International Surgery Journal

Conservative management of splenic rupture in an elderly patient with Hodgkin lymphoma on Filgrastim

2026-05-28T08:41:57+0530

The spleen plays a substantial role in the human body, with major functions including eliminating abnormal erythrocytes, and producing immunoglobulins. Splenomegaly is a condition affecting around two-percent (2%) of the US population. It can occur secondary to hemoglobinopathies such as hereditary spherocytosis, infectious mononucleosis (i.e., Epstein-Barr virus, cytomegalovirus, etc.), sporadic venous anomalies, and drug reactions. Certain medications have been recently implicated with splenomegaly. Granulocyte-colony stimulating factor (G-CSF) used in patients undergoing chemotherapy or blood stem cell transplants recipients (PBSCT) has been increasingly reported in association with splenic injury secondary to splenomegaly. The enlarged spleen carries an increased risk for spontaneous or traumatic rupture. Management of splenic injury is a highly streamlined process. Indications for operative versus non-operative management (NOM) rely mainly on hemodynamic status of the patient, grade of splenic injury, as well as the presence of other injuries, comorbidities, and etiology of the splenomegaly. In ruptures associated with hemoglobinopathies, erythrocyte membrane disorders, lymphoproliferative and myeloproliferative disorders, splenectomy is more often chosen. The current guidelines favor conservative approaches for hemodynamically stable patients. Whereas for those who fail conservative management or are hemodynamically unstable, considerations for interventional radiology involvement or emergent operative management are indicated. We present a patient with Hodgkin’s lymphoma, being treated with GCSF (filgrastim) and who developed splenomegaly with subsequent splenic rupture.

A rare case of colonic metastasis of endometrial adenocarcinoma

2026-05-28T08:40:06+0530

Colorectal cancer is a leading cause of cancer-related morbidity and mortality, with primary adenocarcinoma of the colon accounting for the majority of cases. Less frequently, metastatic involvement of the colon from other primary malignancies may occur. The authors present the case of a 68-year-old female patient with past history of endometrial adenocarcinoma, who developed a colonic metastasis. The patient was previously treated for endometrioid adenocarcinoma with hysterectomy and bilateral anexectomy and now presented with elevated tumour markers during oncologic follow-up. Imaging revealed a suspicious thickening in the sigmoid colon and endoscopic biopsy confirmed moderately differentiated adenocarcinoma. A laparoscopic sigmoidectomy with liver biopsy was performed, revealing metastatic disease. Immunohistochemistry showed estrogenic and progesterone receptor positivity, as well as other markers suggestive of endometrial adenocarcinoma origin. This case highlights a rare instance of colonic metastasis from endometrial adenocarcinoma, a condition rarely observed in clinical practice. Understanding the histological and immunohistochemical characteristics of both cancers is critical for accurate diagnosis and treatment. This case underscores the importance of considering metastatic diseases when diagnosing colorectal lesions, especially in patients with past history of other malignancies.

Undiagnosed simultaneous umbilical and femoral hernias complicated by ascites: a case study of a 13-year-old girl at the Iringa Regional Referral Hospital in Iringa, Tanzania

2026-05-28T08:39:52+0530

Concurrent umbilical and femoral hernias are unusual instances defined by an intra-abdominal bulge caused by abnormalities in the abdominal wall at the umbilical ring and the femoral canal in the upper thigh/groin area. Untreated femoral hernias provide a danger of strangulation, imprisonment, and intestinal blockage. This disorder is more frequent in females and affects youngsters more than adults. Concurrent umbilical and femoral hernias accompanied by ascites are extremely rare and can be corrected surgically. A 13-year-old girl from Mawelewele, Iringa, was presented with abdominal swelling and back discomfort. She had a history of chronic abdominal TB with recurrent ascites for four years. The patient had roughly one liter of yellowish discharge with a bad odor, which was accompanied by increased abdominal distention but no vomiting or diarrhea. She reported acute back discomfort with no aggravating or alleviating causes. The discomfort was linked with lower limb pain, fatigue, and limited mobility. There was no history of trauma. The patient had a four-year history of recurring abdominal distension, for which she had visited Benjamin Mkapa Hospital several times. And was diagnosed with abdominal TB, requiring numerous ascitic taps. And was receiving ant tuberculosis medication, albeit the regimen and adherence were not properly documented. She lost weight gradually, had low-grade fever on and off, and coughed intermittently throughout her illness. There was no prior history of bowel abnormalities, urinary complaints, hematemesis, or melena. The findings of an abdominal ultrasound indicated that a patient had significant ascites at Morrison's pouch, and an MRI revealed that a patient had huge ascites secondary? Correlate clinically. The patient had no hepatitis B or C, and the chest X-ray showed normal results. The decision was made to operate on the patients and remove their fluids while repairing the umbilical and femoral hernias. Under general anesthesia in the supine position, the patient was aseptically cleansed and draped before the incision was performed. Loculated ascitic fluid, a loop of viable small bowel in the hernia sac. Approximately 3000 ml of loculated ascitic fluid were extracted. Reduction of viable small bowel, excision of superfluous sac, and sublay mesh hernioplasty were performed, and the patient was alleviated of his previous complaints and symptoms. He was discharged after five days with a four-week follow-up. The patient totally healed and returned to school, which she had missed for nine months. Umbilical and femoral hernias complicated by ascites in the setting of chronic abdominal tuberculosis should be managed surgically, which was successfully done with sublay mesh hernioplasty, and the girl was rescued after four years of suffering due to misdiagnosis of the simultaneously umbilical and femoral hernia complicated by ascites as abdominal tuberculosis. Following that, the nutritional status improved.

