Nutritional factors in carcinoma oesophagus: a case-control study

A case control study was conducted on 170 patients with oesophageal cancer. An equal number of healthy persons (attendants of patients) were included in the study as controls to identify nutritional risk factors for oesophageal cancer. The majority (55%) of the patients were of low socio-economic status and from Northern parts of India. They were predominantly male (66%). Increase in risk was associated with low consumption of green leafy vegetables, other vegetables and fresh fruits, milk and milk products. Heavy use of spices and use of very hot tea or food were also associated with increased risk. Differences in the past dietary consumption patterns of oesophageal cancer patients and controls suggest a role for nutritional factors in oesophageal cancer pathogenesis. At the same time substance abuse by cigarette or bidi smoking, alcohol consumption, paan and tobacco chewing also increased risk. After multivariate analysis, green leafy vegetables, other vegetables spices, bidi usage and fresh fruits provided protection against oesophageal cancer.

Short segment oesophago-cardiomyotomy for achalasia cardia

Over a seven year period, 25 patients of achalasia cardia underwent a transabdominal short segment oesophago-cardiomyotomy. There was no operative mortality. Two patients had a mucosal tear, detected intraoperatively and promptly repaired. All patients were regularly followed up (range 1 to 7 years). Clinical results were excellent in 76%, good in 20% and fair in 4%. No patient developed reflux or required reoperation for residual dysphagia. We conclude that a transabdominal short segment oesophago-cardiomyotomy performed carefully is a safe and effective procedure in the treatment of achalasia.

Emptying of the intrathoracic stomach using three different pylorus drainage procedures--results of a comparative study

Patterns of gastric emptying in the vagotomized intrathoracic stomach (used for esophageal replacement) were studied using radioisotope techniques. Following esophagectomy and gastric mobilization, the patients were randomized into three groups: group 1, pyloroplasty; group 2, pyloromyotomy; and group 3, pylorus stretching. A total of 30 patients surviving the operation and who were still alive at least 3 months afterwards were included in this study. Gastric emptying (GE) was evaluated 6-8 weeks after the operation. The mean GE time for liquids was 3.3 +/- 2.7, 4.1 +/- 3.1, and 5.5 +/- 4.3 min in the three groups, respectively. The corresponding GE time for solids in the three groups was 9.9 +/- 5.1, 10.31 +/- 6.6, and 7.7 +/- 3.4 min. No statistical difference was observed in the GE in the three groups even though liquids tend to empty faster than solids. Clinically there was also no significant difference in their ability to tolerate normal meals. When evaluated for clinical evidence of altered GE (effect of vagotomy) there did not appear to be any significant differences between the three groups. It is therefore concluded that all pylorus drainage procedures behave in much the same way. Patients may develop some problems, but these disappear in due course after proper adjustments have been made in both posture and diet.

Primary hyperparathyroidism in children

Primary hyperparathyroidism is an uncommon condition in childhood that is easily amenable to surgical treatment with excellent results. Pathologically, the parathyroid glands may show generalized hyperplasia or, more commonly, adenoma formation, the latter frequently being seen in adolescence. Two girls with solitary parathyroid adenomas and predominantly skeletal manifestations resembling rickets are reported, underlining the need to suspect and appropriately investigate these children. The literature on the subject is reviewed.

The role of estimation of the ratio of preoperative serum thyroglobulin to the thyroid mass in predicting the behaviour of well differentiated thyroid cancers

Although serum thyroglobulin (STg) is a useful tumour marker to detect the recurrence of tumour in well differentiated thyroid carcinoma, it has as yet not been reported to be of value in predicting the behaviour of thyroid cancer. In the present study of 20 patients, the measurement of preoperative Stg/thyroid mass has been utilised to find out Tg synthesizing capacity of the tumour. This ratio was significantly higher in the patients with follicular variety than in papillary thyroid carcinoma. It was significantly higher in the metastasis group than in the group of patients without metastasis. The patients with functioning metastasis had a higher than average value of this 'ratio' than those with non functioning metastasis, though the difference was not statistically significant. Despite the limitation of a small number of patients included in this study, it is possible to highlight the possible utility of preoperative Stg estimation as a tumour marker in categorization of the patients of carcinoma of the thyroid gland.

