Nanda Kishore Maroju

Delay in surgery for acute appendicitis

Background:  The present study investigates the effect of delay in appendicectomy on the outcome of surgery and also examines the contribution of patient and physician related delay to the stage of appendicitis.

Sternocleidomastoid Muscle Myocutaneous Flap for Corrosive Pharyngoesophageal Strictures

BackgroundStrictures at the pharyngoesophageal junction represent a subgroup of corrosive esophageal strictures requiring a specialized management approach. Non-dilatable cricopharyngeal strictures need surgical intervention. We report the use of the sternocleidomastoid muscle myocutaneous inlay flap (SCMMIF) for reconstruction of the cervical esophagus in patients with corrosive strictures.MethodsA SCMMIF was used in four patients with cricopharyngeal strictures. The surgical technique is described. All patients had complete dilatation of the stenosed cricopharyngeal segment as seen on postoperative endoscopy and contrast studies. One patient was managed successfully for a short midesophageal stricture by serial endoscopic dilatations. Another patient underwent an esophagocoloplasty subsequently for bypass of the long distal esophageal stricture The last two patients await esophagocoloplasty.ConclusionsThis is the first report on the use of sternocleidomastoid muscle myocutaneous inlay flap for corrosive cricopharyngeal strictures. The flap is simple to construct, is effective and can be performed in a short time, and yields good cosmetic results.

Enterocutaneous fistulae: Etiology, treatment, and outcome - A study from South India

Background/Aim: Enterocutaneous fistula (ECF) is a difficult condition managed in the surgical wards and is associated with significant morbidity and mortality. Sepsis, malnutrition, and electrolyte abnormality is the classical triad of complications of ECF. Sepsis with malnutrition is the leading cause of death in cases of ECF. Although it is a common condition, no recent report in literature on the profile of patients with ECF has been documented from the southern part of India. Materials and Methods: All consecutive patients who developed or presented with ECF during the study period were included in the study. The etiology, anatomic distribution, fistula output, clinical course, complications, predictive factors for spontaneous closure, and outcomes for patients with ECF were studied. Results: A total of 41 patients were included in this prospective observational study, of which 34 were males and 7 were females. About 95% of ECF were postoperative. Ileum was found to be the most common site of ECF. Also, 49% of fistulas were high output and 51% were low output. Serum albumin levels correlated significantly with fistula healing and mortality. Surgical intervention was required in 41% of patients. Conclusion: Most of the ECF are encountered in the postoperative period. Serum albumin levels can predict fistula healing and mortality. Conservative management should be the first line of treatment. Mortality in patients with ECF continues to be significant and is commonly related to malnutrition and sepsis.

Axial Torsion of Gangrenous Meckel’s Diverticulum Causing Small Bowel Obstruction

Meckel′s diverticulum (MD) is a commonly encountered congenital anomaly of the small intestine. We report an extremely unusual case of an axially torted, gangrenous MD presenting as acute intestinal obstruction. A 26-year-old male patient presented to our emergency department with 3 days history of abdominal pain, distention and bilious vomiting. On laparotomy, there was minimal hemorrhagic fluid localized in right iliac fossa and small bowel loops were dilated. A MD was seen attached to the mesentery of nonadjacent small bowel by a peritoneal band. The diverticulum was axially torted and gangrenous. In addition, there was compression of ileum by the peritoneal band resulting in intestinal obstruction, which was relieved on dividing the band. Resection and anastomosis of the small bowel including the MD was performed. We hereby report a rare and unusual complication of a MD. Although treatment outcome is generally good, pre-operative diagnosis is often difficult.

Helicobacter pylori Infection and Upper Gastrointestinal Disorders

It has been thirty years since the two Australians Robin Warren and Barry Marshall discovered Helicobacter pylori (H. pylori) in 1983 [1]. In order to fulfil the Kochs postulates, Marshall and Morris drank a solution which was a suspension of H. pylori. This produced gastritis from which the bacteria could be reisolated [2]. It will be interesting to see how the approach to treatment has progressed in these three decades after the discovery of the organism-based both on consensus guidelines and other research in this field. The changes in the consensus statements have been highlighted. The isolation of H. pylori from the gastric mucosa and the report of the organisms urease activity generated excitement especially when it was postulated by Marshall that these microorganisms could be the cause of gastritis and could be a dominant etiological factor in the pathogenesis of peptic ulcer disease (PUD). With the isolation of H. pylori, floodgates opened to a new era of discovery and understanding of gastroduodenal pathology. These results were a paradigm shift from the earlier belief that PUD disease was related to stress, lifestyle, and acid secretion based on the dictum of Schwarz “no acid no ulcer.” The early nineteen eighties when Warren and Marshall reported their findings coincided with omeprazole belonging to the group of proton pump inhibitors (PPIs) being introduced. This PPI was documented as a potent antisecretory agent which yielded very good results for ulcer healing and achieving a potential cure for patients with PUD when compared to the earlier drugs belonging to the group of H2 receptor antagonists. Hence there was lot of scepticism in the gastroenterology community world over to accept that PUD was the result of infection. However, it was found that patients with PUD continued to have remission of the disease even after cessation of antisecretory therapy.