Right hepatectomy for advanced hepatocellular carcinoma (cT4N0M0) with inferior vena cava invasion: challenges and curative surgical strategies

2026-05-28T08:39:19+0530

Advanced hepatocellular carcinoma (HCC) with major vascular involvement remains a surgical challenge, particularly in cases classified as cT4N0M0. Inferior vena cava (IVC) invasion significantly increases operative complexity and perioperative risk. However, in selected patients with preserved liver function and adequate future liver remnant (FLR), curative-intent hepatectomy may still be considered. A 46-year-old male presenting with persistent right upper quadrant pain. Imaging studies including contrast-enhanced CT scan and three-phase whole abdominal CT demonstrated a right lobe liver mass consistent with malignant tumor, staged as cT4N0M0. Multidisciplinary evaluation was performed. FLR was 80%, and portal vein embolization was not indicated. The patient underwent open right hepatectomy with Pringle maneuver, right Glissonean pedicle ligation, and cholecystectomy. Intraoperatively, tumor involvement led to two ruptures of the IVC, which were managed with primary repair. Advanced HCC (cT4N0M0) with macrovascular invasion, including portal vein or IVC involvement, has traditionally been associated with poor prognosis; however, recent meta-analyses and nationwide cohort studies demonstrate that curative-intent liver resection can achieve meaningful survival benefits, with 1 and 3 year overall survival rates exceeding those of non-surgical therapy in carefully selected patients. Right hepatectomy with IVC repair can be performed safely in selected patients with advanced HCC (cT4N0M0) and sufficient FLR. Careful preoperative planning, multidisciplinary evaluation, and meticulous vascular control are critical to achieving curative resection in complex cases involving major vascular structures.

Epithelioid angiosarcoma arising from Schwannoma: report of a rare case and potential of circulating tumor DNA as a useful biomarker

2026-05-28T08:41:52+0530

Epithelioid angiosarcoma arising from Schwannoma (EASS) is an exceptionally rare and aggressive malignant neoplasm with a poor prognosis. To date, only 22 cases have been reported in the literature, and its risk factors, etiology, and pathogenesis remain poorly understood. There is no established consensus for optimal management or surveillance strategies. These tumors may present as an asymptomatic or symptomatic mass, with most diagnoses being unexpected. Given the rarity and therapeutic challenges of EASS, we present a 58-year-old man diagnosed with EASS, highlighting the potential role of next generation sequencing (NGS) in identifying therapeutic targets and the use of circulating tumor DNA (ctDNA) as a potential tumor burden biomarker. Tumor-informed ctDNA was elevated to 30.49 at the time of diagnosis and increased to 213.90 after presence of metastasis. This case is the first documented instance of a SMARCB1 mutation in EASS, suggesting a potential therapeutic target. Further research is needed to better understand the etiology, pathogenesis, and optimal management strategies for EASS, including the role of targeted therapies based on NGS findings and the utility of ctDNA as a monitoring tool. Overall, the rarity and aggressive nature of EASS, a comprehensive metastatic workup, including cross-sectional imaging, is crucial for staging and management.

Combined Rives–Albanese technique in the management of a complex incisional hernia: a case report

2026-05-28T08:38:49+0530

Incisional hernias of the abdominal wall affect up to 20% of patients undergoing laparotomy and may evolve into a complex condition associated with significant physical and psychological morbidity. Several surgical techniques have been developed for their repair. The Rives technique enables midline reconstruction through retromuscular dissection and medial advancement, achieving low recurrence rates. In contrast, the Albanese technique employs lateral releasing incisions in the abdominal wall musculature to facilitate tension-free closure. We report the case of a 58-year-old female with a complex incisional hernia following a prior midline laparotomy for appendicular peritonitis. The patient presented with progressive abdominal bulging and pain. Preoperative evaluation revealed a 12 cm defect without loss of domain. Surgical repair was performed using a combined Rives–Albanese technique, including retromuscular mesh placement and lateral releasing incisions to facilitate tension-free closure. Repair of complex incisional hernias using this combined approach is feasible in experienced hands. Postoperative outcomes were favorable, with no significant complications observed, demonstrating the functional effectiveness of the technique. Management of complex abdominal wall defects with muscle retraction remains challenging and requires advanced surgical expertise. The combination of retromuscular repair (Rives) and lateral releasing incisions (Albanese) represents a valuable option for achieving primary closure with acceptable morbidity. Long-term success depends on comprehensive multidisciplinary management beyond the surgical procedure.

When open surgery fails: endovascular treatment of a surgically inaccessible high cervical internal carotid artery aneurysm – a case report

2026-05-28T08:38:28+0530

Extracranial internal carotid artery (ICA) aneurysms are rare vascular lesions associated with a risk of thromboembolism, rupture, and cranial nerve compression. Open surgical reconstruction has traditionally been considered the standard treatment; however, lesions located high in the cervical segment may pose significant technical challenges due to limited exposure and difficulty in obtaining distal control. This report describes the case of a 36-year-old man presenting with several weeks of left-sided neck pain and headache. Computed tomography angiography demonstrated a saccular aneurysm of the proximal left ICA measuring approximately 31×17×18 mm. Open surgical repair was attempted but intraoperative findings revealed a high cervical aneurysm with a fragile arterial wall and inability to safely obtain distal control, leading to abandonment of reconstruction. Definitive treatment was subsequently achieved using a staged endovascular approach with deployment of a covered stent graft. Completion angiography confirmed complete exclusion of the aneurysm with preserved antegrade flow and no evidence of endoleak. The postoperative course was uneventful and the patient remained neurologically intact. This case highlights the importance of intraoperative decision-making and supports endovascular reconstruction as an effective alternative in anatomically challenging extracranial carotid aneurysms.

Primary gastric volvulus: a case report

2026-05-28T08:38:11+0530

Gastric volvulus is a rare surgical emergency whereby rapid diagnosis and intervention is imperative to prevent morbidity and mortality. This case report discusses a 45-year-old woman, with no prior medical or surgical concerns, who presented to Thelle Mogoerane Regional Hospital in South Africa with an acute abdomen after bouts of vomiting and nausea, which prompted a computed tomography (CT) scan. The CT findings were suggestive of a gastric volvulus and the patient was optimised before successful surgical intervention was done. This case report highlights the importance of prompt diagnosis via multi-modal techniques and rapid surgical intervention.

