Acute pancreatitis following endoscopic ampullary biopsy: A case report

BACKGROUND

Endoscopic biopsy is mandatory for the diagnosis of malignant and premalignant ampullary tumours. The commonly reported inadvertent complications following routine mucosal biopsy include perforation and haemorrhage. Acute pancreatitis is an extremely rare complication following this procedure.

CASE SUMMARY

This report details the case of a 59-year-old man who underwent biopsy of the ampulla for a suspected periampullary tumour. Following the procedure, the patient presented with symptoms of acute pancreatitis which was substantiated by laboratory and radiological investigations. He was conservatively managed and discharged following complete resolution of symptoms.

CONCLUSION

This case report serves to highlight the importance of this potential complication following routine endoscopic biopsy of the ampulla.

To drain or not to drain following thyroidectomy.: A prospective, randomized study

OBJECTIVES

To ascertain the use of draining the thyroid bed following surgery.

METHODS

Fifty four patients who underwent total thyroidectomy were enrolled in the study between March 2021 and July 2022 and randomly allocated into 2 groups - a drain group and a no drain group. The hospital stay, operating time, post operative pain, post operative complications, cosmesis, and patient's perspectives were compared.

RESULTS

The mean duration of hospitalization was significantly shorter in the no drain group as compared to the drain group. The post operative pain, as assessed by the Mankoski Pain Scale (MPS) was significantly higher in the drain group than in the no drain group. The cosmetic evaluation undertaken using the Hollander Wound Evaluation Scale, noted that there was a statistically significant difference in scarring between the 2 groups. There was no statistically significant difference in the duration of surgery and post operative complications between the two groups. Patient satisfaction was also noted to be superlative in the no drain group.

CONCLUSION

The routine drain placement following thyroidectomy places the patient at a disadvantage in terms of longer hospitalisation, increased post operative pain and poor cosmetic outcome.

An interesting case of laparoscopic management of traumatic diaphragmatic rupture in an acute setting

Traumatic rupture of the diaphragm is an uncommon injury, often diagnosed late as it is associated with concurrent abdominal and thoracic visceral injuries which are the main cause of morbidity and mortality. Diaphragmatic rupture has been reported in 1-7 % of the patients following major blunt thoracoabdominal trauma and 10-15 % of the patients following penetrating trauma. In an emergency scenario, open approach remains the mainstay of management; however the laparoscopic approach has been steadily gaining acceptance. We report the case of a 35 year old male who was diagnosed with diaphragmatic rupture following blunt trauma to the chest and abdomen. The patient underwent emergency laparoscopic reduction of contents with anatomical repair of the ruptured diaphragm.

Hydrocele of Canal of Nuck In an Adult Female: A Case Report

Hydrocele of the canal of Nuck is a rare abnormality, developing in the protruded part of the parietal peritoneum within the inguinal canal in a female. It is homologous to the processus vaginalis in males and obliterates from the seventh month of gestation to one year of age. Failure of obliteration, results in Nuck hydrocele or herniation of intra-abdominal contents through the patent Canal of Nuck. These are usually detected and repaired in young girls within the first five years of life. Reports of Canal of Nuck hydrocele in adults are sparse. Most of these patients are misdiagnosed on clinical examination and correctly diagnosed intraoperatively during surgery for suspected ‘inguinal hernia’. Here, this case is about a 25-year-old female, who presented with swelling in the right groin for one month. Computed Tomography of the abdomen showed features suggestive of a hydrocele within the Canal of Nuck. She underwent laparoscopic hydrocelectomy and laparoscopic hernia repair via the transabdominal preperitoneal approach. This case report highlights the novel approach of laparoscopic management of this rare case.

Liposarcoma of Spermatic CordEncountered While Operating the Inguinoscrotal Hernia

Liposarcomas in the spermatic cord are rare and difficult to diagnose preoperatively, since they present as inguinal or scrotal masses which are frequently evaluated only by ultrasonogram, and other imaging modalities. This case report is about a 48-yearold male, who presented with a painless swelling in the right inguinal region extending to the scrotum, since two years. Upon inguinal exploration, a single irregular fatty mass, arising from the cord, was found in addition to a small inguinal hernia. En-bloc resection of the mass with inguinal orchidectomy was done and histopathology proved it to be a well-differentiated liposarcoma. A rare malignancy with a deceptive presentation must be taken into account while evaluating scrotal masses, particularly in patients with suspected recurrent hernias of the inguinal region.

