Thakur Deen Yadav

Prospective validation of 4-category classification of acute pancreatitis severity.

Objective Atlanta classification divides patients with acute pancreatitis (AP) into mild and severe disease. A 4-category severity classification has been proposed based on the presence or absence of local and systemic determinants, giving rise to mild, moderate, severe, or critical AP. The aim of this study was to validate this new 4-category system of severity classification by examining markers of severity and outcome. Methods Data from 151 consecutive patients with AP from January 2009 to December 2010 [mean age (SD), 41.1 (3.5) years; 101 men] were collected. Management was standardized. Patients were classified as mild [no necrosis or organ failure (OF)], moderate (sterile necrosis or transient OF), severe [infected necrosis (IN) or persistent OF], or critical (IN and persistent OF) AP. Data were compared between groups for severity and outcome. Results There were 21 (13.9%) patients with mild, 63 (41.7%) moderate, 59 (39.1%) severe, and 8 (5.3%) critical AP. There was a significant difference between these categories for length of hospital stay, computed tomographic severity index scores, occurrence of bloodstream infections, incidence of IN, requirements for percutaneous catheter drain, numbers of operations, and mortality. Conclusions This prospective case series clinically validated the 4-category classification of AP severity.

OUTCOME AFTER PANCREATIC NECROSECTOMY: TRENDS OVER 12 YEARS AT AN INDIAN CENTRE

Background:  Pancreatic necrosectomy for necrotizing pancreatitis is a formidable operation. There are limited data from the Indian subcontinent regarding outcome and recent trends in management.

Closed lesser sac lavage in the management of pancreatic necrosis.

Background and Aim:  Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of morbidity and mortality. We evaluated the efficacy of necrosectomy and closed lesser sac lavage as a method of management of pancreatic necrosis.

Surgical management of gastric cicatrisation resulting from corrosive ingestion

BACKGROUND Caustic injury to the stomach can be complicated by gastric stenosis. We review our experience with surgical management of symptomatic gastric stenosis. METHODS This is a retrospective chart review of patients who underwent surgery for gastric stenosis within 6 weeks to 26 months following corrosive ingestion. The data analyzed included the extent of cicatrisation, surgical procedure performed and outcome. Preoperative evaluation in these patients included a barium contrast study and upper gastrointestinal endoscopy. RESULTS Main presenting symptoms were nonbilious vomiting, early satiety, dysphagia and significant weight loss. Antropyloric strictures were present in 28 (64%) patients, total gastric involvement was seen in 16 (36%) patients, associated esophageal stenosis was present in 18 (40.91%) patients. Surgical procedures performed included distal gastrectomy with Billroth1 reconstruction in 31.82%, distal gastrectomy with Roux-en-Y reconstruction in 20.45%, stricturoplasty in 11.36%, subtotal gastrectomy in 18.18% and total gastrectomy with pouch reconstruction in another 18.18% patients. Complications encountered were pneumonitis in 18.18%, wound infection in 11.36%, intra-abdominal infection, anastomotic breakdown, reactivation of pulmonary tuberculosis and dumping syndrome, each in 2.27% patients. One patient (2.27%) died. CONCLUSION Surgical procedure should be tailored according to the extent of gastric involvement. Surgical resection is feasible and safe. Our results suggest that satisfactory outcome could be expected with different therapeutic modalities based on degree of cicatrisation.

Dynamic nature of organ failure in severe acute pancreatitis: the impact of persistent and deteriorating organ failure

BACKGROUND AND AIMS In acute pancreatitis (AP), patients with persistent organ failure [POF, duration of organ failure (OF) ≥48 h] and transient organ failure (TOF, duration of OF <48 h) have different outcomes. We have compared the clinical course and outcome of patients with severe AP (SAP) with TOF and POF in the first week of hospitalization as well as the impact of change in the OF score in the first week on patient outcome. METHODS Consecutive patients with SAP were evaluated for OF and its dynamics during the first week of hospitalization. The modified multiple organ failure score (MOFS) was used to identify OF, grade its severity and monitor its progression. The clinical course and outcome of patients were studied. RESULTS Of 114 patients, mean age 39.2 ± 13.7 years, 37 (32.5%) patients had no OF, 34 (29.8%) had TOF and 43(37.7%) had POF. Patients with POF had the higher infected necrosis, increased requirement for percutaneous drain placement, surgery and higher mortality as compared with those with TOF. The odds ratio for mortality with persistent and deteriorating OF was 26.2 [confidence interval (CI) 5.1-134.9] compared with only persistent OF. CONCLUSION The dynamics of OF in the first week of SAP predicts the clinical course and outcome. Persistent and deteriorating OF indicates a poor outcome.