A case report on intestinal malrotation in an adult patient

2026-05-28T08:38:08+0530

Intestinal malrotation corresponds to an embryological developmental anomaly resulting from a defect in the rotation and fixation of the midgut around the axis of the mesenteric artery. It is diagnosed in 75-85% of cases during childhood, with an incidence between 0.0001% and 0.19%. A case is presented of a 22-year-old young adult with multiple episodes of pain that worsened over the course of a year, abdominal distension, vomiting of gastric contents, and occasional constipation. She visited various healthcare services and was diagnosed with gastritis due to H. pylori infection, received treatment, and showed partial improvement. Subsequently, she returned to the emergency services with symptoms of intestinal obstruction. Studies were conducted, including an IV contrast computed tomography (CT) scan, which showed the presence of a characteristic whirl sign, associated with abnormal rotation of the midgut around the superior mesenteric artery. Early recognition of the diagnosis of intestinal malrotation in adults is important because its occurrence is rare, which necessitates the use of diagnostic tools such as imaging studies for an appropriate surgical intervention, which is the cornerstone for improving the prognosis of these patients.

Colorectal adenocarcinoma infiltrating inguinal hernia mesh: a case report and systematic review

2026-05-28T08:41:45+0530

Inguinal hernia repairs are standard procedures globally, but while reducing recurrence, they can introduce complications such as infection, migration, and bowel obstruction. The extent of prosthetic mesh involvement in synchronous malignancies, particularly regarding cancer seeding or direct invasion, remains underexplored. This case report highlights an uncommon presentation of colorectal adenocarcinoma, initially manifesting as a mesh-related complication, in a 74-year-old male with a history of two previous right inguinal hernia repairs. Initial evaluations, including colonoscopy and carcinoembryonic antigen levels, offered no indication of cancer. However, subsequent investigation led to robotic adhesiolysis, preperitoneal debridement, and mesh explantation, definitively revealing metastatic moderately differentiated adenocarcinoma on the mesh, strongly suggesting a colorectal primary neoplasia. Despite multiple interventions and chemotherapy, the patient developed progressive metastasis. We identified only 8 reported cases describing mesh invasion or complications due to various primary tumors presenting as inguinal masses, pain, or swelling, making this an extremely rare complication. Surgical management in these cases primarily involved tumor resection and mesh removal, with mixed outcomes. This case therefore underscores the rare but significant occurrence of metastatic colorectal adenocarcinoma seeding prosthetic mesh following inguinal hernia repair.

A giant fibroepithelial polyp of vulva

2026-05-28T08:39:55+0530

Fibroepithelial stromal polyps (FEPs) are benign mesenchymal lesions commonly found in cutaneous folds and the lower female genital tract. They are typically small and asymptomatic, but rarely may grow to a large size and mimic other vulvar tumors. We report a case of a giant fibroepithelial polyp of the vulva in a 48-year-old postmenopausal woman presenting with a painless, progressively enlarging pedunculated mass arising from the right labia majora for 2.5 years. The lesion measured approximately 9×5×13 cm and caused discomfort during daily activities. Complete surgical excision under local anaesthesia was performed. Histopathological examination confirmed fibroepithelial stromal polyp. Giant vulvar fibroepithelial polyps are rare and may clinically mimic more aggressive lesions; therefore, histopathological confirmation and surgical excision are essential for definitive diagnosis and treatment.

Kikuchi-Fujimoto disease: a case report

2026-05-28T08:39:37+0530

Kikuchi-Fujimoto disease is unique because it mimics serious illnesses yet has a benign course, requiring awareness to avoid misdiagnosis. Its novelty lies in its mysterious origin, possible autoimmune associations, and evolving clinical profile in the era of new infections and immunologic events. Given the potential for recurrence and its association with autoimmune diseases like systemic lupus erythematosus, further research is needed to clarify its pathogenesis and guide standardized treatment protocols. A 19-year-old Marathi (Indo-Aryan) female presented with multiple, painless, gradually enlarging neck swellings and occasional low-grade fever without systemic symptoms. Similar complaints occurred in childhood. On examination, firm, mobile, non-tender lymph nodes were found in the posterior neck triangle, with no skin changes or lymphadenopathy elsewhere. FNAC suggested reactive lymphadenitis, and antibiotics were ineffective. An excision biopsy was performed, and histopathology confirmed the diagnosis of Kikuchi-Fujimoto disease. The patient was treated with symptomatic treatment with good results. The aim of the case report is to increase awareness of this disease so that it can be recognized early and prevent misdiagnosis and subsequent over treatment. The best way to diagnose this non-specific lymphadenopathy is to do a biopsy of the lymph node. Once diagnosed, it can be managed conservatively as it is mostly self-limiting.

Eccentric osteolytic lesion of the proximal tibia secondary to solitary bone plasmacytoma managed with reconstruction surgery: a case report

2026-05-28T08:39:28+0530

Solitary bone plasmacytoma (SBP) is a rare plasma cell neoplasm characterized by localized monoclonal proliferation without systemic involvement, most commonly affecting the axial skeleton, while involvement of long bones such as the tibia remains distinctly uncommon. We report a case of a 51-year-old male presenting with progressive pain in the right proximal leg and difficulty in weight-bearing for three months. Clinical examination revealed localized tenderness over the medial proximal tibia with restricted knee motion. Radiographs demonstrated a well-defined eccentric osteolytic lesion with cortical breach and pathological fracture, while advanced imaging confirmed an intramedullary lesion with cortical destruction. Histopathological evaluation revealed sheets of malignant plasma cells, confirming plasmacytoma. Comprehensive systemic work-up, including skeletal survey, bone marrow biopsy, and biochemical analysis, excluded multiple myeloma. The patient underwent intralesional curettage followed by polymethylmethacrylate cement augmentation and proximal tibial locking plate fixation to restore structural stability. SBP involving the tibia is uncommon and may mimic other osteolytic lesions, necessitating thorough diagnostic evaluation to exclude systemic disease. Surgical management becomes essential in cases with structural compromise, where cement augmentation provides immediate mechanical stability, facilitates early mobilization, and may contribute to local tumor control. Intralesional curettage combined with cement-augmented internal fixation represents an effective reconstructive strategy for tibial SBP, enabling early weight-bearing and favorable functional outcomes. Long-term surveillance remains essential to monitor for progression to multiple myeloma.

