Primary closure of common bile duct versus T-tube placement after open choledocholithotomy

Background: Choledocholithiasis is primarily managed by endoscopic retrograde cholangiopancreatography (ERCP) but in certain situation particularly large and impacted common duct stone, the procedure may not succeed and this small group of patients require either open or laparoscopic common bile duct exploration followed by T-tube insertion. Usually T-Tube cholangiogram is performed on 10th postoperative day and tube is removed on 12-14th day. Alternatively, primary closure of duct after post exploratory choledochoscopy to ensure duct clearance with or without biliary stent can be done.Methods: This study was performed on 25 patients of failed endoscopic extraction, subjected to open choledocholithotomy. Group A (n=7) had T-tube insertion whereas group B (n=18) had primary closure of duct after choledochotomy.Results: 19 patients had calculus cholecystitis whereas 6 patients had prior cholecystectomy and later developed choledocholithiasis. 52% patients had impacted stone and 40% had large stone as a cause of ERCP failure. Postoperative pyrexia, cholangitis, septicemia, sub-hepatic bilious drainage and postoperative hospital stay was higher in T-tube group as compared to primary closure group.Conclusions: Primary closure over the biliary stent after cholecystectomy and/or choledocholithotomy has less morbidity as compared to T-tube insertion and hence should be preferred choice in choledocholithiasis, provided stone free duct is ensured peroperative using choledochoscopy.

Nucleophosmin mutation analysis in acute myeloid leukaemia: Immunohistochemistry as a surrogate for molecular techniques.

Background & objectives: Mutation of nucleophosmin (NPM1) gene in the absence of FLT3-ITD (FMS related tyrosine kinase 3 - internal tandem duplications) mutation carries a good prognosis in cytogenetically normal acute myeloid leukaemia (AML). NPM1, a multifunctional nucleolar phosphoprotein that shuttles between nucleus and cytoplasm, gets trapped in the cytoplasm when mutated. Immunohistochemical (IHC) demonstration of its aberrant cytoplasmic location (NPMc+) has been suggested as a simple substitute for the standard screening molecular method. This study was aimed to assess the diagnostic utility of IHC on formalin fixed bone marrow biopsies in comparison with the reference molecular method (allele specific oligonucleotide - polymerase chain reaction; ASO-PCR) to predict NPM1 mutation status in AML patients. Methods: NPM protein IHC was performed using mouse anti-NPM monoclonal antibody on 35 paraffin-embedded bone marrow biopsies of patients with primary AML of any French-American-British (FAB) subtype. Results of IHC were compared with those of ASO-PCR. Results: Of the 35 AML patients, 21 (60%) were positive for NPM1 exon 12 gene mutation by ASO-PCR, 19 (90.47%) of these 21 were NPMc+. Thirteen of the 35 patients were negative by both the methods. One NPMc+ patient was not detected by ASO-PCR. IHC had a sensitivity and specificity of 90 and 93 per cent, respectively, compared to the molecular screening gold standard. Interpretation & conclusions: Mutation of NPM1 determined by the widely available and inexpensive IHC agrees closely with results of the standard molecular methods. Thus, technically and financially not well endowed laboratories can provide the prognostically and potentially therapeutically important information on NPM1 mutation using IHC.