Divya Dahiya

Comparative Effectiveness of Ultrasonography, 99mTc-Sestamibi, and 18F-Fluorocholine PET/CT in Detecting Parathyroid Adenomas in Patients With Primary Hyperparathyroidism

Purpose Accurate preoperative localization of parathyroid lesion(s) is crucial for successful surgical management of primary hyperparathyroidism (PHPT). This study was conducted to compare the effectiveness of ultrasonography (USG) of the neck, 99mTc-sestamibi (MIBI) imaging with or without SPECT/CT, and 18F-fluorocholine (FCH) PET/CT imaging in the preoperative localization of parathyroid lesions in patients with PHPT. Methods Fifty-four consecutive patients with PHPT were included in this prospective study who underwent preoperative localization of the parathyroid lesion(s) using 3 diagnostic modalities followed by surgery. The sensitivity, positive predictive value, and accuracy of the 3 imaging procedures to accurately detect abnormal parathyroid glands were determined using histopathology as criterion standard with postoperative biochemical response confirmation. Results 18F-fluorocholine PET/CT detected 52 of 54 patients and 52 of 56 lesions with histopathologically proven parathyroid adenomas on patient-based and lesion-based analysis, respectively. Preoperative USG, MIBI, and FCH PET/CT localized abnormal parathyroid gland(s) in 39 (72.2%), 43 (79.6%), and 54 (100%) patients, respectively. The sensitivity and positive predictive value were 69.3% and 87.1% for USG, 80.7% and 97.6% for MIBI, and 100% and 96.3% for FCH PET/CT. The accuracy was 62.9%, 79.6%, and 96.3% for USG, MIBI, and FCH PET/CT, respectively, in patient-wise analysis. In 6 patients with ectopic lesions, FCH PET/CT demonstrated higher sensitivity and accuracy than MIBI and USG (100% vs 66.6% and 16.7%, respectively). Conclusions Among the 3 imaging techniques tested simultaneously, FCH PET/CT was superior for accurate preoperative localization of parathyroid adenomas, especially for ectopic or small parathyroid lesions.

Effects of varying intraperitoneal pressure on liver function tests during laparoscopic cholecystectomy.

BACKGROUND Laparoscopic cholecystectomy at standard-pressure pneumoperitoneum uses a pressure of 12-14 mm Hg, which may cause a variety of adverse physiological changes involving the respiratory, cardiovascular, and hepatorenal systems reflected as subclinical abnormalities in biochemical parameters. The use of low-pressure pneumoperitoneum in the range of 8-10 mm Hg has been shown to reduce the adverse physiological changes without affecting the outcome of surgery. SUBJECTS AND METHODS This study was done in a randomized controlled manner. Patients with gallstone disease (n=101) underwent laparoscopic cholecystectomy. Patients were randomly assigned to high-pressure laparoscopic cholecystectomy (HPLC) (n=51) and low-pressure laparoscopic cholecystectomy (LPLC) (n=50) and underwent surgery at pressures of 14 mm Hg and 8 mm Hg, respectively. Liver function tests, including total bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase, were obtained preoperatively and on postoperative Days 1 and 7. RESULTS The two study groups had similar demographic profiles, and there were no significant differences in the operative time (HPLC, 47.25 ± 6.73 minutes; LPLC, 48.00 ± 7.76 minutes; P=.6071) and pneumoperitoneum time (HPLC, 34.02 ± 5.29 minutes; LPLC, 34.60 ± 6.13 minutes; P=.6115). On postoperative Day 1, the total bilirubin levels were 1.0684 ± 0.4108 mg/dL and 0.8926 ± 0.3162 mg/dL for HPLC and LPLC (P=.0179), respectively, AST levels were 66.0810 ± 25.5868 IU/L and 42.2420 ± 14.7301 IU/L (P=.0001), respectively, and ALT levels were 68.1410 ± 31.4572 IU/L and 42.7460 ± 17.9405 IU/L (P=.0001), respectively. Thus, liver enzyme activities were significantly elevated in the HPLC group compared with the LPLC group. CONCLUSIONS LPLC causes less abnormality in liver function tests in the postoperative period compared with HPLC. LPLC should be considered in all patients undergoing laparoscopic cholecystectomy, especially those patients with compromised liver functions.

