Anterior or posterior gastro-jejunostomy with truncal vagotomy for duodenal ulcer--are they functionally different?

Truncal vagotomy with gastrojejunostomy (GJ) is the standard treatment for chronic cicatrizing duodenal ulcer with gastric outlet obstruction. We tried to determine if a significant functional difference exists in the early and late outcomes following anterior and posterior types of GJ to treat this condition. The case records of 106 patients who underwent truncal vagotomy and GJ at our institute from 1 January 1995 to 31 December 1999 were studied retrospectively. Patients were followed up with a personal interview. Perioperative and long-term parameters were compared in the anterior and posterior G.I. groups. Sixty-five patients (61.32%) were followed up; 31 in the anterior group and 34 in the posterior group. The median follow-up was 5 years (range 2.5-7.5 years). Except for a significant difference in length of afferent loop (p < 0.0001), there were no significant differences in the duration of hospital stay, nasogastric aspirates on postoperative days 1, 2, 3 and 4 and the day the nasogastric tube was removed. Early postoperative complications were uncommon and not different in the two groups and long-term outcomes were similar. The Anterior GJ, being technically easier and needing less operative time, may be advocated in all cases of chronic duodenal ulcer, with gastric outlet obstruction requiring truncal vagotomy and drainage.

Clinical aspects of adhesive intestinal obstruction.

BACKGROUND: Mechanical intestinal obstruction remains one of the commonest surgical emergencies. With hernias being electively repaired and obstructive hernias becoming less common, adhesive obstruction has emerged as the leading cause of intestinal obstruction in the west. This study was designed to analyse any such changes in the pattern of intestinal obstruction in the population of Pondicherry of Tamilnadu of South India. METHODS: Data were collected from the compiled case records at JIPMER, Pondicherry, both retrospectively and prospectively from 1984 to 1992 about the clinical aspects of intestinal obstruction and analysed. RESULTS: There were 572 patients admitted with a diagnosis of intestinal obstruction in this period. Obstructed external hernia occurred in 219 patients and adhesive obstruction in 176 patients. Fourteen percent of the patients with adhesive obstruction had appendicectomy as the index laparotomy in the past. Majority of the patients presented within 10 years of the index laparotomy. Adhesive obstruction was managed mainly by conservative treatment in 109 cases. There were 25 patients with recurrent obstruction; most of them were conservatively managed. CONCLUSIONS: Obstructed external hernias were the commonest cause of intestinal obstruction. Increasing the patient awareness will help to decrease the incidence of obstructed hernias significantly. Adhesive obstruction deserves a conservative approach with judicious application of surgical intervention. A careful approach is required to avoid the increased morbidity and mortality associated with delay in the diagnosis of gangrenous obstructions.

Clinical and sonographic findings in carcinoma of the penis.

PURPOSE: This study was performed to assess the accuracy of high-resolution sonography in measuring penile carcinoma. METHODS: Sonography was performed using a 7.5-MHz linear-array transducer in 59 patients with penile carcinoma. The sonographic measurement of tumor extent was compared with clinical and pathologic measurements. The tumor extent measured by gross pathologic evaluation on cut sections of the fresh penectomy specimen was used as the definitive standard. The echogenicity of the tumor was compared with that of the surrounding normal penile tissue to classify the tumor as hyperechoic, hypoechoic, or of mixed echogenicity (containing both hyperechoic and hypoechoic elements). We evaluated the relationship between the echogenicity of the tumor and both tumor morphology (exophytic or infiltrative) and tumor grade as determined on pathologic examination. RESULTS: The overall mean difference +/- standard deviation in the tumor extent between clinical and gross pathologic evaluation was 3.9 +/- 5.3 mm (range, 1-9 mm), whereas the overall mean difference between sonographic and gross pathologic evaluation was 1.2 +/- 1.7 mm (range, 1-7 mm). As determined with reference to the gross pathologic extent, the error in measuring the extent on clinical examination was significantly greater than the error on sonography (p < 0.001). Lesions involving the glans alone were more often underestimated by clinical examination than were lesions involving the shaft (with or without glanular involvement). The error in measuring the extent of tumor by sonography was not related to the site of the tumor. The tumor was hyperechoic in 21 cases (36%), hypoechoic in 28 cases (47%), and of mixed echogenicity in 10 cases (17%). There was no significant association between echogenicity and tumor morphology or grade. CONCLUSIONS: Sonography gives a more accurate estimate of penile tumor extent than does physical examination. Routine use of sonography for such measurements should enable preservation of more of the penis.

The histological extent of the local spread of carcinoma of the penis and its therapeutic implications.

