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ABSTRACTS OF PAPERS PRESENTED AT THE 102ND RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY 9TH DECEMBER 2002, 2.30 PM, SP JAIN CAETERIA (CONVENOR DR. HL DHAR)


1. CO-ORDINATION OF PLASTIC SURGERY AND ORTHOPAEDIC SURGERY IN THE MANAGEMENT OF LIMB TRAUMA
RF Ginwalla, SR Tambwekar, K Khadalia, VS Tambwekar, MI Goswami
In the last several years, due to advances in technology, high velocity injuries producing high energy trauma to
bone and soft tissue have become common.

The modern day multi-pronged approach to trauma management has led to a decreased hospital stay, patient morbidity
and the saving of far more lives and limbs than before.

The work done in Bombay Hospital by the combined units for the last two years shall be reviewed. And the
bene.ts accrued to the patients highlighted.

Total No. of patients - 86 Upper limb trauma - 34 Lower limb trauma- 52
Time of presentation- Early- 25% (<7 days post-trauma) Late - 75% (> 7 days post-trauma)

 

The bulk of the patients in our series were admitted late as they were primarily treated in other centres. Management
begins with eliciting a good history, from the patient if his condition allows it or the relatives, as this will help to explain the dynamics of the incidence and the distorting forces involved, as well as the prevailing conditions at the time.

The next step is a careful assessment of the wounds, preferably under anaesthesia, along with the requisite radiological
.lms. The wounds may be classi.ed into three types according to salter-Harris depending on the extent, radiographic
findings and soft tissue damage assessed at the time of debridement.

A thorough debridement of the wound is extremely important, to reduce contamination, remove dead tissue and
determine the extent of the wound, which may not be apparent at the time of debridement, but knowledge of this
“Zone of Trauma” will help the surgeon plan his procedure better. Debridement should ideally be performed under
tourniquet, and all non-viable tissue excised. Assessment of the limb is done initially to determine whether the
limb can be salvaged, whether the blood supply is adequate for survival and healing, and whether adequate bony
taxation can be achieved.

Most patients with type III wounds require some soft tissue cover, done primarily or as a secondary procedure. Soft
tissue cover may be in the form of Skin Grfting or Flap cover.

A few procedure performed at Bombay Hospital will be discussed, and their results demonstrated and analysed. All four
patients shown had presented late, and were treated in multiple stages, varying from Skin Grafts to Free Latissimus Dorsi
Flaps. One patient was referred late and had to undergo a BK amputation for gangrene of the foot.

The analysis of the statistics show that most patients with complicated fractures were treated primarily by
orthopaedic surgeons alone, the large majority in other medical centres, and were referred to plastic surgery only
for a complication or delay in healing.

Most of these patients underwent multiple surgeries, leading to prolonged hospitalization and repeated admissions.
The patients which presented in acute stages and were treated by orthopaedic and plastic surgeons together from the
beginning had to undergo fewer surgeries, and were usually discharged earlier.

The conclusion is that cooperation between plastic and orthopaedic surgeons at the time of primary assessment

Jand debridement can bene.t the patient greatly, both in the healing of his bone and soft tissue wounds, as well as
economically, getting him back on his feet literally and .guratively. The role played by both is complementary and
synergistic, the ultimate bene.ciary being the patient.

2. EFFECTS OF BILEVEL POSITIVE AIRWAY PRESSURE VENTILATION IN RESPIRATORY FAILURES
Ram Bhai Patel, Krishna Chandavarkar, Shoba Atre, Seema Haridas

The purpose of this talk is to outine how to initiate bilevel therapy and to explain some of the features of the device,
which can improve both patient tolerance and clinical outcome.

The settings of our study has been the Cardiac recovery, 14th .oor ICU, 12th .oor ICU and the 3rd .oor old BH ICU
some of the wards in Bombay Hospital and Medical Research Centre.

The main outcome measures are arterial blood gases, SpO2 and use of endotracheal intubations.

BiPAP is Bilevel positive airway pressure administered without conduit access to airways to avoid complications of
mechanical ventilation. The principle of bilevel pressure device is that it delivers a higher pressure on inspiration, which
acts as a pressure support and augments the patient effort. (IPAP) and a lower pressure of expiration, which is used to
splint open the upper airway to maintain the upper airway patency (EPAP).

