Successful management of a thoracoabdominal impalement injury

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Successful management of a thoracoabdominal impalement injury

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Polidocanol versus phenol in oil injection sclerotherapy in treatment of internal hemorrhoids: A randomized controlled trial

BACKGROUND/AIMS

Management of Haemorrhoids is suboptimal and is largely based on traditional practices in the Indian population. Though injection sclerotherapy is a well-accepted treatment modality in early grade haemorrhoids, there is no consensus on the effectiveness of the drugs used for sclerotherapy. The study was done to compare the safety and efficacy of a standard sclerosant (polidocanol) and the conventionally used phenol in oil in bleeding grade-1 and 2 internal haemorrhoids.

MATERIALS AND METHODS

All patients with grade-1 and 2 hemorrhoids, were selected and randomised into two groups, 3% polidocanol and 5% phenol group. All patients were followed-up for three months and observed for "free of bleeding" or "persistent bleeding." Pain, pruritus and patient satisfaction following the procedure was also assessed.

RESULTS

A total of 150 patients were enrolled, 75 in each group. At the end of the first sclerotherapy session with polidocanol, 60.6% of patients versus 38.1% in phenol group had stopped per rectal bleeding (p=0.009). After the second sclerotherapy session, 94.7% of patients in the polidocanol group and 84% of patients in the phenol group were treated successfully. Polidocanol group required significantly fewer treatment sessions than the phenol group (1.39±0.49 vs. 1.62±0.49; p=0.035), and the total volume of injected sclerosant was also less (3.30±0.96 mL vs. 4.86±1.46 mL; p=0.001). The patient satisfaction was 87% in polidocanol group versus 73% in phenol group (p=0.040).

CONCLUSION

3% polidocanol is safe and more effective than 5% phenol in oil when used as injection sclerotherapy in the treatment of first and second-degree internal hemorrhoids.

Coinfection of Typhoid Fever With Tuberculosis: A Challenge to Surgical Management

Ileal perforation is one of the most dreaded complications of abdominal tuberculosis. It is more common in immunodeficient patients, where ulcerative type of intestinal tuberculosis predominates. Various factors play role in the outcome of these patients, such as age and comorbid illness, though the lag period (advent of symptoms to time of admission to hospital) correlated directly to the mortality in these patients. Herein we present a 28-year-old male who had a coinfection of typhoid fever along with intestinal tuberculosis. The patient presented with abdominal pain and fever for one-week duration. On examination, he had diffuse tenderness of his abdomen with guarding. X-ray revealed free air under diaphragm. The patient underwent limited resection of terminal ileum and cecum with end ileostomy for ileal perforation. The patient’s serum Widal test was positive and blood culture grew Salmonella Typhi, and the patient was started on intravenous (IV) antibiotics based on culture and sensitivity. The patient’s general condition worsened after two weeks with bile leak from the surgical site. The patient succumbed to severe sepsis. Postoperative histopathology of the resected ileo-cecal segment showed features of ileo-cecal tuberculosis. As typhoid is a common cause of ileal perforation in the developing countries, the co-existence of typhoid fever in this patient lead to the delay in the diagnosis and appropriate management of tubercular ileal perforation. Knowledge about various causes of typhoid perforation is essential for treating surgeons. 

Profile of Pediatric Trauma among the Patients Attending Emergency Department in a Tertiary Care Hospital in South India

Background

Pediatric trauma is emerging as an epidemic worldwide; the epidemiology of pediatric trauma is different in different parts of the world. There are very few studies describing the pediatric trauma in developing countries.

Objectives

The objectives of this study were to assess the type, mechanism, and extent of trauma among pediatric trauma patients and its association with clinical outcome.

Methodology

This was a prospective observational study conducted in the department of emergency medicine and trauma at a tertiary care hospital in South India from September 2015 to March 2017. All children aged <12 years with a history of injuries irrespective of the cause for attending our trauma center were included in the study.

Observations and Results

Of the 911 children enrolled, 63.9% sustained injuries at home. The leading modes of injury were fall at level ground (26.9%), road traffic accidents (RTAs) (25.5%), and fall from height (16.8%). Majority of RTA victims were two-wheeler pillion riders (40.5%) and pedestrians (31.9%). Nearly 49% of children had head and maxillofacial injuries. Polytrauma was found in 3.6% of children. Based on the Pediatric Trauma Score (PTS), 72.6% of children had mild trauma and 6.1% severe trauma. Totally, 18.9% of children required inpatient management, 7.5% surgical intervention, and 1.8% expired.

