International Surgery Journal

Interval appendectomy-do we need to do it in current era?

2023-03-04T04:54:40+00:00

Background: Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. Aim was to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy.

Methods: It was a retrospective study conducted for a period of 5 years (2017-2022). To assess the number of patients with appendicitis and a peri-appendiceal mass, all patients in both hospitals encoded for appendicitis were listed. Over this period of 5 years a total of 2,090 patients were diagnosed with acute appendicitis. Of these, 230 patients were operated through Interval appendectomy. All medical records of these patients were then reviewed and relevant variables were registered.

Results: It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2°C ranging from 36 to 40.5°C. Ultrasound examination was done in 70% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy.

Conclusions: We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.

A retrospective audit of robotic versus laparoscopic anterior resection for diverticular disease in a single surgeon’s experience

2023-04-12T10:24:40+00:00

Background: There has been a shift towards elective resection for recurrent or complicated diverticular disease to prevent recurrent episodes of diverticulitis. Our study aims to compare the outcomes in elective robotic and laparoscopic anterior resection for diverticular disease by a single surgeon experienced in both techniques.

Methods: This is a retrospective study of patients who underwent elective anterior resections at Nepean Public Hospital, Nepean Private Hospital, and Sydney Adventist Hospital (SAN) in the last 10 years. The single surgeon is an experienced surgeon who has performed laparoscopic anterior resections from January 2013 to December 2018; and mainly robotic anterior resections from January 2018 to July 2022. The primary outcome of this study was to determine if there were any differences in length of stay and post-operative complications in laparoscopic and robotic anterior resections. Secondary outcome measures included operating time, rate of conversion to open surgery, and 30-day mortality and morbidity.

Results: There were 53 patients included in this study. There was no significant difference in conversion to open rates (p=0.528), mean operative time (p=0.095), stoma formation rates (p=0.528) and post-operative complication rates (0.609). Length of stay was significantly shorter in the robotic group (p=0.024), and a higher proportion of patients who had laparoscopic surgery stayed for ≥6 days (p=0.08). There were no anastomotic leakages, or 30-day mortality and morbidity.

Conclusions: Robotic anterior resection is a feasible approach in experienced hands and produces comparable results to laparoscopic anterior resection for diverticular disease in terms of length of stay, post-operative complications, and operative timings.

Outcome of uncommon intestinal foreign bodies in pediatrics

2023-04-19T04:59:33+00:00

Background: Foreign body (FB) ingestion in children is very common. Children can ingest a wide variety of Foreign Bodies. Most FBs pass spontaneously through the gastrointestinal tract. Other FBs, especially uncommonly ingested objects, can present with complications and need intervention to be extracted. The aim of the study was to highlight the importance of closed observation, proper investigation, and timely intervention for uncommon gastrointestinal FBs.

Methods: This was a prospective study, conducted at pediatric surgery department, Al-Azhar University Hospitals, between November 2020 and September 2022, that included all patients who presented to our department with variously ingested FBs, were prospectively evaluated to detect those who needed surgical intervention to extract these FBs.

Results: During the specified time period, 86 patients with FB ingestion presented to our hospital. Out of these children, four patients ingested uncommon FBs, presented with symptoms of complications, and needed intervention to extract these FBs. One patient swallowed magnet tools; two patient’s swallowed toothpicks; and one patient swallowed a needle with a necklace, which was impacted in the small bowel and surgically removed.

Conclusions: Children who ingest uncommon FBs are more likely to present with complications of impaction or perforation. Negative plain films are not sufficient to conclude conservative treatment especially for radiolucent FBs. CT should be done to rule out retained and radiolucent foreign bodies; closed observation and timely intervention are mandated to avoid serious complications.

Prospective analysis of cerebrovascular events in patients following coronary artery bypass surgery

2023-04-19T10:02:25+00:00

Background: Cerebrovascular events are the most common cause of disability in adults and can be classified into two categories: ischemic stroke and hemorrhagic stroke. Risk factors for stroke include age, gender, race, family history of stroke, hypertension, smoking, heart disease, valvular heart disease, arrhythmias, diabetes, obesity, and dyslipidemia. Low cardiac output syndrome, myocardial infarction, and atrial fibrillation can also contribute to stroke. This study aims to investigate the incidence of stroke post-cardiac surgery and the risk factors contributing to it.

Methods: A prospective observational study with a sample size of 516 patients was conducted. Patients over the age of 40 who were undergoing CABG (both off and on pump) were included. Patients were subjected to on-pump or off-pump coronary artery bypass surgery as per requirement, but preferably off-pump.

Results: Out of 516 patients, 13 developed strokes, of which 8 (61.5%) had hypertension and 10 (76.9%) had diabetes, 4 (30.8%) were smokers, 6 (46.2%) had normal LDL values, 7 (53.8%) had high LDL levels, none had normal HDL values, 1 (7.7%) had normal LV function, 4 (30.8%) had mild LV dysfunction, 4 (30.8%) had moderate LV dysfunction, and 4 (30.8%) had severe LV dysfunction. 11 (84.6%) had COPD. 7 (53.8%) had no prior MI, 5 (38.5%) had a recent MI, and 1 (7.7%) had a prior MI that was more than ten years old. 8 (61.5%) had normal renal functions, while 5 (38.5%) had disturbed renal functions.

