Solitary popliteal neurofibroma: an unusual encounter.

Diagnosing a popliteal fossa mass can be intriguing at times, and are not always Baker's cysts, as expected. We present an uncommon case of a young lady who presented with a palpable firm mass in the popliteal fossa with no neurological deficit or compromised distal pulsations. On surgical exploration, it was found to be a well defined, firm mass, closely abutting the neurovascular bundle, which on histopathological study revealed a solitary encapsulated neurofibroma.

Effect of intravenous lignocaine on perioperative stress response and post-surgical ileus in elective open abdominal surgeries: a double-blind randomized controlled trial.

BACKGROUND: Perioperative stress response can be detrimental if excessive and prolonged. Intravenous (i.v.) lignocaine, while being an effective analgesic, has the added benefit of anti-inflammatory activity. This study was done to assess the effect of i.v. lignocaine on operative stress response and post-surgical ileus after elective open abdominal surgeries. METHODS: Patients (n = 134) were randomized into two groups (n = 67 each) to receive an i.v. infusion of lignocaine (group L) or saline (group S) as a bolus of 1.5 mg/kg at intubation followed by an infusion of 1.5 mg/kg/h throughout the surgery until 1 h post-surgery. Total leukocyte count (TLC), C-reactive protein (CRP) and interleukin-6 (IL-6) levels immediately and 24 h after surgery were compared with preoperative levels. Time to first passage of flatus and stools post-operatively was noted. Post-operative pain scores, analgesic requirements, and incidence of post-operative nausea and vomiting (PONV) were assessed in the two groups. RESULTS: Post-operative surge in TLC, CRP and IL-6 was attenuated in group L as compared to group S (P < 0.001, 0.018, <0.001). Time to passage of flatus and stools was earlier in group L (P = 0.04, 0.02). PONV was lesser in group L at 6 and 18 h post-surgery (<0.001, 0.28). Post-operative pain scores and post-operative morphine requirement were significantly less in group L at each point of time post-operatively (P < 0.001, <0.001). CONCLUSION: Perioperative i.v. lignocaine infusion attenuates the operative stress response, provides effective analgesia and reduces the need for opioids post-operatively. Through these effects, it reduces post-operative ileus and the incidence of PONV.

Giant inguinoscrotal hernia--report of a rare case with literature review.

Massive inguinoscrotal hernias extending below the midpoint of the inner thigh, in the standing position constitute giant inguinoscrotal hernias. We report a patient who presented with giant right inguinal hernia with bilateral hydrocele for 25 years. He had no cardiorespiratory illnesses. He was taken up for surgery under general anesthesia after preoperative respiratory exercises. Sliding hernia with entire greater omentum, small bowel, and appendix as contents was identified. Meshplasty after omentectomy with bilateral subtotal excision of sac, right orchidectomy, and scrotoplasty were done. Giant inguinoscrotal hernias pose significant problems while replacing bowel contents because of the increase in intraabdominal and intrathoracic pressures. Recurrence is another complication seen after successful surgical management. Various techniques such as preoperative pneumoperitoneum, debulking abdominal contents with extensive bowel resections, or omentectomy and phrenectomy have been tried. Postoperative elective ventilation is also needed in many cases. We describe simple reduction with omentectomy as a viable technique in this patient. He did not need elective ventilation due to preoperative respiratory exercises and preparation and review of the literature.

Carcinoma cecum presenting as right gluteal abscess through inferior lumbar triangle pathway--report of a rare case.

Gluteal abscess commonly follows intramuscular injections with contaminated needles. Carcinoma cecum is known to present with pericolic abscess due to microperforations and may rupture intraperitoneally. Gluteal abscess secondary to perforated carcinoma cecum with pericolic abscess is extremely uncommon. A 50-year-old woman who was receiving intramuscular iron injections for anemia presented with a 10×10-cm abscess in the right gluteal region and a vague mass in the right iliac fossa. After investigations, a diagnosis of perforated carcinoma cecum with pericolic abscess tracking into the right gluteal region was made, and incision and drainage were done. Fine-needle aspiration cytology from the cecal growth revealed adenocarcinoma. Unfortunately, the patient was not willing to undergo definitive treatment. This case is being reported for its rarity and as an uncommon etiology for a common condition.

Comparison of standard-pressure and low-pressure pneumoperitoneum in laparoscopic cholecystectomy: a double blinded randomized controlled study.

