Esophageal carcinoma during pregnancy: a case report.

Association of pregnancy with esophageal cancer is an extremely rare event. The symptoms are frequently masked by factors related to normal pregnancy and diagnostic approaches are restricted by physical and psychological clinical events. Hence, the cancer stage is usually advanced at the time of diagnosis. The approach to cancer surgery and chemotherapy must be modified in pregnant patients to minimize fetal and maternal risks. We present an extremely rare case of carcinoma esophagus during pregnancy.

Posterior Superior Mesenteric Artery (SMA) First Approach vs. Standard Pancreaticoduodenectomy in Patients with Resectable Periampullary Cancers: a Prospective Comparison Focusing on Circumferential Resection Margins.

BACKGROUND: The 'SMA-first' (P-SMA) pancreatoduodenectomy (PD) allows dissection directly on the right lateral aspect of superior mesenteric artery (SMA) which may decrease circumferential resection margin (CRM) positivity. This comparative study between standard PD (sPD) and P-SMA approach was planned focusing on CRM involvement. METHODS: This was a prospective study comparing consecutive patients with resectable periampullary cancers (PACA) undergoing PD using the standard or P-SMA approach. The perioperative outcomes and the CRM positivity rates (specimens analysed according to the standardized Leeds pathology protocol (LEEPP)) were compared. RESULTS: Overall, 39 patients (28 men; mean age 54 years; sPD 21, P-SMA 18) were included. Both groups were comparable with regard to demographic/tumour characteristics and perioperative outcomes. The P-SMA technique was significantly faster (321.1 ± 54.0 vs. 357.6 ± 55.8 min; p = 0.05). Though the mean tumour size (2.2 vs. 2.1 cm; p = 0.84) and T stage (T2 and T3) distribution were similar in both groups, lymph node yield was significantly higher in the P-SMA group (10.7 vs. 5.95; p = 0.001; mean 8 (2-21)). Though CRM positivity (margin <1 mm) occurred in 8 (21.1%), we did not find the P-SMA PD to yield significantly lower CRM positivity rates compared to the sPD (3/17 (17.6%) vs. 5/21(23.8%); p = 0.71). At a median follow-up of 28 months, fewer patients in the P-SMA PD group developed recurrence (2/15 vs. 5/19; p = 0.3) or died (3/15 vs. 7/19; p = 0.19), though this difference was not significant. CONCLUSIONS: In patients with resectable PACA, P-SMA PD was significantly faster and yielded higher lymph node counts in the specimen but did not lower the rate of CRM positivity as determined by the LEEPP.

Evaluation of Pringle maneuver during liver resection in a rat model of surgical obstructive jaundice.

Temporary portal triad clamping (Pringle maneuver) during liver resection reduces intraoperative blood loss. A normal liver can safely tolerate normothermic ischemia for up to 60 min. However, its safety in patients with surgical obstructive jaundice (SOJ) is not known. Therefore, we investigated the effect of hepatic ischemia in an experimental rat model of SOJ created by ligating the bile duct. Four groups of rats were created: Group I (sham operation, 10 days later, liver resection); Group II (sham operation, 10 days later, liver resection with 5 min of hepatic ischemia); Group III (bile duct ligation, 10 days later, liver resection); and Group IV (bile duct ligation, 10 days later, liver resection with 5 min of hepatic ischemia). The ischemic injury was assessed by the survival of rats, liver tissue malondialdehyde and total glutathione (markers of free radical injury), serum alanine aminotransferase, aspartate aminotransferase, and liver histology. The results showed decreased survival (47.6% vs. 90% [p = .046]), increased liver tissue malondialdehyde (161 +/- 35 vs. 129 +/- 33 microg/gm liver tissue [p = .05]), and decreased liver tissue total glutathione (565 +/- 169 vs. 1075 +/- 276 nmol/gm liver tissue [p = .05]) in rats with SOJ subjected to hepatic ischemia when compared to nonjaundiced rats. The changes in serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase showed an increasing trend in the SOJ group but were not statistically significant. Ischemic changes in liver histology were seen more often in the SOJ group but were not statistically significant. These data suggest that temporary portal triad clamping in an experimental model of SOJ is detrimental to the outcome of liver resection.

Esophageal squamous cell carcinomas with DNA replication errors (RER+) are associated with p16/pRb loss and wild-type p53.

