Genetic Susceptibility of DCC Gene in Gallbladder Cancer in Kashmir and Meta-Analysis.

Deleted in colorectal carcinoma (DCC) A > G (rs714) is the most widely studied SNP of tumor suppressor DCC gene found to be associated with increased risk of various cancers. Therefore, the aim of present case control study was to investigate the role of DCC A > G (rs714) in gallbladder cancer (GBC) in Kashmir and to conduct a meta-analysis of DCC A > G (rs714) polymorphism to demonstrate the more accurate strength of these associations. Genotyping was done by PCR/RFLP and confirmed by sequencing in 100 GBC cases, and 150 controls. We also performed a comprehensive meta-analysis of 2223 subjects (1118 cases and 1105 controls) to evaluate the association between DCC A > G (rs714) polymorphisms and cancer. In present case control study DCC A > G (rs714) genotypes did not modulate the GBC cancer risk. Meta-analysis results showed that DCC A > G (rs714) is associated with increased overall cancer risk. DCC A > G (rs714) polymorphism conferred significant risk for cancer in dominant model but in recessive model P-value was at borderline. DCC A > G (rs714) genotype was associated with increased risk of cancer in Asians and Kashmiri population whereas no such association was observed in Europeans. The evidence in this meta-analysis supports a modest involvement of DCC A > G (rs714) tumoursupressor pathway genes in cancer susceptibility.

Role of Glutathione-S-Transferases in Gallbladder Cancer and Cholelithiasis Susceptibility and Meta-Analysis.

Glutathione-S-transferase T1 (GSTT1) and glutathione-S-transferase M1 (GSTM1) genes are associated with increase susceptibility to developing different types of cancers. The aim of present study was to investigate the role of genetic variants of GSTM1 and GSTT1 in gallbladder cancer (GBC) and cholelithiasis in Kashmir valley. Genotyping was done by multiplex polymerase chain reaction in 100 GBC, 100 cholelithiasis, and 150 controls adjusted by age and sex. We also performed a meta-analysis of published studies on GSTM1 and GSTT1 to evaluate the association between the GSTM1 and GSTT1 polymorphisms and GBC. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using random- or fixed-effects model. In the present study, no association was observed between GSTM1 null and GSTT1 null genotypes and GBC and cholelithiasis. Meta-analysis results showed that GSTM1 null genotype was associated with GBC risk (P = 0.042). Subgroup analysis by ethnicity showed that GSTM1 null (P = 0.024) and GSTT1 null genotype (P = 0.037) were significantly associated with risk of GBC in Asians. This is the first study to investigate the role of genetic variants of GSTM1 and GSTT1 in GBC in Kashmir valley and cholelithiasis in the world.

Dual Parasitization of the Biliary Tree: First Reported Case.

Cases of biliary ascariasis and hydatid cysts in liver and elsewhere are common in endemic areas and are routinely encountered in surgical outpatient departments. We describe the diagnosis and management of a unique case, who presented with manifestations of biliary ascariasis, but on further investigation was found to harbor ascarids as well as ruptured hydatids in his biliary passages. To our knowledge, this is the first reported case of simultaneous parasitization of common bile duct by ascarid and hydatid forms, resulting in obstruction of the biliary system. This report highlights the diversity of presentation and challenges in the management of such cases, when encountered in practice.

Prevalence and pattern of growth abnormalities in children with extrahepatic portal vein obstruction: Response to shunt surgery.

OBJECTIVE: Growth retardation is common in children with extrahepatic portal vein obstruction (EHPVO) and growth hormone (GH) resistance may play a dominant role. The aim of this study was to ascertain growth parameters and growth-related hormones in children with EHPVO, comparing with controls and to study the response of shunt surgery on growth parameters. MATERIALS AND METHODS: The auxological and growth-related hormone profile (GH; insulin-like growth factor binding protein-3 [IGFBP-3] and IGF-1) of thirty children with EHPVO were compared with controls. The effect of shunt surgery on growth parameters in 12 children was also studied. RESULTS: The mean height standard deviation score (HSDS) of cases (-1.797 ± 1.146) was significantly lower than that of controls (-0.036 ± 0.796); the mean weight SDS of cases (-1.258 ± 0.743) was also lower than that of controls (-0.004 ± 0.533). The mean GH level of cases (5.00 ± 6.46 ng/ml) was significantly higher than that of controls (1.78 ± 2.04 ng/ml). The mean IGF-1 level of cases (100.25 ± 35.93 ng/ml) was significantly lower as compared to controls (233.53 ± 115.06 ng/ml) as was the mean IGFBP-3 level (2976.53 ± 1212.82 ng/ml in cases and 5183.28 ± 1531.28 ng/ml in controls). In 12 patients who underwent shunt surgery, growth parameters significantly improved. CONCLUSIONS: Marked decrease in weight and height SDSs associated with GH resistance is seen in children with EHPVO, which improves with shunt surgery.

Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple's technique.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard procedure for resecting tumors arising from the periampullary area and the pancreatic head. Nevertheless this procedure is inherently difficult and associated with high morbidity and mortality. Besides, the technique applied for exposing the portal and superior mesenteric veins is time-consuming, difficult and associated with the risk of major venous injury. Recently we have introduced a modified approach for making this part of the procedure quick, safe and bloodless, which constitutes the subject of this study. METHODS: Patients who underwent pylorus preserving pancreaticoduodenectomy (PPPD) either by superior approach technique (group 1) or by classical Whipple's technique (group 2) were retrospectively identified. Age-sex composition, body mass index (BMI), total operative time, operative blood loss, intraoperative blood transfusion requirement, morbidity, mortality and length of hospital stay were compared between the two groups. RESULTS: Between January 1997 and December 2011, 72 patients underwent PPPD by the superior approach technique (group 1) and 38 underwent PPPD by the classical Whipple's technique (group 2) at our institution. Statistically significant differences were observed in operative time (208.1+/-46.3 minutes in group 1 vs 322.0+/-33.8 minutes in group 2), operative blood loss (601.0+/-250.3 mL in group 1 vs 1371.5+/-471.8 mL in group 2), and intraoperative blood transfusion requirement [10 (13.9%) patients in group 1 and 24 (63.2%) in group 2]. Among 18 (16.4%) obese patients, significant differences in operative time, operative blood loss and intraoperative blood transfusion requirement were observed between groups 1 and 2. There was no significant inter-group difference in complication rate among obese patients, but comparing obese patients with normal weight patients revealed higher rates of complications like pancreatic fistula (27.8% vs 6.5%), delayed gastric emptying (16.7% vs 5.4%), and infective complications like wound infection and intra abdominal collection (44.4% vs 5.4%). CONCLUSIONS: On the basis of analytical data, we conclude that the superior approach technique is effective for PD compared with the classical Whipple's technique. It allows fast, safe and virtually bloodless dissection for exposure of the superior mesenteric and portal veins during early steps of PD. PD is normally a difficult and tedious procedure carrying a remote risk of major venous injury leading to substantial blood loss.

Cystic dilatation of the cystic duct: a type 6 biliary cyst.

Choledochal cysts of the cystic duct are extremely unusual and only single case reports are documented in the literature. The widely used Todani classification does not include such type of lesions. We present a case of a young girl with a cystic duct choledochal cyst diagnosed preoperatively and confirmed intraoperatively. Due to the site and mass effect of the cyst, excision of the lesion included a part of bile duct. Reconstruction was achieved by Roux-en-Y hepaticojejunostomy. While such lesions are extremely rare, they do occur and need to be recognized as a separate entity in the Todani classification.

Left-sided hepatic resection for hepatolithiasis: a longitudinal study of 110 patients.

BACKGROUND: Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis. METHODS: One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined. RESULTS: Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3-134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones. CONCLUSIONS: This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.

Management of variceal hemorrhage in children with extrahepatic portal venous obstruction-shunt surgery versus endoscopic sclerotherapy.

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.

Hydatid cyst of the pancreas. An experience with six cases.

