A retrospective study of diagnosis and management of gallbladder perforation: 10-year experience from a tertiary health care centre.

Objectives: The aim of this study was to perform retrospective analysis of data collected from patients of gallbladder perforations for diagnosis, management and outcome. Material and Methods: A retrospective analysis of data was carried out for 40 patients of gallbladder perforations from the hospital record of patients who were diagnosed preoperatively and intraoperatively as a case of gallbladder perforation over a period of 10 years and were managed in our surgery unit of a tertiary health care centre. Patients were included irrespective of sex except cases of trauma and patients of the paediatric age group. Results: Among 40 patients, 26 were females and 14 were males. As per Anderson modification of Neimeier classification, 13 (32.5%) had type 1, 23 (57.5%) had type 2, and four (10%) patients had type 3 perforations and none of the patients had type 4 perforation. Twenty-three patients (57.5%) were found to have fundal perforation, followed by body in 11 patients (27.5%), three (7.5%) in Hartman's pouch while in three patients (7.5%), there were multiple perforations. All patients of type 1 Neimer classification were diagnosed clinically as cases of biliary peritonitis, whereas most cases of type 2 Neimer classification were diagnosed preoperatively by CECT abdomen 12/23 patients (52%) and ultrasound abdomen 10/23 (43.47%). All patients underwent surgery, and there were three mortalities. Conclusion: In our study, there was female predominance in patients having gallbladder perforation. Of the patients, 52.5% were diabetic and mean age was 55.9 years. CECT abdomen was the most useful modality for diagnosis of type 2 gallbladder perforations. Timely surgical intervention is mandatory for a better outcome of these cases.

Monopolar electrocautery versus ultrasonic dissection of the gallbladder from the gallbladder bed in laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Ultrasonic dissection has been suggested as an alternative to monopolar electrocautery in laparoscopic cholecystectomy because it generates less tissue damage and may have a lower incidence of gallbladder perforation. We compared the 2 methods to determine the incidence of gallbladder perforation and its intraoperative consequences. METHODS: We conducted a prospective randomized controlled trial between July 2008 and December 2009 involving adult patients with symptomatic gall stone disease who were eligible for laparoscopic cholecystectomy. Patients were randomly assigned before administration of anesthesia to electrocautery or ultrasonic dissection. Both groups were compared for incidence of gallbladder perforation during dissection, bile leak, stones spillage, lens cleaning, duration of surgery and estimation of risk of gallbladder in the presence of complicating factors. RESULTS: We included 60 adult patients in our study. The groups were comparable with respect to demographic characteristics, symptomatology, comorbidities, previous abdominal surgeries, preoperative ultrasonography findings and intraoperative complications. The overall incidence of gallbladder perforation was 28.3% (40.0% in the electrocautery v. 16.7% in the ultrasonic dissection group, p = 0.045). Bile leak occurred in 40.0% of patients in the electrocautery group and 16.7% of patients in ultrasonic group (p = 0.045). Lens cleaning time (p = 0.015) and duration of surgery (p = 0.001) were longer in the electrocautery than the ultrasonic dissection group. There was no statistical difference in stone spillage between the groups (p = 0.62). CONCLUSION: Ultrasonic dissection is safe and effective, and it improves the operative course of laparoscopic cholecystectomy by reducing the incidence of gallbladder perforation.

Current management of pancreatic trauma.