Structural and functional aspects of the thoracic stomach

The acid secretory and emptying function of the thoracic stomach was evaluated in 10 patients, following total oesophagectomy and gastric pull-up for oesophageal cancer. All patients had a Heinecke Mickulicz pyloroplasty. Endoscopic features and histological review of endoscopic biopsies were also studied in these patients. Acid secretion was higher in those with prolonged emptying. This was however, not statistically significant. Gastritis was more severe in those with prolonged emptying. Endoscopic diagnosis of gastritis was found unreliable while histopathology of endoscopic biopsy gave definite evidence of gastritis.

Prognostic significance of argyrophilic nucleolar organizer regions (AGNOR) in oesophageal cancer

AgNOR (Argyrophilic nucleolar organiser region) has been shown in recent times, to have value in knowing the prognosis of carcinoma oesophagus. We have evaluated the significance of AgNOR in oesophageal cancer with reference to prognosis following treatment. Fifty patients of histologically proven squamous cell carcinoma of the oesophagus were studied. Following oesophagectomy the specimens removed were evaluated for AgNOR number. Of the resected specimens, 25 (50%) had an AgNOR count < or = 3.0, 18 (36%) had an AgNOR count of more than 3 per nucleus and in the remaining 7 cases, AgNOR number was not quantifiable due to the total absence of tumour tissue in the postoperative specimen due to preoperative radiotherapy. When followed up for an average period of 25 months (3 to 47 months), it was seen that patients with AgNOR count of < or = 3.0 per nucleous had a similar mean survival (30.39 +/- 3.29 months) as those with counts > 3.0 per nucleus (27.80 + 3.33 months). The survival in the seven patients in whom no tumour was present following preoperative radiotherapy, was 30.30 +/- 2.42 months. An analysis was done for the presence of change in the AgNOR count before and after radiotherapy in twenty eight case of carcinoma oesophagus treated with preoperative radiotherapy. It was found that the counts on an average were lower in patients after radiotherapy (2.89 +/- 1.04 per nucleus), than before radiotherapy (3.17 +/- 9.69). This was found in 24 cases, while the remaining 4 cases showed no change in count after radiotherapy. This suggested that radiotherapy caused a reduction in AgNOR counts. Mean survival in those with decreased count after radiotherapy was 33.65 (+/- 3.35) months. Since the AgNOR counting is a simple method and can be applied to paraffin embedded section, estimation of the AgNOR number may help in determination of prognosis in patients with oesophageal carcinoma. Preoperative radiotherapy seems to decrease AgNOR count with improved survival. These observations need however, to be reproduced with a larger sample size.

Primary actinomycotic lung abscess

A case of recurrent massive haemoptysis in whom primary actinomycotic lung abscess was diagnosed following right pneumonectomy is reported.

Role of gastrografin study in the assessment of anastomotic leaks from cervical oesophagogastric anastomosis

Gastric pull-up with cervical oesophagogastric anastomosis is a common procedure after oesophageal resection. Contrast studies are used by many surgeons for detection of anastomotic leaks but may be unnecessary. A prospective study was undertaken to compare gastrografin study and test feeding using water for detection of cervical anastomotic leaks. In 25 patients, gastrografin study showed three leaks, two of which were clinically silent and patients did not have any problems. One patient had aspiration of contrast and the study could not be completed. Two of the leaks detected clinically were missed by contrast study (one because of an incomplete study and the other was a satisfactory study). Delayed leaks occurred in two patients. All leaks healed spontaneously. A contrast study may thus be unnecessary for evaluation of a cervical oesophagogastric anastomosis and can be replaced with the simpler and safer technique of 'test feeding' using water.

Liposarcoma of the mesocolon--case report of a rare lesion

A middle-aged man with a 2-month history of lower abdominal pain was found to have a large left-sided abdominal lump. Radiological investigations (barium enema, ultrasound, and computed tomography scan) revealed a mass lesion in the area of the descending colon, the sigmoid colon, and the rectum. Flexible sigmoidoscopy showed only mucosal edema and luminal narrowing. At laparotomy, a diffuse thickening of both the descending and sigmoid mesocolon extending into the mesorectum was seen, which suggested an inflammatory pathology. A left hemicolectomy with Hartmann's procedure was performed. After obtaining a histopathological diagnosis of liposarcoma of the mesocolon, an abdominoperineal resection of the rectum was done. The patient was advised to undergo postoperative radiotherapy but he did not comply and was thereafter lost to follow-up.

