Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis.

The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.

Endoscopic Ultrasound-Guided Gallbladder Drainage.

The mainstay of management of acute cholecystitis is surgical. Despite the advances in anesthesia and laparoscopic surgery, there is a significant pool of patients that are not candidates for surgery given their significant comorbidities and limited functional reserve. Historically percutaneous gallbladder drainage has been utilized to temporize these patients. Recently, endoscopic approaches are being explored with transpapillary and transmural drainage. In this article, we discuss the background, current status, technical challenges, adverse events, and outcomes of endoscopic ultrasound-guided gallbladder drainage for management of acute cholecystitis.

Percutaneous endoscopic sigmoidopexy using T-fasteners for management of sigmoid volvulus.

BACKGROUND: Sigmoid volvulus (SV) is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. SV has traditionally been managed via endoscopic detorsion and decompression followed by non-emergent surgical resection owing to the high risk of recurrence. Most cases of SV occur in elderly debilitated patients with multiple comorbidities and may not be candidates for surgical resection. Endoscopic sigmoidopexy has been described as an alternative to surgical resection. Here, we describe our experience with endoscopic sigmoidopexy using T-fasteners. METHODS: Three patients with recurrent SV that were identified as poor surgical candidates by our colorectal surgery team underwent endoscopic sigmoidopexy. The patients received preoperative bowel preparation. A colonoscope was inserted and the site of the volvulus was visualized and assessed for adequate decompression. Subsequently, four points of fixation were identified and T-fasteners were deployed. RESULTS: Two patients underwent successful sigmoidopexy without any complications or recurrence on follow-up. One patient developed post procedure pneumoperitoneum that was successfully treated conservatively; however, he passed away from their underlying comorbidities. CONCLUSION: Overall, preliminary results for sigmoidopexy using T-fasteners have been promising, offering a potential option to prevent recurrence in high risk patients unsuitable for surgical intervention.

A comparative analysis of toluidine blue with frozen section in oral squamous cell carcinoma.

BACKGROUND: Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins. METHODS: After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section. RESULTS: Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%. CONCLUSIONS: Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available.

Endocrine complications in patients of beta thalassemia major in a tertiary care hospital in Pakistan.

OBJECTIVE: To determine the major endocrine complications present in patients of Thalassemia major presenting to a tertiary care center in Karachi, Pakistan. METHODS: Records of all thallasemia major patients at a Haematology Department in a tertiary care hospital of Karachi were retrospectively reviewed from May to August 2009 with specific focus on endocrine data and investigations. The patients' data was recorded in a questionnaire and analyzed using SPSS v.17, frequencies and percentages along with corresponding 95% confidence interval were computed. RESULTS: Our data revealed that a significantly small percentage of those under care received regular endocrine follow-up. Male hypo-gonadal abnormalities had the highest probability; 100% of the tested patients had decreased levels of testosterone, while 95.2% had raised serum creatinine levels. Parathyroid dysfunction was noted in 40% of the patients. Of those screened 29.4% had blood glucose levels in the diabetic range and 11.8% of the tested patients had reduced levels of FT4. CONCLUSION: A high frequency at endocrine dysfunctions seen in thalasaemia patients included: male hypogonadism, parathyroid dysfunction, deranged blood glucose and FT4 levies.

Primary central nervous system lymphoma causing multiple spinal cord compression and carcinomatous meningitis in a 6-year-old: a case report.

Primary central nervous system lymphoma (PCNSL) is an uncommon form of non-Hodgkin lymphoma affecting the brain, spinal cord, and leptomeninges. Carcinomatous meningitis (CM) and spinal cord compression in PCNSL are very rare and usually present in advanced stages of the disease. The average survival time of a CM patient is about 4 to 6 weeks, which may be extended to about 4 to 6 months with treatment. Here we present a case of CM and spinal cord compression by multiple PCNSL in a 6-year-old girl, who has survived 2 years and 9 months posttreatment with no recurrence. To the best of our knowledge this is the very first case reporting survival after CM. The patient presented with weakness of her right arm, right leg, and left side of the face. Examination revealed mild facial asymmetry with left facial lower motor neuron palsy and lateral gaze restriction of left eye. Magnetic resonance imaging of her spinal cord showed postcontrast enhancement of the intradural structures on the spinal canal at levels C3-C6 and L1-L5 and along with the intracranial leptomeninges. Histopathological examination of the neoplastic tissue from cauda equina revealed B-cell non-Hodgkin lymphoma. After chemotherapy her disease regressed and magnetic resonance imaging showed no evidence of recurrence or residual disease. In our experience the response to chemotherapy was remarkable and recommend that aggressive tumor resection strategies should be reserved for cases with severe signs of spinal compression.

