Double Trouble: An Unusual Presentation of Bilateral Penile Fracture.

A penile fracture results from the rupture of the tunica albuginea due to blunt trauma to an erect penis and is a rare urological emergency. Double penile fractures involving both corpora cavernosa injuries are extremely uncommon. We report the case of a 38-year-old male who experienced acute penile pain, swelling, and a "cracking" sound during sexual intercourse. Examination and ultrasound confirmed bilateral tunica albuginea ruptures and hematoma. The surgical repair involved hematoma evacuation and suturing of the tears. The patient recovered without complications. This case highlights the necessity for prompt recognition and surgical intervention in double penile fractures to prevent long-term complications and ensure optimal recovery.

Leiomyoma of the Nipple: A Rare Entity at Rare Site.

Cutaneous leiomyomas are benign and rare smooth muscle tumors. Genital leiomyoma includes leiomyomas located in the nipple, scrotum, areola or vulva. Nipple leiomyomas are the least common genital leiomyomas and are commonly seen to occur in middle-aged women. Here, we present a case of a 40-year-old female complaining of a growth over the right nipple for six months. On local examination, it was a 1cm x 1cm growth on the lateral aspect of the nipple. Finally, a treatment plan of complete excision was done. Grossly, it was a well-circumscribed skin-covered soft tissue bit with a skin flap measuring 0.6cm x 0.6cm and soft tissue measuring 0.6cm x 0.5cm x 0.2cm. Histopathological examination revealed a skin-covered section with dermis showing a well-circumscribed unencapsulated lesion that showed intersecting fascicles of spindle cells with no atypia or mitoses noted. Microscopically, the growth had tumor-free resection margins. Immunohistochemical confirmation with S100, smooth muscle actin (SMA) and caldesmon was done. Diagnosis of nipple leiomyoma was given with strong SMA positivity. Nipple leiomyoma is a rare, benign lesion and needs to be correctly diagnosed microscopically. Biopsy and immunohistochemistry is a confirmatory investigation that can lead to timely management of the patient.

Hughes Abdomen Closure Technique Versus Continuous Closure in Emergency Midline Laparotomy: A Randomized Controlled Study.

Background Abdominal wound dehiscence, a serious postoperative issue, remains a significant concern for surgeons due to its potential to increase patient mortality and morbidity. Disruption can occur at any point after surgery, sparking debate over the optimal closure method for midline vertical abdominal wounds. Therefore, it's crucial to determine the safest approach. Our randomized clinical trial is planned to compare the risk of a burst abdomen associated with the Hughes abdominal closure technique to that of continuous abdominal closure. Methods All patients >18 years scheduled for emergency midline laparotomy were randomly assigned into two groups using computer-generated random numbers: Group A underwent Hughes repair (12 patients) and Group B underwent continuous closure (17 patients). Preoperative data, including patient demographics, and postoperative outcomes, such as time for rectus closure, wound dehiscence, surgical site infection (SSI), and length of hospital stay, were documented for analysis. Results The study found that the average patient age was 37.89 years, with more males than females. Both groups had an equal distribution of co-morbidities (p = 0.468), but none of these factors were statistically significant. Burst abdomen occurred in 25% of group A and 41.1% of group B (p = 0.367, not significant). Incisional hernia was absent in both groups. Surgical site infection (p = 0.119) and respiratory complications (p = 0.16) were not statistically significant between groups. However, in group A, the regressive analysis showed significant associations between burst abdomen, surgical site infection (p = 0.018), and respiratory complications (p = 0.007), while in group B, these associations were not significant (p = 0.252 for SSI and p = 0.906 for respiratory complications). Conclusion The occurrence of burst abdomen and closure time differences between continuous and Hughes techniques were not significant. The Hughes technique was quicker to learn (32 vs. 22 minutes). Burst abdomen was more common in continuous closure (group A: 25% vs. group B: 41%), favoring the Hughes technique. Factors like age, gender, and others didn't significantly impact the burst abdomen in either group.

Evaluating the Emergency Surgery Score (ESS) in Predicting Postoperative Outcomes Following Emergency Laparotomy: Insights From an Indian Tertiary Center.

