Pneumo-peritoneum, pneumo-retroperitoneum and subcutaneous emphysema following endoscopic retrograde cholangiopancreatography with sphincterotomy-an uncommon complication case report.

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive for pancreaticobiliary diseases. Perforation is a rare but severe complication among its associated risks. A 45-year-old female with biliary colic and multiple gallbladder calculi was diagnosed with choledocholithiasis based on imaging showing CBD dilation and gallstones. ERCP was planned for stone removal. Sphincterotomy was performed, but stone retrieval attempts failed, leading to severe pneumo-peritoneum and respiratory compromise. Immediate CBD stenting was done, avoiding surgical intervention. The patient recovered uneventfully, later undergoing laparoscopic cholecystectomy with CBD exploration and stone removal. ERCP-related perforations, rare but severe, involve retroperitoneal air collection. Clinical signs include abdominal discomfort, and imaging confirms diagnosis. Management varies by type, with some requiring surgical repair. Conservative management sufficed in this case, with successful patient recovery. ERCP-related complications like pneumo-peritoneum require prompt diagnosis and conservative management if no perforation is evident.

Successful excision of a giant stomach gastrointestinal stromal tumour-A case report.

INTRODUCTION: Gastrointestinal stromal tumours are rare, but most common mesenchymal tumours originate from the gastrointestinal tract. Though surgery is the primary treatment, advanced tumours require targeted therapy in combination with surgery. CASE PRESENTATION: A 62-year-old lady who presented with abdominal distention and pain was found to have a large abdominal mass. A contrast-enhanced computed tomography revealed a large abdominal mass extending from the epigastrium to the pelvis, with a solitary omental deposit. Despite receiving Imatinib for six months, the disease progressed, and she underwent open En block tumour excision with distal gastrectomy and distal pancreatectomy with Roux-en-Y gastrojejunostomy and part of omental resection after multi-disciplinary team discussions. Histological examination confirmed a spindle-type gastrointestinal stromal tumour, which arrived from the stomach's submucosa; immunohistochemistry showed strong cytoplasmic and membranous positivity for CD117. CLINICAL DISCUSSION: While rare (0.1-3 % of GI malignancies), GISTs are most common in the stomach (56 %) and small bowel (32 %). Even large tumours can present with vague symptoms without obstructive features. Advanced tumours can be treated with targeted tumour therapy like Imatinib in combination with surgery. Surgical resection, usually laparoscopic, is the gold standard, but open surgery may be needed for large laparoscopically unresectable tumours. CONCLUSION: Though large tumours may present with vague symptoms without obstructive features, they tend to be more aggressive and can progress despite imatinib therapy. While laparoscopic surgery is the gold standard, open surgery is preferable for large, laparoscopically unresectable tumours.

Unusual discovery: Incidental diagnosis of adrenal myelolipoma, initially confused with liposarcoma, following bee sting bite, resolving chronic right hypochondrial discomfort - A case report.

INTRODUCTION AND IMPORTANCE: Adrenal myelolipomas are uncommon benign tumors of the adrenal gland. It has various other sites of origin. CASE PRESENTATION: A 51-year-old male with elevated serum creatinine and an incidentally discovered adrenal mass underwent right adrenalectomy for an adrenal myelolipoma, a benign tumor with fat and haematopoietic components after bee string bite. As the patient was experiencing right hypochondrial pain surgery was planned. After surgery, he developed a surgical site infection, which was treated with antibiotics, and his wound healed well. Excision biopsy confirmed the non-malignant nature of the tumor. CLINICAL DISCUSSION: Adrenal myelolipomas are often unilateral, non-functional, and diagnosed using imaging (CT/MRI). While radiological findings can be specific, inconclusive cases may require biopsy for confirmation. Surgical intervention is reserved for hormonally active, symptomatic, or rapidly growing myelolipomas, particularly if they exceed 5 cm. CONCLUSION: Adrenal myelolipomas are common in adrenal glands, typically diagnosed in midlife with no gender bias. Imaging, especially CT, is effective in detecting fat components. In cases of diagnostic uncertainty, fine needle biopsy is crucial for confirmation, and surgery is considered when tumors are hormonally active, grow substantially, or cause symptoms, highlighting personalized care based on patient and imaging data.

Outcome Analysis of Total Thyroidectomy: Conventional Suture Ligation Technique vs Sutureless Technique.

