Microsurgical approach for resection of the filum terminale internum in tethered cord syndrome-a case demonstration of technical nuances and vignettes.

BACKGROUND: In tethered cord syndrome due to filum terminale pathology, the surgical approach to achieve detethering of the spinal cord may vary. Traditionally, sectioning the filum through a laminectomy at the lumbosacral level is performed. METHOD: A microsurgical technique at a higher level to approach the filum below the conus tip is performed. This allows for removal of the entire distal portion of the filum through a limited interlaminar approach and dural opening. CONCLUSION: We propose a technique to transect the filum terminale below the conus tip and extract the distal filum by releasing it from its intradural attachments to minimize any remnants of the filum terminale.

Superficial temporal artery injury and delayed post-cranioplasty infection.

OBJECTIVE: Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication. METHODS: A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups. RESULTS: Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26). CONCLUSIONS: There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Positive Peritoneal Lavage Cytology -Implications for Staging and Management of Gastric Cancer.

The survival rates of gastric cancer patients with cytology-positive peritoneal lavage fluid without macroscopic dissemination (CY+/P-) is the same as that of patients with overt peritoneal metastasis.The 5-year survival rate of such patients is only 2%. The current study aims to highlight its significance in the staging of gastrointestinal malignancies and its implications for patient care. Prospective nonrandom analysis of peritoneal wash cytology in patients with gastrointestinal malignancies was conducted in the department of Surgical Gastroenterology, Nizams Institute of Medical Sciences, Hyderabad from January 2012 to June 2013. Descriptive statistics and ANOVA variance analysis was performed to estimate incidence, risk factors and the effect of surgery in causing peritoneal dissemination of malignancy. A total of 60 patients with operable gastric cancer underwent peritoneal lavage for evaluation of malignant cells. The incidence of Positive peritoneal lavage cytology was 8.3% (5/60).Four patients with positive lavage fluid belong to T3 stage (11.7%, p-0.309).Poorly differentiating and mucinous tumors had a higher incidence of positive cytology (18.1% and 25%).None of the patients with positive cytology had positive resection margin. Tumors with advanced T stage, lymph nodal involvement, lympho-vascular and perineural invasion have higher incidence of positive peritoneal cytology. Surgical handling has a negligible effect in peritoneal dissemination of tumor. Large scale studies are warranted to validate the findings and define it's role in management of gastric cancer.

Predictors of successful non-operative management of grade III & IV blunt pancreatic trauma.

INTRODUCTION: Although surgery is the preferred treatment for grade III&IV pancreatic trauma, there is a growing movement for non-operative management. in blunt pancreatic trauma. Very few studies compare operative versus non-operative management in adult patients. METHODS: Retrospective analysis of a prospectively maintained database was performed from 2004 to 2013 in the department of gastrointestinal surgery, NIMS, Hyderabad. Comparative analysis was performed between patients who failed versus those who were successfully managed with non-operative management. RESULTS: 34 patients had grade III/IV trauma out of which 8 were operated early with the remaining 26 initially under a NOM strategy, 10 of them could be successfully managed without any operation. Post-traumatic pancreatitis, Necrotizing pancreatitis, Ileus, contusion on CT, surrounding organ injuries are independently associated with failure of NOM on a univariate analysis. On multivariate logistic regression presence of necrosis& associated organ injury are factors that predict failure of NOM independently. Development of a pseudocyst is the only significant factor that is associated with a success of NOM. CONCLUSIONS: Non-operative measures should be attempted in a select group of grade III&IV blunt pancreatic trauma. In hemodynamically stable patients with a controlled leak walled off as a pseudocyst without associated organ injuries and pancreatic necrosis, NOM has a higher success rate.

The role of image guided percutaneous drainage in multidisciplinary management of necrotizing pancreatitis.

