Synchronous Malignancies: Pathological Analysis of Three Patients, Each with Dual Malignancies.

Multiple primary malignancies are defined as two or more malignancies arising independently to each other in the same or different anatomical sites, while excluding the possibility of metastasis from the primary malignancy. Here, we present three cases, each with dual malignancies involving different anatomical locations.

A Retrospective Cohort Study of Major Salivary Gland Tuberculosis: Our 13 Year Experience.

The tuberculous infection of major salivary glands is rare because they are relatively resistant to tubercle bacilli. The aim of this study is to present our 13 year experience on major salivary gland tuberculosis. The clinical, histopathological, microbiological and imaging records of 9 cases of major salivary gland tuberculosis were reviewed retrospectively. The cases diagnosed with either microbiological culture and/or polymerase chain reaction assay and/or Histopathological examination were included in the study. Descriptive statistics were used to summarize the data. There were 9 cases with tuberculous involvement of major salivary glands; parotid (n = 5), submandibular (n = 3), sublingual (n = 1). The most common local symptom was painless swelling present in 8 cases and constitutional symptoms were present in all the cases. The previous history of TB was present in 5 out of 9 cases. Surgical intervention was done in 2 cases of parotid TB for diagnostic purpose and therapeutic intervention was required in 1 patient. Patients responded well to medical therapy. Two patients with disseminated disease died. The major salivary gland is rare in both immunocompetent and immunocompromised patients. Diagnosis is difficult and requires high degree of suspicion especially in isolated cases. Medical management yields satisfactory results.

Submandibular Gland Tuberculosis: A Literature Review and Update.

Submandibular salivary gland is an uncommon and unusual site for tuberculosis. It is a rare extrapulmonary manifestation of a common infection caused by Mycobacterium tubercle bacillus. Submandibular gland TB can be due to primary or secondary infection. The clinical features are non-specific and depend on its manifestations. A delay in diagnosis is common because of the rarity of disease. Direct histological examination is the best method of diagnosis. As the disease is curable with antituberculous drugs; treatment should not be withheld in suspected cases until the diagnosis is confirmed. Surgery is indicated for non-responsive disease and complications. Till date, only 15 cases have been reported in the literature. First case was reported in the year 1990. The authors encountered three cases in last 10 years. The aims of this study are to review clinical presentation, epidemiological features, diagnostic methods and to provide our data and guidelines for optimum management of this rare pathology.

Gastrosplenic Fistula: a Systematic Review.

Gastrosplenic fistula is an unusual complication of benign as well as malignant gastric and splenic pathologies. This pathology acquires an important clinical significance due to its rare association with life-threatening upper gastrointestinal haemorrhage. The aim of this article is to review the English-language literature in order to gain a better understanding of etiological factors, diagnostic evaluation, and management of gastrosplenic fistula. The systematic search of the literature was performed on PubMed and MEDLINE from January 1950 to September 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We retrieved 44 articles matching our selection criteria from the search. There were 3 case series, 37 case reports, and 4 review of the literature. In our appraisal of articles published in PUBMED, a total of 36 cases of malignant and 10 cases of benign gastrosplenic fistula could be identified. Gastrosplenic fistula is an exceptional complication of malignancies of the gastrointestinal tract. Lymphomas particularly arising from the spleen are the commonest cause. Gastric adenocarcinoma causing GSF is extremely rare. Most cases occur spontaneously, but at times, it can be secondary to tumour necrosis following chemotherapy.

Rectal tuberculosis: A systematic review.

Rectal tuberculosis is an uncommon entity. It has unique epidemiological features, specific medical treatment and surgery is rarely indicated. The first case of rectal tuberculosis was reported in 1957. Delayed diagnosis is common. Patients who develop rectal tuberculosis have been reported to have some risk factors or associated comorbid conditions or pathologies with some form of abnormal host-defence mechanism such as acquired immunodeficiency syndrome, complement deficiency. Rectal tuberculosis has been reported to be more common in females as compared to males. Haematochezia is the most common presenting symptom. The definite diagnosis requires demonstration of Mycobacterium tuberculosis bacillus on histopathologic examination. Once a correct diagnosis has been made, rectal tuberculosis is curable with antituberculous treatment. Surgery is indicated for diagnostic dilemmas, non-responsive disease and complications. The authors encountered 3 cases in the last 10 years. The aim of this study is to provide our data on this rare disease and to review the reported literature comprehensively so as to provide guidelines for diagnosis and management.

