Search

Background: Management of the pancreatic stump after pancreaticoduodenectomy (PD) is still a matter of debate. Pancreaticojejunostomy (PJ) is used commonly but is associated with a significant incidence of pancreatic leaks. Pancreaticogastrostomy (PG) is an alternative that has been reported to be safer. Methods: The study is a retrospective analysis of all patients having PD for ampullary carcinoma in one surgical unit at All India Institute of Medical Sciences over 18 years, with PG being the only drainage procedure for the pancreatic stump. Results: Among 125 patients having PD for ampullary carcinoma, overall morbidity rate was 28%, mortality rate was 4.8%, with no cases of leakage from the pancreaticogastrostomy. Conclusions: In world literature (including the current series), the leakage rate of PG is 2.5% (14 of 553) with only 2 deaths (2 of 14) due to leakage from PG. Our large experience and these data conclusively prove the safety of pancreaticogastrostomy, which should be the drainage procedure of choice for the pancreatic stump following pancreaticoduodenectomy.

Dietary intake and plasma lipids were estimated in 200 patients with gallstones and 98 control subjects from a hospital in Northern India and were matched for age, sex, and social class. The intake of total calories and carbohydrates and the plasma triglyceride values were higher in all gallstone patients as compared with controls (p < 0.05 and p < 0.01, respectively). The dietary intake of refined carbohydrates was higher than in controls, but only in the female patients with gallstones (35.6 +/- 32.9 g/day compared with 24.5 +/- 11.8 g/day; p < 0.001). By contrast, the male patients with gallstones had an increased intake of fat (patients 79.0 +/- 38.1 g/day vs. controls 60.2 +/- 24.3 g/day; p < 0.05) and had increased plasma cholesterol values (patients 166.4 +/- 54.2 mg/dl vs. controls 140.3 +/- 32.8 mg/dl; p < 0.01). Such sex differences in the dietary intake and plasma lipid values may form a special feature of gallstone disease in Northern India and should be studied further.

Fifty-three patients with suspected gallbladder carcinoma underwent ultrasonography and laparoscopy. Laparoscopy correctly excluded malignancy in five patients when ultrasonography had suggested gallbladder neoplasia. Of 48 patients with gallbladder carcinoma, laparoscopy identified 46 (95.8%) as compared with 30 (62.5%) by ultrasonography (p less than 0.001). Distant metastases in the liver, parietal peritoneum, or omentum were present in 41 patients (85.4%) and were detected by laparoscopy in 39 (sensitivity 95%) and by ultrasonography in 21 (sensitivity 51.2%) (p less than 0.001). Combination of ultrasonography and laparoscopy improved the overall diagnostic accuracy to 100%. Laparoscopy provided histological diagnosis of the disease in 36 patients (75%) and circumvented unnecessary laparotomy in 40 (83.3%) patients by revealing advanced or associated disease. When laparoscopy suggested that the disease was localized, the diagnosis was correct in 83.3% (5 of 6) patients. Laparoscopy under local anesthesia is useful in the diagnosis and staging of gallbladder carcinoma, and therefore helpful in planning management.

Sixty nine patients with a median age of 45 years, 62.3 per cent of whom were premenopausal, with locally advanced breast cancer (T 4, N 0-3, M 0; Stage IIIb) were treated with 3 cycles of either neoadjuvant cyclophosphamide, doxorubicin and 5-fluorouracil, being the CAF group: 36 patients, or cyclophosphamide, methotrexate and 5-fluorouracil, being the CMF group: 33 patients. Patients achieving complete response or with residual disease of less than 2 cm in diameter received radical radiotherapy while those with more residual disease underwent radical mastectomy. Nine cycles of adjuvant chemotherapy were administered. Complete responses and disease control by radiotherapy with complete breast preservation were more frequently observed after CAF than CMF, being 25 per cent vs 3 per cent (p = 0.025) and 48.5 per cent vs 12 per cent (p = 0.002), respectively. Overall response rates, adverse effects, disease control following radiotherapy/surgery, local relapses and metastases were similar for both regimes. Relapsing patients were young, with a median age of 38 years, 68.4 per cent of relapses occurred at metastatic sites and 42 per cent of relapses occurred during adjuvant chemotherapy. This study suggests that in locally advanced breast cancer, a greater proportion of patients can be rendered disease free after neoadjuvant CAF and radiotherapy compared to neoadjuvant CMF and radiotherapy.

