Complex-compound Odontome with 526 Denticles: A Unique Case Report.

Aim: To report a unique case presentation of a complex-compound odontome with 526 denticles. Background: Odontoma is a hamartoma of the jaws that has both epithelial and mesenchymal components differentiating to form enamel and dentin. It is of compound and complex types. Rarely, the features of both the types are present together in what is called the compound-complex type of odontoma. Case description: The case report discussed here is that of a 7-year-old boy who presented with a compound-complex odontoma in the right posterior mandibular region. Conclusion: Timely diagnosis and prompt surgical treatment aid in preventing complications and bony expansion. Thus, proper histopathological examination is essential for the confirmation of odontoma. Recurrence of odontoma is rare and usually has a favorable prognosis if diagnosed early. Clinical significance: The odontome contained 526 denticles, the maximum reported in the literature so far, making this a case of extreme clinical significance. How to cite this article: Marimuthu M, Prabhu AR, Kalyani P, et al. Complex-compound Odontome with 526 Denticles: A Unique Case Report. Int J Clin Pediatr Dent 2022;15(6):789-792.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis.

Background: Chronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long-term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long-term follow-up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment. Methods: This was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow-up of 1 year at a tertiary-care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency. Results: Some 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow-up respectively. Conclusion: Laparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

Evaluation of Three-Dimensional Changes in Pharyngeal Airway Following Isolated Lefort One Osteotomy for the Correction of Vertical Maxillary Excess: A Prospective Study.

BACKGROUND: Orthognathic surgery involves movement of jaws in all three planes, and this being a part of airway complex, displacement of jaws can influence the dimension of airway at all levels. Lefort one osteotomy surgery with superior repositioning is a common procedure done for patients with vertical maxillary excess. PURPOSE: The purpose of this study was to evaluate the three-dimensional volumetric changes in airway after lefort one impaction surgery using three-dimensional cone beam computed tomography (3D-CBCT) in patients with vertical maxillary excess (VME). METHODS: A prospective analysis of 15 patients who underwent isolated lefort one impaction surgery was done with pre-operative (T0) and 3-months (T1) post-operative 3D-CBCT scans. Airway was divided into three segments, nasopharyngeal, velopharyngeal and oropharyngeal. Volumetric analysis of all these segments was done before and after surgery. Paired 't test' was used to assess the mean difference in airway volume and area between T0 and T1. One-way ANOVA was used to check the mean percentage difference in airway volume and area among the three segments. RESULTS: The mean percentage of nasopharyngeal volume difference was - 0.6299 ± 0.9146%, velopharyngeal volume difference was - 0.5205 ± 1.107%, oropharyngeal volume difference was - 1.492 ± 2.745%. Though volume and area of pharyngeal airway were decreased after maxillary impaction surgery in all three segments of airway studied, they were not statistically significant. CONCLUSION: Among the three segments of airway studied, oropharyngeal airway volume has shown the highest post-surgical reduction though statistically insignificant. ESS scores were within normal limits. Hence, we are of the opinion that there is lack of evidence to conclude that the patients undergoing lefort one superior repositioning for the treatment of VME might develop significant narrowing of PAS that may predispose the patient to breathing disorders.

Laparoscopic management of recurrent ventral hernia: an experience of 222 patients.

