Surgery Journal最新文献

Intussusception, although quite common in children with the classic triad of cramping abdominal pain, bloody diarrhea, and palpable masses, is a rare cause of acute abdomen with myriad presentations in adults. It is defined as the telescoping of a proximal segment of the gastrointestinal (GI) tract, called the intussusceptum, into the lumen of the adjacent distal segment of the GI tract, called intussuscipiens. Due to its different manifestations and time course, adult colonic intussusception often poses a diagnostic challenge for emergency doctors. The treatment of colonic intussusception in adults typically involves surgery, often with bowel resection and anastomosis followed by a defunctioning loop ileostomy. We report a case of left-sided colocolic intussusception secondary to a tubular adenoma as the lead point, which was successfully treated by resection and primary anastomosis. The pathological diagnosis of the lesion was reported as adenocarcinoma and resected bowel margins were found free of the tumor.

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract accounting for less than 1% of all gut tumors. GISTs occurring in the rectum are extremely rare and these usually present at an advanced stage compared with other sites. We report a case of a middle-aged female who presented with features of anemia and subacute obstruction due to a large rectal tumor and underwent abdominoperineal resection. The histopathological examination confirmed the diagnosis of high-grade malignant GIST with multiple lymph nodal metastasis. She was started on adjuvant imatinib therapy and is on follow-up without any evidence of recurrence. The authors conclude that GIST must be included in the differential diagnosis of a rectal tumor. Diagnosis is established by biopsy and immunohistochemistry studies. Surgical resection with histological negative margins is the standard curative treatment. Adjuvant targeted therapy can reduce long-term recurrence in high-risk cases.

Reconstruction of full-thickness eyelid defects is done to provide a mobile lid with corneal protection, having good aesthetic quality, and acceptable donor site morbidity. Various flap procedures have been described and used for the lower eyelid reconstruction; however, the nasolabial flap is rarely employed. It is a random pattern cutaneous flap with redundant blood supply from the perforating branches of the facial and angular arteries and can be used as an inferiorly or superiorly based flap. Here, we aim to present the clinical results of using the superiorly based nasolabial island flap for reconstruction of anterior lamella and turnover/hinge flap of infraorbital skin and palpebral conjunctiva with support of conchal cartilage for reconstruction of posterior lamella for lower eyelid defect. To our best knowledge, this reconstructive combination of flaps has not been described previously for total and full-thickness posttraumatic defect of lower eyelid.

Recent studies have suggested that morbidity and mortality rate of transhiatal esophagectomy is comparable to that of thoracotomy, calling the need for the modifications in the surgical procedures. Our methodology includes stripping of esophagus by nasogastric tube to reduce the manipulation of thoracic cavity and associated complications. We also present the comparison between the stripping and classic (Orringer's technique) esophagectomy. Patients presenting esophageal carcinoma from 2015 to 2017 were the target of this study. Patients undergoing esophagectomy were randomized to have classic or stripping esophagectomy. Operating time, manipulation time, blood losses during the surgery, duration of hospitalization, volume intake, hypotension time, arrhythmia, and transfusion were the recorded parameters. Complications, such as anastomotic leak, cardiac effects, and morbidity, were also studied. Seventy patients were referred for transhiatal esophagectomy for esophageal carcinoma at the Al Zahra Hospital. Mean ages of patients in the stripping and Orringer group were 64.00 ± 10.57 and 57.42 ± 12.20 years, respectively. Manipulation time, operating time, blood loss during the surgery, and transfusion were statistically significant variables between the two groups. Although volume intake and duration of hospitalization were not significantly different parameters, however, betterment in the outcomes was evident. Substantial decrease in overall complications via stripping method was obtained, hence can be suggested as an effective alternative, to remove the need of thoracotomy, for transhiatal esophagectomy.

Background  Incarcerated hernia is a common surgical emergency with considerable morbidity or even mortality. Manual reduction (taxis) and elective surgery could be an alternative management approach. This study examines the role of taxis with the adjuvant use of the visual analogue scale (VAS) score in treating incarcerated hernias and thereby decreasing the emergency surgery rate, especially during the novel coronavirus disease 2019 (COVID-19) pandemic. Methods  All adult patients admitted to the emergency department of our hospital with incarcerated hernias of anterior abdominal wall were prospectively submitted to hernia manual reduction. The VAS score was used as an adjuvant tool for monitoring the success of this maneuver. Patients with successful taxis and low VAS score were hospitalized for a 24-hour period of observation. On their discharge, they were scheduled for an elective hernia repair. Patients with unsuccessful taxis or with less than a 50% reduction in VAS score after successful taxis were submitted to emergency surgical repair. Age, sex, type of hernias, time until taxis, VAS scores before and after taxis, length of hospital stay, and adverse events for both groups were recorded. Results  Between September 2018 and September 2020, 86 patients with incarcerated hernias were included. The types of hernias were incisional in 8 patients, umbilical in 15 patients, inguinal in 56 patients, and femoral in 7 patients. Taxis was successful in 66% of patients with a mean reduction in VAS score from 83 to 17 mm. Following successful taxis, patients were hospitalized for a 24-hour period of observation. No taxis-related complications were observed. Fifty-two patients were safely discharged from hospital and scheduled for an elective repair during the first month. Thirty-four patients were operated emergently. Five patients had successful taxis but with a reduction of posttaxis VAS score less than 50% (a mean reduction from 86 to 62 mm), while taxis failed in twenty-nine patients. Patients with emergency surgery had longer time until reduction and longer stay of hospitalization. In this group, two patients required admission to the intensive care unit while one patient died. Conclusion  In this protocolized approach, taxis is a safe and feasible option for most patients with incarcerated hernias. It should be kept in our armament, especially in times when emergency surgery capabilities are under strain like the ongoing COVID-19 pandemic.

