Clinical profile of primary hyperparathyroidism from western India: a single center experience.

BACKGROUND: Primary hyperparathyroidism (PHPT) has a variable clinical presentation and symptomatic PHPT is still the predominant form of the disease in India. Data from western India is lacking. AIM: To present the clinical profile of PHPT from western India. SETTINGS AND DESIGN: This retrospective study was conducted at a tertiary care referral center. MATERIALS AND METHODS: We analyzed the clinical presentation, biochemical, radiological features, and operative findings in adult patients with PHPT (1986-2008) and compared with our published data of children and adolescent patients with PHPT. STATISTICAL ANALYSIS: was done with SPSS 16 software. RESULTS: Seventy-nine patients (F: M-2:1) with age ranging from 21 to 55 years (mean 33.5+/-8.82) were analyzed. Skeletal manifestations (75.5%), renal calculi (40.5%) and proximal muscle weakness (45.5%) were the most common symptoms of presentation with mean duration of symptoms being 33.70 (median: 24, range 1-120) months. Biochemical features included hypercalcemia (total corrected calcium 12.55+/-1.77 mg/dl), low inorganic phosphorus (1.81+/-0.682 mg/dl), elevated total alkaline phosphatase (mean: 762.2; median: 559; range: 50-4930IU/L) and high parathyroid hormone (PTH) (mean+/-SD: 866.61+/-799.15; median: 639.5; range: 52-3820 pg/ml). Preoperative localization was achieved in 74 patients and single adenoma was found during surgery in 72 patients. Hungry bone disease was seen in 30.3% and transient hypoparathyroidism developed in 62% patients. In comparison to PHPT in children there were no significant differences with regard to clinical, laboratory and radiological features. CONCLUSIONS: PHPT in western India is symptomatic disorder with skeletal and renal manifestations at a much younger age. Clinical profile of PHPT in children is similar to that of adults.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Laparoscopic splenectomy using conventional instruments.

INTRODUCTION: Laparoscopic splenectomy (LS) is an accepted procedure for elective splenectomy. Advancement in technology has extended the possibility of LS in massive splenomegaly [Choy et al., J Laparoendosc Adv Surg Tech A 14(4), 197-200 (2004)], trauma [Ren et al., Surg Endosc 15(3), 324 (2001); Mostafa et al., Surg Laparosc Endosc Percutan Tech 12(4), 283-286 (2002)], and cirrhosis with portal hypertension [Hashizume et al., Hepatogastroenterology 49(45), 847-852 (2002)]. In a developing country, these advanced gadgets may not be always available. We performed LS using conventional and reusable instruments in a public teaching the hospital without the use of the advanced technology. The technique of LS and the outcome in these patients is reported. MATERIALS AND METHODS: Patients undergoing LS for various hematological disorders from 1998 to 2004 were included. Electrocoagulation, clips, and intracorporeal knotting were the techniques used for tackling short-gastric vessels and splenic pedicle. Specimen was delivered through a Pfannensteil incision. RESULTS: A total of 26 patients underwent LS. Twenty-two (85%) of patients had spleen size more than 500 g (average weight being 942.55 g). Mean operative time was 214 min (45-390 min). The conversion rate was 11.5% (n = 3). Average duration of stay was 5.65 days (3-30 days). Accessory spleen was detected and successfully removed in two patients. One patient developed subphrenic abscess. There was no mortality. There was no recurrence of hematological disease. CONCLUSION: Laparoscopic splenectomy using conventional equipment and instruments is safe and effective. Advanced technology has a definite advantage but is not a deterrent to the practice of LS.

Nonfunctioning islet cell tumor presenting with ascites and portal hypertension.

Nonfunctioning islet cell tumors commonly cause no symptoms. A 22-year-old woman presented with lump in the left hypochondrium, refractory high-protein ascites and evidence of left-sided portal hypertension. At exploratory laparotomy, a 30 cm x 15 cm mass was seen at the splenic hilum, with large collateral vessels around. Distal pancreatectomy with splenectomy was done. Histology of the mass showed malignant islet cell tumor infiltrating the spleen. The patient died in the postoperative period.

Laparoscopic repair of Morgagni hernia in adult.

Foramen of Morgagni hernias require surgical treatment; laparoscopic repair is another option with lower morbidity. We describe a 35-year-old man with Morgagni hernia treated successfully by laparoscopy.

Laparoscopic cholecystectomy in patient with portal cavernoma and portal hypertension.