The advantages of BiPAP are that it is small and portable with a good amount of leak compensation. Patient can
speak and swallow. Being easy to apply and remove it can be used outside ICU settings it preserves the airway defense
mechanism hence reduces nosocomial pneumonia and prevents airway injuries. It is also cheaper than other modes of
ventilation. There is reduced need for sedation. Patient is much more comfortable and the machine can be handled by not
only by the medical personals but also by the relatives of the patients if it has to be used in a home setup.

It is indicated in hypoxemic respiratory failure cases, hypercapnic respiratory failures and neurological conditions
that will be speci.ed in the main paper.

The aim of this device is to give rest to the respiratory muscles and to reduce the work of breathing to support and
augment patient’s own respiratory efforts, improves gas exchange and oxygenation and prevent CO2 retention.
The limitations to mask ventilation is that it is not used in patients with facial traumas, uncooperative and unmotivated
patients. Also not used in patients with high risk of aspirations, haemodynamically unstable patients, and post op abdominal surgeries. Pneumothorax and neurological patients with a glassgow coma scale of less than 8.
Trained staff who can review and change the setting in case of deterioration, the right location for initiation of
therapy and regular follow ups in cases of patients who have to use it on long term bases is essential for successful
utilization of the device.

The biggest challenge of compliance is accomplished only if there is a Good synchronization between the patient
and the machine. Appropriate mask and good harness causes minimum leak to achieve this it is essential to counsel the
patient about the advantages of the therapy and supervise the practice sessions.

During the period of 1999 and 2002 our department has treated a broad range of cardio pulmonary diseaes, COPD,
pneumonia, pulmonary oedema, postoperative atelectasis and neurological dysfunctions causing respiratory complications where bipap was used as the .rst line of intervention in their management. So this study will involve a combination of all these patients. This presentation will summarize the evidence on where and how Non Invasive Positive Pressure Ventilation in the form of BiPAP should be performed and the outcome of the same.

The ratio of the patients who bene.ted by the use of BiPAP was much higher than those who did not benefit of it. Details will be dealt with in the main paper.

The results of this study indicates that application of BiPAP is effective in treating haemodynamically stable patients
with respiratory failure and causes few and minor complications.

 

3. INCISIONAL HERNIA REPAIRED UNDER LOCAL ANAESTHESIA - OUR EXPERIENCE
Niranjan Agarwal, T Naresh Row, MM Begani
The more experience a surgeon gets, the more con.dent he becomes, with an increased willingness to get more out of
these routine cases. Some times circumstances force him to opt for newer methods of dealing with old problems.

We would like to present our experience with fairly large sized, that is, up to 10 to 12 cm sized incisional hernias being
repaired under local anaesthesia, where, we have been able to do simple herniorraphy as well as hernioplasty.

In the past 20 years, we are now doing more and more cases of incisional hernia under local anaesthesia, which
we would like to share with you.

Mrs. Goyal, 83 years, female, presented with lower abdomen swelling, partly reducible, on and off pain, and
with symptoms of intestinal obstruction.

Patient is a known case of hypertension, post CABG, with permanent pace maker.

On examination, a clinical diagnosis of partly reducible incisional hernia was made. 8 cm in size, with a 4 cm neck.

She was operated for hysterectomy few years back.

She was investigated and Cardiologist’s opinion was taken for surgical fitness.

She was not .t for any type of anaesthesia, therefore, repair under local anaesthesia was undertaken, same scar was
used, in this case repair was done by opening the sac, excision of the sac and the omentum, which was the content
of the sac, with onlay prolene mesh plasty.

She recovered well post operatively.

We have operated several cases of incisional ventral hernias of varying sizes, with different type of repair
techniques, different from case to case, in cases unfit for any type of anaesthesia, as well as fit patients under
local anaesthesia and sedation.

4. GIANT CONDYLO ACCUMINATA : CASE REPORT
Mahentesh Halmali, T Naresh Row, Niranjan Agarwal, MM BeganiMA


Fifty years old male patient presented with swelling in the anal region, chronic constipation, and dif.culty in passing
motions, painful defaecation, on and off bleeding per rectum, since many years.

On examination, he was found to have a giant Condyloma, covering all his anus, perineum and extending from
the end of the sacrum to the base of the scrotum.

We could .nd the anal opening with difficulty.

He did not give any history of contact or exposure or any other signi.cant history. Biopsy did not show any
malignancy.

