Reuse of single-use devices: Looking back, looking forward.

The reuse of medical devices marked as ‘single use’ by manufacturers has been going on for several decades. The process has been rationalized and legislated in the West as well as in Japan. However, the practice continues in an unregulated manner in India due to a paucity of guidance from the Food and Drug Administration in India. We trace the evolution of reuse policies, look at the prevalent practices in the Indian and international contexts, analyse the available Indian literature and address the ethical and economic implications of reuse. We also suggest some guidelines which may be adopted to formulate policies.

Treatment of symptomatic polycystic liver disease with resection-fenestration.

Polycystic liver disease with severe symptoms is difficult to treat. We report a 35-year-old man with advanced disease, who had a successful outcome after resection and fenestration.

Bleeding isolated gastric varices: a retrospective analysis.

OBJECTIVE: Isolated gastric varices (IGV) are rare and are believed to be associated with left-sided portal hypertension. We studied patients presenting with bleeding from IGV and compared them with those bleeding from both esophageal and gastric varices. METHODS: A retrospective analysis of 14 patients with bleeding from IGV was carried out. Portovenography findings (pattern of collateralization and natural shunts) in these patients were compared with a matched group of 69 patients with both esophageal and gastric varices. RESULTS: Of 14 patients with IGV, 2 had isolated splenic vein thrombosis and 12 had generalized portal hypertension. Portovenograms in 11 of the latter 12 revealed predominantly 'left-sided' collateralization in 8 patients as compared to 17 of 69 (25%) patients with esophageal and gastric varices (p = 0.004); natural shunts were seen in 6 of 11 cases and 15 of 69 (22%) patients in the two groups, respectively (p = 0.05). Abdominal devascularization operation gave good short- and long-term control of bleeding. CONCLUSIONS: Contrary to belief most patients with isolated gastric varices may have generalized portal hypertension rather than splenic vein obstruction as the cause and hence should be treated by a more extensive procedure than just splenectomy. The IGV could be a result of predominant collateralization to the retroperitoneal area (left-sided collateralization and natural shunts) rather than the usual pattern to the azygos system which results in esophageal varices.

Surgical management of the Budd-Chiari syndrome: early experience.

BACKGROUND: Early decompression is needed in the Budd-Chiari syndrome (BCS) to prevent liver dysfunction and death. AIMS: To study the technical difficulties during surgery and the results of surgery for BCS. METHODS: Retrospective review of nine patients operated on between 1994 and January 1998 for BCS--1 for uncontrolled fundal variceal bleed and 8 for chronic BCS. Isolated hepatic vein block was found in 5, inferior vena cava (IVC) block in 1 and a combination in 3 patients. Preoperative liver biopsies did not reveal cirrhosis in any patient. Portacaval shunt (3), portorenal shunt (2), mesocaval shunt (1), mesoatrial shunt (2) and devascularisation (1) were the operations performed. RESULTS: In 3 patients, side-to-side portacaval shunt was not possible because of caudate lobe hypertrophy (1), aberrant right hepatic artery (1) and presence of IVC stent (1); they required portorenal (2) or interposition mesocaval (1) shunts. Both mesoatrial shunts were unsuccessful. Devascularisation was effective in controlling the acute bleed. There was no intraoperative death. Postoperatively there were 3 deaths. Of the 6 survivors, 5 are asymptomatic over a mean follow up of 19.7 months. CONCLUSIONS: Side-to-side portacaval shunt is effective in the management of BCS; results with the mesoatrial shunt are disappointing.

Hepatic sickling crisis mimicking recurrent cholangitis.

A 22-year-old man with homozygous sickle cell disease presented with recurrent fever, right upper quadrant pain and jaundice. Liver biopsy confirmed the diagnosis of hepatic sickling crisis; the symptoms responded to hydroxyurea therapy. Hepatic vasocclusive crisis can diagnosed on liver biopsy, and need not be a diagnosis of exclusion.

Pseudomyxoma peritoneii.

A middle aged male patient presented with gradual distension of the abdomen. Imaging modalities showed classical features of pseudomyxoma peritoneii which was confirmed by aspiration cytology. Details of the case are described and relevant literature is reviewed.

Helicobacter pylori gastritis masquerading as gastric lymphoma.

A 30-year-old man presented with acute acid-peptic symptoms. Endoscopy and radiological studies revealed generalized thickening of gastric folds with multiple superficial ulcerations and infiltration of the distal stomach simulating gastric neoplasm. Endoscopic biopsies revealed acute gastritis with foveolar hypertrophy with numerous Helicobacter pylori. The symptoms and endoscopy findings resolved completely with combination triple-drug therapy for H pylori.

Fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma, a histological variant of hepatocellular carcinoma, distinct pathological and clinical features and a better prognosis than other types of hepatocellular carcinoma. We report here a patient who was treated on successful surgically.

Splenic abscess--a possible complication of endoscopic variceal sclerotherapy.

Endoscopic variceal sclerotherapy, though a safe and effective therapy for esophageal varices, is not devoid of local and distant complications. We report a patient with postnecrotic cirrhosis and diabetes mellitus who developed a splenic abscess while on a sclerotherapy program. The abscess may have been a consequence of retrograde thrombosis of the portal venous system or of bacteremia following sclerotherapy.

Total hepatic vascular exclusion for major hepatic resection.

Use of vascular occlusion techniques during hepatic resection has besides decreasing blood loss improved the feasibility of surgical extirpation of large hepatic tumors. We report successful use of this technique to resect a large hepatoma in the right lobe of the liver. The hemodynamic and biochemical changes in the perioperative period are documented.

Experience with the pectoralis major myocutaneous flap for head and neck reconstruction in a general surgical unit.

The pectoralis major myocutaneous (PMMC) flap or its modification was used in 19 cases after resectional surgery for malignancy of the oral cavity with minimal morbidity and no mortality. The resection as well as reconstruction was done by the same team consisting only of general surgeons. The final functional and cosmetic results were satisfactory. The pectoralis major myocutaneous flap is a hardy flap and can be performed with relative ease even by those not specialised in plastic surgery. This makes it an important tool for a general surgeon practicing in a country like India with its high incidence of head and neck malignancy.

Obstructed Morgagni's hernia (a case report).

A forty-year-old male patient was admitted with acute intestinal obstruction, plain X-ray abdomen and chest revealing air fluid levels on the right side of chest. A successful operation was carried out and the patient made an uneventful recovery. Obstructed Morgagni's Hernia is an uncommon case and hence the presentation.