The role of transportation in developing the tourism sector at high altitude destination, Kinnaur.

As a supporting factor, transportation is an important element of destination image that provides a base for the successful tourism industry. It is like the blood vessels of an area and is considered a determinant in developing a tourist destination. The article aims to characterize the status or problem of transportation accessibility in Kinnaur. GARMIN hand GPS (Global Positioning System) has been used to identify the damaged roads from their start to endpoints. In addition, a simple random sample technique has been used to register the opinion of 280 tourists about the transport facilities. Study results suggest that the bad condition of National Highway-22 is one of the barriers to tourism development in Kinnaur. There were no significant differences found between the selected destinations. Overall, the district headquarters, Kalpa, has been perceived significantly higher agreements by tourists. The government should ensure that the Border Road Organization, the organization entrusted with the responsibility of construction and maintenance of roads in international border areas, has sufficient resources to invest in transport development and its maintenance.

Laparoscopic cholecystectomy: an Indian experience of 1233 cases.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a well-established procedure for symptomatic cholelithiasis in India, but there are few data available regarding the procedure and its related complications. PATIENTS AND METHODS: This paper represents a retrospective review of 1233 patients who underwent LC at Government Medical College and Hospital, Chandigarh, India, over 4 years (1997-2000). The case files of all these patients were analyzed for patient particulars, intraoperative findings, reason for any open conversion, postoperative stay, and mortality. RESULTS: The overall conversion rate was 7.06% (87 patients). The commonest cause of conversion was a frozen Calot's triangle (52 patients), followed by injury to the common bile duct (8 patients). The average postoperative stay in successful LC was 1.32 days. The overall mortality rate was 0.16% (2 deaths). The quality of life after LC was good to excellent in more than 90% of patients. CONCLUSIONS: Despite multiple hands in training, the complication rates of LC are within acceptable limits. The overall conversion rate has risen because of the increase in elective conversions, but the incidence of complications has come down because of a "no hesitation" policy in converting. In spite of multiple operators, LC is the procedure of choice for symptomatic cholelithiasis at our hospital.

Current perspectives in gallbladder carcinoma.

Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in long- term survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the symptoms but does not prolong survival. The role of adjuvant chemotherapy with or without cytoreductive surgery has not been fully explored in CaGB. The present review quotes experience that seems to support the above contention. However, a number of well-designed multicentric trials are required to confirm the above philosophy of treatment for the benefit of patients suffering from CaGB.

Helicobacter pylori eradication with lansoprazole, amoxycillin and clarithromycin: testing an ideal regimen in a multicultural south east Asian population and examining factors potentially influencing eradication.

BACKGROUND: From European and North American data, it is recommended in the Asia Pacific consensus statement, that one week therapy with a proton pump inhibitor, amoxycillin and clarithromycin be used for Helicobacter pylori eradication, in areas of high metronidazole resistance. The efficacy of this regimen is unknown in Singapore. AIM: To assess the efficacy, safety and compliance of an H. pylori eradication regimen and examine clinical factors that potentially determine eradication. METHODS: Consecutive outpatients from a multicultural, south east Asian, population with H. pylori infection, with or without peptic ulcer, were treated with lansoprazole 30 mg, amoxycillin 1 gm, clarithromycin 500 mg, twice a day for seven days. Eradication was assessed by either rapid urease, histology or urea breath test. Compliance and side effects were recorded. The eradication rate and effect of ethnicity, age, sex, usage of alcohol, smoking and non-steroidal anti-inflammatory drugs, history of ulcer and endoscopic diagnosis on eradication were examined by univariate and multivariate analysis. RESULTS: Of 113 patients, the eradication rate by intention to treat was 98/113 (87%) (95% confidence interval [CI] 80-93%) and per protocol was 98/106 (92%) (95% CI 87-97%). Using Fisher's exact test, eradication was more successful in Chinese (intention to treat and per protocol respectively p=0.02 and p<0.001) compared to non-Chinese. By logistic regression analysis ethnicity was an independent factor associated with eradication success (p=0.0025). Side effects occurred in five (4.4%), resulting in cessation of treatment. CONCLUSIONS: This one week eradication regimen is safe and effective in south east Asians. Chinese ethnicity may be associated with a higher likelihood of eradication success.

An unusual manifestation of severe caustic injury.

Knowledge of the sequelae of caustic ingestion is of relevance to staff of the Emergency Room, Intensive Care Unit, surgical and gastroenterology services. It poses a considerable management problem and may result in life-threatening complications such as visceral perforation. This case report demonstrates an unusual and previously unreported manifestation of caustic injury.

Autoimmune hepatobiliary disease in trisomy 21.

Two patients with abnormal liver biochemistry are presented with hepatobiliary disorders rarely described in trisomy 21. The first was considered to have primary sclerosing cholangitis (PSC) and Crohn's disease. Liver biochemistry was normal after six months' treatment with ursodeoxycholic acid and diarrhea resolved after sulfasalazine. The second patient had autoimmune hepatitis that responded to immunosuppression. Autoimmune hepatobiliary disorders, highlighted by this report, occur in trisomy 21 but are rare. A high index of suspicion for these potentially treatable disorders is required.

An audit of percutaneous endoscopic gastrostomy in a general hospital in Singapore.

