Laparoscopic management of pediatric renal and ureteric stones.

OBJECTIVE: To assess the feasibility of laparoscopy in the treatment of pediatric urolithiasis, we report our experience with the transperitoneal laparoscopic removal of stones. METHOD: Renal pelvic stones of size ≥1 cm on ultrasound were included for laparoscopic pyelolithotomy while smaller stones were managed with shock-wave lithotripsy monotherapy. Intrarenal stones, calyceal stones, complete staghorn stones, multiple stones and kidneys with intrarenal pelvis were excluded. Ureteric stones included for laparoscopic ureterolithotomy were of size ≥1 cm in the upper, mid or lower ureter, and smaller stones not responding to non-operative treatment. RESULTS: A total of 22 procedures were performed: 12 pyelolithotomies, and 8 lower and 2 upper ureterolithotomies. Complete removal of calculi was accomplished in 21 (95.45%) procedures. Complications associated with laparoscopic lithotomy included urinoma (4.54%), failure (4.54%) and omental prolapse (4.54%). CONCLUSION: Laparoscopic lithotomy is safe and feasible in pediatric urolithiasis with pyelic and ureteric stones, with minimal complications and failure rate.

Abdominoanterior sagittal approach for sphincter-saving low anterior resection for carcinoma of the rectum in females: a modified anatomical approach.

Safe access to the lower rectum is of the utmost importance when performing sphincter-saving resection for rectal cancer. We describe an abdominoanterior sagittal approach for low anterior resection in females. The abdominal part of the procedure is similar to conventional low anterior resection. The perineal part includes making an anterior sagittal incision from the posterior fourchette to the anterior edge of the anus. The use of a muscle stimulator allows identification of the external sphincters. The rectum and both puborectal slings are identified. Lower margin division and completion of total mesorectal excision is done from below, under vision. The specimen is delivered and mobilized colon is brought down, a hand-sewn end-to-end colorectal anastomosis is formed, and a diverting colostomy is fashioned. Seven patients underwent low anterior resection via the abdominoanterior sagittal approach. Two patients (29%) developed anastomotic stricture, one in association with a rectovaginal fistula and still had a defunctioning stoma, while the other responded to dilatation. The six patients who underwent stoma closure achieved continence to solid stools with a mean Kelly score of 5. The abdominoanterior sagittal approach for low anterior resection is an alternative option for sphincter-saving resection in female patients as it defines the sphincteric anatomy, and minimizes the risk of sphincter injury.

Epidemiology of Japanese encephalitis in context with Indian scenario.

Japanese encephalitis (JE) has been prevalent in various countries of East and South-East Asia since long. In India, JE virus activity was, however, first detected in 1952 through sero-epidemiological surveys in Nagpur district of Maharashtra and Chingleput district of Tamil Nadu. Japanese encephalitis as a disease was first reported in 1955 when cases of JE occurred in Vellore and Pondicherry in southern India. The virus was however, not recovered from man until 1958 when three isolations were made from the brain tissue of cases of encephalitis. This served to confirm JE as a case of encephalitis in India. Until early 1970s, the disease was reported only from southern India with periodic focal reports of its occurrence. A major outbreak resulting in 763 cases and 325 deaths [case-fatality rate (CFR)--42.6%] was reported from Bankura district of West Bengal in 1973. Subsequently, the disease spread to other states and caused a series of outbreaks in different parts of the country. In 1978, cases were reported from 21 states/UTs. Currently disease is reported from the states of Andhra Pradesh, Assam, Bihar, Goa, Haryana, Karnataka, Kerala, Mahrashtra, Manipur, Tamil Nadu, Uttar Pradesh, West Bengal and Nagaland. Till 2007 103389 AES/JE cases and 33729 deaths (CFR 32.62%) have been reported since 1978. Government of India launched vaccination campaign in highly endemic states of Assam, Karnataka, West Bengal and Uttar Pradesh in 2006 and in Andhra Pradesh, Bihar, Haryana, Maharashtra, Tamil Nadu in 2007 and 2008 respectively which has resulted in reduced incidence of JE in these states.

Congenital arhinia: A rare case.

Congenital arhinia or absence of nose is a rare condition with only 30 cases reported so far. We report a rare case and briefly review the literature.

Lymphatic filariasis in Bilaspur district, Chhattisgarh.

As per earlier reports only Ratanpur PHC of the district Bilaspur of Chattisgarh was endemic for filariasis. During the present survey microfilaria infection and disease manifestations were detected in two more PHCs namely Bilha and Bilaspur. 3426 Night blood smears were collected from 24 randomly selected localities (13 rural and 11 urban) covering 25% known endemic areas and 75% reportedly non-endemic areas. Sample size was calculated taking 12% prevalence rate using standard statistical formula. Sixty-two indigenous residents (mf rate 1.80%) were found positive for W. bancrofti infection. Males (2.17%) were more affected than females (1.19%). The mf carriers were 2.05% in rural and 1.45% in urban communities, which indicates that lymphatic filariasis is prevalent in rural areas also. The mean mf density was 5.06. No infective or infected mosquitoes could be detected in Culex quinquefasciatus (544 nos.), M. annulifera (13 nos.) and M. uniformis (2 nos.). Comparing the earlier studies, in Bilaspur district the infection has been showing a declining trend and Brugia malayi infection has disappeared.

