Kk Maudar

Mesenteric cyst—An unusual presentation

Mesenteric and retroperitoneal cysts develop from ectopic lymphatic tissue. Most of them present as symptomless abdominal swellings or are found coincidentally during abdominal operations. One third of patients may present with acute abdominal pain, and few may present with chronic abdominal pain. However, mesenteric cyst presenting as inguinal hernia is extremely rare. Only four cases have been reported in the English-language literature. The present case is the fifth, and only the second from this subcontinent. The treatment of choice is complete surgical excision.

CONGENITAL URETHRAL FISTULA: Case Report

M ale congenital urethral fistula is most commonly seen in association with anorectal malformations [I]. Congenital posterior urethro-perineal fistula as a variant of urethral duplication is a relatively more common type of fistula. Isolated congenital urethral fistula is very rare with less than 20 cases reported in the available literature. We report here such a case and discuss its management.

SUPRACLAVICULAR FIRST RIB RESECTION FOR TREATMENT OF THORACIC OUTLET SYNDROME

Twelve patients with thoracic syndrome were operated during a 15 month period. Eleven patients had features of neurogenic thoracic outlet syndrome, while one presented with arterial ischemia due to distal embolism. The diagnosis was based on the characteristic history and positive stress tests. Cervical rib was present in 7 patients. Abnormal nerve conduction studies were present in 7 out of 8 cases. Supraclavicular first rib resection was done in all patients in view of the severity of symptoms. If present, the cervical rib was also excised. There was no major operative complication. Eleven out of twelve patients reported relief of symptoms. Thoracic outlet syndrome is not an uncommon disorder and often goes undiagnosed. Resection of first rib via the supraclavicular approach gives good results in majority of the patients who have incapacitating symptoms.

PAEDIATRIC HAND TUMOURS-SYNOVIAL SARCOMA : A RARE MALIGNANCY

T he rarity of soft tissue sarcoma overall and their even rarer presentation in distal portion of an extremity has limited the number of patients in most reports. Among soft tissue tumours, synovial sarcoma is uncommon & occurs rarely in children. Till date only one case of synovial sarcoma of the left palm has been reported in the English literature [I]. Here we describe another case of this rare entity and its management.

ENDOTHELIAL CELL CULTURE AND SEEDING OF PROSTHETIC VASCULAR GRAFTS: AN EXPERIMENTAL STUDY

Current synthetic vascular prostheses do not acquire lining of vascular endothelium in humans or dogs. Endothelial seeding of vascular grafts has been proposed as a means of reducing the thrombogenicity of these grafts. We examined feasibility of cultivating endothelial cells (EC) by tissue culture technique and their subsequent seeding onto small diameter polytetra fluoroethylene (PTFE) grafts. Twenty adult dogs underwent common carotid artery interposition with 4 mm PTFE grafts. Ten dogs received seeded and the remaining ten received unseeded grafts. Grafts were removed at 4 and 12 weeks and their gross/morphological features compared. Cumulative patency rates for seeded grafts were 70% as compared to unseeded ones 30%. Seeded grafts were completely surfaced with a mono-layer of endothelium by 4 weeks. Small graft patency appears to be related to the establishment of an endothelial surface, the development of which is clearly facilitated by seeding with autogenous endothelium.