Esophageal Tuberculosis: A Systematic Review.

Involvement of esophagus with tuberculous infection is a rare form of extrapulmonary tuberculosis. Secondary esophageal tuberculosis is much more common than primary TB. The most common source of secondary esophageal involvement is tuberculous mediastinal lymphadenitis. Esophageal tuberculosis mimics carcinoma esophagus. Clinical features are same and it is difficult on imaging studies also to differentiate the two pathologies. Misdiagnosis is common. The disease is medically curable; therefore, it is essential to make all efforts to diagnose the pathology with non-surgical diagnostic modalities in suspected cases so as to save patients from the trauma of major surgical resection. Surgical intervention is indicated for failed medical therapy and complications. A total of 133 cases of esophageal TB have been reported till date. The authors encountered 4 cases of esophageal TB between April 2011 and March 2019. The aim of this article is to present our data and to provide comprehensive review of the available literature on this pathology in order to gain a better understanding of diagnostic methods and provide guidelines for the diagnosis and management of esophageal TB.

A Retrospective Cohort Study of Coexistence of Carcinoma and Tuberculosis of Colon: 12-Year Experience.

Coexistence of carcinoma colon and tuberculosis is rare. The aim of this study is to present our 12-year experience on colonic carcinoma with coexisting colonic TB. Histopathology and imaging records of 189 patients of colonic carcinoma patients who underwent treatment in surgical unit 6 in our institute between January 2006 and December 2017 were reviewed. In 7 patients, histopathology and/or imaging studies were suggestive of coexistence of colonic carcinoma and tuberculosis. Fifteen cases of colonic tuberculosis were also reviewed. Descriptive statistics were used to summarize the data. Colonoscopic biopsy was suggestive of only malignant lesion in 6 cases and coexistence of TB and carcinoma in 1 case. The duration of symptoms spanned between 2 and 7 weeks. Anorexia and weight loss were the predominant symptoms. Colonoscopic biopsy was suggestive of only malignant lesion in 6 cases and coexistence of TB and carcinoma in 1 case. The morbidity was low and there was no surgery associated mortality. Clinical awareness and advancement in diagnostic studies and improvement in management strategies may guide and lead to early diagnosis, optimum therapeutic guidelines and thus improved outcome.

Gastric tuberculosis.

Tuberculosis of the stomach is an extremely rare manifestation of Mycobacterium tuberculosis infection and mimics gastric carcinoma in its presentation. Most of our knowledge about this rare disease comes from case reports and there are only a few case series published on this disease and thus the majority of the part remains uncovered. Diagnosis is made commonly only after a major surgery. Endoscopy and guided biopsy are the diagnostic modality of choice. Surgery is indicated in cases which present with complications. Patients respond well to antituberculous therapy. The authors encountered 4 cases of gastric tuberculosis over 5 years. This study summarises the available literature and gives comprehensive update on this rare disease.

Short Bowel Syndrome: An Uncommon Clinical Entity and a Therapeutic Challenge-Our Experience and Review of Literature.

Short bowel syndrome (SBS), one of the commonest types of intestinal failure, usually secondary to extensive bowel resection, traditionally has been associated with a high mortality rate and hence a big challenge for the treating surgeons. It requires comprehensive clinical care to minimise the morbidities and mortality associated with the condition. We report a retrospective review of a series of seven patients with SBS, who presented at our surgical emergency within a period of 1 year and their outcome so as to encourage others in managing such a challenge with more positive mindsets. A retrospective analysis of seven patients with SBS admitted from January 2014 to January 2015 with a follow-up of 1 year has been done in terms of their demographic characteristics, underlying pathology and clinical outcome. A rising incidence of SBS in the younger age group (71.4%) has been observed in this analysis. Majority of patients (57.1%) had mesenteric ischemia as the underlying cause followed by each case of small bowel volvulus, internal herniation and blunt trauma abdomen. A discharge rate of 71.4% and mortality rate of 28.5% were observed. With this analysis, we believe that SBS is no more an uncommon condition. A structured clinical approach, timely surgical intervention and multidisciplinary postoperative management are essential for managing such frail patients to achieve best possible results. This will encourage others in managing such a critically challenged condition with a more positive approach and thus beneficial for both the patients and the treating surgeon.

Risk Assessment Tool for Pressure Ulcer Development in Indian Surgical Wards.

