Clinical importance of duodenal recesses with special reference to internal hernias.

INTRODUCTION: The detailed knowledge of the peritoneal recesses has great significance with respect to internal hernias. The recesses are usually related to rotation and adhesion of abdominal viscera to the posterior abdominal wall and/or the presence of retroperitoneal vessels which raises the serosal fold. The duodenal recesses are usually related to the 3rd and 4th parts of the duodenum. Internal hernias with respect to these recesses are difficult to diagnose clinically and usually noticed at the time of laparotomy. So, the knowledge of these recesses can be valuable to abdominal surgeons. MATERIAL AND METHODS: The present study was conducted in 100 cases including 10 cadavers, 45 post mortem cases and 45 cases undergoing laparotomy. RESULTS: We found superior and inferior duodenal recesses in 28% and 52% respectively, paraduodenal in 12%, mesentericoparietal in 3%, retroduodenal in 2% and duodenojejunal in 18% of cases. Two abnormal duodenojejunal recesses were found, one on the right (instead of the left) of the abdominal aorta, and in the other the opening was directed upwards instead of downwards. The incidence of internal hernias was 3%. CONCLUSIONS: Thus it was observed that there is low incidence of superior and inferior duodenal recesses, and high incidence of paraduodenal recess. The abnormal recesses might be due to malrotation of the gut. In laparotomy cases, the internal hernia was noticed when the abdomen was opened for intestinal obstruction. The incidence of internal hernia was found to be high.

Primary carcinoma of the cystic duct: a case report and review of classifications.

BACKGROUND: The incidence of extrahepatic bile duct malignancies is about 2-3.6% of all gastrointestinal malignancies. Primary carcinoma of cystic duct is a rare condition comprising a fraction of all extrahepatic bile duct malignancies with less than 70 cases reported worldwide. Majority of these cases were reported from East Asia. There is paucity in such case being reported from Indian subcontinent. We present a case of primary carcinoma of the cystic duct encountered during laparoscopic cholecystectomy. CASE PRESENTATION: A 65-year-old lady presented to us with symptomatic gall stone disease. Investigations revealed a distended gall bladder with multiple stones. Patient was taken up for laparoscopic cholecystectomy, during surgery a stony hard structure was found at cystic duct-common bile duct junction which was not amenable for clear dissection. Procedure was converted to open, and the patient underwent cholecystectomy with resection of common bile duct with Roux-en-Y hepaticojejunostomy and regional lymphadenectomy. Histopathological findings revealed it to be moderately differentiated adenocarcinoma of the cystic duct. CONCLUSION: Primary carcinoma of cystic duct is a rare condition where early diagnosis can be difficult and if accidentally detected may add to surgeon's dilemma. Proper surgery with en-bloc resection of gallbladder, cystic duct, common bile duct, and regional lymphadenectomy is the mainstay of treatment. The prognosis of carcinoma of cystic duct is better than extrahepatic bile duct malignancies. The old classification system has outlived its time and is more rigid in definition which is not practical in advanced cases; the new classification systems of this century offer better insight into understanding the tumor characteristics and prognosis.

Expression of p63 and Bcl-2 in Malignant Thyroid Tumors and their Correlation with other Diagnostic Immunocytochemical Markers.

INTRODUCTION: Bcl-2 is a marker recently studied in thyroid tumours and proposed to have prognostic significance. p63 is expressed in a proportion of papillary thyroid carcinoma cases and may have a role in tumour progression. AIM: To study expression of Bcl2 and p63 in thyroid tumours and correlation of Bcl-2 with diagnostic markers including Thyroglobulin, Calcitonin and Carcinoembryonic antigen. MATERIALS AND METHODS: Cytology smears of 35 cases of thyroid cancer were studied over a period of 18 months. In 20 cases histopathology was available. Immunocytochemistry for Bcl-2 and p63 was done, and diagnostic markers were applied as and when required. RESULTS: p63 showed focal nuclear expression in 46.1% of papillary thyroid carcinoma cases, and was negative in all other tumours. Bcl-2 was positive in 88.9% of follicular carcinomas, 100% of papillary carcinomas and 83.3% of medullary carcinoma cases, and showed focal weak expression in 40% of Anaplastic Carcinoma (ATC) cases, thereby signifying down regulation (p-value = 0.001). There was significant down regulation of Thyroglobulin (Tg) in ATC vs well differentiated follicular derived tumours (p-value ≤ 0.016). Positive correlation was noted between expression of Bcl-2 and Calcitonin (0.93) and Bcl-2 and Carcinoembryonic Antigen (CEA) (0.89), and weak positive correlation (0.65) between Tg and Bcl-2. CONCLUSION: Bcl-2 is downregulated in anaplastic carcinomas as compared to well differentiated thyroid tumours, and shows correlation with differentiation associated tumour antigens. Thus, loss of Bcl-2 was associated with loss of differentiation in thyroid tumours. Anaplastic carcinoma as such is associated with worse prognosis and loss of Bcl-2 may be partly responsible for the same. p63 is specific but less sensitive marker for PTC. Further studies are required to determine the role of Bcl-2 and p63 in thyroid tumours.

