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ABSTRACTS OF PAPERS AT THE 86TH RESEARCH MEETING OF THE MEDICAL RESEARCH CENTRE OF BOMBAY HOSPITAL ON MONDAY, 9TH APRIL 2001, 2.30 PM, SP JAIN CAFETERIA (CONVENOR DR. HL DHAR)
1. ASSESSMENT OF VENOUS FLOW IN NORMAL AND HIGH-RISK FOET USES
Sanjay Yuwanati, Ambrish Dalal, Dinesh Chaudhary, Somesh Lala
Aim of this study was to show that, there is need to Incorporate the venous flow studies [ductus venosus, umbilical vein, and inferior vena cava] into assessment of foetii at high risk. There have been varying reports of reliability of abnormal umbilical artery waveform and foetal outcome, i.e. inspite of absent diastolic flow in umbilical artery time interval before actual foetal distress and pregnancy outcome varied significantly.
Therefore need to better evaluate foetal physiology at stress lend to evaluation of waveform on venous side of foetus.
The foetus is known to centralize its circulation during hypoxaemia and abnormal venous blood flow velocities have been reported in cases of heart failure and imminent asphyxia.
The aim of this study was to evaluate blood flow velocities recorded with Doppler ultrasound in ductus venosus, umbilical vein, and inferior vena cava as predictors of survival in foetuses with absent or reversed end-diastolic flow in the umbilical artery. An abnormal blood flow in ductus venosus was recorded in only one foetus, which died two dayslater. The results suggest that abnormal venous flow is a sign of a severely compromised foetus, while abnormal blood flow velocimetry in the umbilical artery and middle cerebral artery might be an earlier sign of foetal hypoxia, with a better prognosis.
In 50 cases of normal and high risk pregnancy, foetus were examined between third trimester, the following investigations were performed : foetal biometry, placental location, amniotic fluid index, and Doppler sonography of the umbilical arteries, middle cerebral artery, Aorta, ductus venosus, inferior vena cava, and umblical vein. These cases are followed up for mode of delivery, perinatal outcome.
Vessel Normal Waveform Abnormal waveform Umbilical vein Monophasic flow Pulsatile flow Ductus venosus Triphasic forward flow (VS, VD, AC) Waveform touches
Baseline or Reversed
Flow during ACInferior vena cava Triphasic flow (VS, VD)and minimal
Reversed flow in ACPulsatile flow increased reversed flow in AC Portal vein Phasic variation with Respiration Increased flow Pulsatile flow [VS = ventricular systole, VD = ventricular diastole, AC = atrial contraction]
Doppler investigation of the ductus venosus, inferior vena cava, and umblical vein provides important information on the foetal condition, and prognosis.
Incorporating the venous flow (umbilical vein, inferior vena cava and ductus venosus) into foetal assessment may help in optimising the management of the at risk foetus. It may help in prolonging pre-term pregnancies, in determining the optimal time for delivering the "at risk" foetus and decrease the false positive rate of "a compromised foetus" and, may help in time and mode of intervention.
2. ROLE OF POST MYELOGRAPHY CT SCAN
Sanjay Yuwanati, Inder Talwar, DB Modi
CT myelography will never be completely replaced by MRI, primarily because there are patients with contraindications to MRI such as : metallic implants and devices, certain biomedical implants, such as pacemakers, spinal cord stimulators, cerebral aneurysm clips or cochlear implants cannot undergo an MRI study, and last patient size or severe claustrophobia. In addition, the CT myelogram also provides exquisite high resolution detail of bone which many surgeons find very helpful. CT myelography should generally be reserved for surgical candidates.
MRI has led to considerable improvement in spinal imaging. It’s vastly superior depiction of soft tissue anatomy and pathology when compared to X-ray techniques, however coupled with some potential drawbacks. This makes it necessary to exercise caution when employing MRI in diagnosing spinal trauma and degenerative disease. For example 1) Spinal trauma: Spinal cord contusion can be easily and directly imaged. Nerve root avulsion can usually be adequately demonstrated by MRI, but the resolution of CT myelography is better in difficult cases.
2) Low Back Pain : CT myelography had the advantage in detecting nerve root compression largely related to better visualization of root compression.
Advantages of postmyelography CT scan
# CT scanning will show contrast in the canal and around cord at much lower concentrations
# CT scanning will often show contrast beyond an apparent block of low extrathecal pathology in lumbar spine.
# Myelography does poorly in diagnosing sacral tumours. Combining myelogram with follow-up CT is desirable if inadequate clinical findings/history to confirm nerve root compression, caused by disc.
# Intraspinal calcification is better seen with CT.
# In case of syringomyelia, myelography followed by CT are definitive procedure as syringomyelia takes time to fill up and CT is quick to do after it gets filled up.
# In cases of Neuroenteric and developmental cyst, delayed post myelo show contrast layering within the cyst.
# Chiari malformation 2-anatomical details are better seen with post myelo CT
# Myelomalacia demonstrated by intramedullary contrast penetration and retention best shown on delayed postmyelography CT scan
# less cost than MRI
In general, though MRI is superior diagnostic modality CT-myelography has few advantages in spinal imaging.
