Verrucous carcinoma at ileostomy site / Carcinoma verrucoso em local de ileostomia

ABSTRACT We describe of a case, a 50 year old male who was operated for carcinoma of the descending colon and diverting loop ileostomy, developed a fungating lesion in mucocutaneous junction of ileostomy after one year which on histology revealed to be a Verrucous carcinoma.

RESUMO Descrevemos um caso, homem, 50 anos, que foi operado para carcinoma de cólon descendente e ileostomia em alça para desvio. Transcorrido um ano, o paciente desenvolveu uma lesão vegetante na junção mucocutânea da ileostomia; a histologia revelou ser um carcinoma verrucoso.

Castleman's disease in carcinoma gall bladder.

Castleman's disease (CD) also known as angiofollicular lymph node hyperplasia represents a group of uncommon non-clonal lymphoproliferation. We herein report a case of CD associated with carcinoma of the gall bladder. To the best of our knowledge, it is the first of its kind and has not been reported in the past. The hypothesis regarding the aetiopathogenesis of CD is that it is associated with interleukin-6 surges. This may be explained by the overproduction of IL-6 by tumour cells or IL-6 production due to a long-standing/smouldering localised inflammatory response. An important question raised by this observation is whether the finding of CD has any effect on the outcome of this patient of carcinoma of the gall bladder. Further research is required in this matter.

Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery?

There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.

Retroperitoneal perforation of the appendix presenting as a right thigh abscess.

A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. An MRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findings were confirmed. A segmental ileocaecal resection was done. The patient made an uneventful recovery. The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolving thigh and groin abscesses should lead to the evaluation of the gastrointestinal tract as origin. Diagnostic clues may also be provided by culture reports what as happened in this case.

Liver Transplantation in India: At the Crossroads.

As the liver transplant journey in India reaches substantial numbers and suggests quality technical expertise, it is time to dispassionately look at the big picture, identify problems, and consider corrective measures for the future. Several features characterize the current scenario. Although the proportion of deceased donor liver transplants is increasing, besides major regional imbalances, the activity is heavily loaded in favor of the private sector and live donor transplants. The high costs of the procedure, the poor participation of public hospitals, the lack of a national registry, and outcomes reporting are issues of concern. Organ sharing protocols currently based on chronology or institutional rotation need to move to a more justiciable severity-based system. Several measures can expand the deceased donor pool. The safety of the living donor continues to need close scrutiny and focus. Multiple medical challenges unique to the Indian situation are also being thrown up. Although many of the deficits demand state intervention and policy changes the transplant community needs to take notice and highlight them. The future of liver transplantation in India should move toward a more accountable, equitable, and accessible form. We owe this to our citizens who have shown tremendous faith in us by volunteering to be living donors as well as consenting for deceased donation.

Fast-track surgery in India.

Fast-track surgery or 'enhanced recovery after surgery' or 'multimodal rehabilitation after surgery' is a form of protocol-based perioperative care programme. It is an amalgamation of evidence-based practices that have been proven to improve patient outcome independently and exert a synergistic effect when applied together. The philosophy is to treat the patient's pathology with minimal disturbance to the physiology. Several surgical subspecialties have now adopted such protocols with good results. The role of fast-track surgery in colorectal procedures has been well demonstrated. Its application to other major abdominal surgical procedures is not as well defined but there are encouraging results in the few studies conducted. There has been resistance to several aspects of this programme among gastrointestinal and general surgeons. There is little data from India in the available literature on the application of fast-tracking in gastrointestinal surgery. In a country such as India the existing healthcare structure stands to gain the most by widespread adoption of fast-track methods. Early discharge, early ambulation, earlier return to work and increased hospital efficiency are some of the benefits. The cost gains derived from this programme stand to benefit the patient, doctor and government as well. The practice and implementation of fast-track surgery involves a multidisciplinary team approach. It requires policy formation at an institutional level and interdepartmental coordination. More research is required in areas like implementation of such protocols across India to derive the maximum benefit from them.