Conclusions: In this study, the incidence of CVE after CABG is 2.52%. All the patients who developed stroke had multiple risk factors. High LDL, low LVEF, deranged renal functions, PVD, arrhythmia pre-op, anti-coagulation pre-op, on pump surgery, Cardioplegia usage, CCF pre-op, urgent surgery, LCOS post-operatively are risk factors for post-operative stroke.

Assessment of accuracy of BISAP score as a predictor of severe acute pancreatitis: a retrospective study

2023-05-04T16:58:28+00:00

Background: The prevalence of acute pancreatitis (AP) has increased in the past 20 years. Most patients with AP experience a clinical course that is mild and self-limited. However, 10% to 20% of patients develop a rapidly progressive inflammatory response necessitating prolonged length of hospital stay and high rates of morbidity and mortality. There are various scoring systems already in place to assess the severity of acute pancreatitis. However, they have significant drawbacks. Since the BISAP score offers the advantages of being inexpensive, rapid, and simple, we conducted this study to gauge its usefulness.

Methods: This study enrolled 138 patients with AP admitted in surgical wards of McGann District Teaching Hospital, during a time period between January 2022 to June 2022, meeting the various inclusion criteria.

Results: We found that the percentage of severity, necrosis, organ failure, death, and hospital stay increased as the BISAP score increased. In terms of sensitivity and specificity, the accuracy of the BISAP score for predicting severe acute pancreatitis was 76.2% and 63.4%. According to our study, patients with severe acute pancreatitis had BISAP scores of 3 or above.

Conclusions: BISAP can be used to identify the patients who are at risk, and this information can serve as an early guidance for appropriate and necessary therapy, improving patient outcomes. Present study concludes the increased accuracy of BISAP score for risk stratification.

Multiple core histopathologies for discriminative diagnosis of phyllodes pathology in breast

2023-01-06T04:47:47+00:00

Background: Historical patient’s records were analyzed. Patients diagnosed with phyllodes tumors of the breast who received preoperative core needle biopsy and undergone breast surgery at a tertiary cancer centre in Patna, Bihar, India from January 2020 to December 2020. The resulting data allowed us to compare the accordance between core needle biopsy and final histopathology of phyllodes tumor of the breast patients and evaluate the accuracy of core needle biopsy in preoperative diagnosis.

Methods: This is a retrospective study evaluated the case records of one hundred twenty (n=120) patients for core needle biopsy findings and subsequent histopathology reports post-surgery. Sensitivity and significance of core needle biopsy was determined for phyllodes tumor of the breast.

Results: A total of one hundred twenty (n=120) patients’ data were analyzed. There were ninety (n=90) fibroadenoma and thirty (n=30) phyllodes tumor patients. Sensitivity of core needle biopsy for benign tumor was 64.2%, borderline 40% and a malignant phyllodes tumor was 100% respectively.

Conclusions: Core needle biopsy provides a pathological basis for pre-operative diagnosis of phyllodes tumor, but it has a low accuracy and offers limited guidance for surgical decisions, if used alone. An integrated assessment using needle biopsies in combination with clinical data and imaging features is suggested as a reliable strategy to aid phyllodes tumor diagnosis and subsequent treatment.

Surgical stress markers for postoperative complications: a prospective prognostic factor study

2023-03-22T05:48:40+00:00

Background: Postoperative complications have previously been defined as “deviation from the normal postoperative course”. Although surgical advancements have reduced the postoperative mortality over the last few decades, the postoperative morbidity has remained high. Multiple factors as well as the severity of the surgical procedure itself are associated with adverse postoperative outcomes. Having prognostic factors established and available to assist with prognosis would be helpful in treatment planning and decision-making in post-operative patients. Objective of the study was to assess surgical stress markers as potential prognostic factors for postoperative complications.

Methods: This is a prospective cohort study conducted in department of general surgery over a period of 4 months. A total of 120 patients were included in the study. Data entry and statistical analysis were done using statistical package for the social sciences (SPSS) version 23. Chi-square test was used. Area under curve (AUC) and logistic regression were applied and odd’s ratio was calculated in 95% confidence interval.

Results: Serum C-reactive protein (CRP) levels done at 72 hours, ALB levels at 24 hours were most predictive postoperative levels compared to the other perioperative serum levels.

Conclusions: Elevated serum CRP, albumin were associated with infective and non-infective complications and longer length of hospital stay and duration of the procedure.

Effect of intraurethral instillation of cooled versus room temperature lignocaine gel on pain perception during outpatient rigid cystoscopy

2023-03-27T14:27:27+00:00

Background: Reducing temperature of topically applied lignocaine gel for maximal anesthesia during cystoscopy in conscious patients have yielded mixed results. This prospective randomised controlled study was undertaken to compare pain mitigating effect of lignocaine gel at 4°C versus at room temperature during rigid cystoscopy in male patients.

Methods: The study consists of 126 consecutive patients (n=126) who were randomly assigned into two groups: Group 1 (control, n1=63) received 2% topical lignocaine at room temperature, Group 2 (L4, n2=63) received topical lignocaine cooled to 4°C prior to insertion of rigid cystoscope. Pain during instillation of lignocaine and during performance of rigid cystoscopy was measured by independent evaluator on non-graphical 100-mm visual analogue scale (VAS).

Results: Mean pain score for cystoscopy in L4 was lower (46.69±10.38) than that in CONTROL (49.19±12.47), this difference was statistically not significant (p value, one tail =0.11, >0.05). Mean pain score for instillation in L4 was 14.80±6.00 and that for control was higher at 17.04±6.54 with difference in pain scores being statistically significant (p value, one tail =0.02, <0.05).