Introduction  Choledochal cyst is a premalignant condition and surgical excision with biliary enteric anastomosis is the standard of care. Surgical treatment in adults may be difficult due to associated biliary pathology and high incidence of postoperative complications is reported. Postoperative pancreatic fistula (POPF) is a rare early complication following choledochal cyst excision. Material and Methods  A 23-year-old male patient was operated for a Todani type IV-A choledochal cyst with anomalous pancreaticobiliary junction. Cyst excision with hepaticojejunostomy was performed. Distal stump closure was technically challenging due to extreme thickening of the cyst wall with neovascularization. On postoperative day 2, patient developed tachycardia and progressive tachypnea with 200 mL of pancreatic fluid in the drain. Endoscopic pancreatic stenting was attempted but was technically not possible. At reexploration, leak from oversewn distal cyst stump was identified and the suture line was reinforced. After the second surgery the patient was hemodynamically stable but continued to have a low output pancreatic fistula for few days which was managed conservatively successfully. We conducted a review of English literature with an aim to identify the risk factors and predictors of pancreatic fistula following cyst excision. An electronic search was performed in Medline and Google Scholar during September 2020 and available literature since January 2000 were reviewed. The keywords used were "pancreatic fistula" and "choledochal cyst." Results  Preoperative cholangiography (magnetic resonance cholangiopancreotography/endoscopic retrograde cholangiopancreatography) is essential to know the extent of cyst and delineate biliary pancreatic junction. Literature review including our case revealed that Todani type I-c, type IV, and forme fruste type of choledochal cyst are at high risk of pancreatic injury and POPF. Recurrent cholangitis makes excision technically more challenging and complete removal is not always possible. Conclusion  Postoperative pancreatic fistula can be anticipated in select group of patients with high-risk preoperative findings. Chronic inflammation due to recurrent cholangitis promotes scarring and neovascularization which adds to surgical complexity. Operative technique in these high-risk patients needs further refinement.

Teratomas of the ovary rarely present as inguinal hernias. Teratomas most commonly occur in the gonads or along with midline structures. Although the majority are asymptomatic, complications such as spontaneous rupture are known to occur. We present a previously unreported case of a ruptured ovarian teratoma presenting as an irreducible inguinal hernia. The patient underwent an open exploratory laparotomy with left oophorectomy, and the right inguinal hernia was repaired in the same setting with a separate inguinal incision.

Introduction  Brunner's gland hamartomas (BGH) are rare benign lesions with an incidence of <0.01%, accounting for 5 to 10% of all benign tumors of the duodenum. It requires expeditious management by a multidisciplinary team. The aim of the study is to report our experience with surgery for BGH. Methodology  Data of all patients who underwent surgical intervention for duodenal polypoidal mass between August 2007 and March 2020 were retrieved from our prospectively maintained gastrointestinal (GI) surgery database. All patients whose histopathology report of the resected specimen confirmed BGH ( n  = 9) were included in the present study. Other pathological diagnosis like duodenal lipoma ( n  = 2), ganglioneuroma ( n  = 1), adenoma ( n  = 10), and adenocarcinoma ( n  = 4) were excluded. Results  Nine patients had confirmatory histopathological diagnosis of BGH and met our inclusion criteria. Three (33.3%) of them were men with a median age of 45 (range: 24-61) years. The median interval between onset of symptoms and diagnosis of duodenal polyp was 14 (range: 4-180) days. Five patients (55.5%) presented with upper GI hemorrhage. Three (33.3%) patients presented with abdominal pain, and one (11.1%) patient presented with episodes of bilious vomiting. Diagnostic endoscopy could detect the lesion in all (100%) patients. Contrast-enhanced computed tomography detected duodenal polypoidal lesion in five (55.5%) patients. The mean size of tumor was 4.78 ± 1.36 cm. These lesions were symptomatic in all the patients and warranted intervention. In view of failed endoscopic intervention ( n  = 7, 77.7%), or extramural extension of the tumor ( n  = 2, 22.2%), surgical intervention was considered. Most commonly performed operation was duodenal polypectomy ( n  = 6, 66.6%). Three postoperative complications developed in two (22.2%) patients. There was no surgery-related mortality. After a median follow-up of 60 (12 -78) months, no patient developed GI bleed or intestinal obstruction. Conclusion  In this study, the clinical profile of BGH was explored from the surgeon's point of view. Although endoscopic management is the first-line treatment, surgery plays an important role, particularly, if this fails or is not feasible. In experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes.

Kimura's disease (KD) is a chronic inflammatory disorder of the lymph node which is very rare in the Indian population. A 34-year-old female presented with left postauricular region swelling for the past 3 years at an outpatient department. On histopathological examination, it was diagnosed as KD. It should be kept in mind when treating a patient with lymphadenopathy and eosinophilia or a high immunoglobulin E level. This unique case report highlights this impressive clinical entity.