The mule who took us for a ride.

Foreign body ingestion is not uncommon in patients with mental disorders, alcohol intoxication and for purposes of drug trafficking. Small objects pass spontaneously; however, larger ones may get stuck in the oesophagus, stomach or at narrow areas of the bowel. 'Body packers' is a term used to describe persons who swallow or insert drug-filled packets into a body cavity. They are also called 'swallowers', 'internal carriers', 'couriers' or 'mules'. We report a 37-year-old previous drug abuser who presented with dysphagia. Upper GI endoscopy showed an oblong foreign body covered in plastic in the lower oesophagus. This could not be extracted and hence was pushed into the stomach. Three weeks later, he presented with bowel obstruction that was shown on abdominal radiograph and confirmed by CT indicating multiple dilated small bowel loops with a transition point in the terminal ileum where the ingested package was identified. The package was then removed through a longitudinal enterotomy. Ingested foreign bodies causing dysphagia should ideally be extracted endoscopically. If not possible, then a watch-and-wait policy may be justified. While most ingested objects pass spontaneously, unusual and larger ones may require surgical extraction. The contents, nature and reason for ingesting this strange object remain a mystery. With history of drug abuse and the consistent denial of knowingly swallowing that object, we can only conclude that the patient was trying to transport an illicit drug in the packet.

Microsatellite instability in young patients with mucinous colorectal cancers - characterization using molecular testing, immunohistochemistry, and histological features.

CONTEXT: The incidence of colorectal cancers (CRCs) in young Indian patients is higher than the international average. CRCs in young patients are commonly of mucinous type and show microsatellite instability (MSI). AIMS: To ascertain the MSI status of mucinous CRCs in patients ≤40 years of age by molecular testing and to correlate this with immunohistochemical (IHC) analysis and tumor histology. SUBJECTS AND METHODS: Archived formalin-fixed paraffin embedded tissue blocks of 30 young mucinous CRC patients were retrieved. MSI testing was done using two mononucleotide markers - BAT26 and NR24. IHC analysis was done using MLH1, MSH2, and MSH6. Histological features of all cases were studied. Data were analyzed using the SPSS software and the Pearson's chi-square test and Fisher's exact test. RESULTS: Eight out of 30 cases (26.7%) showed MSI by molecular testing. IHC identified seven of these cases. Histological features showing a statistically significant association with MSI were the presence of a well-differentiated adenocarcinoma component (P = 0.003), peritumoral lymphocytes (P = 0.002) and tumor budding (P = 0.021). CONCLUSION: The detection of defective mismatch repair (MMR) proteins using IHC for MLH1, MSH2, and MSH6 and molecular testing using BAT26 and NR24 appears to be a good protocol to detect CRCs with MSI. Histology could be useful in identifying cases that require screening for presence of MMR protein defects.

Demographics and outcomes of surgically treated right sided colon cancer in India: a 9-year single institution experience.

Background: There is sparse Indian data on right colon cancer. Available literature suggests that it affects the young and survival is poor. Aim: This article reviews demographics and outcomes of surgically treated right sided colon cancer over a nine year period in a single colorectal unit in a tertiary care teaching hospital. Methods: A retrospective review of all patients undergoing right hemicolectomy for adenocarcinoma of the colon between January 2004 and December 2012 was undertaken. Data was collected from hospital records and telephonic interview when possible. Results: Two hundred and thirteen patients were studied. Mean age was 49 years with 57.1% being 50 years or younger. Stage 1 disease was seen in 9.9%, stage 2 in 35.2%, stage 3 in 42.3%, and stage 4 in 12.7%. Follow up was available for 81.6% with a mean follow up of 35.6 months. Five year disease free survival (DFS) and overall survival (OS) was 81% and 74%. Presence of lymphovascular invasion and age >50 years were predictors of poor survival. Poor prognostic features on histopathology were not different between the young and the old. The 5 year DFS was similar in both, but the 5 year OS was better for the young (90% vs. 73%, p=0.029). Conclusion: Patients with right colon cancer are younger in India. They have similar histopathology when compared to the older population. Operable right colon cancer has an excellent prognosis. Five year DFS is similar in the young and the old, but OS is lower in the older population.

Surgical manifestations of scrub typhus: A diagnostic dilemma.

