Amyand's hernia: Our experience in the laparoscopic era.

Amyand's hernia is a rare presentation of inguinal hernia, in which the appendix is present within the hernia sac. This entity is a diagnostic challenge due to its rarity and vague clinical presentation. A laparoscopic approach can confirm the diagnosis as well as serve as a therapeutic tool. When the appendix is not inflamed within the inguinal hernia sac, then appendicectomy is not always necessary. Our case series emphasize the same presumption as three patient of Amyand's hernia underwent laparoscopic transabdominal preperitoneal hernioplasty without appendicectomy. The aim of this paper is to review the literature with regards to Amyand's hernia and provide new insight in its diagnosis and treatment.

Transfascial suture in laparoscopic ventral hernia repair; friend or foe?

'Suture hernia' is fairly a new and rare type of ventral hernia. It occurs at the site of transfascial suture, following laparoscopic ventral hernia repair (LVHR). Employment of transfascial sutures in LVHR is still debatable in contrast to tackers. Prevention of mesh migration and significant post-operative pain are the pros and cons with the use of transfascial sutures, respectively. We report an unusual case of suture hernia or transfascial hernia, which can further intensify this dispute, but at the same time will provide insight for future consensus.

A Case Series on Superior Mesenteric Artery Syndrome Surgical Management, Single Institution Experience.

Compression of duodenum by Superior Mesenteric Artery (SMA) causing proximal intestinal obstruction is an uncommon condition. Treatment of this condition involves conservative management initially followed by surgical management in those patients who have persistent symptoms. This case series evaluates surgical management and outcome of six patients after one year, who presented with SMA syndrome and describes a brief review of literature. Three patients underwent open duodenojejunostomy and the rest three underwent laparoscopic duodenojejunostomy. All patients had uneventful postoperative recovery. Postoperative requirement of analgesics was less in laparoscopic group versus open group. All the three patients in laparoscopic group could be mobilised out of bed on the day of the surgery itself. Mean duration of hospital stay was seven days for open surgery group and three days for the laparoscopy group. Outcome in terms of resolution of abdomen pain and vomiting was similar in both the groups. Four patients were asymptomatic after one year of follow up. A high index of clinical suspicion is needed for the diagnosis of SMA syndrome. Laparoscopic approach is feasible, safe, less morbid and effective as compared to open surgery. In the presence of facilities and surgical expertise, laparoscopic duodenojejunostomy should be considered the procedure of choice for SMA syndrome. Majority of patients remain symptom free at one year follow up.

Duodenal Lipomatosis as a Curious Cause of Upper Gastrointestinal Bleed: A Report with Review of Literature.

Lipomas of the gastrointestinal tract are rare. Duodenal lipomas are incidental and mostly asymptomatic. Tumours may produce symptoms of abdominal pain and discomfort or cause bleeding due to ulceration or intestinal obstruction due to intussusception. We describe a 45-year-old man presenting in emergency with 3 days history of melena with normal gastroduodenoscopy and contrast enhanced computed tomography revealing multiple polypoid lesion in duodenum and proximal jejunum suggestive of lipoma. Due to ongoing bleed, he underwent laparotomy with duodenectomy and uneventful postoperative recovery. Our review of cases published in last 67 years indicate that duodenal lipomas are rare to occur but commonly found in second part, they may be seen in third and fourth part of duodenum which may be missed on endoscopy. They can be multiple and may present as severe UGI bleeding which could be managed surgically. Though CT is diagnostic, histopathology confirms the diagnosis which shows lipomatous lesion composed of mature adipose arranged in lobules.

A curious discourse of Krukenberg tumor: a case report.

Krukenberg tumor is usually but not always a bilateral involvement of ovaries from metastatic deposit from adenocarcinoma of stomach and rarely from other gastrointestinal (GI) and non GI organs. The route of metastatsis of this rare condition is still not proven. It is still uncertain whether surgical resection of ovarian metastases and/or primary tumor could improve the outcome. We report even a rare presentation of this rare disease entity.

Promoter methylation status of DNA repair gene (hMLH1) in gastric carcinoma patients of the Kashmir valley.

Cancer is a multi-factorial disease and variation in genetic susceptibility, due to inherited differences in the capacity to repair mismatches in the genome, is an important factor in the development of gastric cancer (GC), for example. Epigenetic changes, including aberrant methylation of 5/CpG islands in the promoter regions of mismatch repair (MMR) genes like hMLH1, have been implicated in the development of various types of GC. In the present study we evaluated the role of hMLH1 promoter hypermethylation in Kashmiri GC patients and controls, and assessed correlations with various dietary and lifestyle factors. The study included 70 GC patients (56 males and 14 females; age (mean ± S.D) 50 ± 11.4 years). Distinction between methylated and unmethylated was achieved with MS-PCR and DNA band patterns. The Chi-square test was applied to assess the risk due to promoter hypermethylation. We found a strikingly high frequency of promoter hypermethylation in GC cases than in normal samples (72.9% (51/70) in GC cases vs 20% (14/70) in normal samples (p=0.0001). We also observed a statistically significant association between methylated hMLH1 gene promoter and smoking, consumption of sundried vegetables and hot salted tea with the risk of GC. This study revealed that hMLH1 hypermethylation is strongly associated with GC and suggested roles for epigenetic changes in stomach cancer causation in the Kashmir valley.