 

5. DRUG INDUCED ULCERS : A CASE PRESENTATION
Anand Kashid, T Naresh Row, Niranjan Agarwal, MM Begani

Case presentation of a 49 year old male patient, from North India, presented with a large non-healing ulcers
on his left forearm, since 2000.

He was addicted to injection - pentazocin hydrochloride, since 18 years, which he self injected.

Patient is from a middle income group, with sedentary life style, owner of a small business.

In the past, in ’69-70, he has severe pain in the right hip and was diagnosed as having TB of the right hip joint. Anti
Kochs treatment was started, which the patient did not complete.

He had a relapse in ’84, when the pain in the hip joint restarted and he was diagnosed as having necrosis of the
head of femur, and was operated upon.

Due to severe pain, he was prescribed several oral analgesics, followed by injectable analgesic, in the form of fortwin,
patient used to go to the doctor or the local hospital and get him self injected at least once a day, this increased to 8 injectionsbper day. Initially the injections were given intramuscularly, later, intravenous injections were given.

By now he was fully addicted. He started purchasing and injecting himself with the 1 ml injections of fortwin,
intravenously. He would develop shivering, palpitation and depression on not getting his ‘.x’. With the injection, he was able to attend to his day to day activities, normally and con.dently. Due to the faulty method of self injection and extravasation, the acidic medium of the injection, he developed a blister on the right hand, but he continued to inject himself. Gradually, skin ischaemia, leading to necrosis, sloughing and ulcer formation, which gradually increased in size and woud not heal due to repeated injections; it covered most of the dorsal surface of his forearm. There was severe oedema of the .ngers and wrist in the hand due to lymphatic blockage. This was the right hand, and he came to us in ’99, for the treatment of the ulcer, which developed since ’96. Several methods of treatment was given, including homoeopathy, when nothing worked, he was referred to Mumbai Investigations showed Hb of 7 gm%, with serum albumin of 2 gm.

We hospitalized him, referred to a psychiatrist for de-addiction, antibiotics, correction of anaemia, hypo-proteinaemia
by whole blood transfusion and heat therapy for reduction of lymphoedema. Once the wound was found to be healthy
and his blood picture improved, split skin grafts were taken from his thigh and grafted on to the ulcer. Followed up
regularly for dressing, which showed a good takeup of the graft.

He was hospitalized for 23 days.

He went back and started abusing himself again, this time on the left hand, and came back to us with exactly similar
type of ulcer, which was again treated similarly, and this time he was admitted for 17 days.

He will followup in the month of March for a 6 monthly follow-up.

6. POST LAPAROSCOPIC CHOLECYSTECTOMY INCISIONAL HERNIA-REPAIRED BY LAPAROSCOPIC ASSISTED METHOD
MM Begani, T Naresh Row, Niranjan Agarwal
More we do the more we learn, holds true in any form of work. Complications of laparoscopic surgeries present
in many forms, but to identify and treat it laparoscopically or laparoscopic assisted repair, is unique and demanding
to every laparoscopic surgeons skill.

We would like to present one case of incisional hernia, post laparoscopic cholecystectomy, repaired by laparoscopic
assisted method.

 

7. MEDLINE DERANGEMENT IN HEMIPLEGICS - PUSHER SYNDROME
Priti K Shah, Roshan M Vania
Stroke is de.ned as rapid onset of focal neurological de.cit resulting from disease of cerebral vasculature. It could be
categorized depending on aetiology (ischaemic, haemorrhagic, etc.), Anatomic distribution (Speci.c vascular distribution)
or clinical presentation (Sensory, motor, or mixed with or without cognitive and language dysfunction). Most studies concerning rehabilitation of the patients with hemiplegia showed that the majority are able to achieve independent walking, irrespective of the quality of the gait pattern with conventional treatment. But minority of them fails to achieve independence and remain wheelchair bound, or considered unsuitable for rehabilitation when treated with conventional approach. Patricia Davies, Swiss therapist in early 80’s observed that most of the patients who failed exhibited common uniform dif.culties that could be grouped together in a syndrome, Pusher syndrome. The name is derived from the most striking symptom, i.e. the patient pushes strongly with the good side (ipsilateral side of lesion) towards the hemiplegic side in all positions and resists any attempt of the therapist to correct the posture and shift his weight toward the midline and over to the normal side. Hence the term midline derangement. Therefore, on observation by the therapist we can classify hemiplegics in 2 types.

