Omar Javed Shah

Biliary Ascariasis: A Review

Ascariasis, a helminthic infection of humans, is the most common parasitic infestation of the gastrointestinal tract. It infects about 25% of the world’s population; around 20 thousand deaths occur per year from an adverse clinical course of the disease. This review is focused on biliary ascariasis, examining in some detail the pathogenesis of the disease with special reference to postcholecystectomy ascariasis and related issues. Although an endemic disease of tropical and subtropical countries, increasing population migration facilitated by fast improving communication facilities demands that clinicians everywhere be familiar with the clinical profile and management of biliary ascariasis.

Hydatid Cyst of the Pancreas

A rare case of hydatid cyst of the pancreas is reported. Although ultrasonography and computerised tomography scan confirmed the presence of a cystic mass in the body and tail of the pancreas, diagnosis was made only on laparotomy. A distal pancreatectomy was done and the diagnosis of hydatid cyst of the pancreas was confirmed by histopathology. Though very rare, pancreatic hydatidosis should be considered in the differential diagnosis of cystic lesions of the pancreas in the appropriate epidemiological setting.

Surgical Management of Splenic Hydatidosis

AbstractPurpose. This study was conducted to evaluate the surgical management of splenic hydatidosis in an area where the disease is endemic. Method. Over a period of 16 years, 26 patients with splenic hydatidosis underwent surgery in our department. Preoperative investigations included plain abdominal X-ray, serology, ultrasonography, and computed tomography. Results. In our series, splenic hydatidosis represented 3.5% of total abdominal hydatidosis. The majority of patients presented with abdominal discomfort and palpable swelling in the left hypochondrium. Twenty-two patients were operated on electively and 4 as emergency cases, including 2 with ruptured hydatids and 2 with infected hydatids of the spleen. Isolated splenic hydatid cysts were present in 21 patients, associated liver hydatid cysts in 4, and diffuse abdominal hydatidosis in 1 patient. All patients underwent splenectomy except for one patient who initially had partial splenectomy for a lower polar cyst. This patient also ended up undergoing a splenectomy for postoperative hemorrhage. One patient died on the sixth postoperative day (mortality rate 3.8%) as a result of multiorgan failure, and 4 developed minor complications (morbidity 15.4%). Conclusion. Splenic hydatidosis, although rare, is the third most common type of hydatidosis after liver and lung hydatidosis. This entity should thus be kept in mind when encountering a splenic cyst especially in areas where the disease is endemic. A splenectomy remains the treatment of choice because it demonstrates low morbidity and mortality rates.

Management of Mirizzi syndrome: A new surgical approach

Background: In a prospective study of a patient population of 1340 with biliary calculus disease, that ran from January 1993 to December 1997, 34 patients (2.53%) were identified as having Mirizzi syndrome. Eight patients were found to have type I (A and B) and 26 patients were found to have type II Mirizzi syndrome. A history of recurrent biliary colic and jaundice was present in the majority of patients.

Role of endoscopic ultrasonography in preoperative staging of gastric carcinoma

Background:   Preoperative staging of tumour extent in upper gastrointestinal malignancy greatly facilitates planning of therapy. The present study was undertaken to see whether preoperative endoscopic ultrasonography (EUS) accurately predicts the tumour stage in gastric carcinoma.

Management of Biliary Ascariasis in Pregnancy

Ascariasis is a helminthic infection of humans caused by the nematode Ascaris lumbricoides. Biliary ascariasis is one of the most common and well described entities caused by ascaris. In endemic areas pregnant women are prone to develop biliary ascariasis. Its management poses a great challenge to both the attending surgeon and the endoscopist. Between January 1993 and March 2003, 15 cases of biliary ascariasis were seen in pregnant patients in our institution. Ultrasonography was used as the main investigative tool. Treatment involved management by conservative, endoscopic, and surgical methods, taking due care of both the mother and the fetus. Ten patients (66.6%) were in the third trimester of pregnancy, and 10 (66.6%) patients were in their third pregnancy. Ultrasonography proved to be the best tool for diagnosing and monitoring worms inside the biliary ductal system. Nine (60%) patients responded to the conservative treatment; endoscopic extraction was successful in 4 (66.6%) patients. Surgical treatment was required in 2 (13.3%) patients. One (6.6%) patient had had spontaneous abortion at 12 weeks gestation, and one (6.6%) patient had a premature labor. The remaining patients had normal pregnancies. Management of biliary ascariasis in pregnancy is a challenge for both the attending surgeon and the endoscopist. Safe and effective management requires special attention to the gestational age and accurate recognition of the specific pathology in the patient. The majority of patients respond to conservative treatment, but endoscopic extraction may be needed in nonresponsive cases. Lead shielding of the fetus and limitation of the total fluorscopic exposure during therapeutic endoscopy can minimize the teratogenic risk of ionizing radiation. Failures of endoscopic extraction may lead to surgical intervention, which carries risks of fetal wastage and premature labor. Routine worming of women in the child-bearing years is recommended in endemic areas of ascariasis. Though ascariasis is a problem in developing countries, because of increased travel and population migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Postoperative biliary ascariasis : Presentation and management-experience

