Parveen Shah

Choledochal Cysts in Children and Adults with Contrasting Profiles: 11-Year Experience at a Tertiary Care Center in Kashmir

BackgroundCholedochal cyst is a surgical problem usually related to infancy and childhood. Despite advancements in management, a large number of cases still present during adulthood. The clinical course and outcome in children varies from that in adults. This study focuses on these variations in terms of presentation, management, histopathology, and outcome.MethodsAn in-depth retrospective analysis was carried out on 79 patients presenting with choledochal cysts between December 2007 and January 1997. The patients were segregated into two groups: group A comprising 32 children and group B with 47 adults. The presentation, clinical evaluation, radiologic, and biochemical findings; operative details; pathologic findings; and early and long-term complications in the two groups were studied on a comparative basis.ResultsThe male/female ratios were 1:3 and 1.0:2.3 in groups A and B, respectively. A history of previous biliary surgery, pancreatitis, cholangitis, peroperative difficulties, and early and late postoperative complications were 5.1, 5.4, 6.4, 5.4, 2.0, and 3.3 times more common in group B than in group A. However, the classic triad of jaundice, abdominal pain, and a mass was 6.7 times more common in group A than in group B. The classic triad and cholangitis were the only parameters that were statistically significant. Rare presentations of spontaneous perforation of the cyst or cachexia manifested only in group A patients. The methods of detection and operative treatment were identical for both groups. Histologically, fibrosis of the cyst wall was a feature peculiar to group A, whereas signs of inflammation and hyperplasia were predominantly seen in group B. In the group B series, one patient had cholangiocarcinoma and another gallbladder carcinoma; one more patient developed malignancy during follow-up. Long-term complications were seen in 29.7% of patients in group B versus 9.3% in group A; the most rampant complication was a type IVa cyst, seen in 68.7% of patients.ConclusionsCholedochal cysts present differently in adults and children; whereas children present with the classic triad, adults present with common biliary or infective complications. Although the methods of detection and surgical treatment are similar for the two groups, the type IVa cyst typically seen in the adult group creates a marked deviation with respect to long-term complications such as ascending cholangitis, anastomotic strictures, stone formation, and development of cholangiocarcinoma. These are areas of grave concern that can be addressed to a large extent by providing an access loop during the initial surgery especially for type IVa cysts. The glaring differences in terms of presentation, histologic picture, and outcome urges us to consider choledochal cysts in children as a separate entity.

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.

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.

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.

Left-sided hepatic resection for hepatolithiasis: a longitudinal study of 110 patients

BACKGROUND Hepatolithiasis affecting the left hepatobiliary system is common in the Asia Pacific region. This aim of this study was to describe an experience with the diagnosis and treatment of patients with isolated left-sided hepatolithiasis. METHODS One hundred and ten patients with isolated left-sided hepatolithiasis who underwent a left-sided hepatic resection between January 1999 and February 2010 were included for further analysis. The clinical profile, cholangiograms, operative procedures and early and late results were examined. RESULTS Analysis of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) findings revealed left hepatic ductal anatomical details in 101 patients. Three types of left hepatic ductal variations were observed (type 1 in 90.1%, type 2 in 5.9% and type 3 in 4.0% patients). Eighty-four (76.4%) patients had the presence of strictures in the left hepatic ductal system and in 26 (23.6%) patients no strictures could be seen. Out of 84 patients with strictures, 78 could be classified (type I in 89.7% and type II in 10.3%). Of the 110 patients, 75 (68.2%) underwent a left lateral sectionectomy, 33 (30%) a left hepatectomy and 2 (1.8%) patients were treated with a left hepatectomy combined with a caudate lobe resection. Of the patients who underwent a left hepatectomy 11.4% developed a bile leak. Eight per cent of patients who underwent a left lateral sectionectomy had infective complications. During a median follow-up period of 63 (range 3-134) months, 2 (2.1%) patients were discovered to have residual stones and five (5.2%) others possessed recurrent stones. CONCLUSIONS This study highlights the impact of the presence or absence of bile duct stricture on the clinical and histological profile of patients as well as their operative and the post-operative behaviour. It is concluded that hepatic resection is an appropriate treatment modality in localized left-sided hepatolithiasis.

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.

Non hodgkin's lymphoma of tongue - A case report

Primary non-Hodgkins lymphoma (NHL) of the oral region is rare. Oral manifestations are present in 3-5% of cases of NHL and oral lesions are rarely the initial manifestation. We describe a 40 year old male who presented with a mass lesion primarily involving the tongue and was diagnosed as diffuse large B cell lymphoma. The patient was treated with CHOP chemotherapy with complete disappearance of lesion after first cycle. Pertinent literature is being reviewed.

Diagnostic value of Tzanck smear in various erosive, vesicular, and bullous skin lesions

Background: Cutaneous cytology has long been shown to be useful in the diagnosis of several erosive, vesicular, and bullous skin lesions. The Tzanck smear although an old tool, still remains a simple, rapid, easily applied, and inexpensive test for these skin lesions. Aims and Objectives: The aim of this study was to evaluate the diagnostic value of Tzanck smear by determining its sensitivity and specificity in various erosive, vesicular, and bullous skin lesions. Materials and Methods: One hundred and forty-two patients with erosive, vesicular, and/or bullous skin lesions were included in the study. Four groups of disorders were identified: infections, immunologic disorders, genodermatosis, and spongiotic dermatitis. All the study cases were evaluated by Tzanck smear. Definitive diagnosis was established by standard diagnostic techniques (including when appropriate, viral serology, bacterial culture, histopathology, direct immunoflourescence). Results: The sensitivity and specificity of cytologic findings was respectively 86.36% and 91.30% for viral infections; for bacterial infections, it was 85.7% and 66.6%. The sensitivity and specificity of Tzanck smear was respectively 85.0% and 83.33% for pemphigus; for bullous pemhigoid it was 11.11% and 100.0%. Tzanck smear sensitivity in genodermatoses was 100%. The sensitivity and specificity of the test in spongiotic dermatitis could not be calculated due to an insufficient number of patients. Conclusion: The Tzanck smear is a quick and reliable tool for the evaluation of various erosive and vesiculobullous skin lesions.

Primary Fibrosarcoma of the Liver: We Don’t Know Much

A 60-year-old lady presented to us with a right upper abdominal mass. With a clinical diagnosis of liver tumor, she was evaluated with abdominal CT, MRI, nuclear scan, tumor markers, USG guided FNAC and other baseline investigations. On evaluation she had a massive right lobe tumor crossing the midline. In view of the ambiguous diagnosis she was subjected to laparotomy where the lesion was judged unresectable and a biopsy was taken. Histopathological examination showed the rare pathology of primary fibrosarcoma of the liver with features of homogeneous, spindle-shaped cells with abundant collagen fibers showing a classic herringbone pattern. Tissue samples were then sent to another referral cancer hospital for immunohistochemistry and immunoreactive vimentin was found in the tumor cells. Electron microscopically, the tumor cells were rich in rough endoplasmic reticulum without a basement membrane, and were surrounded by large amounts of collagen fibers. The fibroblastic character of the tumor cells was suggested by light and electron microscopy.