PREDICTIVE VALUE OF PLASMA UREA: CREATININE RATIO IN PATIENTS PRESENTING WITH MELAENA.

The usefulness of plasma urea:creatinine ratio in predicting the site of bleeding was studied in 40 patients admitted with melaena. Patients presenting with frank haematemesis and those in whom the site of bleeding could not be ascertained were excluded from the study. In 26 patients the source of bleeding was above the ligament of Trietz, while in 14 the source was below this level. In 22 of 26 (84.6%) patients with upper gastrointestinal bleeding, the urea:creatinine ratio was more than 36. In only 2 of 14 patients with lower gastrointestinal bleeding the ratio was similarly raised (p < 0.001). Our study suggests that urea:creatinine ratio of 36 or more has a positive predictive value for upper gastrointestinal bleeding.

OUR EXPERIENCE WITH DIAGNOSTIC AND THERAPEUTIC CHOLEDOCHOSCOPY.

Flexible choledochoscope was used in 16 patients undergoing common bile duct (CBD) exploration for suspected stones. Stones were found in the CBD in 4 patients in whom introperative cholangiogram was normal. T-tube cholangiogram done between the 10th and 14th postoperative days was normal in all 16 patients. None of the patients had symptoms suggestive of retained stones during follow-up ranging from 6 to 19 months. We feel that the use of choledochoscopy in patients undergoing CBD exploration will help reduce the incidence of retained stones.

Audiovisual aids: guidelines for the use of overhead projector.

The overhead projector is a versatile audio-visual (AV) aid. When used effectively, it can render a presentation very impressive. It is easy to maintain and operate, and offers considerable flexibility of text and image projection. It is the most commonly used AV aid in teaching institutions and an appreciation of its strengths and weaknesses can be useful to teachers and students alike.

THE CHANGING FACE OF MEDICAL LIBRARIES.

Reading has been a source of joy to man since several hundreds of years. The invention of paper made books widely available and libraries became commonplace. But now the situation is slowly but surely changing. Paper and books are becoming costlier and the popularity of the electronic media is increasing. Medical books and libraries also face competition from the electronic media. The MEDLARS, an excellent example of this technological revolution is now available all across India through the National Informatics Centre and it appears to be very cost effective decision for even peripheral hospitals to acquire a MEDLARS facility.

Endoscopic laser ablation of duodenal carcinoids: a new treatment modality.

Four cases of polypoidal carcinoid tumors in the duodenum were treated with Nd:YAG laser ablation after histological confirmation. None of the patients had any distant spread of the tumor. All the four tumors were less than 2 cm in size. In each case, the tumor was fully ablated in a single endoscopic laser sitting. All cases were done under local anesthesia and the patients were hospitalized for 1 day. All patients have been symptom free over a mean follow up period of 13 months (6 to 20 months). There has been no endoscopic evidence of local recurrence. Laser therapy is safe and effective and carries no mortality or morbidity. Endoscopic laser ablation is an effective alternative to surgical resection of small carcinoid tumors.

Nd-YAG laser therapy for palliation of obstructed colorectal carcinomas.

Twenty three cases of colorectal carcinoma with partial or complete obstruction were managed by laser ablation of tumour tissue. There were 14 males and 9 females with a mean age of 63 years (30-87). Nineteen cases (82.6%) were in the rectosigmoid while two cases each were in the anal canal and descending colon. Fifteen (65.2%) were proliferative growths and the remaining (8, 34.7%) were circumferential growths. Prior dilatation under fluoroscopic control was done where required. Lumen was achieved in a single sitting in 14 (60.8%) cases, while in the others two to five sittings were required. None of the patients required colostomy. Thirteen (56.5%) of these patients have died during the follow up period, lasting from 4 to 27 months (mean 10.4 months). There were no major complications related to the procedure.

Neodymium: YAG laser in the management of tracheal stenosis.

Thirty-five cases of benign stenotic lesions involving the upper respiratory passages were managed by laser photocoagulation of the scar tissue. The stenosed segment was around the site of tracheostomy in 28 cases (80%), subglottic in five cases (14.3%), and as a result of congenital webs, at the level of the larynx in two cases (5.7%). Adequate lumen was achieved in 29 cases (83%). The procedure was unsuccessful in five patients (all with subglottic stenosis). One to 11 laser settings (mean 2.8) were required to achieve satisfactory lumen. Complications (three cases, 8.5%) included bleeding in two cases and cervical emphysema in one case. Patients have been followed-up for two to 34 months (mean 23 months). One patient (2.8%) had recurrent stricture formation for which recanalisation was done. There were no procedure-related deaths. Neodymium: Yttrium-Aluminium-Garnet (Nd: YAG) laser photocoagulation is effective in the management of tracheal stenosis due to benign lesions except when they are located in the subglottic region. It carries minimal morbidity and no mortality risks.