PURPOSE: Microsatellite instability (MSI) as a determinant of propensity to esophageal squamous cell carcinoma (ESCC) at seven microsatellite markers at 2p (2p15-16), 3p (3p13, 3p14.1-3, 3p25, and 3p26) and 16q (16q12.1-3) was investigated to analyze their putative role as indicators of predisposition to esophageal malignancies. METHODS: Seven microsatellite loci were amplified by polymerase chain reaction, from surgically resected tumor tissues from 30 ESCC patients from Indian population, to assess the loss of heterozygosity (LOH) and replication error repeats (RER) and to correlate these alterations with aberrations in major cell cycle regulatory proteins and histopathological parameters. RESULTS: LOH and RER analyses at these loci demonstrated moderate microsatellite alterations, suggesting the involvement of MSI in esophageal tumorigenesis in a subset of the Indian population. MSI, defined as RER in at least two or more of the loci studied, was observed in ten of 30 (33%) patients. Twenty-two of 30 patients (73%) showed LOH at one or more loci, while 17 of the 30 patients (60%) showed RER in at least one of the loci studied. RER-positive patients showed a trend towards better prognosis when compared to RER-negative patients. MSI demonstrated a significant association with concomitant loss of p16 and pRb (p16-/pRb- phenotype) (P=0.046). Interestingly, we observed an inverse correlation between MSI and p53 mutations (P=0.03) suggesting that MSI may provide a p53-independent pathway for esophageal tumorigenesis in RER+ patients. MSI showed a trend towards longer survival and absence of distant organ metastasis (P=0.06). CONCLUSIONS: The present study demonstrates the probable role of MSI in esophageal squamous cell carcinoma in the Indian population. Instability associated with the repetitive sequences--the revealing marks of loss of DNA replication fidelity may serve as an indicator of predisposition to esophageal cancer.

Antileishmanial activity of mycobacillin.

Mycobacillin, a cyclic polypeptide antifungal antibiotic effectively inhibits the growth of promastigote form of the protozoal organism, Leishmania donovani, strain 81 in liquid medium. Oxygen uptake by intact cells of the protozoa with exogenous glucose is appreciably reduced within first 30 minutes in presence of the antibiotic at a concentration of 15 microng/ml. Appreciable leakage of intracellular 260 nm and 280 nm absorbing materials takes place from the protozoan cells incubated with the antibiotic at similar concentration.

Relative merits of ultrasonography, computed tomography and cholangiography in patients of surgical obstructive jaundice.

Fifty consecutive patients with surgical obstructive jaundice were evaluated prospectively with ultrasonography (US), computed tomographic scans (CT scan) and cholangiography-percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangio-pancreaticography (ERCP). The diagnostic accuracy of ultrasound in defining the level of obstruction was 86% as compared to 86% and 94.8% for CT scan and cholangiography, respectively. To measure the etiology of the obstruction, the accuracy of ultrasound, CT scan and cholangiography were 84%, 86% and 75%, respectively. The sensitivity of CT scans and cholangiography in the diagnosis of choledocholithiasis was 100%, 81.8% and 90%, respectively, whereas specificity was 97%, 100% and 100%, respectively. Sensitivity for a diagnosis of malignant disease was 100% for both US and CT scans whereas specificity was 90% and 81%, respectively. Ultrasonography as a single radiological investigation is sufficient in the evaluation of the majority of patients with surgical obstructive jaundice. CT scan and cholangiography should be done only when US gives equivocal findings or if concomitant therapeutic procedures like basketing and stenting are also planned.

Intussuscepting ileal hemangioma with perforation.

A rare case of solitary intussuscepting capillary hemangioma in the distal ileum with perforation and peritonitis is presented. The diagnosis was made only at surgery for presumed acute intestinal obstruction.

Video assisted thoracoscopic surgery (VATS) in the diagnosis of intrathoracic pathology: initial experience.

We report our experience with the use of video-assisted thoracoscopic surgery [VATS] in the diagnosis of intrathoracic disease of unknown origin. In the last two years, 32 patients (18 males) underwent this procedure for diagnostic purposes. Of them, 18 patients had lung pathology, eight mediastinal and six pleural disease. All attempts at achieving a tissue diagnosis were unrewarding. In all of them, diagnostic thoracotomy was being contemplated to procure tissue for histopathological diagnosis. Diagnostic thoracoscopy was successful in providing tissue diagnosis in all the patients with lung disease; seven of the eight patients with mediastinal pathology and five of the six patients with pleural lesions. Diagnostic thoracoscopy was associated with minimal morbidity, short hospital stay, better cosmetic result and quicker return to work as compared to conventional thoracotomy. We conclude that video-assisted thoracoscopy is an excellent diagnostic tool to confirm tissue diagnosis in patients with undiagnosed chest diseases.