The aims of this paper were to compare the predictive validity of three pressure ulcer (PU) risk scales-the Norton scale, the Braden scale, and the Waterlow scale-and to choose the most appropriate calculator for predicting PU risk in surgical wards of India. This is an observational prospective cohort study in a tertiary educational hospital in New Delhi among 100 surgical ward patients from April to July 2011. The main outcomes measured included sensitivity, specificity, positive predictive value (PVP) and negative predictive value (PVN), and the area under the curve of the receiver operating characteristic (ROC) curve of the three PU risk assessment scales. Based on the cutoff points found most appropriate in this study, the sensitivity, specificity, PVP, and PVN were as follows: the Norton scale (cutoff, 16) had the values of 95.6, 93.5, 44.8, and 98.6, respectively; the Braden scale (cutoff, 17) had values of 100, 89.6, 42.5, and 100, respectively; and the Waterlow scale (cutoff, 11) had 91.3, 84.4, 38.8, and 97, respectively. According to the ROC curve, the Norton scale is the most appropriate tool. Factors such as physical condition, activity, mobility, body mass index (BMI), nutrition, friction, and shear are extremely significant in determining risk of PU development (p < 0.0001). The Norton scale is most effective in predicting PU risk in Indian surgical wards. BMI, mobility, activity, nutrition, friction, and shear are the most significant factors in Indian surgical ward settings with necessity for future comparison with established scales.

Prospective randomized trial comparing laparoscopic transabdominal preperitoneal (TAPP) and laparoscopic totally extra peritoneal (TEP) approach for bilateral inguinal hernias.

INTRODUCTION: Bilateral inguinal hernias form a part of the complex spectrum of weakness in the region of the myopectineal orifice. Laparoscopic surgery is one of the standard approaches for bilateral hernias. We describe the results of a randomized trial that was undertaken to compare and evaluate TAPP and TEP repair for bilateral inguinal hernias. METHODS: Sixty patients were randomized into two groups. Group I (TAPP) and Group II (TEP) were compared in terms of procedure related variables, conversion, post-operative recovery and complications. Analysis was done using SPSS software version 17. RESULTS: Seventy-seven patients were assessed for fitness to include in the study. Seventeen patients had to be excluded due to either not meeting the inclusion criteria's or for not giving consent. The median age (52 yrs) was comparable in both groups. In Group II (TEP) mean operating time was 120.89 ± 29.28 min compared to 108.16 ± 16.10 min in Group I (TAPP). Post-operative pain scores were less in Group I(TAPP) at all levels of recording (8 h-48 h), though most patients required injectable analgesic for 32 h in both groups (p-value 0.029). Subcutaneous emphysema was more commonly noted in the Group II (TEP) (p-value 0.038). In Group I (TAPP) mean hospital stay was 52.0 ± 14.21 h while in Group II (TEP) it was 52.29 ± 9.36 h (p-value 0.427). Mean time for return to work was 11.8 ± 2.35 days in Group I (TAPP) and 12.41 ± 2.22 days in Group II (TEP) (p-value 0.339). CONCLUSION: The procedures though different in approach were quite similar in outcome. Mean operating time was increased in the TEP repairs along with immediate post-operative pain scores. The pattern of some complications like subcutaneous emphysema was significantly more in the TEP group while minor vascular injury though not significant was different in both groups. The indirect cost incurred from consumables did not vary other than need for more tacks in the TAPP group.

Laparoscopic management of nonmidline ventral hernia.

INTRODUCTION: Ventral hernias may be primary or incisional and classified as midline ventral hernias (MVHs) or non-MVHs (NMVHs). NMVHs are rarer, and their laparoscopic management is technically challenging because of varied anatomic locations, differences in patient positioning at time of surgery, and lack of adequate lateral space for mesh fixation, compounded by the proximity of major organs and bony landmarks. A retrospective review of all the NMVHs operated on in a clinical unit is presented. SUBJECTS AND METHODS: One hundred eighty-three cases met the criteria of ventral hernia, with 25 cases (13.66%) as NMVH. These NMVHs included lumbar (n=5), suprapubic (n=7), iliac (n=10), and subcostal (n=3). Univariate and multivariate analyses were done using SPSS version 19 software (IBM, Armonk, NY). Continuous data were analyzed using the Mann-Whitney U test/t test, and categorical data were analyzed using the chi-squared test. A P value of ≤.05 was considered significant. RESULTS: Demographic profile and presentation were similar in all groups. One case each had seromuscular intestinal injury in the iliac group (P=.668), splenic injury in the lumbar group, and liver injury in the subcostal group (P=.167). In the iliac group there was 1 patient with hematoma (P=.668), whereas seroma was seen in 1 lumbar group patient and 2 iliac group patients (P=.518). Persistent cough impulse was seen in 1 case each in the iliac and lumbar groups (P=.593). One case in the iliac group recurred after primary surgery (P=.668). CONCLUSIONS: NMVHs have a similar spectrum of difficulty and complication profile as those of laparoscopic MVH repairs. Laparoscopic repair of a non-midline hernia is technically challenging but definitely feasible. The incidence of complications and recurrence rate might be more than those for MVHs, but its actual validation needs a much larger comparative study having a longer follow-up.