Promoter hypermethylation inactivates CDKN2A, CDKN2B and RASSF1A genes in sporadic parathyroid adenomas

Cyclin D1, a G1-S phase regulator, is upregulated in parathyroid adenomas. Since cyclin-dependent kinase (CDK) inhibitors, CDKN2A and CDKN2B, and RASSF1A (Ras-association domain family 1, isoform A) are involved in G1-S phase arrest and act as potential tumor suppressor genes, we aimed to study potential methylation-mediated inactivation of these genes in parathyroid adenomas. Gene expressions of cyclin D1 (CCND1) and regulatory molecules (CDKN2A, CDKN2B and RASSF1A) was analysed in parathyroid adenoma tissues (n = 30). DNA promoter methylation of cyclin D1 regulators were assessed and correlated with clinicopathological features of the patients. Gene expression analysis showed a relative fold reductions of 0.35 for CDKN2A (p = 0.01), 0.45 for CDKN2B (P = 0.02), and 0.39 for RASSF1A (p < 0.01) in adenomatous compared to normal parathyroid tissue. There was an inverse relationship between the expressions of CDKN2A and CDKN2B with CCND1. In addition, the promoter regions of CDKN2A, CDKN2B, and of RASSF1A were significantly hyper-methylated in 50% (n = 15), 47% (n = 14), and 90% (n = 27) of adenomas respectively. In contrast, no such aberrant methylation of these genes was observed in normal parathyroid tissue. So, promoter hypermethylation is associated with down-regulation of CCND1 regulatory genes in sporadic parathyroid adenomas. This dysregulated cell cycle mechanism may contribute to parathyroid tumorigenesis.

Conservative surgery for pancreatic neck transection

Pancreas is the fourth solid organ injured in blunt abdominal trauma. Isolated pancreatic injury is present in less than 1% of patients. As it is associated with high morbidity and mortality, management is controversial. Isolated pancreatic trauma cases with pancreatic neck transection following blunt abdominal trauma were analyzed. All these patients were treated with immediate surgery involving lesser sac drainage and feeding jejunostomy only. Authors conclude that lesser sac drainage can be used as an alternative to distal pancreatectomy or pancreaticojejunostomy or pancreaticogastrostomy.

Effect of perioperative glutamine administration on C-reactive protein and liver function tests in patients undergoing hepatic resection

UNLABELLED Hepatic resections are commonly associated with high morbidity and mortality. Nutrition plays an important role in reducing postoperative complications besides improvement in intensive care and perioperative management. The aim of the study was to evaluate the role of glutamine as an immunonutrient in patients undergoing hepatic resection. MATERIAL AND METHODS The study included 22 patients who underwent hepatectomy. Patients were randomized into two equal groups wherein group A patients received perioperative glutamine whereas group B patients served as controls. Primary outcome measures were level of serum albumin, C‑reactive protein (CRP), liver function tests and absolute neutrophil counts in the postoperative period while secondary outcome included post operative complications. RESULTS Glutamine decreased the CRP response in liver resection in a statistically significant manner (p=0.028) on the fifth post operative day. This may signify that glutamine decreases the post operative inflammatory response associated with liver resection. Glutamine did not have any significant effect on liver function tests. Postoperative morbidity was less in patients who received glutamine. CONCLUSION Glutamine successfully blunted the CRP response in patients who received glutamine postoperatively. Decrease in morbidity following glutamine administration is an attractive area of prospective research and requires further consideration involving larger patient groups.

Day Care Laparoscopic Cholecystectomy: Next Standard of Care for Gall Stone Disease

Background To access the feasibility, safety and success of day care laparoscopic cholecystectomy in a tertiary center in India. Methods This is a retrospective analysis of prospectively collected data between 2004 and 2009 from a tertiary center in north India. All patients of symptomatic gallstone diseases having age less than 70 years, American Society of Anesthesiologists (ASA) grade I and grade II, living within 20 Kilometers of the hospital, availability of a responsible adult care taker at home, access to a telephone and a means of transportation to hospital if needed, underwent laparoscopic cholecystectomy under the care of the two participating surgeons, were considered for day care laparoscopic cholecystectomy. Clinical and operative data were recorded prospectively. All patients were discharged 6 to 8 hours after surgery with the advice to contact the surgical team over phone whenever necessary or on the day after discharge. Results A total of 602 laparoscopic cholecystectomies were performed over a period of 6years, among them 309 (51.32%) were operated on day care basis. Nine patients in day care procedure group had conversion to open procedure (5 due to distorted anatomy of calot’s triangle, 2 due to common bile duct stones, 1 due to bile duct injury and 1 due to bleeding from cystic artery stump). One patient had myocardial infarction and 3 had nausea and vomiting which failed to resolve by intravenous ondensteron and all these (13) patients (4.20%) needed unplanned admission to the hospital. Two hundred and ninety-six patients (95.79%) were discharged on same day. Conclusions In conclusion day care laparoscopic cholecystectomy is feasible, safe and equally effective in selected patients in Indian setup.