Short segment oesophago-cardiomyotomy for achalasia cardia.

Over a seven year period, 25 patients of achalasia cardia underwent a transabdominal short segment oesophago-cardiomyotomy. There was no operative mortality. Two patients had a mucosal tear, detected intraoperatively and promptly repaired. All patients were regularly followed up (range 1 to 7 years). Clinical results were excellent in 76%, good in 20% and fair in 4%. No patient developed reflux or required reoperation for residual dysphagia. We conclude that a transabdominal short segment oesophago-cardiomyotomy performed carefully is a safe and effective procedure in the treatment of achalasia.

Dumping syndrome in the intra-thoracic stomach.

Thirty seven patients who survived at least 6 months after oesophagectomy and cervical oesophagogastrostomy for benign and malignant diseases of the oesophagus were evaluated for dumping syndrome. Twenty two of these patients had a pyloroplasty and fifteen had no drainage procedure. All these patients were subjected to a dumping provocation test. Evidence of dumping was noted in four patients, all having a pyloroplasty. Clinically, these four patients had mild symptoms which improved with dietary adjustment. We conclude that dumping does occur following thoracic transposition of the stomach and seems to occur more in patients with pyloroplasty than those without it.

Peroperative cholangiogram--routine or selective results of a prospective study.

Peroperative cholangiography (POC) performed as a routine during cholecystectomy for cholelithiasis was evaluated in 102 patients. POC was normal 93 patients. Nine patients had abnormal POCs: 5 were true positive--CBD stones (4) and sphincteric fibrosis (1): 4 were false positive--air bubbles (2) and sphincteric spasm (2). Preoperative indication of CBD stones were present in 12 patients-5 of these had abnormal POC (4 true positive and 1 false positive). CBD exploration was avoided in 7 patients with normal POC. Ninety patients did not have any preoperative indication of CBD stones-4 of these had abnormal POC (1 true positive and 3 false positive). None of the patients with a normal POC had any clinical evidence of residual stones on follow up for one year. POC did not help in any case to delineate biliary ductal anatomy. Routine POC during cholecystectomy should be abandoned and should be performed selectively in patients suspected to have CBD stones only to avoid a negative CBD exploration.

Prognostic significance of argyrophilic nucleolar organizer regions (AGNOR) in oesophageal cancer.

AgNOR (Argyrophilic nucleolar organiser region) has been shown in recent times, to have value in knowing the prognosis of carcinoma oesophagus. We have evaluated the significance of AgNOR in oesophageal cancer with reference to prognosis following treatment. Fifty patients of histologically proven squamous cell carcinoma of the oesophagus were studied. Following oesophagectomy the specimens removed were evaluated for AgNOR number. Of the resected specimens, 25 (50%) had an AgNOR count < or = 3.0, 18 (36%) had an AgNOR count of more than 3 per nucleus and in the remaining 7 cases, AgNOR number was not quantifiable due to the total absence of tumour tissue in the postoperative specimen due to preoperative radiotherapy. When followed up for an average period of 25 months (3 to 47 months), it was seen that patients with AgNOR count of < or = 3.0 per nucleous had a similar mean survival (30.39 +/- 3.29 months) as those with counts > 3.0 per nucleus (27.80 + 3.33 months). The survival in the seven patients in whom no tumour was present following preoperative radiotherapy, was 30.30 +/- 2.42 months. An analysis was done for the presence of change in the AgNOR count before and after radiotherapy in twenty eight case of carcinoma oesophagus treated with preoperative radiotherapy. It was found that the counts on an average were lower in patients after radiotherapy (2.89 +/- 1.04 per nucleus), than before radiotherapy (3.17 +/- 9.69). This was found in 24 cases, while the remaining 4 cases showed no change in count after radiotherapy. This suggested that radiotherapy caused a reduction in AgNOR counts. Mean survival in those with decreased count after radiotherapy was 33.65 (+/- 3.35) months. Since the AgNOR counting is a simple method and can be applied to paraffin embedded section, estimation of the AgNOR number may help in determination of prognosis in patients with oesophageal carcinoma. Preoperative radiotherapy seems to decrease AgNOR count with improved survival. These observations need however, to be reproduced with a larger sample size.

Spontaneous hemoperitoneum due to rupture of hepatocellular carcinoma.