CT-myelography is recommended in cases where the MRI results are equivocal, and in cases where MRI technically not possible.
3. CT FINDINGS IN ACUTE ABDOMEN
Devang Desai, Inder Talwar, Meher Ursekar
Severe abdominal pain, that develops suddenly over several hours or less, is the characteristic symptom of an acute abdomen. Abdominal tenderness and rigidity, either generalized or localized, usually are severe and indicate an urgent need for prompt diagnosis and treatment. The causes for acute abdomen vary, some need surgical intervention, while others need a conservative protocol. The requirement for prompt treatment, makes the use of CT an important modality in the diagnosis of the acute abdomen.
Of particular importance is its role in the evaluation of acute pancreatitis, both in its diagnosis and prognosis. The use of CT, with its ability to detect necrosis and pancreatic sepsis, has tremendously reduced the morbidity and mortality in this condition. CT is also useful in evaluation of patients with acute cholecystitis, and its complications. In acute appendicitis, CT helps in diagnosis as well as in evaluation of complications when the clinical picture is not clear, such as in children (who cannot give an adequate history) and the elderly (in whom there may not be adequate localization of the pain). Another important application is in the gastrointestinal causes of acute abdomen like obstruction, where it detects bowel dilatation and the zone of transition from dilated to collapsed bowel. It may also reveal the cause of obstruction.
The acute abdomen is often accompanied by the occurrence of adynamic ileus, which does not in any way hinder CT evaluation, and probably that is its greatest advantage.
Over the last two decades, CT has evolved as a rapid, cost effective and powerful tool in the evaluation with acute abdominal pain. Regardless of duration of signs and symptoms, CT is an excellent examination technique for these patients.
But above all, clear communication between the radiologist, the patient and the referring physician is essential for narrowing the differential diagnosis into a working diagnosis prior to CT.
4. SURGICAL AUDIT OF A CANCER SURGERY UNIT
JK Ramchandani, PM Mullerpatan, S Gangwal, GT Hegde, JJ Vyas
Surgical Audit is defined as The systematic critical analysis of the quality of surgical care.
A more comprehensive definition as recommended by the Department of Health, UK is the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and the quality of life for the patient and states that an effective programme of medical audit will also help to provide reassurance to doctors, their patients, and managers that the best quality of service is being achieved, having regard to the resources available.’ The efficient and effective use of resources is important but not the first priority of clinical audit.
We analyzed patient data of one year between April 1, 2000 and March 31, 2001. The aim of the study was to assess the quality of surgical care offered by our unit, and make recommendations to improve upon our shortcomings. Of the 765 admissions, 682 surgeries were performed and ours being a cancer surgery unit, 80.2% (547) were major surgeries. We classified the surgeries depending on the region/system operated. The number of surgeries performed on the breast constituted 29.7% and of these modified radical mastectomies constituted 68.9% with a complication rate of 0.9% in the breast surgery group and an overall complication rate of only 0.1% thus reflecting that our unit offered a very good quality of health care for patients undergoing breast surgery. In the Gynae-onco surgery 72 (10.5%) surgeries were performed with an overall complication rate of 0.7%. Thoracic surgery constituted 5.5% of the total surgeries; 6 surgeries on the lung and 18 oesophagectomies were performed. There was only one mortality in the oesophagectomy group who died of septicaemia and renal failure. Only 1 patient in the Lung group had post operative chest infection. The important feature in the thoracic surgery group was that there was no anastomotic leak. Head and neck surgery was the second commonest region we operated upon constituting 23.4% of the total surgeries performed; 60% in this group were major composite resections performed on the buccal mucosa, tongue, and alveolus with plastic reconstructive procedures. There were 2 chyle leaks and 2 pharyngeal anastomotic leaks among the 8 total complications in this group, with a rate of 5% in this group and an overall complication rate of 1.1% which is low considering that a large load (60%) were major composite resections with major reconstructive procedures. Of the 105 (15.3%) surgeries in the GIT, 14 hemicolectomies, 16 gastectomies, 17 abdomino-perineal resections and 13 anterior resections were performed. Though our mortality in this group was none, the complication rate was 15.2%. Of the 14 hemicolectomies, 9 had anastomotic leaks. This has highlighted the lacunae in the quality of surgical care we offer to patients undergoing colonic surgery and prompted us to review our technique. The Genito-urinary group constituted 1.9% of the surgeries, wide excisions for soft tissue tumours constituted 3%, the hepato-biliary group constituted 0.5% and the miscellaneous group 2.1% with a low morbidity. There was only one mortality in the hepato-biliary group who died of ARDS.
In conclusion thus, the audit has thus shown that our mortality rate is 0.2% the morbidity being 5.4% considering that about 80% are major/supra-major surgeries. Though our major shortcoming was in colonic anastomoses with a high leak rate, we could also boast of a ‘no’ anastomotic leak rate in esophageal anastomoses.
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