A) Patient exhibiting classic picture of hemiplegia apart from sensory motor disturbance-shortened hemiplegic side, decreased weight bearing on hemiplegic side, inadequate or absent equilibrium and protective reactions on hemiplegic side.
B) Pusher syndrome.
Here we would like to share salient features of pusher syndrome, treatment guidelines and our experiences
with the same.
• Pusher syndrome is more commonly observed in left hemiplegics than right.
• The degree of dif.culty is not in proportion to loss of active movements.
Generally, these patients suffer a severe stroke. A Danish study (Pederson, 1996) has shown prevalence of the

syndrome more with involvement of posterior limb of internal capsule.
• The individuals with this problem have impairment in judging the vertical (vertical perception).

• Majority of them also exhibit somatosensory, visuospatial, body image and body schema problems.

• On clinical observation, their hemiplegic side appears lengthened. Patient pushes on hemiplegic side resulting in
faulty weight bearing on hemiplegic side. Sound side appears shortened because of faulty weight bearing. Patient
tends to hold sound side very tight to maintain balance.

 

Above factors are considered during assessment, treatment and follow up apart from sensory, motor and tone
assessment.

The treatment principle aims at providing the patient with the correct tacto-kinesthetic input and environmental
information, during the speci.c active functional, goal oriented activity to regain his affected motor skills, visuospatial
and vertical orientation. NDT and sensory integrative principles are used during the treatment. The patient, relatives
and nurse are actively involved from the very beginning. As many of these patients have very short attention span they
respond well to short duration and more frequent inputs.

From year 2001 to Nov. 2002 we have studied 135 hemiplegic patients. And out of which 35 patients were Pusher
syndrome of varying degree. And in our experience, with such patient if the problem is identi.ed early and accordingly
treated almost 60% of them achieve standing and walking with support at the end of four weeks. Rehabilitation of this
patient take longer but the effort is well rewarding.

8. ENTEROLITHIASIS
MM Begani, T Naresh Row, Niranjan Agarwal


Mr. IHJ, a 65 year, old male presented with, on and off distension of abdomen and feeling of a mobile lump in the
abdominal cavity, which gave him on and off pain, since 5 years.

During the episodes of pain and distension of abdomen, he would have vomiting and inability in passing motions
or gases, he would be hospitalized and Ryle’s tube aspiration with IV .uids, would settle his complaints, he was
diagnosed as sub-acute intestinal obstruction.

He was a very lean and thin. Did not have any associated medical pathology.

On examination, multiple scars were seen over the abdomen, he had undergone bilaeral inguinal herniorraphy 10
years ago, piles 8 years ago and appendicectomy 5 years ago, this was an emergency surgery, done in his country. No
lump was found, abdomen felt ‘doughy’, but was soft and non tender.

Investigations showed, multiple ring shaped concretions which were radio-opaque, in the lower abdomen on plain
X-ray abdomen, about 7 to 8 in number, of size 2 cm each. USG showed intra-luminal shadows, with intestinal .uid
moving around the shadows, 7 to 8 in numbers, 2 to 2.5 cm in size, in the lower abdomen. GB and CBD were normal.
Patient was taken for surgery, midline, infra-umbilical incision was taken under spinal anaesthesia. On exploration of
the bowel loops, at about 60 cm from the terminal ileum, a narrow stricture, with proximal dilatation was seen. This
dilatation was like a pouch which was .lled with large stones. Enterotomy and removal of stone was done, there were
7 large stones with an average size of 2 cm, dark in colour, with smooth surface. There were 3 outer shell of cardamom
(illaichi) also found along with the stones. The stricture was very narrow, allowing only your little .nger to pass,
stricturoplasty was done in two layers. Rest of the bowel was normal.

 

In retrospective, most probably along with his appendicectomy, a Meckel’s divetriculum was found and excised,
which later developed into a stricture, or some sort of damage to the bowel loop has occurred during the emergency
appendicectomy.