Role of dynamic MRI in differentiating benign from malignant follicular thyroid nodule.

OBJECTIVES: Thyroid nodular swellings are very common, consisting of both benign and malignant ones. Fine needle aspiration cytology is an excellent diagnostic modality for papillary cancers, medullary cancers, colloid goiter and lymphoma but fails in differentiating follicular adenomas from carcinomas. The purpose of this study was to evaluate role of Dynamic MRI with signal intensity time curve evaluation in differentiating benign from malignant follicular nodules. MATERIALS AND METHODS: This study was carried out in Department of Surgery in collaboration with department of Radiodiagnosis, Maulana Azad Medical College, Delhi. 28 patients with solitary thyroid nodule (STN) having follicular etiologies were included in the study. Dynamic MRI with signal intensity time curve analysis was carried out in all the cases and findings were compared with the final diagnosis based on histopathological examination of surgical specimen. RESULTS: In the present study, rapid enhancement was seen in 87.5% of malignant cases and washout pattern was seen in 87.5% of malignant STN (p=0.019). Only 20% of the benign lesions showed washout pattern (p=0.0034). Benign cases demonstrated gradual enhancement in 85% cases as compared to 12.5% in malignant STN (p=0.0098). CONCLUSION: This study suggests that signal intensity time curve may help in differentiating benign from malignant follicular thyroid nodules.

Evaluation of the role of magnetic resonance spectroscopy in the diagnosis of follicular malignancies of thyroid.

OBJECTIVES: To evaluate role of magnetic resonance spectroscopy in differentiating benign from malignant follicular nodules. DESIGN: Prospective study. SETTING: Department of Surgery in collaboration with Department of Radio Diagnosis, Maulana Azad Medical College, Delhi, India. PATIENTS: Twenty-five patients with a solitary thyroid nodule with follicular etiology. INTERVENTIONS: Magnetic resonance spectroscopy was carried out in all the cases, and its findings were compared with the final diagnosis based on histopathological examination of sample obtained at surgery. MAIN OUTCOME MEASURES: Choline peak detected on MRS. RESULTS: There were 17 benign cases, 16 follicular adenomas, and 1 colloid goiter. Of the 17 benign cases, only 1 showed choline peak; however, all 8 follicular carcinoma cases showed prominent choline peak. Hence, the sensitivity is 100% while the specificity is 94.11%. CONCLUSION: Magnetic resonance spectroscopy may prove to be a sensitive diagnostic tool in differentiating follicular adenomas from carcinomas.

Magnetic resonance spectroscopy as a diagnostic modality for carcinoma thyroid.

AIM: The aim of this study was to observe the findings of magnetic resonance spectroscopy of solitary thyroid nodules and its correlation with histopathology. MATERIALS AND METHODS: In this study, magnetic resonance spectroscopy was carried out on 26 patients having solitary thyroid nodules. Magnetic resonance spectroscopy (MRS) was performed on a 1.5T super conductive system with gradient strength of 33mTs. Fine needle aspiration cytology was done after MRS. All 26 patients underwent surgery either because of cytopathologically proven malignancy or because of cosmetic reasons. Findings of magnetic resonance spectroscopy were compared with histopathology of thyroid specimens. RESULTS AND CONCLUSION: It was seen that presence or absence of choline peak correlates very well with presence or absence of malignant foci with in the nodule (sensitivity=100%; specificity=88.88%). These results indicate that magnetic resonance spectroscopy may prove to be an useful diagnostic modality for carcinoma thyroid.

Iliac artery pseudoaneurysm as a complication of laparoscopic rectopexy.

The occurrence of arterial pseudoaneurysms after laparoscopic cholecystectomy in the right hepatic artery, common hepatic artery, and cystic artery has been well documented. We describe a case of pseudoaneurysm of the common iliac artery presenting after laparoscopic stapled mesh rectopexy. As the benefits of minimal access surgery are extended to more and more procedures, surgeons should recognize the possibility of such a complication.