AIMS AND OBJECTIVES:  To determine the predictive value of Emergency Surgery Score (ESS) with regard to mortality and morbidity rates of patients undergoing emergency laparotomy. METHOD: The ESS ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics, preoperative treatment, comorbidities, and laboratory values. Twenty patients who underwent emergency laparotomy were preoperatively assessed and ESS was calculated for each. After establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Postoperatively, patients were monitored clinically as well as with laboratory and radiological investigations as per case needed till discharge and further followed up physically in OPD/ward or interviewed telephonically for 30 days on a weekly basis. Incidence of mortality and morbidity in terms of postoperative complications, ICU admission, reoperation and readmission among the cases occurring within 30 days of procedure were recorded. RESULTS: ESS correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications. Mean ESS was higher among non-survivors. Ability of ESS to predict postoperative mortality, morbidity and ICU stay was proven statistically with c-statistics of 0.853, 0.84, 0.879 respectively. ESS was found to be a good predictor for the development of postoperative lower respiratory tract infection (LRTI) (c-statistic=0.828), sepsis (c-statistic=0.867), disseminated intravascular coagulation (DIC) (c-statistic=0.805), acute kidney injury (AKI) (c-statistic=0.804). ESS showed poor correlation with reoperation and readmission rates. CONCLUSION: The current study underscores the critical importance of employing risk stratification through ESS for patients undergoing emergency laparotomy. By employing ESS, healthcare professionals can accurately anticipate resuscitation requirements and stabilize patients preoperatively. This proactive approach enables the identification and optimization of patients unsuitable for immediate surgery, facilitating informed decisions on targeted treatment, surgical intervention, and postoperative care pathways.

The Great Mimicker of Gastric Cancer: A Case Report of Ménétrier's Disease.

This is the case of a 52-year-old Indian lady who presented with hematemesis, severe anemia, and an abdominal lump in cardiac failure. On radiographic evaluation, the lesion appeared to be gross circumferential asymmetric proximal gastric wall thickening, with suspicion of gastric lymphoma or tubercular hypertrophic gastritis. After stabilization with multiple transfusions, she underwent proximal D2 gastrectomy with esophago-gastric anastomosis and a total splenectomy. Grossly, the gastric rugae appeared to be hypertrophied and firm. No growth was identified grossly; however, necrotic areas were identified at the distal end. Microscopic examination of multiple sections studied showed significant foveolar hyperplasia, tortuous glands, and a few cystically dilated foveolar glands, which were limited up to the muscle layer. Mild serosal congestion was seen. No atypia or invasion was seen. An impression to consider is the possibility of Ménétrier's disease (MD). MD is an acquired protein-losing enteropathy with giant gastric rugal folds, decreased acid secretion, and increased gastric mucous production. Radiographically, endoscopically, and grossly, the condition can be confused with malignant lymphoma or carcinoma. It is difficult to diagnose, and histopathological confirmation of the resected specimen is needed for a definitive diagnosis. Our intention in presenting this case is to emphasize that MD can present as massive hematemesis and should be considered in a differential diagnosis. Surgical treatment by total or partial gastrectomy is recommended for cases with persistent, debilitating symptoms or a risk of cancer.

A Path Less Travelled: A Case Report of an Unusual Trip of a Gall Stone.

Gall stone ileus is one of the rare complications of patients with cholelithiasis and usually affects elderly females. The usual sites for the stone to get impacted are the distal ileum and ileocaecal valve. Computed tomography (CT) remains diagnostic and surgery is the treatment of choice. A 60-year-old diabetic female, who was diagnosed with gall stone-induced pancreatitis one month ago, presented to the surgical emergency department with complaints of right upper abdominal pain with recurrent vomiting and constipation of five days duration. The patient was managed conservatively. A provisional diagnosis of subacute intestinal obstruction was kept and a barium meal follow-through (BMFT) was requested. However, BMFT was inconclusive. After two weeks, she presented again to the emergency department with clinical features of subacute intestinal obstruction. The patient was planned for exploratory laparotomy in view of recurrent episodes of obstruction and the presence of peritonism. Intraoperatively, we encountered a cholecystogastric fistula with a gall stone of size approximately 6.5x4 cm impacted at approximately 60 cm from the ileocaecal junction and dilated proximal small bowel loops. The surgical procedure comprised enterolithotomy and cholecystectomy along with repair of cholecystogastric fistula done. The patient had an uneventful postoperative course. Gall stone ileus is a rare cause of small bowel obstruction. Gall stone ileus presenting with a recent history of pancreatitis further makes the suspicion very unlikely.

Effect of Octreotide on Lymphorrhea in Patients After Modified Radical Mastectomy for Carcinoma Breast: A Randomized Controlled Trial.

