An Epiphrenic Diverticulum with Previous Perforation Excised Laparoscopically.

An epiphrenic diverticulum (ED) is a rare pseudodiverticulum commonly located at the lower end of the oesophagus. Surgical treatment is only required in patients with worsening dysphagia or repeated chest infection due to microaspirations, and most patients are now treated with minimally invasive surgery (MIS) using the laparoscopic or thoracoscopic approach. Laparoscopic surgery is considered difficult in the presence of previous perforation of the diverticula owing to the intraperitoneal and mediastinal adhesions and is associated with an increased incidence of complications. We were able to perform a laparoscopic transhiatal resection safely on a patient who had a large ED with a wide neck and dense abdominal and mediastinal adhesions due to previous localized perforation.

The Role of Palliative Surgery in the Management of Acute Intestinal Obstruction Secondary to Peritoneal Carcinomatosis.

Introduction: Acute intestinal obstruction secondary to extensive peritoneal carcinomatosis is an end stage event. The role of palliative surgery in these patients is debatable in view of the anticipated severe complications and its doubtful role in achieving adequate palliation. The primary objective of our study was to evaluate the feasibility and ability of patients to resume oral nutrition after palliative surgery for acute intestinal obstruction due to peritoneal carcinomatosis. Patients and Methods: It is an observational study in which we retrospectively reviewed the data from a prospectively maintained clinical database of 40 patients. The predefined pre- and intraoperative variables were obtained. The immediate outcome variables like postoperative complications, length of hospital stay, and mortality were analyzed. The short-term outcomes at 3 months in the form of survival, ability to resume enteral nutrition were analyzed. Results: Among the 40 patients 18 were males and 22 females. Ovarian cancer was the most common primary (27.5%) in the study. Twelve patients had acute intestinal obstruction as their first presentation without any past events and 25 (62.5%) patients had been operated on previously or received adjuvant systemic treatment. The palliative surgical option was technically feasible in 37 (93.5%) patients. The median length of hospitalization for the patients who were discharged was 10 days with a range of 6-18 days. Six (15%) patients died in the postoperative period. Severe post-operative complications were seen in 9 (26.4%) patients. Among the patients (n=34) discharged 26 (76.4%) were alive at 3 months. In those who were alive, 21 (80.7%) of them were on some form of oral nutrition at 3 months. Conclusion: Palliative surgery in patients with acute intestinal obstruction secondary to peritoneal carcinomatosis is feasible with acceptable morbidity and mortality. The enteral nutrition can be restored in the majority of these patients.

Peri-operative outcomes of pancreaticoduodenectomy comparing an isolated Roux loop or single loop for reconstruction: An ambispective observational study.

BACKGROUND: A post-operative pancreatic fistula is a major cause of morbidity and mortality in patients undergoing pancreaticoduodenectomy. We compared two methods of reconstruction of pancreaticojejunal anastomosis, an isolated loop with a single loop, to assess their effects on the incidence and severity of fistula. METHODS: The data was collected in an ambispective manner. The drain fluid was sent for amylase measurement on post-operative day 3 and a fistula was defined and classified according to the 2016 modification of the International Study Group for Pancreatic Surgery definition. The patients were divided into the isolated (Group I) and single (Group II) loop groups and compared for the incidence and severity of clinically relevant fistula along with other parameters. RESULTS: A total of 349 (Group I: 201, Group II: 148) patients were included in the study. The incidence of clinically relevant fistula was comparable (p = 0.206). Grade C fistula was found to be lower in the group I (7 % vs 11.6 %, p = 0.137), in patients with a soft pancreas (8.5 % vs 18.3 %, p = 0.049) and pancreatic duct diameter less than 5 mm (9.8 % vs 17.2 %, p = 0.036). The operative time was lower in Group I than in Group II (438 min vs 478, p < 0.001). CONCLUSION: We found that the incidence of clinically relevant fistula was similar in both the groups but the isolated reconstruction method reduced the incidence of severe fistula. In patients with a smaller pancreatic duct, soft pancreas echotexture and obesity, it provides a safer alternative and can be performed in less time than a single loop reconstruction.

A Case Report of Roundworms Causing Intestinal Obstruction in a Child.

