Two Different Upper Tract Urological Malignancies on Either Side.

INTRODUCTION: The genitourinary system is a recognized site for multiple primary malignant neoplasms even without syndromic anomalies. However, to the best of our knowledge, a case of upper tract urothelial carcinoma (UTUC) with contralateral renal cell carcinoma (RCC) is not reported in surgical literature so far. Case Presentation. A 52-year-old Sri Lankan male patient was found to have a right lower ureteric tumour and a left renal mass together upon investigating for painless visible hematuria. The right ureteric tumour measured 32 × 22 mm resulting in moderate hydronephrosis and cortical thinning of the right kidney, and the left renal mass measured 43 × 38 mm involving the lower pole. The biopsy of the right ureteric lesion revealed a high-grade transitional cell carcinoma with focal nested pattern and that of the left renal mass revealed a clear cell carcinoma. Right nephroureterectomy followed by a left partial nephrectomy was performed in six weeks' interval. The histology of both the resected specimens confirmed the biopsy findings. Discussion. A high-risk upper tract urothelial carcinoma such as the right ureteric tumour of this patient required a nephroureterectomy which makes the management of the contralateral renal cell carcinoma more complex. An adequate functional renal remnant was ensured after offering oncologically sound surgical treatment for both the malignancies of this patient. CONCLUSION: A UTUC when associated with a contralateral RCC poses challenges in patient management. The preservation of renal excretory function has to be considered as an important determinant in addition to oncologically sound surgical resection when managing complex cases of genitourinary malignancies involving both sides of the upper urinary tract.

Hospital-Based Case Series Analysis of Road Traffic Trauma Patients in Sri Lanka.

Road traffic accidents claim many lives each year worldwide and cause significant disability among survivors. Resulting socioeconomic burden is severe in low- and middle-income countries. Global emphasis currently focuses on trauma education and prevention in addition to improving post-injury care. Sri Lankan government recently made compulsory legislation to improve the safety standards of imported motor vehicles. Such regulations would not directly protect vulnerable road users (VRUs) who form the main bulk of Sri Lankan and South Asian automobile trauma casualties. With the objective of reviewing the management outcome of automobile trauma in order to correlate the potential impact of new legislation on injury prevention, data of all admitted road traffic injury victims were audited for 2 months. Out of 473 eligible cases (332 (70.2%)-males; mean age 37.2 years), there were 14 (3%) fatalities. Of 459 (97%) survivors, 77 (16%) suffered major injuries. Twelve out of 14 (85.7%) fatalities, 64 of 77 (83.1%) survivors with major injuries and 263 of 382 (68.8%) cases of lesser injuries were VRUs (p value = 0.02: chi-square). VRUs had a significantly higher mean Injury Severity Score (ISS) of 10.96 ± 8.43 SD than non-VRUs who had a mean ISS of 8.14 ± 6.04 SD (p = 0.003: t test). Among all survivors, 33/39 (84.6%) with permanent disability, 95/110 (86.4%) with temporary disability and 199/310 (64.2%) with no residual disability were VRUs (p value < 0.0001: chi-square). Of 222 drivers/riders, 45 (20.3%) had consumed alcohol prior to the incident and 20 (9%) were driving without a valid licence. Thirty-four out of 162 (21%) motor bike travellers were not wearing a protecting helmet. Results denote that VRUs suffer significant majority of the fatalities and major injuries after road traffic trauma and to have higher residual temporary/permanent disability among survivors. Recent compulsory motor vehicle safety measures are unlikely to directly protect majority of automobile trauma victims in Sri Lanka. To obtain a higher impact on road traffic injury prevention, main emphasis has to be given to improve the safety standards of VRUs in developing countries.

Histological assessment of cholecystectomy specimens performed for symptomatic cholelithiasis: routine or selective?