Conclusions

Most of injuries in children occurred at home. This was followed by injuries on road. The leading cause of polytrauma was RTA. RTA victims were more likely to have severe injuries and poor outcome. They were more likely to require inpatient management compared to those who fell from height or fell at level ground. Glasgow Coma Scale and PTS may be used reliably to assess the severity of injuries sustained by children.

Evaluation of Serum Vitamin D Levels in Diabetic Foot Infections: A Cross-Sectional Study in a Tertiary Care Center in South India

Background

The impact of diabetic foot infections is enormous in India. Studies on vitamin D levels in diabetes mellitus foot infections are scarce. The primary objective of the present study was to compare the serum vitamin D level between diabetics with foot infections and those without foot infections and the secondary objective was to assess the association between the vitamin D level and the severity of foot infections and outcomes.

Methods

The study included 176 type 2 diabetics who attended Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, between September 2012 and June 2014. The serum vitamin D level was measured for 88 diabetics with foot infections (Group 1) and 88 without foot infections (Group 2) using the ELISA 25OH vitamin D DIAsource kit (DIAsource ImmunoAssays S.A., Belgium) and compared. Both groups were followed up for 6 months for outcomes. The qualitative variables were analyzed using the χ2 test and the quantitative variables using the Student t test. The statistical analyses were performed using SPSS, version 17.0. A P value of less than 0.05 was considered significant.

Results

The mean serum vitamin D level was not significantly different between the two groups (P=0.306). Among the patients in Group 1 who either required amputations or died, 97.44% had subnormal vitamin D levels in contrast to 59.18% in those who were grafted or achieved wound healing (P=0.001). Among those who achieved wound healing within 6 months, 78.9% had normal vitamin D levels (P=0.0006).

Conclusion

The study found no significant difference in the serum level of vitamin D between diabetics with and without foot infections. However, vitamin D deficiency was associated with a poor outcome in diabetics with foot infections.

Gastric Carcinoma in a Patient with Chronic Lymphocytic Leukemia: Coincidence or Consequence?

Chronic lymphocytic leukemia (CLL) is a neoplasm of mature B-cells of unknown etiology. There is a site-specific increased incidence of second malignancy in patients with CLL. Leukemia and cancer can thus occur in the same patient either simultaneously or sequentially. We present a case of gastric adenocarcinoma in a patient with chronic lymphocytic leukemia.

A 47-year old female presented with a history of abdominal pain for one year, along with nausea and vomiting for two months. On examination, she was pale and had generalized lymphadenopathy. Her abdominal examination revealed vague fullness in the epigastrium, but there was no definite palpable mass. The complete hemogram showed features suggestive of CLL, which was later confirmed by a lymph node biopsy and bone marrow examination. While upper gastrointestinal endoscopy revealed an ulceroproliferative growth in the body of the stomach, its biopsy revealed a well-differentiated adenocarcinoma.

Gastric cancer developing in a patient with CLL may be due to the immunological impairment associated with other etiological factors, such as Helicobacter pylori infection, smoking, etc. The treatment of gastric cancer consists of a gastrectomy with regional lymphadenectomy followed by adjuvant chemotherapy. The co-existence of CLL and carcinoma stomach can pose a challenge in the management of such patients.

Pediatric Trauma - An Emerging Epidemic

We enrolled 911 children aged <12 years presenting to the trauma center of a tertiary-care hospital (over a period of 18 months) with history of injuries. Majority (582; 63.9%) of children had sustained injuries at home; 56 (6.1%) had severe injuries based on Pediatric Trauma Score. Of road traffic accidents victims (n=232), majority (40.5%) were two-wheeler pillion riders or pedestrians (31.9%). More Indian data are required and efforts are needed to prioritize injury prevention efforts in children.

