Effect of Trendelenburg's Operation With Subfascial Ligation of Perforators in Clinical Improvement and Quality of Life Among Patients With Varicose Veins.

Background Assessing patients' quality of life has received increasing attention, mainly because questions have been raised regarding the direct benefits of the treatment provided. Hence, clinical outcomes and quality of life must be measured after chronic venous disease treatment. The primary objective of the study was to assess the improvement in clinical outcome and improvement in quality of life using the revised venous clinical severity score and chronic venous insufficiency questionnaire-14, respectively, in patients with varicose veins undergoing Trendelenburg's surgery and subfascial ligation of perforators. The secondary objective was to identify the relationship between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. Method The present study is a single-center, prospective cohort study to assess the clinical improvement and quality of life in patients with varicose veins undergoing Trendelenburg surgery and subfascial ligation of perforators. All the study participants were evaluated preoperatively with the clinical, etiological, anatomical, and pathophysiological stage of the disease, revised venous clinical severity score for the clinical severity, and the chronic venous insufficiency questionnaire-14 questionnaire for the quality of life. The study participants were reviewed 90 days after surgery and reassessed for clinical severity and quality of life, both scores. Results Of the 87 screened varicose vein patients, 52 were included in the study. However, one patient was lost to follow-up. There were 38 (74.5%) males and 13 (25.5%) females. There was a significant difference in the preoperative and postoperative mean revised venous clinical severity score of the C3, C4, and C6 stages of the disease (p-value = <0.01). There was a significant difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score in C3, C4, and C6 (p-value = <0.01). There was a significant difference in the median preoperative and postoperative revised venous clinical severity score (p-value = <0.01). There was a considerable difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score (p-value = <0.01). The correlation coefficient between the preoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.26 (p-value = 0.58), and the correlation coefficient between the postoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.42 (p-value = <0.01).  Conclusion Patients undergoing Trendelenburg's surgery and subfascial ligation of perforators for varicose veins significantly improved the clinical severity and quality of life. There was significant improvement among the overall revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score after surgery among the different clinical classes. There was no preoperative correlation between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. However, there was a significant correlation between the postoperative revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score.

Duodeno-duodenal intussusception presenting as upper gastrointestinal bleed.

Duodeno-duodenal intussusception (DDI) is the type of intestinal intussusception in which a segment of the duodenum invaginates into the next part of the duodenum. We present a case of a male patient in his 50s presenting with right upper abdominal pain with multiple episodes of vomiting and a history of melena for 1 month. Imaging studies showed the presence of DDI without apparent growth. The patient underwent upper gastrointestinal endoscopy, which showed a doubtful growth in the duodenum, and the biopsy, was suggestive of adenocarcinoma. The patient underwent Whipple's procedure, and postoperative histology was diagnostic of Brunner's gland adenoma. The patient improved well without any complications.

Small Cell Carcinoma of the Gallbladder.

Primary neuroendocrine carcinoma of the gallbladder (GB) is a rare, highly dismal lethal disease with a fatal prognosis. A 45-year-old female presented with right upper abdomen pain and multiple vomiting episodes. Imaging studies showed diffuse thickening of the wall of the GB with locoregional invasion into the nearby structures with extensive abdominal lymph node metastasis and arteriovenous encasements. Ultrasound-guided fine-needle aspiration was done, which was diagnostic of small cell carcinoma of the GB. The patient was planned for palliative chemotherapy. A small cell variant of neuroendocrine carcinoma of the GB is a rare entity with a moribund lethality associated with it. Patients are diagnosed in advanced stages with not many treatment modalities to offer. Usually, patients are treated with palliative chemotherapy.

A Breast Imaging Case of Steatocystoma Multiplex: A Rare Condition Involving Multiple Anatomic Regions.

Steatocystoma multiplex is an uncommon disease consisting of multiple cysts erupting over the chest, arms, axilla, and neck. It is of unknown incidence and can occur as a spontaneous mutation or inherited in an autosomal dominant pattern. A 47-year-old female with a past medical history only significant for multiple skin infections presented for a routine mammogram. Her imaging showed multiple circumscribed oil cysts. When contacted regarding the results, the patient said she has noticed multiple cysts presenting on her inner arms, chest, and trunk, of which one would occasionally exsanguinate oily material. She denies any other associated symptoms and says that she is the only member of her family to have these symptoms. The patient was informed of her diagnosis and requested to follow up with her primary care physician to monitor her symptoms. In summary, steatocystoma multiplex is a rare benign condition that can present similarly to a variety of other pathologies. It is important to note the unique clinical features of steatocystoma multiplex in order to prevent unnecessary and costly workup for patients who have this benign condition.