OBJECTIVE: To explore the possibility of reducing the margin of clearance at surgery for carcinoma of the penis without causing an increase in the incidence of local tumour recurrence, so that the functional and cosmetic compromise associated with penectomy might be minimized. PATIENTS AND METHODS: Sixty-four patients underwent partial or total penectomy based on the extent of tumour. The specimens were evaluated histologically for grade and for proximal microscopic extensions beyond the grossly visible tumour margin, by examining serial proximal 5 mm sections. The histological grade of the lesion was correlated with its clinical site, morphology and proximal microscopic spread. Differences were assessed using the chi-squared test. RESULTS: Of 64 tumours, 31% were grade 1, 50% grade 2 and the remaining 19% grade 3. Higher grade lesions were more likely to involve the penile shaft. The maximum proximal histological extent was 5 mm for grades 1 and 2, and 10 mm for grade 3 tumours; there was no discontinuous spread. CONCLUSIONS: Histological grading is mandatory in the management of carcinoma of the penis. A 10-mm clearance is adequate for grade 1 and 2 lesions, and 15 mm for grade 3 tumours. This approach would qualify more patients for partial rather than total amputation; the residual length of the penis would then be cosmetically and functionally more acceptable.

A unique case of metastatic penile basal cell carcinoma.

Basal cell carcinoma rarely arises in the penis and metastasizes infrequently. This article presents probably the first case report of a metastatic penile basal cell carcinoma.

A study of the risk of strangulation and obstruction in groin hernias.

BACKGROUND: Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. METHODS: This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high-risk factors. RESULTS: Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. CONCLUSIONS: The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).

Gastrojejunocolic fistula following surgery for peptic ulcer.

This article aims to emphasize that gastrojejunocolic fistula following peptic ulcer surgery, though uncommon in the post vagotomy era, still continues to occur. We stress the changing trends in its epidemiology, aetiopathogenesis and treatment. The case records of 12 patients with gastrojejunocolic fistula (seen over a 15 year period) were reviewed. Details regarding clinical presentation, investigations and treatment were analyzed and the results compared with previous published series. All the 12 patients in this study had a short loop posterior retrocolic gastrojejunostomy as part of the primary peptic ulcer surgery. Diarrhoea and profound weight loss was present in all of them. Incompleteness of vagotomy was proved in all the six patients investigated for the same. The fistula was demonstrated in all of them on barium enema, while it was seen on upper GI endoscopy in 4. Eight patients were treated by a one stage resection and repair of fistula. A three stage procedure was performed in two.

Primary actinomycosis of the breast: a clinical review and a case report.

An uncommon situation of primary actinomycosis of the breast is reported in a 40-year-old woman who presented with a lump, clinically simulating malignancy, in the right breast. Diagnosis of actinomycosis was established by incision biopsy. Resolution of infection, while conserving the breast, was achieved by timely diagnosis, limited surgery, and effective antibiotic therapy. Diagnostic failures leading to avoidable mastectomies have not been uncommon in cases previously reported in the literature. It is, therefore, imperative that this condition be considered in the differential diagnosis of intractable breast abscess and malignancy.

Malignant granular cell tumour. A case report and review of literature.

A rare case of malignant granular cell tumour of the anterior abdominal wall in a woman of 30 years is reported and and the relevent literature is briefly reviewed.

Primary disseminated fusarial infection.

Among the fungal pathogens the species Fusariam solani causing systemic infection is very rare and generally causes systemic infection only in an immuno-compromised host. We report a systemic infection caused by F. solani in a non-immunocompromised adult male, to our knowledge the first such case report.

Postoperative peritoneal lavage in generalised peritonitis. A prospective analysis.

Fifty patients with generalised peritonitis were studied in the period between November 1984 and May 1986, 20 with postoperative peritoneal lavage and 30 with only conventional treatment. The study revealed that lavage could not reduce mortality. There was a large number of reperforation and anastomotic leak associated with it. Among patients who survived, lavage did however aid in rendering patients afebrile and in the return of the bowel sound early. Hospital stay was also reduced. We agree with earlier suggestions that the use of peritoneal lavage with its labour, intensiveness and potential complications is restricted to gross peritoneal contamination and its use in lesser degree of peritonitis is questionable.

A study on laboratory diagnosis of liver abscess in Pondicherry.

A study was carried out to evaluate the role of laboratory investigations for diagnosis of liver abscess from the year 1976 to 1981. Bacteriological, parasitological, serological, haematological, histopathological studies and liver function tests were carried out in 240 confirmed cases of liver abscess during the study period. Out of 219 cases, pus culture for pyogenic bacteria was positive in 68 cases (including 27 cases of secondary bacterial infection of amoebic liver abscess) and sterile in 151 cases. Ent histolytica was demonstrated in pus of 24 cases. The diagnostic titre of 1:128 and above was detected in 137 sera by isohaemagglutination test. The liver function tests were of limited value. Albumin globulin ratio was altered in 91.25% cases and there was moderate increase in the levels of alkaline phosphatase. Histopathological studies demonstrated Ent histolitica in 2 cases only. Changes characteristic of pyogenic liver abscess were observed in 6 cases. Rest showed no specific changes.