Acute Pancreatitis as the Index Manifestation of Parathyroid Adenoma.

Acute pancreatitis is one of the most common clinical emergencies encountered in our day-to-day practice. Although gallstones are the most common cause worldwide, alcohol consumption remains the leading cause of acute pancreatitis in the Indian population. We report a rare case of parathyroid adenoma, which presented with acute pancreatitis as its initial manifestation in an elderly patient. A 65-year-old gentleman with acute abdominal pain, distension, and obstipation, underwent emergency laparotomy in view of acute intestinal obstruction and was found to have acute pancreatitis intra-operatively. On post-operative evaluation, his serum calcium was >14 mg/dl and serum parathormone (PTH) was >2,000 pg/ml. Single-photon emission computed tomography (SPECT) and technetium (Tc-99m) sestamibi scintigraphy revealed a right inferior parathyroid adenoma, which was surgically excised, following which the patient made an uneventful recovery. Hypercalcemia induced by hyperparathyroidism causes auto-activation of pancreatic enzymes within the pancreatic parenchyma and is also believed to cause pancreatic duct obstruction by calcium deposition, thus causing pancreatitis. Radionucleotide scan, in addition to contrast-enhanced computed tomography, can help in localizing the lesion causing hyperparathyroidism. Appropriate resuscitation and stabilization with anti-hypercalcemic measures, including hydration and forced calciuresis, followed by surgery form the mainstay of treatment in patients with primary hyperparathyroidism. Patients with acute pancreatitis without a history of gallstone disease or alcohol intake should be evaluated for other rare causes. Early diagnosis and prompt treatment of the underlying condition can prevent the recurrence of pancreatitis.

Effect of Peri-Operative Hyperoxygenation on Surgical Site Infection in Patients Undergoing Emergency Abdominal Surgery: A Randomized Controlled Trial.

Background: The rationale for hyperoxygenation in controlling surgical site infection (SSI) has been described in many studies yet has not been defined clearly. Some studies in colorectal surgery have reported beneficial effects, whereas studies in gynecologic surgery have reported either no effect or a deleterious effect. This study assessed the effectiveness of hyperoxygenation on the reduction of SSI in patients undergoing emergency abdominal surgery. Patients and Methods: Eligible patients were assigned randomly to two groups (study group, 80% oxygen or control group, 30% oxygen). The patients in the study group received 80% oxygen and the patients in the control group received 30% oxygen intra-operatively and for two hours after surgery. Arterial blood gas analysis was done after resuscitation, at the end of the surgery, and at two hours after extubation. All patients were assessed for SSI, post-operative nausea and vomiting, and respiratory complications. Patients were followed post-operatively for 14 days. Surgical site infection was diagnosed according to U.S. Centers for Disease Control and Infection (CDC) criteria and by aerobic wound cultures. Results: After exclusion, 85 patients in the control group and 93 patients in the study group were analyzed. There was no difference for baseline, intra-operative, and post-operative characteristics between the two groups, except for higher oxygen saturation at closure and two hours post-operatively, in the 80% group (p = 0.01). Surgical site infection occurred in 29 patients (34.11%) in 30% fraction of inspired oxygen (FIO2) group and in 19 patients (20.43%) in 80% FIO2 group (p = 0.04). The risk of SSI was 59% lower in the 80% FIO2 group (adjusted odds ratio, 0.41; 95% confidence interval [CI], 0.19-0.88 vs. the 30% FIO2 group). There were no differences in post-operative nausea and vomiting and respiratory complications between the two treatment groups. Conclusions: Administration of 80% peri-operative hyperoxygenation in emergency abdominal surgery reduces SSI and is a cost-effective method.

Does negative pressure wound therapy with saline instillation improve wound healing compared to conventional negative pressure wound therapy? - A randomized controlled trial in patients with extremity ulcers.

BACKGROUND: Wounds are important health problems that cause significant financial burden and loss of time to work, more so in low and lower middle income countries. Negative pressure wound therapy (NPWT) is widely established in managing acute and chronic extremity wounds. We studied the effects of addition of normal saline instillation to NPWT in terms of changes in granulation tissue, bacterial-burden and overall wound healing using readily available means and materials including wall suction for negative pressure, sponge and adhesive transparent sheet for dressing and normal saline for irrigation. METHODS: All patients with extremity ulcers initially underwent surgical debridement. They were then allotted into two groups, group 1 (NPWT with normal saline instillation- NPWTi) including 25 patients and group 2 (NPWT) including 23 patients. Tissue-bit samples taken on day1 and day 10 were used for bacteriology and for assessing histology. The wound surface-area was measured using the software ImageJ on day 1 and day 10. RESULTS: Median log difference in colony-count between day1 and day10 was 0.6 (0.2-1.4) in group1 and 0.13 (0.04-0.6) in group 2 (p < 0.05). Mean percentage reduction in wound size was 28.82 and 19.80 in group 1 and group 2 respectively (p < 0.05). Histological parameters of wound healing assessed as surface epithelium, granulation, inflammatory cells, proliferative blood-vessels and fibroblasts were significantly better in group1. A drawback observed with NPWTi was skin maceration around the ulcer which was successfully managed. CONCLUSION: Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue.

Radiation-induced sarcoma presenting as a gluteal abscess: a diagnostic and therapeutic challenge.