Spontaneous rupture with hemoperitoneum is one of the atypical modes of presentation of hepatocellular carcinoma (HCC), common in the orient (8-14% cases) but reported only once from India. Another case is being reported here. Hemostasis can be achieved by transcatheter hepatic artery ligation, intralesional alcohol injection, microwave application, curettage with suturing or gauze packing. Resectional surgery, preferably at a second stage, has the best long term outcome. Prognosis remains poor with few long term survivors.

Functional outcome and patient satisfaction after ileal pouch anal anastomosis for ulcerative colitis in a developing country.

AIM: To study the long-term outcome and patient satisfaction of patients with an ileal pouch-anal anastomosis (IPAA) for ulcerative colitis in India. PATIENTS AND METHODS: We studied 35 patients who had undergone IPAA for ulcerative colitis between 1985 and 1998 and had intestinal continuity restored for more than 6 months. These patients were asked to answer a detailed questionnaire on their bowel function, urogenital function, etc. A complete haemogram, serum iron studies, liver function tests and D-Xylose absorption test were done. In addition hepatobiliary ultrasound, stool microscopy, pouchoscopy and pouch biopsies were also performed. Patient satisfaction after the procedure was also evaluated. RESULTS: Thirty-five patients (17 men and 18 women) underwent a complete evaluation. The duration after restoration of continuity ranged from 6 months to 164 months (mean 78.6 months). The mean stool frequency was 7.2 stools per 24 hours. Five patients had urgency of stool, 9 had occasional soiling and 1 had major incontinence. Four patients had minimal restriction of social activities and 1 discontinued his employment. All patients were sexually satisfied except one man who had impotence and one woman who had dyspareunia. Fifteen patients had abnormal serum iron studies (Haemoglobin < 9 g/dl in 11). Eleven patients had D-Xylose absorption below normal values. Two patients were found to have gallstones. All pouch biopsies showed chronic inflammation and 1 patient had histological evidence of pouchitis. Eighty-five percent of patients reported that they were very satisfied with the procedure. CONCLUSION: Good functional recovery and acceptance of the procedure over the long term suggests that it is a valid procedure to be recommended for patients with ulcerative colitis in India.

Splenic abscess--case report and review of literature.

Isolated splenic abscess is a rarity and remains a diagnostic dilemma. The presentation is nonspecific and diagnosis is often delayed. We present a case which had roentgenographic signs suggestive of splenic suppuration at admission. Of particular interest was the isolation of Salmonella paratyphi in this patient. Antibiotic therapy alone is insufficient and splenectomy remains the treatment of choice. The literature on splenic abscess is briefly reviewed.

Structural and functional aspects of the thoracic stomach.

The acid secretory and emptying function of the thoracic stomach was evaluated in 10 patients, following total oesophagectomy and gastric pull-up for oesophageal cancer. All patients had a Heinecke Mickulicz pyloroplasty. Endoscopic features and histological review of endoscopic biopsies were also studied in these patients. Acid secretion was higher in those with prolonged emptying. This was however, not statistically significant. Gastritis was more severe in those with prolonged emptying. Endoscopic diagnosis of gastritis was found unreliable while histopathology of endoscopic biopsy gave definite evidence of gastritis.

Intussusception due to gastrointestinal stromal tumour of the colon: diagnosis by colonoscopy.

Intussusception of the intestine is rare in adults. We report a case of a 45-year-old male who presented with long-standing pyrexia of unknown origin, abdominal pain, gastrointestinal bleeding and constitutional symptoms. Colonoscopic examination revealed a large invaginated mass suggestive of colonic intussusception due to gastrointestinal stromal tumour of the colon. His symptoms disappeared after surgical removal of the tumour.

Fine needle aspiration cytology, sonography and radionuclide scanning in solitary thyroid nodule.

One hundred and ninety three consecutive patients with solitary thyroid nodule (STN), with a mean age of 36.0 +/- 12.8 years and male to female ratio of 5.6:1, were studied. Ninety five percent of patients came from iodine deficient regions. Seventy two percent presented for local neck swelling, 12.4% for hyperthyroid state and in 7.7% STN was discovered incidentally. Scintigraphically, 77.7% of nodules were cold, 12.4% hot and 8.5% warm. Sonographic evaluation did not reveal any characteristic echotexture diagnostic of malignancy, but detected clinically nonpalpable accessory nodules in 20.6% of patients. Fine needle aspiration cytology was positive for malignancy in 6.2% of patients. Features of follicular and Hurthle cell neoplasm were seen in 12.9% of aspirates. Eighty eight (45.6%) STN were resected surgically. Histologically, there was one false positive and one false negative aspirate and a case of parathyroid adenoma on aspiration proved to be parathyroid carcinoma on histology.