Abstract Subsequent to preoperative and perioperative indications the common bile duct was explored in 705 patients over a 12-year period, from January 1983 to December 1994. Consequent postoperative T-tube cholangiography revealed the presence of worms in 22 patients. Expulsion of the worms followed T-tube irrigation with 0.9% normal saline in 18 patients. Only one patient had to be reexplored to remove the ascaris. In two patients the worm was removed along with the T-tube, and in one patient the worm came out through the T-tube tract.

Hydatid cyst of the pancreas. An experience with six cases.

CONTEXT The pancreas is an infrequent site of hydatid disease. OBJECTIVE This study aims at giving better insight into the diagnostic and managerial approach to the disease. PATIENTS Six patients with hydatid cysts of the pancreas. DESIGN Retrospective review of the clinical records. RESULTS The six patients (four men, two women) ranged in age from 18 to 68 years. Five of the cysts were primary while one had an associated cyst in the liver. Abdominal pain, vomiting, abdominal mass and dyspeptic symptoms were seen in cysts involving the body and tail. Two patients having cysts in the head of the pancreas presented with obstructive jaundice. An indirect hemagglutination test and an enzyme-linked immunoabsorbent assay were positive for the presence of specific hydatid antibodies in four patients. Abdominal ultrasonography, computed tomography and magnetic resonance cholangiopancreatography (MRCP) successfully imaged the cysts and also defined the relationship of the lesion with the pancreatic duct. All patients underwent surgical exploration. Three patients had intraoperative fine needle aspiration cytology of the cystic lesion for microscopic and electrolyte analysis. A preoperative diagnosis was possible in two patients and, in the other four, the diagnosis was made intraoperatively and confirmed on histopathological examination. PATIENTS with cysts located in the tail underwent a distal pancreatectomy with a splenectomy while those with cysts in the body had a pericystectomy or central pancreatectomy. Cysts of the head were treated with evacuation, partial cystectomy and tube drainage. There were no postoperative complications, and no evidence of cyst recurrence was observed during the follow-up period. All the patients were followed up at three-month intervals with a mean follow-up time of 58.7 months (rang: 4-120 months); no patient had cyst recurrence or dissemination. CONCLUSION A hydatid cyst is an uncommon cause of cystic lesions in the pancreas and should be included in the differential diagnosis of cystic lesions of the pancreas, especially in endemic areas. Intraoperative fine needle aspirate for microscopic and electrolyte estimation seems to be an effective method for establishing a proper diagnosis. MRCP, which can depict the communication of the cystic lesion with the pancreatic duct, helps in defining the type of surgical treatment. Cysts in body and tail are best treated by resectional methods whereas, for those in the head region, a cystectomy with simple drainage is a simple, quick and effective solution.

Clinicopathological study of male breast carcinoma: 24 years of experience.

Background and Objectives : Because breast cancer in men is rare, few patients are available for prospective studies. To learn more about its epidemiology, risk factors, clinical features, genetics and pathology in our country, we conducted a retrospective study of all cases seen in recent decades at our institution. Patients and Methods :We identified each case of male breast cancer in the database at the Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India, between the years 1983 to 2007. Results: We identified only 32 cases of male breast cancer over the 24-year period. Male breast cancer accounted for 32 (2.8%) of 1141 resected breast specimens, which included all breast lesions and 32 (4.1%) of 780 breast cancer cases. Of the 32 cases, 20 (62.5%) had various associated risk factors. Invasive ductal carcinoma was seen in 30 cases (93.7%). Of 20 cases that underwent molecular studies, 16 (80%) patients had estrogen receptor positivity whereas 14 (70%) had progesterone receptor positivity. Six cases (30%) overexpressed HER2 and p53. The BRCA2 mutation was observed in 4 cases (40%) while no patient presented with the BRCA1 mutation. Conclusion: An incidence of 4.1% for male breast cancer indicates that this disease is not as uncommon as presumed in this part of the world. Breast cancer in men seems more frequently to be hormone receptor positive and the BRCA2 mutation confers a significant risk to men.

Cystic Dilatation of the Cystic Duct: a Type 6 Biliary Cyst

Choledochal cysts of the cystic duct are extremely unusual and only single case reports are documented in the literature. The widely used Todani classification does not include such type of lesions. We present a case of a young girl with a cystic duct choledochal cyst diagnosed preoperatively and confirmed intraoperatively. Due to the site and mass effect of the cyst, excision of the lesion included a part of bile duct. Reconstruction was achieved by Roux-en-Y hepaticojejunostomy. While such lesions are extremely rare, they do occur and need to be recognized as a separate entity in the Todani classification.