Aortosternal venous compression along with bovine arch masquerading as internal jugular vein thrombus: a case report

2026-05-28T08:39:06+0530

We present the case of a 31-year-old male who presented with pain and swelling of the left side of the neck and left upper limb. Initial ultrasonography demonstrated thrombosis of the left internal jugular vein with partial thrombosis of the left subclavian and axillary veins. Subsequent contrast-enhanced computed tomography of the neck and thorax revealed an anatomical variant of the aortic arch with a common origin of the brachiocephalic artery and left common carotid artery (bovine arch), resulting in significant compression of the left brachiocephalic vein between the aortic arch, clavicle, and manubrium sterni. No mediastinal mass or aneurysm was identified. Computed tomography (CT) venography confirmed severe stenosis of the left brachiocephalic vein, establishing the diagnosis of aorto-sternal venous compression after exclusion of other causes. The patient was managed conservatively with limb elevation and anticoagulation therapy, with marked symptomatic improvement on follow-up.

Salmonella typhi infection in walled-off pancreatic necrosis following recurrent acute pancreatitis: a rare case report and review of pathogenesis

2026-05-28T08:38:01+0530

Infected pancreatic necrosis is a serious complication of acute pancreatitis, typically caused by enteric Gram-negative organisms. The isolation of atypical pathogens, particularly Salmonella enterica serovar Typhi, from pancreatic collections is exceedingly rare and poses diagnostic and therapeutic challenges. A 28-year-old male with alcohol-related recurrent acute pancreatitis presented with abdominal pain, vomiting, and high-grade fever. He had been initially managed at an outside facility and was referred approximately four weeks after symptom onset with clinical deterioration. Imaging revealed a large necrotic pancreatic collection involving the body and tail, with internal debris and features suggestive of infection. The computed tomography severity index (CTSI) was 8/10, and the collection was classified as infected walled-off necrosis. Given persistent sepsis and unfavorable anatomy for endoscopic drainage, a minimally invasive step-up approach was adopted, and CT-guided percutaneous catheter drainage (PCD) was performed. Microbiological analysis of the drained fluid revealed growth of Salmonella enterica serovar Typhi, sensitive to third-generation cephalosporins and azithromycin but resistant to fluoroquinolones. Blood cultures were not obtained at initial presentation. Targeted intravenous antibiotic therapy was initiated based on culture sensitivity, resulting in progressive clinical improvement. The patient stabilized with resolution of fever and reduction in drain output and was discharged with the catheter in situ for follow-up. The presence of Salmonella typhi in pancreatic necrosis is rare, with only a limited number of cases reported in the literature. Possible mechanisms include hematogenous dissemination during transient bacteremia and bacterial translocation in the setting of necrotic pancreatic tissue. This case highlights the importance of differentiating true infection from contamination and underscores the role of culture-directed therapy. It also reinforces the effectiveness of a tailored, minimally invasive step-up approach in managing infected walled-off necrosis. Atypical pathogens such as Salmonella typhi may rarely complicate pancreatic necrosis and should be considered in patients with persistent sepsis. Integration of microbiological data with clinical and radiological findings is essential for accurate diagnosis and targeted management. Early recognition and individualized intervention strategies can significantly improve patient outcomes.

Regenerative touch: enhancing post-burn scar quality through autologous free fat grafting

2026-05-28T08:37:54+0530

Post-burn scars lead to functional and cosmetic deformities. Conventional treatments have limited outcomes. Autologous fat grafting has emerged as a regenerative modality. A hospital-based prospective study was conducted on 17 patients with post-burn scars (>6 months). Fat grafting was performed using a modified Coleman technique. Scar assessment was done using POSAS scale at baseline, 1 month, and 3 months. Statistical analysis was done using repeated measures ANOVA. There was a statistically significant improvement in both subjective and objective POSAS scores (p<0.001). Maximum improvement was noted in itching, thickness and pliability. Histological analysis showed collagen remodelling, increased vascularity, and reduced fibrosis. Complications were minimal, mainly transient edema. Autologous fat grafting is a safe, effective, and minimally invasive technique for improving post-burn scar quality with significant clinical and histological benefits.

Oligometastatic breast cancer: back to square one in the era of precision oncology

2026-05-28T08:38:18+0530

Metastatic breast cancer (MBC) has long been considered the paradigm of an incurable systemic disease. Once distant dissemination occurs, therapeutic strategies have traditionally focused on disease control, symptom palliation, and survival prolongation rather than cure. Yet, as systemic therapies become increasingly effective and diagnostic tools more sensitive, the classical distinction between localized and metastatic disease appears progressively less absolute.

Enhanced recovery after surgery protocol: impact on postoperative recovery and complications

2026-05-28T08:41:33+0530

The enhanced recovery after surgery (ERAS) protocol consists of a set of multimodal strategies aimed at optimizing perioperative care, with the goal of reducing the surgical stress response and improving postoperative outcomes. In this systematic review, it was observed that the implementation of ERAS reduces length of hospital stay, decreases postoperative complications, and reduces opioid use. However, the benefits were less evident in patients with greater clinical severity or those undergoing more invasive surgeries. Thus, the ERAS protocol appears to be effective in optimizing surgical recovery, especially when there is high adherence and individualized care.

