Unusual postoperative complication of minimally invasive transhiatal esophagectomy and esophageal substitution for absolute dysphagia in a child with corrosive esophageal stricture.

Esophageal substitution in children is a rare and challenging surgery. The minimally invasive approach for esophageal substitution is novel and reported from a few centers worldwide. While detailed report on the various complications of this approach has been discussed in adult literature, the pediatric experience is rather limited. We report the laparoscopic management of a rare complication which developed after laparoscopic esophagectomy and esophageal substitution. The timely recognition and management by the minimally invasive approach have been highlighted.

ERRß signalling through FST and BCAS2 inhibits cellular proliferation in breast cancer cells.

BACKGROUND: The overexpression of oestrogen-related receptor-ß (ERRß) in breast cancer patients is correlated with improved prognosis and longer relapse-free survival, and the level of ERRß mRNA is inversely correlated with the S-phase fraction of cells from breast cancer patients. METHODS: Chromatin immunoprecipitation (ChIP) cloning of ERRß transcriptional targets and gel supershift assays identified breast cancer amplified sequence 2 (BCAS2) and Follistatin (FST) as two important downstream genes that help to regulate tumourigenesis. Confocal microscopy, co-immunoprecipitation (CoIP), western blotting and quantitative real-time PCR confirmed the involvement of ERRß in oestrogen signalling. RESULTS: Overexpressed ERRß induced FST-mediated apoptosis in breast cancer cells, and E-cadherin expression was also enhanced through upregulation of FST. However, this anti-proliferative signalling function was challenged by ERRß-mediated BCAS2 upregulation, which inhibited FST transcription through the downregulation of ß-catenin/TCF4 recruitment to the FST promoter. Interestingly, ERRß-mediated upregulation of BCAS2 downregulated the major G1-S transition marker cyclin D1, despite the predictable oncogenic properties of BCAS2. INTERPRETATION: Our study provides the first evidence that ERRß, which is a coregulator of ERα also acts as a potential tumour-suppressor molecule in breast cancer. Our current report also provides novel insights into the entire cascade of ERRß signalling events, which may lead to BCAS2-mediated blockage of the G1/S transition and inhibition of the epithelial to mesenchymal transition through FST-mediated regulation of E-cadherin. Importantly, matrix metalloprotease 7, which is a classical mediator of metastasis and E-cadherin cleavage, was also restricted as a result of ERRß-mediated FST overexpression.

Effect of endoscopic variceal sclerotherapy on esophageal motor functions and gastroesophageal reflux.

UNLABELLED: Sclerotherapy results in significant local complications, both immediate and delayed. This study was designed to examine the esophageal pathophysiology underlying these complications. METHODS: We prospectively evaluated esophageal transit, motility abnormalities and gastroesophageal reflux (GER) with barium studies and esophageal functional scintigraphy in 24 patients (20 men, 4 women; mean age 33 +/- 12.4 yr) before sclerotherapy (Phase I), after two sessions (Phase II), following variceal eradication (Phase III) and 4 wk later (Phase IV). RESULTS: Varices were obliterated after 5.6 +/- 1.9 sessions of intravariceal sclerotherapy performed weekly with 1% polidocanol (17.3 ml per session). There was no baseline Phase I dysmotility or reflux. Phase II studies recorded a marked delay of esophageal global and segmental (mid and distal) transit time in 98.2% of patients by scintigraphy and 90% by barium studies. Incoordinate contractions and aperistalsis were observed in 0, 66.7%, 58.3% and 33.8% of patients from Phases I-IV studies, respectively. Barium studies revealed tertiary waves and reverse peristalsis in 0, 50%, and 75% of patients from Phases I-III; strictures were observed in 0, 1, and 3 patients during Phases I-III. GER was detected scintigraphically in 0, 58.3%, 25% and 16.6% during Phases I-IV sequentially. In contrast, barium studies grossly underestimated GER (0, 5% and 15% at phases I-III). CONCLUSION: There was strong concordance between esophageal symptoms, transit, motility abnormalities and GER (p < 0.05). Variceal eradication (Phases III and IV) was associated with a gradual recovery of esophageal symptoms, ulcers and all abnormal scintigraphic parameters. Sclerosant-induced chemical esophagitis in association with peptic esophagitis due to gross reflux following sclerotherapy possibly can explain the symptoms in most patients.

