Transcatheter closure of atrial septal defects has evolved significantly over the last 20 years. Transcatheter closure has replaced surgical closure for the treatment of most secundum atrial septal defectsat the current time. A major reason for this is the lower morbidity of transcatheter closure procedures. Several closure devices have come into clinical use. The Amplatzer septal occluder (AGA Medical Co.) currently has the largest reported experience and subsequently the best-established safety and efficacy features. Clinically challenging situations, such as larger atrial septal defects, atrial septal defects with deficient rims and multiple atrial septal defects, are increasingly being addressed using the transcatheter approach, with improved results. The incidence of most complications has significantly reduced over time, and serious side effects are relatively uncommon. In this review, the literature is summarized regarding the current role of transcatheter closure, the evolution of the different available devices for clinical use and the complications that occur with their use. A comparison is also made with surgical closure techniques.

Xanthogranulomatous cholecystitis masquerading as malignancy with liver metastasisa ns_5150 946..947 Case noteA 52-year-old diabetic woman was admitted to our hospital with a history of intermittent pain in her right upper abdomen, radiating to the back for 5 years. There was no history of jaundice, anorexia or weight loss. Her physical examination was unremarkable except that a firm non-tender liver was palpable about 2 cm below the right coastal margin in midclavicular line. Routine biochemical parameters were within normal limits. Abdominal ultrasonography showed gall bladder stones with loss of interphase between gall bladder and segment V of liver showing evidence of contiguous metastasis. Contrast enhanced computed tomography (CECT) of abdomen and gall bladder showed irregular circumferential wall thickening with evidence of metastasis into segment IV and V and a separate nodule with a small hypoattenuated area in segment V of the liver (Fig. 1). It also showed few small lymph nodes in peripancreatic regions. Fine needle aspiration (FNAC) from the lesion was inconclusive with no evidence of dysplasia. As her imaging findings were strongly suggestive of malignancy, she was taken up for surgery. Gall bladder mass was densely adherent to and invading the liver bed with a single nodule about 3 cm distant from the gall bladder (Fig. 2). There were no obvious nodes in the area, however, the hepatoduodenal ligament tissues were a bit densely adherent. Assuming malignancy, extended cholecystectomy with wedge resection of about 5 cm from liver bed including the mass was done along with clearing of hepatoduodenal ligament tissue. Patient had an uneventful post-operative period.Histological examination showed acute on chronic xanthogranulomatous cholecystitis (XGC) with cholelithiasis. The liver bed showed collection of foamy histiocytes and lymphocytes forming nodules in liver, with no evidence of malignancy. DiscussionXGC is an uncommon inflammatory lesion of gall bladder characterized by marked proliferative fibrosis with infiltration of macrophages and foamy cells involving gall bladder walls. 1 The clinical presentation is similar to cholecystitis with imaging studies and per-operative findings may also sometimes mislead as gall bladder carcinoma. 2 XGC represents about 0.7 to 13.2% of cholecystectomies 3 and affects men and women equally. 1 Its aetiology is uncertain but current opinion favours acute inflammation of gall bladder due to calculous outflow obstruction. 3 Bile enters into the stroma of gall bladder wall through the ruptured Rokitansky-Aschoff sinuses or mucosal ulcerations secondary to presence of gallstones. The extravasated bile in stroma causes an inflammatory reaction with accumulation of histiocytes which engulf the insoluble cholesterol and bile lipids to form xanthoma cells. Microabscesses can form in gall bladder wall eventually resulting in xanthogranulomata. A fibrous reaction follows resulting in scarring. 3 Macroscopically, XGC is characterized by formation of multiple yellowish nodules ...

Endoscopic brush cytology (EBC) was performed in antral and duodenal brushings of children subjected to upper GI endoscopy for the detection of H. pylori (Hp) and trophozoites of Giardia lamblia (Glt) in addition to routine endoscopic grasp biopsy (EGB). It was hospital based prospective study. EBC was performed in children subjected to upper GI endoscopy with a sheathed cytology brush. Mucosal brushings were collected from antrum, body of the stomach and second or third part of duodenum by gently rubbing the surface of the brush with the mucosal wall in all the directions, brush withdrawn and brushings performed on a glass slide. The smears were placed in 95% ethyl alcohol and later examined for Glt and Hp using Giemsa and Hematoxylin & Eosin stain. EGB was taken from antrum, body of the stomach and duodenum from sites other than those used for brushings. One hundred and seventy children between 1-13 years (median age = 5 years) were subjected to upper GI endoscopy for malabsorption (n = 94), recurrent abdominal pain (n = 49), failure to thrive (n = 16) and recurrent vomiting/regurgitation (n = 11) and EBC was performed in addition to routine EGB. Thirty five children (20.4%) were colonized by Hp, 14 (8.2%) were detected to have Glt and in 6 cases (3.5%) both Hp as well as Glt were detected. Out of 41 cases colonized by Hp, 24 cases (58.5%) were detected by EGB and 27 cases (65.8%) were detected by EBC. Out of 20 children in whom Glt were detected from their duodenum, the detection was by EBG in 12 cases (60%) and by EBC in as many as 19 cases (95%). Comparison of EGB and EBC suggested that detection rates with EBC were higher than EGB. Detection by EBC was significantly higher for Glt than Hp. There were no complications attributed to EBC and procedure time for endoscopy was not significantly prolonged. On the contrary, detection of Hp and particularly Glt in higher proportion of cases with the help of EBC was helpful in their appropriate management. Our results suggest that EBC is a safe and useful tool to enhance the value of diagnostic endoscopic procedure when used in combination with routine EGB.

Our results suggest that a combination of diagnostic modalities may be required to diagnose GER in young children. Ambulatory 24 hour pH monitoring appears to be the single best investigation and combining it with EB and/or GS can help to detect maximum number of cases.