Xanthogranulomatous cholecystitis.

Twelve cases of xanthogranulomatous cholecystitis are reported. The clinical presentation was similar to chronic cholecystitis. All patients had associated gallstones. The diagnosis was achieved at histopathological examination of the resected gall bladders and none had any focus of malignancy. Cholecystectomy was curative.

Preoperative autologous plateletpheresis in patients undergoing open heart surgery.

Blood conservation is an important aspect of care provided to the patients undergoing cardiac operations with cardiopulmonary bypass (CPB). It is even more important in patients with anticipated prolonged CPB, redo cardiac surgery, patients having negative blood group and in patients undergoing emergency cardiac surgery. In prolonged CPB the blood is subjected to more destruction of important coagulation factors, in redo surgery the separation of adhesions leads to increased bleeding and difficulty in achieving the haemostasis and in patients with negative blood group and emergency operations, the availability of sufficient blood can be a problem. Harvesting the autologous platelet rich plasma (PRP) can be a useful method of blood conservation in these patients. The above four categories of patients were prospectively studied, using either autologous whole blood donation or autologous platelet rich plasma (PRP) harvest in the immediate pre-bypass period. Forty two patients were included in the study and randomly divided into two equal groups of 21 each, control group (Group I) in which one unit of whole blood was withdrawn, and PRP group (Group II) where autologous plateletpheresis was utilised. After reversal of heparin, autologous whole blood was transfused in the control group and autologous PRP was transfused in the PRP group. The chest tube drainage and the requirement of homologous blood and blood products were recorded. Average PRP harvest was 643.33 +/- 133.51 mL in PRP group and the mean whole blood donation was 333.75 +/- 79.58 mL in the control group. Demographic, preoperative and intra operative data showed no statistically significant differences between the two groups. The PRP group patients drained 26.44% less (p<0.001) and required 38.5% less homologous blood and blood products (p<0.05), in the postoperative period. Haemoglobin levels on day zero (day of operation) and day three were statistically not different between the two groups. We conclude that autologous plateletpheresis is a better method of blood conservation in terms of better haemostasis, and less requirement of blood and blood products in the postoperative period as compared with the autologous whole blood donation. This technique can be especially useful in the above-mentioned categories of patients.

Intracystic tetracycline therapy for hypofunctioning cystic thyroid nodules.

OBJECTIVES: Hypofunctioning benign cystic thyroid nodules are a common occurrence in iodine deficient region. There are reports of resolution of recurrent thyroid cysts with tetracycline instillation. Hence we conducted a study in 20 patients with hypofunctioning benign cystic thyroid nodules to document response to intracystic instillation of tetracycline as a primary modality of treatment. METHODS: Twenty patients were thoroughly investigated for the presence of malignancy clinically, radiologically and cytologically. One milliliter of tetracycline was instilled under ultrasonographic guidance. Response to therapy was assessed clinically and ultrasonographically at one, three, six and 12 months. RESULTS: Study group comprised of five male and 15 female patients with mean age 30 +/- 8 years. Initial mean volume of nodules was 15 +/- 7 ml (6 to 27 ml), which was decreased to 3 +/- 3 ml at one month, 2 +/- 3 ml at three months, and 1 +/- 2 ml at six months. Maximum number of patients (75%) responded within three months, however two patients required reaspiration and reinstallation of tetracycline. Ultrasonography revealed fibrotic scar as thick wall with internal echodensities in six patients (30%) six month after sclerotherapy. There was high rate of patient satisfaction, as cosmetically tetracycline did not leave any scar, which was unavoidable with surgery. Six patients (30%) reported mild pain after injection, and one patient developed redness at the site of injection. CONCLUSIONS: Intracystic tetracycline sclerotherapy is highly effective as primary mode of treatment in hypofunctioning benign cystic thyroid nodule in selected group of patients not at high risk of malignancy.

Importance of venting the left ventricle in aortic valve surgery.