Study to evaluate the role of severity stratification of skin and soft tissue infections (SSTIs) in formulating treatment strategies and predicting poor prognostic factors.

BACKGROUND: Diagnosis of skin and soft tissue infections (SSTIs) is difficult as they commonly masquerade as other clinical syndromes. So, the prospective cohort study was carried out to study the clinical profile, evaluate the existing method of severity stratification of SSTIs and identify factors responsible for prolonged stay and poor outcome in patients with SSTIs. METHODS: The prospective study was carried out based on clinical profile to evaluate the role of severity stratification of SSTIs in 105 patients attending the surgical outpatient department and surgical emergency. The patients were managed conservatively on oral or intravenous antibiotics and dressing or combined with surgical intervention based on severity stratification. Sometimes radiological investigation helped to know the deep seated abscess and thereby need of early intervention by surgical drainage, fasciotomy and rarely amputation. The data collected, summarised and evaluated using chi-square method. RESULT: SSTIs has been categorized into mild, moderate and severe form based on clinical and demographic profile of the patient. The study revealed risk factors that were statistically significant to be male patients of lower socioeconomic groups, temperature above 38 °C, hypotension, TLC > 15000, presence of gangrene, bullae, crepitus, trauma, animal/insect bite, BSA > 9% except when involving hand, head & scrotum, loss of sensation, loss of movement/function of affected part and restriction of joint movement (P < 0.05). CONCLUSION: Based on above findings, an algorithm for severity stratification is formulated for reducing the morbidity and mortality of the patients with SSTIs.

Appraisal of Laparoscopic Liver Resection in the Treatment of Liver Metastasis with Special Reference to Outcome in Colorectal Malignancies.

Treatment of metastatic liver disease is at the crossroads of an evolutionary transformation with more and more reports reiterating the benefits of resectional therapy in various cancers. A quest for application of laparoscopic approaches to the management of liver metastasis has arisen due to the projected benefits of less morbidity, early recovery, and equivalent oncological outcome in selected malignancies. However, the diverse and heterogenous data on indications, operative technique, and outcome evaluation make a comparative analysis of these studies difficult. This review is an appraisal of technique and outcome of minimally invasive liver resection as reported in the current literature with special reference to treatment of metastatic colorectal cancers.

A rare case of multiple jejunal diverticulosis presenting as intestinal obstruction.

Diverticulosis is rare in jejunum and its unusual presentation of mechanical obstruction is difficult to diagnose pre-operatively. We report a case of a 54-year old male patient who had symptoms of general abdominal pain and vomiting off and on for three years. He had been assessed elsewhere and had received a course of anti-tubercular treatment empirically based on features of recurrent intestinal obstruction due to prevalence of tuberculosis in this region. The patient had presented himself with signs and symptoms of dynamic intestinal obstruction. On examination, the abdomen was found to be swollen with a central abdominal distension and hyperactive bowel sounds. The erect abdominal radiograph showed multiple air-fluid levels and dilated jejunal loops. Following this, the patient underwent an emergency exploratory laparotomy. This revealed multiple jejunal diverticulae, multiple bands and adhesions involving jejunum and proximal ileum. The bands and adhesions were removed and the jejunum was resected along with the inflamed diverticulae.

Laparoscopic drainage of a large pancreatic pseudocyst.

Laparoscopic cystogastrostomy is an established procedure for the drainage of pancreatic pseudocysts. Cysts are mainly present in the lesser sac (retro-gastric), which is completely amenable to cystogastrostomy. We discuss the problems faced and simple solutions to the problems in managing a huge pancreatic pseudocyst of 22 cm×18 cm in a young boy 18 y of age.