BACKGROUND: Although pancreatic trauma is uncommon, it poses a diagnostic and therapeutic challenge. Any delay in diagnosis raises morbidity and mortality. This study highlights the current management and outcome in patients of pancreatic trauma at a single tertiary care center. METHODS: This is a retrospective analysis of prospectively collected data of 24 patients diagnosed to have pancreatic trauma. Collected data was analyzed for age, gender, mechanism of injury, hemodynamic status at presentation, initial serum amylase levels, CECT abdomen findings, AAST-OIS grade of pancreatic injury, injury to other organs, management, complications and outcome. RESULTS: The mean age of these 24 patients was 25 years; 19 were male and 5 females. The mechanisms of pancreatic trauma included blunt abdominal trauma in 21 (87.5%) cases and penetrating injury in 3 (12.5%). Seven (29.16%) patients were managed by non-operative management and 17 (70.83%) underwent surgery. Complications were more frequent in the operative group as compared to the non-operative group. Neither endocrine deficiency nor any mortality was noted in the non-operative management group; while there were 2 cases of endocrine deficiency and 3 mortalities in the operative group. CONCLUSIONS: Pancreatic trauma is more common in young male patients and more commonly inflicted by motor vehicles accidents. Low grade blunt pancreatic injury in hemodynamically stable patients and selected patients with high grade blunt pancreatic injury can be managed successfully by non-operative management with no increase in morbidity or mortality and most patients with high grade blunt pancreatic injury and those having penetrating injuries need surgical intervention.

Newcastle Disease Virus Induced Pathologies Severely Affect the Exocrine and Endocrine Functions of the Pancreas in Chickens.

Newcastle disease virus (NDV) causes a highly contagious and devastating disease in poultry. ND causes heavy economic losses to the global poultry industry by decreasing the growth rate, decrease in egg production high morbidity and mortality. Although significant advances have been made in the vaccine development, outbreaks are reported in vaccinated birds. In this study, we report the damage caused by NDV infection in the pancreatic tissues of vaccinated and specific-pathogen-free chickens. The histopathological examination of the pancreas showed severe damage in the form of partial depletion of zymogen granules, acinar cell vacuolization, necrosis, apoptosis, congestion in the large and small vessels, sloughing of epithelial cells of the pancreatic duct, and mild perivascular edema. Increased plasma levels of corticosterone and somatostatin were observed in NDV-infected chicken at three- and five- days post infection (DPI). A slight decrease in the plasma concentrations of insulin was noticed at 5 DPI. Significant changes were not observed in the plasma levels of glucagon. Furthermore, NDV infection decreased the activity and mRNA expression of amylase, lipase, and trypsin from the pancreas. Taken together, our findings highlight that NDV induces extensive tissue damage in the pancreas, decreases the activity and expression of pancreatic enzymes, and increases plasma corticosterone and somatostatin. These findings provide new insights that a defective pancreas may be one of the reasons for decreased growth performance after NDV infection in chickens.

Role of Mushroom as Dietary Supplement on Performance of Poultry.

The objective of this review is to summarize the effect of commonly used mushrooms (particularly Pleurotus ostreatus or oyster mushroom, Agaricus bisporus or Button mushroom, Lentimula edodes or shiitake mushroom, and Ganoderma lucidum or reishi mushroom) in poultry diets on performance of broilers and layers. It can be concluded from different studies that mushrooms and their polysaccharides can play important roles in poultry production: (1) Polysaccharides in mushrooms may act as immune enhancers or immunomodulators and show antibacterial, antiviral, antiparasitic bioactivities; (2) phenolic compounds of mushrooms may act as antioxidants; (3) mushrooms in broiler's diet may be used as growth promoters as an alternative to antibiotics; (4) mushrooms in the diet may improve egg production and quality; (5) mushrooms may be used as a safe and effective alternative for inducing molt, enhancing immunity, reducing Salmonella growth, and returning to egg production. Further studies are needed to investigate the effects of mushrooms to improve productive performance in chickens and to illuminate the possible modes of action related to the gut ecosystem and the immune response.

Conceptual Design of Composite Sandwich Structure Submarine Radome.

Radomes are usually constructed from sandwich structures made of materials which usually have a low dielectric constant so that they do not interfere with electromagnetic waves. Performance of the antenna is increased by the appropriate assortment of materials enabling it to survive under marine applications, and it depends on composite strength-to-weight ratio, stiffness, and resistance to corrosion. The design of a sandwich core submarine radome greatly depends on the material system, number of layers, orientation angles, and thickness of the core material. In this paper, a conceptual design study for a sandwich core submarine radome is carried out with the help of finite element analysis (FEA) using two unidirectional composite materials-glass fiber reinforced polymer (GFRP) and carbon fiber reinforced polymer (CFRP)-as a skin material and six different core materials. Conceptual designs are obtained based on constraints on the composite materials' failure, buckling, and strength. The thickness of the core is reduced under constraints on material and buckling strength. Finite element analysis software ANSYS WORKBENCH is used to carry out all the simulations.

Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute.

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.

CA 19-9 as a serum marker in urothelial carcinoma.

INTRODUCTION: CA 19-9 is a carbohydrate antigen related to Lewis A blood group antigen. It is well-known marker for pancreatic carcinoma and is being investigated for other malignancies including carcinoma bladder. We evaluated the role of serum CA 19-9 as a tumor marker and correlated its level with tumor stage and grade. MATERIALS AND METHODS: Seventy-five patients with histologically proven urothelial carcinoma were included in this study as case and 25 healthy volunteers as control. Preoperative 5 ml blood sample was collected. Serum level of CA 19-9 was measured using solid-phase enzyme-linked immunosorbent assay kit. The value of CA19-9 was expressed in U/ml and 37 U/ml was taken as cut-off upper value of normal. RESULTS: The range of CA19-9 in patients of urothelial carcinoma was 2 to 122 U/ml with a mean of 26.33±29.28, while in control, it was 8.48±5.01 U/ml (P<0.001). The sensitivity of CA19-9 was 29%. Serum CA19-9 was significantly elevated in invasive disease in comparison with superficial disease (47.17±34.43 vs 16.53±20.13) (P<0.001). Significantly high proportion of patients with invasive disease had value ≥37 U/ml (14/24 [58.3%] vs 8/51 [15.7%]) with P value <0.001. High proportion of high-grade tumor had raised value, 14/34 (41.25%); all patients with metastatic disease had value more than 37 U/ml. CONCLUSIONS: Serum CA19-9 is a marker of aggressiveness of urothelial carcinoma and is almost invariably raised in patients with metastatic disease. Thus, it may be used as a prognostic marker but not as a screening tool due to its low sensitivity.

Traumatic Pseudoaneurysm of Superior Rectal Artery - an Unusual Cause of Massive Lower Gastrointestinal Bleed: A Case Report.

Traumatic pseudoaneurysm of superior rectal artery is an unusual cause of massive lower gastrointestinal bleed. We are reporting the first case as we could not come across any similar report in the literature. Patient underwent exploratory laparotomy, diversion sigmoid loop colostomy, perineal wound debridement and antiseptic dressing for traumatic perineal wound. Patient had repeated episode of massive lower gastrointestinal bleeding and was diagnosed as a case of bleeding from superior rectal artery pseudoaneurysm which was managed by selective superior rectal artery embolization after failure of surgical treatment.

Day Care Laparoscopic Cholecystectomy: Next Standard of Care for Gall Stone Disease.

BACKGROUND: To access the feasibility, safety and success of day care laparoscopic cholecystectomy in a tertiary center in India. METHODS: This is a retrospective analysis of prospectively collected data between 2004 and 2009 from a tertiary center in north India. All patients of symptomatic gallstone diseases having age less than 70 years, American Society of Anesthesiologists (ASA) grade I and grade II, living within 20 Kilometers of the hospital, availability of a responsible adult care taker at home, access to a telephone and a means of transportation to hospital if needed, underwent laparoscopic cholecystectomy under the care of the two participating surgeons, were considered for day care laparoscopic cholecystectomy. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge. RESULTS: A total of 602 laparoscopic cholecystectomies were performed over a period of 6years, among them 309 (51.32%) were operated on day care basis. Nine patients in day care procedure group had conversion to open procedure (5 due to distorted anatomy of calot's triangle, 2 due to common bile duct stones, 1 due to bile duct injury and 1 due to bleeding from cystic artery stump). One patient had myocardial infarction and 3 had nausea and vomiting which failed to resolve by intravenous ondensteron and all these (13) patients (4.20%) needed unplanned admission to the hospital. Two hundred and ninety-six patients (95.79%) were discharged on same day. CONCLUSIONS: In conclusion day care laparoscopic cholecystectomy is feasible, safe and equally effective in selected patients in Indian setup.