Conclusions: With regard to reducing pain perception during rigid cystoscopy, cooled lignocaine gel at 4°C has no benefit over room temperature lignocaine gel, however cooling lignocaine gel to 4ºC does significantly decrease pain of instillation of gel into urethra.

Analysis of histopathological findings of breast biopsies at a tertiary care centre

2023-03-28T10:06:16+00:00

Background: In India, breast cancer has become a leading cause of cancer death. The indication of a breast lump can be cause of great concern in most patients. While most of the lumps are benign in nature, there is a possibility of an increased risk of developing premalignant lesions. Any breast mass/lump requires histological diagnosis to get a clear picture of the lump associated problems.

Methods: This is a retrospective, descriptive and a cross-sectional study of all the patients with breast lumps seen in Bhaktivedanta Hospital and Research Institute from January 2018 till March 2022. Histopathology reports of breast biopsies of patients required at Bhaktivedanta Hospital and Research Institute were included in the study.

Results: The total number of cases of breast biopsies available were 449. These cases are grouped into benign and malignant cases which comprise of 276 (61.47%) and 173 (38.53%) cases respectively. The most common benign diagnosis observed was fibroadenoma which accounted for 184 (66.67%) cases. Based on age grouping, the 21-40 age group contained the maximum number of benign cases. The most common malignancy observed was of ductal carcinoma with 163 (94.21%) cases. Based on age grouping, the age group of 41-60 contained the maximum number of malignant cases.

Conclusions: It is imperative that all breast lesions should undergo biopsies irrespective of clinical findings for the following reasons: rising incidence of breast cancer, to rule out/confirm malignancy and to complete the diagnostic triad of clinical diagnosis, radiology and pathology.

Magnetic resonance imaging features of parotid mucoepidermoid carcinoma: a retrospective analysis

2023-03-29T07:24:59+00:00

Background: Parotid mucoepidermoid carcinoma (P-MEC) is the most common of malignant salivary gland tumors and its accurate preoperative diagnosis is crucial for better management and prognostication. This becomes even more critical because in most cases P-MEC is difficult to distinguish from other common benign parotid lesions including abscess both clinically and radiologicall, but where management is entirely different. MRI could prove a vital cog in the wheel in this whole endeavor. This study aims to analyse the various MRI features in parotid mucoepidermoid carcinoma and the control group of non-MEC benign parotid masses which will aid in better distinguish between the two entities thereby coming to a confident diagnosis which will aid in management planning and better prognosis.

Methods: This retrospective study was conducted at Sree Uthradom Thirunal Academy of Medical Science (SUTAMS), Thiruvananthapuram, India from July 2021 to July 2022 after obtaining Institutional Ethical committee approval. An informed consent was obtained from all patients before conduct of MRI imaging. The various MRI findings was applied in 60 patients in age bracket of 45-90 yrs with HPE proven parotid gland tumors. The cohort was divided into 2 groups: MEC (n=30) and non–MEC (n=30) as a control group.

Results: Logistic regression analysis identified presence of cystic component (p<0.001), T1 hypointense signal (p<0.001), T2 hyperintense signal (p<0.001), heterogeneous post contrast enhancement (p<0.001) and perineural invasion (p=0.002) as characteristic MRI features of parotid MEC that aided in its accurate distinction from other non-MEC lesions of parotid.

Conclusions: MRI can be a valuable tool for reliably distinguishing parotid mucoepidermoid from other parotid lesions.

Thrombolytic therapy as first line treatment in prosthetic mitral valve thrombosis

2023-03-31T17:10:06+00:00

Background: A very common post-operative mechanical complication of a prosthetic valve is thrombosis leading to valve being stuck. This leads to rapid development of heart failure and can result in sudden death of the patient in an aggravated manner. The study aims to put forth the importance of immediate thrombolysis in such patients which can provide bridging between the event and immediate surgery.

Methods: A total of 50 patients were retrospectively studied after presentation with prosthetic valve thrombosis and the thrombolytic agent used in all the cases was injectable streptokinase or urokinase. Post streptokinase patients were given heparin infusion and oral anticoagulants. The therapy was considered failure if transvalvular gradients decreased less than 50% or in case of persistent valve motion abnormality.

Results: 94% patients had complete normalisation of valve function and decrease in transvalvular gradients to less than 50% within the first 24 hours. 4% patients required surgery and 2% patients could not survive the treatment.

Conclusions: Immediate thrombolysis on presentation has shown significant improvement in survival without the risk of subjecting patients to redo surgeries which are associated with multiple complications in the perioperative period.

Management of giant amoebic liver abscess with severe sepsis by open drainage: a study of 28 cases in 20 years

2023-04-03T14:01:57+00:00

Background: Presently large amoebic liver abscesses are treated by intravenous antibiotics coupled with less invasive procedure like pigtail drainage. Pigtail drainage may not be adequate enough to drain thick pus and solid necrotic component in good number of large amoebic liver abscesses. In these cases, with severe sepsis, open surgical drainage is a life saver and a game changer. Aim of this study was to determine whether in critically ill patient with large amoebic liver abscesses results in good clinical outcome, by open surgical drainage.

Methods: Over a 20-year period, 28 patients with giant amoebic liver abscesses, in severe sepsis, were managed by, an up-front open surgical drainage. In this prospective study we tried to evaluate time to reversal of the toxic features of sepsis, recovery of hemodynamic stability, degree of morbidity and hospital stay.

