Doctors and Padma awards.

Background. The announcement of the annual Padma awards in January always generates a great deal of interest as well as controversy and, some believe that many good candidates are excluded and many less deserving ones included. We analysed the recipients in the field of medicine to determine whether or not a pattern emerged regarding who were bestowed these honours. We were not able to objectively evaluate whether or not the honours were ‘deserved’. Methods. We obtained and then analysed the list of awardees from newspapers and the official website of the Ministry of Home Affairs. Between 2000 and 2010, a total of 1166 awards were announced, of which 157 (13.4%) were in the field of medicine. We excluded foreigners and those from ‘alternative’ fields (20), and evaluated the remaining 137 in detail. Results. Sixty-two (45.3%) recipients were from Delhi, 18 (13.1%) from Maharashtra and 17 (12.4%) from Tamil Nadu. Of the 137 awardees, 31 (22.6%) were cardiologists or cardiac surgeons. Many large states of the country, such as West Bengal, Gujarat, Rajasthan, Madhya Pradesh, Punjab and Haryana, did not have a single awardee. Conclusion. The over-representation of Delhi and cardiology in the Padma awards for medicine suggests that their distribution is not entirely fair.

Liver hemangioma mimicking cholangiocarcinoma - a diagnostic dilemma.

A 55-year-old man presented with a liver mass that had been diagnosed on ultrasonography, carried out in response to the patient’s complaint of non-specific abdominal pain. Triphasic computed tomography (CT) revealed a lesion involving segments 1, 4, 5 and 8 of the liver. It was centrally hypodense with peripheral enhancement in the arterial phase suggesting a cholangiocarcinoma. The middle hepatic vein was encased and the tumour was present near the junction of the left hepatic and middle hepatic veins. We planned a right hepatic trisegmentectomy including resection of the caudate lobe but since the estimated volume of the liver remnant was only 17% of the total, we first embolised the right portal vein. CT scan repeated 5 weeks later revealed that the lesion was still resectable and that the left lateral segment had hypertrophied to 27% of the liver volume. We performed a right trisegmentectomy including caudate lobe resection using intra-operative ultrasonography to establish that the left hepatic vein was not involved. The removed lesion was hard with ill-defined margins. Histopathological examination revealed a hemangioma.

Distinguishing between periampullary carcinoids and carcinomas--is this possible preoperatively?

It is difficult to distinguish between carcinoid tumors of the pancreatic head and periampullary region and carcinomas preoperatively. Between 1996 and 2002, 125 consecutive pancreaticoduodenectomies done by us for periampullary tumors (14 carcinoids, 111 carcinomas) were analyzed. Patients with carcinoid tumors had significantly younger mean age (48 vs. 54 years), longer history (32 vs. 8 weeks), lower serum total bilirubin levels (1.4 vs. 6.3 mg/dL) and on CT scan, had larger, well-localized tumors (5 cm vs. 2 cm). Their postoperative course was better with no mortality or major morbidity, whereas after resection for carcinoma 7 (6.3%) patients died and 30 (27%) had major postoperative complications. Thus, a tumor of this region in a young patient with indolent history, low bilirubin level and with CT scan depicting a large expansile lesion suggests a carcinoid. Such tumors may be safely resected with low postoperative morbidity and mortality and good long-term prognosis.

Management protocol for acute gastrointestinal bleeding.

Gastro-intestinal haemorrhage is not uncommon and is manifested as haematemesis, melaena or haematochezia. The first step is to resuscitate the patient if necessary and then proceed to make a diagnosis as well as divide patients into high and low-risk groups after taking a good history and performing a physical examination especially to detect the presence of an enlarged spleen. Then one should proceed with an endoscopy and other investigations chosen carefully for their usefulness. Control of bleeding is then tailored to the diagnosis and is usually with drugs, endoscopy, angio-embolisation and surgery in that order. The mortality rate for upper GI bleeding varies from 10 to 30% depending on the proportion of patients with variceal haemorrhage included. For lower GI bleeding mortality is in the region of 20% and for obscure GI bleeding outpatient mortality is 12%. The main points to remember are that the management of these patients in India should be different from those described in Western textbooks and suited to their specific needs and the facilities available locally. However, in spite of the widespread lack of complex diagnostic techniques and a shortage of blood for transfusion we believe that by adopting an aggressive step-by-step approach tailored to our own environment we will be able to save most of our patients who are usually young and have few comorbid conditions.

Prophylactic surgery in non-cirrhotic portal fibrosis:is it worthwhile?

BACKGROUND: In cirrhotic patients with portal hypertension prophylactic portasystemic shunts have been found to be ineffective as deaths from post-shunt liver failure exceed those from bleeding. However, in patients with non-cirrhotic portal hypertension, variceal bleeding rather than liver failure is the common cause of death. In developing countries shortage of tertiary health-care facilities and blood banks further increases mortality due to variceal bleed. AIM: To study the results of prophylactic operations to prevent variceal bleeding in patients with portal hypertension due to non-cirrhotic portal fibrosis (NCPF). METHODS: Between 1976 and 2001, we performed 45 prophylactic operations in patients with NCPF, if the patients had high-risk esophagogastric varices or symptomatic splenomegaly and hypersplenism. Proximal lienorenal shunt was done in 41 patients and the remaining underwent splenectomy with (2 patients) or without (2 patients) devascularization. RESULTS: There was no operative mortality. Thirty-eight patients were followed up for a mean 49 (range, 12-236) months. Three patients bled - one was variceal and two due to duodenal ulcers; none died of bleeding. There were 2 late deaths (6 weeks and 10 years after surgery), one from an unknown cause and one due to chronic renal failure. The delayed morbidity was 47%. This included 7 patients who developed portasystemic encephalopathy, 4 glomerulonephritis, 2 pulmonary arteriovenous fistulae and 5 ascites requiring treatment with diuretics. Thus only 20 (53%) patients were symptom-free on follow up. CONCLUSIONS: Prophylactic surgery is safe and effective in preventing variceal bleeding in NCPF but at the cost of high delayed morbidity.