BACKGROUND: Scrub typhus, a zoonosis caused by Orientia tsutsugamushi, is a systemic febrile illness. The disease presents with diverse clinical manifestations, ranging from subclinical disease to multiorgan failure and fatal disease. It may rarely present as an acute abdomen which may lead to a diagnostic dilemma. We describe two serologically confirmed cases of scrub typhus presenting as acute abdomen-one mimicking acute appendicitis and the other acute cholecystitis, both managed non-operatively. A high index of suspicion, along with subtle indicators in the history and clinical examination help avoid unnecessary surgery in such cases.

Factors influencing forces during laparoscopic pinching: Towards the design of virtual simulator.

BACKGROUND: The design of good virtual simulators for laparoscopic training requires realistic visual and tactile perception. This is a study to characterize the factors that contribute to forces during laparoscopic pinching. METHODS: Surgeons were divided into four groups according to years of experience in laparoscopic surgery. They were asked to grasp six different types of porcine abdominal tissue in a randomly sequenced manner, using two different types of sensorized graspers, under two regimes of perceptual feedback (with and without visual feedback). The forces (grasper handle force and grasper tip force) and grasper handle angle were recorded and analyzed. RESULTS: The factors that determine forces during laparoscopic pinching can be ranked as follows: surgical experience (p < .001), tissue type (p = .007) and visual feedback (p = .033), but not grasper type (p = .071). Handle force depends significantly on surgical experience (p < .001), tissue type (p = .001) and visual feedback (p = .019), but not on grasper type (p = .203). Tip force depends significantly on surgical experience (p < .001) and marginally on tissue type (p = .082) and visual feedback (p = .053) but not on the grasper type (p = .180). CONCLUSION: Forces during laparoscopic pinching depend on surgical experience, tissue type and presence of visual feedback but not on grasper type. Our data can be an input in the design of virtual simulators with force feedback, for training laparoscopic pinching.

Indian Society of Gastroenterology consensus statements on Crohn's disease in India.

In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

The effect of autologous bone marrow-derived cells on healing chronic lower extremity wounds: results of a randomized controlled study.

Case studies suggest that bone marrow-derived stem cells may improve chronic wound healing. A prospective, randomized, clinical study was conducted to compare the rate of healing chronic lower limb wounds in patients with diabetes mellitus whose wounds were treated with topically applied and locally injected bone marrow-derived cells or whole blood (control). Of the 48 patients participating in the study, 25 were randomized to study treatment and 23 to control treatment. At baseline, no significant differences were observed between the two groups for patient age (average for treatment group was 54 years, 3 months; range 33 to 76 years and for the control group 58 years, 7 months; range 28 to 69 years), comorbidity (82% in the treatment group and 78% in the control group had diabetes mellitus), ulcer history (mean duration was 14.28 months in the treatment group and 10.21 months in the control group; SD 0.28), or baseline area (mean was 65.32 cm2 in the treatment group and 48.83 cm2 in the control group). After obtaining informed consent, all wounds were surgically debrided. Wounds of study participants randomized to the treatment group were injected and oversprayed with a total of 5 cc of autologous bone marrow-derived cells. Using a similar procedure, the wounds of patients randomized to the control group were injected with 5 cc of autologous peripheral blood. All wounds were covered with saline-moistened gauze and cotton pads. Patients were followed for a maximum of 3 months. The average decrease in wound area at 2 weeks was 17.4% (39.6-43.4 cm2) in the treatment group compared to 4.84% (41.6-42.8 cm2) in the control group. After 12 weeks, the average decrease in wound area was 36.4% (SD 0.48) in the treatment group compared to 27.32% (SD 0.32) in the control group. No adverse events were observed. None of the patients complained of significant pain or discomfort following the procedure, no wound infections occurred, and all patients reported resumption of normal daily activity the day after the procedure. The results of this study show that a single application of autologous bone marrow-derived cells increases the rate of healing chronic lower extremity wounds in the early weeks of treatment. Additional studies to elucidate the treatment mode of action and optimal application frequency as well as comparisons between this and other treatment modalities are warranted.

Radiologic and pathological correlation of staging of rectal cancer with 3 Tesla magnetic resonance imaging.