Results: In all 28 patients treated by open surgical drainage (OSD), there was certainly rapid reversal of toxic features of sepsis, decrease in leukocyte count and accelerated recovery of hemodynamic stability in all are cases Three patients had surgical site infection, which were managed accordingly. The average hospital stay was 12 days. No mortality occurred in our study.

Conclusions: The results of our study show that for large amoebic liver abscesses with severe sepsis, OSD provides better clinical outcomes in terms of treatment success, rapid recovery, recovery of hemodynamic stability, less morbidity and no mortality.

Implantless osteosynthesis of lateral end of clavicle fractures using autologous palmaris longus tendon graft for coracoclavicular ligament reconstruction

2023-04-04T10:03:10+00:00

Background: Lateral end clavicle fractures require operative management because of significant displacing forces of trapezius, sternocleidomastoid and weight of the arm. Coracoclavicular ligaments are usually torn hampering vertical stability. Currently used implants for osteosynthesis are associated with implant impingement on acromion, poor purchase of lateral fragment and implant cut-out. There is a lack of consensus regarding ideal treatment of these fractures.

Methods: 31 patients with lateral clavicle fracture who were admitted from May 2019 to August 2022 were enrolled in this study and underwent coracoclavicular ligament reconstruction using ipsilateral palmaris longus graft looped around coracoid and tied over clavicle to hold it reduced. Patients were assessed for pain, shoulder range of motion and functional outcome with 6-month follow-up.

Results: All patients showed radiological union with good to excellent outcome in 79.3% patients and mean abduction of 157⁰. Mean duration of surgery was 104 minutes (SD±12.118) and 10.3% patients showed shoulder stiffness.

Conclusions: The study shows encouraging prospect in purely biological osteosynthesis with functional outcome at par with other methods of fixation while avoiding implant related complications.

An observational study to assess the Helicobacter pylori infection rates in patients with cholelithiasis

2023-04-11T12:22:01+00:00

Background: Cholelithiasis and chronic cholecystitis cholelithiasis is fairly common all around the world. Since chronic inflammation causes repeated trauma to the gallbladder mucosa and DNA damage led by high or abnormal bile acid exposure, gallstones are closely related to the development of hepatobiliary cancers. After cholecystectomy, some patients experience ongoing upper abdomen pain, which is distressing for the surgeons and raises the possibility of a concomitant upper gastrointestinal issue, which in most cases turned out to be peptic ulcer disease. Numerous studies have found various Helicobacter species in the gallbladder tissue, gallstones, and bile taken from the gallbladder. We conducted this study to assess the relationship between cholelithiasis and H. pylori infection in the stomach. Ascending infection of H. pylori from the stomach and duodenum to biliary tree may have function in development of gall stone production and hepatobiliary carcinomas.

Methods: Hospital based cross sectional observational study on patients admitted in surgical wards of SMS Hospital Jaipur for laparoscopic cholecystectomy. All patients underwent UGI and gastric antral biopsy followed by laparoscopic cholecystectomy, gastric mucosa and GB mucosa were subjected to Warthin starry silver stain for detection of H. pylori.

Results: Out of 116 patients who underwent upper GI endoscopy followed by laparoscopic cholecystectomy, 29 (25%) patients were positive for H. pylori infection.

Conclusions: This study shows significant positive co-relation between H. pylori infection in stomach, gall bladder to chronic cholecystitis and cholelithiasis, which signifies gastric colonisation of H. pylori has it’s role in biliary pathologies through ascending infection, the effectiveness of H. pylori eradication therapy in preventing these pathologies need to be studied further.

Pancreaticoduodenal injuries at a tertiary care centre-clinical profile, associated injuries, management modalities, and outcomes

2023-04-17T12:15:12+00:00

Background: Pancreaticoduodenal injuries are considerably associated with high morbidity and mortality due to delayed diagnosis and subsequent delay in treatment. This makes the treatment of these injuries challenging. We have studied the presentation, diagnosis, management and outcome of these complex injuries.

Methods: A prospective observational study was done at general surgery department, Government medical college Nagpur from October 2020 to September 2022. Mortality, morbidity, and various treatment modalities were evaluated.

Results: Thirty two patients presented to the Trauma care center with history and symptoms suggestive of isolated pancreatic, duodenal, and combined pancreaticoduodenal injuries. Most of the injuries were blunt trauma cases. The ratio of hemodynamically stable: unstable was 1:1. Majority injuries were to pancreas followed by duodenum and combined organ injuries. Most of cases were diagnosed by CT scan. In this study 56% of cases had a non-operative line of treatment while 44% underwent surgical intervention. Among the patients operated 5 died, within 7 days of admission due to post-operative complications-hemorrhage, sepsis, aspiration pneumonia, and anastomotic leak. Two patients died due to delayed complications due to the development of pancreatic fistula and enterocutaneous fistula. Mortality rate was 27.2% in this study.

Conclusions: Early presentation and prompt diagnosis is the key to the management of such injuries. Patients managed conservatively need close monitoring, repeated assessments, and long-term follow-up.