Tuberculous appendicitis in India.

Tuberculous appendicitis (TBA) is a rare condition. The present study has been conducted to study its prevalence and presentation. This retrospective study was performed in the Department of Surgery, NSCB Government Medical College, Jabalpur, MP, India, in 870 consecutive appendectomies performed between January 1991 and December 2000. Of 870 consecutive appendicular specimens, 10 cases of primary (1.1%) and 16 of secondary TBA (1.8%) were encountered. Results of all pre-operative investigations were non-specific and the diagnosis was made only after histopathology. The prevalence of TBA in this study was 2.9%. Although it is a rare condition, its possibility should be kept in mind by clinicians as well as pathologists. All surgically removed appendix specimens should be histopathologically examined, whether or not the specimens are macroscopically normal. Given antitubercular treatment in addition to appendectomy, patients recover without complications.

Quality of life after peptic perforation.

AIM OF STUDY: Quality of life (QOL) as outcome during treatment of acid peptic disease has been studied, but, peptic perforation, which is the commonest complication of acid peptic disease, has not been studied in the light of QOL outcome. The present-study addresses the important issue of QOL after peptic perforations. METHODS: This prospective study was carried on 51 adult consecutive survivors of peptic perforation managed in Gastrointestinal Surgery Unit, Department of Surgery, Government NSCB Medical College and Hospital, Jabalpur (MP) India. These underwent exploratory laparotomy with repair of perforation, and subsequently were discharged on anti-ulcer therapy (Pantoprazole 40 mg once a day) for 6 weeks. The instrument chosen to study their QOL was gastrointestinal quality of life index (GIQLI). Patients were assessed before they underwent surgery and 3 months and 6 months after operation. RESULTS: The overall GIQLI score (t = 20.1, p < 0.00 at 3 months; t = 8.2, p < 0.001 at 6 months) as well as its G I core (t = 14.5, p < 0.001 at 3 months; t = 7.3, p < 0.001 at 6 months), G I disease specific (t = 12.9, p < 0.001 at 3 months; t = 2.6, p < 0.02 at 6 months), psychological (t = 15.4, p < 0.001 at 3 months; t = 3.5, p < 0.001 at 6 months) and physical and social components (t = 10.9, p < 0.001 at 3 months; t = 4.2, p < 0.001 at 6 months) significantly increased over 3 and 6 months of follow-up, reflecting improvement in quality of life as perceived by the patients. Variations in the pattern of recovery, based on age and gender were not seen in the present study. CONCLUSION: Peptic perforation does not result in any long lasting impairment of QOL and the QOL improves to near normal in 6 months time after the perforation.

A simplified prognostic scoring system for peptic ulcer perforation in developing countries.

BACKGROUND: Several complex prognostic scoring systems are available for abdominal sepsis. We constructed and assessed a simplified scoring system for peptic perforation, which can be easily used in developing countries. METHODS: One hundred and forty consecutive patients with perforated pre-pyloric or duodenal ulcer undergoing Graham's patch omentopexy closure were studied prospectively. Each factor was given a score based on its severity in accordance with the APACHE-II scoring system to construct the simplified prognostic (Jabalpur) scoring system, and multiple regression analysis was used to identify risk factors. This system was prospectively validated in the next 50 consecutive patients and compared to existing systems. RESULTS: The factors associated with mortality were age, presence of co-morbid illness, perforation-to-operation interval, preoperative shock, heart rate, and serum creatinine. The mean score in survivors (4.9) was less than that in those who died (12.5; p<0.0001). This scoring system compared favorably with other scoring systems. CONCLUSIONS: The Jabalpur scoring system is effective for prognostication in cases of peptic perforation. It is simple and user-friendly as it uses only six routinely documented clinical risk factors.

Correlation between serum-ascites albumin concentration gradient with gastrointestinal bleeding in patients of portal hypertension.

Non-availability of endoscopic screening to detect portal hypertensive patients at a high risk of index gastrointestinal (GI) haemorrhage led us to examine the relationship between serum-ascitic albumin concentration gradient (SAAG) measurements and the occurrence of GI haemorrhage in patients with portal hypertension and ascites. Fifty-six consecutive patients of portal hypertension with ascites attending the GI surgery outpatients clinic were divided into two groups on the basis of history: (a) those who had no history of GI bleeding; and (b) those who had an episode of GI bleeding within the past 21 days. Child-Pugh score was calculated for all patients. All the patients were assessed by ultrasonography and SAAG was estimated. Groups (a) and (b) were compared and sensitivity, specificity, positive and negative predictive value of using SAAG as a possible screening test for GI bleeding were calculated. SAAG values correlated significantly with bleeding and splenomegaly. For prediction of bleeding, SAAG had a sensitivity of 100% and specificity of 33.33%, positive predictive value of SAAG for GI bleeding was 71.4% and the negative predictive value was 100%. Estimation of SAAG is possible even in a small, modestly equipped laboratory, and could provide a new means for the identification of high-risk patients for GI bleeding and define patients more accurately for future clinical studies. The results of the present study are encouraging for clinicians working in developing countries and may help in optimizing prophylactic therapy and where available, improving the cost effectiveness of screening endoscopy.