 

ABSTRACTS OF PAPERS PRESENTED AT THE 103RD RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY 13TH JANUARY 2003,
2.30 PM, SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. USE OF GADOLINIUM BASED CONTRAST FOR DIAGNOSTIC ANGIOGRAPHY AND INTERVENTIONAL PROCEDURES

FG Irani, SJ Punamiya, R Pant
To evaluate the diagnostic utility and safety of gadolinium based contrast medium in patients with renal insuf.ciency.
Six patients with azotaemia underwent angiographic procedures including diagnostic angiography (n=3), bilateral renal
stenting (n=2), and embolisation (n=1). Gadodiamide contrast was used in all patients, with total dose ranging from
0.1 to 0.4 mmol/kg. Patients were followed with serum creatinine measurements at 24-48 hours and 7 days following
procedure. All patients had satisfactory opaci.cation of the vessels. All 3 patients that underwent interventional
procedures had a successful outcome. There was no elevation of serum creatinine following the procedure. Gadolinium
is a safe, angiographic contrast medium that can be used effectively in patients where nephropathy from iodinated
contrast is a concern.

2. CT AND MRI OF RENAL MASSES
Devang Desai, Inder Talwar, Meher Ursekar

Computed tomography (CT) is the standard de.nitive investigation for haematuria or a renal mass. Initial evaluation
may be done by intravenous urography or ultrasound. Patient with suspected metastases to the kidney, or palpable mass
in the renal region, may undergo CT scan as a .rst line investigation. CT is also indicated in persistent or ecurrent
haematuria, even if IVU or USG are normal. It is more sensitive than USG or IVU for detecting renal masses, as well as
to establish a de.nitive diagnosis and to differentiate renal from pararenal masses. It serves as a good tool for staging of
renal malignancies. CT is also an excellent guide for aspirations and biopsies in indeterminate cases. Dual phase spiral
CT has enhanced evaluation of vascular renal masses.

Magnetic resonance imaging, with its multiplanar and angiographic capabilities, has proved to be even more powerful
tool in evaluating renal masses and for staging renal cell carcinoma. It is very sensitive in assessing renal vein invasion.
MRI is clearly indicated in patients who cannot tolerate iodinated contrast. For these patients, MRI should replace CT
for evaluation of a USG detected indeterminate mass. Initial drawbacks included artefacts resulting from physiological
motion, intestinal peristalsis, and vascular pulsations. But with the advent of faster imaging sequences, respiratory
and cardiac gating, this is now a rarity.

3. MR IMAGING IN DEGENERATIVE DISEASES OF SPINE AND FAILED BACK SYNDROME
Preeti Neve, Inder Talwar, Meher Ursekar


Low back pain due to degenerative spine is the commonest cause of disability. MRI spine is a frequency requested
investigation for its evaluation.

 

Routine imaging sequences for the spine include T1 weighted, T2 weighted, sagittal and axial imaging. Gradient echo
images, 2D and 3D acquisitions and parasagittal images are suitable for evaluating the neural foramina. MR myelogram
acquires images comparable and superior to CT myelography without radiation hazards. Diffusion MR can be used to
differentiate malignant bone marrow oedema from benign.

Contrast enhanced MRI has a role for evaluation of causes of failed back syndrome such as arachnoiditis, discitis,
residual/recurrent disc, epidural .brosis/tumour.

MR imaging is a best suited modality for evaluating the spine due to its excellent soft tissue resolution, multiplanar
imaging and availability of various sequences to optimise the visualisation of cord, CSF, ligaments, cartilage disc.
Screening of the whole spine allows for disc disease at other levels to be diagnosed. Incidental lesions such as
epidural/vertebral metastasis, infection, conus medullaris tumours, perineural cysts, etc. presenting as low backache are
also evaluated. Another advantage is simultaneous evaluation of the spinal cord for signal abnormalities. In summary, MRI spine plain and post gadolinium are excellent modalities for evaluation of degenerative spine and failed back syndrome. CT nevertheless has a role in detecting calci.cation, bony lesions and for image guided interventional procedures.

4. PAROTID SCINTIGRAPHY
Alka Mundas, Vinay Goyal

Parotid scintigraphy is done to evaluate the function of the salivary glands.

It is done using 5-10 mCi of 99mTc pertechnetate. Dynamic images are recorded for 15 minutes duration- initially
1 sec/frame for 2 minutes followed by 1 minute/frame for 13 minutes. The lime jice stimulation is given 10th minute
to demonstrate salivary excretion. Later 500 K count static images of the anterior, right and left lateral images taken.
It is usually done to evaluate the following:

i. To differentiate Warthin’s tumour from other benign or malignant tumours.
ii. To evaluate salivary gland function, especially after head and neck irradiation.
iii. Infection / in.ammation.
iv. Salivary excretion post-lime juice stimulation.

