Biomedical subjects

Dinesh Singhal

Publications and source records attributed to Dinesh Singhal.

10 recordsLinked to original sources

PubMed2007

Transabdominal gastroesophageal devascularization without transection for bleeding varices: results and indicators of prognosis.

BACKGROUND: Esophagogastric devascularization is an operation that can be performed for endoscopically uncontrolled variceal bleeding in hospitals having only basic surgical instruments and is therefore an appropriate procedure for small hospitals in developing countries. The aim of this study was to analyze one hospital's experience of this operation in consecutive patients with variceal bleeding. METHODS: Between 1996 and 2003, 45 patients (30 male, 15 female) who had a mean age of 40 years (range 7-78 years) underwent devascularization procedures. Of the 45, 23 had cirrhosis and 22 had non-cirrhotic portal hypertension (11 extrahepatic portal venous obstruction, 11 non-cirrhotic portal fibrosis), and 18 patients had emergency procedures and 27 were elective. Mortality, morbidity, rebleeding rates and the prognostic factors for death were assessed. RESULTS: Elective and emergency mortality was one (3.7%) and 11 (61%) patients, respectively. There was no rebleeding in hospital. At follow up (mean 48 months, range 3-92 months) overall survival in patients with cirrhosis was 7 out of 20 and in patients with non-cirrhotic portal hypertension was 19 of 21. Five (17%) had recurrent variceal hemorrhage, of whom three, all cirrhotic patients, died. Preoperative prognostic indicators for death were emergency surgery, a Child-Pugh score >or=10, preoperative blood transfusion >or=20 units and renal failure. CONCLUSIONS: Gastroesophageal devascularization effectively controls variceal bleeding especially in non-cirrhotic patients with portal hypertension. In the elective situation it carries a low mortality and rebleed rate. In emergencies the prognosis is poor with advanced cirrhosis, following large quantities of blood transfusion and deranged renal function. It is suggested that this operation be offered especially to non-cirrhotic patients in hospitals in developing countries where facilities for more sophisticated procedures are not available.

Adolescent↗

PubMed2006

Current role of portosystemic shunt surgery in the management of hepatic venous outflow obstruction.

BACKGROUND: Hepatic venous outflow obstruction (HVOO) is a rare disorder that occurs predominantly due to a hypercoagulable state. The syndrome may result from hepatic vein obstruction, inferior vena cava obstruction or a combination of both and manifests with post-sinusoidal portal hypertension. The presentation may be fulminant with poor prognosis or as either acute, subacute or chronic forms with relatively better prognosis. Portosystemic shunt surgery (PSS) has thus far been the mainstay of treatment for HVOO. However, over the last decade, transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation have emerged as viable options. This review aims to evaluate the available treatment options and the current relevance of PSS for the management of HVOO. METHODS: A literature review on investigations and treatment was performed using Medline and additional library searches. RESULTS: Portosystemic shunts form the mainstay of treatment for patients with subacute presentation (preserved liver function) with medically intractable ascites or recurrent variceal hemorrhage. Excellent results with 5-year survival of more than 90% have been reported from specialized centers. The main limitation for PSS is the reported perioperative mortality of 10-20% and a declining technical expertise for such surgery. Liver transplantation with disease-specific 5-year survival between 50 and 95% is presently the treatment of choice for patients with fulminant presentation, end-stage liver disease (ESLD), unshuntable anatomy or decompensation after PSS. TIPS may be preferable for sick patients with acute presentation with isolated hepatic vein thrombosis or as a temporizing measure for those with ESLD awaiting transplantation. The drawback of TIPS is late shunt dysfunction that occurs in more than 50% of patients at 1 year. CONCLUSIONS: Due to rarity of the disorder there is a lack of trials comparing the different treatment modalities. Hence, the current treatment recommendations are based on retrospective studies. In a select group of HVOO patients (subacute presentation with preserved liver function), PSS remains the treatment of choice with excellent long-term results.

Budd-Chiari Syndrome↗

PubMed2006

Surgery for obscure lower gastrointestinal bleeding in India.