PURPOSE: To assess the sensitivity and specificity of 3 Tesla magnetic resonance imaging (MRI) in the prediction of extramural spread and metastatic adenopathy in rectal carcinoma. MATERIALS AND METHODS: This was a prospective cohort study that included forty consecutive patients with rectal carcinoma from the Department of Colorectal Surgery. Three Tesla (3T) MRI was performed on these patients after a 4-hour fast and cleansing water enema. TI-weighted and T2-weighted images were obtained with high-resolution images T2-weighted sequences through the pelvis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 3T MRI for prediction of metastatic adenopathy and extramural spread were calculated. The TNM staging based on MRI was compared with histopathology of the resected specimen (taken as the criterion standard). RESULTS: In our study, sensitivity, specificity, PPV, and NPV of 3T MRI for prediction of metastatic adenopathy were 100%, 78.3%, 77.3%, and 100%, respectively. Sensitivity, specificity, PPV, and NPV of 3T MRI for prediction of extramural tumour spread were 100% and 20%, 89.7% and 100%, respectively (ie, prediction of stages T3 and above). CONCLUSION: MRI allows accurate measurement of the depth of extramural tumour spread. In the assessment of metastatic adenopathy, however, MRI has a low specificity. This study shows that MRI is unlikely to miss any significant parameter in staging of rectal carcinoma. However, it has a tendency to overstage extramural spread of tumour.

Evidence-based surgery: knowledge, attitudes, and perceived barriers among surgical trainees.

OBJECTIVES: This study was conducted to assess the knowledge and attitude of surgical trainees toward evidence-based medicine (EBM) and their perceived barriers to its practice. DESIGN: The McColl questionnaire and the BARRIERS scale were modified and incorporated into a single questionnaire, which was administered to all surgical trainees attending a Continuing Surgical Education meeting. SETTING: Department of Surgery, Christian Medical College, Vellore, India. PARTICIPANTS: One hundred ten surgical trainees from 22 medical colleges. RESULTS: In all, 84.5% (93/110) trainees returned the questionnaire. The attitudes toward EBM were welcoming, although individual participants reported they welcomed EBM more than their colleagues did. Participants agreed that EBM was useful in everyday practice and that it improved patient care. About 50% of actual practice was considered evidence based. In all, 12.6% (10/89) of participants had received formal training in EBM, and 64.3% (54/84) of participants were aware of the Cochrane database of systemic reviews, but only 35.7% (30/84) read it regularly. Also, 67.8% (61/90) of respondents used protocols and guidelines developed by colleagues. However, 61.5% (56/91) of participants were interested in learning the skills of EBM. The terms absolute risk, relative risk, and clinical effectiveness were understood by >80% of respondents, whereas publication bias, confidence interval, and heterogeneity were poorly understood. The major barriers to practice of EBM were the inability to understand statistical analysis, inadequate facilities for implementation, lack of a single compiled source of literature, relevant literature not being readily available, and insufficient time on the job. CONCLUSIONS: Surgical trainees have a positive attitude towards EBM and have some familiarity with the common terms used in EBM. There is a need to increase awareness of, and provide access to, available sources of medical literature. Formal training in EBM, as well as basic statistical analysis, should form a part of the surgical curriculum to foster an environment favorable to the practice of EBM.

Transanal excision of anorectal lesions--a single centre experience.

BACKGROUND: Transanal excision is commonly used to treat lesions of the anorectum. It avoids the morbidity of radical pelvic surgery, while allowing for complete histopathological examination of the lesion. AIM: The aim of this study was to look at the spectrum of disease treated by transanal excision, and their outcomes, in a tertiary care institute. METHODS: Records of patients who underwent transanal excision between 2004 and 2008 were reviewed. Patients were divided into three groups. (1) Resection for benign disease (2) Curative and (3) Palliative resection for malignant disease. RESULTS: Forty six patients underwent transanal excision, 21 for benign and 25 for malignant disease, 20 with curative and 5 with palliative intent. Tubulovillous adenomas and hyperplastic polyps were the commonest benign lesions. The mean follow up was 18.6 months (4-49). There was one recurrence and one patient returned with liver metastasis. Seventeen patients with adenocarcinoma, two with melanoma and one with verrucous carcinoma underwent curative resection. Three required a second local excision and two abdominoperineal excision. Mean follow up was 28 months (4-63). There were three recurrences, one requiring a local excision and two abdominoperineal excision. Four patients with malignant melanoma and one with adenocarcinoma underwent palliative resection. All these patients had good symptom palliation. CONCLUSION: Transanal excision, when technically feasible, remains the treatment of choice for benign disease of the rectum. It offers good palliation of local symptoms in advanced malignant disease. It can be used in a carefully selected group of patients with early rectal cancer.