Outcomes of Patients With Acute Limb Ischemia in Patients With COVID-19: A Systemic Review and Meta-Analysis.

A systemic review and meta-analysis of perioperative outcomes of acute limb ischemia (ALI) in patients with and without coronavirus disease-2019 (COVID-19) to determine the outcomes of ALI and compare the outcomes in patients with and without COVID-19 infection. A literature search of the Medline, Science Direct and Cochrane Library was performed from inception to July 15, 2021. Studies involving ALI in patients with COVID-19 were searched through three electronic databases. The endpoints include limb salvage, re-thrombosis, and mortality, and these outcomes were compared between patients with and without COVID-19 infection and type of management. The primary outcome was early limb salvage (till the patient was discharged from the hospital). The other outcomes assessed were re-thrombosis and mortality. These outcomes were compared between patients with and without COVID-19 infection and the type of management. Pooled estimates were presented as odds ratios (ORs) using a random or fixed effect model based on the results of the chi-square test and calculation of I2. Comparing the ALI outcomes in patients with and without COVID-19 infection, there was no significant difference in limb salvage rate (OR=0.26, 95% CI:0.02-3.09), but there was a significantly higher re-thrombosis (OR=2.65, 95% CI:1.34-5.23) and mortality rate (OR=4.71, 95% CI:1.11-19.99) in patients with COVID-19 infection. On comparing outcomes based on management, intervention group, and anticoagulant alone group, no significant difference was noted concerning limb salvage (OR=1.40, 95% CI:0.27-7.13) and mortality rates (OR=0.2, 95% CI:0.04-1.07). This meta-analysis demonstrates a higher re-thrombosis and mortality in ALI patients with COVID-19 infection when compared to patients without COVID-19 but with similar limb salvage.

A Rare Case of Kissing Gastric Ulcers Secondary to Non-steroidal Anti-inflammatory Drug (NSAID) Intake.

Peptic ulcer disease is a heterogeneous disease caused by the imbalance between mucosal protective and aggressive factors. Such ulcers are common in the anterior wall of the duodenum and gastric antrum. Kissing ulcers, although commonly reported in the duodenum, are rarely seen in the stomach. We present a rare case of an 85-year-old lady who had an index presentation of sudden onset hematemesis following ibuprofen intake. Endoscopy revealed kissing gastric ulcers, which are extremely rare secondary to non-steroidal anti-inflammatory drugs. She had complete healing after treatment with proton pump inhibitors.

Solitary lower limb cutaneous metastasis in a case of esophageal adenocarcinoma: a rare presentation.

Esophageal cancer is the ninth most common cancer all over the world and is sixth in the list of cancer-related mortality. Here in this report, we present an elderly male with solitary subcutaneous metastasis to right thigh 2 years following esophagectomy for esophageal adenocarcinoma. Operative notes revealed inadequate margins on frozen section analysis during initial resection, which were subsequently revised. Postoperative histopathology showed ypT3N0M0 Grade 3 mucin-secreting adenocarcinoma. A wedge biopsy from the thigh growth revealed metastatic mucinous adenocarcinoma. Positron Emission Tomography (PET) was done, which showed a higher tracer uptake in the ulcero-proliferative lesion arising from the subcutaneous plane in the right thigh with no evidence of any other metastasis or recurrence at the primary site. As the reported incidence of distant unexpected metastases is growing, careful physical examination with a preoperative PET-CT is indispensable. Further knowledge on options on treatment of such isolated cutaneous metastasis needs to be studied by the scientific community.

Co-infection of intestinal tuberculosis and mucormycosis in a patient with Down syndrome: a unique case report with literature review.

Mucormycosis represents several unusual opportunistic infection caused by saprophytic aseptate fungi. There is a recent rise in cases of mucormycosis due to an increase in diabetic and immunodeficient patients like patients on long-term steroids, immunomodulators due to organ transplantation, malignancies, mainly haematological malignancies, and autoimmunity. Anatomically, mucormycosis can be localised most commonly as rhino-orbito-cerebral followed by pulmonary, disseminated, cutaneous and gastrointestinal, rarest being small intestinal. Patients with Down syndrome are immunodeficient due to their impaired immune response. Disseminated tuberculosis is also common in immunodeficient patients. We report a rare case of small intestinal mucormycosis in a patient with Down syndrome with coexisting intestinal tuberculosis. Due to the invasiveness of mucormycosis, the patient succumbed to death despite providing aggressive surgical debridement and medical management.

Gastric Carcinoma: An Unexpected Complication of Loop Gastro-Jejunostomy Done in Childhood.

