Indian Journal of Surgery最新文献

Abstract

Segmental absence of the intestinal musculature (SAIM) is a rare clinicopathological entity in childhood. The etiology of SAIM has not been fully elucidated. Cases of SAIM are mostly documented in neonate and adult population. A 10-year-old girl was admitted to our clinic with the complaint of acute abdominal pain that was not relieved on medical management. Ultrasound abdomen showed diffuse thickening of duodenum, jejunum, and transverse colon wall. There was fluid collection in the left lower abdomen. In view of unrelieved abdominal distention, acute abdominal pain, and intestinal obstruction, a midline laparotomy was performed. Fibrous bands were compressing the jejunum with a small jejunum segment that appeared ischemic and was resected. Histopathological examination of this jejunum segment was reported as SAIM—a clear cut histopathological picture of mucosa and sub-mucosa with no muscularis propria was seen.

This study is to compare different substitutional urethroplasties in female urethral stricture (FUS). FUS constitutes 4–13% of patients, with voiding symptoms, commonly treated by urethral dilatation or internal urethrotomy with a poor success rate. A urethral reconstruction is a viable option. We compared the results of different substitutional urethroplasty for the stricture urethra in females. Symptoms identified FUS. Urethral calibration (unable to pass 8 Fr catheter) and urinary flow rate of less than 12 ml per second were taken as inclusion criteria. Substitution urethroplasty was performed using vaginal ventral onlay flap vaginal dorsal graft (n = 8), dorsal buccal mucosa (n = 8), and labial skin grafts (n = 4) over 3 years. Twenty patients with urethral stricture were identified (mean age of 49.9 years). We found a good stream immediately after removing the catheter in all vaginal flap patients with post-void dribbling. With the three vaginal graft patients (75%), six buccal mucosa graft patients (75%), and two patients (50%) in the labia minora graft, 14 Fr catheter calibration is accessible in all patients except 50% of patients of the labia minora group on 1st follow-up. They require repeated dilatation. Uroflowmetry at six months showed normal flow in all vaginal flap/ graft patients and buccal mucosa grafts, while only 50% of labia minora grafts showed mild improvement. Urethroplasty using dorsal onlay buccal mucosa and vaginal graft gives the best results in women. The vaginal wall can be used safely in nonavailability of buccal mucosa. Labia minora grafts showed poor results.

Pancreatic trauma is often associated with high mortality and morbidity. Current management protocol advises conservative management when the duct is not involved but if there are higher-grade injuries with duct disruption it requires major pancreatic surgeries. These surgeries are technically challenging and carry a significant risk of morbidity and mortality. In this article, we propose open pancreatic duct stenting as the open counterpart of endoscopic retrograde cholangiopancreatography (ERCP) in open surgeries for pancreatic preservation. A 20-year-old male presented to emergency 3 days after blunt trauma abdomen with the chief complaint of upper abdominal pain and vomiting. Lab parameters were normal except S. amylase was − 1563 IU/L. Contrast-enhanced computerised tomography (CECT) abdomen shows almost complete transection at the level of the neck of the pancreas with complete disruption of the main pancreatic duct (MPD). Exploratory laparotomy with stenting of the pancreatic duct with pancreatic tissue repair with feeding jejunostomy was done instead of major pancreatic resection and anastomosis. The recovery period was uneventful, and the patient was discharged on the 8th postoperative day. In the literature, there are very few reports available where intraoperative pancreatic duct stenting was done without ductal repair in the trauma setting. Until now, ten cases have been reported in which a pancreatic duct could be approximated and was repaired over a stent. In recent years, there has been a paradigm shift in trauma management that advocates organ preservation. Existing pancreatic trauma guidelines still recommend morbid surgeries such as distal pancreatectomy or pancreaticoduodenectomy for severe-grade pancreatic trauma. However, there is an obvious need to consider organ preservation because pancreatic resection procedures have inherent complications as well as high morbidity and mortality.