Routine use of left ventricular vent is controversial in patients undergoing open heart surgery. However, surgeons use it during valvular surgery to maintain a dry field to make the operation easier. In addition it helps to prevent left ventricular distention during the critical period of rewarming and reperfusion, if ventricular function does not return immediately following the release of aortic cross clamp. In our country, patients present for valvular surgery at a very late stage and they often have severe left ventricular hypertrophy. This may affect the return of cardiac rhythm after the release of aortic cross clamp with progressive left ventricular distention. In the authors' experience, insertion of left ventricular vent through the apex is occasionally necessary to decompress the left ventricle as the left atrial vent usually fails to do so. This paper deals with retrospective analysis of the seven patients (out of a total of 395 patients who underwent valve surgery) who required insertion of left ventricular vent through the apex and reviews the beneficial effects of an apical left ventricular vent under refractory circumstances. It is recommended that insertion of left ventricular vent through apex should be strongly considered in patients having severe aortic valve disease with hypertrophied hearts, if cardiac rhythm in not restored with conventional management with left atrial vent and 3 to 5 DC shocks following the release of aortic cross clamp.

Control of tachycardia and hypertension following coronary artery bypass graft surgery: efficacy and haemodynamic effects of esmolol.

Hypertension following coronary artery bypass grafting is not uncommon, especially in patients having good left ventricular function. It is often accompanied by tachycardia. The purpose of this study is to determine the efficacy of esmolol in the treatment of tachycardia and hypertension immediately following cardiopulmonary bypass and to study other haemodynamic effects of esmolol. Thirty patients undergoing elective [corrected] coronary artery bypass grafting were included in this prospective study. Morphine-based anaesthetic technique along-with standard bypass techniques were used in all the patients. The study was performed in the operating room about 30-45 minutes after the termination of cardiopulmonary bypass. Patients having a heart rate of more than 90 bpm and systolic blood pressure of more than 130 mm Hg without any inotropic support were included and randomly assigned to esmolol or control group. Esmolol was administered in a bolus dose of 500 micrograms/kg followed by infusion of upto 100 micrograms/kg/min. The patients in the control group were administered comparable volumes of normal saline. Baseline haemodynamic measurements were obtained just before the administration of esmolol or normal saline and were repeated after 5, 10, 15, 30 and 45 min. The baseline measurement in both the groups showed that patients were maintaining a state of hyperdynamic circulation with high systolic blood pressure (esmolol group 148 +/- 15 mm Hg, control group 140 +/- 8 mm Hg; p = NS), heart rate (esmolol group 128 +/- 17 bpm, control group 127 +/- 17 bpm; p = NS) and cardiac index (esmolol group 3.1 +/- 1 L/min/m2, control group 3.3 +/- 0.5 L/min/m2; p = NS). Esmolol decreased systolic blood pressure (p < 0.001), heart rate (p < 0.01) and cardiac index (p < 0.05) at five minutes. These changes persisted throughout the study period. The left ventricular stroke work index decreased at five minutes (p < 0.05) and remained so till 30 minutes. The maximum fall in heart rate (15%) and systolic blood pressure (16%) was observed at 45 minutes. There were no haemodynamic changes in the control group except that cardiac index, stroke volume and left ventricular stroke work index increased at five minutes. We conclude that esmolol lowers the indices of cardiovascular work in patients who demonstrated hyperdynamic circulation. This was achieved by decreasing the heart rate and systolic blood pressure which was accompanied by decrease in cardiac index and left ventricular stroke work index.

Post-cardiotomy intra-aortic balloon counter pulsation: application and prognostic evaluation.