A Case of Mesenteric Border Intestinal Perforation- An Unusual and Unnoticed Site of Perforation

Incisional hernia which if not repaired at the earliest might increase in size and eventually end up in complications like incarceration or strangulation. Perforation of the bowel loop in case of incarcerated or strangulated incisional hernia without any precipitating events like trauma is very rare. Intestinal perforation, if identified is a life-threatening condition that requires emergency surgical management. Perforation of the small bowel along its mesenteric border is a rare entity with only very few cases being reported. Authors hereby, present a case of a 55-year-old female with long standing incisional hernia who was diagnosed as an incarcerated incisional hernia after computed tomography and was proceeded with an exploratory laparotomy, which on further exploration revealed perforation of the incarcerated ileum along its mesenteric border for which resection and anastomosis was done.

An Ectopic Intrathoracic Kidney in an Adult Female: A Case Report

The kidney is an organ prone to congenital anomalies owing to its complex and sequential development. Ectopia of the kidney is a rare entity with intrathoracic ectopia being an exceptionally uncommon occurrence. Intrathoracic kidneys represent less than 5% of all renal ectopias with a prevalence rate of less than 0.01%. The concurrent association of an intrathoracic kidney with a Bochdalek hernia is extremely infrequent with an incidence of 0.25%. Most of the patients are asymptomatic and have an uneventful clinical course. It is often incidentally detected simulating a posterior mediastinal mass. Thoracic kidney is a condition that shows male predominance. Here, present case is of a 43-year-old female patient who presented to the institution with breathlessness and associated chest pain. Computed Tomography (CT) scan revealed left-sided Bochdalek hernia with the left kidney, adrenal gland, transverse colon, splenic flexure and proximal descending colon within the thorax. The patient underwent elective diagnostic laparoscopy followed by reduction of the contents and mesh repair of the diaphragmatic defect. The patient was discharged and remained asymptomatic on a periodic follow-up of over a year. Awareness regarding this rare entity can obviate the need for a battery of unnecessary investigations and operative procedures.

A Case Series on Epiploic Appendagitis: An Underdog in Acute Abdomen

Epiploic appendagitis is an uncommon yet a significant surgical diagnosis that every surgeon should be aware. It occurs due to the torsion of the epiploic appendage which gives rise to acute abdominal pain that can mimic other common causes of acute abdominal pain like appendicitis or cholecystitis. The treatment of epiploic appendagitis depend on clinical presentation, severity and it varies from conservative management to surgical excision. This case series is about eight patients presented with complaints of lower abdominal pain. After clinical examination they were initially diagnosed to have appendicitis or diverticulitis. The Computed Tomography (CT) -based diagnoses were appendicitis, omental infarct, diverticulitis or epiploic appendagitis. All of them were subjected to diagnostic laparoscopy and found to have an inflammed epiploic appendage which was excised laparoscopically.

A Single Surgeon’s Experience of Total Extra Peritoneal Repair Vs Transabdominal Preperitoneal Repair- A Prospective Cohort Study

