C.S. Naidu

Donor outcome in live-related liver transplantation

BACKGROUND Live donor liver transplant has become an accepted, effective and lifesaving alternative to deceased donor transplant. The effect on donor and his safety remains a cause of concern. The donors are all in productive age and in our setting may have to go back to active service. This study is aimed at knowing the results of donor hepatectomies at our centre. METHODS Data of all donor hepatectomies done at our centre from Apr 2007 to Jun 2013 reviewed. This included the preoperative workup, operative details and postoperative follow-up. RESULTS 35 Donors of age between 20 and 50 years were taken up for procedure of which one was abandoned due to haemodynamic instability after intubation. In the 34 procedures done the percentage of the residual liver was at least 30%. No donor required blood transfusion. The overall complication rate was 26.5% which was stratified according to the modified Clavien classification of postoperative complications. There was transient rise of bilirubin and liver enzymes in all which returned back to normal with time. Infections were the most common cause of complication. All the donors had gone back to their work after a mean of 42 days after surgery. All donors were willing to donate again if needed. CONCLUSION Living donor liver transplant a widely practiced modality for end-stage liver disease. It is a safe procedure with good recovery and results. Our study shows that meticulous selection criteria and strict adherence to protocols leads to good outcome.

Primary non seminomatous germ cell tumour with liver metastasis

IntroductionCategorised as poor-risk disease, primary mediastinal non-seminomatous germ cell tumours (PMNSGCT) with metastasis have a dismal survival rate.Case ReportWe report herein a case of PMNSGCT with liver metastasis that underwent primary chemotherapy followed by staged resection of the mediastinal disease and resection of the liver metastasis from a difficult anatomical position, the caudate lobe.ConclusionPrimary mediastinal non-seminomatous germ cell tumour with metastasis has a poor prognosis. Recurrence is common in this group of patients even after chemotherapy and radical resection.

Hepatic alveolar hydatidosis — A malignant masquerade

A 43-year-old male presented with clinical features of obstructive jaundice. Biochemical tests and radiologic imaging were suggestive of intrahepatic cholangiocarcinoma with hilar block. Multiple attempts to obtain tissue diagnosis in the form of USG-guided FNAC & tru-cut biopsy failed. Exploratory laparotomy and wedge biopsy confirmed E. multilocularis (alveolar hydatid disease). The patient was managed with albendazole therapy. At 8-month follow-up, the patient was clinically asymptomatic with near normalization of biochemical parameters and significant regression of the lesion as shown by computed tomography. E. Multilocularis infection of the liver is quite rare in the Indian subcontinent and poses a diagnostic dilemma. Nonetheless, despite its rarity, it should be considered in the differential diagnosis when a patient presents with clinical and radiological features of a space-occupying lesion of the liver while attempts to set pathological diagnosis by FNA/ tru-cut biopsy are inconclusive. Awareness of this emerging infectious disease could prevent a fatal outcome, particularly amongst patients who have been exposure to wild life.

Alveolar hydatid disease of the liver: A rare entity in India

Col Jasvinder Kaur Bhatia *, Brig R. Ravikumar , Surg Cmde C.S. Naidu, VSM, T. Sethumadhavan d Associate Professor, Department of Pathology, Armed Forces Medical College, Pune 411040, India b Professor and Head, Department of Radiology, Armed Forces Medical College, Pune 411040, India Professor and Head, Department of Surgery, Armed Forces Medical College, Pune 411040, India Resident, Department of Pathology, Armed Forces Medical College, Pune 411040, India m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a x x x ( 2 0 1 5 ) x x x – x x x

Management of acute mesenteric isxcaemia: A retrospective analysis

Aim-BackgroundAcute mesenteric ischaemia (AMI), although an uncommon condition with a difficult diagnosis, has a high rate of complications and is associated with a high mortality rate. We reviewed our experience of patients presenting with AMI in order to evaluate the current management and factors associated with survival in a tertiary care hospital.Material and MethodsClinical data of all patients who were diagnosed with AMI between 01 January 2012 and 30 June 2013 were retrospectively reviewed. Preoperative presentation, investigation, management and outcome in this group of patients were analyzed.ResultsThirteen patients were included in the study, of whom twelve were male and one female, mean age 44.5 years ranging from 35 to 78 years. The cause of AMI was embolism in three patients (23.1%), and thrombosis in ten patients (76.9%). Abdominal pain was the most common presenting symptom (100%). Four patients (30.8%) had previous symptoms of chronic mesenteric ischaemia in the form of postprandial pain. Nine patients (69.2%) had been exposed to high altitude for more than two weeks, four of whom displayed a procoagulant state. Eleven patients underwent abdominal exploration and endovascular treatment. Percutaneous transcatheter balloon angioplasty was performed in two (15.4%) cases. Eight out of eleven patients (72.7%) who underwent exploratory laparotomy had major small bowel resections involving more than 200 cms of small bowel. However, none of these patients underwent any reconstructive procedures due to extensive thrombus within the SMA and late presentation. Six patients were submitted to second-look exploration within 48 hours, all of whom underwent repeat resections of the bowel. Laparostomies were performed in two patients. None of these patients had a primary anastomosis. End jejunostomy/ileostomy was performed with mucous fistula in all 11 patients. Two patients died within a month, and the 30-day mortality rate was 15.4%; severe sepsis with multiorgan failure was the cause of death in both patients. Four patients (30.8%) had permanent intestinal failure without intestinal adaptation requiring permanent total parenteral nutrition (TPN) with indications for intestinal transplant. The survival rate at one year was 69.2%. Two late deaths occurred owing to complications of TPN.ConclusionA relatively uncommon diagnosis, AMI is often identified late and invariably with complications. Exploratory laparotomy with resection of the bowel is the most viable option in such a situation. The individuals exposed to high altitude and displaying a procoagulant state that present with AMI tend to belong to a much younger age group than that reported in the literature. Short bowel syndrome is a frequent long-term complication in surviving patients. Administration of TPN in strict aseptic conditions, control of sepsis, intestinal adaptation and intestinal transplant will increase the long-term survival of these patients.