Introduction Lymphorrhea or seroma formation after modified radical mastectomy (MRM) is a serious and disabling complication of axillary lymphadenectomy. Octreotide is a hormone with general anti-secretory effects. The potential role of octreotide in the treatment of lymphorrhea after axillary lymph node dissection in patients undergoing MRM is being investigated in this study. The purpose of this research is to study the effect of octreotide on the magnitude and duration of lymphorrhea in patients after MRM for carcinoma breast. Methods This clinical trial was registered in the Clinical Trials Registry India (CTRI/2017/11/010653). It was conducted in the Department of General Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi from September 2015 to March 2017. This study is a parallel randomized controlled trial with a 1:1 allocation ratio. Thirty patients were enrolled and allocated equally into two groups. The intervention group received standard medical care plus injection octreotide 100 micrograms eight hourly intravenously post-operatively for five days and the control group received only standard medical care. The primary outcomes were lymphorrhea volume from 24 hours post-surgery till five days post-operatively and the number of days till the suction drain was removed. Secondary outcomes were surgical site infection, the incidence of seroma formation, complications of octreotide, duration of hospital stay, and the number of lymph nodes isolated. All the patients were followed up twice a week for the first six weeks after discharge followed by three monthly visits. Results A total of 30 patients were included in the study. The mean age was 46.2 years. The mean operative time in the control group was 137.87 ± 23.28 minutes and in the octreotide group was 128.13 ± 12.29 (p = 0.163). The volume of lymphorrhea in the control group was 354.67 ± 346.28 ml and in the octreotide group was 194.00 ± 240.62 ml (p = 0.081). Seroma occurred in 9% of patients in the control group and 2 % of patients in the octreotide group (p = 0.010). The duration of lymphorrhea was 4.93 ± 2.49 days in the control group and 3.13 ± 1.36 days in the octreotide group (p = 0.029). The duration of stay was 7.07 ± 2.40 days in the control group and 5.13 ± 1.06 days in the octreotide and was found to be statistically significant (p = 0.010). No obvious adverse reactions related to injection octreotide, namely, nausea, vomiting, abdominal discomfort, hypotension, bradycardia, and dysglycemia, were seen in any of our patients. Conclusion The duration of lymphorrhea, incidence of seroma formation, and duration of hospital stay were lesser in the octreotide group, and the difference was statistically significant. The wound infection rates were similar in both groups. Thus injection octreotide can be used safely and effectively.

Spontaneous Hepatic Hydatid Cyst Rupture Into the Transverse Colon.

Hydatid disease is a prevalent parasitic infestation caused by the cestode Echinococcus  granulosus in predominantly rural areas of the Mediterranean region, South East Asia, Australia, and South America. This report discusses a unique case of a 32-year-old lady who presented to the Emergency Surgery Department with complaints of abdominal pain, distension, and constipation for five days. Radiological investigations showed air-fluid levels within a large cyst originating from the liver. Surgical exploration revealed a large hepatic hydatid cyst communicating with the transverse colon with the presence of multiple peritoneal hydatid cysts. Evacuation of the cyst contents, lavage, and excision of the rest of the hydatid cysts was done. Dense adhesions were present involving the liver, large bowel, and duodenum. Therefore, a terminal ileum diversion loop ileostomy was made. Ileostomy was reversed after checking the large bowel anatomy with a distal loopogram.

Asymptomatic gossypiboma with complete intramural migration and ileoileal fistula.

Retained gossypiboma is a rare and under-reported complication of surgery, which can present in a variety of ways. Thus, a very high index of suspicion is required by the clinician to clinch the diagnosis in a postoperative patient. A 45-year-old woman, who was otherwise asymptomatic, presented to the General Surgery outpatient department (OPD) with a contrast-enhanced CT suggestive of a retained intra-abdominal foreign body from previous surgery. An exploratory laparotomy was planned on elective basis. Intraoperatively, dense inter-bowel adhesions were found in the upper abdomen. After a meticulous adhesiolysis, an ileoileal fistula and an intraluminal surgical sponge were discovered. Resection and anastomosis of the involved ileal segment was done. An asymptomatic patient with a migrated intramural gossypiboma with an ileoileal fistula is an extremely rare occurrence. In these circumstances, it becomes almost impossible for the surgeon to clinch the diagnosis of a gossypiboma in an otherwise asymptomatic patient, without the aid of radiological investigations.

Paraneoplastic cerebellar degeneration with bilateral facial palsy: a rare primary presentation of breast cancer.

Paraneoplastic cerebellar degeneration is a rare dysfunction of the cerebellum associated with malignancy. Nevertheless, it is the most common paraneoplastic syndrome affecting the brain. A 50-year-old woman presented to the neurology outpatient department (OPD) with symptoms of cerebellar dysfunction since 4 months and complaints of a painless lump in the right breast and drooling from mouth since 1 month. Examination revealed classical signs of cerebellar dysfunction and a 5×5 cm lump in the right breast with a single right axillary lymph node. Serum anti-Yo antibody titre was strongly positive. The patient was referred to General Surgery OPD for opinion. After establishing the diagnosis of right breast carcinoma; she underwent a right modified radical mastectomy. She was referred to the oncologist for chemo/radiotherapy but because of poor performance status, only symptomatic treatment was pursued. Follow-up till now shows no improvement in the neurological dysfunction.

Ingestion of nine metallic nails with corrosive: what happened next?

