Pande Gk

Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

BACKGROUND & AIMS Organ failure is the usual cause of death in acute necrotizing pancreatitis. Our objective was to study whether the extent and infection of pancreatic necrosis correlate with organ failure and mortality. METHODS All consecutive patients with acute pancreatitis were prospectively studied. They underwent a detailed clinical and investigative evaluation. Pancreatic necrosis, diagnosed on a computed tomography scan, was graded as <30%, 30%-50%, and >50% necrosis and characterized as either sterile or infected. Logistic regression analysis was done to find out the association of the extent and infection of pancreatic necrosis with organ failure and mortality. RESULTS Of 276 patients (mean age, 41.25 years; 172 men), 104 had pancreatic necrosis: 30 had <30% necrosis, 37 had 30%-50% necrosis, and 37 had >50% necrosis; 74 had sterile necrosis, and 30 had infected necrosis. Of them, 37 (35%) patients developed organ failure. Two significant factors were associated with the development of organ failure, the extent of necrosis (<30% necrosis vs 30%-50% necrosis: P = .03; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.15-29.45; <30% necrosis vs >50% necrosis: P = .0004; OR, 18.86; 95% CI, 3.75-94.92) and infected pancreatic necrosis (P = .02; OR, 3.29; 95% CI, 1.17-9.24). The overall mortality was 22%. Infected pancreatic necrosis (P = .006; OR, 4.99; 95% CI, 1.56-16.02) and Acute Physiology, Age, and Chronic Healthy Evaluation II score (P = .004; OR, 1.28; 95% CI, 1.08-1.52) were 2 independent predictors of mortality. CONCLUSIONS Extent of necrosis and infected pancreatic necrosis were associated with the development of organ failure in patients with acute necrotizing pancreatitis. Infected pancreatic necrosis was the most significant predictor of mortality.

Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study

AbstractBackground: This prospective study evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) for the treatment of symptomatic cavernous hemangiomas of the liver. The technique, its complications, and effectiveness also were analyzed. Methods: Eight patients (five male, three female; mean age ± SD = 47.75 ± 8.59 years) with symptomatic cavernous hemangiomas of the liver were treated by TAE with polyvinyl alcohol particles or gelfoam and steel coils (single session) followed by supportive treatment. Tumor characterization (including the extent and number of lesions) was done on triple-phase helical computed tomography or gadolinium-enhanced dynamic magnetic resonance imaging. Results: The lesions were located in the right lobe in five patients, left lobe in one, and both lobes in two. The largest diameter of the lesions was 6–18 cm (9.28 ± 5.13 cm). The treatment response was assessed on follow-up ultrasound and color Doppler and/or contrast-enhanced helical computed tomography. There were no treatment-related deaths and morbidity was minimal. Embolization was the only method of treatment in seven patients; however, one patient had surgery after TAE because the symptoms were only partly relieved. Indications for embolization were abdominal pain (eight patients), rapid tumor enlargement (four of eight), and recurrent jaundice (one of eight). Symptomatic improvement was documented in all patients after embolization. Symptoms did not worsen in any patient. The mean size of the tumor did not show any statistically significant change on follow-up radiologic examinations. However, in one patient, the tumor significantly regressed in size after embolization. Conclusion: TAE of hepatic cavernous hemangioma is a useful procedure in the therapy of symptomatic hemangiomas.

Gastric volvulus: Acute and chronic presentation

Diaphragmatic hernia may be congenital or traumatic in origin. Traumatic hernia may menifest immediately or several months/years after the incident. Congenital hernia usually manifests in the early years of life. Diaphragmatic hernia may be complicated by gastric volvulus. Acute gastric volvulus is surgical emergency where as chronic gastric volvulus presents with nonspecific abdominal symptoms. Diagnosis of gastric volvulus is difficult and is based on imaging studies. We describe four cases of diaphragmatic hernia complicated by gastric volvulus, diagnosed on imaging and managed surgically.

Gallbladder cancer in India: A dismal picture

Background: Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited.