BACKGROUND AND OBJECTIVE: With the safety of laparoscopic cholecystectomy (LC) having been established, the current stress is on reducing the postoperative morbidity associated with this procedure. Hence, this study was undertaken to compare the effect of low-pressure (8 mm Hg) (LPLC) versus standard-pressure (12 mm Hg) (SPLC) pneumoperitoneum on postoperative pain, respiratory and liver functions, the stress response, and the intraoperative surgeon comfort in patients undergoing LC. MATERIALS AND METHODS: Patients undergoing LC (n=43) were randomized into the LPLC (8 mm Hg) group (n=22) and the SPLC (12 mm Hg) group (n=21). Postoperative pain, changes in liver function, peak expiration flow rate, C-reactive protein level, and intraoperative surgeon comfort were assessed. RESULTS: The postoperative pain scores (P=0.003, 0.000, 0.001, and 0.002 at 0, 4, 8, and 24 h), total analgesic requirement (P=0.001), and the number (total and good) of demands for analgesic in the first 24 hours (P=0.002 and 0.001) were lower in the LPLC group. The surgeon comfort in the LPLC group was significantly lesser (P=0.000). The liver function and peak expiration flow rate did not show any significant changes. C-reactive protein levels varied significantly only at 24 hours postoperatively (P=0.001). CONCLUSIONS: The use of low-pressure pneumoperitoneum (8 mm Hg) for LC is associated with a significantly lower postoperative pain. However, the use of this low-pressure pneumoperitoneum can jeopardize the surgeon's comfort.

Solitary tubercular caecal ulcer causing massive lower gastrointestinal bleed: a formidable diagnostic challenge.

Gastrointestinal (GI) haemorrhage is a common surgical emergency accounting for approximately 1% of acute hospital admissions. Lower GI bleed is less common and less severe than upper GI bleed and is usually caused by diverticulosis, neoplasms, angiodysplasia and inflammatory bowel disease. A 51-year-old man presented with massive lower GI bleed. He had no history of tuberculosis. He underwent colonoscopy and an isolated caecal ulcer was noted. Segmental ileocaecal resection was performed and no specific cause was identifiable on histopathology. PCR was performed on this specimen and it was positive for Mycobacterium tuberculosis. This case reports the unusual presentation of tuberculosis as solitary caecal ulcer with massive lower GI bleed and highlights the role of PCR as an adjuvant diagnostic tool for its diagnosis when characteristic histopathological findings are absent.

Gossypiboma presenting as coloduodenal fistula--report of a rare case with review of literature.

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn's disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.

Metachronous multiple primary malignant neoplasms of the stomach and the breast: report of two cases with review of literature.

Multiple primary malignant neoplasm is the occurrence of a second primary malignancy in the same patient within 6 months of the detection of first primary (synchronous), or 6 months or more after primary detection (metachronous). Multiple primary malignant neoplasms are not very frequently encountered in clinical practice. The relative risk for a second primary malignancy increases by 1.111-fold every month from the detection of the first primary malignancy in any individual. We present 2 patients treated for carcinoma of the breast who developed a metachronous primary malignancy in the stomach to highlight the rare occurrence of multiple primary malignant neoplasms. These tumors were histologically dissimilar, with distinct immunohistochemical parameters. The importance lies in carefully identifying the second primary malignancies, not dismissing them as metastases, and treating them accordingly.

Comparison of intravenous and intraperitoneal lignocaine for pain relief following laparoscopic cholecystectomy: a double-blind, randomized, clinical trial.

BACKGROUND: Laparoscopic cholecystectomy (LC) is increasingly being performed as a day-care surgery. Intraperitoneal (IP) instillation of lignocaine has been proved to provide pain relief following LC. Of late, there is an increased interest in using intravenous (IV) lignocaine to provide pain relief following LC. There are no studies in the existing literature as to which form of administration is more effective for pain relief. Hence, this study has been undertaken. METHODS: Patients (n = 50) undergoing LC for symptomatic cholelithiasis were randomized into two groups (n = 25 each) to receive IV 2 % lignocaine from induction until 1 h after surgery or IP instillation of 0.2 % lignocaine in the gallbladder fossa after removal of gallbladder. Postoperative analgesic requirement, pain scores, time to return of bowel activity, and stress response were assessed. RESULTS: The mean total morphine requirement (p = 0.001), median VAS, first analgesic requirement time (p < 0.001), and total PCA demands (p < 0.001) during the 24-h period were statistically significantly less in the IV group compared with the IP group. Return of bowel activity was earlier in the IV group, and it was statistically significant (p < 0.001). However, stress response, respiratory function, and postoperative nausea and vomiting were not significant statistically among the two groups. CONCLUSIONS: IV lignocaine is superior to IP lignocaine in providing pain relief following LC. IV lignocaine has an added advantage of bringing about the early return of bowel activity, which will further facilitate surgeons to perform LC as a day-care procedure.