Anal sphincter repair for fecal incontinence: experience from a tertiary care centre.

AIM: Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit. METHODS: Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria. RESULTS: Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH2O and 90.25 to 111 cmH2O in those with a good outcome. CONCLUSIONS: Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

Surgical intervention for anorectal fistula.

BACKGROUND: Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life. OBJECTIVES: To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence. SEARCH STRATEGY: The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American). SELECTION CRITERIA: Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available. DATA COLLECTION AND ANALYSIS: Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed. MAIN RESULTS: Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates. AUTHORS' CONCLUSIONS: There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.

A blinded, prospective, randomized controlled trial of topical negative pressure wound closure in India.

Wound closure using topical negative pressure (TNP) has been reported to be effective, but equipment costs can be prohibitive in resource-challenged countries. Because nonhealing wounds are exceedingly common in developing countries such as India, the ability to optimize wound care with limited resources is very important. To investigate the feasibility and efficacy of providing TNP in an Indian medical referral center, a randomized controlled trial comparing a locally constructed TNP device (treatment) to wet-to-dry gauze dressings (control) was conducted. Eligible study participants (N = 48) were recruited from the inpatient wards. Wound etiologies included diabetic foot ulcers (15), pressure ulcers (11), cellulitis/fasciitis (11), and "other" (11). Following enrollment, wound size was assessed using computer-aided measurements of digital photographs and block-randomized to the study arms using a concealed allocation table. Wounds in both treatment groups were débrided before dressing application and patients were followed until wound closure or being lost to follow-up for an average of 26.3 days (+/- 18.5) in the control and 33.1 days (+/- 37.3) in the treatment group. No statistically significant differences in time to closure between the two treatment groups were observed except in a subset analysis of pressure ulcers (mean 10 +/- 7.11 days for treatment and 27 +/- 10.6 days in control group, P = 0.05). Direct costs to close a pressure ulcer also were lower in the TNP than in the control group. A review of the literature suggests the outcomes obtained using a locally constructed TNP device are similar to those obtained using commercially available devices. As a result of this study, a dedicated tissue viability team has been established to identify wounds suitable for TNP, oversee treatment, monitor the need for surgical débridement, and employ wound healing principles and technology appropriately. These results suggest that inexpensive materials can be utilized for TNP wound closure in a developing country.

Early activation of mucosal dendritic cells and macrophages in acute Campylobacter colitis and cholera: An in vivo study.

BACKGROUND AND AIM: Macrophages and dendritic cells are closely related mononuclear phagocytic cells. Little is known about their in vivo role in acute intestinal bacterial infections in humans. We undertook to evaluate these cells in rectal mucosal biopsies of patients with acute colitis. METHODS: All mucosal mononuclear phagocytic cells in rectal biopsies of patients with acute Campylobacter colitis (n = 5), shigellosis (n = 5), and cholera (n = 10) were evaluated ultrastructurally and compared with those in controls (n = 5). RESULTS: Mononuclear phagocytic cells in the superficial rectal mucosa showed a higher prevalence of ultrastructural features of activation in Campylobacter colitis and cholera than in controls. A lower prevalence of features of activation with increased monocytes was seen in shigellosis. Cells with the ultrastructural morphology of activated dendritic cells constituted 41% and 45% of all mononuclear phagocytic cells in two of five patients with Campylobacter colitis and 4-22% of cells in four of 10 patients with cholera. Their presence in patients with Campylobacter colitis was associated with significant surface epithelial damage and prominent acute inflammatory changes in the mucosa. CONCLUSIONS: This is the first ultrastructural study to show activated macrophages and dendritic cells in vivo in acute Campylobacter colitis and cholera. Dendritic cell activation occurred early in the clinical course of these infections. Surface epithelial damage may play a role in the activation of dendritic cells.