Endoscopy and biliary parasites.

Biliary parasites demand increased awareness among physicians all over the world in view of international travel and migration. Epidemiology, clinical manifestations, diagnosis, and treatment options for a variety of parasites are discussed in this article. Duodenofiberscopes play an important role in the diagnosis and treatment of these parasites.

Laparoscopic & histological features of hepatocellular carcinoma.

Laparoscopic findings in 17 patients of proven hepatocellular carcinoma are reported. The laparoscopic appearance was of two types viz., solitary mass (in 12) and a multinodular lesion (in 5). Five patients with a solitary lesion involving the right lobe of the liver had associated satellite lesions. There was no evidence of cirrhosis in 8 (47%) patients. Ascites, peritoneal metastasis and splenomegaly were observed in 24, 12 and 17 per cent patients respectively. The commonest histological pattern seen was trabecular (65%) followed by anaplastic (17%), acinar (12%) and fibrolamellar (6%).

Lipids changes in alcoholic & non-alcoholic cirrhotics.

Fasting plasma samples from 29 patients of cirrhosis were analysed for cholesterol and triglycerides and their lipo-protein fractions. The patients included 11 alcoholic cirrhotics consuming over 130 g/day of absolute ethanol and 18 non-alcoholic cirrhotics. The difference in lipid values between the two patient groups was not significant except that VLDL cholesterol was raised in alcoholic cirrhotics (P less than 0.05). However, in comparison to normal healthy controls, the values were significantly altered. The dietary intake, in the two groups showed no difference, except that non-alcoholic cirrhotics consumed more animal proteins. Low intake of exogenous fat and reduced synthesis of endogenous cholesterol in cirrhotic patients seemed to influence the total lipid values.

Cytologic examination as an adjunct to laparoscopy and guided biopsy in the diagnosis of hepatic and gallbladder neoplasia.

Laparoscopic examination guided biopsy and cytologic examination of samples obtained by aspiration, brush or scrape from the liver or gallbladder were performed on 26 patients suspected of having hepatic or gallbladder neoplasia. Laparoscopic findings were diagnostic of hepatic neoplasia (primary or secondary) in 13 cases and gallbladder carcinoma in 9 cases. The yields of positive diagnoses on biopsy alone, cytology alone and combined biopsy and cytology were 11 (84.6%), 11 (84.6%) and 12 (92.3%), respectively, in cases of hepatic neoplasia and 4 (44.4%), 5 (55.5%) and 5 (55.5%), respectively, in cases of gallbladder carcinoma. The cytologic typing concurred with the histologic typing in six of ten cases (60%) of hepatic neoplasia and all four cases (100%) of gallbladder carcinoma. It is suggested that cytologic examination be used as an adjunct to histologic examination of guided biopsies in the diagnosis of hepatic neoplasia. It is also concluded that it is possible to make a tissue diagnosis in patients with gallbladder carcinoma by obtaining material for cytology and biopsy through laparoscopy.

Endoscopic sclerotherapy versus propranolol in prevention of recurrent variceal bleeding in patients with child's B and C cirrhosis: a preliminary report.

Thirty two patients with cirrhosis of the liver of Child's B and C class and an episode of endoscopically proven variceal bleed were randomly assigned to receive endoscopic sclerotherapy (EST) or oral propranolol for the prevention of recurrent upper gastrointestinal bleeding. EST was performed at 3 week intervals using 1% polidocanol intravariceally, till eradication of varices. Propranolol dose was adjusted to reduce the resting heart rate by 25% of the basal value (mean +/- SD, 194.3 +/- 63.9 mg/day) Two patients in the propranolol group were excluded within 48 hours due to side effects of the drug. Thirty patients (EST-16, propranolol-14) completed the trial. Patients were followed up for a maximum of 480 days. Mean follow-up in the EST and propranolol groups was 217 and 243 days respectively. The median bleeding free intervals were 480 and 194 days and number of rebleeding episodes was eight and 16 respectively in the EST and propranolol groups (both p = ns). Our study suggests a trend in favor of EST in preventing variceal rebleeding in patients with hepatic cirrhosis who belong to Child's B and C classes.

