Ajay Kumar Kriplani

Laparoscopy for pre-operative staging and assessment of operability in gastric carcinoma

Laparoscopy was performed in 40 patients with gastric carcinoma, whose lesions were otherwise considered amenable to operation, in order to more accurately stage the disease and ascertain the prospect of resectability. Laparoscopy disclosed hitherto unrecognized distant metastases in 5 cases (12.5%) and locally advanced, unresectable neoplasia in 11 cases (27.5%). Thus, laparoscopy served as a basis for avoiding the burden of futile laparotomy in 16 patients (40%). Laparoscopy confirmed the feasibility of resection in 24 patients, and this finding was borne out in 20 of 23 patients surgically explored (87%). The overall diagnostic accuracy of laparoscopy was 91.6%. Laparoscopy was performed in these patients with no mortality or morbidity. We conclude that laparoscopy is an effective means of evaluating resectability of gastric carcinomas and can provide valuable help in planning surgical approach.

Laparoscopy in primary carcinoma of the gallbladder

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.

Laparoscopic gonadectomy in male pseudohermaphrodites

OBJECTIVE To study patients of male pseudohermaphroditism and establish the laparoscopic approach for gonadectomy in these cases. STUDY DESIGN Seven phenotypic females with XY karyotype were evaluated through a diagnostic protocol which included clinical, cytogenetic, hormonal, endoscopic and histologic evaluation. The gonads were then removed by laparoscopic surgery. RESULTS The seven patients included three patients of pure gonadal dysgenesis, two patients of testicular feminization and one patient each of mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism. Two of the seven patients (28.57%) had gonadal neoplasias on histopathology-one dysgerminoma and one occult seminoma. In all of these patients, removal of the gonads was accomplished laparoscopically. No complications occurred during any of the surgeries. CONCLUSION Due to the reduced morbidity, shorter hospital stay and safety, laparoscopic gonadectomy can be considered the treatment of choice for the removal of gonads in male pseudohermaphrodites in the hands of experienced laparoscopic surgeons.

Multicentric liposarcoma: report of two cases.

We present herein two unusual cases of multicentric liposarcoma which highlight the problems associated with the management of this disease entity. When the surgeon is confronted with multicentric liposarcomas, it is necessary to define whether they are secondary tumors or independently arising multicentric liposarcomas, since the latter situation merits a more aggressive approach. Guidelines for this differentiation are suggested in the discussion following the case reports. Surgery, which is often multiple, remains the mainstay of treatment, although adjuvant chemotherapy and radiotherapy are also usually required.

Male breast cancer: A retrospective study from a regional cancer center in northern India

Over a 7‐year period from 1987 to 1993, 41 male breast cancer patients were seen in the breast cancer clinic of the Institute Rotary Cancer Hospital (IRCH) at the All India Institute of Medical Sciences (AIIMS). Their mean age was 54.2 years; and duration of symptoms ranged from 1 to 84 months with a mean of 15.1 months. Breast lump was the commonest presenting symptom. Fine needle aspiration cytology (FNAC) was the commonest diagnostic procedure. The TNM stage distribution was stage I, 5; stage II, 13; stage III, 17; and stage IV, 6. Radical mastectomy (25/36) was the commonest surgical procedure. Locoregional radiotherapy was given in 15 patients. Thirty patients received systemic adjuvant therapy (chemotherapy or tamoxifen, or a combination of the two). Local or distant recurrence occurred in 8 patients (8/31, 28.3%). Actuarial overall and disease‐free survival was 100% and 80.1% at 2 years and 91.7% and 66.7% at 4 years, respectively. On univariate analysis, axillary lymph node status and age were found to affect disease‐free survival significantly. Advanced stage of disease at presentation is common in Indian patients and will continue to influence treatment policies. Neoadjuvant chemotherapy needs to be evaluated for locally advanced tumors to improve outcome. Multicentric studies are necessary to define the relative roles of tamoxifen and chemotherapy for adjuvant treatment.

Omental herniation following laparoscopic sterilization

Complications after laparoscopic sterilization procedure are rare. When these occur, they are usually bleeding. infection and delayed recognition of bo\vel injurieh ( 1 ). Omental herniation or prolapse after laparoscopy is a rare complication and very fen. cases :ire reported in the literature (1-5). This report describes a case of omental herniation, occurring five da\is after an uncomplicated laparoscopic sterilization. Measures to avoid such a complication and management of the case are described. incision (Fig. I). There was no abdominal distention or tenderness. Bowel sounds were normal. The patient was admitted and was started on intravenous antibiotics and the protruding, infected part of omentum was excised under local anesthesia and intravenous sedation. The incision was closed with 0 vicryl on the fascia and 00 nylon on the skin and subcutaneous tissue. Patient made an uneventful recovery and was discharged after 3 days. Histopathology examination revealed omentum with areas of necrosis and acute inflammation.

Spontaneous gallbladder perforation--an unusual presentation of carcinoma of the pancreas.

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 cholecysto-jejunostomy and gastrojejunostomy were done and the patient had an uneventful recovery.

Neoadjuvant chemotherapy with cyclophosphamide, doxorubicin and 5-fluorouracil (CAF) or cyclophosphamide, methotrexate and 5-fluorouracil (CMF) in 69 cases of locally advanced (stage IIIb) breast cancer

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 <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 centvs 3 per cent (p=0.025) and 48.5 per centvs 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.