Resultado da miotomia endoscópica peroral (POEM) em acalasia avançada em um seguimento mediano de 17 meses / Outcome of per oral endoscopic myotomy (poem) in sigmoid achalasia at a median follow up of 17 months

ABSTRACT Background: Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging. Methods: Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted. Results: Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence. Conclusion: Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.

RESUMO Contexto: Acalasia cárdia avançada representa o estágio final na história natural do megaesôfago. Está emergindo o papel da miotomia endoscópica peroral (POEM) neste subconjunto tecnicamente difícil. Métodos: Foi realizada uma revisão retrospectiva dos pacientes submetidos a POEM para tratamento do megaesôfago avançado. Avaliamos o sucesso técnico, o sucesso clínico e a taxa de eventos adversos. O escore de Eckardt, pré e pós POEM, a pressão integral de relaxamento de 4 seg (IRP-4), a pressão do esfíncter inferior do esôfago e a altura e largura da coluna de bário em 5 minutos, foram anotadas. Resultados: Dos 85 pacientes submetidos a POEM para acalasia cárdia, 10 pacientes apresentaram acalasia cárdia avançado com esôfago com aspecto sigmoide, dos quais dois eram muito avançados. O sucesso clínico e técnico foi de 100% com redução significativa do escore de Eckardt, do IRP-4, da pressão do esfíncter inferior do esôfago e da altura e largura da coluna bário em 5 minutos. Um paciente teve um pequeno evento adverso na forma de lesão mucosa que foi fechada com hemoclipes. Em um seguimento mediano de 17 meses não houve recorrência. Conclusão: Nosso estudo demonstra que a POEM é uma modalidade segura e eficaz de tratamento neste subconjunto tecnicamente difícil de megaesôfago com morfologia sigmoide.

Níveis ascíticos e soros de biomarcadores tumorais (CA 72-4, CA 19-9, CEA e CA 125) em discriminação de causa de ascites: um estudo prospectivo / Ascitic and serum levels of tumor biomarkers (ca 72-4, ca 19-9, cea and ca 125) in discrimination of cause of ascites: a prospective study

ABSTRACT Background: The role of ascitic and serum levels of various tumour biomarkers in the discrimination of cause of ascites is not well established. Objective: To evaluate the role of serum and ascitic levels of tumor biomarkers (CA 72-4, CA 19-9, CEA and CA 125) in discrimination of cause of ascites. Methods: A prospective study was conducted in consecutive patients presenting with ascites. Serum and ascitic levels of CA 19-9, CA 125, CA 72-4 and carcinoembryonic antigen (CEA) were determined at the presentation. The patients with cirrhotic ascites, tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC) were eventually included in analysis. Results: Of the 93 patients (58 males, mean age 47 years) included, the underlying cause was cirrhosis in 31, PC in 42 and peritoneal tuberculosis in 20. The best cutoff for discriminating benign and malignant ascites for serum CEA, CA 19-9 and CA 72-4 were 6.7 ng/mL, 108 IU/mL and 8.9 IU/mL, respectively. The best cutoff for discriminating benign and malignant ascites for ascitic CA 125, CEA, CA 19-9 and CA 72-4 were 623 IU/mL, 8.7 ng/mL, 33.2 IU/mL and 7 IU/mL, respectively. Conclusion: The performance of single biomarker for the prediction of underlying PC is low but a combination of serum CA 19-9 and CA 72-4 best predicted the presence of peritoneal carcinomatosis.

RESUMO Contexto: O papel dos níveis ascíticos e séricos de vários biomarcadores de tumores na discriminação da causa das ascites não está bem estabelecido. Objetivo: Avaliar o papel dos níveis séricos e ascíticos de biomarcadores tumorais (CA 72-4, CA 19-9, CEA e CA 125) na discriminação da causa das ascites. Métodos: Estudo prospectivo foi realizado em pacientes consecutivos que apresentaram ascite. Foram determinados níveis do soro e ascítico de CA 19-9, CA 125, CA 72-4 e antígeno carcinoembrínico (CEA). Os pacientes com ascites cirróticas, peritonite tuberculosa e carcinomatose peritoneal (CP) foram eventualmente incluídos na análise. Resultados: Dos 93 pacientes (58 homens, média de idade 47 anos) incluídos, a causa básica foi cirrose em 31, CP em 42 e tuberculose peritoneal em 20. O melhor corte para discriminação de ascites benignas e malignas para soro CEA, CA 19-9 e CA 72-4 foram 6,7 ng/mL, 108 UI/mL e 8,9 UI/mL, respectivamente. O melhor corte para discriminação de ascites benignas e malignas para CA 125 ascitico, CEA, CA 19-9 e CA 72-4 foram 623 UI/mL, 8,7 ng/mL, 33,2 UI/mL e 7 UI/mL, respectivamente. Conclusão: O desempenho do biomarcador único para a previsão do CP subjacente é baixo, mas uma combinação de soro CA 19-9 e CA 72-4 melhor previu a presença de carcinomatose peritoneal.