Traditionally, all cholecystectomy specimens resected for symptomatic cholelithiasis were sent for histological evaluation. The objectives of such evaluation are to confirm the clinicoradiological diagnosis, identification of unsuspected findings including incidental gallbladder malignancy, audit and research purposes, and quality control issues. Currently, there is a developing trend to consider selective histological evaluation of surgical specimens removed for clinically benign disease. This article discusses the need for routine or selective histopathological evaluation of gallbladder specimens following cholecystectomy. Although several retrospective studies have suggested selective histological evaluation of cholecystectomy specimens performed for symptomatic cholelithiasis, the evidence is not adequate at present to recommend selective histological evaluation globally. However, it may be appropriate to consider selective histological evaluation on a regional basis in areas of extremely low incidence of gallbladder cancer only after unanimous agreement between the governing bodies of surgical and histopathological expertise.

Short-term outcome after resection of neurogenic heterotopic ossification around the hips and elbow following encephalitis.

Heterotopic ossification (HO) is a potential complication following brain or spinal cord injuries and diseases. Post-encephalitis HO is rare, and the number of affected joints is a prognostic predictor. A literature review revealed only a limited number of such cases, with one or two anatomical regions affected in each case. We report the case of a 21-year-old man who developed HO at the peri-articular regions of both hips and the right elbow post encephalitis. He had good functional outcome following excision of the ossific masses. There has not been any recurrence for up to two years from the first surgery. To the best of our knowledge, this is the first such case involving more than two anatomical regions, and the first reported case from Sri Lanka.

An unusual case of adult onset progressive heterotopic ossification suggesting a variant form of fibrodysplasia ossificans progressiva.

Progressive heterotopic ossification (HO) is a rare disease of genetic inheritance. Fibrodysplasia ossificans progressiva (FOP) is an identified debilitating subcategory in which anomalous ossification usually begins in childhood. Congenital big toe anomalies and specific patterns of progression of ossification confirm the classic disease. Adult onset disease is extremely rare. The mechanism of disease progression is still unclear, and there is no consensus on the treatment modalities. We report a 47-year-old man with adult-onset progressive HO around the bilateral pelvic and shoulder girdles and thoracolumbar spine, which suggested a variant form of FOP. Although surgical excision is considered counterproductive in FOP, our patient showed improvement in his shoulder movement following surgery. Other management strategies, including surgery around the hips, indomethacin prophylaxis, irradiation and bisphosphonate therapy, did not improve his range of movement or disease progression.

Therapeutic value and outcome of gastric access loops created during hepaticojejunostomy for iatrogenic bile duct injuries.

BACKGROUND AND PURPOSE: Hepaticojejunostomy is the reconstructive procedure performed for iatrogenic bile duct injuries. Anastomotic site stricture is the most significant complication of this operation. Revision surgery is associated with a significant morbidity and mortality. Creation of access to the anastomotic site facilitates the management of such strictures by minimal access techniques and reduces the need for revision surgery. This retrospective study aims to investigate the technical accessibility, usefulness, morbidity related to and the outcome of hepaticojejunostomy with gastric access loops performed as the treatment for iatrogenic bile duct injuries. METHODOLOGY: Twenty-seven consecutive patients who have undergone hepaticojejunostomy (including three revision surgeries and a re-revision surgery) with gastric access loops from July 2005 to October 2009 were followed up for clinical, biochemical, radiological and endoscopic evidence of anastomotic site occlusion and the need for intervention. Morbidity related to gastric access loops was assessed by dyspepsia disability score. RESULTS: Mean follow up was 35.4 (range 6-61) months. Three patients developed anastomotic strictures at 4, 22 and 5 months after hepaticojejunostomy and had successful endotherapy via the gastric access loop. They remain well at 33rd, 31st and 3rd months, respectively, following intervention. Based on the dyspepsia disability score none of the patients had symptomatic dyspepsia affecting daily activities. CONCLUSIONS: Gastric access loop is accessible and useful for stricture dilation and other endotherapeutic procedures. In the absence of significant symptoms related to bile reflux, gastric access loop could be considered as a useful and safe adjunct in the management of hepaticojejunostomy by surgeons especially in settings with limited facilities and expertise for radiological manipulations.