Retroperitoneal laparoscopic pyelolithotomy

Retroperitoneal laparoscopic pyelolithotomy was successful in 5 of 8 patients using the recently described balloon technique of retroperitoneal laparoscopy. All patients were considered for this new minimally invasive procedure only on economic grounds. However, with improved technique and instrumentation, the retroperitoneal laparoscopic approach could become a practical alternative for the management of patients with medium sized pelvic stones not amenable to extracorporeal shock wave lithotripsy nor ideally suitable for percutaneous nephrolithotomy, or when both of these facilities are not available.

Laparoscopic condom dissection: new technique of retroperitoneoscopy

The laparoscopic condom dissection is an advancement on the recently described balloon dissection technique of retroperitoneoscopy. It allows a simultaneous balloon dissection and retroperitoneal laparoscopic dissection using a telescope placed inside a condom balloon. In spite of a mild masking effect by the balloon, the clarity of vision was satisfactory, and adequate dissection could be carried out in all five patients in whom the condom was placed deep to the fascia transversalis or Gerota's fascia.

Physical growth in Indian affluent children (birth-6 years)

Growth characteristics, viz, height, weight and circumferences of head, chest and mid-arm were measured on urban affluent children from seven centres (Bangalore, Calcutta, Delhi, Kota, Ludhiana and Varanasi--Nutrition Foundation of India study). On each age and sex point there were 200 observations except at 18 and 72 months. The percentiles on pooled data were calculated by smoothed cubic spline least square method. This pooled data showed values lower than European and NCHS (American) standards. Centrewise comparison showed that Ludhiana children approached the latter. The differences in growth seem to be possibly due to lower velocity in Indian children of present study in the first 18 months as compared to American children.

Retroperitoneal laparoscopic ureterolithotomy for multiple upper mid ureteral calculi

A 30-year-old man presented with upper mid ureteral calculi and gross hydroureteronephrosis. The 4 large and 2 small calculi were removed successfully using Gaur's technique of retroperitoneal laparoscopy.

Gastric emptying in patients with gallstone disease with or without dyspepsia: effect of cholecystectomy

Dyspepsia is a common complaint in patients presenting with gallstone disease. Since the stomach appears to be its site of origin, the present study was undertaken to assess gastric emptying in patients with gallstone disease and to find out its correlation with dyspeptic symptoms before and after cholecystectomy. Gastric emptying (t1/2) was prospectively assessed in 43 patients with symptomatic gallstones (29 with and 14 without dyspepsia). These data were compared with that of 20 healthy volunteers (control group). Delayed gastric emptying (> 112 min: mean + 2 s.d. of the control group) was observed in 18 patients (42%; P < 0.002), 10 of whom presented with dyspepsia and eight without (NS). Re-evaluation in 18 of the 29 patients with dyspepsia, 3 months after cholecystectomy, revealed complete disappearance of symptoms in three, improvement in 11 and no change in four patients. After 6 months, two patients had reverted back to their pre-operative dyspeptic status; resulting in three patients completely cured, nine partially cured and six without any change in their dyspeptic status at this time. Gastric emptying was delayed in nine of the 18 patients before cholecystectomy. After cholecystectomy, normal emptying was observed in all but one patient (P < 0.005). Dyspeptic symptoms, however, completely disappeared in one patient, improved in five and remained unchanged in three. In the remaining nine patients, gastric emptying was normal both before and after cholecystectomy. Gallstone disease is associated with delayed gastric emptying but this delay was not the cause of dyspepsia in these patients. Cholecystectomy normalizes gastric emptying, a finding that has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)

Retroperitoneal laparoscopic varicocelectomy

Retroperitoneal laparoscopic varicocelectomy was performed in 27 of 29 patients with clinical varicoceles. Postoperative pain was minimal and all patients were discharged from the hospital within 24 hours. The technique is relatively safe and easy to learn, although identification of the internal spermatic vein may sometimes be difficult. It could become a viable alternative to the transperitoneal laparoscopic procedure in patients with pelvic adhesions or those having recurrent varicoceles due to high collaterals.