A 20-year-old woman was brought to the surgery emergency department with the complaint of epigastric pain since 1 day following ingestion of multiple metallic nails with a cup full of toilet cleaner (corrosive acid) with a suicidal intention. Physical examination was essentially unremarkable, and the abdomen showed no signs of perforation peritonitis. X-rays of the abdomen showed multiple 'nail'-like radiopaque shadows in the abdominal cavity with no evidence of free gas under the domes of the diaphragm. A non-operative expectant management was pursued. The patient had passed all the sharps in stools without any complication and was discharged after 12 days. After 3 weeks, the patient presented with non-bilious vomiting. Further investigations revealed pyloric stenosis with no oesophageal luminal stenosis. To bypass the pyloric stenosis, a Billroth II gastrojejunostomy was performed. The postoperative period was uneventful, and the recovery was smooth.

Relationship of Gallbladder Perforation and Bacteriobilia with Occurrence of Surgical Site Infections following Laparoscopic Cholecystectomy.

Aim. To assess the occurrence of SSIs in patients with spillage of gallbladder contents and bacteriobilia during laparoscopic cholecystectomy. Methods. We evaluated 113 patients who underwent laparoscopic cholecystectomy between September 2013 and April 2015. The SSIs and their relationship with gallbladder rupture and bacteriobilia were assessed. Results. The mean age of patients developing SSIs was 45.57 ± 8.89 years. 18 patients (16%) had spillage of bile from the gallbladder. Percentage of SSIs overall was 6%, while percentage of SSIs in gallbladder content spillage was 5.5%. Organism profile of the culture from surgical site showed monomicrobial infection: 58% Staphylococcus aureus, 14% Pseudomonas, and 14% E. coli. The occurrence of SSIs in patients with bacteriobilia was 16% as compared to 2% in patients without bacteriobilia. Conclusions. Gallbladder content spillage is not a significant risk factor leading to increase in SSIs. The occurrence of SSIs is significantly higher in patients with bacteriobilia.

Isolated pancreatic cysticercal cyst presenting as a diagnostic challenge: diagnosis and treatment review.

Human cysticercosis most commonly affects the subcutaneous tissues, skeletal muscles, lungs, brain, eyes, liver and, rarely, the heart, thyroid and pancreas. Owing to vague clinical presentation and unfamiliarity of clinicians with this entity, it is difficult to diagnosis when seen as an isolated cyst. We present a case of a 16-year-old boy who presented with an upper abdominal lump and jaundice. Ultrasonography (USG) and MRI of the abdomen were carried out, which revealed a cystic mass (8.5 × 7 × 7 cm) in the pancreas. No evidence of solid component or papillary projections was noted within the lesion. Tumour markers carcinoembryonic antigen (CEA) and cancer antigen (CA 19-9) were normal. Fine needle aspiration cytology was performed, which revealed the presence of cysticercus larvae, along with a foreign body giant cell reaction. The patient was treated with therapeutic aspiration and antihelminthic therapy. Since then, he has been symptom free and under regular follow-up for the last 1 year. A diagnosis of cysticercal cyst at atypical sites is very rare and depends mainly on histopathological examination, which, along with USG and MRI, can give an accurate analysis. These cysts can be very well treated non-surgically with antihelminthics and aspiration.

Tongue cleaner, an unusual foreign body in the urethra: A case report.

INTRODUCTION: Various cases of self-inflicted foreign body insertion into the urethra have been reported in adult males. The most common motive for such acts has been postulated as autoerotic stimulation, psychiatric illness or intoxication. CASE PRESENTATION: A 40-year-old male presented with a partially inserted tongue cleaner in his urethra with one end projecting from the urethral meatus and with a history of bleeding and pain. After a gentle attempt of removal using local anaesthetic gel the patient was scheduled for its surgical removal under anaesthesia. CONCLUSION: Large complex foreign bodies may be not amenable to endoscopic removal and may warrant open surgical procedure. Urethral stricture should be suspected in such patients. A psychiatric visit should be recommended for all adult males with self-inflicted foreign body in the urethra.

Is aggressive therapy the answer for all cases of emphysematous pyelonephritis: a report of three cases.

Emphysematous Pyelonephritis (EPN) is a severe, necrotizing, life threatening infection of the renal parenchyma and management is not standardised due to scarcity of literature. We present 3 patients with this rare entity. All 3 patients were of class III on CECT findings based on Huang's classification and had more than two risk factors. Our first patient underwent percutaneous drainage of his condition upon which he recovered. The second and third patients underwent a laparotomy and nephrectomy. The second patient recovered after a stormy post operative period and the third patient died. Management of the first patient was contrary to that recommended in literature, for the other two it was as per recommendations. On successful management of our first patient without surgery and seeing no discernable benefits of surgery for our other two patients, it is possible that percutaneous drainage alone, coupled with antibiotics may be a viable strategy for managing this condition with nephrectomy being considered as a second tier option.