Surgery for a symptomatic massive liver haemangioma.

Liver haemangiomas are the most common benign hepatic tumours, but secondary portal hypertension resulting from haemangiomas is exceedingly uncommon. We present a case of a man in his 50s who presented with a progressively enlarging mass in the right upper abdomen. CT of the liver revealed a large hypodense lesion involving the right lobe, with two smaller lesions in the left lobe. The portal vein was compressed by the tumour, causing portal hypertension. The patient underwent right hepatectomy. Postoperatively, the patient had an uneventful course, and a 3-month follow-up demonstrated resolution of the oesophageal varices, portal gastropathy, with hypertrophy of the left lobe. This case report highlights the successful surgical management of a rare massive hepatic haemangioma causing portal hypertension with surgical resection, emphasising the potential benefits of surgical intervention with minimal complications.

Aggressive Histology and Extensive Metastasis Characteristic of Very Young Gastric Cancer (Less Than 30 Years): A Retrospective Clinical Audit.

Narendran KrishnamoorthiObjectives Gastric cancer (GC) is an aggressive disease and remains one of the most common causes of cancer-related mortality worldwide. Incidence of gastric cancer in young (GCY) varies between 2 and 8%. GCY faces unique challenges such as biological variation, diagnosis at an advanced stage, issues related to fertility preservation, and psychosocial considerations. This study aimed to find the differences in clinical characteristics and treatment outcomes of GCY compared to gastric cancer in older adults (GCO). Material and Methods This is a retrospective study from a tertiary care center. We screened records from 2015 to 2020, identified 33 records of GCY (less than 30 years), and compared the data with GCO (greater than 30 years) during 2015 and 2018. Results We identified 33 patients with GCY with a median age of 28 years (21-30) and a female to male ratio of 2:1. In GCY, 60% of patients presented with metastatic disease. Diffuse-type histology was more common in the GCY than in GCO (66.7% vs. 41.7%, p = 0.001). In patients with metastasis, multiple metastases were common in GCY compared to GCO (45% vs. 15%, p = 0.003). The median duration of follow-up for all patients was 27 (24-29) months. In GCY, the median OS was not reached for patients treated with curative intent, and it was 13 months for those treated with palliative intent. Conclusion The incidence of GCY in our study was like the western literature. Female patients with aggressive diffuse histology and multiple extensive metastases were characteristic of GCY. The survival outcomes were identical to GCO.

The Incidence and Severity of Patient-Reported Side Effects of Chemotherapy in Routine Clinical Care: A Prospective Observational Study.

INTRODUCTION: Understanding patients' self-reported chemotherapy side effects is significant because it affects patients' quality of life (QOL) and compliance with treatment. Our current knowledge of chemotherapy side effects comes from available literature, whose external validity is questionable. Moreover, there are very few studies available in the literature that focus on various cancers and their associated side effects. METHODS: A single-center, prospective observational study was conducted at a tertiary care center from July 2019 to July 2021. After deriving the sample size, we interviewed 76 consecutive study patients with gastric, periampullary, colorectal, and breast cancer for six months after chemotherapy initiation with a structured patient-reported outcome tool adapted in English and Tamil to record the side effects like diarrhea, vomiting, chest pain, constipation, dyspnea, fatigue, mucositis, and rash. The grading of symptoms was done according to the Common Terminology Criteria for Adverse Events version 5.0. The frequency and prevalence of side effects were calculated as the number of patients who reported the side effect of any grade at least once during the follow-up period. The incidence rate of side effects was calculated in terms of person-time. The association between each side effect and cancer type was calculated using the chi-square test and Fisher's exact test as appropriate. RESULTS: Of the 77 patients in the study, 51.9% were male, 63.6% were between 40 and 60 years of age, 45.5% had stage-3 disease, and 44.2% received neoadjuvant treatment. During the six-month follow-up period, 97.4% of patients experienced at least one side effect. Fatigue was the most common side effect (87%), followed by loss of appetite (71.4%) and diarrhea (49.4%). Approximately 66.7% of patients experienced six or more side effects. There was a statistically significant difference in the frequency of side effects between cancer types. However, age, socioeconomic status, BMI, comorbidity, chemo-intent, and stage of disease did not affect the frequency of side effects. CONCLUSIONS: This study highlights the need to integrate patient-reported side effects into routine clinical practice. Identifying these side effects, even if they are mild in intensity, and managing them in a timely manner may improve the patient's emotional state, QOL, and compliance with chemotherapy.

