Rare case of concomitant juxtarenal aortic aneurysm and type 1 Inferior Vena Cava duplication: -intraoperative challenges to avoid catastrophe / Caso raro de aneurisma de aorta justarrenal e duplicação do tipo 1 concomitantes na veia cava inferior - desafios intraoperatórios para evitar catástrofes

Abstract Duplication of the inferior vena cava is a rare congenital anomaly, with an incidence of 0.2-3%. Despite being asymptomatic, anomalies of IVC are important in aortoiliac and retroperitoneal surgeries. Preoperative CT imaging is essential to identify any IVC anomaly and to prevent unexpected hemorrhage during surgery. Here, we report a case of a juxtarenal abdominal aortic aneurysm in which we encountered a type I IVC duplication anomaly intraoperatively while performing transperitoneal aneurysmorrhaphy and took precautions to avoid any iatrogenic injuries to either of the two trunks or the pre-aortic trunk of the anomalous duplicate IVC.

Resumo A duplicação da veia cava inferior (VCI) é uma anomalia congênita rara com incidência de 0,2 a 3%. Apesar de assintomáticas, anomalias da VCI são importantes em cirurgias aortoilíacas e retroperitoneais. A imagem da tomografia pré-operatória é essencial para identificar qualquer anomalia de VCI e para evitar hemorragia inesperada durante a cirurgia. Relatamos um caso de aneurisma de aorta abdominal justarrenal, no qual encontramos uma anomalia de duplicação de VCI do tipo 1 intraoperatório enquanto realizávamos correção cirúrgica de aneurisma transperitoneal. Por isso, tomamos a precaução para evitar qualquer lesão iatrogênica nos dois troncos e no tronco pré-aórtico de VCI duplicada anômala.

Current management of pancreatic trauma.

Background: Although pancreatic trauma is uncommon, it poses a diagnostic and therapeutic challenge. Any delay in diagnosis raises morbidity and mortality. This study highlights the current management and outcome in patients of pancreatic trauma at a single tertiary care center. Methods: This is a retrospective analysis of prospectively collected data of 24 patients diagnosed to have pancreatic trauma. Collected data was analyzed for age, gender, mechanism of injury, hemodynamic status at presentation, initial serum amylase levels, CECT abdomen findings, AAST-OIS grade of pancreatic injury, injury to other organs, management, complications and outcome. Results: The mean age of these 24 patients was 25 years; 19 were male and 5 females. The mechanisms of pancreatic trauma included blunt abdominal trauma in 21 (87.5%) cases and penetrating injury in 3 (12.5%). Seven (29.16%) patients were managed by non-operative management and 17 (70.83%) underwent surgery. Complications were more frequent in the operative group as compared to the non-operative group. Neither endocrine deficiency nor any mortality was noted in the non-operative management group; while there were 2 cases of endocrine deficiency and 3 mortalities in the operative group. Conclusions: Pancreatic trauma is more common in young male patients and more commonly inflicted by motor vehicles accidents. Low grade blunt pancreatic injury in hemodynamically stable patients and selected patients with high grade blunt pancreatic injury can be managed successfully by non-operative management with no increase in morbidity or mortality and most patients with high grade blunt pancreatic injury and those having penetrating injuries need surgical intervention.

Radical surgery for incidental cancergallbladder after laparoscopic cholecystectomy.

Objective: To report our experience in the management of incidentally detected carcinoma gall bladder and establishment of a treatment protocol. Method: Retrospective review of 7 patients with incidentally detected carcinoma gall bladder during and after laparoscopic cholecystectomy for presumed benign disease. Clinical and histopathological data, treatment and long term outcome of all seven patients were reviewed. Exploratory laparotomy and radical surgery with curative intent consisting of liver resection, lymphadenectomy of the pedicle and excision of the port site were performed in all patients. Results: Liver resection including the segments IVB and V was done in 5 patients and in 2 patients resection of a wedge of hepatic parenchyma of more than 2 cm thickness including the gall bladder bed was carried out. Five patients underwent common bile duct excision with hepaticojejunostomy. Postoperatively, 2 patients developed fever and 1 patient had minimal altered blood in the nasogastric tube aspirate. These were successfully managed conservatively. All 7 patients had disease of pathological stage II and beyond. All patients received adjuvant chemotherapy. One patient died after 2 months of cholangitis and sepsis. One patient succumbed to metastatic disease after 12 months. The remaining patients are disease free on follow up. Conclusion: Re-exploration and aggressive resection with adjuvant chemotherapy for incidental carcinoma of the gallbladder is safe and offers hope for long term survival.

A pilot study on hypothalamo-pituitary-adrenocortical axis in primary hyperparathyroidism.

Background & objectives: Parathormone (PTH) and calcium, both have been shown to stimulate adrenal steroidogenesis in animal models and in vitro experiments. This is attributed to structural similarity between 15-25 amino acid region of the parathyroid hormone (PTH) and 1-11 amino acid region of adrenocorticotropin (ACTH). However, there are no in vivo human data regarding the effect of PTHcalcium axis on adrenocortical function. Materials: Ten patients with primary hyperparathyroidism underwent evaluation for cortisol dynamics including 0800 h and 2000 h plasma cortisol on day 1, cortisol response to insulin induced hypoglycaemia (IIH) on day 2, and 1 mg overnight dexamethasone suppression test (ONDST) on day 4. Serum aldosterone was also measured at 0800 h in fasting state on salt ad libitum for three days. These parameters were repeated 3 months after curative parathyroidectomy. Results: Basal plasma cortisol level at 0800 h and 2000 h were within upper normal range and loss of circadian rhythm in cortisol secretion was observed in half and forty per cent of patients had nonsuppressibility with ONDST. The defined peak cortisol response to insulin induced hypoglycaemia (>550 nmol/l) was achieved in all and nearly one third of patients had exaggerated response (>2000 nmol/l). After curative parathyroidectomy, the abnormalities in circadian rhythm and non-suppressibility with ONDST continued to prevail in 40 per cent of patients. The peak cortisol response to IIH showed a decrement but remained higher than normal. No correlation was observed between circulating parathyroid hormone and calcium with cortisol levels. Serum aldosterone was in upper normal range pre - and postoperatively, though it decreased postoperatively, but it could not attain a statistical significance (p = 0.5). Interpretation & conclusion: Abnormalities in hypothalamo-pituitary-adrenocortical axis in primary hyperparathyroidism do occur, however these are inconsistent and do not recover in majority of patients even after 3 months of curative parathyroidectomy.

External duodenal fistula following closure of duodenal perforation.

AIM: Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD: Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS: Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS: EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.

Primary small bowel melanoma: a case report.

The small intestine is the most common site of gastrointestinal metastasis from cutaneous melanoma. However, the small intestine itself is rarely the site of a primary melanotic tumour. We describe a case of primary small bowel melanoma in a 70-year-old man, and discuss the features of primary and metasttic melanoma.