Kirpal Singh

Safe techniques for endoscopic resection of gastrointestinal lipomas.

Purpose Gastrointestinal (GI) lipomas are rare, benign, slowly growing, submucosal tumors, which can either be incidentally found as silent tumors of the GI tract or be the cause for GI bleeding, anemia, intussusception, and bowel obstruction. Endoscopic removal is a valid alternative to surgical resection of these tumors. In the recent past, many submucosal lipomas were for the most part resected surgically due to the risk of perforation using endoscopy. There are newer techniques available to allow safe endoscopic removal of these lesions. We present 3 successful techniques tailored to the location of the lipoma and size. Methods In our unit, 3 symptomatic GI lipomas were referred to us for surgical resection, 2 originating from the duodenum and 1 from the cecum were diagnosed and resected under endoscopic ultrasound and endoscopy. We performed 3 different techniques to remove these lipomas. One of the lipomas in the duodenum was in the duodenal bulb. It was mobile and 3 cm in size. We attempted to remove this broad-based lipoma by snare and cut technique after its borders were elevated with injection of saline and epinephrine. The second duodenal lipoma was 1.5 cm. This pedunculated lipoma was located in the second portion, on the pancreatic side of the duodenum proximal to ampulla. This lipoma was lifted up with a snare and its base was cauterized resulting in successful removal. The third GI lipoma was 3.5 cm in size pedunculated and located in the cecum. The base of this pedunculated lipoma was ligated with poly loop device and endoclip resulting in ischemia and spontaneous separation of the lipoma from the colonic wall. All cases were revisited with follow-up endoscopy. All 3 methods, when used selectively, were found to be very safe and effective. Results All 3 lesions were successfully removed and histopathologically confirmed to be lipomas. After endoscopic removal, no complications were observed. Conclusions Carefully selected GI lipomas, which in the past have required surgical resection due to high risk for perforation can be endoscopically removed with great success.

High Potential Source for Biomass Degradation Enzyme Discovery and Environmental Aspects Revealed through Metagenomics of Indian Buffalo Rumen

The complex microbiomes of the rumen functions as an effective system for plant cell wall degradation, and biomass utilization provide genetic resource for degrading microbial enzymes that could be used in the production of biofuel. Therefore the buffalo rumen microbiota was surveyed using shot gun sequencing. This metagenomic sequencing generated 3.9 GB of sequences and data were assembled into 137270 contiguous sequences (contigs). We identified potential 2614 contigs encoding biomass degrading enzymes including glycoside hydrolases (GH: 1943 contigs), carbohydrate binding module (CBM: 23 contigs), glycosyl transferase (GT: 373 contigs), carbohydrate esterases (CE: 259 contigs), and polysaccharide lyases (PE: 16 contigs). The hierarchical clustering of buffalo metagenomes demonstrated the similarities and dissimilarity in microbial community structures and functional capacity. This demonstrates that buffalo rumen microbiome was considerably enriched in functional genes involved in polysaccharide degradation with great prospects to obtain new molecules that may be applied in the biofuel industry.

HIDA scan ejection fraction does not predict sphincter of Oddi hypertension or clinical outcome in patients with suspected chronic acalculous cholecystitis

BackgroundHepatobiliary iminodiacetic scan with ejection fraction (HIDA EF) is used to evaluate chronic acalculous cholecystitis (CAC). A presumed etiology of CAC is sphincter of Oddi hypertension (SOH). In this study, we evaluated the value of HIDA EF to predict patient response to laparoscopic cholecystectomy and to identify SOH.MethodsA prospective study of 93 patients with biliary pain but without gallstones (CAC) who underwent preoperative HIDA EF was conducted. At laparoscopic cholecystectomy, transcystic antegrade biliary manometry was performed to determine the SO pressure. Patients were evaluated postoperatively for response to cholecystectomy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The outcomes were compared with the clinical impression.ResultsOf the 93 patients with both HIDA EF and SOP measurements, 50 had abnormal EF (<35%); of these, 29 had SOH (SO pressure ≥40 mmHg). Of the 43 patients with normal HIDA EF, 30 had SOH. The sensitivity was 49%, specificity 38%, PPV 58%, and NPV 30%. Eighty-six of the 93 patients returned for follow-up evaluation. Follow-up ranged from 0 to 99 months, with a mean of 26.4 months. Overall, 73 patients (85%) improved. Of the 46 with abnormal HIDA EF, 42 (91%) improved. Of the 40 patients with normal HIDA EF, 31 (77.5%) improved. The sensitivity was 57.7%, specificity 69.2%, PPV 91.3%, and NPV 22.5%.ConclusionAlthough the PPV of abnormal HIDA EF is high, it is not much better than the clinical impression. The sensitivity and specificity are marginal. The NPV is poor. Based on the review of these 93 patients, HIDA EF is not reliable for identifying CAC. We recommend that patients with normal HIDA EF have additional testing or consultation before ruling out CAC. HIDA EF does not predict SOH.

Erratum to: Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)

The online version of the original article can be found under doi:10.1007/s00464-014-3917-8.

Transcystic biliary manometry to evaluate sphincter of oddi dysfunction in chronic acalculous cholecystitis

Relative apoptosis in HepG2 cells was increased with U0126 alone or in combination with NS398 (9-10X control). Relative apoptosis in both cell lines was strongly correlated with changes in the expression of the anti-apoptotic protein Bcl-xL Cellular growth was assessed by colorimetric proliferation assay and confirmed by cell counts (trypan blue exclusion). HepG2 and Hep3B cells had concentration-dependent inhibition of cell growth with NS398 or U0126 treatment alone. The combination of NS398 and U0126 resulted in additive inhibitory effects on growth. Growth inhibitory effects in HepG2 and Hep38 cells appear to be in part secondary to the induction of GO/G1 and G2/M cell cycle arrest respectively, as determined by flow cytometry. Despite differential signaling in HepG2 and Hep3B cells, the sum effect of combining a COX-2 inhibitor and a MEK inhibitor results in enhanced anti-tumor actions. This novel combination may be useful for treating patients with HCC.