The Role of Non-Operative Strategies in the Management of Severe Acute Pancreatitis

CONTEXT Non-operative strategies are gaining preference in the management of patients with severe acute pancreatitis. OBJECTIVE The present study was undertaken to evaluate the efficacy of a non-operative approach, including percutaneous drainage, in the management of severe acute pancreatitis. DESIGN Prospective study. SETTING Tertiary care centre in India. PATIENTS Fifty consecutive patients with severe acute pancreatitis were managed in an intensive care unit. INTERVENTIONS The patients were initially managed conservatively. Those with 5 cm, or more, of fluid collection having fever, leukocytosis or organ failure underwent percutaneous catheter drainage using a 10 Fr catheter. Those not responding underwent a necrosectomy. Depending on the outcome of their supportive care, the patients were divided into three groups: those responding to intensive care, those needing percutaneous catheter drainage and those requiring surgical intervention. Twelve patients were managed conservatively (Group 1) while 24 underwent percutaneous catheter drainage (Group 2), 9 of whom were not operated (Group 2a) and 15 of whom underwent necrosectomy (Group 2b). Fourteen patients were operated on directly (Group 3). MAIN OUTCOME MEASURES Hospital stay, intensive care unit stay, and mortality. RESULTS Among patients requiring surgery, the patients in Group 2b had a shorter intensive care unit stay (22.1±11.1 days) as compared to the patients in Group 3 (25.0±15.6 days) and a longer interval to surgery, 30.7±8.9 days versus 25.4±8.5 days. However, these differences did not reach statistical significance (P=0.705 and P=0.133, respectively). The two groups did not differ in terms of mortality (5/15 versus 3/14; P=0.682). CONCLUSION The use of percutaneous catheter drainage helped avoid or delay surgery in two-fifths of the patients with severe acute pancreatitis.

Outcome of Acute Pancreatic and Peripancreatic Collections Occurring in Patients With Acute Pancreatitis

Objective: To study the outcome of acute collections occurring in patients with acute pancreatitis Background: There are limited data on natural history of acute collections arising after acute pancreatitis (AP). Methods: Consecutive patients of AP admitted between July 2011 and December 2012 were evaluated by imaging for development of acute collections as defined by revised Atlanta classification. Imaging was repeated at 1 and 3 months. Spontaneous resolution, evolution, and need for intervention were assessed. Results: Of the 189 patients, 151 patients (79.9%) had acute collections with severe disease and delayed hospitalization being predictors of acute collections. Thirty-six patients had acute interstitial edematous pancreatitis, 8 of whom developed acute peripancreatic fluid collections, of which 1 evolved into pseudocyst. Among the 153 patients with acute necrotizing pancreatitis, 143 (93.4%) developed acute necrotic collection (ANC). Twenty-three of 143 ANC patients died, 21 had resolved collections, whereas 84 developed walled-off necrosis (WON), with necrosis >30% (P = 0.010) and Computed Tomographic Severity Index score ≥7 (P = 0.048) predicting development of WON. Of the 84 patients with WON, 8 expired, 53 patients required an intervention, and 23 were managed conservatively. Independent predictors of any intervention among all patients were Computed Tomographic Severity Index score ≥7 (P < 0.001) and interval between onset of pain to hospitalization >7 days (P = 0.04). Conclusions: Patients with severe AP and delayed hospitalization more often develop acute collections. Pancreatic pseudocysts are a rarity in acute interstitial pancreatitis. A majority of patients with necrotising pancreatitis will develop ANC, more than half of whom will develop WON. Delay in hospitalization and higher baseline necrosis score predict need for intervention.

Solitary skeletal metastasis in carcinoma gallbladder: two case reports

Abstract We report 2 cases of carcinoma gallbladder with only solitary skeletal metastasis. To the best of our knowledge there are only 3 case reports of carcinoma gallbladder with skeletal metastasis in the English literature.

Tuberculosis of parotid gland masquerading parotid neoplasm

Parotid gland involvement in tuberculosis is rare. We present a case of middle aged male presenting with parotid swelling for 1 year and diagnosed to have parotid tuberculosis on fine needle aspiration cytology. A brief review of radiological findings in tuberculous parotitis is discussed which can help in correct interpretation and timely diagnosis, and thus avoiding unnecessary parotidectomies.

Adult intussusception in Northern India.

BACKGROUND Adult intussusception is infrequently encountered in Asians. The diagnosis is often late because of the variable presentation. The optimal treatment is not universally agreed upon. PURPOSE To determine the causes and management of this uncommon entity in India. METHODS A retrospective review of patients with postoperative diagnosis of intussusception between March 2003 and March 2008 was conducted in a tertiary care centre in North India. Data relating to diagnosis, treatment and histopathology was analyzed. RESULTS Twenty-seven patients, aged 15-72 years with 28 intussusceptions were studied. Four patients (14.29%) had acute presentation, 16 (57.14%) subacute and 7 (25%) had chronic symptoms. The most common type of intussusception was enteroenteric. A diagnosis of intussusception on contrast enhanced computed tomogram was made in 84% and a lead point was identified in 89%. A causative factor could be identified in 89% (25 out of 28 intussusceptions) which was malignant in 37% and benign in 48%. The most common underlying malignant lesions were adenocarcinoma (50%), and lymphoma (25%). Among benign lesions, small bowel polyps were the most common (57%). All cases underwent surgical intervention. Bowel resection was performed in 89%. There was no mortality. CONCLUSION Our series highlights a high frequency of a demonstrable cause of intussusception in a tropical country. Overall our results are similar to those reported from other countries. Resection of the involved bowel is recommended because of high incidence of underlying pathology.