Introduction: Hernia surgery has evolved over a period of 2500 years from the Bassini-Shouldice era to conventional Lichenstein’s meshplasty to the laparoscopic era. Since, inception of the laparoscopic approach 25 years ago, there were several advancements in the techniques of inguinal hernia repairs. The two most commonly practiced laparoscopic approaches are the Total Extra Peritoneal (TEP) and Transabdominal Preperitoneal (TAPP) repair. Aim: To compare the outcomes for TEP and TAPP approaches in laparoscopic inguinal hernia surgery in terms of operative time consumed, postoperative pain, duration of hospital stay, complications and recurrence rate when performed by a single surgeon. Materials and Methods: A prospective interventional cohort study was carried out among 70 patients with uncomplicated inguinal hernia. Patients were divided equally into two groups of 35 patients and underwent TAPP and TEP repairs depending on group randomisation. All surgeries were performed by the same surgeon. Factors including operative time, postoperative pain, duration of hospital stay, complications and recurrence were documented and compared for both the groups. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 21. Unpaired t-test was used to compare the mean between the two groups. The p-value of <0.05 was considered to be statistically significant. Results: The mean operative time measured in minutes for TEP repair was 31.03 minutes and TAPP repair was 42.26 showing a difference of 11.23 minutes which was statistically significant (p-0.001). The mean Standard Deviation (SD) pain score at 24 hours for TEP repair was 2.43 (1.195) and TAPP repair was 3.43 (0.917). The mean (SD) pain score at 48 hours for TEP repair was 1.31 (1.051) and TAPP repair was 2.20 (0.901). The mean (SD) pain score at one week for TEP repair was 0.37 (0.690) and TAPP repair was 0.91 (0.781). The mean (SD) duration of hospital stay in TEP repair was 2.60 days (0.553) when compared to 3.49 days (0.658) in TAPP repair. All the results were statistically significant with a p-value of 0.001. Conclusion: TEP repair had superior outcomes in terms of reduction in operative time, less postoperative pain and shorter hospital stay than TAPP repair.

Case series on variable presentations of tuberculosis of the breast

Tuberculosis (TB) of the breast is extremely rare and is often mistaken for benign or malignant lesions of the breast. They are rare even in countries which are endemic for TB, like India. The most common type of clinical presentation is a vague lump in the breast, but there are even other types of presentations which are documented. In olden days, there was a lot of dilemma and challenge in diagnosing TB of the breast, but thanks to improved pathological knowledge and the advent of investigations such as QuantiFERON-TB gold and GeneXpert, TB can be diagnosed early nowadays and treated accordingly. In this study series, we report 10 cases of TB of the breast with variable clinical presentations as fibroadenosis, breast abscess, duct ectasia and breast lump on evaluation, and the challenges encountered in establishing the diagnosis.

Diagnostic difficulties in obturator hernia: a rare case presentation and review of literature

Hernia arising from obturator canal is rare and it contributes to about less than 1% of incidence of all hernias. Diagnosing an obturator hernia clinically is a challenging one and nearly impossible. These hernias usually present as an intestinal obstruction as more than 50% of obturator hernias goes in for strangulation. Here, we report an unusual presentation of an obturator hernia in a 70-year-old woman who presented to emergency room with acute abdomen and uncomplicated reducible inguinal hernia. Radiological imaging showed obstructed inguinal hernia while on diagnostic laparoscopy, a strangulated and perforated obturator hernia of Richter’s type was seen in addition to an uncomplicated inguinal hernia. Obturator hernia, although very rare, is associated with high morbidity and mortality as it is often underdiagnosed as in our case. Laparoscopy bailed us out from missing out a perforation from an occult obturator hernia.

Comparison of Efficacy of Alginate Filler Dressings with Conventional Saline Dressings for Cavity Wounds in Diabetic Foot Ulcer- A Prospective Cohort Study