Clinico-microbiological Profile of Septic Diabetic Foot with Special Reference to Anaerobic Infection

Introduction Diabetic foot infections are a major cause of non-traumatic amputations. The role of anaerobes in the prognosis of these infections is particularly unclear. This study was conducted with the aim of correlating microbiological profiles with clinical outcomes in these diabetic foot ulcer patients. Methodology This prospective observational study was done in a tertiary care centre in South India. All patients admitted with diabetic foot ulcers for two years were included in the study. Tissue biopsies were collected from the ulcer for aerobic and anaerobic cultures. The patients were grouped as those with aerobic infection alone (anaerobe negative) and those with mixed aerobic and anaerobic infections (anaerobe positive). Anaerobic culture was performed using the Robertson cooked meat (RCM) medium. The ulcer of the foot was described with respect to site, size, duration, history of previous amputation(s), and history of number and class of antibiotic intake prior to hospitalization. Clinical course and Wagner's grades of the diabetic foot ulcers were compared for aerobic and anaerobic infections. Results A total of 104 patients were included in the study. There were no significant differences between the two groups with regards to duration of diabetes, random blood sugar (RBS) at the time of admission, compliance to drugs, and mode of blood sugar control and prior intake of antibiotics. Patients with anaerobic infections were found to have a higher incidence of fever in this study (38.1% vs. 14.5%; p = 0.0057), as compared to patients with aerobic infections. More than half of the patients in the anaerobic infection group presented with Wagner's grade IV and above, as compared to the aerobic infection group (59.5% vs. 32.2%; p = 0.0059), which was statistically significant. Patients with anaerobic infections also had high numbers of major and minor amputations when compared to patients with aerobic infections. Conclusion Septic diabetic foot patients with fever at the time of admission and a high Wagner's grade have a greater chance of harbouring anaerobic infections. Drugs for anaerobic coverage should be considered for wounds beyond Wagner's grade III. Anaerobic infections resulted in increased risk of morbidity in diabetic foot ulcer patients but did not have any influence on mortality.

A Rare Case Report of a Paratesticular Fibrous Pseudotumor Mimicking a Hydrocele

Tumors arising in the spermatic cord are very rare. The common benign tumors of the spermatic cord include adenomatoid tumor, lipoma, neurofibroma, and leiomyoma. We report a rare case of fibrous pseudotumor of the spermatic cord presenting clinically as a hydrocele. A 28-year-old male presented with the complaint of swelling in the left scrotum, which gradually progressed in size over four years. Clinically, the swelling was soft and fluctuant. The left testis was not separately made out and a diagnosis of left hydrocele was made. On scrotal exploration, a large 12 x 7 cm fleshy mass was seen in the left hemiscrotum with the left testis adherent to the upper pole of the mass. The mass was dissected out from the testis, and the histology showed features of fibrous pseudotumor of the spermatic cord. Fibrous pseudotumor of the spermatic cord is a very rare entity and can pose a diagnostic challenge. Preoperative scrotal ultrasound and intraoperative frozen section assessment can prevent unnecessary orchiectomies in young patients with paratesticular fibrous pseudotumors.

Factors Hindering Practice of Day Care Surgery in a Tertiary Care Centre in Southern India: A Patient's Perspective

INTRODUCTION

Day care surgery offers cost containment, effective usage of hospital beds, reduced incidence of nosocomial infection and early recovery in home environment. In developing countries like India, there are various factors that influence the success of day care surgery.

AIM

To assess the factors hindering the practice of day care surgery in a tertiary care centre in South India.

MATERIALS AND METHODS

This observational study was conducted in the Department of General Surgery, JIPMER, Puducherry, India, from January 2013 to March 2014. All male patients with uncomplicated inguinal hernia who were admitted for elective surgery under one particular surgery unit and who were found fit for discharge on Postoperative Day 1 (POD1) based on clinical fitness were included in the study. A questionnaire containing the patient's acceptance decision, VAS (Visual Analogue Scale) pain score and the reason for non acceptance if any was used for assessment.

RESULTS

Among the 89 patients who were fit for discharge on POD1, the decision for discharge was accepted by 57 patients. 32 patients were not satisfied of the decision for discharge on POD1. The common reasons for dissatisfaction with the decision were persistent pain at operated site (13 patients with mean VAS score 8.3), non availability of health care resources in their locality (12 patients) and unwillingness to travel on POD1 (four patients).

CONCLUSION

A comprehensive and well presented preoperative counselling along with an effective primary health service would help in promoting day care surgery in developing countries.

An Unusual Cause of Small Bowel Obstruction: A Case Report

Small bowel obstruction is a common surgical emergency. The common causes are adhesions, malignancies, and hernias. We present a rare case of small intestinal obstruction caused by an enterolith in the distal ileum in a patient with an apparently normal gut. 