Cranial reconstruction after decompressive craniectomy: prediction of complications using fuzzy logic.

INTRODUCTION: Cranial reconstruction after decompressive craniectomy (DC) has been shown to be associated with a relatively high complication rate (16.4%-34%) compared with standard neurosurgical procedures (2%-5%). Most studies that have previously attempted to formulate a multivariate model for identifying factors predictive of postoperative complications of cranioplasty either were unsuccessful or yielded conflicting results. Therefore, fuzzy logic-based fuzzy inference system (FIS), which has proven to be a useful tool for risk prediction in medical and surgical conditions, was used in this study to identify predictors of complications of cranioplasty. METHODS: A retrospective chart review of all the patients who underwent DC followed by elective cranioplasty at Aga Khan University Hospital, during a 10-year period (2000-2010), was carried out to collect data on 24 carefully selected preoperative variables or inputs. The proposed FIS had 24 inputs, 3 outputs, and a set of 7 fuzzy-based rules. All inputs were assigned degrees of membership, and complications were further divided into "severe," "minor," and "least" output classes with each of them representing 2 membership functions: "less" and "more." For each set of inputs, a specific portion of the hypersurface was masked out. The centroid of this subsurface represented the defuzzified output corresponding to 1 percentage value for each output. The maximum of these outputs for each of the 3 output classes was selected to be the final output class. Each output class was compared to the actual outcome of patients, and positive predictive value, negative predictive value, sensitivity, and specificity of FIS for predicting complications were calculated. RESULTS: A total of 89 patients (mean [SD] age, 33.1 [15.0] y; male-to-female ratio, 3:1) were included in the study. The common postoperative complications included seizures (14.6%), cerebrospinal fluid leak (4.5%), neurologic deficits (3.4%), hydrocephalus (3.4%), superficial wound infection (3.4%), and osteomyelitis (2.2%). The FIS correctly identified all 7 patients who developed severe complications after cranioplasty (true positives) and all 82 patients who did not develop severe complications (true negatives). Thus, the FIS has a sensitivity and specificity of 100% in predicting severe complications. CONCLUSIONS: Our study shows that the procedure of cranioplasty is associated with a high complication rate and that FIS has a 100% sensitivity and specificity in predicting severe complications after cranioplasty. It will prove to be an invaluable tool for clinicians once the results are validated by a similar prospective study with a larger sample size.

Neuronavigation assisted endoscopic sinus surgery.

In the past two decades, endoscopic sinus surgeries (ESS) have been widely advocated as a safe and effective treatment for disorders of paranasal sinuses that are refractory to medical therapy. ESS caters surgeons with two-dimensional visualization of the anatomical structures; however in scenarios where there is a close anatomical relation between the disease and delicate intracranial or intraorbital structures drastic complications can occur. Hence, endoscopic procedures had to be converted into open surgical procedures if the extent of the disease could not be visualized or cleared thoroughly. Recently however; neuronavigation systems have been combined with ESS to yield better results and facilitate this procedure. The implementation of these systems with ESS has aided surgeons in difficult approaches. We recently decided to use the neuronavigation system of our Neurosurgical department to help aid eradicate various nasal and sinus pathologies in a series of patients.

Causes of smoking in Pakistan: an analysis of social factors.

OBJECTIVE: To determine the factors contributing to the initiation and propagation of smoking in visitors to a major tertiary health center in Karachi, Pakistan. METHODS: Seven major contributing factors to the initiation and propagation of smoking were presented to consenting study participants (n=170) in a questionnaire. Participants were then requested to use their experience and opinion to rate each of the given factors on a scale of 1 to 5 regarding its importance as a causative factor in the initiation and propagation of smoking. Results were analyzed using SPSSv16.0. RESULTS: Preliminary analysis revealed occupational stress relief as the most important factor contributing to smoking with a mean score of 3.25 +/- 1.32. Peer pressure ranked second (Score 3.20 +/- 1.42). Domestic stress relief ranked third with a score of 3.19 +/- 1.32. Smokers gave lower rating than non-smokers to most factors. Younger participants gave higher ratings to peer pressure, and most participants were found to have begun smoking at a young age. CONCLUSIONS: Even though the addictive power of nicotine or stress may appear as a factor in middle aged smokers, the root of their habit lies in the initiation due to peer pressure.