Oesophageal carcinoma: laser palliation in 231 cases.

Two hundred and thirty-one patients of advanced oesophageal carcinoma were treated with Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG) laser photocoagulation of tumour tissue to relieve distressing dysphagia. There were 155 males (67.1%) and 76 females (32.9%). The mean age was 59.6 years. Eighty-five percent (196 cases) were above 50 years of age. Distribution of tumour by site was as follows: upper one-third--24 cases (10.4%), mid one-third--98 cases (42.4%) and lower one-third--109 cases (47.1%). Squamous cell carcinomas accounted for 83.5% (193) of cases. Nearly two-thirds (144 cases, 62.3%) were more than 4 cm in length. Tumour deposits were found at more than one site in 11 cases (4.7%). Oesophageal lumen was restored in all cases but was poorly sustained in 19 cases (8.2%). Further sessions of laser therapy were required in all these cases. A mean of 2.7 sessions of laser treatment was required to achieve adequate lumen. One hundred and eighty-nine patients (82%) had good relief of dysphagia to liquids and semi solids. Complications were seen in 20 cases (8.6%). There were no deaths related to the procedure. Mean survival was 5.5 months (1-14 months). Nd:YAG laser therapy offers effective palliation of dysphagia in carcinoma of the oesophagus with acceptable morbidity and no mortality.

Laser therapy of solitary rectal ulcers: a new concept.

Fourteen cases of histologically proven benign solitary rectal ulcer were managed with Neodymium: Yttrium-Aluminium-Garnet (Nd:YAG) laser (contact mode) over a three-year period. All patients were symptomatic at presentation (bleeding, mucus or pus discharge per rectum, with or without diarrhoea). Thirteen of the 14 (93%) were relieved of symptoms after a mean of 2.3 sittings of laser (range 1-8). None of the patients had associated rectal prolapse. Successfully treated patients have been followed up for a mean of 14.2 months (two to 25 months) and are symptom free. There was minimal morbidity and no death. Nd:YAG laser excision of benign solitary rectal ulcers is a safe, new and patient-friendly technique.

Neodymium: YAG laser therapy for obstructing tracheobronchial tumours.

Thirty-nine patients with obstructing tracheobronchial tumours were treated with Neodymium: Yttrium-Aluminium-Garnet (Nd: YAG) laser photocoagulation over a period of six years. There were 29 males and ten females with a mean age of 44.3 years (range 6-79 years). Eight benign and 31 malignant lesions were treated with a total of 94 sessions of laser photocoagulation (mean 2.4 sessions). The anatomical distribution of lesions was as follows: larynx--six (three benign and three malignant); trachea--seven (one benign and six malignant), left main bronchus--ten (all malignant), right main bronchus--11 (one benign and ten malignant), and vocal cords--five (three benign and two malignant). There were 21 patients with squamous cell carcinoma, two adenocarcinomas, one adenoid cystic carcinoma, three cases of locally infiltrating tumours, four cases of carcinoid tumour and eight benign lesions. Twenty-one patients had the tracheostomy tube in place when treatment was started. Eighteen of the 21 patients with tracheostomies were weaned off the tube in a mean of 5.5 days from the start of the treatment. Lumen was restored in 31 (79.4%) patients. In the other eight (20.6%), lumen was achieved, but not sustained. Complications included bleeding in three cases which were managed conservatively, two cases of pneumothorax and four cases of bronchospasm. There were six deaths during follow-up (mean 21.2 months), but none attributable to the procedure. Laser photocoagulation offered effective treatment in the majority of patients with obstructing tracheobronchial tumours, with acceptable morbidity.

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY AS A PRELUDE TO LAPAROSCOPIC CHOLECYSTECTOMY.

Seventy patients undergoing laparoscopic cholecystectomy were evaluated with endoscopic retrograde cholangiography (ERC) preoperatively, All the ERCs were performed by the laparoscopic surgeon, 1 to 30 days prior to surgery. In all cases including those converted to open cholecystectomy (5 out of 70, 7.1%), ERC helped in clear delineation of the biliary tree, cystic duct and gallbladder, making dissection of the Calot's triangle safe. Four cases of common bile duct (CBD) stones detected at ERC were managed by papillotomy and basketing. In nine cases (12.8%), anomalies of the biliary tree were detected. Average time taken for ERC was 12 minutes (7-28 minutes); while intraopertaive cholangiogram (one case) took 25 minutes. ERC gives a clear outline of the biliary anatomy and greatly facilitates laparoscopic cholecystectomy, It helps avoid open cholecystectomy because of CBD stones. It also reduces the laparoscopic operating time by the duration normally taken to do intraoperative cholangiography.