CONTEXT: The pancreas is an infrequent site of hydatid disease. OBJECTIVE: This study aims at giving better insight into the diagnostic and managerial approach to the disease. PATIENTS: Six patients with hydatid cysts of the pancreas. DESIGN: Retrospective review of the clinical records. RESULTS: The six patients (four men, two women) ranged in age from 18 to 68 years. Five of the cysts were primary while one had an associated cyst in the liver. Abdominal pain, vomiting, abdominal mass and dyspeptic symptoms were seen in cysts involving the body and tail. Two patients having cysts in the head of the pancreas presented with obstructive jaundice. An indirect hemagglutination test and an enzyme-linked immunoabsorbent assay were positive for the presence of specific hydatid antibodies in four patients. Abdominal ultrasonography, computed tomography and magnetic resonance cholangiopancreatography (MRCP) successfully imaged the cysts and also defined the relationship of the lesion with the pancreatic duct. All patients underwent surgical exploration. Three patients had intraoperative fine needle aspiration cytology of the cystic lesion for microscopic and electrolyte analysis. A preoperative diagnosis was possible in two patients and, in the other four, the diagnosis was made intraoperatively and confirmed on histopathological examination. PATIENTS: with cysts located in the tail underwent a distal pancreatectomy with a splenectomy while those with cysts in the body had a pericystectomy or central pancreatectomy. Cysts of the head were treated with evacuation, partial cystectomy and tube drainage. There were no postoperative complications, and no evidence of cyst recurrence was observed during the follow-up period. All the patients were followed up at three-month intervals with a mean follow-up time of 58.7 months (rang: 4-120 months); no patient had cyst recurrence or dissemination. CONCLUSION: A hydatid cyst is an uncommon cause of cystic lesions in the pancreas and should be included in the differential diagnosis of cystic lesions of the pancreas, especially in endemic areas. Intraoperative fine needle aspirate for microscopic and electrolyte estimation seems to be an effective method for establishing a proper diagnosis. MRCP, which can depict the communication of the cystic lesion with the pancreatic duct, helps in defining the type of surgical treatment. Cysts in body and tail are best treated by resectional methods whereas, for those in the head region, a cystectomy with simple drainage is a simple, quick and effective solution.

Biliary ascariasis: a review.

Ascariasis, a helminthic infection of humans, is the most common parasitic infestation of the gastrointestinal tract. It infects about 25% of the world's population; around 20 thousand deaths occur per year from an adverse clinical course of the disease. This review is focused on biliary ascariasis, examining in some detail the pathogenesis of the disease with special reference to postcholecystectomy ascariasis and related issues. Although an endemic disease of tropical and subtropical countries, increasing population migration facilitated by fast improving communication facilities demands that clinicians everywhere be familiar with the clinical profile and management of biliary ascariasis.

Management of biliary ascariasis in pregnancy.

Ascariasis is a helminthic infection of humans caused by the nematode Ascaris lumbricoides. Biliary ascariasis is one of the most common and well described entities caused by ascaris. In endemic areas pregnant women are prone to develop biliary ascariasis. Its management poses a great challenge to both the attending surgeon and the endoscopist. Between January 1993 and March 2003, 15 cases of biliary ascariasis were seen in pregnant patients in our institution. Ultrasonography was used as the main investigative tool. Treatment involved management by conservative, endoscopic, and surgical methods, taking due care of both the mother and the fetus. Ten patients (66.6%) were in the third trimester of pregnancy, and 10 (66.6%) patients were in their third pregnancy. Ultrasonography proved to be the best tool for diagnosing and monitoring worms inside the biliary ductal system. Nine (60%) patients responded to the conservative treatment; endoscopic extraction was successful in 4 (66.6%) patients. Surgical treatment was required in 2 (13.3%) patients. One (6.6%) patient had had spontaneous abortion at 12 weeks gestation, and one (6.6%) patient had a premature labor. The remaining patients had normal pregnancies. Management of biliary ascariasis in pregnancy is a challenge for both the attending surgeon and the endoscopist. Safe and effective management requires special attention to the gestational age and accurate recognition of the specific pathology in the patient. The majority of patients respond to conservative treatment, but endoscopic extraction may be needed in nonresponsive cases. Lead shielding of the fetus and limitation of the total fluoroscopic exposure during therapeutic endoscopy can minimize the teratogenic risk of ionizing radiation. Failures of endoscopic extraction may lead to surgical intervention, which carries risks of fetal wastage and premature labor. Routine worming of women in the child-bearing years is recommended in endemic areas of ascariasis. Though ascariasis is a problem in developing countries, because of increased travel and population migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Anteriorly placed splenic vein: the first reported case.

