Pneumoperitoneum, pneumothorax, pneumomediastinum with massive subcutaneous emphysema: A rare presentation following transanal colonic barotrauma.

Iatrogenic colonic barotrauma is a well-documented entity, mostly due to endoscopic procedures. Compressed air pressure colorectal injury is less frequent, and the exact mechanism is not defined clearly to date. We present our experience of managing high transanal barotrauma to the colorectum in two similar cases presented with massive pneumoperitoneum, pneumothorax, and pneumomediastinum, a rare presentation in emergency departments, with an accident being the common etiology, where both the patients presented with massive abdominal distension and respiratory distress with diffuse subcutaneous emphysema. A huge amount of gas was noted in the peritoneal cavity on radiographs; the FAST examination was inconclusive and attributed to emphysema impeding the diagnosis. A big gush of air was noted during temporary pneumoperitoneum decompression and laparotomy. Multiple seromuscular tears with perforation in the transverse colon were identified and primarily repaired in the first patient, and the second one had perforation at the rectosigmoid junction, which was brought out as a stoma. The restoration of the stoma was done after ensuring adequate anal tone, with both patients doing well in the follow-up period.

A prospective, non-randomized study to determine the role of intraperitoneal drain placement in perforation peritonitis.

BACKGROUND: Surgical site infection continues to be a major problem after laparotomy for perforation peritonitis, as it increases morbidity and hospital stay and decreases the quality of life. Intra-abdominal drain placement is a routine practice in perforation peri-tonitis. The aim of our study is to compare the incidence of surgical site infection in two groups of patients who were operated for perforation peritonitis: The first group received the intraperitoneal drain, while no drain was placed in the second group. METHODS: The present single-center, prospective, non-randomized study was conducted in the Department of General Surgery at the Postgraduate Institute of Medical Education and Research, India. A total of 122 patients underwent exploratory laparotomy for gastroduodenal and small bowel perforation peritonitis, of which 100 participants were included in this study, based on specified cri-teria for inclusion and exclusion. A total of 50 participants each were included in the drain group and the no drain group, respectively. A drain was placed in every alternate patient with perforation peritonitis who received primary closure or resection anastomosis. Patients with diabetes, renal failure, and hemodynamic instability and those who presented more than 72 h since symptom onset were excluded from the study. Peritoneal fluids were cultured. The primary endpoint was to identify the incidence of surgical site infections (SSIs) in the two groups. We also compared the time taken for the return of bowel movements, duration for which a nasogastric tube was inserted, whether any intervention was performed under local or general anesthesia within 30 days of surgery, the duration of hospital stay, and the ease of diagnosing repair leak in the post-operative period in both the groups. RESULTS: Demographics of participants in both the groups were matched. No significant difference was observed between the drain and no-drain groups with respect to the incidence of surgical site infection (p=0.779). The duration of surgery and length of hospital stay were significantly lower in the no drain group. A significant difference was observed between the two groups concerning the peritoneal culture growth, and increased bacterial growth was seen in the drain group. No significant difference in morbidity was noted between the two groups, which was classified according to the Clavien-Dindo classification. CONCLUSION: Routine use of intra-abdominal drains was not found to be effective in preventing SSIs, but a selection bias cannot be ruled out. Patients with no drains had a significantly shorter duration of hospital stay.

Hepatic hilum-type II choledochal cyst masquerading as gallbladder duplication.

Choledochal cyst and gallbladder duplication are rare congenital anomalies. They typically are surgical problems of infancy or childhood but rarely may present in adults also. Despite high resolution imaging, the differentiation of type II choledochal cyst from gallbladder duplication often causes the diagnostic dilemma; which may result in high risk for intraoperative iatrogenic injury. Operative management of choledochal cyst is the definite treatment because of its malignant potential. A type II choledochal cyst arising from the hepatic hilum presenting as gallbladder duplication on imaging has not been reported earlier in the literature and here we present a case report of the same which was managed successfully.

Rare case of angiofibroma presenting as perineal hernia.

Angiofibroma is a benign soft tissue tumour presenting as a gradually progressive swelling in the vulvovaginal area in women and in the inguinoscrotal region in men. Being a rare tumour, there are only a few case reports in the literature, and among them, presentation as perineal herniation is very rare. En bloc resection of angiofibroma either via laparoscopic or open approach is the choice of treatment to avoid recurrence. Detailed pathological examination and immunohistochemistry workup are imperative to distinguish it from various mesenchymal tumours. Perineal hernia is itself rare and may occur spontaneously or following abdominoperineal resection, sacrectomy or pelvic exenteration. Surgical repair via open transabdominal and transperineal approaches has been described. Here, we report a case of a young woman who presented with spontaneous reducible perineal hernia with a soft tissue tumour as its content, which on histopathological investigation was found to be an angiofibroma.

Illicit Drug Use a Risk Factor for Ileal Mucormycosis Presenting With Acute Abdomen.

Mucormycosis is a rare, life-threatening, angioinvasive opportunistic fungal infection. Most common sites involved are rhino cerebral, pulmonary, cutaneous followed by gastrointestinal. We report a successful management of rare gastrointestinal ileal mucormycosis with perforation peritonitis managed surgically. Later histopathology revealed the ileal mucormycosis with transmural necrotizing inflammation. Histopathological demonstration of the fungus in surgical specimens remains cornerstone of the diagnosis of mucormycosis in view of its non-specific symptoms, low isolation rates of mycological culture and lack of other rapid tests.