INTRODUCTION: Total thyroidectomy is a common surgical procedure in endocrine surgery. However, it carries potential complications such as damage to the recurrent laryngeal nerve, permanent hypoparathyroidism, and bleeding.  Methods: A prospective study was conducted at the Professorial Surgical Unit, Jaffna Teaching Hospital, involving consecutive patients who underwent total thyroidectomy. Patients with certain conditions were excluded from the study. The data collected were analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). RESULTS: This study included 59 patients who had total thyroidectomy from January 2018 to January 2021 at the Professorial Surgical Unit, Jaffna Teaching Hospital. Of these, 45 underwent conventional suture ligation (CSL), and 17 had a sutureless (SL) technique. Mean ages were 44±12.47 years (range: 23 to 68) for CSL and 47.63±13.37 years (range: 27 to 73) for SL. Operative time was 2.16 ± 0.32 hours for CSL and 1.56 ± 0.49 hours for SL. Intraoperative and postoperative bleeding occurred in 2.38% of CSL cases but not in SL. Postoperative hypocalcemia was 7.14% for CSL and 5.88% for SL. Postoperative stays averaged 3.83 ± 1.56 days for CSL and 3.41 ± 1.62 days for SL. DISCUSSION: The study found that the operative time differed significantly between the suture and SL techniques. However, there was no statistically significant difference in postoperative drainage volume or postoperative complications. CONCLUSION: The SL technique was shown to be superior to the conventional suture ligation technique for total thyroidectomy. It resulted in shorter operative time, reduced intraoperative bleeding, lower incidence of postoperative drainage, fewer postoperative voice changes, and shorter hospital stays. Therefore, the SL technique was deemed safe, efficient, and effective for total thyroidectomy compared to the conventional suture ligation technique.

Omental torsion - A mimicker of the acute appendicitis - A case report.

INTRODUCTION: Omental torsion is due to the twisting of the omentum along its axis and is observed in young male patients. The first description of omental torsion was first made by Eitel in 1899. CASE PRESENTATION: A 35-year-old male presented with right iliac fossa pain, nausea, occasional vomiting and loss of appetite for four days. His clinical and radiological findings were suggestive of acute appendicitis. However, he was diagnosed with greater omental torsion intraoperatively and successfully managed with laparoscopic omentectomy. DISCUSSION: Omental torsion is a rare condition with a low incidence. Preoperative diagnosis of omental torsion continues to be a challenge as the symptoms reported in the literature are usually confused with other abdominal pathologies such as appendicitis or cholecystitis etc. Preoperative US or CT scans are mandatory, and these procedures can accurately accomplish the pre-operative diagnosis. In search for the treatment of choice, laparoscopy proved its effectiveness as a diagnostic tool since it allows for confirming the diagnosis, evaluating the severity of the ischemia, and ruling out other surgical pathologies and therapeutic tools. At the same time, the open surgery approach can be described in many cases as being too invasive. CONCLUSION: Greater omental torsion should be considered a differential diagnosis in all patients with acute abdominal emergencies.

Successful management of strangulated incisional hernia in pregnancy - A case report.

INTRODUCTION: Abdominal hernias, including incisional hernias, can occur due to weakness in the abdominal wall. Incisional hernias commonly occur following surgical incisions, and factors such as poor closure technique and patient-related factors can contribute to their development. CASE PRESENTATION: In this case, the patient was presented with a painful, irreducible lump over a previous laparotomy scar, along with bowel obstruction symptoms. The diagnosis was supported by ultrasound findings showing obstructed bowel loop in the hernial sac. Emergency open surgical reduction and mesh repair were performed to treat the strangulated hernia and ensure the mother and fetus's safety. The patient had an uneventful postoperative period and was discharged after three days. DISCUSSION: Incisional hernias can be diagnosed through clinical evaluation, and imaging studies may be necessary in complex cases. However, imaging techniques such as X-rays and Computed Tomography scans are limited in pregnant women due to the radiation risks. Ultrasonography (USS) is preferred in pregnant women for its safety and non-invasiveness, although it may have reduced sensitivity in obese patients. Complicated hernias should be treated with emergency surgical repair, while elective surgery can be considered for asymptomatic or non-complicated hernias. Laparoscopic surgery offers advantages such as shorter hospital stays and fewer complications. Mesh repair reduces the recurrence risk in subsequent pregnancies (relate the discussion with the case). CONCLUSION: Overall, surgical management of hernias in pregnancy requires careful consideration of individual circumstances and the use of appropriate techniques to ensure the safety of both the mother and fetus.

Challenging refractory type B lactic acidosis in gastric adenocarcinoma-a successfully managed case.