Transcatheter arterial embolization in the management of hemobilia

BackgroundThis retrospective analysis evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) in the treatment of significant hemobilia. The imaging findings, embolization technique, complications, and efficacy are described.MethodsThirty-two consecutive patients (21 male, 11 female, age range 8–61 years) who were referred to the radiology department for severe or recurrent hemobilia were treated by TAE. Causes of hemobilia were liver trauma (n = 19; iatrogenic in six and road traffic accident in 13), vasculitis (n = 6), vascular malformations (n = 2), and hepatobiliary tumors (n = 5). Iatrogenic liver trauma was secondary to cholecystectomy in those six patients. Four of five hepatobiliary tumors were inoperable malignant tumors and one was a giant cavernous hemangioma. Arterial embolization was done after placing appropriate catheters as close as possible to the bleeding site. Embolizing materials used were Gelfoam, polyvinyl alcohol particles or steel coils, alone or in combination. Postembolization angiography was performed in all cases to confirm adequacy of embolization. Follow-up color Doppler ultrasound and contrast-enhanced computed tomography was done in all patients.ResultsUltrasonic, computed tomographic, and angiographic appearances of significant hemobilia were assessed. Angiogram showed the cause of bleeding in all cases. Three patients with liver trauma due to accidents required repeat embolization. Eight patients required surgery due to failed embolization (continuous or repeat bleeding in four patients, involvement of the large extrahepatic portion of hepatic artery in two, and coexisting solid organ injuries in two). Severity of hemobilia did not correlate with grade of liver injury. All 13 patients with blunt hepatic trauma showed the cause of hemobilia in the right lobe. No patient with traumatic hemobilia showed an identifiable cause in the left lobe. There were no clinically significant side effects or complications associated with TAE except one gallbladder infarction, which was noted at surgery, and cholecystectomy was performed with excision of the hepatic artery aneurysm.ConclusionTAE is a safe and effective interventional radiologic procedure in the nonoperative management of patients who have significant hemobilia.

Proximal splenorenal shunts for extrahepatic portal venous obstruction in children.

ObjectiveThe results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated. Summary Background DataExtrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion. MethodsBetween 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures — 102 for recurrent bleeding and 38 for hypersplenism. ResultsThe overall operative mortality rate was 1.9%–10% (3/160–2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (11%), and pneumococcal meningitis developed in 1 patient who recovered later. Encephalopathy did not develop in any patient. Four patients died in the follow-up period – two of rebleeding, one of chronic renal failure and a subphrenic abscess, and one of unknown causes. The 15-year survival rate by life table analysis was 95%. ConclusionsA proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.

Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India

BackgroundSteroid-based intensive medical therapy for severe ulcerative colitis is successful in 60–70% of such patients. Patients with complications or those refractory to medical therapy require emergency colectomy for salvage. Little is known about the impact of timing of surgical intervention and surgical outcomes of such patients undergoing emergency surgery in India where the diagnosis is often delayed or missed in patients who are poor, malnourished and non-compliant to medical treatment.MethodsThe clinical records of all patients undergoing emergency surgery for severe ulcerative colitis or its complication in the Department of GI surgery AIIMS, New Delhi, India, between January 1985 and December 2003 were retrieved and data pertaining to demographic features, duration of intensive medical therapy, presence of complications, time from admission to emergency surgery, surgical procedure, in-hospital morbidity and mortality and follow up status extracted.ResultsA total of 72 patients underwent emergency surgery (Subtotal colectomy: 60; ileostomy alone under local anaesthesia: 12). Poor nutritional status was seen in 61% of the patients.Twenty-one patients (29%) underwent emergency surgery for complications of severe ulcerative colitis such as colonic perforation (spontaneous 6, iatrogenic 4), massive lower gastrointestinal haemorrhage (5), toxic megacolon (4) and large bowel obstruction (2). The remaining patients (n = 51) underwent emergency surgery following failed intensive therapy; 17 underwent surgery ≤5 days (Group I) and 34 were operated >5 days (Group II) after initiation of intensive therapy. In this group all the post-operative deaths (n = 8) occurred in those who were operated after 5 days. The difference in mortality in these two groups (i.e. surgical intervention ≤ or >5 days) was statistically significant {0/17 (Group I) vs 8/34 (Group II); p = 0.03}.Overall, 12 patients died (in-hospital mortality: 16.7%). The mortality was higher (10/43; 23.3%) in our early experience (i.e. 1985–1995) when compared to our subsequent experience (2/29; 6.9%) (1996–2003).A total of 48 patients (including 3 awaiting a restorative procedure) are alive on follow up (66.7%; 3 patients lost to follow up). A restorative procedure could be successfully completed in 81% of the survivors of the emergency procedure.ConclusionTo optimize the outcome, a combined team of physicians and surgeons should be involved in the management of patients with severe ulcerative colitis with focus on nutritional support, correction of metabolic derangements, close clinical monitoring and timely assessment for the need for emergency surgery. This retrospective analysis shows that improved results can be achieved with experience and by following a policy of early surgical intervention within 5 days, especially in patients who have failed intensive medical therapy.