Introduction: Diabetic foot ulcers are associated with 25% of patients with Diabetes Mellitus (DM). These diabetic foot ulcers if not given appropriate care at the right time can lead to amputations and poor quality of life. Alginate dressings are newer and help in faster healing of cavity wounds in diabetic foot ulcer. Aim: To compare the advantages of alginate dressings over conventional saline dressings in cavity wounds of diabetic foot ulcer patients. Materials and Methods: A single centre prospective longitudinal cohort study was conducted on 88 patients with diabetic foot ulcers randomising equally into two groups containing 44 patients in each group in a tertiary care hospital. The wounds of all patients included in the study were thoroughly debrided and initial assessment was done using the Pressure Ulcer Scale for Healing (PUSH) scoring system. The patients were started on alginate dressings in one group and saline dressings in other group and were assessed after two and four weeks. The reduction in the surface area of the wound, reduction in the exudate amount, type of the tissue over the ulcer and reduction in the bacterial load (wound cultures) of the ulcers were studied. The statistical analysis were done using Statistical Package for the Social Sciences (SPSS) software version 21. The statistics were done using independent sample tests (Levene’s test for equality of variances and t-test for equality of means), Mann-Whitney test and Wilcoxon test. Results: The results of wound assessment before dressings, at two weeks and at the end of four weeks are as follows: The mean (SD) reduction in wound surface area was 9.07 (1.634) to 6.89 (1.434) to 4.68 (1.272) for alginate group and 9.25 (2.059) to 8.00 (1.905) to 6.50 (1.650) for saline group. The mean (SD) reduction of the exudate amount was 2.02 (0.505) to 1.09 (0.473) to 0.14 (0.347) for alginate group and 1.98 (0.590) to 1.43 (0.625) to 0.75 (0.615) for the saline group. The mean (SD) for tissue type of cavity wounds assessed via PUSH scoring was reduced from 2.30 (0.701) to 0.16 (0.370) for the alginate group in comparison to 2.32 (0.740) to 0.77 (0.743) for the saline group at the end of four weeks. On evaluation of the wound cultures; 6 out of 44 patients (13.6%) were culture positive in the alginate group while 30 out of 44 patients (68.2%) were culture positive from the saline group at the end of four weeks. All the above results were statistically significant with a p-value of 0.001. Conclusion: Alginates dressings are superior to saline dressings in terms of reduction in the size of the ulcer and control of microbial activity in diabetic foot. Alginate absorbs large amount of exudates and fill in irregular shaped cavities which are ideal in treating cavity wounds in diabetic foot syndrome.

A Longitudinal Study on Comparison of Haematocrit, Glasgow Score and Computed Tomography Abdomen as Prognostic Markers in Assessment of Severity in Acute Pancreatitis

Introduction: Acute Pancreatitis (AP) can present from a mild self-limiting process that requires only supportive care to severe disease that can cause multiple Organ Failure (OF) and high mortality. It is therefore important to identify such patients at increased risk of OF and mortality at the earliest. Aim: To evaluate and compare the efficacy of three prognostic markers namely Haematocrit, Glasgow scoring and Computed Tomography (CT) abdomen in assessing the severity of AP. Materials and Methods: A prospective longitudinal study was done on 120 patients diagnosed with AP, over a period of 18 months. Haematocrit was done at admission and at 48 hours. A fall in haematocrit of more than 10% was considered sensitive. Modified Glasgow score was assessed at admission and after 48 hours. Other variables include blood glucose level, white blood count, blood urea nitrogen, serum calcium, partial oxygen pressure (PaO2), decrease in haematocrit, serum Lactate Dehydrogenase (LDH), serum aspartate aminotransferase (AST) and serum albumin. A score of ≥3 was considered sensitive. CT of abdomen was done at 72 hours and a Computed Tomography Severity Index (CTSI) score of ≥4 was considered sensitive. The results of each prognostic marker were graphed and compared to assess Length of Hospital Stay (LOHS), need for Intensive Care Unit Admission (ICUA), OF and mortality. Results: The mean LOHS was six days. Haematocrit was sensitive in 23 of 79 patients that stayed in hospital for >6 days. Modified Glasgow scores were sensitive in 35 of 79 patients. CT of abdomen was sensitive in 59 out of 79 patients. Total 29 of 120 patients were admitted in the ICU, out of which difference in haematocrit was sensitive in 14 patients, Modified Glasgow coma score of ≥3 was seen in 14 patients and CTSI scores were sensitive in 22 patients. Twelve out of 120 patients developed OF. All 12 patients showed a sensitive Modified Glasgow scores of ≥3 and CTSI ≥4, whereas only five patients were sensitive for fall in haematocrit. Five patients died during the study. All five patients were sensitive for fall in haematocrit Glasgow coma scores and CT abdomen. Among the prognostic markers, haematocrit showed 100% sensitivity, specificity and Positive Predictive Value (PPV) than the other prognostic markers making haematocrit the better prognostic marker. Conclusion: CT of abdomen is a reliable prognostic marker in terms of assessment of LOHS, need for Intensive Care Unit (ICU) care and mortality. Modified Glasgow score is accurate in assessing OF. Haematocrit is specific in assessing the need for ICU care and mortality.