A 59-year-old male who underwent gastrojejunostomy 15 years back presented with features of intestinal obstruction of five days' duration. After initial conservative management, the patient was taken up for laparotomy. An enterolith causing obstruction was found in the distal ileum, and it was crushed and milked into the colon. The patient made an uneventful recovery. 

The chyme crossing the ileum is usually liquid or semi-solid and hence luminal obstruction by the faecal bolus in the ileum is very unusual. In patients with previous gastric surgeries where the pylorus is bypassed, the solid food particles enter the small intestine and can form a bezoar. This patient was managed with laparotomy and milking of the stool bolus into the colon. Other treatment options include enterotomy or resection of the diseased bowel and removal of the enterolith. 

Small bowel obstruction due to an enterolith is very rare and can pose a diagnostic challenge. 

A History of Intravenous Anesthesia in War (1656-1988)

The practice of anesthesia in war places significant restraints on the choice of anesthetic technique used; these include, but are not limited to, safety, simplicity, and portability. Ever since intravenous anesthesia became a practical alternative, there have been military doctors who felt that this technique was particularly suited to this environment. The challenge, as in civilian practice, has been to find the appropriate drugs as well as simple and safe delivery systems. The urgency of war has always stimulated innovation in medicine to counteract the ongoing development of weapons of war and their effects on the human body and to achieve improved survival as public expectations rise. This article traces the development of and the use of intravenous anesthesia by military physicians for battle casualties. The story starts long before the era of modern anesthesia, and the discussion concludes in the dog days of the cold war. The rapidly increasing interest in intravenous anesthesia in both civilian and military practice since the early 1990s is left for other authors to examine.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM

To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT).

METHODS

Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up.

RESULTS

Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00.

CONCLUSION

H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM

To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT).

METHODS

Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up.

RESULTS

Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00.

CONCLUSION

H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM: To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT).

METHODS: Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up.

RESULTS: Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00.

CONCLUSION: H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Evaluation of the effect of presence of blood in the stomach on endoscopic diagnostic tests for Helicobacter pylori infection

INTRODUCTION

Presence of blood in the stomach has been thought to affect the performance of diagnostic tests used in detecting Helicobacter pylori (H. pylori) in the stomach. This study evaluated the effect of blood on the efficacy of rapid urease test (RUT) and microscopic appearance of the biopsy after staining with Giemsa stain.

MATERIALS AND METHODS

Patients with bleeding oesophageal varices who met the inclusion criteria were tested for H. pylori by RUT and microscopic examination of the biopsy. A repeat endoscopy, RUT and histology were done one month following initial presentation. The performance of the diagnostic tests was evaluated with and without the presence of intraluminal blood. A combined result of the two tests, RUT and histology, carried out in presence or absence of blood for the diagnosis of H. pylori, when considered together was considered as the gold standard.

RESULTS

Thirty six patients included in the study were in the ages ranging between 15-60 years (mean age = 44.14 years ± 2.1). The combination of tests at both visits showed 20/36 (55.6%) patients were positive for H. pylori. The decrease in H. pylori positivity in the presence of blood was significant for RUT (8.3% vs. 38.9%; P=0.005) and combined test (19.4% vs. 47.2%; P=0.02) but the decrease in positivity for histology (11.1% vs 30.6%) was not significant (P=0.08). In the presence of blood, the sensitivity of RUT, histology and combined tests were 15%, 20% and 35%, respectively. In the absence of blood, the sensitivity of RUT, histology and combination of tests was 70%, 55% and 85%, respectively.

CONCLUSION

Blood in the stomach significantly decreased the sensitivity of RUT, histology and the combination of both. Negative results of these tests in acute upper gastro intestinal (GI) bleeding should therefore be interpreted carefully.

Sequential therapy versus standard triple drug therapy for eradication of Helicobacter pylori in patients with perforated duodenal ulcer following simple closure

BACKGROUND

Resistance to clarithromycin, a component of standard triple therapy, leads to inconsistent eradication rates of Helicobacter pylori infection. Some studies have shown higher eradication rates for H. pylori using sequential regimen. This study was done to compare the eradication rates for H. pylori infection between the standard triple drug therapy and the sequential therapy.

