Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial.

BACKGROUND: This study aimed to compare the postoperative outcomes and success rate of the endorectal advancement flap and ligation of intersphincteric fistulous tract (LIFT) in high-type fistula in ano. STUDY DESIGN: This randomized control trial included patients with high-type fistula in ano of cryptoglandular origin. The primary endpoint was complete fistula healing at the end of 6 months. However, the patients were followed up for 2 years. Other parameters studied were perioperative complications, duration of surgery, postoperative pain, hospital stay in hours, continence, and quality of life at 6 months. RESULTS: A total of 84 patients were recruited (42 in each group). The healing rate in the LIFT arm was better than that in the endorectal advancement flap arm (76.2.% vs 54.7%, p = 0.039). Four patients in the endorectal advancement flap group and two in the LIFT group had flatus incontinence at the end of 6 months, but all were continent at 2 years. At the end of the first week, the Visual Analog Scale score and quality of life at 6 months were better in the LIFT arm (3.7 ± 1.16 vs 4.7 ± 0.81 and 0.7 vs 0.6, p < 0.05). The mean duration of surgery was significantly less in the LIFT group (46.43 ± 9.32 vs 89.29 ± 10.90 minutes). None had any postoperative complications, and >80% were discharged within 24 hours. CONCLUSIONS: The shorter operative duration, better quality of life at 6 months, and higher healing rate make LIFT a superior treatment option for high fistula in ano. However, studies with a large sample size will be needed to verify these results.

Lithotomy versus prone position for perianal surgery: a randomized controlled trial.

PURPOSE: Studies objectively comparing lithotomy and prone positions regarding surgeon comfort, ergonomics, patient comfort, and position related complications are scarce. METHODS: The patients posted for surgery of either fistula in ano, hemorrhoids, or were included in this study. Subjective Mental Effort Questionnaire (SMEQ) and Local Experienced Discomfort (LED) scale were used to score the level of mental and physical stress among the operating surgeon, assistants, and the scrub nurse. Other parameters studied were the exposure of the operative site, patient comfort level, and position-related complications. RESULTS: Thirty patients were operated in each position. Mean±standard deviation of jackknife prone vs. lithotomy surgeon SMEQ score (15.6±10.4 vs. 107.0±11.5, P<0.05) and LED score (1.8±1.5 vs. 6.7±0.5, P<0.05) were found to be statistically significant. Prone vs. lithotomy assistant SMEQ score (29.1±13.1 vs. 100.6±8.7, P<0.05) and LED score (4.6±1.1 vs. 7.4±0.8, P<0.05) were also found to be statistically significant. SMEQ (10.0±0.0 vs. 20.6±2.5, P<0.05) and LED scores (1.1±0.3 vs. 3.3±0.5, P<0.05) of scrub nurses and LED scores (2.5±0.5 vs. 6.3±0.7, P<0.05) of patients were also statistically significant. Exposure of the operative site was significantly better in the prone position (5.0 vs. 2.1, P<0.05). CONCLUSION: Significantly better SMEQ, LED, and exposure score suggests the superiority of jackknife prone position over the lithotomy in terms of significantly less mental and physical stress to the operating surgeon, assistant, and scrub nurse; better ergonomics, and excellent exposure.

Squamous Metaplasia in a Borderline Phyllodes Tumor-an Undocumented Histological Finding in Male Breast: Report of a Case and Review of Literature.

Phyllodes tumor is a paradigm of fibroepithelial neoplasm that accounts for <1% of the breast neoplastic lesions usually detected in females and uncommonly in the male breast. The World Health Organization classifies the tumor into benign, borderline, and malignant based on the predefined morphological criteria. Squamous differentiation in phyllodes tumor is epithelial metaplasia, which has been occasionally documented in English literature. We report the first undocumented case of a recurrent borderline phyllodes tumor with cystic squamous metaplastic change in a 32-year-old male patient. The histology was that of a fibroepithelial neoplasm with the typical leaf-like projections and cystic spaces lined by squamous epithelium containing keratin debris. The purpose of presenting this case is to elucidate the pathogenesis and discuss other malignant and benign breast lesions that may be included in the differential diagnosis when evaluating a breast lesion with squamous metaplasia, particularly in the context of fine-needle aspirates.

Basidiobolomycosis of Right Colon Mimicking as Carcinoma of Colon.

Gastrointestinal basidiobolomycosis (GIB) is a rare fungal infection with limited geographic distribution. However, the incidence of GIB has shown an increasing trend because of globalization and frequent traveling. GIB is commonly seen to mimic gastrointestinal malignancy and other diseases such as intestinal tuberculosis and inflammatory bowel disease. Tissue diagnosis is considered to be the gold standard for differentiating these mycotic lesions from tuberculosis and malignancy with confirmation of species performed by culture or polymerase chain reaction. The diagnosis of GIB should be conjectured in patients with suspicion of malignancy, with an inconclusive biopsy. It seems prudent to proceed with radical excision of mass early because both colonic malignancy and GIB have high mortality if untreated.