Intra-abdominal melioidosis masquerading as a tubercular abdomen: report of a rare case and literature review.

BACKGROUND: Melioidosis, caused by Burkholderia pseudomallei, an important human pathogen in tropical regions, has protean multi-system clinical manifestations. METHODS: Case report and review of pertinent English-language literature. RESULTS: A 33-year-old male, who had been treated for pulmonary tuberculosis and multiple splenic abscesses four years previously, presented with a five-day history of acute-onset high-grade fever, abdominal pain and distension, and dyspnea. Laparotomy and drainage was done for paraumbilical abdominal wall abscess. Omentectomy was performed because the omentum was infarcted and studded with tubercles. Pus culture was positive for B. pseudomallei. The patient developed septic shock and succumbed on the fifth day after surgery. CONCLUSION: This report emphasizes an unusual presentation of melioidosis and the diagnostic challenge posed by its clinical similarity to tuberculosis.

Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy.

BACKGROUND AND OBJECTIVE: As thyroid surgery is being performed as an ambulatory procedure, recent studies concerning post thyroidectomy analgesia have focused on regional techniques such as bilateral superficial cervical plexus block (BSCPB) and bilateral combined superficial and deep cervical plexus block. But, data regarding the efficacy of BSCPB are controversial. Hence we compared the efficacy of BSCPB with 0.25% bupivacaine with and without clonidine in thyroidectomy, as preventative analgesia. METHODS: Patients (n = 60) undergoing thyroidectomy were randomized into 3 groups (n = 20 each) to receive BSCPB using 15 mL of 0.25% bupivacaine (group B) or 0.25% bupivacaine with 1 µg/kg clonidine (group BC) or 0.9% normal saline (group S) on each side after induction. Intraoperative (fentanyl) and postoperative (morphine) analgesic requirements were assessed. Postoperative pain scores, nausea, vomiting, and sedation were assessed for 24 hours. RESULTS: Intraoperative fentanyl requirement was significantly lesser in groups B and BC (P = 0.012). Postoperative pain scores were significantly lower in group BC (compared to S) at 2 (P = 0.002), 4 (P = 0.016), and 8 (P = 0.012) hours. First analgesic requirement time (min) was significantly higher in groups B and BC (P = 0.002), and postoperative morphine requirement was significantly lower in groups B and BC (P = 0.001). Incidence of postoperative vomiting was significantly reduced in group BC (P = 0.022). CONCLUSION: BSCPB with 0.25% bupivacaine with or without clonidine is effective in reducing both intraoperative and postoperative pain and analgesic requirements in thyroidectomy, and adding clonidine to bupivacaine reduces postoperative vomiting.

Clear liquid diet vs soft diet as the initial meal in patients with mild acute pancreatitis: a randomized interventional trial.

BACKGROUND: Patients recovering from mild acute pancreatitis are usually started on a liquid diet and advanced to a solid diet. Evidence suggests a soft diet as the initial meal is tolerated well by such patients. However, the results are controversial. OBJECTIVES: To assess the safety of starting an early soft diet compared with a liquid diet in patients with mild acute pancreatitis as the initial meal. METHODS: We randomized 60 patients with mild acute pancreatitis into 2 groups to receive either a clear liquid diet (CLD) or a soft diet (SD) as the initial meal, and parameters such as tolerance to diet, recurrence of pain, length of hospitalization (LOH), need to stop feeding, post-refeeding length of hospitalization (PRLOH), and postdischarge readmission rate within 30 days were analyzed. RESULTS: The demographic and baseline parameters (amylase, total leucocyte count, Balthazar score) in the 2 groups were comparable. Patients in both groups tolerated the diet well except 1 patient in the SD group, who developed vomiting and diarrhea, not severe enough to stop feeding. LOH and PRLOH were significantly lower in the SD group (4.23 ± 2.08 and 1.96 ± 1.63 days, P < .0001) compared with the CLD group (6.91 ± 2.43 and 4.10 ± 1.64 days, P < .0001). PRLOH in the SD group was 2.14 days less when compared with the CLD group. CONCLUSION: In patients with mild acute pancreatitis, a soft diet as the initial meal is well tolerated and leads to a shorter total length of hospitalization.