Correlation of trauma scoring systems with abdominal septic complications in abdominal trauma.

INTRODUCTION: Anatomical trauma scoring systems can predict the occurrence of postoperative abdominal septic complications (ASC) after major abdominal trauma; however, this has not been validated in any Indian study. We attempted such an evaluation in patients attending a teaching hospital in central India. METHOD: A retrospective analysis of data from 169 patients who had undergone emergency laparotomy for penetrating or blunt abdominal injury between August 1996 and July 2001 was done. Every patient was scored using three trauma severity indices and the occurrence of ASC was identified. RESULTS: Patients who developed ASC had higher trauma severity scores than those who did not. Thirty-eight patients had isolated small bowel injury; trauma scores underestimated the occurrence of ASC in these patients. CONCLUSIONS: Trauma severity indices may serve as useful tools to predict the occurrence of postoperative ASC in patients with abdominal trauma, except in those with isolated small bowel injury. There is thus a need to modify the weight of small bowel injury in these scoring systems.

Surgical bypass is still relevant in the palliation of malignant obstructive jaundice.

Malignant tumours of the biliopancreatic system causing obstructive jaundice are not curable in most of the patients, and palliation plays a very important therapeutic role. The role of surgery in palliation of malignant obstructive jaundice has been questioned in the light of availability of endoscopic techniques. In developing countries, however, exploratory laparotomy and palliative surgery (when possible) is the only option available as sophisticated instruments and the expertise to use them is limited to a very few centres. This was a retrospective study of 83 consecutive cases with malignant obstructive jaundice admitted to the Department of Surgery, NSCB Government Medical College, Jabalpur, MP, India from January 1996 to December 2000.

Palliation by coeliac plexus block for upper abdominal visceral cancer pain.

Palliation of cancer related pain is one of the major concerns of patients suffering from cancer of the upper abdominal organs. The non-availability of imaging techniques to guide needle placement prompted us to use a blind technique of neurolytic coeliac plexus block. Thirty consecutive patients with intractable pain, due to documented inoperable upper abdominal visceral cancers, underwent neurolytic coeliac plexus block by blind percutaneous retrocrural unilateral neurolysis. The severity of pain was documented on a 0-10 visual analogue scale (VAS) performed pre-block and post-block at 1 day, 1 week, 1 month and 3 months. Pain relief was graded as excellent if the score was 0-2, good when VAS was 3-5, satisfactory whenVAS was 6-7 and unsatisfactory if VAS was 8-10. Excellent pain relief was obtained in 26/30 patients (86.6%). Relief from pain diminished with time and after 3 months, 16/30 patients (53.35) graded their pain relief as excellent. Transient but severe hypotension complicated 73% of blocks. Despite the proximity of vital structures, blind unilateral retrocrural neurolytic coeliac plexus blockade is a safe and effective means to relieve the terminal pain associated with upper abdominal visceral cancer. It deserves more widespread use in patients with upper abdominal cancer. Results of the present study are encouraging and relevant for clinicians working in developing countries.

Surgical anatomy of retrohepatic inferior vena cava and hepatic veins: a quantitative assessment.

BACKGROUND: Accurate knowledge of the surgical anatomy of the retrohepatic inferior vena cava (IVC) and hepatic veins is necessary for hepatic surgery. METHODS: Lengths of different segments of retrohepatic IVC and their diameters, and prevalence of various types of ramification and lengths of different hepatic veins, were noted in 100 disease-free human livers during autopsy. RESULTS: The mean lengths of the IVC from entry into atrium to diaphragmatic hiatus, from the hiatus to the upper margin of right hepatic vein, between the upper margins of the right hepatic vein and the right suprarenal vein, from right suprarenal vein to the lowermost dorsal hepatic vein, and from the lower-most dorsal hepatic vein to the right renal vein were 29.1 mm, 8.6 mm, 40.6 mm, 28.6 mm and 33.7 mm, respectively. The mean diameter of IVC at the diaphragmatic level was 30.1 mm. The commonest ramification pattern of the hepatic veins was type I (82%) for the right hepatic vein, type II (63%) for the middle and left hepatic veins, and type II (55%) for the caudate veins. In 96% of cases the middle and left hepatic veins formed a common trunk. In a majority of cases, the diameters of the right and left hepatic veins were between 7 mm and 12 mm. No gender differences were found. CONCLUSION: This study provides an anatomical perspective for various hepatic surgical techniques.