A study of H. pylori infection as risk factor for the gall stone disease

2023-04-25T11:43:37+00:00

Background: Gallstones are one of the widely occurring digestive/hepatobiliary disorders. Chronic cholecystitis, cholelithiasis or symptomatic gallbladder is a prolonged mechanical or functional disorder of abnormal gallbladder emptying. Nearly eighty percent of the gallstones are cholesterol gallstones, and 20% are pigmented stones consisting of bilirubin and calcium, the two components present in the bile. The diagnosis is established by a variety of diagnostic tools like ultrasonography, CT scan, ERCP, liver function tests and pancreatic enzyme studies. The hypothesis of the presence of H. pylori in the biliary epithelium of the patients with hepatobiliary ailments has been sporadically investigated. Helicobacter pylori (H. pylori) is a spiral, microaerophilic, gram-negative bacterium. There are many suggestive evidences that the DNA components of H. pylori is found in the bile, gallbladder tissue and/or cholesterol gallstones. The association of gallstones with Helicobacter pylori has been investigated by many authors, but not clearly established.

Methods: The present study is aimed to identify the Helicobacter pylori infection as a risk factor for gallstone disease. The histopathological samples of gall bladder mucosa were examined by staining with modified giemsa stain, haematoxylin, and eosin.

Results: Our study showed the presence of H. pylori in only one case which is not statistically significant. Moreover, the present study was based on H and E stains only and they should have been substantiated with immunohistochemistry and PCR studies. Thus, further studies are required to establish a causal relationship between the Helicobactor pylori infection and gallstone formation.

Conclusions: Helicobacter pylori as a risk factor for gallstones is yet to be proven.

Upper extremity arterial thrombosis, experience at the General Hospital of Mexico Dr. Eduardo Liceaga: case-series

2023-05-14T16:45:10+00:00

The upper extremity arterial thrombosis has a low frequency of presentation, which is why they have been little studied and their therapeutic alternatives can be controversial with a high risk of limb loss, which represents a crucial factor in the quality of life of patients. In this investigation, cases of upper extremity arterial thrombosis are reported, evaluated and treated by the Department of angiology, vascular and endovascular surgery of the General Hospital of Mexico Dr. Eduardo Liceaga in Mexico City during the period of March 2022 to March 2023.

The role of feeding jejunostomy on supportive enteral nutrition for resectable esofago-gastric junction adeno carcinoma undergoing total gastrectomy and esofago jejunostomy reconstruction: a case series

2023-02-04T17:09:13+00:00

As a part of enhanced recovery after surgery protocols (ERAS), early gut feeding has been applicated in most of gastrointestinal surgery including major resection of distal esophageal and esofago-gastric junction adeno carcinoma. Early gut feeding could be applicated not only in minimally invasive procedure, but also in conventional open technique. Many enteral feeding option can be chosen as a post-operative enteral nutrition for the patients. One of them is feeding jejunostomy tube placement, we will evaluate the safety and effectivity of this enteral route on resectable esofago-gastric cancer resection. We will evaluate the clinical outcome of resectable esofago-gastric cancer patients and reconstruction, feeding jejunostomy tube has been placed as post-operative enteral route for nutrition. The patient with history of neoadjuvant therapy will be excluded. The post-operative evaluation including morbidity associated with jejunostomy tube will be recorded. We reported 4 cases, all of them had stage III esofago-gastric adeno carcinoma and conventional laparotomy technique was done. Feeding jejunostomy was tolerated well by the patients, enteral feeding can be started during the first 24 hours after surgery. No post-operative ileus and surgical site infection has been reported. Tube site infection was not found during this study. Although it still remains controversial, feeding jejunostomy tube was safe, feasible and has been tolerated well on esofago-gastric cancer patients undergoing resection and reconstruction.

Early embolization of atrial septal defect occluder device into the left atrium

2023-03-30T00:56:52+00:00

Atrial septal defect (ASD) is one of the most common types of congenital heart defects. Percutaneous closure of ASD is relatively safe and accepted as an alternative to surgery. However, device-related complications can occur rarely. Embolization of the Amplatzer atrial septal occluder (ASO) is one major complication of percutaneous device closure. The author presents a case of early embolization of ASO device into the left atrium, which removed the device surgically, and the ASD was closed.

Primary small bowel volvulus in adult: an unusual case report

2023-04-02T14:47:39+00:00

Small bowel volvulus (SBV) is an uncommon case which the small intestine rotates around its own mesenteric axis. SBV generally occurs in newborns. We report the case of a 69-year-old man who has been coming with complaints of pain all over his abdomen, vomiting, no bowel movement, and flatus since 2 days ago. The patient underwent plain abdominal radiography and was found to have a high-lying obstructive ileus. The patient was treated with exploratory laparotomy surgery and found to have necrotic bowel sections. During the 5 days postoperative, the complaints improved.

Unusual cause of cervical lymphadenopathy in post-partum patient with atypical presentation: Kikuchi disease

2023-04-13T18:54:45+00:00

Kikuchi-Fujimoto disease, also known as histiocytic necrotising lymphadenitis, is an unusual type of painful lymphadenopathy. It is a self-limiting benign disease; usual management includes supportive therapy. We described a case of Kikuchi Disease in a childbearing-age woman who presented with painless and localised cervical lymphadenopathy during her postpartum period. Histopathology of the affected cervical node reveals areas of apoptosis and necrosis with abundant foamy histiocytes and plasmacytoid monocytes. The cervical node resolves spontaneously, and no subsequent new cervical lymph node was observed in this patient. Patient was given reassurance. It is vital to recognise Kikuchi disease as one of the causes of persistent cervical lymphadenopathy, to provide optimal management and to avoid incorrect treatment.