Utility of biliary microcrystal analysis in predicting composition of common bile duct stones

The high failure rate of contact litholytic therapy for common bile duct stones with currently available cholesterol solvents has been attributed to the inclusion of patients with pigment stones, as no pretreatment investigation is undertaken to distinguish the two stone types. In 36 patients with common bile duct stones we prospectively evaluated the utility of microscopic examination of bile collected from the biliary tree in predicting stone composition. The bile, obtained by means of either an endoscopically placed nasobiliary catheter (n = 27) or a surgically placed T-tube (n = 9), was subjected to microscopic examination, and findings were compared with the composition of stones retrieved subsequently. On the basis of quantitative infrared spectroscopy, stones were classified as cholesterol (n = 28) or pigment (n = 8) stones. The presence of cholesterol crystals in bile correctly identified 24 of 28 patients with cholesterol stones (sensitivity, 86%; specificity, 100%; positive predictive value, 100%). Calcium bilirubinate granules, when present alone (without cholesterol crystals), correctly identified all eight patients with pigment stones (sensitivity, 100%; specificity, 89%; positive predictive value, 73%). Thus, microscopic examination of bile from the biliary tree, if used as a pretreatment screening test, may help distinguish between patients with cholesterol and pigment stones and thereby considerably improve the results of litholytic therapy of common bile duct stones with currently available solvents.

Laparoscopic renal biopsy via retroperitoneal approach

Renal biopsy was performed in 17 patients using the balloon technique of endoscopy of the retroperitoneum. There was good exposure of the kidney and a sufficient amount of renal tissue was obtained in all patients with minimum postoperative morbidity. The preliminary results show that this method could become a safe and reliable alternative to open surgical biopsy.

Muscular sufficiency, serum protein, enzymes and bioenergetic studies (31-phosphorus magnetic resonance spectroscopy) in chronic malnutrition

Muscle sufficiency was significantly lower in 1336 children with chronic malnutrition of moderate to severe degree. Eighteen children with a chronic moderate degree of malnutrition and 8 well-nourished, age-matched controls were selected for biochemical and 31-phosphorus magnetic resonance spectroscopy (31-P MRS) studies. The results showed that: (a) serum total protein, albumin, iron, calcium and inorganic phosphate were similar in both groups; (b) serum enzyme levels were significantly increased in the malnourished group; (c) 31-P MRS showed significantly higher means for total ATP, beta-ATP, alpha-ATP and inorganic phosphate for the malnourished compared to the control group. In chronic malnutrition, proteins are maintained by degradation in muscle resulting in release of amino acids and enzymes. 31-P MRS studies showing increases in total ATP, beta-ATP and inorganic phosphate and a decrease in phosphocreatine suggest that ATP is maintained at the cost of phosphocreatine.

Amebic liver abscess with intra-biliary rupture

The case of a large amebic liver abscess with an atypical presentation is reported. High output bile drainage persisted after ultrasound guided percutaneous catheter drainage because of a preexisting communication of the abscess with the right hepatic ductal system. The abscess was managed successfully by surgical evacuation and internal drainage into a defunctioned jejunal loop.

Brittleness of gallstones to lithotripsy: effect of physicochemical and ultrastructural characteristics

Why some gallstones do not fragment easily to lithotripsy is unclear. The aim of the present study was to determine gallstone factors associated with resistance to fragmentation. Seventy-six cholesterol rich gallstones were subjected to physical evaluation, in vitro computed tomography, chemical analysis by infra red spectroscopy, and ultrastructural studies (of 26 matched stones) by scanning electron microscopy and energy dispersive X-ray microanalysis. In vitro lithotripsy was performed with the Siemens Lithostar Plus machine at a constant energy level. Of 76 stones, 33 required > 1000 shocks for effective fragmentation (largest diameter < or = 5 mm); they had significantly higher maximum diameter (P < 0.001), volume (P < 0.001), weight (P < 0.001) and lower stone density distribution (SDD) index (P < 0.05) and lower calcium bilirubinate content (P < 0.001) than those requiring < or = 1000 shocks. Large (> 15 mm; P < 0.05), round stones (P < 0.02) and gallstones with SDD index of < 50 HU (P < 0.02) and gallstones with SDD index of < 50 HU (P < 0.05) were more difficult to fragment. Clinical application of these parameters may help in better selection of patients for this non-surgical mode of therapy for gallstones.