Cardiac assistance by intra-aortic balloon counter pulsation was studied in 113 cardiac surgical cases comprising 91 male and 22 female patients. This included 82 percent of patients having coronary artery bypass surgery, while 18 percent were operated for valvular lesions. It was observed that the time of institution of cardiac assistance by intra-aortic balloon counter pulsation, following cardiac surgery, was of prime importance to decrease patient mortality. It was lowest (16%) when the balloon was inserted for assistance before termination and highest (50%) when there was delay of more than 15 minutes following termination of cardiopulmonary bypass. Early balloon assistance significantly lowered the pulmonary capillary wedge pressure and usually 1:2 augmentation was more effective, probably because of existing tachycardia in most patients. Advances in catheter technology have reduced the vascular complication at the insertion site. Percutaneous insertion had less local complications (13.3%) than open arteriotomy technique (31.2%). Similarly with sheathless insertion, complications were less (6.6%) in comparison to sheathed insertion (21.7%). Proper placement of balloon avoided position-related complications and there was no compromise of blood flow through left internal mammary artery as noticed in our series.

Azo reductase activity of microbial population from gastrointestinal tract segments of various animals species.

Azo reductase activity of microbial population of stomach, small intestine, caecum and large intestine of different animals was investigated. There was low activity in stomach flora of wistar rat and 3 strains of mice. Flora of proximal portion of small intestine in different species revealed that carnivorous animals exhibited maximum activity followed by grazing animals. Maximum activity in middle portion of small intestine was noted in dog (98.2%), while minimum was observed in guinea pig (23.3%). Majority of test animals revealed maximum floral azo reductase activity (58-98%) in caecum. Activity in proximal portion of large intestine was highest in dog while pigeon and guinea pig had least activity (23.3-27.1%). Appreciable microbial activity in distal end of large intestine was noted in sheep and goat. In all the 15 animal species investigated caecum showed maximum activity followed by pre and post caecal segments while stomach possessed the least. The results suggest that inter-species differences exist in microbial reductive activity which may be due to variation in composition and distribution of GI tract microflora and thus can influence toxicological implication of various dyes.

Comparative azo reductase activity of red azo dyes through caecal and hepatic microsomal fraction in rats.

In order to study the rate of formation of toxic aromatic amines, anaerobic reduction of four red azo dyes viz. amaranth, carmoisine, fast Red E and ponceau 4R was investigated by incubating caecal content and hepatic microsomal fraction of rats with 37.5 microM concentration of dyes in sodium phosphate buffer pH 7.4 using NADPH generating system, glucose oxidase system and nitrogen as the gaseous phase. Caecal suspension exhibited higher azo reductase activity than that of hepatic microsomal fraction using any of the 4 azo dyes. Caecal microbes showed maximal azo reductase activity when ponceau 4R was used as a substrate followed by fast Red E and carmoisine, while with amaranth the activity was minimum. Similarly ponceau 4 R exhibited maximum hepatic microsomal azo reductase activity followed by fast Red E and carmoisine whereas, amaranth had minimum activity. Caecal flora possessed almost 17 fold higher degradative capability of ponceau 4 R and fast Red E colourants than the hepatic microsomal fraction. The higher reductive ability through caecal flora for ponceau 4R and fast Red E signifies the formation of more aromatic amines which may be re-absorbed through the intestine to be either eliminated through urine as conjugates or retained in the target tissues to elicit toxic effects.

Reductive and hydrolytic activities of enteric bacteria on food colours.

Reductive and hydrolytic activities on two food colours namely metanil yellow and indigo carmine by different strains of enteric bacteria were evaluated. Enteric bacteria possessed both reductive and hydrolytic capabilities which depended upon the incubation period and the type of strain. In certain bacterial strains, (Escherichia coli and Vibrio sp.), reductive activity was visible after 3 hr. Other enteric strains showed an increasing activity right from the beginning of incubation. Enterobacter cloacae appeared to be producing maximum reductive capability followed by Enterobacter aerogenes and E. coli. Even enteric bacterial strains demonstrated a good response in obtaining hydrolytic activity of indigo carmine during incubation upto 10 hr, establishing the fact that the gut microflora may cause health problem to consumers.

Thrombolytic therapy for prosthetic valve thrombosis in Third World countries.

