A Literature Review of Microscopic Colitis.

Although the clinical importance of microscopic colitis (MC) is highly increasing, however, the disease is still mysterious due to several challenges. Recent MC data depend mainly on doubts and uncertainties leading to misclassification. This review discussed the current knowledge gaps about MC and various controversies regarding its subtypes, pathogenesis, and management. The diagnosis of MC is based mainly on histology and immunohistopathology which can discriminate two subtypes. However, transitional forms are often associated with misclassification. The site and number of the colon biopsies have been agreed upon as at least three from each side of the colon (right and left) with a total of six. There is no credible, clear explanation for the increased incidence. The etiopathogenesis is possibly multifactorial with a high impact on the immunological background. It is proposed that MC would be the initiative of irritable bowel disease, which needs further data clarification. Although budesonide is an effective treatment in most cases, budesonide-refractory MC represents a significant clinical challenge. Therefore, immunomodulators and biologics are now well-thought to be the second-line choice for treatment.

Does Diagnostic Laparoscopy Still Have a Role in the Evaluation of Right Iliac Fossa Pain Versus Imaging Techniques or Experience?

Background Right iliac fossa (RIF) pain is the most common cause of emergency surgical presentation, and a significant number of patients are eventually diagnosed with acute appendicitis. Typically, appendicitis is a clinical diagnosis, and it is prudent to take the patient to theatre for an early diagnostic laparoscopy (DL) to prevent complications as a result of acute appendicitis with the caveat it may lead to an increased number of negative appendectomies. The primary objective of this study was to ascertain the efficacy of DL in tackling RIF pain. The secondary objective was to compare the results among the diagnostic versus imaging groups (negative appendectomy rate, postoperative complications, and length of stay). Methodology The data were collected retrospectively for patients presenting with RIF pain in the surgical unit of the Royal Oldham Hospital between April 2017 and March 2019. The electronic database was utilized to identify all patients who underwent appendicectomy during this period. Patients were divided into two groups, group one had DL as their primary operation, and group two had imaging prior to surgery. Group two was further subdivided into computed tomography (CT) and ultrasonography (USG). Data included blood results, imaging reports, intraoperative findings, length of stay (LOS), postoperative complications, and histopathology results. The data were analysed using an Excel sheet and SPSS version 27 (IBM Corp., Armonk, NY, USA). Results A total of 340 patients were identified. Group one had 165 (48.53%) and group two had 175 (51.47%) patients. Most surgeries were carried out by middle-grade doctors (80.95%). Comparison with the histopathology report revealed that the negative appendectomy rate was 20% in group one, 3.8% in the CT group, and 27.5% in the USG group. The average length of stay was 2 ± 1.38 days in the diagnostic group and 3 ± 2.7 and 3 ± 0.8 days in subsequent groups. Conclusions This study shows that DL is a valuable first option when trained surgeons are available for tackling RIF pain, particularly in the young age group where it can reduce the risk of radiation exposure, decrease LOS, and avoid complications because of perforation.

Johan Forceps As a Knot Pusher for Extracorporeal Roeder Knot: An Inexpensive Alternative to an Endoloop Ligature in Laparoscopic Appendicectomy.

