The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study.

BACKGROUND: Fistula in ano is always a troublesome condition for the clinician and the patients owing to its complexity, recurrences, and high morbidity since ancient times. There is no gold standard treatment modality to date documented in the literature for complex fistula in ano. MATERIAL AND METHODS: We enrolled 60 consecutive adult patients attending the surgical outpatient department of a tertiary care centre in India, diagnosed with complex fistula in ano. Among them, 20 each in the Ligation of intersphincteric fistula tract (LIFT), Fistulectomy andKsharsutra(Special medicated seton) group were respectively recruited randomly. A prospective observational study was conducted. The primary outcomes were postoperative recurrence and morbidity. Post-operative morbidity is measured in terms of postoperative pain, postoperative bleeding, pus discharge and post-operative incontinence. The result of the study were analysed after 6 months of follow-up by clinical examination at outpatient department and at 18 months follow up done telephonically. RESULTS: At 6 months of follow-up, 2 patients (10%) had a recurrence in the Ligation of intersphincteric fistula tract procedure group, 3 patients (15%) in the fistulectomy group and 6 patients (30%) in Ksharsutra group, however 3(15%), 4(20%) and 9(45%) patients developed recurrence in Ligation of Intersphincteric fistula tract, Fistulectomy and Ksharsutra group respectively at 18 month of follow-up. The differences in the recurrence were not statistically significant.The mean Visual analogue score for postoperative pain after 24 h as well as after 48 h were statistically significant in Ligation of intersphincteric fistula tract versus Ksharsutra group (p < 0.05). The Visual analogue score for post-operative pain was also significant in the Ligation of the intersphincteric fistula tract versus the Fistulectomy group (p < 0.05). The patients treated via Fistulectomy and Ksharsutra had a higher proportion of bleeding (15%) as compared to the Ligation of intersphincteric fistula tract procedure. Postoperative morbidity was statistically significant between the Ligation of intersphincteric fistula tract versus the Ksharsutra and the Ligation of intersphincteric fistula tract versus Fistulectomy. CONCLUSION: Ligation of intersphincteric fistula tract had less postoperative morbidity compared to Fistulectomy and Ksharsutra procedure; although recurrence was less compared to other methods it was statistically not significant.

Migrated K-wire in the urinary bladder not causing symptoms: A rare case report.

INTRODUCTION AND IMPORTANCE: Kirschner wires (K-wires) are commonly used implants in the treatment of bony fracture. The migration of K-wire has been reported in the literature, but such migration into the urinary bladder is extremely rare. PRESENTATION OF CASE: We report a case of an asymptomatic patient with a migrating K-wire in the urinary bladder, who came to our follow-up clinic after treatment of a hip fracture. The patient was absolutely fine but follow-up image showed K-wire in the urinary bladder. In view to prevent further migration and injuries, the laparotomy was planned and wire has been removed under the C-arm image guidance. Postoperative period was uneventful and patient was discharged. CLINICAL DISCUSSION: The aim of reporting this case was to spread the awareness about mandatory follow-up after K-wire placement, its migration, and the recommendation to remove it at earliest. As per my best knowledge, this is the first and unique case of K-wire migration into the urinary bladder, detected on follow-up image without symptoms. CONCLUSION: Bending the end of the K-wires after insertion, the restriction of joint movement, and removal of migrated K-wires at earliest are the key points in a patients with K-wire insertion. The mandatory follow-up in cases of K-wire placement for treatment of bone fracture, and early diagnosis prevent the potentially fatal complications.

Invasive investigation in cases of visceral AVM may be fatal: A rare case report.

INTRODUCTION AND IMPORTANCE: Visceral arteriovenous malformations (AVMs) are extremely rare with only a few cases described in the literature. We have encountered a mesenteric AVM in a 23-year-old girl. Considering the rarity of this entity and diagnostic dilemma, we herein describe a case of mesenteric AVM along with the review of literature. CASE PRESENTATION: A 23-year-old female presented with pain and lump in lower abdomen. During her workup to conclude a final diagnosis, Fine needle aspiration cytology (FNAC) was done. Post FNAC patient went into shock and immediately emergency laparotomy was done. The bleeding mass was resected along with involved gut and anastomosis was done. Histopathology suggested AVM. She was doing well at 2 months of follow up. CLINICAL DISCUSSION: AVM is the rare cause of ischaemic colitis. It can create a diagnostic dilemma with its unusual presentation and its rarity even for both radiologists and surgeons. Usually such malformation reported after trauma or any surgical intervention, but in our case there was no such history of trauma which makes this case more interesting. Invasive investigation is recommended in such condition but needs to be very cautious. As in this index case invasive procedure lead to severe bleeding. Although definitive treatment are embolization and surgery. CONCLUSION: Invasive procedure should be avoided in case of AVM. If angiography is not available its mandatory to keep operating room ready before any invasive procedure.