Duodenal bile examination in identifying potential non-responders to bile salt treatment and its comparison with gall bladder bile examination

The results of bile salt treatment in patients with radiolucent stones and a functioning gall bladder have been poor. In 42 of these patients awaiting cholecystectomy we determined the value of duodenal bile examination in predicting gall stone composition, and thus identifying those less likely to respond to bile salt therapy. Based on chemical analysis and scanning electron microscopy, 28 of 42 (67%) gall stones retrieved at surgery were potentially insoluble. Microscopic examination of duodenal bile correctly identified 21 (75%) of them: it predicted all four (100%) pigment stones, three of six (50%) calcium carbonate containing cholesterol stones, and 14 of 18 (78%) cholesterol stones with pigment shells. It was nearly as reliable as microscopic examination of bile aspirated directly from the gall bladder during surgery (21 (75%) v 23 (82%); p = NS). Furthermore, the presence of cholesterol crystals in duodenal bile was a more sensitive indicator than chemical detection of supersaturation (34 of 38 (89%) v 25 of 35 (71%); p < 0.05) for prediction of cholesterol gall stones. Microscopic examination of duodenal bile, if used as a screening test, could help to exclude potential non-responders and thereby improve considerably the results of oral bile salt treatment for gall stone dissolution.

Is duodenal bile representative of gallbladder bile? A comparative study

Thirty-nine patients with cholelithiasis were prospectively studied to evaluate the qualitative and quantitative differences between duodenal bile and gallbladder bile. Duodenal bile obtained before cholecystectomy by nasoduodenal intubation and ceruletide injection was qualitatively similar to gallbladder bile obtained during surgery. Microscopic cholesterol crystals as an indicator of cholesterol gallstones (n = 35) could be detected in 31 (89%) and 35 (100%; p = NS), respectively. Moreover, there was no difference in the molar percentage of three biliary lipids and the mean cholesterol saturation index (1.54 +/- 0.72 and 1.74 +/- 0.42; p = NS) of the two sources of bile. Duodenal bile was, however, dilute as compared with gallbladder bile, as evidenced by lower cholesterol crystal counts (167 +/- 247 versus 705 +/- 978; p < 0.01), lower total lipid concentration (5.8 +/- 2.7 versus 11.1 +/- 5.6 g/dl; p < 0.001), and lower concentrations (in mmol/l) of the three bile lipids--that is, total bile acids, phospholipids and cholesterol (p < 0.001). Good concentrated bile (total lipid concentration > or = 5 g/dl) could be obtained in 74% of duodenal bile samples, compared with 90% of gallbladder bile (p = NS). Our study shows that, although duodenal bile is dilute as compared with gallbladder bile, it is qualitatively similar to gallbladder bile and, because of the ease and safety of its collection, can be used to study serial alterations in biliary composition in individual subjects.

An improved chemical substitute for fetal calf serum for the micronucleus test

The routine use of the micronucleus test in the mutagenicity evaluation of xenobiotics is limited by high cost and limited availability of fetal calf serum. On the other hand, there are disadvantages, such as hypotonic damage and clumping of cells, associated with the use of mineral medium substitutes for fetal calf serum. Alternatively, we recommend a chemical medium containing Hanks' buffered salt solution, 1% (w/v) bovine serum albumin, and 0.15% (w/v) ethylenediaminetetraacetic acid, final pH 7.4, to preserve morphology, density and homogeneity of bone marrow cells. Mast cell granules are efficiently removed from rat bone marrow preparations by washing twice with this medium. The morphological preservation of cells is further enhanced by fixation with 70% (v/v) ethanol for 5 min. The proposed medium provides a cost-effective and convenient substitute for fetal calf serum with substantially improved quality of bone marrow preparations for the micronucleus test.