We herein present 2 cases of adult Bochdalek hernia. Only a total of 51 such cases have been reported since 1958, and we have reviewed these cases and discussed their clinical features, operative treatment and final outcome. The majority of these patients presented as acute surgical emergencies and a lack of awareness of this condition lead to an incorrect diagnosis in 38 per cent. Intestinal obstruction with left lung signs and a non-distended abdomen in an adult patient should arouse suspicion of this condition. A plain X-ray of the chest and contrast studies of the gastrointestinal tract are necessary to confirm the diagnosis. A previous normal chest X-ray does not rule out a diaphragmatic hernia, as the defect may be plugged by the spleen or by the presence of a confining sac. The high incidence of strangulation emphasises the need for early diagnosis and prompt operative management which gives highly satisfactory results.

The translocatable receptors categorized as functional receptors were quantitated in a cross-incubation study of breast cancer nuclei with receptor-rich uterine cytosol. Data demonstrated that tumors that contained cytosolic estrogen receptor (ER) but had translocation defect might not be hormone dependent, whereas tumors with low ER but intact nuclear translocation step will respond to antiestrogen therapy. Cytosolic ER was estimated in 114 primary breast cancer tissues and ten metastatic axillary lymph nodes; 58% of postmenopausal and 54% of premenopausal breast cancer tissues were ER+ with a cutoff value of 10 fmoles and 3 fmoles/mg protein, respectively. Of tumors in the premenopausal and postmenopausal state, 62% and 57%, respectively, were positive for nuclear ER, with a cutoff value of 10 fmoles/100 micrograms DNA. This study suggested that evaluation of functional ER level would reduce the number of false-negative and false-positive tumors.

A 30 year old woman with aggressive fibromatosis (desmoid) of the left upper arm and scapular region was treated with wide excision. Two years later she presented with extensive local recurrence of the scapular and deltoid regions. She was treated with tamoxifen (20 mg daily) and, over the next 6 months, the tumour regressed. She has been recurrence-free for the past year. We suggest that, in patients with desmoid tumours, hormone receptor determination and hormone therapy be attempted before subjecting patients to any form of radical treatment with surgery, radiotherapy or chemotherapy.

Pancreaticogastrostomy was done for reconstruction of the pancreatic stump after pancreaticoduodenectomy in 125 cases of ampullary carcinoma. There were no pancreatic leaks. The 5-year survival rate was excellent for patients who had no pancreatic or lymph node involvement.

The nuclear DNA content of 98 operable breast cancers was determined by flow cytometric analysis using paraffin-embedded tissue. All patients were on follow-up and failure of treatment or recurrences were identified. DNA ploidy data in the form of ploidy status and DNA index (DI) has been correlated with various clinical and histopathologic factors. The only significant correlation using univariate analysis exists between the histologic grade and DI (P less than 0.025), recurrence of the disease and ploidy status (P less than 0.005), and recurrence of the disease and DI (P less than 0.005). The absence of correlation of ploidy status with other tumor derived factors indicates the independent nature of ploidy as a prognostic factor. Multivariate analysis showed that in the whole-group ploidy (P less than 0.01), tumor margin (P less than 0.01), and menopausal status (P less than 0.01) were significant factors in the order mentioned. DI with a cut of at 1.29 is not found to be a significant factor in the multivariate analysis. The maximum prognostic value of ploidy status was observed in the postmenopausal group (P less than 0.0005). In the node-negative group ploidy status (P less than 0.05) is the only independent significant factor predicting for early relapse. It is concluded that ploidy status is an independent prognostic factor predicting for recurrence of the disease. In the node-negative subgroup this could be used to identify the subset of patients who may benefit from adjuvant treatment.

Primary breast lymphoma (PBL) is a rare tumor of the breast. Three cases of PBL are being described. All three cases achieved remission following biopsy, chemotherapy, and/or radiotherapy. The literature is extensively reviewed with emphasis on true incidence of PBL and survival rates.

A 50 year old man with a two month history of upper abdominal pain and a one month history of anorexia and weight loss, presented with icterus and evidence of peritonitis. Laparotomy revealed biliary peritonitis which had been caused by a rupture of the fundus of the gallbladder. The common bile duct was dilated and there was a large growth in the head of the pancreas with multiple hepatic metastases. A cholecystojejunostomy and gastrojejunostomy were done and the patient had an uneventful recovery.