Duplex collecting system with renal malrotation: an unusual combination

2023-04-04T12:07:49+00:00

Both duplex collecting system and renal malrotation are congenital developmental anomalies of kidney. They usually present asymptomatic and accidentally diagnosed while patients undergo radiology examinations. We are reporting a case of a 33-year-old-male with a combination of duplex and malrotation kidney. Although these two are common anomalies of kidney, their combination is extremely rare. We found only two reports that had similar combined cases, so our case is the third reported.

Acute appendicitis complicated by ovarian vein thrombosis

2023-04-22T05:50:12+00:00

Ovarian vein thrombosis (OVT) is a rare cause of acute abdominal pain and is mainly related to pregnancy and affects approximately 1 in every 2,000 deliveries and abortions. However, this diagnosis should be considered not only in postpartum patients but also in women with pelvic inflammatory disease (PID), malignancy, women who have recent abdominal surgery and who have a known hypercoagulable state. Anticoagulation and antibiotics are the mainstays of treatment for OVT. Complications of OVT include sepsis, the extension of the thrombus to the inferior vena cava and renal veins, and pulmonary embolism. The incidence of pulmonary embolism is reported to be 13.2% and represents the main cause of mortality due to OVT. We report a case of 40-years old female patient presenting with OVT, which was accompanied by acute appendicitis. In this woman, OVT was not related to pregnancy. The patient underwent an appendectomy, which proved positive on histopathology result. Patient symptoms improved after appendectomy with antibiotics and anticoagulation therapy. A month later, a follow-up computed tomography (CT) scan of the abdomen revealed a complete resolution of OVT. OVT, though a rare presentation, should be included in the differential diagnosis for women presenting with acute abdomen. Proper diagnosis and timely management can prevent catastrophic complications. Our case thus highlights the importance of considering the rare diagnosis of OVT with acute appendicitis.

Ileo-ileal knotting masquerading as internal hernia: a rare cause of acute intestinal obstruction

2023-03-31T16:22:48+00:00

Intestinal knotting is a rare cause of acute intestinal obstruction and in most cases is diagnosed intraoperatively due to its rarity and uncommon presentation. Out of different types of intestinal knots, ileo-ileal knotting is rarest and very few such cases have been reported in the literature. Due to very high mortality, early diagnosis and immediate surgical intervention are needed. Here we present a case of a 52-year-old male patient who presented with a history of non-passage of stool and flatus, after resuscitation patient was planned for exploratory laparotomy. Findings revealed gangrenous ileal loops and an ileo-ileal knot masquerading as an internal hernia. End-to-end anastomosis of the gangrenous ileum was done along with a decompressive proximal loop ileostomy. The patient was transferred to the intensive care unit after surgery. He died on postoperative day 1 due to metabolic acidosis with endotoxic shock. By reporting this case we want to emphasize on the need of keeping intestinal knots as a differential diagnosis while operating a case of acute intestinal obstruction.

Incidental identification of intra-cholecystic papillary neoplasm from a gall bladder polyp mass: a case report

2023-04-22T15:56:43+00:00

Intra cholecystic papillary neoplasm of the gallbladder is a recently established neoplasm among gallbladder tumours by the world health organization in the year 2010. Since it is recently enlisted and rare type of tumour, not much knowledge is available about it in the public domain, intra cholecystic papillary neoplasm of the gallbladder is more common in women than men, and about half of the cases, are incidentally diagnosed, it could be invasive or non-invasive and is histopathologically diagnosed, determines the prognosis and survival rates of the patients. It is closely related to mucinous cystic neoplasm of the pancreas, as it is newly enlisted no defined guidelines to distinguish gall bladder polypoidal mass from adenocarcinoma/adenoma/papillary neoplasm is available, whether a simple cholecystectomy or an extended cholecystectomy would suffice as in our case is to be debated.

Extra cardiac perforation following failed percutaneous transvenous mitral commissurotomy

2023-05-16T06:54:54+00:00

Percutaneous transvenous mitral commissurotomy (PTMC) is the procedure of choice for select patients with mitral valve disease who have favorable valve architecture and meet the requirements for balloon valve dilatation. Complications following PTMC are rare (<3%). A 56-year-old woman with rheumatic valvular heart disease, severe mitral stenosis and moderate mitral regurgitation in atrial fibrillation underwent elective PTMC. She developed an extra-cardiac perforation during PTMC because of abnormal catheter course, and underwent emergency mitral valve replacement with extra-cardiac perforation repair. Catheter-related complications following PTMC are rare but not unheard of. Prompt management of immediate complications result in favorable outcomes.

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

2023-05-19T06:07:02+00:00

Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.

A rare case of wandering spleen with its unreported associations: case report and literature review

2023-03-29T20:15:37+00:00

Wandering spleen (WS) is a rare clinical entity with unclear clinical picture. Patient can be asymptomatic or can present with acute abdomen, based on the degree of associated splenic torsion, but most of the cases needed an emergency splenectomy. We herein report an unusual presentation of a wandering spleen in the elderly with thrombocytosis, portal, and splenic vein thrombosis, and sinistral hypertension. To the best of our knowledge, this is the first case report documenting all these associations altogether. This case report describes how this challenging case was managed well. Splenectomy was inevitable in this patient as the spleen was infarcted. This enlightens the need for timely diagnosis and intervention of wandering spleen for splenic preservation.