Gastric adenocarcinoma is the fifth most common cancer worldwide and the third leading cause of death. The major risk factors include Helicobacter pylori infection, genetic factors, environmental factors, and atrophic gastritis. Gastric remnant cancer is gastric carcinoma that develops in the remnant stomach more than five years after distal gastrectomy for benign disease, incidence ranging from 1% to 8%. However, gastric carcinoma after loop gastro-jejunostomy without gastric resection for benign etiology is rare. We report a case of a 45-year-old lady with gastro-jejunostomy without gastric resection done in childhood, presenting with adenocarcinoma at the anastomotic site after 35 years.

Perforated Blind Pouch: An Unusual Late Complication Following Lateral Anastomosis After a Right Hemicolectomy.

Blind loop syndrome (BLS) is a well-recognized delayed complication in small bowel strictures, stenosis, fistulas, diverticula, or post-gastrectomy afferent loop syndrome. However, due to its delayed presentation, BLS after side-to-side bowel anastomosis is inadequately reported. The vicious cycle of the blind loop is due to bacterial overgrowth, resulting in diarrhea, weight loss, malnutrition, and rarely mucosal erosion, bleeding, and perforation peritonitis. Diagnosis of BLS requires knowledge of previous surgery performed, a high level of clinical suspicion, and experienced radiological abilities. In this case report, we present the clinico-radiological profile of a 54-year-old diabetic patient with a perforated blind ileal pouch occurring four years after a right hemicolectomy with side-to-side ileo-transverse anastomosis.

Strangulated Epigastric Hernia: A Rare Occurrence.

An epigastric hernia is a rare type of abdominal hernia, described in the literature mostly as small, containing only preperitoneal fat. A large true epigastric hernia with herniation of the abdominal viscera is even rarer. Only a few case reports have given an account of strangulation in such an epigastric hernia. This case report describes a middle-aged, morbidly obese man with a big epigastric hernia presenting with incarceration and acute abdominal pain. Emergency surgical exploration revealed a 7 cm midline defect in the rectus sheath and a 30 cm segment of the jejunum and a 6 cm segment of the transverse colon were gangrenous. The gangrenous bowel segments were resected, and an end-to-end jejuno-jejunal and colo-colic anastomosis were done. The patient had an uneventful postoperative recovery.

Swiss Cheese Loin: A Rare Initial Presentation of Pott's Spine.

Spinal tuberculosis (TB) is the most common form of skeletal TB with an exceedingly diverse set of clinical presentations. Most often, there is a slow onset of the disease with patients presenting only with back pain. Although some patients can present later with neurological deficits or with compressive symptoms of an accompanying cold abscess, an initial presentation of a spontaneous cutaneous fistulization of a paraspinal abscess is rare. We present the case of a young boy with such a primary presentation, with no other common symptoms of spinal TB. He was treated with ultrasound-guided percutaneous drainage of the paraspinal abscess and a multidrug anti-tubercular chemotherapy regimen.

Antegrade Jejunojejunal Intussusception: An Unusual Complication Following Feeding Jejunostomy.

Feeding jejunostomy (FJ) is a simple surgical procedure for enteral nutrition. But it can develop complications that may require re-exploration and can be life-threatening. Common complications include mechanical ones such as tube migration or dislocation, infection, gastrointestinal symptoms and fluid and electrolyte imbalances. However, intussusception is a rare complication of FJ. A 54-year-old gentleman underwent a D2 subtotal gastrectomy with Roux-en-Y gastrojejunostomy with FJ. On the sixth postoperative day, he developed severe colicky pain associated with abdominal distension and bilious vomiting. Ultrasonography and computed tomography revealed a 10-cm long jejunojejunal intussusception with the FJ tube at the center of the intussusception with proximal jejunal loops' distension. The patient was taken up for a re-exploratory laparotomy with manual reduction of the intussusception and a new FJ insertion distal to the previous enterotomy site. The patient had an uneventful postoperative recovery.

Anomalous Pancreaticobiliary Duct Junction in an Unusual Case of Synchronous Gallbladder and Bile Duct Malignancy.

Synchronous malignancies involving the gallbladder and the bile duct are exceedingly rare. Moreover, their association with anomalous pancreaticobiliary duct junction (APBDJ) has been reported mostly from the Far Eastern countries. Over time, many studies have suggested the definite risk of malignancy attributable to the 'carcinogenic anatomical configuration' of the long common biliopancreatic channel, allowing reflux of pancreatic juices in the biliary tract. In this report, we present a case of an elderly man from South India who was initially diagnosed with synchronous gall bladder with bile duct malignancy; the patient turned out to have an APBDJ on further evaluation.

Left Gastric Artery Pseudoaneurysm Due to Pancreatitis.