Background. Soil-transmitted helminth (STH) infections are a common global health issue that affects underprivileged communities without adequate access to clean drinking water, sanitation, and hygiene. Ascaris lumbricoides is the main species that infects humans. Among varied presentations, intestinal obstruction is common among children. Early detection of intestinal obstruction due to STH is critical to prevent severe complications. Here, we present the case of a 10-year-old child with acute intestinal obstruction due to roundworms. Case Report. A 10-year-old boy presented to the emergency department with recurrent abdominal pain, distention, and vomiting for three months with signs of peritonitis on examination. CT scan of the abdomen revealed roundworms in the distal ileum and a cocoon formed by adhesions of small bowel loops. Intraoperatively, worm balls were found in the proximal jejunum and ileum, causing small bowel obstruction, and a diseased segment of ileum had to be resected. The worms were removed, and an ileostomy was created. The patient was treated with albendazole and intravenous antibiotics such as ceftriaxone and metronidazole. An early closure of ileostomy was performed after 20 days. Histopathology showed roundworm eggs in the appendix and small bowel mucosa. Discussion. Ascaris lumbricoides infestation is a common cause of intestinal obstruction in children, and early detection is critical for avoiding severe complications. Prompt and appropriate treatment with antihelminthics and antibiotics is necessary to achieve a good outcome. In rare cases, surgical intervention may be required to treat intestinal obstruction caused by STH infections. In conclusion, the prevalence of STH infections highlights the need for public health interventions, such as improving access to clean water, sanitation, and hygiene, and for early detection and treatment to prevent severe complications such as intestinal obstruction.

Preventive hepatology at AIIMS Rishikesh: Delivering comprehensive and integrated care for liver diseases in Northern state of India.

Globally, liver diseases accounts for 4% of all deaths. Annually, over 2 million deaths occur due to preventable causes of chronic liver diseases and liver cancer like fatty liver diseases (alcoholic or non alcoholic) and viral hepatitis B and C. The burden of chronic liver diseases are increasing, and the epidemiology and demographics of people affected by these diseases are changing. Policy changes, vaccination, screening, lifestyle changes and public health awareness is the key to curb down liver disaeses. To achieve the ultimate goal of reducing mortality and linkage to care for those who need specialized care for liver disease, it is vital to have dedicated preventive hepatology clinics in sync with existing liver or gastroenterology clinics at tertary care level.

Synchronous multiple primary neoplasms of the esophagus, rectosigmoid and central nervous system.

INTRODUCTION: Multiple primary neoplasms (MPN) are rare and can affect any system especially the upper aero-digestive system. They can be simultaneous, synchronous or metachronous. Their management depends on the individual organ system affected and simultaneous resection is possible as shown by T. Suzuki. PRESENTATION OF CASE: We encountered a 77-year-old male who had had malena and constipation for 2 months and on investigation was found to have a rectosigmoid and an esophageal adenocarcinoma as well as a calcified lesion in the brain. He underwent surgery for the rectosigmoid growth only (according to the patient's preference) and received chemotherapy. Unfortunately, he developed acute intestinal obstruction after 2 cycles of chemotherapy and died. DISCUSSION: MPNS are defined as presence of two or more histologically distinct tumours in the same individual. It can be synchronous or metachronous. Various factors like genetic and environmental play crucial role in its development. Management of these depends up on the status of the patient, stage of disease. CONCLUSION: MPNS are rare but their rising trend suggests it should be kept in mind while working up a patient with any malignancy.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations.

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Preventive hepatology: An ounce of prevention or pounds of cure to curb liver diseases.

Liver diseases are now the leading cause of both morbidity and mortality profile globally with rising trends due to unhealthy lifestyle. Most of the liver diseases are preventable. Scientific evidences have well supported and documented that almost 90 percent of all major liver diseases are either the manifestations of asymptomatic hepatitis virus infections or poor lifestyle choices leading to accumulation of fat in liver that could be detected even before they present themselves as chronic liver diseases. Understanding liver diseases as a preventable disease and practising necessary preventive measures will help in lowering the risks of various types of liver diseases as well as liver cancer.

Cystic lesions of the adrenal gland.

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively.

Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management.

Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.

Obstructing primary squamous cell carcinoma of caecum: A case report.