Challenging treatment of enterovesical fistula: a scoping review of pros and cons

2026-05-28T08:38:20+0530

Enterovesical fistula (EVF) is rare, morbid conditions primarily caused by diverticulitis. However, Crohn’s disease and pelvic malignancies present distinct operative challenges. Objectives were to evaluate current EVF management strategies, highlighting clinical benefits, limitations, and evidence gaps. We performed a PRISMA-ScR-guided scoping review of PubMed and Scopus (January 2000-February 2026), including English-language clinical studies. We analyzed data on etiology, surgical approach [open vs. minimally invasive surgery (MIS)], bladder management, and patient outcomes. Elective colorectal resection with primary anastomosis is the preferred approach for benign EVF, achieving high closure rates with acceptable morbidity. MIS is increasingly adopted in experienced centers, decreasing length of stay and wound complications. However, conversion to open surgery remains common in hostile pelves (e.g., dense phlegmon, prior surgery). Bladder management favors a selective, organ-preserving approach using intraoperative leak testing, often safely omitting formal cystotomy and routine postoperative cystography. Regarding specific etiologies: Crohn’s-related EVF may initially respond to biologics but typically requires definitive surgery; malignant EVF necessitates en bloc resection, with prognosis driven by oncologic stage and patient frailty. Current management converges on elective one-stage resection, selective bladder preservation, and judicious use of MIS. The persistent heterogeneity in perioperative care underscores the need for prospective, multicenter trials to standardize pathways and optimize outcomes.

Early surgery versus endoscopic therapy in chronic pancreatitis: toward an evidence-based paradigm shift

2026-05-28T08:38:37+0530

Chronic pancreatitis (CP) is a progressive inflammatory disease leading to irreversible pancreatic damage, exocrine and endocrine insufficiency and chronic debilitating pain. Traditional management follows a step-up approach: medical therapy, endoscopic intervention, then surgery for refractory cases. Emerging evidence challenges this sequence, especially for patients with obstructive disease. This review evaluates comparative evidence of endoscopic versus surgical interventions in CP, emphasizing pain relief, durability and timing. Endoscopic therapy including pancreatic duct stenting, stricture dilation and extracorporeal shock wave lithotripsy offers meaningful short-term relief in selected patients with ductal obstruction. However, long-term efficacy is limited; 3–5 years sustained pain relief occurs in only 30–50% of patients, often requiring repeated procedures. In contrast, surgical approaches (pancreaticojejunostomy, Frey or Beger procedures) address both ductal obstruction and inflammatory mass, resulting in more durable outcomes. Randomized trials, including long-term data from the ESCAPE trial (~8-year follow-up), demonstrate superior pain control with early surgery: complete pain relief was achieved in 45% of early surgery patients versus 20% in endoscopy-first patients, with fewer cumulative interventions and higher patient satisfaction. Delayed surgery following repeated endoscopic therapy is associated with reduced efficacy, likely due to central sensitization and neural remodelling. Accumulating evidence supports a paradigm shift toward early, individualized surgical intervention in selected patients with obstructive chronic pancreatitis. While endoscopic therapy retains a role in carefully selected cases, prolonged step-up approaches may compromise long-term outcomes. Timely surgical referral, guided by disease morphology and symptom duration, is critical to optimizing pain relief and quality of life.

Correlation between KRAS mutation status and clinical outcomes in colorectal cancer patients: a retrospective cohort study

2026-05-28T08:39:14+0530

Background: Kirsten rat sarcoma (KRAS) mutations are key drivers in colorectal cancer (CRC), but their prognostic impact in stage III disease remains debated. This study evaluated the correlation between KRAS mutations and clinical outcomes in stage III CRC patients.

Methods: A retrospective cohort study was conducted on 48 patients at Dr. Moewardi General Hospital. KRAS status was determined via immunohistochemistry (IHC) (G12D), and outcomes were analyzed using Fisher’s Exact test.

Results: KRAS mutations were prevalent in 66.7% of patients. Distant metastasis occurred in 45.8% of cases, primarily in the liver and lungs. No significant correlation was found between KRAS mutation status and distant metastasis (p=0.735) or mortality (p=0.648).

Conclusions: While KRAS mutations are frequent in stage III CRC patients in this setting, they did not significantly predict metastasis or survival. Prognostic assessments should incorporate broader molecular profiling and clinicopathological factors.

Comparative analysis of day-surgery versus conventional overnight stay surgery for laparoscopic cholecystectomy

2026-05-28T08:38:52+0530

Background: There is growing momentum toward performing laparoscopic cholecystectomy as a day-case procedure for suitable patients. Nonetheless, surgeons still report barriers to same-day discharge. The purpose of this study was to compare day-case laparoscopic cholecystectomy with conventional overnight-stay laparoscopic cholecystectomy in selected patients with gallbladder stones.

Methods: A prospective comparative observational study was conducted in the Department of Surgery, DHQ Abbottabad, from June 2024 to July 2025. Seventy ASA I patients aged 20–50 years with uncomplicated gallstone disease were allocated to day-case discharge within 12 hours (Group 1, n=35) or discharge after 24 hours (Group 2, n=35). Outcomes included operating time, VAS pain at 6 hours, postoperative nausea and vomiting, complications, readmission, time to return to normal home activities and satisfaction.

Results: Baseline age and BMI were comparable between groups. Mean operating time was 40.43±4.42 minutes in Group 1 versus 40.57±4.05 minutes in Group 2 (p=0.888). VAS pain at 6 hours was 3.23±0.84 versus 3.14±0.91 (p=0.684). Return to normal activities was 4.94±1.76 days versus 4.49±1.80 days (p=0.288). Nausea and vomiting occurred in 8.57% versus 5.71%, readmission in 5.71% versus 2.86% and satisfaction in 97.14% versus 100%.

Conclusions: Day-case laparoscopic cholecystectomy showed comparable short-term outcomes to overnight stay in this setting, with high satisfaction and low event rates under strict selection and discharge criteria.

A clinical study to predict difficult laparoscopic cholecystectomy based on clinicoradiological assessment

2026-05-09T06:42:04+0530

Background: Laparoscopic cholecystectomy is the gold standard for gallstone disease, but operative difficulty varies due to clinical and radiological factors. Predicting difficult cases preoperatively helps improve surgical planning, reduce complications, and guide timely conversion to open surgery.

Methods: This prospective study included 50 patients undergoing laparoscopic cholecystectomy between December 2022 and December 2024. Clinical parameters (age, sex, BMI, comorbidities, prior surgery, history of cholecystitis, ERCP) and radiological findings (gallbladder wall thickness, stone characteristics, gallbladder status, Mirizzi syndrome) were recorded. Intraoperative difficulty was categorized as easy, difficult, or requiring conversion to open surgery, based on predefined criteria.