Sarcomas are a rare and fatal treatment complication following radiotherapy. Radiation-induced sarcomas (RISs) presenting as a gluteal abscess is a rarity, accounting for its varied presentation. We present a case of a middle-aged woman, post-chemo-radiation for carcinoma cervix 5 years ago, who presented with gluteal abscess. Achieving haemostasis post incision and drainage under anaesthesia was a challenge. On further evaluation, she was diagnosed with radiation-induced gluteal soft tissue sarcoma. Haemostasis was achieved after radiation following failed attempts of surgical and radiological interventions. She is currently planned for chemotherapy. Cancer survivors have an increased risk of developing a second malignancy following radiation treatment. RISs are highly aggressive, exhibit a varied clinical presentation and pose a challenge in early diagnosis; thus, have a poor outcome. RISs pose a diagnostic challenge; any dubious lesion in the previously irradiated field should raise suspicion and prompt aggressive management.

Evaluation of B-Mode and Color Doppler Ultrasound in the Diagnosis of Malignant Cervical Lymphadenopathy.

Background B-mode ultrasound (BMUS) and color doppler ultrasound (CDUS) could be valuable in evaluating cervical lymphadenopathy compared to palpation. This study aimed at evaluating the efficacy of BMUS and CDUS in differentiating cervical lymph nodes into benign and malignant nature.  Methodology In this cross-sectional analytical study, a total of 166 patients, who were referred for US-guided fine-needle aspiration cytology (FNAC) of cervical nodes, were included. Patients with cystic/ necrotic cervical nodes or without FNAC/biopsy report were excluded. All study patients underwent BMUS and CDUS, followed by the reference investigation of FNAC/biopsy for analysis. In BMUS, short-axis diameter (SAD), short-axis/long-axis diameter ratio (S/L), presence or absence of echogenic hilum and well defined or ill-defined borders were analyzed. In CDUS, the vascular pattern of a cervical node was categorized as hilar, peripheral or mixed. In cases with multiple cervical lymph nodes, the node having the most suspicious features on the greyscale US was chosen. The results were compared with the final FNAC/biopsy reports. Results A total of 166 patients were analyzed in this study. The cut-off point of SAD and S/L ratio for the cervical lymph nodes was 1.28cm and 0.595. The S/L ratio was the best BMUS parameter with a sensitivity of 75%, the specificity of 81%, and an accuracy of 79%. Loss of echogenic hilum was the most sensitive parameter in this study with a sensitivity of 95.4% and an accuracy of 79.5%. The presence of ill-defined margins was significantly higher in the malignant nodes than the benign nodes with a p-value <0.001. The presence of peripheral/mixed vascularity was higher in the malignant nodes than the benign nodes with a p-value <0.001. Conclusions Malignant nodes had significantly higher SAD, higher S/L ratio, loss of echogenic hilum, presence of ill-defined margins and peripheral/mixed vascularity compared to benign nodes. The loss of echogenic hilum was the most accurate and sensitive parameter, while the S/L ratio was found to be the most specific BMUS parameter in the detection of malignant nodes. BMUS and CDUS identify malignant nodes and also helps in guiding FNAC/biopsy.

Carcinoma of the Accessory Axillary Breast: A Diagnostic Dilemma and a Management Challenge.

Carcinoma of the accessory axillary breast is uncommon, with an incidence of 0.2 to 0.6%. We report a patient whose biopsy of a suspicious lesion in the axilla present for one year revealed invasive ductal carcinoma (IDC). There was presence of breast tissue and absence of lymphoid tissue in the biopsy, suggesting a breast malignancy. Magnetic resonance mammography was suggestive of the lesion well away from the normal breast, confirming an accessory axillary breast. She was offered wide local excision of the lesion with axillary lymph node dissection and modified radical mastectomy (MRM), and she chose the latter. Her post-operative biopsy showed the involvement of all the 25 lymph nodes harvested. Any suspicious lesion in the axilla should be promptly worked up for malignancy. Accessory axillary breast carcinoma, if confirmed, can be addressed with wide local excision along with axillary lymph node dissection. However, further studies should clarify this and the outcomes.

Desire for Information and Preference for Participation in Treatment Decisions in Patients With Cancer Presenting to the Department of General Surgery in a Tertiary Care Hospital in India.

PURPOSE: Providing appropriate information to patients about their illness helps them to cope with the diagnosis. Shared decision making is a key concept in managing patients with cancer. There are no data available about the desire for information and preference for participation in treatment decisions among Indian patients with cancer. The objective of this study was to estimate the proportion of patients who have information needs and to study the patient preference for participation in treatment decisions and the factors associated with them. METHODS: A cross-sectional survey was conducted among patients with cancer older than 18 years. They were interviewed with a questionnaire after signing an informed consent. The association of sex, educational level, residence, diagnosis (type of cancer), Eastern Cooperative Oncology Group performance status, and treatment status with information needs and decision-making preference was analyzed using χ2 test. RESULTS: Approximately 81% of patients said that they had an absolute need to know if the illness was cancer, and > 70% of patients either had an absolute need to know or would like to know about the prognosis, treatment options, and adverse effects. Regarding the decision-making preferences, 97% wanted their treating physicians to make the decision regarding their treatment, and 66% preferred to share decision making with their family. CONCLUSION: The majority of the patients with cancer expressed a need for knowing whether they had cancer. When it comes to treatment decisions, most of them preferred a passive role, and the majority wanted to involve their families in the decision-making process. We recommend that the treating physician should elicit the patient's preference in participating in treatment decisions and their preference about involving their family in making treatment decisions.

Portal Annular Pancreas: Case Report of a Rare Anomaly.

Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.