A Rare Case of Kissing Gastric Ulcers Secondary to Non-steroidal Anti-inflammatory Drug (NSAID) Intake.

Peptic ulcer disease is a heterogeneous disease caused by the imbalance between mucosal protective and aggressive factors. Such ulcers are common in the anterior wall of the duodenum and gastric antrum. Kissing ulcers, although commonly reported in the duodenum, are rarely seen in the stomach. We present a rare case of an 85-year-old lady who had an index presentation of sudden onset hematemesis following ibuprofen intake. Endoscopy revealed kissing gastric ulcers, which are extremely rare secondary to non-steroidal anti-inflammatory drugs. She had complete healing after treatment with proton pump inhibitors.

Outcomes of Emergency Abdominal Wall Hernia Repair: Experience Over a Decade.

Background Abdominal wall hernias are a common surgical entity encountered by the general surgeon. Approximately 10% of abdominal wall hernia patients require emergency surgery. However, these surgeries are associated with a high rate of postoperative morbidity and mortality. This study aimed to analyze the morbidity and mortality in patients undergoing emergency abdominal wall hernia repair and to determine the factors associated with surgical site infection (SSI) and recurrence in these patients attending a tertiary care hospital in south India. Methodology Our study was a single-centered, 10-year retrospective and a one-year prospective study conducted in a tertiary care center in India. All patients who underwent emergency abdominal wall hernia repair between April 2009 and May 2020 were included. Patients' demographic details, comorbidities, intraoperative findings, 30-day surgical outcomes including SSI, and recurrence were studied. Results Out of 383 patients in our study, 63.9% had an inguinal hernia, and 54% of the patients underwent tissue repair. SSI was the most common morbidity (21.9%). Postoperative sepsis was the only independent factor associated with perioperative mortality according to the logistic regression analysis (odds ratio = 22.73, p = 0.022). Conclusions Tissue repair for emergency hernia surgery has better outcomes than mesh repair in clean-contaminated cases.

Role of Neoadjuvant Chemotherapy in Locally Advanced Carcinoma Stomach: An Analysis of the Short-Term Outcomes.

INTRODUCTION: Neoadjuvant chemotherapy (NACT) in carcinoma stomach was introduced in an effort to eliminate micro-metastasis and to improve resectablity before surgery which improves R0 resection rates. We aimed to study the short term outcomes of neoadjuvant chemotherapy on the Tumor Node Metastasis (TNM) stage and the operative outcomes including R0 resection rate in locally advanced gastric cancer. METHODS: We prospectively included patients with locally advanced adenocarcinoma stomach staged by contrast-enhanced computed tomography (CECT) in our study. Patients in Group I were started on neoadjuvant chemotherapy (epirubicin, oxaliplatin, and capecitabine). Surgery was done following response assessment CECT. Patients in Group II underwent upfront surgery. We assessed R0 resection rate, number of harvested and metastatic lymph nodes, lymph node ratio, duration of surgery, blood loss, hospital stay and complications between two groups. Response to NACT was assessed in Group I. RESULTS: Out of 47 patients who received NACT, two patients had complete response (4.2%), 13 had partial response (27.7%), 10 had stable disease (21.3%) and 22 patients had progressive disease (46.8%). We found no significant difference in the rate of R0 resection between the two groups (88.2% in NACT group vs 85.1% in surgery group, P=0.55). CONCLUSIONS: The rate of R0 resection does not significantly improve with neoadjuvant chemotherapy. In view of high progression rates, patient selection is required when NACT is planned in carcinoma stomach which are surgically resectable at presentation. We await survival analysis to further validate the role of NACT.

