John C. Muthusami

Mycobacterium fortuitum: an iatrogenic cause of soft tissue infection in surgery.

Background:   Mycobacterium fortuitum is an uncommon cause of soft tissue infections. Treatment is often inadequate with persistence of infection unless the aetiological agent and its antibiotic sensitivity are accurately established.

Management of adult choledochal cysts – a 15-year experience

BACKGROUND Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. METHODS The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. RESULTS The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. CONCLUSIONS Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Subcutaneous bronchogenic cyst.

A34-year-old man presented with a swelling in the suprasternal notch since birth that progressed in size with age. Apart from being a source of embarrassment, the swelling was not associated with any symptom. Clinical examination revealed a 5 5 cm nontender fluctuant subcutaneous swelling in the suprasternal notch. The swelling was brilliantly transilluminant (Fig 1). Preoperative laboratory investigations were normal. Ultrasound evaluation revealed thick-walled cystic swelling of 5.9 2 cm with internal echogenic material seen in the lower neck in midline. With the clinical diagnosis of congenital cyst, the patient underwent the excision of the swelling. Preoperative findings revealed a cystic mass of 4.5 3.5 l.5 cm with congested outer surface containing white gelatinous material. Histopathological examination revealed a cyst wall composed of fibrocollagenous tissue containing few smooth-muscle bundles, lined by ciliated pseudostratified columnar epithelial cells, admixed with goblet cells. Bronchogenic cysts are rare congenital anomalies that are usually located in the mediastinum or lung parenchyma. They are very rare in the neck and are thought to result from abnormal development of the tracheobronchial system. An abnormal budding of the tracheobronchial system between the 22nd and 33rd days of gestation and persistence of such a bud may give rise to bronchogenic cyst. In addition, abnormal migration of a bud may occur during the course of development and rest in different intrathoracic or extrathoracic locations. Maier has classified bronchogenic cysts according to site into paratracheal, carinal, hilar, paraesophageal, and atypical (diaphragm, abdomen, skin, subcutaneous tissue, and supraclavicular region). Most of the cervical bronchogenic cysts are in the midline, usually the upper cervical region. Bronchogenic cysts of the lateral

Persistent chyle leak following radical neck dissection: a solution that can be the solution.

A case report of a chyle leak following radical neck dissection for residual lymph nodal disease performed after chemoradiation for nasopharyngeal carcinoma. This is the first case report of the use of cyanoacrylate for a persistent chyle leak following radical neck dissection.

Angiosarcoma of the scalp

A70-year-old man presented with 6 weeks’ duration of hyperpigmented, blue-black nodular lesions on the left parieto-temporal region of scalp. The lesion started as an erythematous macule behind the angle of left eye and rapidly spread with nodule formation and bled to touch in due course of time. This rapid spread occurred while the patient was still in the ward, with treatment planned for a period of 4 to 5 days. On examination, there were hyperpigmented nodular, soft, compressible lesions with ulcerated surfaces that bled to touch over the left frontal, parieto-temporal area with ecchymotic lesions at the periphery making the margins indistinct. Examination of the neck revealed a 1 1 cm firm mobile node in the ipsilateral level II and V. Biopsy of the scalp nodule showed a tumor composed of irregular vascular channels lined by plump endothelial cells with vesicular nuclei and prominent nucleoli surrounded by lymphocytes and plasma cells. The neoplastic cells were positive for CD34, vimentin, and CD34. Angiosarcomas are rare malignant tumors composed of vascular endothelial cells that can originate from either blood vessels or lymphatic channels. They account for 1% to 3% of all soft tissue sarcomas and are rare in the head and neck region and comprise less than 0.1% of all cancers in that region. Although they are rare, 50% of angiosarcomas occur in the head and neck region. It is also referred to as malignant angioendothelioma, malignant hemangioendothelioma, lymphangioendothelioma, hemangiosarcoma, hemangioblastoma, lymphangiosarcoma, malignant angioma, and malignant endothelioma. They are seen in males 3 to 4 times more frequently than in females, with a median age of 61 to 67 years. Although trauma, previous irradiation, longstanding lymphedema, exposure to thorium dioxide, vinyl chloride, insecticides, anabolic steroids, and synthetic estrogens have all been thought of as etiologic factors, its cause is unknown. The scalp and facial skin are the most common areas followed by nasopharynx, larynx, nose, middle ear, paranasal sinuses, thyroid, orbit, and oral cavity. They usually present as progressive multiple separate foci of vascular reddish colored macules, blue-black nodules with ulcerated surface and

Metachronous bilateral mucoepidermoid carcinoma of the parotid gland.

We report a very rare case of bilateral muco-epidermoid carcinoma of the parotid gland that underwent bilateral parotidectomy with neck dissections and radiotherapy. This case has done well for three years and suggests that metachronous bilateral mucoepidermoid carcinoma of the parotid gland, if treated as per the merits of each side, has a reasonable survival.

Malignant Peripheral Nerve Sheath Tumour of the Small Bowel Presenting with Intussusception and Perforation: a Double Jeopardy?

Malignant peripheral nerve sheath tumours (MPNST) are rare soft tissue sarcomas which largely occur in the extremities and the head and neck region. The tumours are aggressive with a high rate of recurrence. Radical surgical resection remains the treatment of choice with adjuvant radiation therapy and chemotherapy still failing to demonstrate a clear benefit. The gastrointestinal tract is an exceedingly rare site for these tumours. We report an unusual case of a young male with an MPNST of the small bowel who presented with an ileocolic intussusception and sigmoid perforation.

Oral verrucous carcinoma: Ten year experience from a Tertiary Care Hospital in India

Background: Verrucous carcinoma of the oral cavity (OVC) is an uncommon variant of oral squamous cell carcinoma (OSCC). The clinical presentation and surgical outcomes of OVC are unique; however, the management protocols for OVC are largely extrapolated from OSCC. Objectives: The aim is to study the clinical, histopathological demographics, and outcome of OVC at a tertiary care referral hospital in South India. To study the need for lymph node dissection and the role of adjuvant therapy for close resection margins. Materials and Methods: A retrospective review of all patients diagnosed to have OVC between January 2005 and April 2015 was undertaken. Data were collected from hospital records and telephonic interview when possible. Results: Thirty patients were diagnosed to have OVC. The most common site of the presentation was the buccal mucosa. Twenty-three patients had wide local excision of the primary tumor and seven patients had neck dissection as well. None of the patients who underwent neck dissection had node-positive disease pathologically. The margins were considered close in nine patients, only one of these patients received adjuvant radiation therapy; despite among the patients with close resection margins, there was no recurrence or disease-related mortality. Among the thirty patients, there was only one patient who had recurred locally and there was no disease associated mortality. Conclusions: OVC is a unique variant of OSCC which has a good prognosis. Routine lymphadenectomy can be avoided.