Successful laparoscopic cholecystectomy has been reported in patients with cirrhosis of liver with portal hypertension; the procedure has, however, not been reported in patients with portal vein thrombosis, portal cavernoma and portal hypertension. We report an 18-year-old man with portal hypertension due to portal vein thrombosis and portal cavernoma who had symptomatic gallstone disease and was successfully treated with laparoscopic cholecystectomy.

Iatrogenic gastric fistula due to inappropriate placement of intercostal drainage tube in a case of traumatic diaphragmatic hernia.

A 26-year-old, 30 weeks primigravida presented with a gastric fistula through a left intercostal drain, which was inserted for drainage of suspected haemopneumothorax following minor trauma. It was confirmed to be a diaphragmatic hernia, with stomach and omentum as its contents. On exploratory laparotomy, disconnection of the tube and fistulous tract, with reduction of herniated contents and primary suturing of stomach was carried out. Diaphragmatic reconstruction with polypropylene mesh was also carried out. Post-operative recovery was uneventful with full lung expansion by 3rd postoperative day. Patient was asymptomatic at follow-up 6 months.

Castleman's disease: Report of 4 cases of cervical Lymphadenopathy and review.

Castleman's disease is one of the rare causes of cervical lymphadenopathy. A study of 4 cases along with literature review has been done.

Laparoscopic management of hydatid cyst of liver.

We describe the laparoscopic excision of a hydatid cyst in the liver. During the procedure, done after treatment with the scolicidal agents praziquantel and albendazole, care was taken to prevent spillage of scolices during evacuation of contents and to excise the entire germinal epithelium. The patient had no immediate or short-term complications and is asymptomatic 3 months later.

Ruptured true aneurysm of the splenic artery: an unusual cause of haemoperitoneum.

True aneurysm of the splenic artery is rare. Two cases of ruptured true splenic artery aneurysms are presented. The first patient was a 62-year-old female who presented within 6 hours of the onset of symptoms. The other was a 27-year-old non-alcoholic male patient who was admitted in a state of shock after 2 days of observation in a peripheral hospital. Both patients had haemoperitoneum and were subjected to exploratory laparotomy. Aneurysmectomy was performed in both the patients in addition to left splenopancreatectomy in the first case and splenectomy in the second. However, due to the prolonged preoperative shock, the second patient succumbed on the third postoperative day.

Incomplete pancreas divisum with anomalous choledochopancreatic duct junction with choledochal cyst.

The coexistence of incomplete pancreas divisum, an anomalous choledochopancreatic duct junction, and a choledochal cyst is an extremely rare condition, described in only 3 patients in the available medical literature. The symptoms may be similar to any of these 3 distinct pathological conditions. Magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography is usually required for diagnosis. Management of symptomatic pancreas divisum may be accomplished with open accessory duct sphincteroplasty or endoscopic papillotomy with or without stenting. Treatment of choledochal cyst is by complete excision of the cyst whenever possible, with hepaticodochoenterostomy being the treatment of choice. Here, we describe a patient with this complex disorder who was successfully managed with endoscopic minor duct papillotomy with accessory pancreatic duct stenting and resection of the choledochal cyst with hepaticodochojejunostomy.

Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding.

BACKGROUND: Operation is required for patients with portal hypertension who have failed to respond to emergency sclerotherapy for control of acute variceal bleeding. This study evaluates the role of transabdominal extensive oesophagogastric devascularization combined with gastro-oesophageal stapling for control of acute variceal bleeding in patients with portal hypertension of different aetiologies. METHODS: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling was performed in 65 patients (28 with cirrhosis, 17 with non-cirrhotic portal fibrosis and 20 with extrahepatic portal venous obstruction) in whom emergency endoscopic sclerotherapy, and/or pharmacotherapy and balloon tamponade had failed. The Sugiura procedure was modified to minimize operating time and to reduce the operative difficulties due to oesophageal wall necrosis after sclerotherapy. RESULTS: The operative mortality rate was higher in patients with cirrhosis (P = 0.0003); sepsis was the leading cause of death (in nine of 18). A high mortality rate (12 of 15) was seen in patients with Child grade C cirrhosis. Control of bleeding was achieved in all patients. The procedure-related complication rate was 17 per cent with a 6 per cent oesophageal leak rate; four of 47 surviving patients developed oesophageal stricture. During a mean follow-up of 33 months, residual varices, recurrent varices and rebleeding were seen in three, two and three of 47 survivors. CONCLUSION: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling is an effective and safe procedure for control of acute variceal haemorrhage with satisfactory long-term control, especially in patients without cirrhosis and low-risk patients with cirrhosis.