Endoscopic polypectomies in upper gastrointestinal tract.

Nine polyps retrieved from the upper gastrointestinal tract by endoscopic polypectomy in nine patients are reported. Polyps were removed from the distal esophagus (1), stomach (7) and duodenum (1). Dysphagia, obstructive jaundice and upper gastrointestinal bleeding were the presenting features in four patients. In five patients gastric polyps were detected incidentally at endoscopy. Of the nine polyps, six were adenomas, two were hyperplastic polyps and one in the esophagus was inflammatory. All the polyps could be retrieved completely and there were no complications. Thus polyps do occur in the upper gastrointestinal tract in India; their electrosurgical removal is easy and safe and allows histopathological examination of the entire polyp.

Colonoscopy for unexplained lower gastrointestinal bleeding in a tropical country.

Two hundred and forty consecutive patients with recurrent lower gastrointestinal bleeding were studied by colonoscopic examination. These included 187 adults and 53 children. The procedure was successful either in identifying the lesion or in excluding it up to the cecum in 216 (90% patients). The source of bleeding was identified in 138 (74%) adults and 43 (81%) Children. Predominant lesions in adults were nonspecific colitis and ulcers (58%), polyps (19%), cancer (10%), rectal varices (4%) and tuberculosis (3%). Juvenile polyps (77%) and nonspecific colitis and ulcers (23%) were the cause of bleeding in children. Both in adults and children, 92% of these lesions involved the left colon. Rectum and sigmoid colon were mainly involved. Diffuse lesions were seen when nonspecific colitis and ulcers were the source of bleeding. Thus colonoscopic examination was useful in localizing the cause of rectal bleeding and the predominant lesions were different from those reported in the Western hemisphere.

Gastrointestinal leiomyomas in a developing country.

Twenty one consecutive patients with leiomyoma of the gastrointestinal tract were studied. Recurrent gastrointestinal bleeding was found in 18 (85.7%) and recurrent intestinal obstruction in 3 (14.3%) patients. The commonest site of the lesion was the stomach followed by ileum, jejunum and duodenum. Barium meal examination and gastrointestinal endoscopy were suggestive of the diagnosis in 8 and angiography in 2 patients. The remaining patients were diagnosed peroperatively. All patients underwent excision and remained asymptomatic on follow up except two patients who had a recurrence of the tumor as leiomyosarcoma.

Dieulafoy's lesion: a rare cause of massive upper gastrointestinal haemorrhage.

Out of 900 cases of Upper Gastrointestinal haemorrhage seen during 1985-1989, 6 (0.67%) cases had Dieulafoy's lesion as the causative factor. All patients presented with massive upper gastrointestinal haemorrhage. The mean age of the patients was 46.3 year (32-60 yrs) and 4 were males and 2 females. No consistent associated medical factors could be identified. The diagnosis was established by emergency endoscopy which showed an active arterial spurter in 4 patients and located the bleeding site to be close to the fundus in other 2 patients. Injection sclerotherapy tried in 3 patients was not successful. Four patients had bleeding lesion along the greater curvature close to the fundus and two had on posterior wall but all within 6 cm. of gastroesophageal junction. All patients underwent curative emergency surgery with wedge resection of the lesion. We conclude that Dieulafoy lesion should be suspected in a patient with massive, recurrent and obscure upper gastrointestinal bleeding. Emergency endoscopy for diagnosis and prompt surgical intervention can cure the lesion which is potentially fatal if untreated.

Endoscopic injection treatment of non-variceal bleeding lesions of upper gastro-intestinal tract.

Endoscopic injection of actively bleeding non variceal lesions with polidocanol was performed in 15 patients. Eleven of them had associated diseases. Haemostasis was achieved in 12 (80%). Three of them rebled. However, bleeding stopped by reinjection in two and spontaneously in one patient. No significant local or systemic complication was observed. This therapy avoided emergency surgery in 12 of 15 patients. Thus endoscopic injection treatment can be utilized for managing bleeding due to non variceal lesions.