Results: Difficult laparoscopic cholecystectomy occurred in 38% of cases, with a 12% conversion rate. Key predictors of difficulty included acute cholecystitis (50%), obesity (58%), age >50 years, and prior ERCP (54.5% difficulty, 45% conversion). Mirizzi syndrome showed 100% difficulty and 75% conversion. Contracted gallbladder and thickened wall (>4 mm) were associated with higher difficulty. Male patients had higher conversion rates (22.2%) despite fewer difficult cases. Stone size and number were not reliable predictors.

Conclusions: A combination of clinical and radiological factors can effectively predict difficult laparoscopic cholecystectomy. Acute inflammation, prior ERCP, Mirizzi syndrome, obesity, and advanced age are strong indicators of operative complexity and conversion risk. Preoperative risk stratification enables better planning, improves patient counselling, and enhances surgical safety.

From grading to guidelines: recommendations for safe laparoscopic cholecystectomy based on the Parkland grading system

2026-05-28T08:42:16+0530

Background: Laparoscopic cholecystectomy is one of the most studied laparoscopic surgeries. Recently parkland grading scale has added a simple intra-operative component to assessing difficulty of cholecystectomy. We aim to utilise this Parkland grading system for formulating recommendations on how to proceed in the surgery.

Methods: This was a retrospective study of recorded laparascopic cholecystectomies done at Max Hospital, Gurugram, Haryana. All the patients underwent laparoscopic cholecystectomy from October 2022 to March 2024. The Parkland grading scale (PGS) was noted at the start of the surgery and thereafter the progression of surgery was studied under various headings. All the pre-operative, intra-operative and post-operative findings were assessed to formulate recommendations for safe laparoscopic cholecystectomy.

Results: A total of 416 patients were graded utilizing PGS system. Out of 416 gall bladders graded, 127 (29.3%) were assessed to be grade 1, 146 (35.1%) were grade 2, 90 (21.6%)were grade 3, 34 (8.1%) were grade 4 and 24 (5.7%) were grade 5 as per PGS. When talking about any alteration to standard approach of doing a lap cholecystectomy, fundus first approach was the first change used by the operative surgeons. 32.2% of patients in PGS 3 had to be converted to fundus first approach, 61.7% of PGS 4 and 75% of PGS 5 patients had same surgical fate. Conversion to open cholecystectomy was also done in a small number of patients. Only 3 out of 34 and 4 out of 24 patients from PGS 4 and 5 respectively underwent this bailout procedure. Use of harmonic scalpel was used more frequently in higher grades of PGS as high as 95.8% patients in PGS 5 and 50% patients in PGS 4 and 11% in PGS 3. The use of hemolock for clipping of vessel and ducts was similar in occurrences 50% in PGS 5 and 35.2% in PGS 4, 5% in PGS 2, 8.8% in PGS 3. When studied about intra-op injuries, vascular injuries although low in number had a relative increased incidence with increasing parkland grade

Conclusion: PGS can be highly predictive for difficult cholecystectomy and every surgeon with or without adequate experience should be aware of potential complications. PGS grade 4 and higher have higher rate of conversion to fundus-first approach. PGS 4 and 5 had lesser complication rates and have shorter operative time if the decision to convert to a fundus first or open cholecystectomy was taken earlier. Planning appropriate line of further management without wasting much time is what we advocate. The author would like to stress upon the fact that no role of subtotal cholecystectomy was found in our study when timely decisions regarding change in approach was taken.

Rouviere’s sulcus: a surgical GPS guiding laparoscopic cholecystectomy

2026-05-28T08:42:03+0530

Background: Laparoscopic cholecystectomy is the gold standard for managing gallstone disease but carries a risk of bile duct injury, particularly in cases of difficult anatomy or inflammation. Rouviere’s sulcus, an extrahepatic biliary landmark, has been proposed as a guide to safer dissection. This study aimed to determine the prevalence and anatomical variations of Rouviere’s sulcus in patients undergoing laparoscopic cholecystectomy and evaluate its role in preventing biliary tract injuries.

Methods: A prospective descriptive study was conducted between January 2021 and August 2022 involving 100 patients undergoing laparoscopic cholecystectomy at a tertiary care teaching hospital. The presence, type, and clinical utility of Rouviere’s sulcus were documented, along with intraoperative and postoperative outcomes. Demographic, clinical, and surgical data were recorded and statistically analyzed.

Results: Rouviere’s sulcus was identified in 79% of patients. The most common type was the open sulcus (60.75%), followed by closed (20.25%), slit (12.65%), and scar (6.32%) types. The conversion rate to open surgery was 21%, with reasons including difficult dissection, uncontrolled bleeding, bile duct injury, and bowel injury. Bile leak occurred in 5% of cases; four managed conservatively with endoscopic retrograde cholangiopancreatography (ERCP), and one required surgical management. No mortality was observed.

Conclusions: Rouviere’s sulcus is a reliable anatomical landmark present in the majority of patients, aiding in safe dissection and reducing bile duct injury risk during laparoscopic cholecystectomy. The routine identification and use of this landmark should be incorporated into surgical practice, although awareness of its absence or difficult visualization in a minority of cases is essential.

Peritoneal fluid culture and its antibiotic sensitivity in perforative peritonitis patients – a prospective observational study from Southern India

2026-05-28T08:41:38+0530

Background: Multiple microorganisms, including anaerobic bacteria, gram positive and gram-negative bacteria, enter the peritoneal cavity during peritonitis. We studied the microbiological pattern in peritoneal fluid cultures and t the organisms' antibiotic susceptibility and resistance pattern in perforative peritonitis.

Methods: This study was a cross-sectional study conducted for 12 months with 50 patients. The patients presenting with features of perforation peritonitis aged above 18 years were included in the study. Emergency laparotomy done using midline incision and peritoneal fluid was obtained from confirmed the non-traumatic cases and sent for aerobic microbiological culture. Peritoneal fluid culture reports were followed up and the antibiotics were changed according to the sensitivity pattern of organism.