Co-infection of intestinal tuberculosis and mucormycosis in a patient with Down syndrome: a unique case report with literature review.

Mucormycosis represents several unusual opportunistic infection caused by saprophytic aseptate fungi. There is a recent rise in cases of mucormycosis due to an increase in diabetic and immunodeficient patients like patients on long-term steroids, immunomodulators due to organ transplantation, malignancies, mainly haematological malignancies, and autoimmunity. Anatomically, mucormycosis can be localised most commonly as rhino-orbito-cerebral followed by pulmonary, disseminated, cutaneous and gastrointestinal, rarest being small intestinal. Patients with Down syndrome are immunodeficient due to their impaired immune response. Disseminated tuberculosis is also common in immunodeficient patients. We report a rare case of small intestinal mucormycosis in a patient with Down syndrome with coexisting intestinal tuberculosis. Due to the invasiveness of mucormycosis, the patient succumbed to death despite providing aggressive surgical debridement and medical management.

A Rare Case of HIV-Associated Plasmablastic Lymphoma of Anal Canal.

Plasmablastic lymphoma, an acquired immunodeficiency syndrome defining malignancy, is a subtype of diffuse large B-cell lymphoma. It is classically described in the oral cavity, the extraoral presentation being rare. Owing to its rarity and aggressiveness, plasmablastic lymphoma poses a diagnostic and therapeutic challenge to the treating physician. A 40-year-old male, recently diagnosed with HIV infection, presented with bleeding per rectum and spurious diarrhea. Examination revealed proliferative growth in the anal canal. Biopsy of the lesion was diagnostic of plasmablastic lymphoma. Computed tomography and magnetic resonance imaging were done to stage the lesion and assess the local extent, respectively. A multidisciplinary board discussion was done, and the patient was instituted on antiretroviral therapy and chemoradiotherapy. Following six cycles of chemotherapy and 25 fractions of radiotherapy, he achieved complete remission.

Gastric Candidiasis Leading to Perforation: An Unusual Presentation.

Candidal infection of the gastrointestinal tract (GIT) is rare but has recently increased due to the increased number of immunocompromised patients, injudicious use of antibacterial agents, and prolonged use of antacid drugs in immunocompetent patients. The most frequent organ involved in GIT candidiasis is the esophagus, followed by the stomach, small intestine, and large intestine. The clinical spectrum of gastric candidiasis ranges from asymptomatic to gastric perforation and even shock. This case report presents a 58-year-old immunocompetent male patient diagnosed with Candida tropicalis-induced gastric perforation peritonitis.

Gastric Carcinoma: An Unexpected Complication of Loop Gastro-Jejunostomy Done in Childhood.

Gastric adenocarcinoma is the fifth most common cancer worldwide and the third leading cause of death. The major risk factors include Helicobacter pylori infection, genetic factors, environmental factors, and atrophic gastritis. Gastric remnant cancer is gastric carcinoma that develops in the remnant stomach more than five years after distal gastrectomy for benign disease, incidence ranging from 1% to 8%. However, gastric carcinoma after loop gastro-jejunostomy without gastric resection for benign etiology is rare. We report a case of a 45-year-old lady with gastro-jejunostomy without gastric resection done in childhood, presenting with adenocarcinoma at the anastomotic site after 35 years.

Perforated Blind Pouch: An Unusual Late Complication Following Lateral Anastomosis After a Right Hemicolectomy.