Spontaneous hemoperitoneum due to rupture of hepatocellular carcinoma

Spontaneous rupture with hemoperitoneum is one of the atypical modes of presentation of hepatocellular carcinoma (HCC), common in the orient (8-14% cases) but reported only once from India. Another case is being reported here. Hemostasis can be achieved by transcatheter hepatic artery ligation, intralesional alcohol injection, microwave application, curettage with suturing or gauze packing. Resectional surgery, preferably at a second stage, has the best long term outcome. Prognosis remains poor with few long term survivors.

Intragastric bile acid and symptoms in patients with an intrathoracic stomach after oesophagectomy

Bile acid concentration and symptoms were evaluated in 24 patients after total oesophagectomy and gastric pull-up. Patients were randomly allocated to receive pyloroplasty or not. After operation all were followed for a minimum of 6 months. Bile acid concentration in the gastric juice was estimated. The mean(s.d.) bile acid concentration 6 months after surgery was similar in patients with and without pyloroplasty (34.9(30.1) and 25.0(24.2) mg/dl respectively). Postprandial discomfort and bilious eructations were the two most commonly observed symptoms in both groups. Other features noted were vomiting, anaemia and anorexia. These did not however seem to be related to intragastric bile acid concentration of individual patients in either group and occurred irrespective of whether pyloroplasty was performed or not.

Biliary peritonitis secondary to perforation of common bile duct: an unusual presentation of chronic calcific pancreatitis

Common bile duct perforation causing biliary peritonitis is an unusual entity and a pancreatic calculus causing this perforation is all the more rare, and to our knowledge has not been reported previously. Such an unusual presentation of chronic calcific pancreatitis is herein reported.

Congenital tracheo-oesophageal fistula in a young adult

Congenital tracheo-oesophageal fistula (TEF) is rare in adults. Patients who present with repeated attacks of chest infection since birth or cough, choking and cyanosis during feeding should be investigated for TEF. It should be possible to detect all cases of tracheo-oesophageal fistulae using bronchoscopy, oesophagoscopy and CT either singly or in combination. These investigations also help in deciding on the route of exploration and the type of surgery. Disconnection of the abnormal fistulous tract brings dramatic relief of symptom and prevents further pulmonary damage.

Fine needle aspiration cytology, sonography and radionuclide scanning in solitary thyroid nodule

One hundred and ninety three consecutive patients with solitary thyroid nodule (STN), with a mean age of 36.0 +/- 12.8 years and male to female ratio of 5.6:1, were studied. Ninety five percent of patients came from iodine deficient regions. Seventy two percent presented for local neck swelling, 12.4% for hyperthyroid state and in 7.7% STN was discovered incidentally. Scintigraphically, 77.7% of nodules were cold, 12.4% hot and 8.5% warm. Sonographic evaluation did not reveal any characteristic echotexture diagnostic of malignancy, but detected clinically nonpalpable accessory nodules in 20.6% of patients. Fine needle aspiration cytology was positive for malignancy in 6.2% of patients. Features of follicular and Hurthle cell neoplasm were seen in 12.9% of aspirates. Eighty eight (45.6%) STN were resected surgically. Histologically, there was one false positive and one false negative aspirate and a case of parathyroid adenoma on aspiration proved to be parathyroid carcinoma on histology.

Intussuscepting ileal hemangioma with perforation

A rare case of solitary intussuscepting capillary hemangioma in the distal ileum with perforation and peritonitis is presented. The diagnosis was made only at surgery for presumed acute intestinal obstruction.

Peroperative cholangiogram--routine or selective results of a prospective study

Peroperative cholangiography (POC) performed as a routine during cholecystectomy for cholelithiasis was evaluated in 102 patients. POC was normal 93 patients. Nine patients had abnormal POCs: 5 were true positive--CBD stones (4) and sphincteric fibrosis (1): 4 were false positive--air bubbles (2) and sphincteric spasm (2). Preoperative indication of CBD stones were present in 12 patients-5 of these had abnormal POC (4 true positive and 1 false positive). CBD exploration was avoided in 7 patients with normal POC. Ninety patients did not have any preoperative indication of CBD stones-4 of these had abnormal POC (1 true positive and 3 false positive). None of the patients with a normal POC had any clinical evidence of residual stones on follow up for one year. POC did not help in any case to delineate biliary ductal anatomy. Routine POC during cholecystectomy should be abandoned and should be performed selectively in patients suspected to have CBD stones only to avoid a negative CBD exploration.