In order to clarify the role of thrombolytic therapy for treatment of prosthetic valve thrombosis, all cases admitted in the intensive care unit (ICU), between March 1987 and March 1997 with the diagnosis of prosthetic valve thrombosis and treated with streptokinase, were analysed. In total, 42 patients with clinical and echocardiographic evidence of left side tilting disc prosthetic valve thrombosis were treated. All the patients had only mitral valve prosthesis involvement. Streptokinase was administered as a bolus of 2.5 lac units over 30 minutes followed by 1 lac units/hour for 48-72 hours. Thirty-seven (88%) patients had successful thrombolysis. Overall mortality occurred in 9.5 percent patients due to systemic embolism and bleeding complications. Serial clinical, radiological and echocardiographic studies showed successful thrombolysis in 88 percent patients. This study demonstrates that streptokinase therapy is safe and effective first line treatment for left-sided prosthetic valve thrombosis and surgery should be reserved for those patients who fail to respond to thrombolytic therapy.

Anaesthetic management of patients undergoing surgery for tachyarrhythmias. Initial experience with 16 patients.

Sixteen patients suffering from various cardiac arrhythmias were treated surgically. Intraoperative computerised electrophysiologic mapping was used in 14. Thirteen patients were suffering from Wolff-Parkinson-White syndrome. They underwent surgical division or cryoablation of accessory pathways. Two patients who had rheumatic mitral stenosis with left atrial clot underwent "Maze III" procedure with open mitral commissurotomy and clot removal. One patient with paroxysmal refractory ventricular tachycardia and a left ventricular aneurysm had an aneurysmectomy with subendocardial resection of the arrhythmic focus. All antiarrhythmic medications were discontinued preoperatively. Morphine was the principal anaesthetic agent, supplemented with halothane. Muscle relaxation was provided with pancuronium bromide. The various problems encountered included hypotension and arrhythmia during placement of epicardial band array for mapping (4 patients), ventricular tachycardia during internal jugular vein cannulation (1 patient) and continuance of delta wave after cryoablation in 2 patients. Halothane may have interfered with electrophysiologic mapping and accurate localization of accessory pathway leading to persistence of delta wave. The choice of anaesthetic agents should be guided by the electrophysiologic effects and potential influence of these agents on the accessory pathways.

Procedural outcome and follow-up results of balloon angioplasty versus new device interventions for treatment of true bifurcation stenoses.

Strategies for dilatation of bifurcation stenoses have continued to evolve over the past several years. However, there is limited experience on the efficacy of various nonballoon interventional devices and their results in comparison with balloon angioplasty. We, therefore, analysed our data in 72 patients of coronary artery disease with true bifurcation stenoses with balloon angioplasty or new device interventions (NDI). All patients underwent dilatation of both the primary vessel and side branch ostial stenosis. Balloon angioplasty using double guidewire with sequential or simultaneous (kissing balloon) balloon inflation in the two vessels was performed in 42 patients. Thirty patients underwent NDI, using directional coronary atherectomy (DCA) in 12, rotablation in 6 and elective coronary stents in 12 patients. There were no significant differences in the baseline clinical and angiographic variables between patients in the two groups. While the preprocedural luminal diameter stenosis was similar, the residual stenosis was significantly less, both in the primary vessel and side branch, after NDI compared to balloon angioplasty. The procedure was successful in 96.6 percent patients treated with NDI and 83.3 percent with balloon angioplasty (p < 0.01) with relief of obstruction in both branches without any major complications. Freedom from subsequent coronary events in the form of angina, myocardial infarction, PTCA, bypass graft surgery of death was significantly more, both at 6 months (92% versus 65.6%, p < 0.001) and 12 months (81.8% versus 53.1%, p < 0.001) in the group of patients treated with NDI compared to balloon angioplasty. It is, therefore, concluded that NDI including DCA, rotablation and elective stenting are associated with higher rate of success, lesser complications and better event-free survival in comparison to balloon angioplasty for treatment of true bifurcation stenoses.

Elective stenting for type B and C lesions: immediate results and follow-up angiographic restenosis.