Enhancer of Zeste Homolog 2 (EZH2) in Malignant Progression of Gallbladder Carcinoma.

PURPOSE: Data related to the role of epigenetic modifications in gallbladder carcinoma (GBC) is limited. We intended to assess the role of crucial epigenetic modifiers pertaining to histone modification and DNA-methylation system in gallbladder carcinogenesis. METHODS: The expression of EZH2, H3K27me3, and DNA methyltransferases (DNMTs) was analyzed by immunohistochemistry in cases of GBC (n = 39), gallbladder dysplasia (GBD, n = 12), and benign mucosa (BM, n = 16). A semi-quantitative scoring system was used for assessing the immunohistochemical expression. RESULTS: The expression of EZH2 was significantly higher in cases of GBC than GBD (p value 0.001). The cases of BM were negative. Its expression was also higher in poorly differentiated tumors and positively correlated with the proliferative activity (MIB-1 labeling index) (p value 0.03 and 0.01, respectively). There was no significant difference in the expression levels of H3K27me3, DNMT-1, and DNMT-3B among GBC, GBD, and BM cases. Although GBC cases with strong EZH2 expression showed a shorter overall survival, the difference was not statistically significant. CONCLUSION: This study highlights the crucial role of the key epigenetic regulators EZH2 in the pathobiology and evolution of gallbladder carcinogenesis. Given the reversibility of epigenetic alterations, EZH2 may be a novel therapeutic target for gallbladder carcinogenesis.

Malignant Extra-Gastrointestinal Stromal Tumor of the Mesentery.

Gastrointestinal stromal tumors (GISTs), the commonest mesenchymal tumors of gastrointestinal tract are often described to take origin from the interstitial cells of Cajal (ICC) or its precursor cells. Rarely these tumors do arise in structures other than the alimentary tract like omentum, mesentery, retroperitoneum, etc., of varying malignant potential and are known as extra-gastrointestinal stromal tumors (eGISTs). This is a case report of a 70-year-old female with multicentric malignant eGISTs arising in the mesentery of ileum. On laparotomy, a large mass of 20 × 15 cm was found in the small bowel mesentery without involvement of the adjacent ileum, with multiple other small nodules resembling lymph nodes, present adjacent to it. Histopathological study of the excised lump, confirmed the mass to be malignant eGIST without involvement of the adjacent ileum, with cluster differentiation (CD)117 positive and of high-risk stratification. The mesenteric nodule was confirmed on histopathology to be malignant eGIST, similar to that of that of the primary, without any lymphoid tissue. Adjuvant imatinib mesylate treatment was started immediately postoperation with the patient doing well at 1 year of follow-up. We report this case, due to the rare occurrence of multifocal malignant eGISTS of small bowel mesentery, which is yet to be reported. The existing literature is unclear regarding the clinicopathology and management of multifocal malignant stromal tumors of the mesentery.

Multicentric papillary and chromophobe renal cell carcinomas in a patient with autosomal dominant polycystic kidney disease: Report of a rare case.

The causal relationship of autosomal dominant polycystic kidney disease (ADPKD) with the development of renal cell carcinoma (RCC) is still not known. We describe a case of bilateral PKD complicated with a large enhancing mass and multiple small nodules in the left kidney. The histopathological study of the nephrectomy specimen revealed the synchronous occurrence of eosinophilic variant of chromophobe RCC (EVCRCC) and multicentric papillary RCC (PRCC) in a background of ADPKD. To the best of our knowledge, this case is the first to describe the collision tumor of EVCRCC and multicentric PRCC in ADPKD.

Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst.

Savlon (0.5% cetrimide/0.05% chlorhexidine) is used as a scolicidal during surgery of hydatid cysts. It is considered a safe and effective agent. However, there are no recommendations for the appropriate concentration or dosage of these agents. Previously reported to cause severe metabolic acidosis, its effects on the pulmonary system have not been explored. We present a case of acute lung injury and respiratory distress along with acute cardiopulmonary distress, severe metabolic acidosis, and renal failure following its use during surgical removal of pulmonary hydatid cyst. The agent may act as a chemical sclerosant causing pulmonary parenchymal damage through bronchial openings present in the pericyst. Till safe dose limits are known, use of this agent should be limited, especially in large or multiple cyst surgery.

Is laparoscopic cholecystectomy effective in relieving dyspepsia in patients of cholelithiasis? A prospective study.