Blind loop syndrome (BLS) is a well-recognized delayed complication in small bowel strictures, stenosis, fistulas, diverticula, or post-gastrectomy afferent loop syndrome. However, due to its delayed presentation, BLS after side-to-side bowel anastomosis is inadequately reported. The vicious cycle of the blind loop is due to bacterial overgrowth, resulting in diarrhea, weight loss, malnutrition, and rarely mucosal erosion, bleeding, and perforation peritonitis. Diagnosis of BLS requires knowledge of previous surgery performed, a high level of clinical suspicion, and experienced radiological abilities. In this case report, we present the clinico-radiological profile of a 54-year-old diabetic patient with a perforated blind ileal pouch occurring four years after a right hemicolectomy with side-to-side ileo-transverse anastomosis.

Colossal Parotid Tumors: A Diagnostic and Surgical Challenge.

Tumors of the salivary glands constitute 3% of all head and neck tumors. The parotid gland (PG) is the most common site involved in 85% of cases. PG tumors' size varies from a few millimeters to several centimeters and is about 2-6 cm on average. However, because of insidious growth and asymptomatic nature, untreated tumors of the PG can attain large size. Pleomorphic adenoma (PA), as large as 33 cm in size or 26.5 kg in weight, has been reported in the literature. Similarly, untreated Warthin's tumor (WT) rarely becomes giant, size up to 20 cm is reported. Giant PG tumors are commonly symptomatic and have a rare tendency to become malignant. We are reporting two giant PG tumors with different histopathological diagnoses, PA and WT of size 15x15 cm and 10x8 cm, respectively. Therefore, with a size of 10 cm, our case is the second-largest WT reported in the literature. Both the giant PG tumors were present for 15-20 years, and mild pain and discomfort were the only symptoms. We had the differential preoperative tissue diagnosis in fine-needle aspiration cytology (FNAC) because of varying consistency. Contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) of the neck were done for these cases for preoperative planning. Compared to the former, the latter was more informative about nerve involvement preoperatively. Both the patients underwent superficial parotidectomy, and meticulous dissection was done to identify and safeguard the facial nerve and its branches. We had a challenge in closing the flaps, which was achieved with an acceptable cosmetic outcome. Both the patients were discharged in stable condition with minimal facial nerve weakness.

Strangulated Epigastric Hernia: A Rare Occurrence.

An epigastric hernia is a rare type of abdominal hernia, described in the literature mostly as small, containing only preperitoneal fat. A large true epigastric hernia with herniation of the abdominal viscera is even rarer. Only a few case reports have given an account of strangulation in such an epigastric hernia. This case report describes a middle-aged, morbidly obese man with a big epigastric hernia presenting with incarceration and acute abdominal pain. Emergency surgical exploration revealed a 7 cm midline defect in the rectus sheath and a 30 cm segment of the jejunum and a 6 cm segment of the transverse colon were gangrenous. The gangrenous bowel segments were resected, and an end-to-end jejuno-jejunal and colo-colic anastomosis were done. The patient had an uneventful postoperative recovery.

A Rare Case of Dorsal Agenesis of Pancreas, Choledochal Cyst, and Hirschsprung Disease in a Young Patient.

Dorsal pancreatic agenesis is a rare congenital pancreatic malformation. There is just 1 reported case associating it with choledochal cyst. However, no cases have reported yet with both coexisting with Hirschsprung disease. We report a case of a 23-year-old man, presenting with on and off epigastric pain, sometimes radiating to the back. His medical records showed he had Hirschsprung disease as a neonate, for which he underwent Duhamel procedure. Ultrasound imaging revealed a choledochal cyst and a nonvisualized distal portion of the pancreas. Further cross-sectional imaging confirmed the findings-a type 1 choledochal cyst and a dorsal agenesis of the pancreas in a patient with Hirschsprung disease.

Swiss Cheese Loin: A Rare Initial Presentation of Pott's Spine.