Laparoscopic versus mini-lap cholecystectomy for gallstone disease.

AIM: To compare the outcome of laparoscopic cholecystectomy (LC) and mini-lap cholecystectomy (MC) in patients with symptomatic gallstone disease. METHOD: One hundred patients undergoing LC (50) or MC (50) were evaluated for duration of surgery, morbidity, need for analgesia, duration of hospitalization and interval to return to normal work. RESULTS: The mean operative time was significantly longer in the LC group (94 +/- 17 vs 129 +/- 33 min; p < 0.05). The rate of morbidity and conversion to open surgery were similar in the two groups. Patients in the MC group required more oral analgesia (p = ns). The mean post-operative hospital stay in this group was 3.3 +/- 1.5 days as compared to 3.3 +/- 2.7 days in the LC group (p = ns). Patients in the LC group took the same time to return to normal work (19.1 +/- 3.2 days) as those in the MC group 19.5 +/- 5.4 days (p = ns). CONCLUSION: MC and LC are comparable procedures for treatment of gallstone disease in our country.

Massive upper gastrointestinal haemorrhage due to direct visceral erosion of splenic artery aneurysm.

Six male patients (age group: 30-60 years) with aneurysm of the splenic artery presented with massive upper gastrointestinal tract hemorrhage. Five patients presented with hematemesis and one with melena. Chronic pancreatitis was noted in all the patients, four of whom were chronic alcoholics. Endoscopy was not useful in diagnosis. Bleeding through the Ampulla of Vater was seen in the patient with melena. Angiography was diagnostic in all. Pancreatic resection including the aneurysm(2), and bipolar ligation with underrunning of the aneurysm (3) were the operative procedures. Distal pancreatectomy with pancreatogastrostomy was carried out in the patient with hemosuccus pancreaticus. If endoscopy is inconclusive, angiography and early intervention is recommended to reduce the high mortality associated with conservative management.

Primary extrapancreatic gastrinoma.

Extrapancreatic gastrinoma is a rare clinical entity encountered in surgical practice. A patient was referred to us who had a history of recurring symptoms of peptic ulcer disease and ulcer perforation located at an unusual site. Serum gastrin levels were abnormally high. Scopy revealed multiple ulcers in the antrum and duodenum. A mass superior to the head of the pancreas was detected on USG, which later on found to be a separate mass on CT scan. The tumour was excised and confirmed on histopathology. Results of conservative surgery were found to be satisfactory.

Ileo-caeco-colic intussusception due to extensive benign lymphoid hyperplasia of the ileo-caecal region (a case report).

An unusual case of extensive benign lymphoid hyperplasia of the ileo-caecal region causing ileo-caeco-colic intussusception is presented here, with a review of relevant literature. The diagnosis of intussusception was reached with the help of an abdominal ultrasound and barium enema. Histopathology of the resected specimen, revealed lymphoid hyperplasia.

Amebic pericarditis following ruptured right liver lobe abscess.

We present an unusual case of suppurative pericarditis following rupture of a solitary right lobe amebic liver abscess. The condition was treated successfully by drainage of the liver abscess alone.

Endoscopic removal of retained bile duct calculi via T-tube tract.

A simple and safe technique for removal of retained bile duct calculi using a flexible fibreoptic choledochoscope and rigid nephroscope via the T-tube tract has been described. The technique allowed removal of large impacted calculi under direct vision without damage to the bile duct.

Endoscopic and radiological appraisal of gastric varices.

Of 104 patients with portal hypertension who were subjected to oesophageal variceal sclerotherapy, gastric varices were seen in 81 (78 per cent) at endoscopy and 69 (74 per cent) at splenoportography. In 50 (48 per cent) patients gastric varices were seen at the initial endoscopic examination and in 31 they developed during follow-up at intervals varying from 1 to 56 weeks. Gastric varices were seen significantly more often along the lesser curvature than in the gastric fundus and the left gastric vein was the main feeding vessel in 75 per cent of cases. Varices bled in nine of 81 patients and bleeding was seen significantly more often from fundal varices (30 per cent) than from lesser curve varices (5 per cent) (P less than 0.02). The incidence of gastric varices is high, and contrary to popular belief they are more often located along the lesser curvature of the stomach than in the gastric fundus.