Results: Mean age of the study participants was 42.6±15.1 years. Study participants were predominantly male 36 (72%). Nine (58%) does not have any comorbidities. All patients presented with 50 (100%) abdominal pain followed by predominant symptom was vomiting 44 (88%), nausea 29 (58%), oliguria 7 (14%) and anorexia 3 (6%). Among patients without comorbidities, E. coli was the pre-dominant organism isolated 16 (55.2%) followed by Klebsiella 9 (31%), Proteus 3 (10.3%) and Pseudomonas 1 (3.4%). Maximum number of patients were sensitive to ceftriaxone 47 (94%) followed by ciprofloxacin 41 (82%). Maximum number of patients were resistant to higher end antibiotic like ampicillin 46 (92%) followed by co-trimoxazole 45 (90%).

Conclusions: Perforation most commonly seen in antral followed by duodenum. Common etiology found out was peptic ulcer disease. In this study, all organisms showed maximum sensitivity to ceftriaxone followed by ciprofloxacin and amikacin. Hence its recommended to administer empirical therapy with combination of cephalosporins/ fluroquinolones/ aminoglycosides and metronidazole.

A prospective comparative study of retrieval of gall bladder using endobag and without endobag in laparoscopic cholecystectomy

2026-05-28T08:40:02+0530

Background: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic gallstone disease. However, intraoperative gallbladder perforation, bile spillage, and gallstone dissemination may increase the risk of port-site infection (PSI). The use of an endobag during specimen retrieval has been proposed to reduce these complications, but its routine necessity remains debated.

Methods: This prospective comparative study included patients undergoing elective laparoscopic cholecystectomy. Participants were randomized into two groups: group A (endobag used for gallbladder retrieval) and group B (direct extraction without endobag). Outcomes assessed included bile spillage, port-site infection, operative time, and postoperative hospital stay. Statistical analysis was performed using appropriate parametric and non-parametric tests, with a p<0.05 considered statistically significant.

Results: Port-site infection occurred significantly less in the endobag group compared to the non-endobag group. Intraoperative bile and stone spillage were also significantly reduced in group A. No statistically significant difference was observed in operative time or duration of hospital stay between the two groups.

Conclusions: The use of an endobag during laparoscopic cholecystectomy significantly reduces port-site infection and intraoperative bile spillage without increasing operative time or hospital stay. Routine use of an endobag is recommended, especially in high-risk patients.

Hyperbilirubinemia as a predictive factor for appendicular perforation in acute appendicitis: a prospective observational study

2026-05-28T08:39:59+0530

Background: Acute appendicitis is one of the most common surgical emergencies worldwide. Delay in diagnosis may lead to complications such as appendicular perforation. Identifying simple laboratory markers that predict perforation may assist in early intervention. Hyperbilirubinemia has been proposed as a potential indicator of complicated appendicitis. The objective was to evaluate the role of elevated serum bilirubin levels as a predictive factor for appendicular perforation in patients with acute appendicitis.

Methods: This prospective observational study was conducted in the Department of General Surgery at Sher‑i‑Kashmir Institute of Medical Sciences (SKIMS), Soura and SKIMS Medical College Hospital, Bemina, Srinagar, India from March 2023 to February 2025. A total of 198 patients with clinically or radiologically diagnosed acute appendicitis were included. Serum bilirubin levels measured at admission were correlated with operative and histopathological findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and odds ratio were calculated.

Results: The majority of patients belonged to the 20–30-year age group (50.5%). Males constituted 53% of the study population. Hyperbilirubinemia (>1.2 mg/dl) was observed in 74.2% of patients. Among patients with appendicular perforation, 90.2% had elevated bilirubin levels compared with 70.1% of patients with uncomplicated appendicitis. Sensitivity, specificity, positive predictive value, negative predictive value and odds ratio were 90.2%, 29.9%, 36.4%, 87.2% and 3.92 respectively.

Conclusion: Hyperbilirubinemia is significantly associated with appendicular perforation in patients with acute appendicitis. Serum bilirubin estimation is a simple, inexpensive and widely available investigation that may aid in early detection of complicated appendicitis when interpreted alongside clinical findings.

Comparative study between excision with primary closure versus Z-plasty in the management of pilonidal sinus in the natal cleft

2026-05-28T08:39:57+0530

Background: Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the sacrococcygeal region with significant morbidity and recurrence. Although excision with primary closure is technically simple and facilitates faster recovery, off-midline techniques such as Z-plasty aim to reduce wound complications and recurrence by altering natal cleft anatomy. This study compares outcomes between primary closure and Z-plasty in the management of pilonidal sinus.

Methods: A randomized controlled study was conducted in the Department of General Surgery, Mahatma Gandhi Medical College and Hospital, Jaipur, from March 2024 to January 2026. Patients aged 18-75 years diagnosed with pilonidal sinus were allocated to excision with primary closure or Z-plasty. Demographic variables, intraoperative parameters, and postoperative outcomes including wound infection, flap necrosis, and recurrence were analyzed. Statistical analysis was performed using SPSS v26.0, with p<0.05 considered significant.

Results: Baseline characteristics were comparable between groups. Operative time was significantly shorter in the primary closure group (49.07±12.79 min) compared to Z-plasty (66.80±14.56 min; p<0.001). Wound length was also significantly less with primary closure (p<0.001), while blood loss was similar (p=0.260). Early postoperative infection was more frequent in the primary closure group, though not statistically significant. No flap necrosis was observed. At 6 months, recurrence occurred in 3.3% of the primary closure group and none in the Z-plasty group (p=1.000).

Conclusions: Both techniques are safe and effective for sacrococcygeal pilonidal sinus. Primary closure offers shorter operative time, whereas Z-plasty shows a favorable trend toward reduced postoperative infection and recurrence. Procedure selection should be individualized based on patient and surgical factors.