BACKGROUND: To evaluate the predisposing factors and characteristics of recurrent ventral hernia (RVH) along with the feasibility and outcome of laparoscopy in managing RVH. METHODS: This study is a retrospective analysis of all patients with reducible or irreducible, uncomplicated RVH who underwent surgical management from January 2012 to June 2018. RESULTS: Out of 222 patients, 186 (83.8%) were female, and 36 (16.2%) were male. The mean age was 54.1 ± 10.1 years; an average body mass index was 31 kg/m2 (19-47.9). The most common previous abdominal operations among female patients were cesarean sections (43.5%) and abdominal hysterectomy (36.6%). Most of the patients had a history of open mesh repair (43.7%) and open anatomical repair (36.9%). The median time of recurrence was 4 years (1-33 years). The median defect size was 10 cm2 (range 2-150 cm2), and 73% defects were in the midline. Total 181 of 222 (81.6%) patients underwent laparoscopic intraperitoneal onlay mesh plus (L-IPOM+), 19 (8.5%) laparoscopic-assisted IPOM+, 17(7.7%) laparoscopic anatomical repair, while remaining 5 (2.3%) patients required open mesh reconstruction. The median size of the composite mesh used was 300 cm2 (150-600 cm2). The mean operating time was 145 (30-330) min, and median blood loss was 15 (5-110) ml. The median hospital stay was 3 days, and median follow-up period was 37 months. The post-operative symptomatic seroma rate was 3.1%, and re-recurrence rate was 1.4%. CONCLUSION: Obesity, old age, female sex, previous lower abdominal surgeries, and previous open repair of a hernia are factors associated with recurrence. Laparoscopic repair is feasible with excellent outcome in most of the patients.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery.

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Laparoscopic excision of rare case of recurrent presacral teratoma.

Tumours of the presacral space are rare to present. Most of them are benign masses, very rarely malignant. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. Their surgical excision is often difficult because of their anatomic location. Very few cases have been reported so far concerning a laparoscopic management of presacral tumour. We hereby present a young girl with recurrent presacral teratoma. She underwent laparoscopic successful excision of tumour with uneventful post-operative recovery. Here, we are highlighting the importance of laparoscopic approach for this scenario in terms additional advantages of minimally invasive approach such as better visualisation of the deep structures in the narrow presacral space, precise dissection in a limited space between the tumour and neighbouring structures with avoiding injury to neurovascular structure.

Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours.

BACKGROUND: Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial. METHODS: Patients with periampullary cancers were randomized to either laparoscopic or open pancreatoduodenectomy. The outcomes evaluated were hospital stay (primary outcome), and blood loss, radicality of surgery, duration of operation and complication rate (secondary outcomes). RESULTS: Of 268 patients, 64 who met the eligibility criteria were randomized, 32 to each group. The median duration of postoperative hospital stay was longer for open pancreaticoduodenectomy than for laparoscopy (13 (range 6-30) versus 7 (5-52) days respectively; P = 0·001). Duration of operation was longer in the laparoscopy group. Blood loss was significantly greater in the open group (mean(s.d.) 401(46) versus 250(22) ml; P < 0·001). Number of nodes retrieved and R0 rate were similar in the two groups. There was no difference between the open and laparoscopic groups in delayed gastric emptying (7 of 32 versus 5 of 32), pancreatic fistula (6 of 32 versus 5 of 32) or postpancreatectomy haemorrhage (4 of 32 versus 3 of 32). Overall complications (defined according to the Clavien-Dindo classification) were similar (10 of 32 versus 8 of 32). There was one death in each group. CONCLUSION: Laparoscopy offered a shorter hospital stay than open pancreatoduodenectomy in this randomized trial. Registration number: NCT02081131( http://www.clinicaltrials.gov).

A case report of modified laparoscopic keyhole plus repair for parastomal hernia following ileal conduit.

Parastomal hernia is one of the most common but challenging complication after stoma formation. Modified Sugarbaker technique is the recommended procedure for repair parastomal hernia, however, keyhole repair technique had also been used in certain instances. In cases of parastomal hernia following ileal conduit procedure, the Sugarbaker technique is been described, although with associated theoretical risk of conduit failure. We are reporting a case of post-radical cystectomy with ileal conduit presented with symptomatic large parastomal hernia. Laparoscopic modified keyhole plus repair has been done successfully in this patient with no recurrence in 2 years of follow-up. The purpose of our case report is to describe our novel modification of the laparoscopic keyhole technique which can be a feasible and acceptable alternative surgical method in these types of patients.

Laparoscopic management of 'Y-shaped' gallbladder duplication with review of literature.

Gallbladder duplication is a rare congenital malformation that occurs in about 1:4000 cases. Congenital anomalies of the gallbladder and anatomical variations of their position are associated with an increased risk of complications during laparoscopic cholecystectomy. We report a case of gallbladder duplication with symptomatic cholelithiasis, who presented with recurrent episodes of biliary colic and subsequently underwent laparoscopic cholecystectomy with intraoperative cholangiography. We also discussed in brief about the available literature support in relation to incidence of this disorder, imaging modalities used, intraoperative strategies and recommended measures for safe outcomes.

