Structural Challenges in Native Atrioventricular Valves Replacement.

Atrioventricular (AV) valve disease is a major burden in our Indian subcontinent, where rheumatic heart disease is still prevalent, when compared to the Western world, where degenerative heart disease is more prevalent. Worldwide, nearly 300,000 valve replacements are done every year but not without complications. These challenges can be multidimensional and multiscalar with the macroscopic and microscopic properties of the native patient tissue interacting with the mechanical and bioprosthetic heart valves and rings. Understanding the complex and variable anatomy of the AV valves is essential to know the exact pathophysiology of the disease and to decide the treatment of choice.

Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians.

A 49-year-old multiparous woman presented with a swelling in the left groin of 6 months duration. The swelling was associated with a dull aching pain. The patient reported increase in size of the swelling during lifting of heavy weights. Menstrual history was normal and there was no increase in pain over the swelling during menstruation. She underwent a caesarean section 20 years ago and the scar had healed by primary intention. She was provisionally diagnosed to have a left-sided inguinal hernia. Ultrasonography showed a multiloculated cyst measuring 5.3×1.5×5.2 cm within the inguinal canal. The patient had excision of the cyst under spinal anaesthesia. Intraoperatively the cyst was found to arise from the left round ligament. It measured 7×6 cm extending to the left lateral vaginal wall. Histopathology revealed endometriosis of the round ligament. Her gynaecological assessment was normal and they recommended no further treatment. On follow-up the patient was asymptomatic and wound had healed well.

Jejuno-jejunal intussusception: an unusual complication of feeding jejunostomy.

The jejuno-jejunal intussusception is a rare complication of jejunostomy tube placement. We are reporting a case of 33-year-old man who was suffering from absolute dysphagia due to carcinoma of cricopharynx with advanced metastatic disease, who underwent Stamms feeding jejunostomy as a part of palliative care. After 1 month he presented with colicky type of pain in the abdomen and vomiting. Sonogram of abdomen revealed a target sign and a feeding tube in a dilated jejunum. Abdominal CT proved the sonographic impression of jejuno-jejunal intussusception. He, therefore, underwent exploratory laparotomy and resection and anastomosis of the intussuscepted bowel. New feeding jejunostomy (FJ) was done distally from the anastomotic site. As per the literature this complication has been reported in Witzels jejunostomy. In our case the patient had undergone Stamms jejunostomy with placement of a Ryle's tube. Intussusception should be considered if a patient comes with abdominal pain and vomiting following FJ.

Portal pyaemia secondary to open haemorrhoidectomy: need for prophylactic broad spectrum antibiotics.

A 70-year-old man presenting with long standing grade 3 Haemorrhoids, underwent open haemorrhoidectomy under spinal anaesthesia. The patient passed stools on subsequent day and there was no bleeding per rectum. On day 5, he complained of dull aching upper abdominal pain. On physical examination, the abdomen was soft and there was mild tenderness in the epigastric region. Subsequently, he developed high temperature with chills and rigors. His condition failed to improve and the abdominal pain increased in severity. There was no pain in the perianal region and per rectum examination was normal. Leucocyte count rose to 12×10(9)/L and there were toxic changes on peripheral smear. Blood culture grew Staphylococcus aureus. Liver enzymes were mildly elevated. Coagulation profile was deranged. Fibrin degradation products were positive. D-dimer was high. CT revealed acute thrombosis of left portal vein and microabscesses suggestive of portal pyaemia.