BACKGROUND: Percutaneous catheter drainage (PCD) has become popular as a minimally invasive technique in the treatment armamentarium of patients with necrotizing pancreatitis requiring intervention. It obviates surgery and its attendant morbidity in a considerable number of patients in this setting. AIM: The aim of the study was to examine whether PCD upfront avoids surgery in a cohort of patients with necrotizing pancreatitis requiring intervention, and to identify factors predicting its failure. METHODS: We retrospectively reviewed demographic, clinical, and perioperative details of patients with severe acute pancreatitis from January 2009 to December 2011. Of 40 patients with necrotizing pancreatitis admitted to the surgical gastroenterology unit at our institute, 23 patients requiring PCD or surgical intervention were included in this study. Patients with successful and failed PCD were compared to identify factors predictive of failure of PCD. We also compared patients undergoing open necroseotomy with those undergoing PCD upfront, and open necrosectomy in terms of major complications including death. RESULTS: . Surgery was avoided in 7/23 (30%) patients with necrotizing pancreatitis who underwent PCD upfront. Higher APACHE II score (p=0.003) and extent of intrapancreatic necrosis (> 50%, p=0.03) were statistically significant predictors of failure of PCD. Although the complications were not different in patients undergoing PCD upfront followed by surgery, they had lower APACHE II and SOFA scores after PCD and had resolution of organ failures. CONCLUSIONS: PCD obviates surgery or acts as a temporizing measure in a significant number of patients with necrotizing pancreatitis. APACHE II scores and extent of intrapancreatic necrosis are principle factors determining success of PCD.

ARID1B, a member of the human SWI/SNF chromatin remodeling complex, exhibits tumour-suppressor activities in pancreatic cancer cell lines.

BACKGROUND: The human ATP-dependent SWItch/sucrose nonfermentable (SWI/SNF) complex functions as a primary chromatin remodeler during ontogeny, as well as in adult life. Several components of the complex have been suggested to function as important regulators of tumorigenesis in various cancers. In the current study, we have characterised a possible tumour suppressor role for the largest subunit of the complex, namely the AT-rich interaction domain 1B (ARID1B). METHODS: We performed Azacytidine and Trichostatin A treatments, followed by bisulphite sequencing to determine the possible DNA methylation-induced transcription repression of the gene in pancreatic cancer (PaCa) cell lines. Functional characterisation of effect of ARID1B ectopic expression in MiaPaCa2 PaCa cell line, which harboured ARID1B homozygous deletion, was carried out. Finally, we evaluated ARID1B protein expression in pancreatic tumour samples using immunohistochemistry on a tissue microarray. RESULTS: ARID1B was transcriptionally repressed due to promoter hypermethylation, and ectopic expression severely compromised the ability of MiaPaCa2 cells to form colonies in liquid culture and soft agar. In addition, ARID1B exhibited significantly reduced/loss of expression in PaCa tissue, especially in samples from advanced-stage tumours, when compared with normal pancreas. CONCLUSION: The results therefore suggest a possible tumour-suppressor function for ARID1B in PaCa, thus adding to the growing list of SWI/SNF components with a similar function. Given the urgent need to design efficient targeted therapies for PaCa, our study assumes significance.

Cefoperazone-sulbactam for treatment of intra-abdominal infections: results from a randomized, parallel group study in India.

