Arjun Saxena

‘Free Omental Plug’: A Nostalgic Look at an Old and Dependable Technique for Giant Peptic Perforations

Peptic perforation is a serious complication of peptic ulcer disease. The defect in the intestinal wall usually does not present a difficult technical problem of surgical management, in most cases perforation can be closed primarily. On rare occasions an extremely large defect (giant peptic perforation – defined as any perforation greater than 2.5 cm in size) cannot be closed by these simple techniques. Modalities of treatment advocated for such an ulcer over the years are: free omental plug in the form of a mushroom; serosal patch technique; jejunal pedicle graft, partial gastrectomy, and finally the possible addition of proximal gastrojejunostomy. The omental plug is a simple procedure which does not require expertise and can even be performed in a very short time by a trainee general surgeon in a seriously ill patient in emergency. We review 7 cases of giant peptic perforations closed by a free omental plug.

Anorectal Avulsion: An Unusual Rectal Injury

Traumatic injuries to the rectum although uncommon can result in virulent complications and even death. Diverting colostomy, presacral drainage, distal wash out and rectal repair, when feasible, have become the standard treatment for rectal injuries. We report an unusual case of rectal injury resulting in anorectal avulsion from skin and surrounding tissues.

A modified technique of devascularization for surgical management of portal hypertension in children.

In developing countries surgery is indicated in patients with portal hypertension for a variety of reasons. This study prospectively evaluates a modified technique of devascularization for secondary prophylaxis of variceal bleeding in patients with portal hypertension of different aetiologies. Transabdominal extensive oesophagogastric devascularization combined with transmural ligation of oesophageal and gastric varices was performed in 16 paediatric patients (nine with extrahepatic portal venous obstruction, and seven with non-cirrhotic portal fibrosis) in an elective setting. The Sugiura devascularization procedure was modified to minimize the operating time and to avoid the problems associated with oesophageal transection and anastomosis. The operative mortality rate as well as the oesophageal leak rate was zero. One patient developed an oesophageal stricture. During a 12-month follow-up, patients were seen with residual varices (2), recurrent varices (3) and rebleeding (1). Porto-systemic encephalopathy was seen in one patient only. This technique is a simple, straightforward, safe and effective modification of the Sugiura procedure in controlling bleeding, providing good quality of life with minimal porto-systemic encephalopathy.

In-Continuity Fundic Bypass for Palliation in Unresectable Carcinoma of the Oesophagus: A Previously Unreported Procedure

Surgical bypass for the palliation of dysphagia in patients with unresectable oesophageal carcinoma continues to be an option in developing countries, as the cost of a good quality endo-prosthesis is well beyond the means of most patients. One such case is presented in which an in-continuity fundic bypass (without resection of the lesser curvature and cardia, thereby not disconnecting the oesophago-gastric junction) was made with gratifying results with regard to quality of life. Awareness of this previously unreported procedure is important because it adds to the armamentarium of surgeons wanting to provide palliation for dysphagia and aspiration in patients with unresectable carcinoma of the oesophagus.

Eosinopenia as a Prognostic Marker in Patients with Peritonitis

Introduction. Eosinopenia has been, recently, found to have strong association with inflammatory-syndrome-associated bacterial infectious diseases. This prompted us to investigate its use as a prognostic marker in perforation peritonitis patients. Methods. A prospective study of perforation peritonitis patients admitted to the surgical wards at a teaching hospital in Central India was conducted. jabalpur prognostic score (JPS, a simplified prognostic score for developing countries), C-reactive protein (mg/dL) levels, and absolute eosinophil counts (cells/cmm) were measured on admission. Their correlation with inpatient mortality was evaluated. Results. 94 consecutive patients were studied, peptic (𝑛=55) followed by ileal, colonic, and appendicular perforations were the commonest cause of peritonitis. 13/94 died; ileal perforations had the highest (𝑛=6/34, 17.6%) mortality. When correlated with mortality, univariate analysis showed JPS, CRP, and AEC to be accurate prognostic markers (𝑃<0.00001), while multivariate analysis showed only AEC to be accurate (𝑃=0.03). At a cut-off value of 8, JPS showed sensitivity of 77%, a specificity of 85.1%, positive predicted value (PPV) of 55%, negative predicted value (NPV) of 95%, and area under receiver operating curve (AUROC) was 0.86. CRP level, at a cut-off value of 7.4, yielded sensitivity of 92.3%, specificity of 79%, PPV of 41%, NPV of 98%, and AUROC was 0.93. At a cut-off value of 45, the sensitivity of the AEC was 92.3%, specificity of 92.5%, PPV 85%, NPV of 99%, and AUROC was 0.96. Discussion. Eosinopenia on admission is a prognostic marker of mortality in patients with peritonitis.