A 48 year old male presented with a one and a half year history of a progressively increasing, asymptomatic lump in the left hypochondrium and no history of hematuria. His general physical examination was unremarkable, and an abdominal examination revealed a large, firm, irregular and tender mass in the left hypochondrium extending into the lumbar region. Chest X-ray was normal. An intravenous urogram revealed a normally functioning right kidney with non-visualization of the left kidney. CT-scan of the abdomen revealed a large, mixed attenuating mass replacing the left kidney. At laparotomy, a large, fleshy, well-encapsulated tumor was found in the left kidney with no surrounding infiltration and a left radical nephrectomy was performed. Microscopic examination revealed a poorly differentiated tumor comprised of small round cells with focal areas of abortive embryonal tubular and glomerular differentiation suggestive of Wilms' tumor. The patient was advised chemotherapy and radiotherapy but he absconded and was lost to follow-up.

Fifteen patients (eight males, seven females; age range: 23-76 years) presenting with acute suppurative cholangitis underwent endoscopic retrograde cholangiography and sphincterotomy within 1-10 days of hospitalization. Cholangitis was due to common duct stones in all patients; all but one of them had their gall-bladders in situ. All of them had fever, jaundice, abdominal pain, leucocytosis and deranged liver function while 26.6% were in shock, 13.3% in coma and 40% in azotaemia. Cardiac or other associated diseases caused 21% of the patients to be high risk candidates for surgery. An adequately sized sphincterotomy was done in 14 (93.3%) patients; in eight of them it was immediately followed by a successful stone extraction while in another four patients either the stone passed out spontaneously (one patient) or was retrieved by a repeat basketing. Thus, the common bile-duct was cleared of stones in 80% patients. Of 14 patients with satisfactory sphincterotomy, 11 (73.3%) had a dramatic clinical improvement, two (14.3%) had a somewhat delayed benefit and one patient died due to unrelieved cholangitis. Ten patients subsequently underwent elective cholecystectomy while three patients continue to have their gall-bladders in situ. There has been no recurrence of biliary tract symptoms in these 13 patients during the subsequent 3-26 months (mean follow-up: 15.1 months). It is concluded that urgent duodenoscopic sphincterotomy is rewarding in patients with acute suppurative cholangitis when it is performed early.

A study was carried out in the patients with intestinal tuberculosis and obstruction requiring surgery to determine the pathogenesis of malabsorption in this condition. Fifteen of the 20 patients studied had malabsorption, nine of 17 (53%) had intestinal bacterial overgrowth and 10 of 16 (62.6%) had free bile acids in their jejunal aspirates. In a comparable group of nontuberculus intestinal obstruction requiring surgery, six of seven (85.7%) had malabsorption, and four of five (80%) had both the bacterial overgrowth as well as bile salt deconjugation. Among a group of 10 patients with intestinal tuberculosis without significant obstruction, four were found to have malabsorption but only one had evidence of bacterial overgrowth and bile salt deconjugation. In contrast, only one of the 10 patients with extraintestinal tuberculosis and none of the 12 healthy, normal subjects had malabsorption. None had bacterial overgrowth or bile salt deconjugation in either group. Resection of the obstructing lesion corrected the malabsorption as well as the bacterial overgrowth and the bile salt deconjugation in all four patients tested with intestinal tuberculosis. Malabsorption in intestinal tuberculosis thus appears to be associated with obstruction rather than with the tuberculous process. Demonstration of bacterial overgrowth and bile salt deconjugation in the upper small intestine of patients with intestinal tuberculosis with obstruction and malabsorption indicate the presence of a stagnant loop syndrome.

The present study was carried out at the Department of Surgery, All India Institute of Medical Sciences Hospital, New Delhi, between January 1982 and October 1984. Clinical diagnosis of acute cholecystitis was confirmed by ultrasound scanning or Tc99m labelled HIDA Scan. Group I (n=24) comprised patients who underwent emergency cholecystectomy while Group II (n=23) comprised patients who were managed conservatively, and had an elective cholecystectomy performed 6-12 weeks later. There was no mortality or wound infection in either group. The incidence of other complications was 8.3 per cent and 8.6 per cent in Groups I and II, respectively. Emergency cholecystectomy (Group I) reduced the total hospital stay of a patient by approximately 70 per cent and post cholecystectomy syndrome was seen in Group II patients only. We thus recommend emergency or early cholecystectomy during the acute stage of cholecystitis, as it is safe, effective and economical, provided it is done by an experienced surgeon.