Background: Securing of the appendix stump is one of the key steps in performing laparoscopic appendicectomy (LA). This can be achieved by a variety of methods including endoloops, stapler, and clips. An alternative technique, previously described by authors, is the use of Johan forceps as a knot pusher, to deploy an extracorporeal Roeder knot at the base of appendix. We aimed to evaluate the safety and cost-effectiveness of our technique. Patients and Methods: A single surgeon's, prospective cohort, and multicenter study was undertaken at three different hospitals in the United Kingdom. We collected data of all patients, who underwent LA by this technique between 2014 and 2019. Demographics, operative findings, postoperative complications and readmissions were recorded and analyzed. Results: In total, 227 appendicectomies were performed. Median age was 24 years (interquartile range [IQR]: 16-58) with 58% male preponderance. Operative findings were 57% (n = 130) acutely inflammatory appendicitis, 16.74% (n = 38) were complicated appendicitis (perforated, gangrenous). Rest of the operative findings were macroscopically normal appendix (with no other pathology in 18.06% (n = 41), and macroscopically normal appendix but with gynecological pathologies in 7.9% (n = 18). Postoperatively, there were no cases to report complication of blow out stumps neither clinically nor radiologically. Surgical site infections rate has been 3.5% (n = 8). One patient had small intra-abdominal abscess (0.4%), treated by IV antibiotics. Mean hospital stay was 1.89 days (standard deviation [SD] 1-5 days). Thirty days readmissions rate was 4.8%. None of the complications or readmissions was related to the surgical technique. There were no deaths recorded in this series. Cost of handmade endoloop was $0.69. Conclusion: Use of Johan forceps as knot pusher for extracorporeal Roeder knot is a safe, feasible, cost-effective, and easily reproducible technique for carrying out LA.

A Rare Case of Intestinal Low-Grade Endometrial Stromal Sarcoma With Glandular Differentiation and Associated Endometriosis.

Endometrial stromal sarcoma is a rare tumour. It is even rarer to find it arising in the background of endometriosis in an extrauterine location. This case report describes a case of missed diagnosis of intestinal extra-uterine endometrial stromal sarcoma associated with endometriosis, and the subsequent presentation with distant metastases. The potential pitfalls are highlighted and differential diagnoses are discussed.

Appendiceal inflammation affects the length of stay following appendicectomy amongst children: a myth or reality?

The effect of the severity of appendiceal inflammation on post-operative stay in children following appendicectomy has shown conflicting results. This study was conducted to determine the association between the severity of appendiceal inflammation and post-operative stay amongst children undergoing open appendicectomy. A retrospective cohort study was conducted at a District General Hospital for two years. A total of 204 patients were included in the study with an age range between 3 and 16 years. Females were 54.9% while the rest were male. Mean age was 12.5 ± 3 years. The association of the severity of appendiceal inflammation and post-operative stay was assessed by multivariable Cox Proportional hazards model. Mean post-operative stay was 2.32 days (95% CI 2.14-2.51). Macroscopically perforated appendix, histological inflammation and post-operative complications were significantly associated with post-operative stay on univariable analysis (P < 0.05). Whereas, the multivariable analysis showed that the post-operative stay was significantly prolonged only in case of either perforated appendix or post-operative complications while it remained unaffected by the histological inflammation.

Spontaneous Atraumatic Mediastinal Hemorrhage: Challenging Management of a Life-Threatening Condition and Literature Review.

Spontaneous atraumatic mediastinal hematomas are rare. We present a case of a previously fit and well middle-aged lady who presented with acute breathlessness and an increasing neck swelling and spontaneous neck bruising. On plain chest radiograph, widening of the mediastinum was noted. The bruising was later confirmed to be secondary to mediastinal hematoma. This life-threatening diagnostic conundrum was managed conservatively with a multidisciplinary team approach involving upper gastrointestinal and thoracic surgeons, gastroenterologists, radiologists, intensivists, and hematologists along with a variety of diagnostic modalities. A review of literature is also presented to help surgeons manage such challenging and complicated cases.

One-stop cholecystectomy clinic: an application of lean thinking--can it improve the outcomes?

Lean thinking principles were utilised to set up 'One-stop cholecystectomy clinics' at which patients underwent the surgical and the preoperative assessment during the same visit. The main aims were to reduce the number of patient hospital visits, preoperative admissions and the waiting time to surgery. The results showed a significant reduction in the number of patient visits as well as the waiting time to surgery thus highlighting that patientcare can be improved by good team working and lean management.

Effectiveness of hydrocolloid dressing in postoperative hip and knee surgery: literature review and our experience.