METHODS

Seventy-three patients with perforated duodenal ulcer following simple closure with H. pylori infection were randomized to receive either standard triple drug therapy or the sequential therapy. Standard triple drug therapy comprised of omeprazole, clarithromycin, and amoxicillin for 10 days. Sequential therapy comprised of omeprazole and amoxicillin or the first 5 days followed by omeprazole, clarithromycin, and amoxicillin for the next 5 days. Follow-up endoscopy was done at 2 months to assess the eradication rates, compliance, and side effects with each regimen.

RESULTS

Eradication rates for standard triple therapy and sequential regimen were 81.25% and 87.09%, respectively (p = 0.732). The cost of sequential therapy was cheaper and incidence of side effects and compliance were similar in each group.

CONCLUSION

Standard triple therapy and sequential therapy have similar efficacy for eradication of H. pylori and sequential therapy is an economical alternative to standard triple therapy.

Total intravenous anaesthesia for war surgery

Total intravenous anaesthesia (TIVA) and target-controlled infusion (TCI) of anaesthesia are techniques that have benefited from recent advances in microprocessor technology and drug design. Though dependant on technology, they offer significant clinical benefits and logistic advantages. Manipulation of complex data derived from population pharmacokinetics has enabled greater understanding of drug handling models, thus enabling individual patient titration of anaesthesia. This has also informed manual techniques of intravenous anaesthesia. These approaches constitute a useful and logical alternative in the field, both in austere circumstances as well as the more established deployed setting. The pharmacodynamics and pharmacokinetics of potent intravenous anaesthesia agents in the complex combat trauma patient require continued examination.

Role of bone biopsy specimen culture in the management of diabetic foot osteomyelitis

INTRODUCTION

There has been increasing evidence in favor of conservative management of diabetic foot osteomyelitis which requires targeted antibiotic therapy to the causative pathogen. But the method of reliable microbiological isolation is controversial.

AIMS AND OBJECTIVES

To study the concordance of superficial swab culture with bone biopsy specimen culture in patients with diabetic foot osteomyelitis.

MATERIALS AND METHODS

A prospective study was conducted from July 2008 to July 2010. All consecutive patients with suspected diabetic foot osteomyelitis were included in the study. Superficial swab and Percutaneous bone biopsy specimens were obtained for culture. The culture results in these two groups were compared for concordance.

RESULTS

A total of 144 patients were included in the study. 134 cases of bone biopsy specimen and 140 cases of superficial swab showed positive culture results. Mean number of isolate per sample was similar. Staphylococcus aureus was the commonest organism grown in both cultures. The bone pathogen was identified in the corresponding swab culture in only 55 cases (38.2%). Staphylococcus aureus had the highest concordance percentage of 46.5% which was not statistically significant.

CONCLUSION

Superficial swab culture may not be accurate in identifying all the organisms causing diabetic foot osteomyelitis. Bone biopsy specimen taken simultaneously would increase the accuracy of detecting the bacterial isolate.

Prophylactic antibiotics in open mesh repair of inguinal hernia - a randomized controlled trial

The role of prophylactic antibiotics in mesh repair of inguinal hernia is unclear. A Cochrane meta-analysis in 2005 concluded that "antibiotic prophylaxis for elective inguinal hernia repair cannot be firmly recommended or discarded" and "further studies are needed, particularly on the use for mesh repair." So, we designed a study to define the role of prophylactic antibiotics in mesh repair of inguinal hernia. We conducted a prospective, randomized, double-blind, trial comparing wound infection rates in 450 patients (225 received intravenous Cefazolin, 225 received a placebo) undergoing primary inguinal hernia repair electively using polypropylene mesh. 334 patients who completed a followup period of one month were analyzed. Age, American Society of Anesthesiologists class, type of hernia, type of anesthesia, grade of surgeon, pre and postoperative hospital stay and duration of operation were recorded. CDC criteria was used to define wound infection. Groups were well matched for all preoperative variables studied. The overall infection rate was 8.7% (29 out of 334). The incidence of wound infection in antibiotic group was 7% and 10.5% in control group. One from each group developed deep surgical site infection. Most of the infections occurred between the 7th and 12th post-operative day after discharge from the hospital. Antibiotic prophylaxis was associated with decreased incidence of wound infection when compared to control group, but the difference was not statistically significant. Based on our results we do not recommend the routine use of antibiotic prophylaxis in elective mesh repair of inguinal hernias.