A Rare Case of Primary Sarcomatous Hepatocellular Carcinoma Without Previous Anticancer Therapy

Primary sarcomatous hepatocellular carcinoma (PSHCC) is a rare and aggressive variety of hepatocellular carcinoma (HCC). The recent evidence suggests that anticancer therapy promotes the dedifferentiation of the carcinomatous component and is largely responsible for this aggressive variant of HCC. However, in the absence of any anticancer therapy, occurrence of PSHCC is extremely rare. Herein, we present a rare case report of a 65 year old male patient, with a hepatitis B positive status, presenting with PSHCC without any history of anticancer therapy. Detailed immunohistochemical evaluation of the tumor was performed with comparison of morphological and immunohistochemical features of the sarcomatous and carcinomatous components. This appears to be the first documented case of PSHCC from India, to the best of our knowledge.

Genome Mining and Comparative Genomic Analysis of Five Coagulase- Negative Staphylococci (CNS) Isolated from Human Colon and Gall Bladder

Coagulase-negative Staphylococci (CNS) are known to cause distinct types of infections in humans like endocarditis and urinary tract infections (UTI). Surprisingly, there is a lack of genome analysis data in literature against CNS particularly of human origin. In light of this, we performed genome mining and comparative genomic analysis of CNS strains Staphylococcus cohnii subsp. cohnii strain GM22B2, Staphylococcus equorum subsp. strain equorum G8HB1, Staphylococcus pasteuri strain BAB3 isolated from gall bladder and Staphylococcus haemolyticus strain 1HT3, Staphylococcus warneri strain 1DB1 isolated from colon. We identified 29% of shared virulence determinants in the CNS strains which involved resistance to antibiotics and toxic compounds, bacteriocins and ribosomally synthesized peptides, adhesion, invasion, intracellular resistance, prophage regions, pathogenicity islands. 10 unique virulence factors involved in adhesion, negative transcriptional regulation, resistance to copper and cadmium, phage maturation were also present in our strains. Apart from comparing the genome homology, size and G + C content, we also showed the presence 10 different CRISPR-cas genes in the CNS strains. Further, KAAS based annotation revealed the presence of CNS genes in different pathways involved in human diseases. In conclusion, this study is a first attempt to unveil the pathogenomics of CNS isolated from two distinct body organs and highlights the importance of CNS as emerging pathogens of health care sector.

Duodenal Tuberculosis – A Rare Case Report and Review of Literature

Extrapulmonary tuberculosis is rare and often difficult to diagnose infection. We report a case of duodenal tuberculosis, who presented with upper gastrointestinal symptoms. There was evidence of obstruction in the third part of duodenum (D3) on oesophagogastro endoscopy, barium meal follow through and CT scan of abdomen. On exploration there was thickening of D3 and D4 causing luminal obstruction. Resection of stricturous segment with end-to-side duodenojejunostomy was done. Biopsy of the diseased segment was tubercular. Antitubercular treatment was given to the patient for 6 months and he is doing well on follow up (1 year after surgery). Duodenal tuberculosis being the rarest form of intestinal tuberculosis poses great difficulty in diagnosis. High index of suspicion supported by radiological investigation, exploratory laparotomy and histopathological examination of the tissue can only lead to a definitive diagnosis of this rare condition. Treatment is both surgical which involves resection or by-pass for an obstructive lesion and medical which includes antitubercular therapy.

Objective assessment of delayed gastric emptying using gastric scintigraphy in post pancreaticoduodenectomy patients

No objective assessment of delayed gastric emptying is carried out in patients undergoing Whipples procedure. All definitions and criteria along with evaluation of incidence of delayed gastric emptying are based on subjective assessment of the patient with clinical overview, so this study was carried out for an objective and accurate assessment of delayed gastric emptying in post Whipples patients using gastric scintigraphy.