A sporadic case of colorectal carcinoma with multiple polyps in a 16-year-old boy: An unusual presentation

Aim and BackgroundColorectal carcinoma associated with multiple colonic polyps is rare in children and adolescents without any previous family history of colorectal cancer/hereditary polyposis syndrome.Case ReportWe present the case of adenocarcinoma of the colon and rectum detected by biopsy in a 16-year-old boy with multiple polyps treated at our institution.ConclusionThough uncommon, sporadic cases of multiple polyps associated with colorectal carcinoma without any positive family history must always be considered in children with history of a colorectal polyp associated with bleeding. A high degree of suspicion is necessary to detect and treat such cases, thus preventing morbidity and mortality.

Unusual presentation of Rapunzel syndrome

BackgroundThe Rapunzel syndrome is an unusual form of trichobezoar found in patients with a history of psychiatric disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing their hair) who subsequently develop gastric bezoars. The principal symptoms are vomiting and epigastric pain.Case presentationA 15-year-old female presented with a two-month history of continuous dull aching epigastric pain, vomiting, loss of appetite and weight loss. Further examination and imaging showed a large trichobezoar. Nevertheless, the patient refused any intervention. A few days later, she presented to the emergency department with features of peritonitis. After adequate resuscitation, she was taken for exploratory laparotomy. Her postoperative course was uneventful.ConclusionDelayed treatment of Rapunzel syndrome can lead to a complication such as gastric perforation which albeit extremely rare, could prove catastrophic.

Fungal splenic abscess in a sickle cell trait

Aim-BackgroundWith an incidence of 0.07–0.14%, splenic abscess is a rare entity that occurs mainly in immunocompromised patients and carries a dismal outcome. With the advancement of chemotherapy and the widespread emergence of immunodeficiency disorders, splenic abscess is becoming more prevalent. This paper highlights the case of a unilocular fungal abscess in an immunocompetent patient with no known underlying immunodeficiency disorder, and with sickle cell trait being found at subsequent workup as the only predisposing factor.Clinical ProfileA 39-year-old lady presented with low grade fever, pain in the left upper abdomen and a one-month history of shortness of breath. At admission, the patient appeared well but displayed high grade fever, tachycardia and tachypnoea. Abdominal examination revealed diffuse tenderness all over the abdomen with localized guarding and rigidity in the left hypochondrium.InvestigationsLaboratory investigations showed Hb 12.0gm/dl, leukocytosis − 24,000 /mm3, differential polymorphonuclear count 56%, lymphocytes 30%, eosinophils 8%, monoctyes 4%, basophils 2%, and a platelet count of 650,000/cumm. Biochemical parameters indicated a mildly deranged renal function test. Abdominal CECT showed a large unilocular splenic abscess that had ruptured in the peritoneum. The patient was taken for exploratory surgery, which disclosed moderate splenomegaly with 1.5 litres of non-purulent fluid and a large abscess in the lower pole. A splenectomy was performed, followed by a thorough peritoneal lavage. A pus culture revealed candida species which was confirmed on Lacto phenol cotton blue mount. The patient was treated with fluconazole therapy for 21 days. An aetiological workup was done to rule out infective endocarditis, tuberculosis, diabetes, and other immunocompromised conditions. Haemoglobulin electrophoresis showed sickle cell trait. Twenty months later, the patient is currently completely asymptomatic.ConclusionAlthough a rare entity, fungal splenic abscess should be kept in mind as a possibility, particularly in patients with a long relevant history and imaging showing a single abscess. Such patients need to receive appropriate antifungal treatment to achieve good results.

Mature teratoma of the pancreas: A rare entity

Aim and BackgroundPancreatic cystic lesions are being increasingly recognized and comprise different pathological entities. The management of these lesions is often challenging, because of inadequate preoperative diagnosis. Among this family of lesions, mature cystic teratomas are an extremely rare finding and are usually found in children.Case ReportWe present the rare case of a 60-year-old man being evaluated for melena. Preoperative investigation revealed a pancreatic mass. The patient underwent a Whipple pancreaticoduodenectomy. Surprisingly, histopathology revealed a mature teratoma of the pancreas.ConclusionThis case highlights the difficulty in establishing a preoperative diagnosis of this benign pathological entity. Though unusual in older patients, mature teratomas can present in this subgroup of patients. Mimicking malignancy, they warrant a radical surgical resection.

Amyand’s hernia — Always an operative surprise

Acute appendicitis in an inguinal hernia is termed an Amyand’s hernia. This is an extremely rare condition that is often misdiagnosed. It may present as a tender inguinal or inguinoscrotal swelling. The clinical presentation varies depending on the extent of inflammation in the hernia sac and associated peritoneal contamination. The authors report a rare case of Amyand’s hernia in a 2-month-old boy who presented with features of a strangulated right inguinal hernia. The patient was successfully managed with strict adherence to the basic principles of resuscitation and stabilisation before surgery. Our aim is to highlight the rare presentation of a common disease and to review the relevant available literature. In paediatric patients with Amyand’s hernia, the type of hernia repair and the operative approach is determined mainly by the inflammatory status of the appendix. Incidental appendicectomy in the case of a normal appendix is not favoured. However, in cases of children with an inflamed or complicated appendix, treatment includes appendicectomy (via the hernia sac) and hernia repair. After reviewing the literature, authors emphasise the extreme rarity of the case, underlining the diagnostic dilemma it creates.