Enterocutaneous fistula due to mesh fixation in the repair of lateral incisional hernia: a case report

Enterocutaneous fistula following mesh repair of incisional hernia is usually due to mesh erosion of the underlying viscus and presents late. We describe an early enterocutaneous fistula due to an unusual but a potential mode of bowel injury during mesh fixation. This case is reported to emphasize the need for greater attention to the technique of mesh fixation. We suggest laparoscopic guidance to prevent this serious complication in lateral Incisional hernias with ill defined edges of the defect.

Bedsores: "top to bottom" and "bottom to top"

Bedsore is a global problem concerning the bedridden, infirm, debilitated and malnourished patients in hospitals and community setups. The cost of treatment is enormous involving billions of dollars to nations and individuals. Mortality increases two to six times if bedsores are present. There is little research done despite its commonness to understand how they occur or why they occur; etiology is not much understood. The two theories called 'top to bottom' and 'bottom to top' contradict each other. It is thought that 'pressure', shear-stress' and 'ischemia' may be causing it in some yet to be understood way.There is little awareness on how to prevent them or how to treat them if they do occur. Seldom applied, various scales exist and should be used to identify patients at high risk. Braden scale is the most tested and widely accepted scale. The various available dressings and pressure relief devices are mostly inadequately studied; which is superior is a question that begs an answer. This article aims to underline the importance of bedsores by reviewing our current and past knowledge with emphasis on practical implications thereof.

Ultrasound guided hydrostatic reduction of intussusception in children by saline enema: our experience

BACKGROUND

Intussusception is a common cause of acute intestinal obstruction with potentially serious complications. The treatment of choice is an attempt at initial non-operative treatment.

AIM

The purpose of the study was to evaluate the efficacy of the technique of hydrostatic reduction of intussusception using saline enema and ultrasound being practiced in our institute; the secondary goal was to identify patient subset in which it is more successful.

MATERIAL AND METHODS

The case records of all patients treated for intussusception in our institute from 1st January 2000 to 30th June 2007 were retrospectively analyzed to collect information. All patients with ultrasound diagnosed intussusception that were not having signs of shock or peritonitis were treated with normal saline enema under ultrasound guidance. Failure of three such attempts was an indication for operation.

RESULT AND CONCLUSIONS

We found that this technique is easy, safe and extremely effective in treating intussusception in children. The success rate was 81.37% (83 out of 102 cases) and mortality rate was 1.2%. Ileoileocolic type of intussusception failed enema reduction more often (statistically significant; P value = 0.0032) while older patients (statistically significant, P value = 0.001) had higher success rates with the technique. Patients who had colocolic type of intussusception (P value = 0.29) and patients who present early (P value = 0.262) appear to have higher success rates but this was not statistically significant.

A hospital-based study of splenomegaly with special reference to the group of indeterminate origin

In any study there remains a proportion of cases, about 25-40%, where cause of splenomegaly is not identified on usual evaluation, that is labelled as indeterminate group. The aim of this study was to evaluate various causes of splenomegaly. Thereafter the patients with splenomegaly of indeterminate origin were to be re-evaluated with detailed investigations (for the cause of splenomegaly). Causes of splenomegaly were looked into 100 adult patients with splenomegaly, admitted over a period of ten months in a teaching hospital in South India. Patients having ascites were excluded from the study. Malaria was the commonest cause of splenomegaly, observed in 22 patients. Other causes, in order of importance, were chronic myeloid leukaemia (n=11), non-cirrhotic portal fibrosis (n=9), enteric fever (n=9), cirrhosis of liver (n=8) and hyper-reactive malarial splenomegaly also called as tropical splenomegaly syndrome (n=7) and so on. Hyper-reactive malarial splenomegaly was the commonest cause (7 of 24 patients) of massive splenomegaly. Twenty-three patients had splenomegaly of indeterminate origin ie, cause could not be detected on first assessment. Detailed re-evaluation with repeat investigations including liver biopsy revealed the causes as follows: Hyper-reactive malarial splenomegaly -7 (30.4%), non-cirrhotic portal fibrosis - 4 (17.4%), cirrhosis of liver - 4 (17.4%) and iron deficiency anaemia - 5 (21.7%). In 3 patients (13.0%), no diagnosis could be arrived at despite best efforts. Obscure splenomegalies may be due to conditions like hyper-reactive malarial splenomegaly, non-cirrhotic portal fibrosis, iron deficiency anaemia, and even cirrhosis of liver, while malaria is still the most important cause of splenomegaly in India. Whereas the overall incidence of hyper-reactive malarial splenomegaly was only 7% in this study, it stood as the leading cause (29.2%), when analysed among patients with massive splenomegaly. Liver biopsy should be performed in all cases of obscure splenomegaly to arrive at the final diagnosis.