Effect of routine abdominal drainage on postoperative pneumoperitoneum induced pain after elective laparoscopic cholecystectomy: a randomised controlled trial

2026-05-28T08:39:45+0530

Background: Postoperative pain following laparoscopic cholecystectomy remains a clinical challenge despite the minimally invasive nature of the procedure. Residual pneumoperitoneum causes diaphragmatic irritation and phrenic nerve stimulation, causing referred shoulder pain affecting patient recovery. Various strategies have been proposed to address this problem, including routine abdominal drainage to facilitate carbon dioxide evacuation and sub - diaphragmatic instillation of local anesthetic agents. However, the comparative effectiveness of these two approaches remains inadequately investigated, with conflicting evidence in existing literature regarding their relative benefits.

Methods: This prospective randomized comparative study was conducted over 18 months. 46 patients undergoing elective laparoscopic cholecystectomy were randomly allocated into two equal groups. The study group received sub hepatic abdominal drainage, while the control group received sub-diaphragmatic instillation of local anesthetic agent. Primary outcome was postoperative pain intensity assessed using Visual Analog Scale (VAS) at 3,6,9 and 12 hours post-surgery.

Results: Both groups were comparable in demographic characteristics. VAS scores at 3,6 and 9 hours postoperatively showed no statistically significant differences between groups. However, at 12 hours post-surgery, the study group demonstrated significantly lower pain scores compared to the control group.

Conclusions: Routine abdominal drainage demonstrates statistically significant superiority over sub-diaphragmatic local anesthetic instillation in reducing postoperative pain at 12 hours following elective laparoscopic cholecystectomy, though both interventions show comparable efficacy during the initial 0-9-hour period.

A comparative study of modified Smead-Jones versus conventional continuous method in closure of the linea alba in case of emergency laparotomy

2026-05-28T08:39:31+0530

Background: Wound dehiscence following emergency midline laparotomy is a serious postoperative complication associated with increased morbidity, prolonged hospital stay, and incisional hernia risk. The optimal method for closing the linen alba remains controversial, particularly in contaminated and emergency settings. This study aimed to compare the effectiveness of the modified Smead-Jones technique with that of the conventional continuous closure method in preventing wound dehiscence following emergency laparotomy.

Methods: This single-center, single-blind randomized controlled trial was conducted over one year in a tertiary care hospital. A total of 132 patients who underwent emergency midline laparotomy were randomized in a 1:1 ratio to either modified Smead-Jones closure (Group B) or conventional continuous closure (Group A) of the linea alba. The primary outcome was the incidence of wound dehiscence within 30 postoperative days. Secondary outcomes included surgical site infection, need for secondary suturing, duration of hospital stay, and incisional hernia during the six-month follow-up. Statistical analysis was performed using SPSS version 21.0, with p<0.05 considered significant.

Results: Wound dehiscence occurred significantly more frequently in the conventional closure group than in the modified Smead-Jones group (21.2% vs. 7.5%, p=0.04). The rates of surgical site infection, requirement for secondary suturing, and incisional hernia were also significantly higher in the conventional closure group.

Conclusions: The modified Smead-Jones technique significantly reduced the incidence of wound dehiscence and postoperative complications compared to conventional continuous closure in emergency laparotomy and should be considered a preferred method in high-risk emergency settings.

The utility of the Boey scoring system in predicting postoperative morbidity and mortality in patients with perforative peritonitis

2026-05-28T08:38:13+0530

Background: Perforated peptic ulcer remains a common surgical emergency despite advances in medical therapy. The Boey score-based on duration of perforation >24 hours, preoperative shock, and significant comorbidity-has been proposed as a simple prognostic tool for postoperative outcomes.

Methods: In this prospective observational cohort study conducted over 18 months at a tertiary rural hospital, 46 consecutive patients with confirmed perforated peptic ulcer underwent urgent open repair with primary closure and pedicled omentoplasty. Boey scores (0-3) were calculated at admission, and patients were classified as low risk (0-1) or high risk (2-3). Demographic, clinical, radiographic, operative and postoperative data were recorded. Associations between Boey score components and mortality were analyzed using chi-square/Fisher’s exact tests and multivariate logistic regression. Diagnostic performance was assessed by ROC analysis, sensitivity, specificity, predictive values, and Likelihood ratios (LR).

Results: Forty-six patients (mean age 52.07±15.97 years; 73.9% male) were studied; overall mortality was 13.0% (6/46). Comorbidities were present in 14 (30.4%). Boey scores: 0 (n=13, 28.3%), 1 (n=19, 41.3%), 2 (n=11, 23.9%), 3 (n=3, 6.5%); high scores (2-3) comprised 14 (30.4%). Mortality increased with Boey score (score 2: 27.3%; score 3: 66.7%). Preoperative shock was significantly associated with death (p=0.009); delayed presentation (>24 h) was more frequent among deaths but not significant (p=0.198). Boey score and age were independent predictors; AUC for Boey=0.792 (p=0.022).

Conclusions: The Boey score is a practical and moderately accurate predictor of postoperative mortality in perforated peptic ulcer patients; preoperative shock is the strongest individual predictor, and delayed presentation and comorbidity further increased risk.

Bariatric surgery in the elderly: findings from a community hospital

2026-05-28T08:39:10+0530

Background: Obesity is a significant problem among elderly patients. While bariatric surgery has been shown to be safe and effective for elderly patients in clinical trials, it remains underutilized in this population. The current study examined the safety and efficacy of this bariatric surgery among elderly patients in a real-world hospital setting.

Methods: This retrospective study examined complication rates and percentage weight loss (%WL) up to 12 months following bariatric surgery among patients (n=115) seen at a general medical hospital between 2016-2021. Differences in complications and %WL were compared between elderly (65+ years.) and non-elderly (50-64 years.) patients.

Results: Compared to non-elderly patients, elderly patients had significantly higher rates of specific comorbidities and significantly greater overall disease severity. Nevertheless, similar trends in complication rates and %WL were found between elderly and non-elderly patients. High rates of treatment compliance were observed for the sample overall.

Conclusions: The findings of this study provide support for evidence of clinical trials demonstrating the safety and efficacy of bariatric surgery among elderly patients. Clinical implications and directions for future research are discussed.