Adult onset nesidioblastosis treated by subtotal pancreatectomy.

CONTEXT: Nesidioblastosis is a rare cause of non insulinoma pancreatogenous hypoglycemic syndrome seen in adults. It is characterized by postprandial hypoglycemia with high insulin and C-peptide levels without any detectable pancreatic lesion. The definitive diagnosis can be made only on histopathological examination of the resected specimen. CASE REPORT: We report a case of a 50-year-old lady presenting with hypoglycemic attacks being misdiagnosed preoperatively as insulinoma and treated with enucleation leading to recurrence of symptoms after 6 months. Later medical therapy was tried which failed and patient needed subtotal pancreatectomy for resolution of symptoms. CONCLUSION: Nesidioblastosis should be suspected in patients with endogenous hyperinsulinemic hypoglycemia without any detectable pancreatic tumor on preoperative imaging.

Rectal adenocarcinoma in an adult with imperforate anus at birth.

A 43-year-old man with imperforate anus surgically corrected at birth presented with bleeding per rectum and constipation. On investigations, there was an adenocarcinoma at 2 cm from anal verge involving mid and lower rectum. He underwent abdominoperineal resection. During surgery, he was found to have a rectourethral fistula. The relationship between imperforate anus, rectourethral fistula and carcinoma of rectum is disclosed.

Management of a large retroperitoneal primitive neuroectodermal tumour: 'a multimodal approach'.

Retroperitoneal primitive neuroectodermal tumour (PNET) is a rare disease having poor prognosis. Treatment mainly consists of en block resection of the tumour to achieve RO resection, however multimodal approach has also been used with improved survival. The authors report a 40-year-old male with large retroperitoneal PNET adherent to aorta and compressing the inferior vena cava. He was subjected to P6 protocol chemotherapy (cyclophosphamide, adriamycin, vincristine, ifosfamide and etoposide) in view of borderline operability. Postchemotherapy contrast enhanced CT revealed significant reduction in size of the lesion. He underwent complete resection of the tumour followed by concurrent chemoradiation. He remains asymptomatic on follow-up over a period of 2 years.

Pseudomyxoma peritonea: uncommon presentation.

Pseudomyxoma peritonei is rare being characterized by intraperitoneal accumulation of mucinous ascites produced by neoplastic cells, mostly originating from a perforated appendiceal adenoma. The clinical presentatation of the disease is variable, and preoperative diagnosis is often difficult. We describe the clinical case of a 60-year-old patient who presentated predominantly with urological symptoms. CECT revealed an appendiceal lesion infiltrating and projecting into the urinary bladder. Surgical cytoreduction was performed and patient remains symptomatically better on follow up.

Surgery in a patient with liver disease.

Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones and hernia are more common in patients with cirrhosis. Assessment of severity of liver dysfunction before surgery is important and the risk benefit of the procedure needs to be carefully assessed. The disease severity may vary from mild transaminase rise to decompensated cirrhosis. Surgery should be avoided if possible in the emergency setting, in the setting of acute and alcoholic hepatitis, in a patient of cirrhosis who is child class C or has a MELD score more than 15 or any patient with significant extrahepatic organ dysfunction. In this subset of patients, all possible means to manage these patients conservatively should be attempted. Modified Child-Pugh scores and model for end-stage liver disease (MELD) scores can predict mortality after surgery fairly reliably including nonhepatic abdominal surgery. Pre-operative optimization would include control of ascites, correction of electrolyte imbalance, improving renal dysfunction, cardiorespiratory assessment, and correction of coagulation. Tests of global hemostasis like thromboelastography and thrombin generation time may be more predictive of the risk of bleeding compared with the conventional tests of coagulation in patients with cirrhosis. Correction of international normalized ratio with fresh frozen plasma does not necessarily mean reduction of bleeding risk and may increase the risk of volume overload and lung injury. International normalized ratio liver may better reflect the coagulation status. Recombinant factor VIIa in patients with cirrhosis needing surgery needs further study. Intra-operatively, safe anesthetic agents like isoflurane and propofol with avoidance of hypotension are advised. In general, nonsteroidal anti-inflammatory drug (NSAIDs) and benzodiazepines should not be used. Intra-abdominal surgery in a patient with cirrhosis becomes more challenging in the presence of ascites, portal hypertension, and hepatomegaly. Uncontrolled hemorrhage due to coagulopathy and portal hypertension, sepsis, renal dysfunction, and worsening of liver failure contribute to the morbidity and mortality in these patients. Steps to reduce ascitic leaks and infections need to be taken. Any patient with cirrhosis undergoing major surgery should be referred to a specialist center with experience in managing liver disease.

