A Prospective Randomized Controlled Trial Comparing Clinical Equivalence of PD Synth and PDS Polydioxanone Sutures.

Introduction Incisional hernia is a common complication of midline laparotomy that may develop even after several years of surgery. Abdominal fascia closure with ideal suture material reduces the incidence of incisional hernia. This study compared the clinical equivalence of PD Synth (Healthium Medtech Limited) and PDS (Ethicon, Johnson & Johnson) slowly absorbed polydioxanone suture with respect to the occurrence of incisional hernia, following elective/emergency midline laparotomy. Methods Eighty-eight subjects undergoing elective/emergency midline laparotomy were randomized to PD Synth (n=45) and PDS (n=43) groups of this prospective, multicenter, randomized (1:1), single-blind, two-arm, parallel-group study (December 2020-May 2023). Primary endpoint was incidence of incisional hernia, occurring within six and 12 months of surgery. Secondary endpoints included incidence of fascial dehiscence, surgical site infection (SSI), suture sinus, seroma, hematoma, scar tenderness, and re-suturing, and evaluation of operative data, hospital stay, intra-operative suture handling, pain, time to return to normal day-to-day activities and work, overall patient satisfaction score, and adverse events. Results One subject in both PD Synth and PDS groups (p>0.05) developed incisional hernia at umbilicus 12 months post-laparotomy. In PDS group, one subject each had incidences of SSI on day 2, day 7, and one month, two subjects developed seroma on day seven, and one subject had readmission on one month; two subjects in PD Synth group developed superficial SSI (one month). Findings of other secondary endpoints were comparable between the groups. Conclusion Primary and secondary outcomes manifested that PD Synth and PDS slowly absorbed polydioxanone sutures are clinically equivalent, and can be used for abdominal fascial closure following midline laparotomy.

Endoscopic closure of fecal colo-cutaneous fistula by using metal clips.

Fecal colo-cutaneous fistula often requires surgical intervention for successful closure increasing the morbidity and mortality associated with this condition. Endoscopic fistula closure can be a less invasive modality. We report successful closure of fecal colo-cutaneous fistula by endoscopic application of metal hemo-clips after failure of prolonged treatment including diverting proximal ileostomy in 2 consecutive patients after emergency primary repair of cecal perforation caused by stab injury of abdomen and iatrogenic fecal fistula after left hemicolectomy and colo-colic anastomosis for adenocarcinoma of descending colon, respectively. The endoscopic closure of fecal colo-cutaneous fistula by using metal clips is an effective, safe, and less invasive treatment modality. It can add to therapeutic armamentarium of surgeons and may obviate the need for additional surgical intervention and associated morbidity in a proportion of such patients.

Pitfalls of radiofrequency assisted liver resection.

BACKGROUND/AIMS: Radiofrequency has been used recently for bloodless liver resection. We studied the safety and feasibility of using RF energy for liver parenchymal transection in 8 patients. METHODOLOGY: We performed eight (n=8) open RF assisted liver resection for various malignancies. There were 5 men and 3 women, with mean age of 56.5 years (range 20-80 years). RESULTS: All patients had successful liver resection. The mean operating time for liver resection was 45 minutes (range 25-60 min). The average blood loss for wedge resections and segmentectomies was 30 mL (range 10-100 mL). None of the patients required postoperative transfusion. Three out of eight patients developed minor complications in the form of intra-abdominal abscesses which were managed by USG guided drainage of abscess in two patients and one patient had open surgical drainage of the subhepatic abscess. CONCLUSIONS: RF assisted liver resection is safe and effective with minimal blood loss for minor liver resections. Though the procedure is slightly more time consuming presently, with further improvement in technology and needles, the operative time may be reduced for this technique. RF assisted liver resection should be avoided in the presence of overt local sepsis.

Rapunzel syndrome reviewed and redefined.

Rapunzel syndrome is a rare presentation of a trichobezoar, with 24 cases having been reported in literature so far. This syndrome has been reported in 23 female and 1 male patient with a mean age of 10.8 years. The patients commonly present with abdominal pain, nausea, vomiting and signs of obstruction. The distal end of the bezoar may be in the jejunum, ileum or the colon. We evaluate the various cases reported and discuss the various modes of presentation of this uncommon syndrome, and also present a series of 3 cases, all females, aged 16, 18 and 21 years, and had a trichobezoar in the stomach with a tail extending into the ileum.

Primary transitional cell carcinoma of spleen.

Transitional cell carcinoma arises from the lining of the urogenital tract and ovary. We report a 39-year-old lady with transitional cell carcinoma of the spleen that presented as a complex cystic lesion. Exhaustive search for another primary was negative. She is doing well 18 months after splenectomy was performed.

Radiofrequency ablation of unresectable pancreatic carcinoma: feasibility, efficacy and safety.

CONTEXT: Unresectable pancreatic cancer has a dismal prognosis. Palliative surgery and chemo-radiotherapy have not produced significant improvement in survival. We evaluated the safety and the efficacy of radiofrequency ablation for cytoreduction of unresectable tumors of the pancreas. CASE REPORT: Radiofrequency ablation was performed in three patients with histologically proven unresectable cancer of the pancreas: two females and one male; 48, 60, and 66 years of age (mean 58 years). The sizes of the pancreatic tumors were 5.0, 6.5, and 8.0 cm (mean 6.5 cm), respectively. Two patients underwent radiofrequency ablation during an open operation while one patient had percutaneous CT guided radiofrequency ablation. All had endobiliary stenting for obstructive jaundice. Partial necrosis (up to 3 cm) of the tumor was achieved in all cases. There was no major morbidity or mortality. Self-limiting minor complications occurred in two patients. CONCLUSION: Radiofrequency ablation is a local ablative method used with increasing frequency and may be used safely for cytoreduction in locally advanced inoperable pancreatic malignancies. Further studies are required to ascertain whether this can improve survival/quality of life alone or in combination with other therapies.

IgG4 negative sclerosing cholangitis associated with autoimmune pancreatitis.

BACKGROUND: Sclerosing pancreatitis is an autoimmune condition characterized by periductal lymphocytic infiltration on histology, and elevated serum auto-antibodies and IgG4. Bile duct involvement is often associated with sclerosing pancreatitis but it is rarely the dominant feature. CASE REPORT: We report a patient with dominant biliary stricture and obstructive jaundice associated with IgG4 negative autoimmune pancreatitis. Due to uncertainties regarding the preoperative diagnosis, the patient underwent bilio-enteric bypass with an intraoperative pancreatic and bile duct biopsy. Post operatively, due to disease recurrence, the patient was started on steroids with consequent remission of the disease. CONCLUSION: Sclerosing pancreatitis may sometimes present with biliary stricture due to bile duct involvement due to the inflammatory process. The condition is often recognized after surgical exploration for a suspected malignancy. Preoperative diagnosis permits treatment with steroids and endoscopic biliary decompression, and avoids unnecessary surgery.

Squamous cell carcinoma of the distal common bile duct.

CONTEXT: Squamous cell carcinoma of the biliary tree is rare. Although few cases of squamous cell carcinoma of the intrahepatic bile-duct and gallbladder have been reported, until today, only four cases of squamous cell carcinoma of the extrahepatic bile duct have been reported in the literature. CASE REPORT: We present a case of squamous cell carcinoma of the distal common bile duct presenting with obstructive jaundice in a 60-year-old male which was successfully managed by a Whipple's pancreaticoduodenectomy. CONCLUSION: Squamous cell carcinoma of the distal bile duct without lymph node metastasis can be managed by pancreaticoduodenectomy alone.