Hydrocolloid dressings are impermeable dressings that provide an optimal environment for wound healing. These dressings are very effective in healing chronic wounds but evidence regarding their use for the post-operative knee and hip surgery is scarce. Our experience shows that hydrocolloid dressing (Duoderm) helps in preventing not only superficial surgical site infection (SSSI) but also blister formation in patients undergoing lower limb orthopaedic surgery.

Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis.

OBJECTIVES: Simple investigations like white cell count (WCC) and C-reactive protein (CRP) may help to improve the accuracy of diagnosis in paediatric appendicitis. We evaluated the diagnostic accuracy of WCC and CRP for the severity of acute appendicitis in children. DESIGN: Cross-sectional study. SETTING: This study was conducted on all children who underwent open appendectomy from January 2007 to December 2008 at a District General Hospital. Data regarding demographics, WCC, CRP, histology and postoperative complications were analysed. PARTICIPANTS: All children who underwent open appendectomy during the study period. MAIN OUTCOME MEASURES: Diagnostic accuracy of WCC and CRP for simple acute appendicitis and a perforated appendix. RESULTS: Out of 204 patients, 112 (54.9%) were girls. At surgery, appendix was grossly inflamed in 175 of which 32 had perforation. Histology revealed simple acute appendicitis in 135 (66.2%) and gangrenous appendicitis in 32 (15.7%). The rest were normal. The duration of symptoms, temperature, length of stay, WCC and CRP were significantly worse in the perforated group (P value <0.05). Postoperative complications included wound infection (n = 18), pelvic collection (n = 5) and intestinal obstruction (n = 6); and were more common among patients with a perforated appendix (P value <0.05). WCC had a higher diagnostic accuracy and higher sensitivity than CRP in diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increased to 95% and 100% for the diagnosis of simple acute appendicitis and a perforated appendix, respectively. CONCLUSION: Accuracy of WCC is higher than CRP for diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increases for simple acute appendicitis as well as a perforated appendix.

Spontaneous bilateral neck of femur fractures and shoulder dislocation.

Non-traumatic fractures mostly present a diagnostic dilemma. Fracture risk is less reported in non-epileptic seizures. Various metabolic conditions leading to a decrease in bone mineral density may also cause fractures. The authors report the case of non-traumatic fracture of an old woman who presented with fever, shortness of breath and right shoulder pain without any history of epilepsy. Episode of seizures was noted prior to admission. The patient had poorly controlled diabetes mellitus and severe hypoglycaemia was noted at the time of admission. She was admitted to a medical ward for a severe chest infection. Non-traumatic fracture dislocation of the right shoulder was also noted upon admission and treated conservatively. Bilateral hip fractures were not diagnosed till the fourth day. Patient had multiple comorbidities making the management very difficult. Here the authors will discuss the possible aetiology of this pattern of pathologies and the multidisciplinary management of such a rare case in detail.

Epstein-Barr virus (EBV) positive anal B cell lymphoma: a case report and review of literature.

This case report is on a very rare case of giant anal canal ulcer with rectal prolapse causing total faecal incontinence. An elderly patient in her eighties presented to the emergency department with complaints of a mass protruding thorough anus along with fresh rectal bleeding. Examination revealed a large ulcer measuring 6 cm x 8 cm involving the entire anal canal with rectal prolapse. Here, we discuss the management of this patient with a rare cause of giant anal canal ulceration.

Giant mesenteric lymphangioma: a rare cause of a life-threatening complication in an adult.

Mesenteric cyst lymphangiomas (MCLs) are rare benign tumours of unknown aetiology seen mostly in children. Clinical presentation can be diverse ranging from incidental abdominal cysts to an acute abdomen. A 24-year-old previously fit and healthy young man presented with a 2-week history of cramping, central abdominal pain and vomiting requiring acute hospital admission. He was a diagnostic conundrum despite extensive preoperative investigations. Recurring symptoms required urgent surgical exploration, resection and histological confirmation with a successful outcome. We review the literature and present here this rare case in an adult of MCL that has the potential to grow, invade and develop major life-threatening complications.