Long-term outcomes after open cholecystectomy are largely unknown. We aimed to investigate long-term mortality rate and incidence of intestinal obstruction after open cholecystectomy. Reporting of this systematic review and meta-analysis was according to the PRISMA 2020 guideline. A protocol was registered at PROSPERO (CRD42020178906). We searched the databases PubMed, Embase, and Cochrane CENTRAL in February 2022 for studies on long-term complications with n > 40 and follow-up ≥ 6 months. Outcomes included mortality and intestinal obstruction. Meta-analyses were conducted, and results were presented in forest plots. Risk of bias was assessed with the Newcastle–Ottawa Scale or Cochrane risk-of-bias tool 1. We included 21 studies. Long-term mortality after open cholecystectomy was reported in 17 studies including 125,222 patients, and it ranged from 0–35%. Follow-up ranged from six months to ten years. Meta-analysis estimated a long-term mortality rate of 9.2% (95% CI 6.8–11.6). One study with 90 patients reported on mini-laparotomy and none died during the 12 months follow-up. Three studies with 66,257 patients reported on intestinal obstruction after open cholecystectomy with an incidence ranging from 0.5% to 2.6%. Follow-up ranged from 36 to 67 months. Meta-analysis estimated a long-term rate of intestinal obstruction of 2.0% (95% CI 1.0–3.0). After a follow-up of six months to ten years, long-term mortality was 9.2%, and long-term incidence of intestinal obstruction was 2% up to 67 months after open cholecystectomy.

Anal fistula is a complicated medical condition that poses a unique challenge in treatment due to its intricate anatomy and high recurrence rates. However, India’s rigorous research in this domain has been transformative, with several groundbreaking innovations and discoveries. This review aims to shed light on India’s outstanding contributions to anal fistula management and treatment, potentially reshaping the way we approach this ailment. A review of the last 10-year articles focused on the various novel aspects of anal fistula was performed using papers obtained from electronic databases, including PubMed, Embase, and Scopus. The search was restricted to articles published in the English language, and the search terms included “anal fistula,” “fistula-in-ano,” “MRI,” “tuberculosis,” and “sphincter-sparing.”

With the growing need for health services, proper bed capacity management is mandatory to avoid patient rejection or cancellation of a procedure. Hence, the day of surgery admission (DOSA) protocol is gaining popularity with safety concerns. We conducted this study in a 120-bed hospital. Our unit has four operating lists per week for elective cases. All patients who planned for elective surgery, with no medical illness or who had a controlled medical illness, were recruited. Every patient was seen in the surgical clinic with his plan of management written in his admission paper. Patients were admitted from 07:00 to 11:00 am through the special admission counter. We evaluated hospital stay, postoperative complications, and mortality. The total number of patients was 18,500 in a 13-year duration. The total number of case cancellations was 396 patients (2.1%). The general surgical procedures were 6987 (38%), the GIT procedures were 5469 (30%), the endocrine and breast procedures were 3545 (18%), the pediatric surgery procedures were 1431(8%), while urology procedures were 1068 (6%). The hospital stay was 1 day or less in 10,305 (56%) patients. The total number of patients who developed postoperative complications was 491 (2.6%). The mortality rate was 0.05% (10 patients). DOSA is a valid and safe protocol for selected patients. It minimizes hospital stays, reducing expenses. Adoption of DOSA will increase bed availability and avoid case cancellation.

Abstract

Subvesical ducts are a common source of post-cholecystectomy bile leaks. These ducts typically run along the gallbladder (GB) bed and drain into the right hepatic duct or the common hepatic duct. Identifying these and other morbid anatomical structures at the time of routine cholecystectomy for safe surgery, the use of indocyanine green fluorescence (ICGF) is highly recommended. This case demonstrates the identification of the subvesical bile duct during dissection, which prevented inadvertent injury and bile leakage. While this was an incidental case, it serves as the basis for our argument that ICGF should be routinely used in high-volume centres. After the initial capital investment, the running costs are low. A cost-benefit analysis should be conducted regarding the routine use of ICGF in high-volume hepato-biliary and cholecystectomy performing units.

Nicolau syndrome (embolia cutis medicamentosa) is a condition where we see variable degrees of tissue necrosis including the skin and deeper tissues, due to an iatrogenic cause, intramuscular, subcutaneous, intra-articular injections, could be some of them. It occurs due to intravascular inoculation leading to crystal embolization causing thrombotic occlusion, vasospasm, and marked inflammation and surrounding necrosis. Here, we present a case of a 35-year-old gentleman who presented to us with bluish-purple discoloration of the skin followed by a necrotic patch and ulceration with multiple hyperpigmented spots over the back and lower limb post intramuscular diclofenac sodium injection. Routine investigation showed neutrophilia and thrombocytosis with increased creatinine. A diagnosis of Nicolau’s syndrome (embolia cutis medicamentosa) was made clinically, which was confirmed by histopathology following biopsy. Adequate surgical debridement and a combination therapy of analgesics, intravenous antibiotics, intravenous anticoagulants, and vasoactive therapy were administered. Split thickness skin grafting was done once the wound was healthy with rich granulation tissue, after 4 weeks of index surgery in this case. Patient recovered uneventfully.