Multilineage hempoietic stem cell defects in Budd Chiari syndrome

Abstract Background/Aims: Erythropoietin-independent endogenous growth of erythroid colony from bone marrow cells has been shown in many patients with Budd Chiari syndrome in earlier studies. In another report, increased megakaryocyte colony growth has also been documented in this disease. However, defects in granulocyte-macrophage cell lines in Budd Chiari syndrome have yet to be reported in the literature. Methods: Both in vitro erythroid and granulocyte-macrophage colony cultures from peripheral blood mononuclear cells with and without erythropoietin or granulocyte-macrophage colony stimulating factor, respectively, were studied in 32 patients with Budd Chiari syndrome, along with 20 normal healthy controls and ten patient controls with portal hypertension (five patients each with noncirrhotic portal fibrosis and liver cirrhosis). In 18 patients the occlusion was only in the inferior vena cava, in five patients only in hepatic veins, and in nine patients both inferior vena cava and hepatic veins were blocked. Result: Endogenous erythroid or granulocyte-macrophage colony growth was not observed in any of the normal healthy controls or in patient controls with portal hypertension. However, 22 of the 32 (68.8%) patients showed endogenous erythroid colony growth. Moreover, four of them also showed endogenous growth of granulocyte-macrophage colony, not previously reported in Budd Chiari syndrome. Conclusion: It may be inferred that stem cell defects affecting all three hemopoietic cell lines (erythroid, megakaryocyte and granulocyte-macrophage) occur in Budd Chiari syndrome, which may be the primary defect responsible for the pro-thrombotic state causing venous thrombosis in them.

Three-dimensional helical computed tomography cholangiography with minimum intensity projection in gallbladder carcinoma patients with obstructive jaundice: comparison with magnetic resonance cholangiography and percutaneous transhepatic cholangiography.

Objective:  Computed tomography (CT) is traditionally used for evaluation and staging of gallbladder carcinoma (GC). However, in the subgroup of patients with obstructive jaundice, magnetic resonance cholangiography (MRC) is generally required to assess the level of biliary obstruction. The present study was  undertaken  to  evaluate  the  diagnostic potential of three‐dimensional helical CT cholangiography (3‐D CTC) with minimum intensity projection (minIP), to determine the presence and level of biliary obstruction.

Transhiatal esophagectomy for benign and malignant conditions

BACKGROUND Experience with transhiatal esophagectomy (THE) for both benign and malignant diseases of the esophagus as practiced over an 18-year period is presented. METHODS Between 1982 and 2000, 411 consecutive patients underwent THE for both benign (n = 44) and malignant (n = 367) diseases of esophagus. Surviving patients were followed up for a mean of 30.4 months. RESULTS The overall operative mortality was 11% which had reduced to 6% for the last 111 patients. Operative mortality in the benign group was less than 5%. Respiratory complications were the most frequent cause of morbidity and mortality. Nonfatal anastomotic leaks occurred in 14%. The overall actuarial survival rates at 2, 5, and 10 years for carcinoma patients were 54%, 38%, and 18% respectively. The 2- and 5-year actuarial survival rates for postcricoid cancers were 83% and 64%, respectively. CONCLUSIONS Transhiatal esophagectomy is safe and effective, and its results including long-term outcome are comparable with most published series.