Clostridioides difficile from intracardiac vegetation.

Extracolonic manifestations by Clostridioides difficile are uncommon. Here, we report a case of monomicrobial C. difficile intracardiac vegetation in a 11-year-old girl with a predisposed heart disease who responded well to the treatment. C. difficile has been isolated from a variety of specimens outside the intestinal tract and is not always associated with gastrointestinal symptoms.

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial.

BACKGROUND: Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP. PATIENTS AND METHODS: Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications. RESULTS: Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention. CONCLUSIONS: Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

Large sternal exostoses presenting as stridor: A surgical and anesthetic challenge.

BACKGROUND AND AIMS: Large osteochondroma arising from chest wall and sternum is uncommon and presentation with airway compression is further uncommon. METHODS: Here we present a case of large chest wall osteochondroma as a part of hereditary multiple exostoses in a 9-year-old boy presented with a history of stridor and shortness of breath. The bony mass of the right chest wall was extending up to a suprasternal notch and compressing the trachea. RESULTS: The case was successfully managed by initial femoro-femoral cardiopulmonary bypass under local anesthesia before the induction of anesthesia to prevent respiratory collapse, followed by debulking surgery was done.

Surgical bypass of superior and inferior mesenteric arteries with Dacron graft in a patient with acute on chronic mesenteric ischaemia with atherosclerotic complete occlusion of the infrarenal aorta.

A 67-year-old male presented to us with symptoms of postprandial abdominal pain for the last 3 months and was not able to take meals for the last month. The computed tomography (CT) angiogram showed complete occlusion in the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) with complete occlusion of infrarenal aorta and bilateral iliac arteries. While waiting for elective surgical mesenteric bypass, patient suddenly developed signs of peritonitis for which emergency surgery was done using a Dacron bifurcated graft 12 × 6 mm size. Inflow was taken from the supra coeliac aorta. At 6 months follow-up, the patient was doing well and the CT angiogram showed a patent graft. In our case, the challenge was from where to take inflow, as the patient's aorta was atherosclerotic and infrarenal aorta was completely occluded, and he was also not suitable for endovascular stenting. So, we decided to take inflow from the supra coeliac aorta and a distally mesenteric bypass was done. Although mesenteric ischaemia has very high morbidity and mortality rates, prompt and well-planned mesenteric bypass surgery can save both bowel and patients life as well.

Successful open surgical repair of large ilio-caval fistula presenting with congestive heart failure.

Ilio-caval arteriovenous fistula is a rare sequel of lumbar disc surgery or penetrating injury. We report a case of 40-year gentleman presenting with symptoms of congestive heart failure and continuous murmur heard over right iliac fossa. His past history was significant for lumbar disc surgery done twice 1 year back. Computed tomography angiogram confirmed a large fistulous communication between right common iliac artery and inferior vena cava. Open surgical repair was performed as the fistula was not well suited for endovascular repair. We successfully managed this case by open surgical ligation of right common iliac artery proximal and distal to fistula and continuity restored with interposition Dacron graft. He was relieved of symptoms and performing well on follow-up.

Extracranial carotid artery pseudoaneurysm due to Mycobacterium tuberculosis.

Mycobacterium tuberculosis is a very rare cause of extracranial carotid artery pseudoaneurysm. A 39-year-old man presented with a rapidly increasing neck mass and hoarseness of voice for 15 days. He was on antitubercular treatment for pulmonary tuberculosis. Computed tomography angiography showed a large pseudoaneurysm of the right common carotid artery. Emergency surgery was performed to excise the pseudoaneurysm sac and repair the artery with a Dacron graft. Postoperative angiography showed normal flow in the carotids and cerebral circulation. Histology of the excised tissue was consistent with a tubercular etiology of the pseudoaneurysm.