Laparoscopic management of symptomatic residual appendicular tip: A rare case report.

Appendectomy is one of the most common emergency surgical procedures. Stump appendicitis is well-recognised entity has been described in the literature. Still, with recent advance in imaging technique, it remains as a clinical challenge for diagnosis and effective treatment. We present a case of 13-year-old boy who underwent laparoscopic appendectomy 3 months back and presented to us with acute abdomen associated with vomiting and fever. Imaging revealed the presence of a tubular residual inflamed tip of the appendix of size 4 cm laying in paracaecal position with approximately 50cc purulent collection around it. Subsequently, the patient underwent successful laparoscopic completion appendectomy with uneventful postoperative recovery. Histopathological examination confirmed that resected structure as an inflammatory residual appendix. For our knowledge, after an extensive search of English literature, no study had described about laparoscopic completion appendectomy for residual tip appendicitis. We authors hereby would like to emphasise the importance of complete removal of appendix not only stump part but also tip, especially in certain locations such as paracaecal, retrocaecal and subhepatic. Laparoscopy can be an option for the management of these patients, in selected cases, and with available expertise.

Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India.

AIM: Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management. METHOD: A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed. RESULTS: There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts. CONCLUSION: LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.

Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas - case report.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us.

Long-term results of hepatic hydatid disease managed using palanivelu hydatid system: Indian experience in tertiary center.

BACKGROUND: Incidence of hepatic hydatid disease is increasing due to globalization. Surgery is the gold standard treatment. Laparoscopy has gained enough evidence regarding its safety and efficacy. Complete evacuation of hydatid contents without spillage remains a challenge. We aimed to determine long-term results of hepatic hydatid disease managed laparoscopically using palanivelu hydatid system (PHS) at our institution. METHODS: One hundred and five patients underwent laparoscopic surgical management using the PHS at our institute from May 1997 to May 2013. Clinical presentations, surgical strategy, postoperative morbidity, and long-term recurrence rate were evaluated. RESULTS: Of the 105 patients, 76 were male and 29 female with a mean age of 32 years (range 14-71 years). The most common presentation was abdominal pain in 61 patients (58%). Sixteen patients had multiple cysts of which nine had involvement of both lobes. Seventy-seven (73.3%) cysts were uncomplicated. Nineteen (18.09%) had a cyst-biliary communication, two were ruptured cysts, and seven were recurrent cysts. All patients underwent successful laparoscopic management where conservative surgery was performed in 94 patients and radical surgery in 11 patients. Post-operative morbidity was seen in 18 (17.14 %) patients, which included deep cavity infection in two cases, post-operative bile leak in 13 cases, and duodenal injury in one case without any mortality. Mean long-term follow-up was 36 months (range 6 months-5 years) with recurrence in two cases. CONCLUSION: Our long-term results with PHS showed good outcomes in the laparoscopic management of hepatic hydatid disease with conservative surgery as the preferred approach reserving radical surgery only in selected cases.

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome.

BACKGROUND: Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate. METHODS: The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013. RESULTS: Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%. CONCLUSION: Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.

Concomitant laparoscopic ventral hernia mesh repair and bariatric surgery: a retrospective study from a tertiary care center.

OBJECTIVE: To analyze the safety in combing laparoscopic ventral hernia repair with a mesh and bariatric surgery. BACKGROUND: Obesity is one of the important precipitating factors for primary and recurrent ventral hernias (incisional and umbilical) and it is not uncommon to find these hernias in patients opting for obesity surgery. But, with no consensus or recommendation and concern of mesh infection, surgeons fear in combining these procedures, especially Roux en Y gastric bypass and sleeve gastrectomy. METHODS: In this study, we have retrospectively analyzed all patients who underwent concomitant bariatric procedure and mesh repair for ventral hernia at our institute. RESULTS: A total of 36 out of 765 patients operated at our institute between 2003 and 2011 had concomitant procedures. Eleven patients had Roux en Y gastric bypass (group I) and remaining 25 had sleeve gastrectomy (group II) performed on them. The operating times were 149 min(120-210 min) in group I and 122 min (90-220min) in group II. No immediate complications or any incidence of mesh infection or recurrence in either of the groups. CONCLUSION: Concomitant mesh repair for ventral hernias can be safely combined with bariatric procedures like Roux en Y gastric bypass and sleeve gastrectomy. But, for beginners, these should be done only in selected cases after fully informed consent from the patients.