The medical records of 277 consecutive patients who underwent cholecystectomy for benign gall stone disease, were reviewed to determine the incidence and cause of biliary tract obstructuion.Obstructive jaundice (icteric obstructive biliopathy) was present in 38 cases. This was due to choledocholithiasis in 22, Mirizzi's Syndrome in two, biliobiliary fistula in eight and biliary stricture in five patients. Preoperative direct cholangiography (ERCP/PIC) was helpful.Anicteric patients were classified on the basis of a history of jaundice, serum alkaline phosphatase, sonography and operative findings. Anicteric patients with evidence of biliary tract pathology (anicteric obstructive biliopathy) had a significant incidence of choledocholithiasis (33.3% ). Biliary complications were uncommon in this group (4.3%). Peroperative cholangiography was carried out and was valuable in these patients but was normal in all 83 patients who had no evidence of biliary obstruction.

Summary Cold injury was produced by immersing the rabbits' hind limbs in a mixture of ice and alcohol at a temperature of −5°C. to −10°C. for 2 hours. The limb was thawed slowly at the room temperature. Extent of damage was classified into six degrees, depending upon tissue survival. The efficacy of nicotinic acid, 10 to 20 mg. per kilogram of body weight, administered orally in three divided doses, was studied in different groups of rabbits. Nicotinic acid proved useful in reducing or preventing the damage caused by local cold injury in rabbits. Some possible explanations for this beneficial effect are discussed.

Traumatic ventral herniae are uncommon. The authors present a patient with traumatic intermuscular hernia in the anterior abdominal wall. Early recognition and differentiation from haematoma is important. In this case, the overlying intact muscle layer masked the classical clinical signs. The incision should be adequate and all internal organs carefully examined. Primary repair is usually possible.

Spontaneous choledochoduodenal fistula is a rare complication of peptic ulcer disease, the surgical therapy of which is generally directed towards the ulcer disease itself, in the form of vagotomy with antrectomy or gastrojejunostomy. The case reported herein is of a 40 year old man who presented with a spontaneous choledochoduodenal fistula which was successfully treated by a truncal vagotomy and posterior retrocolic gastrojejunostomy. Such procedures as cholecystectomy, common bile duct exploration and bilio-enteric reconstruction, should only be performed in the case of a biliary stricture, which occurs rarely.

A case of liver cell carcinoma in an eight-month-old male infant is presented, with a review of the literature. Radical surgery is recommended in all cases.

A case of primary malignant cyst of the parotid gland is described, and the possible origins of such cysts are discussed.

An unusual case of leiomyosarcoma of the parotid gland is reported. The tumour recurred thrice and metastasized to one of the adjacent lymph nodes. Histologically, a leiomyosarcoma in the salivary gland closely resembles a tumour of myoepithelial cells origin but lacks the dual cell morphology seen in the latter.

Two hundred one consecutive patients with gallstone disease who had undergone cholecystectomy were analyzed to determine the relative frequency of occurrence of cholesterol and pigment gallstones and to identify distinguishing features of the two stone types. Cholesterol stones (CS) formed the majority (94%) of gallstones. There were no distinctive clinical, biochemical, or radiological features of CS or pigment stones (PS). However, CS were found significantly more often than PS (P less than 0.05) in multiparous women leading a sedentary life-style. Although multiplicity of gallstones was somewhat commoner with CS (P less than 0.05) and radiopacity with PS (P less than 0.05) as compared with the other stone type, these differences were certainly not discriminatory between CS and PS.

The results of a new out-patient approach to fistula in ano are presented. The technique involved passing a multi-strand stainless steel wire through the fistulous tract and has been used in 56 patients with low fistulae as well as high horseshoe anal fistulae. Recurrence was seen in only 2 patients and none of the patients experienced temporary or permanent incontinence of flatus or faeces.

The fourth case of benign leiomyoma of the anal canal thus far reported is presented. The literature is briefly reviewed. These tumors are treated locally without recurence, but the patients should be followed carefully.

Peritoneal adhesions were produced in 20 rabbits and 35 monkeys by traumatizing the cecum and corresponding parietal peritoneum. Adhesions were classified into six grades, depending on the extent and density. Combined therapy with oxyphenbutazone, proteolytic enzymes from carica papaya, and dextran 40 after lysis of adhesions reduced the reformation of peritoneal adhesions significantly, and the percentage reduction was greatest as compared to the individual use of the drugs. It is emphasized that the role of any therapy in peritoneal adhesions should be evaluated only by the decrease in the reformation of adhesions after lysis.