Acute Chest Presentation following a Laparoscopic Nissen Fundoplication.

We describe a case of an acute paraoesophageal hernia in the early post-operative period following a laparoscopic Nissen fundoplication. Patient developed intraoperative tension pneumothorax requiring an immediate chest drain and subsequently needed respiratory support of a continuous positive airway pressure (CPAP) ventilation. A short discussion of this rare but deleterious complication and the difficulty of making a prompt diagnosis are included as delayed revision surgery can be technically challenging with a poor outcome.

Comparison of superficial surgical site infection following use of diathermy and scalpel for making skin incision in inguinal hernioplasty.

BACKGROUND: The method of making surgical incision remains a complex problem. Although controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rate or postoperative pain is reported with the use ofDiathermy. However, the fear ofexcessive scarring and poor wound healing has curtailed its widespread use for skin incision. OBJECTIVE: The objective of the study is to compare superficial surgical site infection (SSSI) in diathermy and scalpel skin incision in inguinal hernioplasty. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Study was conducted at Surgical Unit II, Holy Family Hospital. Rawalpindi from 1st Jan. 2008 to 30th September 2008. PATIENTS AND METHODS: A total of 80 patients who presented with inguinal hernias were included in the study. Patients were divided in two groups. Group1: In 40 patients skin incision was made with Diathermy, Group 2: The other 40 had skin incision with scalpel. RESULTS: The mean age of patients in the intervention group (Group 1) was 50 years while in the control group (Group 2) it was 46 years. 48% patients in Group 1 and 55% in the Group 2 had indirect inguinal hernias. SSSI was noted in 12.5% cases in Group 1 whereas in Group 2 it was 17.5% but this difference was not found to be statistically significant (p value=0.378). CONCLUSION: The use of diathermy for making skin incisions is as safe as scalpel and there is no significant difference amongst both regarding wound infection.

Evaluation of the aetiological spectrum of obstructive jaundice.

BACKGROUND: Jaundice is a common problem in medical and surgical gastroenterological practice. The surgical jaundice can be caused by the obstruction of the bile duct as with gall stones, strictures, malignancy, such as cholangiocarcinoma (in which the jaundice is persistent and progressive), periampullary carcinoma, carcinoma gall bladder and carcinoma head of pancreas. The objective of this descriptive study was to evaluate the Etiological spectrum of obstructive jaundice. METHODS: A prospective, descriptive study was carried out at Surgical Unit-II Holy family Hospital, Rawalpindi, from mid of May 2006 till March 2007. Sixty patients, who presented in the surgical OPD of Holy family Hospital, were included in the study. Thorough history and physical examination was followed by biochemical tests and various investigations like USG abdomen, ERCP, CT-Scan, & MRCP and histopathology. The data was analyzed using SPSS ver 14.0. RESULTS: Of the 60 patients; 40 (66.66%) were male and 20 (33.33%) were female, their mean age being 49.50 years. Malignant obstructive jaundice was seen in 34 (56.66%) patients while 26 (43.33%) had benign etiology. Amongst the commonest symptom; clay coloured stools (75%) was more frequent in patients with malignant disease whereas abdominal pain (51.66%) was most common in benign conditions. Commonest malignancy was Carcinoma (Ca) of the head of pancreas 18/60 (30%) followed by Ca gall bladder 8/60 (13.33%), cholangiocarcinoma 7/60 (11.66%), and periampullary carcinoma 1/60 (1.66%). Choledocholithiasis 21/60 (35%) was the commonest benign cause followed by stricture of common bile duct 3/60 (5%) and acute pancreatitis 2/60 (3.33%). CONCLUSION: Obstructive jaundice is common amongst females and the cause is mostly malignant. Ca head of pancreas is the commonest malignancy while Choledocholithiasis is the commonest benign cause. USG, ERCP and CT-Scan are important diagnostic modalities for evaluation of patient with obstructive jaundice with ERCP having the additional advantage of being therapeutic as well.