Congenital diaphragmatic hernia “Occulta”

Congenital diaphragmatic hernia usually presents with cyanotic attacks, dyspnoea and dextrocardia, a typical triad which is almost considered pathognomonic.The case records of 10 patients (out of a total of 20) of congenital diaphragmatic hernia presenting beyond the neonatal period were reviewed retrospectively. Age and symptoms at presentation and signs elicited were paid special attention. All the patients underwent operative repair of hernia under general anaesthesia. Given below is an explanation for such a high incidence of late presentation in our series. This nomenclature (Congenital Diaphragmatic Hernia “Occulta”) will help clinicians in remembering this entity if and when such patients present to the clinicans.

Is prognostication in congenital diaphragmatic hernia possible without sophisticated investigations

Congenital diaphragmatic hernia is a complex disorder, in which the anatomical defect is only one part of the spectrum of disease. Hypoplasia of lung complicated by pulmonary hypertension and right to left shunting results in serious hypoxemia. Many factors, based on degree of alterations in respiratory physiology and involving analysis of blood gases and acid base systems, have been used in an attempt to prognosticate the outcome. Majority of these investigations are not available in a modest set up like ours. The case records of all 20 patients admitted and operated for congenital diaphragmatic hernia in pediatric surgery unit of Government Medical College Hospital, Jabalpur from 1978 to 1997 were reviewed retrospectively in an attempt to prognosticate without the sophisticated investigations. It was found that even in a very modestly equipped hospital it is possible to prognosticate-to some extent — the outcome in these cases. Major prognosticators found were APGAR score (if child born in hospital), late age of presentation, location of stomach and identification of hernial sac.

Thoracoscopic pericardiotomy for management of purulent pneumococcal pericarditis in a child.

Purulent pericarditis is an extremely rare complication of pneumococcal pneumonia in children that may result in to cardiac tamponade. While image‐guided pericardiocentesis is the treatment of choice for such a condition, it may fail in the presence of thick pus; loculations and thoracoscopic pericardiotomy are useful procedures for such situations. Herein, we report such a case involving a 6‐year‐old boy who presented with purulent pneumococcal pericarditis that was managed with thoracoscopic pericardiotomy and who recovered well. Thoracoscopic pericardiotomy is a safe procedure that allows effective drainage under vision, pericardial biopsy for diagnosis, and a simultaneous opportunity to perform thoracoscopic pleural drainage.

Dissection with a metal dissector: a useful adjunct to transhiatal oesophagectomy.

OBJECTIVE Intraoperative cardiovascular instability is frequently observed during blunt finger dissection for transhiatal oesophagectomy. We conducted a prospective study using a metal ring dissector for blunt dissection of the oesophagus to overcome this problem. METHODS Dissection with a metal ring dissector was used in 30 consecutive patients undergoing transhiatal oesophagectomy for carcinoma of the lower oesophagus (n=26) and oesophagogastric junction (n=4). RESULTS Dissection of the oesophagus proximal to the growth was quick and straightforward in all instances. The procedure appeared less traumatic than the conventional manual technique and was not associated with any intraoperative cardiovascular instability or intramediastinal bleeding. None of the patients had tracheal injury or recurrent laryngeal nerve paralysis. There was one anastomotic leak and no deaths. CONCLUSION Oesophageal blunt dissection with a metal ring dissector is safe, easy and quick. The correct plane of dissection minimizes the risk of intramediastinal bleeding and inadvertent trauma to neighbouring structures.