet and personal habits. A preventive approach is needed by public health education. Indians should be encouraged to retain their traditional protective diets, eat more fruits and vegetables, do more physical activity, and abstain from tobacco. Gastroenterologists can also help in secondary prevention by screening high-risk individuals, e.g., patients with chronic liver disease for liver cancer and relatives of patients with familial bowel cancer.

Palliation of malignant colonic obstruction by self-expandable metal stent.

Advanced obstructive colorectal cancer is routinely treated by surgical colostomy. Self-expandable metal stents are a promising alternative. We report the use of an expandable metal stent to relieve colonic obstruction in an elderly lady with advanced colorectal malignancy.

Small cell carcinoma of gall bladder.

Small cell carcinoma of the gall bladder is very rare. We report a 25-year-old woman with this tumor. These tumors typically occur in elderly women with cholelithiasis; chemotherapy is not known to improve survival.

Gastric carcinoids--a clinicopathologic study.

AIM: Our objective was to document the clinical and pathological findings in eight patients with gastric carcinoids seen in our institution over a 16-year period (1980-96). METHODS: All cases reported during this period as microcarcinoids, atypical carcinoids and mixed carcinoid-carcinoma of the stomach were retrieved from pathology records. Eight cases with typical histologic features of carcinoid were studied. RESULTS: Seven cases were men (median age 53 years, range 35-55). Four patients presented with upper abdominal pain. Serum gastrin level was elevated in two cases. The endoscopic appearances and the endoscopic biopsy histology were not diagnostic. Surgical treatment ranged from simple nodule excision to partial, subtotal or extended gastrectomy and Whipple's pancreatico-duodenectomy. Lymph node and liver metastasis were seen in four patients each. The median duration of follow-up was one year. CONCLUSION: Gastric carcinoids have varied etiopathogenesis. These may arise in a background of hypergastrinemic conditions or may be sporadic. Most appear to be slow growing but aggressive neoplasms are capable of distant metastasis.

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost.

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.

Precut papillotomy using a needle knife: experience in 100 patients with malignant obstructive jaundice.

BACKGROUND: Precut papillotomy enhances the success of selective bile duct cannulation. Doubts have been raised about the relative safety of the procedure. This study was undertaken to assess the success rate and complications of precut papillotomy using a needle knife. METHODS: 100 consecutive patients undergoing precut papillotomy for biliary endoprosthesis placement were studied. A needle knife was used in these patients after bile duct cannulation was not successful using other techniques. The success rate, complications and mortality were determined. RESULTS: Selective bile duct cannulation was achieved in 65 patients. There were six complications: bleeding (3), pancreatitis (2), and perforation (1). One patient died following duodenal perforation. The success rate for endoprosthesis placement was increased by 14.2% following precut papillotomy. CONCLUSIONS: Precut papillotomy enhances the success of selective bile duct cannulation, with complication rates similar to standard papillotomy.

Adenocarcinoma arising in "J" pouch after total proctocolectomy for familial polyposis coli.

A patient of familial adenomatous polyposis (FAP) without extra intestinal lesions is presented. The patient underwent a proctocolectomy with J pouch ileal reservoir with an ileoanal anastomosis. The clinical course was further complicated by an adenocarcinoma developing in the J pouch. This was excised totally and a terminal illeostomy was constructed. The aim of doing a prophylactic proctocolectomy in familial polyposis coli is to prevent a malignancy developing and to restore function with an illeoanal pouch. However polyps can occur in the gastric, duodenal and intestinal mucosa, which can lead to malignancy. Greater awareness and close follow up is needed even after prophylactic proctocolectomy.

Synchronous adenocarcinoma and lymphoma of the colon.

Synchronous lymphoma and adenocarcinoma of the colon are extremely rare. A 32-year-old woman was referred to us for colon cancer. Investigations revealed two primary tumors, one in the cecum and the other in the sigmoid colon. Subtotal colectomy with ileorectal anastomosis was performed. Histology revealed the cecal tumor to be non-Hodgkin's lymphoma, diffuse small cell type with plasmacytoid features. The sigmoid colon tumor was moderately differentiated adenocarcinoma. The patient received 6 cycles of chemotherapy postoperatively for lymphoma but died of recurrent disease after 17 months.

Spontaneously occurring liver cell adenoma in an adult male.

Spontaneously occurring liver cell adenoma is an extremely rare event. One such tumour in an adult male which was resected surgically is reported here.

Solid and cystic papillary neoplasm of pancreas--a report of seven cases.

OBJECTIVE: To study the clinico-pathological features of patients with solid and cystic papillary neoplasm of the pancreas. METHODS: The clinico-pathological features of solid and cystic papillary neoplasm of the pancreas were studied in seven fully documented and confirmed cases presented during the last seven years. RESULTS: All the patients were women with a median age of 18 years (range 12-40). Four presented with epigastric pain and three had a painless abdominal lump. The median duration of symptoms prior to presentation was 3 months (range 1-6). The tumor size ranged from 6-16 cm (mean 10 cm). Preoperative diagnosis was established by fine needle aspiration cytology in three patients. All the seven underwent resection. Pericapsular adhesions were found in two patients. All the patients were free of disease on follow-up ranging from 3-60 months (median 16 mo). CONCLUSION: Occurrence in young females, solid and cystic areas on imaging, resectability in spite of large size, and good prognosis are the important features of this tumor.

Unusual bone metastasis as the initial symptom of gastric cancer--a report of four cases.

Four cases of gastric cancer presenting with bone pain due to metastasis as the initial symptom are reported. Investigations revealed solitary osteolytic metastasis in the mandible in one, and left scapula in one patient. Third patient had multiple osteosclerotic metastasis with elevation of acid phosphatase and another had multiple discrete osteolytic metastasis simulating multiple myeloma. All the primary gastric cancers were poorly differentiated adenocarcinoma and three were of Borrman type III on gross appearance. One patient had sparing of the liver inspite of extensive metastasis. Chemotherapy was in effective in two patients and the prognosis was uniformly poor.