Surgical treatment of portal hypertension is undertaken to reduce the portal pressure to a level that allows recession of the collateral circulation. For this purpose, surgeons usually carry out anastomosis of the splenic vein with the left renal vein. The splenic vein is a large, nontortuous vessel that runs along the posterior surface of the pancreas but very rarely crosses in front of the gland. It is therefore important that a thorough preoperative study of the anatomical details of the spleno-portal venous axis be made by imaging before attempting surgery. We are presenting herewith the surgical management of a unique case of anteriorly placed splenic vein, which has not yet been described. The embryological basis of such an anomaly is discussed in this article.

A simplified technique of performing splenorenal shunt (Omar's technique).

The splenorenal shunt procedure introduced by Robert Linton in 1947 is still used today in those regions of the world where portal hypertension is a common problem. However, because most surgeons find Linton's shunt procedure technically difficult, we felt that a simpler technique was needed. We present the surgical details and results of 20 splenorenal anastomosis procedures performed within a period of 30 months. Half of the patients (Group I) underwent Linton's conventional technique of splenorenal shunt; the other half (Group II) underwent a newly devised, simplified shunt technique. This new technique involves dissection of the fusion fascia of Toldt. The outcome of the 2 techniques was identical with respect to the reduction of preshunt portal pressure. However, our simplified technique was advantageous in that it significantly reduced the duration of surgery (P <0.001) and the amount of intraoperative blood loss (P <0.003). No patient died after either operation. Although Linton's splenorenal shunt is difficult and technically demanding, it is still routinely performed. The new technique described here, in addition to being simpler, helps achieve good vascular control, permits easier dissection of the splenic vein, enables an ideal anastomosis, decreases intraoperative blood loss, and reduces the duration of surgery. Therefore, we recommend the routine use of this simplified technique (Omar's technique) for the surgical treatment of portal hypertension.

Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area.

BACKGROUND: Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world. METHOD: Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value. RESULTS: The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%. CONCLUSION: Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.

Diagnosis of adrenal myelolipoma by imaging and guided biopsy.

Adrenal myelolipoma is a rare, benign, endocrinologically inactive, and asymptomatic tumour which is usually found incidentally at imaging or autopsy. Symptomatic tumours are very rare. We describe a case of adrenal myelolipoma where the diagnosis was made on the basis of radiological features and image-guided fine needle biopsy, without resorting to an operation.

Surgical management of splenic hydatidosis.

PURPOSE: This study was conducted to evaluate the surgical management of splenic hydatidosis in an area where the disease is endemic. METHOD: Over a period of 16 years, 26 patients with splenic hydatidosis underwent surgery in our department. Preoperative investigations included plain abdominal X-ray, serology, ultrasonography, and computed tomography. RESULTS: In our series, splenic hydatidosis represented 3.5% of total abdominal hydatidosis. The majority of patients presented with abdominal discomfort and palpable swelling in the left hypochondrium. Twenty-two patients were operated on electively and 4 as emergency cases, including 2 with ruptured hydatids and 2 with infected hydatids of the spleen. Isolated splenic hydatid cysts were present in 21 patients, associated liver hydatid cysts in 4, and diffuse abdominal hydatidosis in 1 patient. All patients underwent splenectomy except for one patient who initially had partial splenectomy for a lower polar cyst. This patient also ended up undergoing a splenectomy for postoperative hemorrhage. One patient died on the sixth postoperative day (mortality rate 3.8%) as a result of multiorgan failure, and 4 developed minor complications (morbidity 15.4%). CONCLUSION: Splenic hydatidosis, although rare, is the third most common type of hydatidosis after liver and lung hydatidosis. This entity should thus be kept in mind when encountering a splenic cyst especially in areas where the disease is endemic. A splenectomy remains the treatment of choice because it demonstrates low morbidity and mortality rates.

Ascariasis-induced empyema of gallbladder: report of a case.

A rare case of a 52-year-old woman with empyema of the gallbladder due to ascariasis causing an obstruction in the cystic duct is presented. She was admitted on September 20, 2000, and on September 23 an emergency cholecystectomy was performed. Ultrasonography is a highly sensitive and specific method for diagnosing gallbladder ascariasis, and a cholecystectomy is considered mandatory for the treatment of empyema of the gallbladder.