Background: Laparoscopic cholecystectomy (LC) is routinely done for symptomatic gallstone disease; however, its role in relieving dyspeptic symptoms in cholelithiasis is controversial. Aim: The study was designed to assess the role of laparoscopic cholecystectomy in relieving dyspeptic symptoms in patients having cholelithiasis with only dyspeptic symptoms. Methods: Patients with cholelithiasis having only dyspeptic symptoms not attributable to other causes (like Helicobacter pylori) were subjected to laparoscopic cholecystectomy. Dyspepsia scores (Dyspepsia Severity Assessment Score-DSAS and Gastrointestinal Quality of Life Index- GIQLI) were measured before and after surgery and analyzed using Greenhouse-Geisser, McNemar's and ANOVA tests. Results: 27 patients (M:F=1:26, mean age=40.48±10.60 years) having dyspepsia with asymptomatic gallstones were included in the study. There was significant improvement in DSAS (20.11±4.36 vs 28.63±3.42; p<0.001) and GIQLI(106.11±5.77 vs 122.56±7.95; p<0.001) after 2 months of LC. All symptoms improved individually; relief in early satiety and vomiting was the maximum (outcome benefit ratios=0.954, p=0.007 and 0.937, p=0.005 respectively). Multiple gallstones caused more dyspepsia than single (p=0.005). There was no significant difference between H. pylori positive and negative groups in terms of improvement of DSAS and GIQLI scores after LC (p=0.897 and p=0.375 respectively; however dyspepsia was seen to improve significantly within both groups). Conclusion: Dyspepsia may be a symptom of gallstone disease, and these patients can benefit from LC especially when early satiety and vomiting are the main symptoms. A larger sample size may offer more insight.

Ancient Schwannoma of Ansa Cervicalis: A Rare Clinical Entity and Review of the Literature.

Ancient schwannoma is an uncommon variant of schwannoma, a benign tumor arising from the nerve sheath. It is reported to arise from any nerves except optic and olfactory. However, only six cases of ancient schwannomas arising from ansa cervicalis nerve have been reported to date in English literature. Proper preoperative evaluation is necessary to rule out other causes of neck mass such as thyroid lesions, lymphadenopathy, and carotid body tumor. We report a case of ancient schwannoma arising from the ansa cervicalis nerve. The origin of the lesion from ansa cervicalis was confirmed by intraoperative finding. Postoperative histopathological examination revealed degenerative changes including pleomorphism, cellular atypia, large nuclei with prominent nucleoli, and paucity of mitotic figures. Periphery of the mass showed nuclear palisading with characteristic verocay bodies. Immunohistochemical evaluation for S-100 showed diffuse positivity of the tumor cells, thereby confirming the diagnosis of schwannoma. We consider that schwannoma of cervical region can have origin from any nerve and should try to identify the origin pre- and intraoperatively. The postoperative complications depend on the nerve of origin and the precision of the surgery performed.

Sternalis Muscle: An Unexpected Finding during Mastectomy.

Sternalis muscle also called rectus sternalis, rectus thoracis, or episternalis is an anomalous muscle of the anterior chest wall with unknown anatomical function. It is regularly observed in lower animal but infrequently in humans. Presence of this muscle can create confusion with tumours of the anterior chest wall during routine mammography. Although less is known about its origin and innervations, knowledge about this muscle can have many clinical implications. A case of unilateral sternalis muscle detected during mastectomy, in a female with carcinoma of the right breast, is being reported with a brief review of the literature and highlighting its clinical significance.

Port site infection in laparoscopic surgery: A review of its management.

Laparoscopic surgery (LS), also termed minimal access surgery, has brought a paradigm shift in the approach to modern surgical care. Early postoperative recovery, less pain, improved aesthesis and early return to work have led to its popularity both amongst surgeons and patients. Its application has progressed from cholecystectomies and appendectomies to various other fields including gastrointestinal surgery, urology, gynecology and oncosurgery. However, LS has its own package of complications. Port site infection (PSI), although infrequent, is one of the bothersome complications which undermine the benefits of minimal invasive surgery. Not only does it add to the morbidity of the patient but also spoils the reputation of the surgeon. Despite the advances in the field of antimicrobial agents, sterilization techniques, surgical techniques, operating room ventilation, PSIs still prevail. The emergence of rapid growing atypical mycobacteria with multidrug resistance, which are the causative organism in most of the cases, has further compounded the problem. PSIs are preventable if appropriate measures are taken preoperatively, intraoperatively and postoperatively. PSIs can often be treated non-surgically, with early identification and appropriate management. Macrolides, quinolones and aminoglycosides antibiotics do show promising activity against the atypical mycobacteria. This review article highlights the clinical burden, presentations and management of PSIs in LS as shared by various authors in the literature. We have given emphasis to atypical mycobacteria, which are emerging as a common etiological agent for PSIs in LS. Although the existing literature lacks consensus regarding PSI management, the complication can be best avoided by strictly abiding by the commandments of sterilization techniques of the laparoscopic instruments with appropriate sterilizing agent.