Malignant (Warthin’s) tumours are unique in that they show a tendency to retain tracer within the mass. Normal salivary glands show a signi.cant decrease in activity after lemon administration. Advantages of parotid scintigraphy over conventional sialography are:
i. Simultaneous evaluation of bilateral parotid and submandibular salivary glands.
ii. Salivary excretion following limejuice stimulation.
iii. Also a painless procedure.

 

ABSTRACTS OF PAPERS PRESENTED AT THE 104TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY 10TH FEBRUARY 2003, 2.30 PM, SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. DILEMMAS IN MANAGEMENT OF BLUNT RENAL TRAUMA - A CASE REPORT

UP Acharya, MK Dubey, S Punamiya, SW Thatte
Thirty year old male, presented with the blunt abdominal trauma with haematuria. His CT scan showed a large
perinephric haematoma without disruption of pelvicalyceal system. But as the patient’s condition did not improve, a
repeat CT scan was performed which showed disruption of pelvicalyceal system with a large urinoma. A percutaneous
tube drainage was performed with double-J stenting or ureter. Follow up imaging showed complete resolution of
urinoma and good renal function.

This case report indicates the dilemmas in management of such severe injuries and its successful management without
exploration, which would have had high morbidity and even possible nephrectomy.

2. RETROPERITONEAL LEIOMYOMA MIMICKING ADRENAL MASS — A RARE CASE
Shiv Kumar, SJ Rizvi, MR Prabhudesai, HM Punjani

Primary retroperitoneal tumours are rare entities. Still rarer are primary benign retroperitonal tumours. We encountered
a case of primary benign retroperitoneal tumour which presented as an adrenal mass.

A 35-year old woman presented with a history of vague mild pain in the right .ank for six months. Her vitals and
general examination were unremarkable. Routine laboratory tests were within normal limits. Sonography revealed a
solid 4 x 4.5 cm mass in the right adrenal gland. CT scan showed a heterogenously enhancing mass in the right adrenal
gland 4.9 x 4 cm in size with normal kidneys. Dexamethasone suppression test was negative and urinary VMA
and metanephrine was normal. MIBG scan was negative. A working diagnosis of right adrenal incidentaloma was
made. A decision was made to manage her conservatively based in the benign nature of most adrenal incidental
tumours less than 5 cms in size.

The patient was put on expectant management and asked to come for regular follow-up. She presented 3 months later
with a marked increase in the severity of her right .ank pain. Repeat CT scan showed revealed an increase in the size of the mass to 10 x 4.6 x 4.2 cms, with displacement of the right kidney and peripheral hypervascularity.

The patient was explored and a 10 x 6 x 6 cm size .rm to hard nodular mass was excised from the right adrenal area.
The kidney, renal vessels and inferior vena cava were free. Histopathological examination showed a benign appearing
spindle cell tumour with an uninvolved adrenal gland. Immunohistochemistry was done, which was positive for vimentin
and smooth musculatin, and negative for desmin and S100 protein. These .ndings were consistent with leiomyoma.
Eighteen months postoperatively the patient is normal with no evidence of recurrence.

Primary retroperitoneal tumours are rare. 85% are malignant and 15% benign. Origin of benign retroperitoneal
tumours is neural (30%), cysts (22%), lipomas (10%) and leiomyomas (5%).

3. VESICAL PARAGANGLIOMA MASQUERADING AS TCC
R verma, MR Prabhudesai, SJ Rizvi, JN Kulkarni, AG Phadke
Vesical paraganglioma is an uncommon neoplasm which has been estimated to constitute less than 0.06% of all
bladder tumours. We encountered a case of vesical paraganglioma, which was unusual for being clinically inactive and
for an atypical histologic appearance which led to a mistaken preoperative diagnosis of transitional cell carcinoma.
Paraganglioma is a general term for tumours of the paraganglion system, whereas phaeochromocytoma is usually referred for these tumours when they occur in the adrenal gland.