Astounding Fibro Lipoma of Spermatic Cord: A Diagnostic Dilemma.

BACKGROUND: Fibro lipoma of the spermatic cord is a very rare tumor with few cases reported in literature. Atypical presentation and site of swelling mystifies the diagnosis and creates bewildering situation intraoperatively. Case Summary. A 30-year-old farmer presented with an elastic firm nonreducible, nontender swelling at inguinoscrotal region with positive cough impulse and history of laparoscopic inguinal hernia repair 3 years ago. Ultrasonography of the swelling revealed a heteroechoic lesion of size 7 × 6 centimeter with probable features of lipoma or desmoid. Fine needle aspiration drawn in consideration of the diagnostic dilemma reported a benign lipomatous swelling which on final histopathology turned out to be a fibro lipoma of size 7 × 6 × 5 cm. CONCLUSION: Considering the age and presentation of the patient, it was astonishing. It provided an insight to the occurrence of fibro lipoma even in younger age group which in fact is the first case of its kind as per best of our knowledge. Malignancy should be ruled out in such cases, and complete excision is the treatment of choice.

Mobile caecum as a content in recurrent incisional hernia an incidental finding: A rare case report.

INTRODUCTION: Recurrence in ventral hernia after laparoscopic repair is less as compared to conventional approach. Mobile caecum as a content of ventral hernia is a very rare entity. Standard treatment for mobile cecum is caecopexy using lateral peritoneal flap. CASE REPORT: A 40-year-old obese female, homemaker by occupation with a history of incisional hernia 2 year back and treated with intraperitoneal on lay mesh repair presented with swelling in the left lower abdomen for past 6 months. Radiological investigations revealed defect in left lower anterior abdominal wall with protruding bowel loops. Urgent exploratory Laparotomy revealed mobile segment of ileocecal junction in the hernial sac cavity. Caecopexy for the mobile caecum was done. DISCUSSION: Mobile caecum is due to embryological failure of fusion of right colonic mesentery with lateral peritoneal wall. Pre-operative diagnosis of mobile caecum is difficult to establish unless it presents as caecal volvulus Caecopexy using the lateral peritoneal flap is the standard of care. CONCLUSION: Mobile caecum can surprise the attending surgeon as a content of ventral hernia. Caecopexy using lateral peritoneal flap is the treatment of choice in all with a mobile caecum.

Effective management of a firearm injury with multiple intestinal perforation in a COVID 19 positive patient: A rare case report.

INTRODUCTION: A challenging situation lies in front of every surgeon to perform emergency surgeries in a pandemic scenario. Gunshot injuries in a COVID-19 affected individual increases the chances of post-operative morbidity and mortality. Such cases require multidisciplinary approach with an advanced COVID care for the satisfactory outcome. CASE PRESENTATION: We present a case of 30-year-old male with an alleged history of an accidental fire arm injury. His rapid antigen for COVID was positive. Contrast enhanced computed tomogram (CECT) abdomen was suggestive of multiple bowel injuries. Emergency exploratory laparotomy confirmed multiple bowel perforations with no associated solid organ injury. Perforated sites were sealed by primary repair and loop ileostomy was performed. Patient was discharged on post-operative Day 17 with satisfactory clinical improvement. DISCUSSION: Deleterious effects of COVID-19 has questioned the reliance on health care system across the globe. Pulmonary complications affect the post-operative course in patients undergoing surgery. However not every patient with peri operatively detected COVID-19 will have complicated post-operative course. Managing such patients with perioperative COVID-19 is an uphill task. Hemodynamic instability and clinical signs of peritonitis mandates the operative management. Multidisciplinary approach with advanced post-operative COVID care is required for satisfactory outcome. CONCLUSION: Management of patients undergoing emergency procedure with peri-operative COVID 19 is challenging for the attending surgeon. Consider all surgical emergencies as COVID positive unless proved otherwise. Multidisciplinary approach for management of COVID-19 infection along with good post-operative care is required.

An unusual vaginal injury in a young primigravida patient: A rare case report.

INTRODUCTION: Assault with iron made belan causing penetration of it into vagina and perforation of posterior fornix is extremely rare. The commonly used weapon in assault are knife, wood, iron stick, wire, bomb or gun and most commonly affected body parts are cheeck, throat, back, abdomen, chest wall and extremities. PRESENTATION OF CASE: We report a case of iron made belan penetrated into vagina with posterior fornix perforation and mesenteric tear in a 30 years old lady with history of pregnancy of 14 weeks. She was haemodynamically unstable at the time of presentation. She was treated with advanced trauma life support Protocol (ATLS), taken to operation room where iron made belan was removed with repair of posterior fornix and mesentery was done. DISCUSSION: Assault to genital organ in female is not uncommon. In present case the offender used the metallic iron made belan for assault which is the house hold material in India. In such situation high degree of suspicion and diagnostic modality are helpful to save the golden hour of patient and save the life of patients. General principles of trauma management is really very helpful to save the life threatening conditions. Urgent exploratory laparotomy with control of bleeding and repair of damaged structures are the cornerstone steps to manage such cases. CONCLUSION: Assault with iron made belan and its penetration inside vagina is extremely rare mode of injury. Timely intervention, concept of ATLS and definitive surgical interventions are the key steps in managing such patient.