Spontaneous uterine perforation presenting as acute abdomen: a diagnostic challenge

2023-03-30T17:35:07+00:00

Spontaneous uterine perforation resulting in generalized peritonitis in postmenopausal women is a very rare entity usually caused by pyometra and is associated with high morbidity and mortality. The clinical picture of uterine perforation secondary to pyometra are similar to hollow viscus perforation which makes preoperative diagnosis difficult. Definitive diagnosis can be made with laparotomy or laparoscopy. We report a case of 62 years old female patient who presented with acute generalized peritonitis with pneumoperitoneum having history of pigtail insertion right kidney for right non-functional kidney with gross hydronephrosis two days back, which was more complicating the clinical picture. This case report aims to alert surgeons to the possibility that uterine perforation secondary to pyometra also shows air under diaphragm apart from hollow viscus perforation.

Pseudoaneurysm of the profunda femoris artery following hip surgery

2023-04-01T08:17:51+00:00

Pseudoaneurysm of the profunda femoris artery has been described as an iatrogenic phenomenon following orthopedic surgery. It may result due to trauma or direct arterial wall injury during dynamic hip screw fixation for proximal femur fracture. We present a case of a 65-year-old female who developed sudden pain and left thigh swelling one month after surgery for left sided intertrochanteric femur fracture. Computed tomography angiography of the left lower limb revealed the presence of a pseudoaneurysm in the upper left thigh. It was successfully treated with endovascular glue embolization followed by surgical excision of the pseudoaneurysm.

Carcinosarcoma of pancreas: an unusual pancreatic tumour: case report

2023-04-07T07:04:25+00:00

Carcinosarcoma of pancreas is a rare tumour with limited clinical and pathological data reported in literature. Although carcinosarcoma predominantly found in uterus, it has been identified in breast, liver, prostate, kidney, salivary glands and pancreas. Carcinosarcoma is a biphasic tumour with epithelial and mesenchymal components. About less than 40 cases had been reported in literature. The treatment of choice in most reported cases is surgery. Given such rarity, we report a case of pancreatic carcinosarcoma diagnosed in our institution, review tumour clinicopathological characteristics, and describe our surgical and medical management strategy.

Peritoneal dermoid cyst, rare location with no other primary focus: a rare case report

2023-04-10T09:29:12+00:00

Growth of dermoid cyst on parietal peritoneum without any prior history of ovarian dermoid cyst is considered a rare condition. The presentation of peritoneal dermoid cyst is vague and depends on the location of the cyst. We report a case of a 28-year-old young female who presented at our outpatient department with vague right upper quadrant pain and no other complaints, but upon examination a swelling was felt on the right upper quadrant, she was investigated radiologically, which reported as a peritoneal cyst, she was taken up for surgery. The cyst was excised and confirmed histopathologically as a dermoid cyst. Clinical progress was uneventful and postoperative recovery was excellent.

Giant ovarian endometrioma presenting as intestinal obstruction

2023-04-16T19:10:47+00:00

Ovarian endometriomas, also commonly referred to as chocolate cysts are seldom found in postmenopausal women. Ovarian endometriomas rarely exceed 10-15 cm in diameter. Its symptoms are non-specific and presentation as acute intestinal obstruction is extremely rare. The present case is of a 66 years old postmenopausal female who presented with symptoms of acute intestinal obstruction. On investigation she was detected with a large right ovarian mass occupying almost entire abdominal cavity and adherent to appendix. She underwent exploratory laparotomy with complete excision of mass and appendicectomy.

Gastric volvulus and wandering spleen: a rare case report

2023-04-18T17:10:00+00:00

Gastric volvulus (GV) is a rare disease. The exact incidence of GV is unknown and patients with chronic presentation may never be diagnosed. The peak age group of incidence is in the fifth decade. GV can be classified as organo-axial and mesentero-axial. Clinical presentation of gastric volvulus depends on the rapidity of onset and the degree of rotation. This is an interesting rare case report of a patient presenting with abdominal pain since 48 hours, associated with dyspnoea, nausea and vomiting. Nasogastric tube placement was unsuccessful. An abdominal computed tomography scan revealed gastric volvulus with pneumoperitoneum. Emergency surgery was indicated and a typical gastrectomy was performed. Acute GV usually presents with Borchardt’s triad. With the advent of CT and laparoscopic surgery, the gold standards for diagnosing and treating this disease are constantly evolving. Surgical treatment should be performed according to aetiology and patient’s characteristics.

Metal hypersensitivity causing implant migration after anterior cruciate ligament reconstruction

2023-04-19T07:39:09+00:00

A young female in her early twenties was diagnosed with Anterior cruciate ligament (ACL) deficiency. Operative intervention was advised with ACL reconstruction using a hamstring graft. The procedure was uneventful, and she was discharged on the second day. She was improving as per expectations. Six months later, the patient came with complaints of a discharging sinus which was located at the site of the tibial entry wound which healed with conservative therapy. However, she developed a similar discharge from the same site after one year of surgery. Radiographs showed migration of the implants away from the bone and towards the skin on the femoral and tibial side. The tibial implant was seen lying just beneath the skin through the discharging sinus. Finally, it was decided to remove the implants surgically. After implant removal, regular dressing was done, and the sinuses healed well without any further complications.

Emergency right hepatectomy for a rare presentation of hepatic adenoma

2023-04-19T08:18:13+00:00

We describe a unique case of a 65-year-old woman who had a hepatic adenoma compressing her right lung, inferior vena cava, and right ventricle, which had been the cause of her breathing problems, which had been becoming worse for the preceding six months. Through a right thoracoabdominal incision, an urgent right hepatectomy was carried out to manage her condition.