Management of post-operative maxillofacial oncology patients without the routine use of an intensive care unit.

AIM: To assess the safety and efficacy of immediate postoperative management of major maxillofacial oncology patients in a High Dependency Unit (HDU). PATIENTS AND METHODS: All operated maxillofacial oncology patients were included. Detailed records and clinical parameters were assessed for diagnosis, procedure, diagnosis, American Society of Anaesthiologists (ASA) grade, procedure, type of reconstruction, duration of surgery, post operative location, days of hospitalization risk factors and complications if any. RESULTS: All the patients were placed in a HDU care for 48 h for closed monitoring and thereafter were shifted to the head and neck general ward. Only 7/117 (6%) patients required ICU admission because of development of systemic complications. Of our cases, 108/117 made an uneventful recovery (92.3%) with no serious complications. We noted a correlation between the incidence of perioperative complications and risk factors of ASA status (χ(2) = 7.81, P = 0.005). Majority of the patients (94%) were managed successfully in the HDU care in the post operative period. Survival of free flaps proved to be extremely reliable with a survival rate of 99.1% (1/15 failed). CONCLUSIONS: The routine use of a HDU care for 48 hours followed by shifting the patient to a maxillofacial head and neck general ward is more appropriate for management of post-operative maxillofacial oncology patients. This practice has helped in offering high quality, cost effective and efficient services without having any adverse effect on the quality of care.

Minimally invasive oesophagectomy for carcinoma oesophagus--approaches and options in a high volume tertiary centre.

Minimally invasive oesophagectomy is being increasingly performed for treatment of carcinoma oesophagus. In this article, we overview the different types of minimally invasive oesophagectomies we used in our experience. To present an overview of the different types of minimally invasive oesophagectomies used to treat carcinoma oesophagus and to propose a simple working algorithm for surgical management of carcinoma oesophagus, a retrospective review of patients with carcinoma oesophagus who were operated at this centre during the period 1997-2009 was made. Data regarding type of surgery, level of growth, type of carcinoma, and complications were reviewed. A total of 463 patients underwent minimally invasive oesophagectomy for carcinoma oesophagus. Of these, 121 patients (26%) were female. There were no conversions. The mean age of patients was 61.6 years (range 36 years-77 years). Most patients (n = 330; 71%) had squamous cell carcinoma while 133 patients (29%) had adenocarcinoma. Overall mortality was 0.9%. Overall morbidity was 16%. Minimally invasive approaches to oesophagectomy are safe and the type of approach has to be tailored for the histology, level and stage of growth.

Bariatric to metabolic surgery: management options and experience at a tertiary centre.

Obesity proves to be a growing pandemic with severe health and economic implications. Bariatric surgeries are now recognised as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. This concept of metabolic surgery is now applied to non-obese population with metabolic disorders. The type II diabetes mellitus remission rates as high as 95% have been reported, least with restrictive procedures and maximum with malabsorptive procedures and such effect occurs even before substantial weight loss. This has led to increased understanding of diabetes pathophysiology and formulation of foregut and hindgut hypothesis. The aim of this study was to briefly review the management options for morbid obesity and present the results at a high volume centre. Data from 518 patients who underwent laparoscopic bariatric surgeries at this institute since 2002 were taken up for analysis retrospectively. Study population included 518 patients with 310 males and 208 females. Excess body weight loss and comorbidity resolution rates were analysed. Laparoscopic bariatric surgery is safe and effective for excess body weight loss and confers excellent resolution of associated comorbidities.