CAROLI DISEASE AND CAROLI SYNDROME

A lO-years-old boy was admitted with complaints of pain in the upper abdomen, fever, vomiting and lump abdomen of 2 1/2 months duration. There was no family history of hepatic disease. He was poorly developed. Weight was 20 kg and height was 128 cm. He was febrile (102 OF). No icterus was present. The abdomen was full in upper part. The liver was firm , nontender and palpable 7 cm below the right costal margin. Features of portal hypertension in the form of ascites, splenomegaly and distended abdominal wall veins were present. Laboratory investigations revealed Hb 6.2 gm%, TLC 12,200/mm; Liver function tests: S.bilirubin 2.8 mg%, ALT 21 IUIL, AST 56 IUIL, ALP 89 IUIL, Total proteins 8.5 gmJdl, Albumin 3.0 gmJdl, Globulin 5.6 gmJdl and A:G Ratio 0.55:1. HBsAg was negative by RPHA. Serum Amylase was 92 Somogyi Units. Ultrasonography revealed multiple cystic dilatations in both lobes of liver and both kidneys (renal polycystosis). Computed tomography (Fig I) and endoscopic retrograde cholangiography (Fig 2) confirmed the presence of multiple communicating dilatations of the bile ducts affecting the whole of the liver but mainly of right lobe of liver. Patient was managed with nasogastric aspiration, broad spectrum antibiotics, blood transfusions and other supportive measures. Endoscopic papillotomy and nasobiliary drainage (endoprosthesis) was carried out to decompress the biliary tree. The cholangitis resolved and patient is in the waiting list for liver transplantation.

A COMPARATIVE STUDY OF REPAIR OF INGUINAL HERNIAS BY SHOULDICE TECHNIQUE VIS-A-VIS BASSINIS TECHNIQUE

A comparative study of repair of inguinal hernias by Shouldice technique (ST) vis-a-vis Bassinis technique (BT) was conducted on 100 patients who presented with inguinal hernia in the OPD services of our hospital. The patients were worked up and alternatively distributed to undergo repair by ST (n=50) or BT (n=50). Repair by ST required longer operating time (Avg 95 min vs 80 min), but involved lesser hospitalization (4.0 days vs 4.5 days), lesser complication rate (2 vs 4), lesser recurrence rate (0 vs 2) and higher rate of satisfaction. The study confirms the advantages of Shouldice repair in the treatment of inguinal hernia.

REVASCULARIZATION OF THE ISCHEMIC UPPER LIMB

Eighteen cases of upper limb ischemia were operated during a 24 month period. Eleven patients presented with features of chronic ischemia, while 7 had acute ischemia with a threatened limb. There were 15 males and 3 females. The average age was 38 years. Associated medical problems were present in 8 patients. Limb perfusion was restored in all patients after direct arterial (bypass) surgery, intra-arterial thrombolysis or percutaneous transluminal angioplasty (PTA). There was no mortality. The limb salvage rate was 100 per cent. Follow-up of upto 24 months reveals a patent bypass in all patients with no recurrence of symptoms. Upper limb ischemia is not uncommon, and can be treated by thrombolysis, angioplasty or bypass surgery. Direct arterial surgery for upper limb revascularization, though technically demanding, is safe and results in relief of symptoms in the vast majority of patients.

SYRINGE SUCTION : A SIMPLE AND EFFECTIVE CLOSED DRAINAGE SYSTEM

Two exceptions where the Armed Forces figures exceed the international limits are average length of stay (ALS) (11.60) and caesarian section rate (9.36). The ALS ought to be more as the service hospitals can not dump the patients under convalescence in the barracks. The hospitals also function as convalescent homes unlike the civil. The caesarian section rate shows an increased demand for that procedure. The statistical figures at Table 1 are broad indicators. But, each hospital should have its own figures, its own analysis and its own remedial measures. Although die Statistical data are utilised in clinical practice, they are not effectively used in administration of hospitals. It should be utilised for administrative control over functional activities, for assessing utilisation of hospital facilities, for budgeting, for projecting future requirements, for health intelligence and for medical audit.

UNDESCENDED TESTIS: A STUDY OF 50 CASES

Fifty consecutive cases of undescended testis treated at a service hospital over a period of 3 years from January 1993 to December 1995 were studied. Only 2 patients (4%) were below the age of 2 years and 25 (50%) were past the age of 15 years. Two cases presented with seminoma in intraobdominal testis. Ultrasonography was found unreliable in localizing the impalpable testis. Subdartos pouch orchiopexy (Winsburry-White) was the definitive procedure adopted in 21 out of the 25 orchiopexies performed and the results were good. Orchidectomy seems the best option of treatment in post-pubertal patients with unilateral symptomatic maldescent.