From January to December 1995, 73 out of 174 patients with coronary artery disease underwent elective stenting for type B and C lesions. The age ranged from 35 to 73 years (mean +/- SD : 52.1 +/- 12.6) and the majority (91.7%) were males. Of the 74 vessels treated, the target vessel was LAD in 49 (66.4%), LCx in 13 (17.6%), RCA in 8 (10.8%) and SVG in 4 (5.2%). Based upon the ACC/AHA task force classification, 58 (79.5%) patients had type B1, 9 (12.3%) B2 and 6 (8.2%) had type C lesions. A total of 89 stents were deployed to treat 76 lesions with a range of 1 to 3 stents per lesion. A single stent was required for 67 lesions, 2 stents for 8 and 3 stents for 2 lesions. The stents used were Wiktor (29), Palmaz-Schatz (26), Gianturco-Roubin (24), Microstent (6) and Freedom (4), depending upon the anatomical and morphological characteristics with the lesion. Using high pressure strategy, the stents were deployed successfully in all (100%) with a reduction in luminal diameter stenosis from 92 +/- 5.4 to -5 +/- 6 percent. There was no subacute stent thrombosis despite nonusability of oral anticoagulation in 95.9 percent patients. None had any major complication in the form of acute myocardial infarction, need for emergency bypass graft surgery or death. Minor complications were encountered in 9 (12.3%) patients. At a mean follow-up of 26 +/- 14 weeks, 74 percent of the patients were asymptomatic. Out of 31 patients who had completed 6 months after the procedure, repeat angiography was performed in 29 (93.5%) at a mean duration of 29 +/- 6 weeks. The angiographic restenosis was found in 6 (20.7%) patients. In conclusion, type B and C lesions can be treated successfully using elective stenting with excellent immediate results and clinical outcome. Angiographic restenosis, which develops in about one-fifth of patients, appears to be much lower than reported after balloon angioplasty for these complex lesions.

Bio-metabolic disposition of metanil yellow, orange II and their blend by caecal microflora of rats.

Caecal microflora were employed to study the degradation pattern, with time course of Metanil yellow and Orange II-two extensively used non-permitted food colours. Metanil yellow and Orange II showed the respective Degradation Index 50 (DI 50) values of 369 and 288 min. However, the blend of Metanil yellow and Orange II (1:1) resulted in the D1 50.value of 288 min. Metanil yellow, Orange II and their blend were resolved into respective metabolites in different solvent systems.

Blood conservation in valve surgery.

Blood utilization in 40 patients undergoing elective valve surgery was prospectively studied. The patients had valvular lesions of rheumatic origin with a mean age of 29.1 years and a mean preoperative hematocrit of 35.23 +/- 4.16. Blood was removed from all patients after induction of anesthesia and reinfused after bypass (mean 365.12 +/- 66.96 ml). Membrane oxygenator was used in all the patients. All discard suction was routed through a regionally heparinised collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was also processed by cell saver and used for subsequent reinfusion. Normovolemic anemia was accepted in hemodynamically stable patients. Thirty two patients (80%) received no bank blood or blood products during their entire hospital course. A total of twelve units of whole blood was transfused into eight patients.

Dual exposure and repair technique for ruptured aneurysms of aortic sinus of Valsalva.

Thirteen patients with ruptured sinus of Valsalva aneurysm have been operated over a 3-1/2 year period. Right coronary sinus was predominantly involved and right ventricle was the most common site of rupture. Early surgery was performed in all cases. Both aorta and chamber of entry were explored for effective repair. Main repair was always done in the chamber of rupture either with a patch or interrupted pledgeted sutures followed by assessment at either end. Subannular ventricular septal defects in three cases were closed with a common patch with additional fixation in the middle at the aortic annulus to prevent aortic leak into the left ventricle. Three patients needed aortic valve replacement for gross aortic incompetence. Postoperative echocardiographic study revealed uniformly excellent results with good aortic valve or prosthetic function. One patient developed fatal pulmonary embolism two weeks following surgery. All other surviving patients are doing well and are in NYHA class I. We recommend dual exposure and repair technique for the repair of ruptured sinus of Valsalva aneurysms for optimal results.