Squamous cell carcinoma (SCC) of the colon is a rare malignancy and usually a pathological surprise. Clinical presentation is usually very similar to adeno carcinoma variety. We report a case of a 56 year old male with primary SCC of caecum presenting as small bowel obstruction and managed with surgery and adjuvant chemotherapy. It was labelled as primary SCC after extensive search for other primary malignant SCC in body with possible metastasis to caecum. Due to rarity of the disease and lack of literature standardized protocols for neo-adjuvant and adjuvant therapy are not available.

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

BACKGROUND: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. PATIENTS AND METHODS: We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. RESULTS: A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) - the proportion increased significantly from 23% in 1996-2004 to 51.6% in 2013-2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). CONCLUSION: The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

Whipple's Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience.

INTRODUCTION: Whipple's pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple's PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child's A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child's B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. CONCLUSION: Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple's PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Single stage repair of anorectal malformation with rectovestibular fistula in adult.

Anorectal malformations are a wide spectrum of disorders, affecting both genders and rare adult presentation as with increased knowledge and advancements, the majority of cases are diagnosed and rectified at birth. This case is a classic example of delayed presentation caused by illiteracy and a lack of adequate health care in rural locations and highlights the uniqueness of this disease, presentation in adult age group and its management and effect on patient psychology and mental health. Because all low anorectal abnormalities can be treated in a single stage, neonatal assessment at birth and early referral to advanced health care centres are critical, with anterior or posterior sagittal anorectoplasty performed by the age of six months. Concerning the anomaly, parent education is an important aspect of patient care.

Native oesophageal mucocoele: A rare complication of double exclusion of oesophagus.

INTRODUCTION AND IMPORTANCE: Native oesophageal mucocoele usually follows bipolar exclusion of oesophagus for various reasons and is very rare in literature. Though mostly asymptomatic, its symptoms can be divided into 3 groups - Compressive, Infective and fistulizing symptoms. The management options described in the literature are percutaneous drainage, chemical ablation, esophagectomy and internal drainage using Roux-en-Y reconstruction. CASE REPORT: A 40 year old female, presented with complaints of dysphagia, weight loss and chest pain for 6 month. She had history of retrosternal gastric pull-up for oesophageal stricture following corrosive injury. On evaluation with CT chest, there was a well-defined fluid attenuated tubular elongated lesion in the mediastinum in the region of oesophagus which was non-opacified with oral contrast and a diagnosis of giant oesophageal mucocoele was made. She underwent internal drainage of mucocoele by roux-en-Y esophagojejunostomy with placement of transanastomotic drain and discharged with an uneventful recovery with the trans-anastomotic drain in situ, which was removed on outpatient basis. Now she is asymptomatic in the subsequent follow up. CLINICAL DISCUSSION AND CONCLUSION: Though rare, mucocoele of oesophagus can lead to life threatening complication like respiratory distress, sepsis. Its diagnosis requires high index of suspicion and CT chest is helpful. Management options depend upon nutritional status of the patient and associated co-morbidities. Esophagectomy is the definitive form of treatment but not always possible and other options can be internal or percutaneous drainage.

Ectopic gall bladder: A case report.

Ectopic gall bladder under the left lobe of liver is a rare congenital anomaly of the position of gall bladder, which is mostly detected during surgery and causes technical difficulty at the time of operation. We operated a 64-year-old male who presented with gall stone disease and pre-operative ultrasound did not report any abnormality in position. On laparoscopy, it was found to be attached on the left side of falciform ligament under segment III. It was a true ectopic gall bladder without situs inversus. Early division of the falciform ligament and a careful and complete dissection of the gall bladder are advocated before clipping the cystic artery and duct to avoid complications. The present case report discusses about this rare anomaly and the available literature on the subject.

Spectrum of presentation in primary anorectal malignant melanoma and its management.

The article presents a series of four patients with primary anorectal melanoma presenting to our institute between 2016 and 2021. The primary objective of the series is to give an overview of the variable presentation of this rare entity from a high-volume colorectal tertiary care centre in a developing country. The patients ranged in age from 55 to 73 years and were mostly women (except one). The clinical presentation varied from bleeding per rectum to tenesmus and mucus in stools, overlapping with those of inflammatory bowel disease and primary anorectal adenocarcinoma. All patients were treated with surgery (laparoscopic or open), ranging from local excision to abdominoperineal resection. All our patients had a good outcome after surgery with no mortality at 30 or 90 days after surgery. The article aims to present a comprehensive overview of the various options of management with evidence from the surgical literature.