Type B lactic acidosis is a rare complication of gastric adenocarcinoma and is associated with poor prognosis. Very few cases have been reported in the literature. A 48-year-old female presented with recurrent episodes of vomiting, loss of appetite and loss of weight for 1 month duration. Endoscopy and subsequent biopsy revealed poorly differentiated adenocarcinoma at the pyloric antrum causing gastric outflow obstruction. Contrast enhanced computed tomography scan of the chest, abdomen and pelvis revealed a malignant neoplasm of the pylorus with no distant metastasis. She developed refractory lactic acidosis not responding to medical treatment. Distal gastrectomy with limited lymph node clearance was done and lactic acidosis improved. Pathophysiology of type B lactic acidosis in solid organ malignancies can be due to the rapid turnover of cells inducing anaerobic glycolysis, thiamine deficiency and extensive hepatic metastasis. This patient did not have hepatic metastasis. This is a successful, surgically managed case of type B lactic acidosis in a patient with gastric adenocarcinoma so far reported in the region. Type B lactic acidosis is very rare in gastric cancer. Patients with refractory lactic acidosis should bring about high suspicion of solid organ malignancies and good clinical outcomes can be obtained by the reduction of tumour burden.

Intermittent malperfusion of bilateral upper limbs - An uncommon presentation of Type A Acute Aortic Dissection (TAAD).

INTRODUCTION: Aortic dissection occurs following a tear in the tunica intima of the aortic wall resulting in blood entering between the intima and media. Type A aortic dissection can rarely manifest as upper limb malperfusion. CASE PRESENTATION: This is regarding a patient who presented with intermittent malperfusion of the bilateral upper limbs and was initially managed as acute limb ischemia. An attempt of embolectomy didn't yield any clots. Urgent imaging with computed tomography angiogram of bilateral upper limbs revealed type A aortic dissection (TAAD). DISCUSSION: TAAD is a surgical emergency which can rarely manifest as intermittent malperfusion of upper limbs. This could be explained by the dissection flap's dynamic obstruction of the right brachiocephalic trunk and left subclavian artery. CONCLUSION: In patients with a discrepancy in pulse between both limbs or intermittent ischemia of limbs, aortic dissection should be considered a differential diagnosis.

Minimal invasive management of generalized peritonitis as a result of spontaneous ureteral rupture.

INTRODUCTION AND IMPORTANCE: Generalized peritonitis following proximal ureteral rupture is a very rare complication. This is about a successfully managed case without open surgical intervention. CASE PRESENTATION: A lady in her 70s presented with generalized abdominal pain, high spiking fever and low urine output for 3 days. She was haemodynamically unstable on admission and was resuscitated and managed at intensive care unit. CECT abdomen revealed partial anterior ureteral rupture with pyonephrosis. She was managed with percutaneous nephrostomy and subsequent anterograde stenting. Her recovery was uneventful and follow up imaging revealed no features of malignancy. CLINICAL DISCUSSION: Generalized peritonitis due to renal pathology is very rare and it can be due to urolithiasis or neoplasm. Retroperitoneal infections may lead to irritation of peritoneum or fistulation into the peritoneum leading to generalized peritonitis. This can be managed by various surgical and non-surgical management modalities. CONCLUSION: There are various pathological causes for acute abdomen. One of the rare causes is spontaneous rupture of ureter in pyonephrotic kidney which can also be managed successfully with minimal intervention.

Distant Lung Recurrence of Rectal Cancer 20 Years After Primary Surgery.

A male patient in his 70s, who had undergone an abdominoperineal (A1) resection for rectal cancer 20 years prior, presented with hemoptysis. Imaging studies revealed distant lung recurrence, with no evidence of local recurrence. Biopsy revealed an adenocarcinoma, possibly of rectal origin. Immunohistochemical markers were suggestive of rectal cancer metastasis. However, carcinoembryonic antigen (CEA) levels were normal, and colonoscopy did not reveal any metachronous lesions. Curative left upper lobe resection was performed via posterolateral thoracotomy. The patient's recovery was uneventful.

Prevalence of Neuroendocrine Tumours (NET) in Patients Undergoing Appendicectomy for Acute Appendicitis: A Tertiary Care Study.

Introduction Acute appendicitis is one of the common causes of acute abdomen in adults, which is managed widely with appendicectomy. Neuroendocrine tumours are the most common appendiceal tumours diagnosed incidentally on appendicectomy specimens.  Methods  Demographic data, presenting complaints, indications for appendicectomy, and the histology findings based on histopathological reports of the patients who have undergone appendicectomy for appendicitis at surgical units of Teaching Hospital, Jaffna, from 1st of January 2019 to 31st of December 2022 were retrospectively analyzed.  Results Of the 1341 histopathology reports, 0.2% (n=3) were neuroendocrine tumours (NET). The mean age of the patients with NET was 48.6, and 66.6% of them were females. All three NETs identified in appendicectomy specimens were well differentiated and smaller than 2 cm. All three had negative resection margins and were managed only with appendicectomy.  Conclusion  NETs of the appendix are the commonest appendiceal neoplasms. The majority of them are diagnosed incidentally in appendicectomy specimens. Surgical management of the tumours is either by appendicectomy or hemicolectomy, which depends mainly on tumor size. Surgical decisions should be tailor-made to the patients based on multi-disciplinary team decisions.