 

A 65-year old man presented with complains of severe painless haematuria for one week, which had been severe
enough to require the blood transfusions. On examination he was found to be very pale. Rectal examination revealed
a mobile mass above the prostate. On cystoscopy a solid tumour was seen to be arising from the anterior wall of the
bladder involving the bladder neck. A transurethral resection of the tumour was done and the histopathological report
was transitional cell carcinoma grade III with muscle invasion. CT scan con.rmed a mass in the anterior wall of the
bladder with perivesical spread and no enlarged lymph nodes. Chest X-ray and bone scans were normal. After building
him up with blood transfusions the patient ws explored. A mobile tumour 6 x 8 cms in size con.ned to the bladder wall
was found. Pelvic lymph nodes were not enlarged. A radical cystectomy was done and diversion achieved by creating
an ileal conduit. Histopathology of the resected specimen showed a paraganglioma with muscular invasion. Clumps of
plump polyhedral acidophilic cells in a typical ‘zellballen’ arrangement with vascular septa were seen with extensions
deep into the vesical musculature. Subsequent review of the biopsy specimen in the light of the resection specimen
revealed a paraganglioma with an in.ltrating margin. Immunohistochemistry con.rmed the tumour as a paraganglioma.
This was an atypical histologic appearance for a paraganglioma, which classically have pushing margins without
in.ltration into surrounding muscle. Differentiation between benign and malignant phaeochromocytomas is not possible
on histopathology, as criteria of malignancy like nuclear anaplasia, mitotic .gures and hyperchromasia have been
observed in proven benign tumours. The diagnosis of malignancy is based on clinical behaviour, including lymphatic
and distant metastases and recurrences.

At one year follow-up the patient asymptomatic with no evidence of local recurrence or metastasis.
Most vesical paragangliomas are active, and suspected preoperatively on the basis of clinical presentation, classically
headache, hypertension and micturition syncope. Ten per cent of vesical paragangliomas have been estimated to
be malignant. The commonest site is over the bladder neck and trigone. Adequate treatment is provided by partial
cystectomy if the location permits. Although cure following transurethral resection has been reported, most of these
tumours are intramural and so not amenable.

4. REVIEW OF CURRENTLY AVAILABLE METHODS OF ESTIMATION OF CARDIAC OUTPUT
Pradnya Kulkarni, Deepa Mandale
Evaluation of cardiac output (CO) is an important parameter for monitoring critically ill patients. Various methods
have been described in the past for measuring the CO, with varying degree of success. We review the old and current
methods used in the peri-operative period for patients undergoing cardiac surgery. The methods utilised include
Swan-Ganz pulmonary .oatation catheter and thermodilution technique, Picco pulse counter CO monitoring, Lithium
dilution CO monitoring and IQ transthoracic impedance monitoring. The scienti.c basis, methodology, complications,
limitations, cost and ef.cacy of each method are reviewed.

5. INCONTINENCE IN CHILDREN URODYNAMIC INDICATIONS AND DIAGNOSIS
Jamal, BK Dastur

Incontinence is a very common problem in children, Urodynamic plays an important role in the management of
children with complex Urological and Neurological conditions.
Urodynamic provides insight into pathophysiological mechanism involved in voiding dysfunctions.
Urodynamic helps:
1. To identify type of Dysfunction
2. Forms baseline for future comparison
3. Determine those children at risk of upper tract deterioration or damage.
Total 127 children between the age group 11/2 months to 14 years underwent urodynamic evaluation from
2001 to 2002.
Incontinence was the main presenting symptom in 76 children; daytime in 41 children, diurnal in 31 and primary
nocturnal enuresis in 4.


Diagnosis - types of cases

Myelodysplasia and occult spinal dysraphism in

51


Posterior urethral valve in

8

Primary nocturnal enuresis in

4

Urinary tract infection in

3

Vesico ureteric re.ux in

2

Hypospadius in

1

Imperforate anus in

1

Mentally retarded in

3

Fracture coccy

1

Fracture D9 vertebra

1

TB meningitis

1

     

Posterior urethral valves : 104 studies were performed in 95 boys age ranging from 11 months to 14 years. Forty two
boys (44.2%) were less than 5 years old and 53 boys between 5 years and 14 years age.