Spinal tuberculosis (TB) is the most common form of skeletal TB with an exceedingly diverse set of clinical presentations. Most often, there is a slow onset of the disease with patients presenting only with back pain. Although some patients can present later with neurological deficits or with compressive symptoms of an accompanying cold abscess, an initial presentation of a spontaneous cutaneous fistulization of a paraspinal abscess is rare. We present the case of a young boy with such a primary presentation, with no other common symptoms of spinal TB. He was treated with ultrasound-guided percutaneous drainage of the paraspinal abscess and a multidrug anti-tubercular chemotherapy regimen.

Anomalous Pancreaticobiliary Duct Junction in an Unusual Case of Synchronous Gallbladder and Bile Duct Malignancy.

Synchronous malignancies involving the gallbladder and the bile duct are exceedingly rare. Moreover, their association with anomalous pancreaticobiliary duct junction (APBDJ) has been reported mostly from the Far Eastern countries. Over time, many studies have suggested the definite risk of malignancy attributable to the 'carcinogenic anatomical configuration' of the long common biliopancreatic channel, allowing reflux of pancreatic juices in the biliary tract. In this report, we present a case of an elderly man from South India who was initially diagnosed with synchronous gall bladder with bile duct malignancy; the patient turned out to have an APBDJ on further evaluation.

Intraductal Papillary Neoplasm of the Bile Duct: A Rare Case of Intrahepatic Space-Occupying Lesion.

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare tumor and is considered one of the precursor lesions for cholangiocarcinoma. Though relatively common in the far east countries, it is uncommon in the Indian population. A 67-year-old gentleman presented with vague upper abdominal pain with no history of fever, jaundice, melena, or hematemesis. An abdominal ultrasound showed a solid cystic lesion in the left lobe of the liver with upstream dilatation of bile ducts. Computed tomography and magnetic resonance imaging showed similar findings. With a differential diagnosis of intrahepatic cholangiocarcinoma, intraductal papillary neoplasm, and biliary cystadenoma, he underwent robotic-assisted left hepatectomy. Histopathology was suggestive of IPNB. Following surgery, he had an uneventful recovery and was advised for follow-up visits every six months. A clinical, radiological, and pathological profile of this rare tumor has been described here with a review of the existing literature.

Antegrade Jejunojejunal Intussusception: An Unusual Complication Following Feeding Jejunostomy.

Feeding jejunostomy (FJ) is a simple surgical procedure for enteral nutrition. But it can develop complications that may require re-exploration and can be life-threatening. Common complications include mechanical ones such as tube migration or dislocation, infection, gastrointestinal symptoms and fluid and electrolyte imbalances. However, intussusception is a rare complication of FJ. A 54-year-old gentleman underwent a D2 subtotal gastrectomy with Roux-en-Y gastrojejunostomy with FJ. On the sixth postoperative day, he developed severe colicky pain associated with abdominal distension and bilious vomiting. Ultrasonography and computed tomography revealed a 10-cm long jejunojejunal intussusception with the FJ tube at the center of the intussusception with proximal jejunal loops' distension. The patient was taken up for a re-exploratory laparotomy with manual reduction of the intussusception and a new FJ insertion distal to the previous enterotomy site. The patient had an uneventful postoperative recovery.

Leiomyosarcoma of the inferior vena cava posing as an adrenal incidentaloma.

Adrenal incidentalomas are incidentally detected adrenal lesions on imaging, which have a variety of differential diagnoses, the most common being a non-functioning adenoma. Surgical intervention for these lesions is needed when there is hypersecretion, for lesions larger than 4 cm and smaller lesions with suspicious characteristics. Here we present a young woman who was incidentally found to have a right suprarenal mass with loss of fat planes with the inferior vena cava (IVC). She underwent resection of the tumour along with the posterior wall of IVC, which was primarily repaired. Her postoperative biopsy was suggestive of leiomyosarcoma arising from the IVC. In the absence of distant metastasis, the sole prognostic factor for this tumour is achieving negative margins through radical resection of the tumour with IVC resection. Retroperitoneal leiomyosarcomas should be considered as a differential diagnosis for larger lesions, especially those more than 10 cm.