Minimally Invasive Management of Bile Leak Following Displaced Percutaneous Transhepatic Biliary Stent.

Biliary endoprosthesis plays a crucial role in the management of patients with obstructive jaundice. However, a biliary leak is a life-threatening complication of this procedure. A 52-year-old otherwise healthy man presented with obstructive jaundice and was found to have a stricture at the confluence of the right and left hepatic ducts, which was managed with the placement of an uncovered self-expanding metallic stent. He rapidly deteriorated, and an active bile leak in the peritoneum due to stent displacement through the liver was discovered, which was successfully managed in a minimally invasive manner via laparoscopy. The extrahepatic part of the metallic stent was cut and removed, the peritoneum was washed out, and multiple drains were placed. The patient improved clinically, and his biochemical parameters returned to normal.

Inflammatory myofibroblastic tumour: case report of a rare form of bladder tumour.

INTRODUCTION AND IMPORTANCE: Inflammatory myofibroblastic tumour (IMT) is a rare tumour with malignant potential and has been described in many major organs with the most frequent site being the lungs. However, bladder is an extremely rare location. IMT presents a unique diagnostic challenge because of the characteristics it shares with malignant neoplasms. CASE PRESENTATION: Here we report the case of a 47-yearold male who presented with storage lower urinary tract symptoms associated with non-specific lower abdominal pain for one month duration. Contrast-enhanced computed tomography of abdomen and pelvis revealed a 6 cm tumour at the dome and left side anterior wall of the bladder. He underwent laparotomy and partial cystectomy. Histopathology results were consistent with an IMT. CLINICAL DISCUSSION: Even though bladder IMT is indolent in course, typical IMTs can be locally aggressive. Due to the lack of specificity in clinical symptoms, it is not easy to arrive at a precise diagnosis before surgery. Hence, the final diagnosis depends on histomorphological features and the immune histochemical profile. CONCLUSION: It can be challenging to distinguish IMT from malignant neoplasms both clinically and histologically. As such, local surgical resection with close follow-up remains the mainstay of treatment for urinary tract IMT.

Minimally invasive management of massive giant hydronephrosis in tertiary care centre Northern Sri Lanka: A case report.

INTRODUCTION & IMPORTANCE: Giant hydronephrosis (GH) is defined as a kidney containing greater than 1000 ml of urine in its collecting system. It is a rarely presented condition in an adult. Common aetiology for GH is due to congenital ureteropelvic junction obstruction. We present a case of a late presentation of GH was being managed by a minimally invasive laparoscopic technique. CASE PRESENTATION: A 63-year-old Sri Lankan male presented with worsening of generalized abdominal swelling with vague abdominal symptoms for a six-month duration, found to have a GH of the left kidney on USS. The Contrast-enhanced computerized tomography (CECT) scan confirmed the diagnosis with 12l of fluid and possible ureteropelvic junction obstruction (UPJO). CT did not show any excretion of the left kidney. Hydronephrosis was drained one day before the surgery by a percutaneous nephrostomy tube. Laparoscopic transperitoneal nephrectomy was performed. The patient had a smooth and fast recovery. DISCUSSION: A neglected congenital UPJO can present with GH in adults. It causes vague abdominal symptoms like abdominal distension, dyspepsia, and fatigue. CECT will give the diagnosis and identify the aetiology of GH. Non-functional GH kidneys can be treated with nephrectomy by open or laparoscopic surgical technique. Laparoscopic nephrectomy shoes less blood loss during surgery, less postoperative pain and early recovery after surgery. However, in GH, surgeons need the experience to overcome the challenges like adhesions and working in a small space. CONCLUSIONS: The percutaneous nephrostomy decompression followed by laparoscopic transperitoneal nephrectomy is feasible for a massive GH.

Hemorrhagic Cholecystitis: A Rare Cause of Melena.

Hemorrhagic cholecystitis -- a rare cause of hemobilia and melena -- is an atypical presentation of calculous cholecystitis, associated with significant morbidity and mortality. A 75-year-old woman with multiple comorbidities, who was undergoing dual antiplatelet therapy, presented with symptoms of acute cholecystitis. Two days later, she developed melena and symptoms of obstructive jaundice. Following radiological evaluation, a diagnosis of hemorrhagic cholecystitis was made. The patient was managed conservatively with IV antibiotics and blood transfusion in the initial period (clopidogrel was withheld); an interval cholecystectomy was performed six weeks later. Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, and its diagnosis is challenging as it mimics various other hepatopancreaticobiliary diseases. Management options include early surgery or conservative management at the initial stage, followed by interval cholecystectomy.