Western patients with obscure lower gastrointestinal hemorrhage (OLGIH) are usually 60 years or older, bleed from colonic diverticulosis or angiodysplasia, and need localizing investigations. In India, patients are younger, the causes of bleeding different, and health resources scarce. We followed a policy of early surgical exploration operation and excision of the bleeding source or, if this was not identified, did a right hemicolectomy. The outcome of this strategy was evaluated. Between 1996 and 2003, we managed 62 patients with OLGIH. Localizing investigations such as enteroclysis, radioisotope scanning, angiography, and peroperative enteroscopy were infrequently performed. Fifty patients underwent surgery, emergency (35 pts) or elective (15 pts), and comprised the study group. At operation the lesion was localized in 33 (66%) patients (jejunum in 9 and terminal ileum or cecum in 24) and was resected. In 17 patients no lesion was found and they had a right hemicolectomy. The 30-day mortality was six patients (12%) and included persistent bleeding (three), liver failure (one), and chest infection (one). Five (10%) patients rebled after operation at a mean follow-up of 31 months. Cirrhosis (P=0.003) as a comorbid illness was the only significant factor for rebleed in the right hemicolectomy group. Advanced age (>60 years; P=0.08) might be another risk factor in a larger study. In conclusion, patients with obscure OLGIH in India should have an early operation. If a lesion is not detected, a right hemicolectomy may be done. In this group those with cirrhosis have a higher chance of rebleed, as well as, perhaps, elderly patients.

Adult↗

PubMed2006

Sinistral portal hypertension. A case report.

Sinistral portal hypertension is a clinical syndrome of gastric variceal hemorrhage in the setting of splenic vein thrombosis due to a primary pancreatic pathology. The distinguishing features from other forms of portal hypertension are preserved liver function and a patent extrahepatic portal vein. The important causes include acute and chronic pancreatitis, pancreatic pseudocysts and pancreatic carcinomas. Benign pancreatic neoplasms only rarely cause sinistral portal hypertension. Splenic vein thrombosis complicates 7-20% of patients having pancreatitis or a pancreatic pseudocyst; however, bleeding occurs in only approximately 5% of patients. The diagnosis of sinistral portal hypertension is achieved by a combination of gastroscopy, liver function tests, ultrasound examination (with Doppler) and/or contrast-enhanced CT scan of the abdomen. A mere demonstration of sinistral portal hypertension does not warrant intervention. An expectant management is justifiable in asymptomatic patients with pancreatitis. However, concomitant splenectomy may be considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are present. In patients presenting with gastric variceal hemorrhage, splenectomy (with treatment for the primary pancreatic pathology, e.g. distal pancreatectomy) is curative with excellent long term results.

Carcinoma, Adenoid Cystic↗

PubMed2006

Issues in management of pancreatic pseudocysts.

Pancreatic pseudocysts (PPs) comprise more than 80% of the cystic lesions of the pancreas and cause complications in 7-25% of patients with pancreatitis or pancreatic trauma. The first step in the management of PPs is to exclude a cystic tumor. A history of pancreatitis, no septation, solid components or mural calcification on CT scan and high amylase content at aspiration favor a diagnosis of PP. Endoscopic ultrasound (EUS)-guided FNAC is a valuable diagnostic aid. Intervention is indicated for PPs which are symptomatic, in a phase of growth, complicated (infected, hemorrhage, biliary or bowel obstruction) or in those occurring together with chronic pancreatitis and when malignancy cannot be unequivocally excluded. The current options include percutaneous catheter drainage, endoscopy and surgery. The choice depends on the mode of presentation, the cystic morphology and available technical expertise. Percutaneous catheter drainage is recommended as a temporizing measure in poor surgical candidates with immature, complicated or infected PPs. The limitations include secondary infection and pancreatic fistula in 10-20% of patients which increase complications following eventual definitive surgery. Endoscopic therapy for PPs including cystic-enteric drainage (and transpapillary drainage), is an option for PPs which bulge into the enteric lumen which have a wall thickness of less than 1 cm and the absence of major vascular structures on EUS in the proposed tract or those which communicate with the pancreatic duct above a stricture. Surgical internal drainage remains the gold standard and is the procedure of choice for cysts which are symptomatic or complicated or those having a mature wall,. Being more versatile, a cystojejunostomy is preferred for giant pseudocysts (>15 cm) which are predominantly inframesocolic or are in an unusual location. In PPs with coexisting chronic pancreatitis and a dilated pancreatic duct, duct drainage procedures (such as longitudinal pancreaticojejunostomy) should be preferred to a cyst drainage procedure.

