NMR spectroscopy-based analysis of gallstones of cancerous and benign gallbladders from different geographical regions of the Indian subcontinent.

Analysis of the chemical composition of gallstones is vital for the etiopathogenesis of gallstone diseases that can ultimately help in the prevention of its formation. In the present study, gallstones from seven different regions of India were analyzed to highlight the major difference in their composition. Also, gallstones of different pathological conditions i.e., benign (chronic cholecystitis, CC) and malignant gallbladder disease (gallbladder cancer GBC) were characterized. The type of polymorphs of cholesterol molecules was also studied to provide insight into the structure of gallstones. 1H solution state NMR spectroscopy 1D experiments were performed on a total of 94 gallstone (GS) samples collected from seven different geographical regions of India. Solid-State NMR spectroscopy 13C cross-polarization magic angle spinning (CPMAS) experiments were done on the 20 CC GS samples and 20 GBC GS samples of two regions. 1H NMR spectra from the solution state NMR of all the stones reveal that cholesterol was a major component of the maximum stones of the north India region while in south Indian regions, GS had very less cholesterol. 13C CPMAS experiments reveal that the quantity of cholesterol was significantly more in the GS of CC in the Lucknow region compared with GBC stones of Lucknow and Chandigarh. Our study also revealed that GS of the Lucknow region of both malignant and benign gallbladder diseases belong to the monohydrate crystalline form of cholesterol while GS of Chandigarh region of both malignant and benign gallbladder diseases exists in both monohydrate crystalline form with the amorphous type and anhydrous form. Gallstones have a complicated and poorly understood etiology. Therefore, it is important to understand the composition of gallstones, which can be found in various forms and clinical conditions. Variations in dietary practices, environmental conditions, and genetic factors may influence and contribute to the formation of GS. Prevention of gallstone formation may help in decreasing the cases of gallbladder cancer.

Bacteriological profile of pancreatic juice in patients with chronic pancreatitis.

CONTEXT: Information regarding the association of bacteria in the pancreatic fluid in patients with chronic pancreatitis is limited. OBJECTIVE: This study was designed to analyze the prevalence of bacteria in pancreatic juice in patients with chronic pancreatitis and the association of positive pancreatic fluid culture with pre-operative and post-operative parameters. METHODS: All patients with chronic pancreatitis who underwent operation from November 2011 to October 2013 were prospectively included in the study. Intra-operatively pancreatic duct fluid was collected and sent for culture sensitivity in all patients. The bacteriology of the fluid was analyzed and was correlated with preoperative, intraoperative and postoperative parameters. RESULTS: A total of 26 patients were analyzed. Two patients underwent endoscopic retrograde cholangio-pancreatography (ERCP) preoperatively. Bacteria was present in pancreatic duct fluid in 11 (42%) patients. Both patients who underwent ERCP had positive cultures. Most common organism observed was Escherichia coli (6/11, 55%) followed by Klebsiella pneumonia (3/11, 27%). Five patients with positive culture developed wound infection. Bacteria isolated from the wound were similar to pancreatic fluid. CONCLUSION: Bacteria is commonly present in the pancreatic juice in patients with chronic pancreatitis and its presence may have an effect on the post-operative infections following operations. Based on the pancreatic fluid culture results appropriate antibiotic can be given to the patients who will develop septic complications following surgery. Role of bacteria in the pathogenesis of the chronic calcific pancreatitis needs to be investigated in future studies.

A hospital-based epidemiological study of corrosive alimentary injuries with particular reference to the Indian experience.

Corrosive alimentary tract injuries are a source of considerable morbidity all over the world. Despite this, actual data on the epidemiology of this problem are scarce mainly due to the lack of a well-established reporting system for poisoning in most countries. The burden of the disease is naturally more in countries such as India where the condition is common because of poor regulation of sale of corrosive substances. We analyse the available data on epidemiology of corrosive injuries, as well as patterns of involvement of the alimentary tract, with special reference to Indian data, and also provide an overview of the management options and long-term sequelae of this condition.

Opportunistic Fonsecaea pedrosoi brain abscess in a patient with non-cirrhotic portal fibrosis-induced hypersplenism--a novel association.

Non-cirrhotic portal fibrosis, a common cause of splenomegaly in tropical countries, can lead to hypersplenism and pancytopenia. Hypersplenism in this setting has not been associated with opportunistic infections. We describe a patient with hypersplenism secondary to non-cirrhotic portal fibrosis who developed a Fonsecaea pedrosoi brain abscess and succumbed to the illness despite aggressive management.

Costs of management of bile duct injuries.