Inontinence was the presenting symptom in 60 (63%). Obstructive symptoms in 30 (31.5%) and nocturnal enuresis in
40 (42.1%). Primary nocturnal enuresis was the only symptom in 9 boys. Seven boys had history of acute retention. Four
children had associated hypertension, 41 boys had vesico ureteric re.ux. On urodynamics 56% had overactive detrusor,
23% underactive, 9% acontractile and remaining 12 were normal. Incidence of overactive detrusor was (75%) higher
in under 5 years age and 37.5% in boys above 5 years whereas incidence of underactive detrusor was higher (30-35%)
in boys above 5 years and less (20.4%) in boys under 5 years. Major cause of incontinence was overactive detrusor,
compliance was low in 47 (45%). Low compliance and myogenic failure have poor prognosis whereas instability alone has lowest incidence of renal failure. Back pressure changes were seen in 59 and impaired renal function in 27. Spastic sphincter was found in two and detrusor sphincter dyssynergia in one with multiple congenital anomalies like cross ectopia, bi.d ureters and spina bifida.

Seventy two boys with primary nocturnal enuresis showed low compliance in 33.73%, detrusor overactivity in 55,
acontractile detrusor in 6 and underactive detrusor in 11.

Nonneurogenic neurogenic bladder dysfunction is also known as learned voiding dysfunction or dysfunctional voiding
or Hinman syndrome. The main hallmark of this syndrome are incontinence and recurrent UTI and is diagnosed when
there is intermittent .ow, no neural abnormality, no anatomic obstruction. Urodynamic studies reveal - re.ex detrusor
contraction. There is basically failure to relax the sphincter during voluntary voiding.

5. THE TREATMENT OF HYPERHOMOCYSTEINAEMIA IN DIALYSIS PATIENTS
Vidya Kadam, S Bichu, AL Kirpalani

1. To determine the incidence of hyperhomocysteinaemia in dialysis patients.
2. To see the effect of high dose of folate on sr. homocysteine levels.

The total of 25 patients on maintaenance haemodialysis thrice a week were included in the study. All the patients were on 5 mg of folate/d. The patients who were on folate antagonist drugs like methotrexate, sulpha and anticonvulsants and the patients with vit B12 < 125 pg/l were excluded from the study.

Baseline predialysis bloodcollection was done for CBC, s. albumin, s. cholesterol, s. creatinine, total homocysteine,
s. folate and vit B12 levels.

Subsequently all patients with hyperhomocysteinaemia (tHcy > 15 mmol/l) were given high dose of folate i.e. 60 mg/d for 4 weeks. The compliance of the patients was assessed during each haemodialysis session. Also the side effects of the drug if any were noted down.

After four weeks of therapy predialysis blood was collected for tHcy levels, s. folate and CBC. Out of 25 patients 22 were males and 3 females.

1.
The incidence of hyperhomocysteinaemia in dialysis patients was 92% (23 out of 25)
2.
Majority of the patients had mild hyperhomocysteinaemia i.e. 88%, while only 8% had moderate. None of the patients had severe type (tHcy > 100 mmol/l)
3
The commonest cause of renal failure in our group was diabetic nephropathy i.e. 52% followed by unknown cause in 36% hypertension, re.ux and amyloidosis accounted for 4% each.
4.
High dose of folate reduces predialysis tHcy by 15% which is statistically signi.cant (p < 0.05) but predialysis normalisation (tHcy < 15 mmol/l) occurred in 14% of patients which is statistically not significant (p > 0.05).
5.
Postdialysis reduction (14.4%) as well as normalisation (69.5%) in tHcy levels was statistically significant after high dose of folate.
6.
The incidence of IHD was 36% in our study group.
7.
No major side effects were observed with high dose of folate treatment.
8.
The incidence of hyperhomocysteinaemia is very high in dialysis patients i.e. 92%.
9.
The hyperhomocysteinaemia of dialysis patients is refractory to even supraphysiological doses of folate in terms of normalisation of tHcy levels.
10.
Since each 5 mmol rise of tHcy increases the risk of CVD by 60% even the reduction rather than normalisation may help to reduce the risk of CVD in dialysis patients.

6. CLINICAL PROFILE OF PATIENTS EXHIBITING PARADOXICAL SEVERE HYPERTENSION DURING MAINTENANCE HAEMODIALYSIS FOR CHRONIC RENAL FAILURE
Praveen Namboodiri, Vidya Dodke, S Bichu, AL Kirpalani
Intradialytic hypotension is a commonly expected haemodynamic complication of maintenance haemodialysis of 26 patients on maintenance haemodialysis in our dialysis unit exhibit paradoxical severe hypertension of unexplained
aetiology, occasionally resulting in severe hypertensive heart failure, headache, vomiting and hypertensive encephalopathy

 

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