Comparative Study of Intraperitoneal Instillation of Levobupivacaine (0.25%) Plus Dexmedetomidine Versus Ropivacaine (0.25%) Plus Dexmedetomidine for Post-operative Analgesia in Patients Undergoing Laparoscopic Cholecystectomy

Background: Instillation of intraperitoneal lignocaine, bupivacaine, levobupivacaine, and ropivacaine has been used followinglaparoscopic gynecological and general surgical procedures to reduce post-operative pain through randomized trials formany years. Hence, the present study was undertaken for assessing and comparing the efficacy of intraperitoneal instillationof levobupivacaine (0.25%) and ropivacaine (0.25%) for post-operative analgesia in patients undergoing laparoscopiccholecystectomy (LC).Materials and Methods: Ninety patients were enrolled and were randomly divided into three groups of 30 each. Group L:Patients were given 20 ml of 0.5% levobupivacaine plus dexmedetomidine at 1 μg per kg body weight and making total volume40 ml by adding normal saline (NS), intraperitoneally after gallbladder removal. Group R: Patients were given 20 ml of 0.5%ropivacaine plus dexmedetomidine at 1 μg per kg body weight and making total volume 40ml by adding NS, intraperitoneallyafter gallbladder removal. Group C: Patients were given 40 ml of NS. Postoperatively, the patients were assessed for painutilizing visual analog scale (VAS). The results were statistically analyzed using latest software.Results: The mean VAS score reading was lower in Group L and Group R in comparison to Group C at all the time intervals. Thenumber of patients requiring rescue analgesia was significantly higher in Group C in comparison to other study groups. Amongthe L group and R group, the number of patients requiring rescue analgesia was lower in Group L in comparison to Group R.Conclusion: Intraperitoneal instillation of local anesthetic solution in LC provided effective post-operative analgesia, butanalgesia provided by levobupivacaine plus dexmedetomidine was significantly better than ropivacaine plus dexmedetomidine

Occult hepatitis B virus infection as a cause of cirrhosis of liver in a region with intermediate endemicity.

BACKGROUND: Serological tests may fail to identify hepatitis B virus (HBV) infection as a cause of liver cirrhosis in a proportion of patients. The frequency of such occult infection in regions with intermediate HBV endemicity is not known. Such cases may be diagnosed by incremental testing for IgG anti-HBc, serum HBV DNA, and HBV DNA in liver tissue. METHODS: We tested sera of 111 patients with cirrhosis, including 39 with history of significant alcohol ingestion, for HBsAg, anti-HBc and serum HBV DNA. In addition, in a subset of 14 patients, HBV DNA was looked for in liver tissue. RESULTS: On HBsAg and anti-HBc testing, 66 patients had HBV infection. Serum HBV DNA testing identified HBV infection in 13 additional cases. Of 18 patients labeled as 'cryptogenic' on serological testing, HBV DNA was detected in the serum in 7 patients. Of 14 patients in whom paired liver tissue and serum specimens were tested, 4 additional patients with HBV infection were detected after liver biopsy analysis. CONCLUSIONS: Serological tests for HBsAg and anti-HBc antibody are insensitive in identifying HBV infection in patients with liver cirrhosis. HBV DNA testing in serum and liver can help in establishing HBV infection as etiology, either alone or in addition to another cause.

Frequency of infection by hepatitis B virus and its surface mutants in a northern Indian population.

INTRODUCTION: The reported prevalence of hepatitis B virus (HBV) infection in the Indian general population varies from 2% to 11%. Epidemiological studies conducted so far have selection biases, since these included populations of defined age group, gender, social class, high-risk group, etc. The present study was designed to look for the molecular epidemiology of HBV infection in the rural and urban general populations in India. METHODS: Sera obtained from healthy volunteers during college and social service camps from parts of northern India were tested for HBsAg and anti-HBc using enzyme immunoassays and for HBV DNA using polymerase chain reaction and Southern blot hybridization. The amplification products were cloned and sequenced, and nucleotide and deduced amino acid sequences of the surface and polymerase genes were analyzed for mutations. RESULTS: Of the 730 subjects (rural 543, urban 187), 15 (2.1%) tested positive for HBsAg and 143 (19.5%) for anti-HBc; 10 were positive for both. The overall HBV exposure rate in the population was 20.3% (148/730). The HBsAg carrier rate was similar in the urban and rural populations (1.5% and 2.3%; p=ns), and anti-HBc positivity was lower in the urban population (8.5% vs. 23.3%; p<0.01). History of parenteral interventions or blood transfusion was associated with markers of exposure to HBV (10.2% vs. 4.6%; p=0.01). Among the 220 representative samples tested for HBV DNA, 14 (6.4%) were positive; of these, only four were positive for HBsAg or anti-HBc. Sequencing of a 388-nt segment of the S-gene from three individuals (two adw and one ayw subtype) revealed four mutations. Two and three of these led to amino acid changes in the HBV surface and polymerase genes, respectively; alterations in known cytotoxic T cell epitopes of HBV surface and polymerase proteins were observed in one individual each. None had the G587A mutation, which is known to be associated with loss of the 'a' determinant of HBsAg. CONCLUSION: Our study shows a high frequency of exposure to HBV infection in the Indian general population; a proportion of HBV infected persons were detectable only by molecular methods. The positivity rate was higher in the rural population.