Fetus in fetu in an adult woman.

Fetus in fetu (FIF) is an extremely rare condition in which malformed fetus is found most commonly in the retroperitoneum of living twin. It occurs in about 1 in 500 000 live births and less than 200 cases have been reported in medical literature. We report FIF in a 17-year-old woman unlike other cases which were usually detected in early age and in male gender. This is the eighth case of adult FIF and the first case of FIF in adult woman worldwide. Preoperative diagnosis of FIF on CT was made and planned for exploratory laparotomy. The excised malformed fetus in a sac was proven as FIF on the basis of histopathological examination. In view to avoid such late presentation, early detection of FIF with radiological imaging in clinically suspected case is recommended. Surgical excision is the ideal treatment even teratoma is the differential diagnosis.

Intrapericardial gossypiboma: Rare cause of intrathoracic mass.

INTRODUCTION: Gossypiboma is a retained surgical sponge inside our body after surgical intervention. It is most commonly found in abdominal cavity. Its occurrence in thoracic cavity as intrapericardial gossypiboma is extremely rare. PRESENTATION OF CASE: We present a 25 year old male with complaint of chest pain for 1 year. He had a history of total correction of Tetralogy of fallot 14 years back, at another hospital. On clinical examination and investigations including contrast enhanced computed tomography (CECT) of thorax; diagnosis of right anterior mediastinal mass of germ cell tumor was made and planned for thoracotomy. On exploration, the gauze piece of 31 cm was removed from the pericardial mass and a final diagnosis of gossypiboma was made. DISCUSSION: Although gossypibomas are commonly reported in abdominal and pelvic surgery but a prolonged operative time, untrained staff, poor communication in sponge count may favour the occurrence in thoracic cavity. A patient with intrathoracic gossypiboma usually presents with chest pain, dyspnoea, thoracic mass or fever. CECT and Magnetic resonance Imaging (MRI) are useful imaging modality in such cases. Surgical exploration with histopathological examination confirms the diagnosis of gossypiboma. CONCLUSION: In a postoperative patient who presents with chest pain and intrathoracic mass, gossypiboma should be a differential diagnosis even it is rare to occur in thorax.

Giant interparietal inguinal hernia with undescended testis-A Rare case report.

INTRODUCTION: An interparietal inguinal hernia is a rare form of hernia. In this type of hernia, the sac passes between the layers of the abdominal wall of the inguinal canal area. Although its treatment is very simple but pre-operative diagnosis is really a challenging issue. PRESENTATION OF CASE: A 62 years old male patient presented with complaint of a large swelling over right lower abdomen with absence of right testes since birth. The lump was measured 26×22cm in size. Ultrasonography (USG) and Contrast enhanced computed Tomography (CECT) failed to diagnose as interparietal inguinal hernia which was proved intra-operatively. Few cases have been reported in the medical literature like this. DISCUSSION: Exploration revealed the large abdominal lump presenting as an interparietal inguinal hernia. Hernia sac was lying in between external & internal oblique muscles. The right testis was intraabdominal & atrophied. The external inguinal ring was almost completely obstructed. CONCLUSION: An interparietal hernia with undescended testis is a very rare presentation. Even with USG & CT scan diagnosis is very challenging and final diagnosis can be made only intraoperatively.

Feasibility of fast track discharge in breast cancer patients undergoing definitive surgery and impact on quality of life: a prospective study from tertiary care center in India.

OBJECTIVE: To evaluate the feasibility and impact of fast track discharge in patients undergoing definitive breast cancer surgery. METHODS: One hundred six breast cancer patients older than 20 years of age were assigned to undergo definitive breast cancer surgery. It was ensured that enrolled patients had a ready access to hospital, reasonable home circumstances. They were assessed by using post-anesthesia discharge scoring system (PADSS) for fast track discharge. Quality of life both in preoperative and postoperative period was assessed by Functional Assessment of Cancer Therapy-Breast cancer version 4 (FACT-B4) questionnaires. RESULT: Overall 90 patients (84.9%) were fit for fast track discharge. Eighty-nine patients (83.96%) were successfully discharged within 48 hr. One patient (0.94%) could not be discharged despite being fit as she was of concern that it would put too much responsibility on the family. Mean duration of postoperative hospital stay in patients fit for fast track surgery was 42.27 ± 5.73 hr with a median of 44 hr. All patients undergoing breast conservation could be discharged on fast track basis with a mean postoperative hospital stay of 32.12 hr. CONCLUSION: Fast track discharges in breast cancer patients after definitive surgery are feasible in Indian setting.