BACKGROUND: Combinations of a third-generation cephalosporin and metronidazole, with or without an aminoglycoside, often are used for the treatment of intra-abdominal infections in surgical settings. Simpler regimens that preserve an adequate spectrum of coverage, but allow easier administration and have fewer side effects, may be a more desirable option. METHODS: This randomized, open-label, active comparator study evaluated the effectiveness (non-inferiority hypothesis) of the beta-lactam/beta-lactamase inhibitor combination cefoperazone-sulbactam (2-8 g/day), compared with ceftazidime (2-6 g/day)-amikacin (15 mg/kg/day)-metronidazole (500 mg three times daily) in 154 and 152 subjects, respectively, having intra-abdominal infections. The study was conducted at 17 centers in India. RESULTS: Non-inferiority of cefoperazone-sulbactam (91.9%) compared with ceftazidime-amikacin-metronidazole (81.8%) was demonstrated for continued resolution of clinical signs and symptoms at the 30-day follow-up (primary endpoint) with a treatment difference of 10.1% (95% confidence interval 2.1%, 18.1%; pre-defined non-inferiority limit > -12.5%). Superiority of cefoperazone-sulbactam also was demonstrated for this endpoint, with significantly more subjects achieving continued resolution at the 30-day follow-up than in the comparator group (p = 0.015). On microbiologic outcomes, cefoperazone-sulbactam had higher success rates than ceftazidime-amikacin-metronidazole (92.9% vs. 80.0%). The pathogens (202 isolated) isolated most commonly were Escherichia coli (38.6%) and Klebsiella spp. (12.9%). The incidence of treatment-related adverse events was 6.5% and 16.4% in the cefoperazone-sulbactam and ceftazidime-amikacin-metronidazole groups, respectively, with more discontinuations due to treatment-related adverse events in the comparator arm (3.2% vs. 9.9%). CONCLUSION: Empirical cefoperazone-sulbactam monotherapy could be a useful adjunct to surgical intervention for intra-abdominal infections.

Postoperative infection of an abdominal mesh due to methicillin resistant Staphylococcus aureus - a case report.

Methicillin resistant Stephylococcus aureus (MRSA) infection has now become a major problem in hospitals. We present a case of postoperative infection MRSA where the primary source of the infection was found to be an abdominal mesh that was used to reinforce the abdominal wall. After one year of surgery, the patient developed wound dehiscence and discharge. MRSA was isolated from the wound, mesh, external nares, throat and axilla. Initially she was started on clindamycin and discharged from the hospital. After 5 months, patient came back to the hospital with infection at the same site. The patient was then treated with vancomycin and MRSA clearance. She responded to the treatment with complete healing of the wound and clearance of MRSA.

Isolated splenic tuberculosis.

The authors report two cases of isolated splenic tuberculosis treated since 1989 in Nizam's Institute of Medical Sciences. One case presented as pyrexia of unknown origin (PUO) and another with idiopathic thrombocytopenic purpura (ITP). Both were found to have splenic tuberculosis after splenectomy. Pre operative diagnosis could not be made in these cases. Splenectomy followed by antituberculous chemotherapy cured the condition in both the cases. The authors underline the diagnostic difficulties, essentially related to the rarity of this condition inspite of the progress in modern imaging.

Pancreatico-biliary ductal union.

A long common channel distal to the pancreaticobiliary junction is the commonest anomalous arrangement of the pancreaticobiliary ductal system and is mostly observed in patients with congenital choledochal cysts. APBDU without choledochal cyst is a high-risk condition for the development of gallbladder carcinomas. Prophylactic excision of the extrahepatic biliary system and reconstruction of the biliary tract with hepatico-jejunostomy are recommended. APBDU should always be kept in mind when a patient with a long history of abdominal pain is found to have gall bladder wall thickness even without gallstones on imaging by a CT Scan or Ultra Sound. ERCP should be performed in these patients in order to detect APBDU. This may allow early detection of carcinoma of the biliary tract. Presence of common channel may be associated with a lower incidence of gallstones. However it requires corroboration by other studies. On the other hand carcinoma of the gall bladder appears to have a close association with abnormally long common channel.

Primary small intestinal adenocarcinoma.

Seven patients with adeno-carcinoma of the small intestine were seen over a period of five years. Four were localized to the duodenum, the jejunum was involved in two and the ileum in one. Abdominal pain, weight loss, anemia and obstruction were the most common presenting complaints. Endoscopy was the primary diagnostic modality for the duodenal tumours. Diagnostic accuracy of barium contrast examination was 83%. Curative resections were performed in two patients and palliative surgery in the rest.

Icterus due to tumor emboli--a rare presentation of hepatoma.

Two cases of hepatocellular carcinoma presenting with features of obstructive jaundice are reported because of their unusual presentation. Both of them had obstruction of the common bile duct by tumor emboli and underwent palliation with surgical evacuation of the tumor thrombus.