OBJECTIVE: We conducted an audit on 50 percutaneous endoscopic gastrostomies (PEGs) performed by physician endoscopists from January 1996 up to November 1997. DESIGN: A retrospective cohort study was conducted. RESULTS: The mean age of the patients was 68.5 years (range 20-101) and the main indications were cerebrovascular accident in 40 (80%), neurological dysphagia in six (12%) and head injury in three (6%). The interval between the diagnosis of dysphagia and PEG was > 60 days in 19 patients (38%), 31-60 days in eight (16%) and < or = 30 days in 23 (46%). The commonest reason for PEG insertion was intolerance to nasogastric tube in 49 patients (98%). Twelve patients had antibiotics given concurrently for other infections and two had antibiotics given specifically to cover PEG insertion. There was evidence of post-PEG infection in two of 14 patients given antibiotics (14%) and in 14 of 36 patients not given antibiotics (39%). By Cox regression, the adjusted relative risk of infection in patients receiving antibiotics versus those not receiving was 0.6927 (95% CI 0.3396-1.4130; not significant). The 30-day mortality was 7/48 patients (15%), with two patients lost to follow-up before 30 days. There were no deaths directly attributable to PEG. CONCLUSIONS: PEG is still not adequately requested by doctors for patients needing enteral feeding for more than 30 days. The use of antibiotics in this retrospective cohort study failed to show any benefit in reducing the rate of infective complications.

Weils' syndrome and concomitant hepatitis B infection.

Leptospirosis is a ubiquitous, spirochetal zoonosis which presents with a broad clinical spectrum. Weil's syndrome, characterised by jaundice, renal failure and bleeding manifestations is the most severe form. A high index of suspicion for the diagnosis is required to institute therapy promptly. We describe a case of serologically confirmed Weil's syndrome with concomitant hepatitis B infection.

Gall bladder cancer: proposal for a modification of the TNM classification.

Gall bladder cancer is the commonest biliary tract malignancy. The TNM classification of AJCC-UICC is the most widely accepted and most commonly used system for staging. We propose some modifications in the existing classification and recommend guidelines for management based on the stage of the disease.

Recovery of liver functions following surgical biliary decompression in obstructive jaundice.

BACKGROUND/AIMS: Derangement of liver functions in obstructive jaundice has been known to influence surgical outcome. The pattern and time frame of liver function recovery in patients with surgical obstructive jaundice undergoing a bilioenteric anastomosis has not been comprehensively defined in human beings. METHODOLOGY: Fifty patients of obstructive jaundice who underwent a bilioenteric anastomosis had their liver function evaluated done by biochemistry (pre-operatively and postoperatively on day 1,4,7 and 6 weeks) and radionuclide mebrofenin scan (preoperatively and 6 weeks postoperative). RESULTS: The results have shown a constant and significant decline in serum bilirubin levels by day 4 (p=0.04), however the decline in serum levels was not uniformly progressive in 54% patients. The decline in serum alkaline phosphatase levels has been constant and progressive reaching significant levels by day 4(p=0.01). Serum transaminases showed an initial rise followed by a rapid fall, again achieving significant levels by day 4 (p=0.003 & 0.009). Serum albumin decreased on day 1 itself but remained static after that. On isotope scanning hepatic uptake showed uniform improvement with 92% of patients having achieved a normal uptake after 6 weeks. Gastrointestinal excretion of the isotope however was still delayed in 26% patients at 6 weeks. Almost all these patients had an abnormal bilirubin level decline in the immediate postoperative period. CONCLUSIONS: Hepatic functional recovery has been seen to start immediately following bilioenteric anastomosis and has usually completed itself by 6 weeks. Patients who show an abnormal recovery pattern based on bilirubin levels need to be observed for a longer time.

Malignant gastroparesis and outlet obstruction in carcinoma gall bladder.

INTRODUCTION: Malignant gastroparesis and mechanical gastric outlet obstruction are two major accompaniments of advanced upper abdominal malignancies. The incidence of such problems has not been well documented in patients of carcinoma gall bladder. The aim of this study was to determine the incidence of gastric outlet problems in patients of carcinoma gall bladder and correlate them with clinical presentation. The role of prophylactic gastrojejunostomy (GJ) and its postoperative outcome was also evaluated. PATIENTS AND METHODS: Thirty seven patients of carcinoma gall bladder were prospectively studied. Twenty five patients underwent radio labelled solid meal gastric emptying study and eleven of these underwent prophylactic GJ and followup gastric emptying study in early postoperative period. RESULTS: Mechanical gastric outlet obstruction was seen in 10 (27%) patients. Delayed gastric emptying on scintigraphic study was found in 10 (40%) of remaining patients (n = 25). Only 6 (60%) of these patients were actually symptomatic. All patients who had delayed gastric emptying also had an advanced disease. No correlation was found between delayed gastric emptying and presence of jaundice and/or serum levels of bilirubin. Prophylactic GJ had 18% postoperative morbidity as compared to 28.5% for therapeutic GJ done during the same period. Oral feed were started latest by 11th postoperative day. Prophylactic GJ did not affect gastric emptying patterns in early postoperative period. CONCLUSION: Mechanical gastric outlet obstruction was present in 27% patients. Delayed gastric emptying was seen in 40% of remaining patients with carcinoma gall bladder. Delayed gastric emptying correlated well with symptoms of gastric stasis and the stage of disease. Functioning of gastrojejunostomy was not fully dependent on presence or absence of malignant gastroparesis.