BACKGROUND: Only a few studies address the financial impact of the management of bile duct injuries (BDI). This study was aimed to assess the cost of BDI sustained during cholecystectomy. METHODS: Patients who underwent surgical repair for post cholecystectomy BDI and due for routine follow up between August 2006 and September 2007 were called for an interview. RESULTS: 47 patients were interviewed. There were 39 (83%) women and 8 (17%) men. The median direct cost was US$ 1626 (451-11,009); 73,983 (20,521-500,910). The median indirect cost was US$ 312 (26-2,708); 14,196 (1,183-123,214). Total median cost was US$ 2,045 (488-12,369); 93,046 (22,204-562,790). The median total costs of management of BDI was 9.98 times the costs of a cholecystectomy at our centre (US$ 205); (9,328) and was 8.41 times the median monthly income of the patients (US$ 243); (11,057). CONCLUSIONS: Our results will help the hospital administrators and the insurance agencies to calculate and revise the packages and premium for cholecystectomy so that the extra cost of a possible BDI is evenly distributed.

Factors predicting failure following high bilio-enteric anastomosis for post-cholecystectomy benign biliary strictures.

INTRODUCTION: Failures following Roux-en-Y hepatico-jejunostomy (HJ) for post-cholecystectomy benign bile duct strictures (BBS) pose significant challenge. This study was aimed to find out the factors predicting failure after surgical repair in patients with BBS. METHODS: Between January 1989 and May 2007, 364 patients underwent Roux-en-Y HJ to the hilum for BBS. With a median follow-up of 61 (6-212) months, 334 (92%) patients had successful outcome and 30 (8%) had failure. A multivariate analysis was performed to find out the factors predicting failure. RESULTS: Thirty patients who had failure became symptomatic after a median of 35 months (3 days-190 months) after surgical repair. Out of 30 patients, 11 (37%) were experiencing occasional episodes of cholangitis responding to antibiotics. All have patent anastomosis on nuclear scintigraphy and/or cholangiography. Cholangiogram demonstrated anastomotic stricture in 19/30 (63%) patients. Eighteen patients underwent re-intervention for re-strictures (nine--percutaneous balloon dilatation of the stricture, five--revision HJ, one--right hepatectomy, three--a combination of interventions). One patient refused to undergo a planned percutaneous balloon dilatation. Out of 18 patients, 12 (67%) had successful outcome following re-interventions. One patient who underwent revision HJ after a failed percutaneous balloon dilatation died in the immediate postoperative period. Preoperative bilirubin (p = 0.001), attempted bilio-enteric anastomosis before referral (0.004), cirrhosis (0.006), portal hypertension (p = 0.056), repair in the presence of external biliary fistula (0.000), and spontaneous bilio-enteric fistula (p = 0.011) were the factors found to be predicting failure of surgical repair on multivariate analysis. CONCLUSIONS: Previous attempts of repair and delay in repair which predispose cirrhosis and portal hypertension may cause failure of surgical management in patients with BBS. In patients presenting with external biliary fistula, for a better outcome, surgical repair may be delayed till the fistula resolves.

Surgical management of patients with post-cholecystectomy benign biliary stricture complicated by atrophy-hypertrophy complex of the liver.

BACKGROUND: Atrophy-hypertrophy complex (AHC) of the liver rarely complicates post-cholecystectomy benign biliary strictures (BBS). This study aimed to analyse the effect of AHC on the surgical management of patients with BBS. METHODS: Between 1989 and 2005, 362 patients underwent surgical repair for BBS at a tertiary referral centre in northern India. A total of 36 (10%) patients had AHC. Patients with AHC (n= 36) were compared with those without (n= 336) to define the factors associated with the development of AHC. RESULTS: Overall, 35 patients with AHC underwent Roux-en-Y hepaticojejunostomy; right hepatectomy was performed in one patient. The interval between bile duct injury and stricture repair did not influence the development of AHC (mean 24 months in AHC patients vs. 19 months in non-AHC patients; P= 0.522). Of the 36 patients with AHC, 26 (72%) had hilar strictures (Bismuth's types III, IV, V), as did 163 of the 326 (50%) patients without AHC (P= 0.012). Patients with AHC had more blood loss at surgery (mean blood loss 340 ml in the AHC group vs. 190 ml in the non-AHC group; P= 0.004) and required more blood transfusion (mean blood transfused 300 ml vs. 120 ml; P= 0.001). Surgery was prolonged in AHC patients (mean duration of operation 4.2 hours in the AHC group vs. 2.8 hours in the non-AHC group; P= 0.001). Over a mean follow-up of 43 months (range 6-163 months), three of 36 (8%) AHC patients required re-intervention for recurrent strictures, compared with nine of 326 (3%) non-AHC patients (P= 0.006). CONCLUSIONS: Iatrogenic injury at the hepatic hilum predisposes for the development of AHC. Surgery is more difficult and blood transfusion requirements are higher in patients with AHC during surgical repair of BBS. Atrophy-hypertrophy complex is a risk factor for recurrent stricture formation after hepaticojejunostomy.