Sclerosing encapsulating peritonitis: complication of laparoscopic cholecystectomy.

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction. It is difficult to make a definite preoperative diagnosis, and most cases are diagnosed at the time of laparotomy. It is usually of unknown origin, although, at times, it may be seen secondary to a variety of conditions. Spillage of bile and gallstones at laparoscopic cholecystectomy is an unusual cause of SEP and has not been reported in literature, to date. Contrast-enhanced computed tomography of the abdomen revealed small-bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle with loculated fluid in the interloop bowel location. Excision of the sac and adhesiolysis was done in our patient for recurrent episodes of intestinal obstruction, who recovered well in the postoperative period.

Primary Small Cell Carcinoma of Liver: A Rare Tumor.

Primary small cell carcinoma of the liver is very rare tumor. Till date only 12 cases have been reported in the English literature. We are reporting a case of primary small cell carcinoma of the liver in a female patient. She had 13 cm x 7 cm tumor in the right lobe of liver and fine needle aspiration cytology revealed features of small cell carcinoma. After ruling primary from elsewhere, patient underwent central bisectionectomy of the liver and histopathology confirmed the diagnosis of primary small cell carcinoma of the liver. On immunohistochemistry examination, the tumor was positive for Neuron-specific enolase and synaptophysin but negative for Thyroid transcription factor 1 and Hep-Par 1. Here we discuss the clinical course and treatment of primary small cell carcinoma of the liver in our case and review the literature.

Management of Esophageal Perforation in Adults.

Perforation of esophagus in the adult is a very morbid condition with high morbidity and mortality. The ideal treatment is controversial. The main causes for esophageal perforation in adults are iatrogenic, traumatic, spontaneous and foreign bodies. The morbidity and mortality rate is directly related to the delay in diagnosis and initiation of optimum treatment. The reported mortality from treated esophageal perforation is 10% to 25%, when therapy is initiated within 24 hours of perforation, but it could rise up to 40% to 60% when the treatment is delayed beyond 48 hours. Primary closure of the perforation site and wide drainage of the mediastinum is recommended if perforation is detected in less than 24 hours. Treatment option for delayed or missed rupture of esophagus is not very clear and is controversial. Recently a substantial number of patients with esophageal perforation are being managed by nonoperative measures. Patients with small perforations and minimal extraesophageal involvement may be better managed by nonoperative treatment Major prognostic factors determining mortality are the etiology and site of the injury, the presence of underlying esophageal pathology, the delay in diagnosis and the method of treatment. For optimum outcome for management of esophageal perforations in adults a multidisciplinary approach is needed.

Assessment of indoor radon doses received by the students in the Azad Kashmir schools, Pakistan.

Several epidemiological studies conducted on thousands of underground miners suggest that long- term exposure to high radon concentration can increase the risk of lung cancer. Keeping in view the importance of the subject, numerous studies throughout the world have been carried out to measure indoor radon concentration and its resulting doses at occupational and non-occupational sites. The purpose of the current study was to measure indoor radon concentration and its resulting doses received by the students of Azad Kashmir government schools. For this purpose, CR-39 radon detectors were installed in 80 carefully selected schools. The detectors were placed at a height of 3-5 ft. (depending upon average height of students in particular class) from the ground. After exposure of 90 d detectors were etched for 9 h in 6 M NaOH at 70°C and the observed track densities were related to radon concentrations. The measured indoor radon concentration ranged from 22 ± 9 to 228 ± 3 Bq m(-3) with a mean value of 78 ± 5 Bq m(-3). Based on the measured indoor radon data, the annual effective doses were found to vary from 0.55 ± 0.04 to 0.71 ± 0.03 mSv y(-1). The overall mean effective dose for the studied area was found to be 0.63 ± 0.04 mSv y(-1). Reported values for radon concentrations and corresponding doses are lower than ICRP recommended limits for workplaces.