Major hemobilia--experience from a specialist unit in a developing country.

BACKGROUND AND AIM: Hemobilia is a rare but potentially life threatening problem, which can be difficult to diagnose and treat. In the last few decades there has been a change in the etiologic spectrum and management of this problem in the West. The aim of this study was to analyze the etiology, clinical features, management and outcome of major hemobilia in a tertiary referral centre from western India. METHODS: A retrospective analysis was undertaken on 22 patients (16 males, 6 females; mean age 39 years, range 13 to 74) who presented with major hemobilia over a 5-year period. RESULTS: The etiology was iatrogenic in 13 patients (percutaneous transhepatic biliary drainage 8, post laparoscopic cholecystectomy 3, endoscopic retrograde cholangiopancreatography 1, and liver biopsy 1), liver trauma in 6 and liver tumors in 3 patients. Twenty patients presented with gastrointestinal bleeding (melena 20 patients, hemetemesis with melena 8 patients), 5 with jaundice and 8 had fever. Abdominal angiography was performed in 20 patients. Angiography revealed pseudoaneurysm of the right hepatic artery or its branches in 14 patients, left hepatic artery in 2, an arterio-biliary fistula in 1, tumor blush in 1 and the source could not be located in 2 patients. Seventeen of the 22 patients were treated with radiological intervention, 3 required surgery (liver resection for tumors 2, laparotomy for venous collateral bleeding of portal cavernoma 1) and two were managed conservatively. Radiological intervention involved embolisation with coils and/or glue in 16, and chemoembolisation in 1 patient. Sixteen of 17 patients responded to embolisation. Overall there were two deaths. CONCLUSION: The spectrum of hemobilia seen in India is now similar to that in the developed world with iatrogenic causes being the commonest. Interventional radiology can treat a majority of patients reducing the need and morbidity associated with surgery.

Chronic abdominal pain--a radiological solution.

Chronic mesenteric ischaemia is not an uncommon disorder. It is associated with high morbidity and mortality. It presents with chronic abdominal pain and the diagnosis is often missed because of nonspecific clinical findings and limitations of diagnostic studies. Although surgery has been considered to be the mainstay of treatment, it is associated with significant morbidity. We report two cases of chronic mesenteric ischaemia managed effectively with endovascular therapy with no morbidity and good long term pain relief.

Anatomy relevant to cholecystectomy.

This review discusses anatomical facts that are of relevance to the performance of a safe cholecystectomy. Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major postoperative complications like biliary injuries following a cholecystectomy, the incidence being higher with laparoscopic cholecystectomy. A look at the basic anatomy is therefore important for biliary and minimally invasive surgeons. This includes normal anatomy and variations of the biliary apparatus as well as the arterial supply to the gallbladder. Specific anatomical distortions due to the laparoscopic technique, their contribution in producing injury and a preventive strategy based on this understanding are discussed. Investigative modalities that may help in assessing anatomy are considered. Newer insights into the role of anatomic illusions as well as the role of a system-based approach to preventing injuries is also discussed.