External duodenal fistula following closure of duodenal perforation.

AIM: Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD: Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS: Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS: EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.

Posterior segment duct injury in laparoscopic cholecystectomy.

We report a 34-year-old woman with posterior segment duct injury during laparoscopic cholecystectomy. The diagnosis was made by intra- and postoperative cholangiogram. The injured duct was repaired over a T-tube. The patient recovered uneventfully.

Utility of intrapleural streptokinase in management of chronic empyemas.

BACKGROUND: The nonsurgical medical approach with use of fibrinolytic agent is an alternative modality in management of chronic empyemas. With the introduction of purer forms of streptokinase, there has been renewed interest generated in the use of intrapleural thrombolytics with documented successful drainage of difficult to drain chronic empyemas. To evaluate the utility of streptokinase in the management of chronic difficult to drain empyemas in a single blind randomized case control study. MATERIAL AND METHODS: Twenty four cases of chronic/multiloculated empyema were included which had cases preferred having loculations or multiloculations and failure of drainage via thoracostomies for less than 100 ml during last 24 hours. Cases were randomized into two groups as 12 cases of streptokinases group and 12 cases of placebo group. Streptokinase given as 2.5 lac units in 100 ml of normal saline instilled intrapleurally for 6 consecutive days. In control group, 100 ml of normal saline without streptokinase was instilled intrapleurally through intercostal drain for 6 days. They were assessed by amount of drainage through intercostal drain for six days after instillation of streptokinase/placebo, duration of intercostal drainage in situ, and radiological improvement by standard x-ray chest. RESULTS: The study revealed increased drainage through intercostal drain in streptokinase group compared to control group. The mean duration of intercostal drainage in situ was shorter in streptokinase group compared to control group. Radiologically, streptokinase group revealed score 3 improvement in eight out of twelve cases and score 2 improvement in rest of the four cases. In control group, score 1 improvement was seen in two out of twelve cases and no improvement was seen in rest of the 10 cases. The observation difference is found to be highly significant statistically (p <0.001). No major adverse effects were noted in the streptokinase group. CONCLUSION: The study concludes the safety, efficacy, reduced hospital stay and decreased morbidity in patients treated with intrapleural streptokinase as compared to control group.

Biliary mishaps in laparoscopic cholecystectomy.

AIM: To determine the incidence and types of biliary complications following laparoscopic cholecystectomy in our patients. METHODS: The clinical records of one hundred and fifty-five patients undergoing laparoscopic cholecystectomy were reviewed. RESULTS: Five patients developed biliary mishaps. The overall incidence of biliary complications was 3.2% (5/155). The incidence of major complications was 1.9% (3/155) and the incidence of minor biliary complications was 1.2% (2/155). In 3 out of 5 patients the mishap was attributed to developmental anomalies. Dense pericholecystic adhesions and cystic duct blow out were responsible for biliary complications in one patient each. Bilioenteric anastomosis was performed in two patients and restoration of continuity of the common hepatic duct over a T-tube was done in one patient. Side hole in an accessory duct was repaired over a T-tube and cystic duct blow out was managed with endoscopic biliary drainage alone. CONCLUSIONS: A high index of suspicion of developmental anomalies, cautions approach in difficult cases and readiness to consider conversion to open cholecystectomy are recommended to reduce the incidence of biliary complications in laparoscopic cholecystectomy.

Clinical significance of carcinoembryonic antigen in colorectal malignancy.

Carcinoembryonic antigen (CEA) assay was performed in 40 patients of histologically proven colorectal carcinoma. The overall incidence of positivity was 72.5%. The incidence increased from 40% in Duke's A stage to 84.6% in Duke's C stage. Similarly the mean CEa levels also increased as the disease advanced i.e. 4.96 ng/ml, 8.07 ng/ml and 12.7 ng/ml in Duke's A, B and C respectively. Cancer with poor prognosis i.e. poorly differentiated and colloid carcinoma, had significantly less rise in CEA values (P < 0.05) as compared to well differentiated carcinoma. There was no relation of CEA values with the gross appearance of the tumour and lymph node involvement. CEA level came down in all the patients after surgery. Based on the postoperative CEA estimation, complete tumour clearance had been achieved in 86.2% of patients.

Multiple dermoid cysts of omentum.

Dermoid cyst of the omentum is an extremely rare condition. We report a case of multiple dermoid cysts of omentum in a 50 years old woman. The aetiopathogenesis, clinical presentation and relevant literature is briefly reviewed.

Churg Strauss syndrome-clinicopathological aspects--report of a case.

An elderly person presented with exertional dyspnoea, cough, rhinorrhea and multiple swelling in submandibular region. This case was found to have marked eosinophilia with upper, as well lower respiratory tract involvements. Erroneous treatment patient received in past for pulmonary tuberculosis without any beneficial result. Open lung biopsy was undertaken, revealed evidence of vascultitis and perivascular inflammatory changes. The case findings and histopathological discussions are reviewed briefly.

Nipple involvement in peripheral breast carcinoma: a prospective study.

Twenty six females patients of carcinoma of the breast were studied prospectively to find out the incidence of microscopic involvement of the Nipple Areolar Complex (NAC). The tumours were situated at minimum of 2.5 cms away from areola and the nipple was grossly normal. Majority of the patients (69.3%) had T.N.M. stage II disease. Tumours were situated within 4 cms of areola in 88.5% of the cases. Axillary lymph node metastasis was present in 38.4% of the cases. Irrespective of the size & stage of the tumour and tumour areola distance, the incidence of the microscopic involvement of NAC was 0%.

Pancreatoduodenectomy in abdominal trauma: a viable alternative.

Pancreatoduodenectomy was performed in five patients with severe pancreatoduodenal trauma following vehicular accidents. Three of them presented within five hours of injury and two patients, four and ten days later. Surgery was performed within 6-12 hours of hospitalization. All patients underwent pancreatoduodenectomy; in one the pancreatic stump was closed completely owing to its friability. Three patients survived; two succumbed to ongoing preoperative septicemia due to late presentation. The results of pancreato-duodenectomy are good when patients are operated on early, before the development of sepsis.

Ectopic pregnancy presenting as lower gastro-intestinal hemorrhage.

A patient with ruptured tubal pregnancy presenting with lower gastrointestinal bleed is described. Colonoscopy and other investigations were not helpful; laparotomy was diagnosis as well as therapeutic.

Hepatopancreatoduodenectomy in advanced carcinoma gall bladder.

A patient with advanced carcinoma of the gall bladder was treated by hepatopancreatoduodenectomy. She had no postoperative complication, and is anicteric six months after surgery despite local recurrence.

Disseminated mucormycosis in healthy adults.

Three patients of disseminated mucormycosis are described. None had predisposing factors. Two of them presented with nonspecific symptoms along with acute renal failure and peritonitis. Third patient had fulminating primary cutaneous mucormycosis which disseminated later. Development of acute renal failure with smooth enlargement of both kidneys in an apparently healthy individual or appearance of mould in a wound should raise the suspicion of mucormycosis. The hallmark of the infection was vascular invasion and thrombosis. Antemortem diagnosis could be made in one patient only. All patients had progressive downhill course despite supportive treatment, antibiotic and amphotericin in-B in one patient.