Transthoracic versus transhiatal esophagectomy for esophageal carcinoma: experience from a single tertiary care institution.

BACKGROUND: There is a lot of controversy about the best surgical treatment for esophageal carcinoma. METHODS: In this retrospective study, 382 patients with carcinoma of the mid-to-distal esophagus underwent transthoracic or transhiatal esophagectomy. Early morbidity and mortality were compared. Principal endpoints were disease-free survival (DFS) and overall survival (OS). RESULTS: A total of 177 patients underwent transthoracic esophagectomy, and 205 patients underwent transhiatal esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative and postoperative morbidity was higher after transhiatal esophagectomy. In-hospital mortality was also higher after transhiatal esophagectomy. The median follow-up was 4.3 years. Estimated 3-year DFS rates were 44.63 and 31.21%, whereas the 3-year OS rates were 57.06 and 41.46% for the transthoracic and transhiatal groups, respectively (statistically significant). Also, the estimated 5-year DFS rates were 26.55 and 21.46%, whereas the 5-year OS rates were 32.76 and 30.24% for the transthoracic and transhiatal groups, respectively (statistically not significant). CONCLUSIONS: Transhiatal esophagectomy was associated with higher perioperative and postoperative morbidity and in-hospital mortality than transthoracic esophagectomy. The DFS and OS were higher in the transthoracic group and were statistically significant at 3 years but statistically insignificant at 5 years.

Clinical profile and surgical outcome for pulmonary aspergilloma: nine year retrospective observational study in a tertiary care hospital.

BACKGROUND: The indications and the outcome of surgery for pulmonary aspergilloma remain highly controversial. This retrospective observational study was conducted to study the clinical profile, indications, post-operative complications and long term outcome of patients having pulmonary aspergilloma. METHODS: From January 2000 to October 2008, 52 patients underwent surgery for pulmonary aspergilloma at our tertiary care institute. RESULTS: The group consisted of 32 males and 20 females with a mean age of 39.3 ± 11.2 years. The most common indication for surgery was hemoptysis (96.15%). The underlying lung diseases were tuberculosis (75%), bronchiectasis (5.76%), and lung abscess (5.76%). In one patient (2%), concomitant ruptured lung hydatid cyst and an aspergilloma was present. The procedures performed were lobectomy (n = 43), bilobectomy (n = 3). pneumonectomy (n = 3), segmental resection (n = 3). The post-operative mortality was 1.92% (one patient). Overall complications occurred in 12 (23.07%) patients. The complications included prolonged air leak (n = 6), bleeding (n = 3), empyema (n = 1), repeated pneumothorax (n = 1), and wound dehiscence (n = 1). The mean follow-up period was 38 ± 18.6 months. There was no recurrence of disease or hemoptysis. CONCLUSION: Pulmonary aspergilloma is common in developing countries like India in which there is high prevalence of pulmonary tuberculosis. Surgical resection of pulmonary aspergilloma is effective in preventing recurrence of symptoms including hemoptysis. We recommend early surgical resection of symptomatic aspergilloma with reasonable complications. Pre-operative preparation of the patients, meticulous surgical technique and post-operative chest physiotherapy reduces the rate of complications. Complications may still occur and are largely related to the underlying lung pathology; however, the long term outcome is good.

Procalcitonin as the biomarker of inflammation in diagnosis of appendicitis in pediatric patients and prevention of unnecessary appendectomies.

Numerous diseases mimic appendicitis, and it is often difficult to rule it out on the basis of clinical presentation. Concentration of procalcitonin selectively increases in inflammatory conditions and determination of its level can help in the diagnosis of acute appendicitis. A prospective, single centre based observational study carried out at our tertiary care institute. Twenty eight patients were admitted with preliminary diagnosis of acute appendicitis. The control group involved around 12 healthy children. Serum Procalcitonin concentration was measured in all patients using the 'Immunoluminometric Method' (LUMI- Test PCT), besides carrying out clinical examination and other investigations. The serums PCT comes out to be a better diagnostic test than serum CRP measurement as serum PCT was able to differentiate patients who came with abdominal pain but were having normal appendix from the patients who were actual cases of acute appendicitis. In patients with histologically confirmed acute appendicitis the level of PCT was above the normal value of 0.5 ng/ml in most cases. The analysis of procalcitonin in different groups of patients showed the serum procalcitonin test having high sensitivity of 95.65% and a specificity of about 100% on the basis of histopathological diagnosis of the removed appendix taking as the standard. The serum procalcitonin test when combined with reliable clinical signs and symptoms is an excellent diagnostic marker of the disease and should be done in the patients of pediatric appendicitis so that proper handling of the patient can be done and we can prevent unnecessary appendectomies.

Hydatid embolism from a thoracic aortic pseudoaneurysm presenting as gangrenous toes.

Cystic echinococcosis (hydatid cyst), caused by Echinococcus granulosus, has worldwide distribution and poses a health problem in endemic areas. Embolization of hydatid cysts into the vascular tree is an unusual manifestation of the disease. The hydatid embolism results from spontaneous or traumatic rupture of the cyst, and rare case reports of this kind are not well documented in the literature. We report a case of a hydatid embolism from a ruptured hydatid in a pseudoaneurysm of the thoracic aorta. A 45-year-old woman presented with gangrenous changes of the toes of her right foot. After embolectomy, the histopathology of the embolus was doubtful about its being blood clots around hydatid membranes. Postoperatively, computed tomography (CT) of the chest revealed a pseudoaneurysm of the descending thoracic aorta. Definitive surgery for the pseudoaneurysm was done during a second operation. Numerous hydatid cysts were evacuated from the pseudoaneurysm. This report emphasizes the need for an early diagnosis and treatment of echinococcosis before disabling and life-threatening complications occur.

Spontaneous cutaneous rupture of a pyogenic liver abscess.

Spontaneous rupture of a pyogenic liver abscess is a rare entity reported. Spontaneous cutaneous rupture of a pyogenic liver abscess is even a rarer clinical entity not well documented in the literature. A patient having spontaneous cutaneous rupture of a pyogenic liver abscess is reported. The condition is rare and serious because of the possible delay in diagnosis. Recently, with the advent of ultrasound (USG) and computed tomography (CT) scan, there has been improvement in the rate of early diagnosis of liver abscess as well as in prognosis. The clinical presentation is variable; in some cases there are delays, misdiagnoses, or incidental recovery. Per cutaneous catheter drainage under USG or CT guidance has become the standard of care.