Acute or chronic pancreatitis can cause pseudoaneurysms of visceral arteries. The left gastric artery (LGA) is the least common visceral artery being affected. Here, we report a case of chronic pancreatitis with a pseudoaneurysm of the LGA. A 42-year-old male, a chronic alcoholic, and smoker, presented with abdominal pain, haematemesis, and melena. Diagnosis of pseudoaneurysm of LGA aneurysm was confirmed by computed tomography abdomen. The endovascular coil embolization was done successfully, following which the patient had an uneventful recovery.

A Rare Case of Spontaneous Splenic Rupture as the Index Presentation of Chronic Myeloid Leukemia.

Splenic injury is usually caused by blunt trauma to the abdomen. Very rarely, spontaneous rupture can occur in patients with splenomegaly due to various underlying pathological conditions such as hematological, neoplastic, inflammatory, and infectious diseases. Here, we report the case of a 48-year-old gentleman who presented to the emergency department with sudden-onset pain in the abdomen and hypotension. Blood investigation revealed anemia and leukocytosis with blast cells on peripheral smear, suggestive of chronic myeloid leukemia (CML) in the chronic phase. Contrast-enhanced computed tomography revealed splenomegaly with grade three splenic laceration and a subcapsular hematoma with hemoperitoneum. Because of persistent hemodynamic instability, despite resuscitation, he underwent emergency splenectomy. The postoperative period was uneventful. Bone marrow biopsy revealed CML in the chronic phase with World Health Organization grade I reticulin fibrosis. Subsequently, he was started on hydroxyurea and discharged for further follow-up with medical oncology.

Inadvertent Bowel Injury Following Repeated Suprapubic Catheterisation in a Patient of Post-Pelvic Radiotherapy.

Suprapubic catheterization (SPC) is one of the standard procedures in urological emergencies. The common complications of SPC include loss of track, hematuria, catheter blockage, and catheter-related infections. However, severe complications like bowel injuries, including intestinal obstructionand perforation, can also occur. We present the case of a 54-year-old lady who had received pelvic radiation 30 years ago for carcinoma cervix. She presented to a secondary-level care center with anuria. On failure of per urethral catheterization, she repeatedly underwent unguided SPC. However, unsatisfied with her recovery, she was brought to our tertiary care center by her relatives. She was found to have inadvertent placement of SPC in the small bowel, which was confirmed preoperatively by ultrasound and CT. Intraoperatively, the SPC catheter was seen inside the terminal ileum causing ileal wall necrosis and a localized feco-purulent collection. Urinary bladder rent was also noted at the site of the earlier SPC. Resection of distal ileum with double barrel ileostomy, followed by primary repair of the bladder wall, was done. Unfortunately, she succumbed to overwhelming sepsis and expired in the postoperative period. This case emphasizes a potential higher risk of life-threatening bowel injury due to SPC insertion in patients with previous pelvic irradiation. Such high-risk cases should be approached with the utmost care, preferably under ultrasound guidance. For safe practice, the British Association of Urological Surgeons' guidelines for SPC insertion should be followed.

Effects of low- and high-pressure carbon dioxide pneumoperitoneum on intracranial pressure during laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic surgeries are a risk factor for raised intracranial **pressure and neurological complications. Even though rare, the consequences may be severe. METHODS: One hundred and one patients of laparoscopic cholecystectomy were enrolled and were randomized into two groups: low-pressure 8 mm Hg (Group A) and high-pressure 14 mm Hg (Group B) carbon dioxide pneumoperitoneum during surgery. Fifty patients were in group A and 51 patients were in group B. Intracranial pressure was measured by measuring the optic nerve sheath diameter (ONSD) using ultrasound examination. Baseline ONSD was recorded followed by ONSD recording at various intervals: at the induction of anesthesia; 30 min, 45 min, at the end of surgery; and 30 min post surgery. RESULTS: The groups were comparable in terms of demographics and comorbidities. The mean age of group A was 45 years and for group B it was 45.75 years. Most common indication for surgery was symptomatic gall stone disease. Baseline ONSD in group A was 0.427 ± 0.0459 mm, whereas it was 0.412 ± 0.0412 mm in group B. There was a significant rise of ONSD (p < 0.05) 30 min after induction of pneumoperitoneum and up to 30 min post anesthesia. In the low-pressure group 7 (14%) patients had a significant rise of ICP, whereas in the high-pressure group 20 (39%) patients had a significant rise of ICP (p < 0.05). CONCLUSIONS: High-pressure pneumoperitoneum causes significant rise in intracranial pressure in comparison to low-pressure pneumoperitoneum during laparoscopic cholecystectomy, which can be monitored by ONSD measurement by ultrasound examination and is totally non-invasive.