Chemical nature and distribution of calcium compounds in radiolucent gallstones

A high failure rate for radiolucent cholesterol gallstones to dissolve with oral bile acids may be due to the presence of insoluble calcium compounds. Twenty sets of radiolucent gallstones, 7-20 mm in diameter, obtained from 20 patients undergoing cholecystectomy, were cut, and the outer surface, outer rim, middle portion, and central core areas were scanned for calcium by energy-dispersive X-ray microanalysis (EDX) and scanning electron microscopy (SEM). Scrapings from the four areas of each stone were analysed by infrared spectroscopy. A sample of the crushed stone was used for chemical estimation of cholesterol. Eleven (55%) of the 20 cholesterol (84-96% dry weight of cholesterol) stones showed presence of calcium by EDX; the distribution was peripheral in 5, homogeneous in 4, and central in 2. The chemical compound was calcium bilirubinate in 10 and calcium carbonate in 8 stones. Calcium compounds are present in a high proportion of radiolucent gallstones considered suitable for chemodissolution by conventional criteria. Their unrecognized presence may explain the high failure rate of such stones to respond to medical therapy.

Simple approach to acute respiratory infection in rural under five children

The feasibility of acute respiratory infection (ARI) control in 5,535 rural preschool children was studied. The Primary Health Centre (PHC) staff and local practitioners (drug distribution centres) were identified and trained in recognition of moderate/severe ARI, referral, drug administration and in the education of the community. Functional ARI classification as envisaged in ARI control programme was followed. There was significant reduction in moderate (42% reduction) and severe (89% reduction) ARI episodes from year 1985 to 1987. Both ARI (27.8%) and non-ARI (18.3%) deaths showed reduction. Majority of children who died due to ARI were also unimmunized. The moderate and severe ARI related morbidity and mortality was significantly reduced in immunized children compared to unimmunized children. Although, strategies of National ARI control programme by health education, standard case management and strengthening of immunization is a good thought but it is clear that proper implementation of immunizations is going to pay more dividends. It is also evident that the local medical practitioners should be trained and involved in this control programme to have community faith as well as to avoid opposition.

What decides: high mortality in paediatric acute renal failure?

Forty paediatric cases of A.R.F. (Acute Renal Failure) of various aetiology were included in the study. 60% of patients were less than 4 years of age with male predominance. 80% cases reported to us very late with oligoanuria of more than 24 hours (2-7 days). Diarrhoea, vomiting and fever were other dominant symptoms. Maximum cases were severely anaemic (87.5%) with mean Hb 7.73 +/- 1.9 gm%. 40% cases were of underweight while only one case (2.5%) was of over weight, inspite of volume excess in 40% cases. All 24 cases, who were estimated for serum albumin, found to have marked hypoalbuminemia. Mortality was found to be as high as 65% inspite of effective peritoneal dialysis in all cases. High mortality seems to be due to profound anuria of many days (because of marked delay in reaching the hospital), fever and malnutrition besides other factors as aetiology.

Young age carcinoma stomach with spontaneous bacterial peritonitis

A case of disseminated carcinoma stomach at the age of thirteen years is reported. The patient in addition had spontaneous bacterial peritonitis.

Solitary non-parasitic cysts of the liver: presentation and management

Four cases (one asymptomatic and three symptomatic) of solitary non-parasitic cysts of the liver are presented. The asymptomatic cysts was an incidental finding at laparotomy. The other three patients presented with abdominal distension, jaundice and malignant transformation respectively. Management of these patients has been discussed and the literature reviewed.