Iatrogenic bile duct injury: a stitch in time

2023-04-19T10:02:00+00:00

Intraoperative bile duct injuries often are difficult to be identified intraoperatively can lead to a variety of complications and require complex surgical procedures for their definitive treatment. With multiple complicated treatment options, these injuries become a therapeutic challenge. We present a case of a 49-year-old lady diagnosed with symptomatic gallstone disease who underwent open cholecystectomy in an outside hospital, during which she had an iatrogenic bile duct injury which was diagnosed postoperatively. She was promptly referred to a higher centre. After investigations, the patient underwent a Roux-en-Y hepaticojejunostomy with a subhepatic drain. The patient was discharged post-successful recovery on post-op day 7. Iatrogenic bile duct injury can be missed intraoperatively in a cholecystectomy. The patient provides non-specific symptoms, and a high degree of suspicion can help in early diagnosis. Prompt treatment by an experienced hepatobiliary surgeon is necessary for the successful treatment of the condition.

Gall bladder stump cholelithiasis: a rare presentation

2023-04-19T11:13:51+00:00

Laparascopic cholecystectomy is a minimally invasive surgical procedure for the removal of a diseased gall bladder which has largely replaced open cholecystectomy since early 1990s. However some exhibit a certain ‘post cholecystectomy syndrome’ where there is a recurrence of symptoms similar to those before cholecystectomy. We reported a previously asymptomatic thirty eight year old woman with right hypochondrium pain and a history of laparascopic cholecystectomy seven years ago. Various causes for the same were evaluated and the patient was found to have gall bladder stump cholelithiasis on magnetic resonance cholangio pancreatography. A complete cholecystectomy was then performed and the patient achieved symptomatic resolution. It is important to be aware of this complication in post cholecystectomy patients who may present several years later.

Metanephric adenoma of kidney: a rare case report

2023-04-21T18:32:31+00:00

Metanephric adenoma is a rare benign neoplasm of kidney and is usually a differential diagnosis of Wilms tumor (in children) and papillary renal cell carcinoma (in adults). Here, we present a case report of a 40-year-old gentleman with a right renal mass that was ultimately diagnosed by immunohistochemistry of the final specimen after surgery to be a metanephric adenoma. To prevent needless radical nephrectomies in middle-aged patients metanephric adenoma must be considered in the differential diagnosis of renal mass.

Sigmoido-vesical fistula secondary to hernia mesh migration; a long-term rare complication of laparoscopic transabdominal preperitoneal inguinal hernia repair

2023-04-29T09:42:22+00:00

A 47-year old male presented with frequent urinary tract infections (UTIs), hematuria and pneumaturia with a past history of laparoscopic bilateral inguinal hernia repair 5 years ago. Ultrasonography (USG) and contrast enhanced computed tomography did not furnish any evidence to arrive at a diagnosis, interestingly, cystoscopy revealed a mesh in the urinary bladder making apparent the diagnosis of Sigmoido-vesical fistula secondary to mesh migration. Later, surgical removal of the mesh from the sigmoid colon and urinary bladder with rent closure of the fistulous opening was done successfully. Our case thus, highlights the long-term rare complication of transabdominal preperitoneal (TAPP) surgery.

Non-steroidal anti-inflammatory drug-induced perforation of Meckel’s diverticulum

2023-03-31T21:12:36+00:00

Meckel’s diverticulum (MD) is commonest congenital gastrointestinal anomaly, the common complications associated with MD are hemorrhage, ulceration, intestinal obstruction, diverticulitis, umbilical anomalies, and neoplasm. Perforation of Meckel’s diverticulum is a rare entity and there’s very less documentation regarding the incidence of Meckel’s perforation. MD perforation is usually a life-threatening complication and is associated with high mortality, perforation is usually due to diverticulitis, peptic ulcer disease occurring in the ectopic gastric mucosa which might be present in MD. NSAID intake associated with Merkel’s perforation has been documented in a few studies. NSAID intake and gastric perforation have been well established but a relation between NSAIDs and heterotrophic gastric mucosa of MD has not been documented. With NSAIDs use becoming very common it is, therefore, important to document this association.

Breast cancer with synchronous renal cell carcinoma: a rare case of dual malignancy

2023-04-22T16:09:10+00:00

Synchronous breast and kidney carcinomas are extremely rare with only 11 cases have been reported in the literature so far in the world. We present a case of a 40-year-old lady diagnosed with right invasive ductal cell carcinoma. During the workup of the patient, an incidental renal mass was identified. After appropriate investigations, the patient underwent a right modified radical mastectomy with a right partial nephrectomy. The patient recovered successfully and was put on regular follow-up post-discharge. We are reporting a case of synchronous presentation of carcinoma breast with RCC which is rare since in world literature, most of the multiple malignancies reported are metastasis/metachronous breast carcinoma with RCC. The aetiology of synchronous malignancy is complex, some primary tumours may not be symptomatic and detected in the routine metastatic workup, and this poses a challenge for the surgical team. Hence with the histopathological report and with the other clinical and radiological parameters, we made a final diagnosis of carcinoma right breast pT2N0M0 with synchronous renal cell carcinoma (RCC) pT1aN0M0. the patient was planned for adjuvant chemotherapy and advised regular follow-up.