Humans↗

PubMed2006

Management protocol for acute gastrointestinal bleeding.

Gastro-intestinal haemorrhage is not uncommon and is manifested as haematemesis, melaena or haematochezia. The first step is to resuscitate the patient if necessary and then proceed to make a diagnosis as well as divide patients into high and low-risk groups after taking a good history and performing a physical examination especially to detect the presence of an enlarged spleen. Then one should proceed with an endoscopy and other investigations chosen carefully for their usefulness. Control of bleeding is then tailored to the diagnosis and is usually with drugs, endoscopy, angio-embolisation and surgery in that order. The mortality rate for upper GI bleeding varies from 10 to 30% depending on the proportion of patients with variceal haemorrhage included. For lower GI bleeding mortality is in the region of 20% and for obscure GI bleeding outpatient mortality is 12%. The main points to remember are that the management of these patients in India should be different from those described in Western textbooks and suited to their specific needs and the facilities available locally. However, in spite of the widespread lack of complex diagnostic techniques and a shortage of blood for transfusion we believe that by adopting an aggressive step-by-step approach tailored to our own environment we will be able to save most of our patients who are usually young and have few comorbid conditions.

Acute Disease↗

PubMed2004

No mean feet.

Explore the source record for details and available documents.

Amputation, Surgical↗

PubMed2002

Febrile episodes in childhood malignancies.

The objectives of the present report were to study the site of infections and pathogenic organisms during febrile episodes in different childhood malignant conditions, to correlate febrile episode with Absolute Neutrophil Count (ANC) and to know the sensitivity pattern of bacteria to different antibiotics so as to know the most appropriate antibiotic regimen in these children. The study material comprised of forty two febrile episodes occurring in children aged lt 12 years with various malignancies. All the episodes were worked up in detail including complete history, physical examination and relevant hematological, microbiological and radiological investigations. Out of the 42 episodes, 15 (36%) occurred in children with acute leukemias, 20 (48%) in children with lymphomas and 7(17%) in children with solid tumors. 26 (62%) episodes were seen in children during chemotherapy, while 12% each in freshly diagnosed and remission and 14% in relapse cases. 12 (28%) episodes occurred in children with ANC < 500/mm3. 36% were microbiologically confirmed. Klebsiella species was the commonest organism isolated followed by E. coli. Maximum sensitivity (75%) was seen with ciprofloxacin against both Klebsiella species and E.coli.

Child↗

PubMedDate not supplied

Distinguishing between periampullary carcinoids and carcinomas--is this possible preoperatively?

It is difficult to distinguish between carcinoid tumors of the pancreatic head and periampullary region and carcinomas preoperatively. Between 1996 and 2002, 125 consecutive pancreaticoduodenectomies done by us for periampullary tumors (14 carcinoids, 111 carcinomas) were analyzed. Patients with carcinoid tumors had significantly younger mean age (48 vs. 54 years), longer history (32 vs. 8 weeks), lower serum total bilirubin levels (1.4 vs. 6.3 mg/dL) and on CT scan, had larger, well-localized tumors (5 cm vs. 2 cm). Their postoperative course was better with no mortality or major morbidity, whereas after resection for carcinoma 7 (6.3%) patients died and 30 (27%) had major postoperative complications. Thus, a tumor of this region in a young patient with indolent history, low bilirubin level and with CT scan depicting a large expansile lesion suggests a carcinoid. Such tumors may be safely resected with low postoperative morbidity and mortality and good long-term prognosis.

Adult↗

PubMedDate not supplied

Squamous cell carcinoma of stomach.

Squamous cell carcinomas in the gastrointestinal tract are known to occur in oro-pharynx, esophagus and anal canal. Gastric squamous cell carcinoma is a rare epithelial tumour. Surgical treatment is the same as that for an adenocarcinoma, though prognosis is probably worse.

Carcinoma, Squamous Cell↗