Laparoscopic control of spontaneous external hemorrhage from umbilical varix

Spontaneous external hemorrhage from an umbilical varix is rare. We describe a 40-year-old man with cirrhosis and portal hypertension, who presented with recurrent external bleeding from an umbilical varix. The first episode was controlled by transfixation of the vein under local anesthesia. Contrast-enhanced CT scan demonstrated a hugely distended recanalized umbilical vein arising from the left branch of the portal vein and ending in the umbilical cicatrix. Recurrent bleeding necessitated laparoscopy and in-situ clipping of the bleeding vein in the falciform ligament. At six months' follow up the patient has no further bleeding.

Fetus in fetu or differentiated teratomas?

Two cases of congenital teratoma were operated upon. In view of the high degree of organoid differentiation of the teratomas with rudimentary limbs, intestine, brain-like and pulmonary tissues, it was difficult to distinguish it from fetus-in-fetu. In the light of the data obtained and extensive review of related literature, we consider that fetus-in-fetu and teratoma may not be unrelated entities. Our cases support the view held that fetuses in fetu are highly differentiated teratomas.

Lymphadenovarix in the axilla--an unusual presentation of filariasis

Clinical manifestations of lymphatic filariasis depend on the area of lymphatic involvement and the duration of infection. A 21 year old man, resident in a filariasis endemic region, presented with multiple matted lymph nodes with cystic areas forming a large mass in his left axilla. An ultrasound scan of the axilla using a 7.5 MHz transducer revealed grossly dilated lymphatics but no filarial dance sign. Fine needle (21 G) aspiration cytology (FNAC) from the dilated lymphatics and solid areas in the lymph node mass revealed multiple microfilariae in a background of reactive lymphoid cells. Peripheral blood smears revealed microfilaremia with significant eosinophilia. Diagnosis of left axillary Bancroftian lymphadenovarix was made. On the administration of oral diethylcarbamazine, the diameter of the lymphatic vessels in the lymphadenovarix reduced considerably in size and microfilaremia disappeared. We report this case because axillary lymphadenovarix is a rare presentation of filariasis. This case is also unique since microfilariae were demonstrated in the fluid aspirated from the dilated lymphatics of the lymphadenovarix in the absence of live adult worms.

Disseminated rhinosporidiosis - an unusual presentation with pulmonary involvement

BACKGROUND AND AIM

Rhinosporidiosis is a chronic granulomatous disease that commonly affects the nasal and nasopharyngeal mucosa. It rarely presents as disseminated disease.

CASE REPORT

We describe a rare case of a patient who had undergone treatment for recurrent nasal rhinosporidiosis and who presented with multiple subcutaneous swellings and pulmonary lesions.

Predicting anastomotic disruption after emergent small bowel surgery

BACKGROUND/AIMS

Small bowel anastomoses performed in the emergent setting have a high risk of leakage. Attention to technical detail is imperative but does not guarantee success in these situations. We sought out factors that could play a role in the process of anastomotic dehiscence under these conditions.

METHODS

70 patients underwent 74 emergency small bowel anastomoses over a 21-month period in our institution during this prospective study. Patients with anastomotic disruption formed the case group and those without, the control group. Several preoperative, intraoperative and postoperative variables identified at the outset of the study were analyzed for possible associations with anastomotic dehiscence.

RESULTS

Suture line disruption occurred in 26 of 74 anastomoses (35%). The duration of symptoms before presentation did not differ significantly between groups. Hypoalbuminemia (p = 0.004), hyponatremia at presentation (p = 0.012), and intraoperative hypotension (p = 0.042) were found to be significantly associated with disruption. Neither the nature of the primary pathology in the bowel nor the anastomotic level had a significant bearing on anastomotic leakage.

CONCLUSION

Risk factors for leakage of emergent small bowel anastomoses include hypoalbuminemia, hyponatremia at presentation, and intraoperative hypotension. Under these circumstances, the creation of a temporary stoma or exteriorization may be a wiser option than primary anastomosis.

Machinery injury to the breast- a case report

Index case of injury to the breast by a sugarcane crushing machine is being reported.

Morbidity and mortality of colostomy and its closure in children

BACKGROUND

This study evaluated the complications of colostomy and its closure in infants and children.

METHODS

One hundred forty-six colostomies were performed in 86 neonates, 23 infants, and 37 children older than 1 year. These children underwent colostomies for anorectal malformation (84), Hirschsprung's disease (47), and other miscellaneous (15) conditions like colonic atresia, volvulus, rectal tuberculosis, traumatic rectal perforation, and intestinal obstruction caused by ascariasis.

RESULTS

Of these, 17 (11.6%) had early complications, and 80 (69.8%) had stomal complications. Three patients died, but only 1 death was directly related to colostomy. Colostomy prolapse, peristomal excoriation, and malnutrition were the major complications. The complications were not dependant on the children's age or primary indication. Sigmoid colostomy had a lower malnutrition rate than transverse colostomy (34.9% v 16.9% P =.009). Among the 56 children who underwent colostomy closure, major complications include death (1.8%), anastomotic leak (7.1%), and wound infection (12.6%).

CONCLUSIONS

A divided sigmoid colostomy should be performed whenever possible. Proper stomal care, regular nutritional assessment, and early closure of the colostomy would minimize morbidity and mortality of colostomy and its closure.

Anterior or posterior gastro-jejunostomy with truncal vagotomy for duodenal ulcer--are they functionally different?

Truncal vagotomy with gastrojejunostomy (GJ) is the standard treatment for chronic cicatrizing duodenal ulcer with gastric outlet obstruction. We tried to determine if a significant functional difference exists in the early and late outcomes following anterior and posterior types of GJ to treat this condition. The case records of 106 patients who underwent truncal vagotomy and GJ at our institute from 1 January 1995 to 31 December 1999 were studied retrospectively. Patients were followed up with a personal interview. Perioperative and long-term parameters were compared in the anterior and posterior G.I. groups. Sixty-five patients (61.32%) were followed up; 31 in the anterior group and 34 in the posterior group. The median follow-up was 5 years (range 2.5-7.5 years). Except for a significant difference in length of afferent loop (p < 0.0001), there were no significant differences in the duration of hospital stay, nasogastric aspirates on postoperative days 1, 2, 3 and 4 and the day the nasogastric tube was removed. Early postoperative complications were uncommon and not different in the two groups and long-term outcomes were similar. The Anterior GJ, being technically easier and needing less operative time, may be advocated in all cases of chronic duodenal ulcer, with gastric outlet obstruction requiring truncal vagotomy and drainage.

Pattern of nontyphoid ileal perforation over three decades in Pondicherry

Two hundred and twelve cases of ileal perforation due to different causes (excluding typhoid) were treated in 3 phases in the Department of Surgery, JIPMER Hospital, Pondicherry, during the periods 1966-78 (phase I), 1981-88 (phase II) and 1990-1998 (Phase III). Forty per cent of the patients were in the second and third decades of life. Male-to-female ratio was 2.2:1. The majority of the perforations (52.8%) were due to non-specific causes. Trauma (19.3%) and mechanical factors (12.7%) were the other principal aetiologies. Pain abdomen (92.3%), constipation (63.6%) and fever (44.3%) were the principal presenting features. Abdominal guarding and rigidity (89%) were the main physical signs. Pneumoperitoneum was present in 66.8% of cases on plain X-ray abdomen. Widal and blood culture for Salmonella typhi were negative in all. Laparotomy was done in most of the cases after adequate resuscitation. Simple closure of the perforation, wedge resection and resection anastomosis were the different procedures of management. Histology of the margin of perforation/excised gut gave added evidence of a non-typhoid etiology. Broad-spectrum antibiotics in different combinations with metronidazole were administered postoperatively. Mortality was 28.2% in Phase I, and 9.4% and 11.9% in phases II and III respectively. The lag period (advent of symptoms and hospitalization) showed definite relationship with mortality and morbidity. Wound infection, wound dehiscence, enterocutaneous fistula and septicaemia were the principal postoperative complications.