A Surgical Conundrum in Feeding Jejunostomy–Jejunojejunal Intussusception: A Case Series

Intussusception is a common cause of intestinal obstruction in the pediatric population. Usually, it is primary and benign and can be managed by nonoperative interventions in 80% of the cases. Adult intussusception accounts for only 5% of all cases of intussusception and 1%–5% of all cases of intestinal obstruction. Unlike in the pediatric population, intussusception in adults is usually caused by a pathologic lead point. The initial investigation to diagnose it is an ultrasound abdomen followed by contrast-enhanced computed tomography (CECT) of the abdomen. The placement of an intestinal tube for feeding purposes has been rarely reported as a cause of intussusception. Here, we present a case series of four patients who had jejunojejunal intussusception following the placement of feeding tubes into the jejunum. Three patients were operatively managed and one was managed conservatively.

Clinical Significance of Candida in an Intraoperative Peritoneal Specimen with Perforation Peritonitis: An Institutional Perspective

Introduction Fungal infection of the peritoneum has become more common in recent years, the most common cause of which is Candida. Candida peritonitis is considered as a severe disease and is regarded as an independent risk factor for mortality in postoperative peritonitis. This study was planned to find out the clinical significance of Candida isolation on the outcome of the patients with peritonitis in terms of morbidity and mortality. Methods This prospective study included consecutive patients admitted and operated for secondary peritonitis over a two-year period in a tertiary care hospital in South India. The time delay was assessed from the onset of symptoms to surgery. The intraoperative peritoneal fluid aspirate was analyzed for culture sensitivity (fungal and bacterial). Patients were followed until their discharge from the hospital or death. This study analyzed the clinico-microbiological profile in patients with perforation peritonitis with special reference to Candida isolation. The analysis also looked the results of antifungal therapy (fluconazole) in patients positive for Candida isolation. Results The study included 407 consecutive patients with hollow viscus perforation diagnosed intraoperatively. Fungal organisms were identified in 153 patients (37.6%). Old age (> 50 years), high lag period (≥ 48 hours), peritoneal contamination, length of hospital stay, the presence of co-morbidities, shock at presentation, and postoperative complications were found to be significantly associated with fungal infection (p < 0.05). The study noted a significant decrease in the perioperative complications in patients who were started on antifungal treatment early (within 72 hours after surgery). There were significant reductions in the length of hospital stay, intensive care unit (ICU) stay, ventilator support, and inotropic support in the postoperative period. However, we did not find any difference in mortality due to early treatment with fluconazole. Conclusion Candida peritonitis was associated with an increase in the mortality and morbidity, especially when associated with diabetes mellitus and fungemia. Early antifungal therapy (within 72 hours after surgery) reduced the morbidity due to Candida peritonitis but did not affect the mortality.

Clinical audit system as a quality improvement tool in the management of breast cancer

INTRODUCTION Quality improvement is recognized as a major factor that can transform healthcare management. This study is a clinical audit that aims at analysing treatment time as a quality indicator and explores the role of setting a target treatment time on reducing treatment delays. MATERIALS AND METHODS All newly diagnosed patients with breast cancer between September 2011 and August 2013 were included in the study. Clinical care pathway for breast cancer patients was standardized and the timeliness of care at each step of the pathway was calculated. Data collection was spread over three phases, baseline, audit cycle I, and audit cycle II. Each cycle was preceded by a quality improvement intervention, and followed by analysis. RESULTS A total of 334 patients with breast cancer were included in the audit. The overall time from first visit to initiation of treatment was 66.3 days during the baseline period. This improved to 40.4 and 28.5 days at the end of Audit cycle I and II, respectively. The idealized target time of 28 days for initiating treatment was achieved in 5, 23.5, and 65.2% of patients in the baseline period, Audit cycle I, and Audit Cycle II, respectively. There was improvement noted across all steps of the clinical care pathway. CONCLUSION This study confirms that audit is a powerful tool in quality improvement programs and helps achieve timely care. Gains achieved through an audit process may not be sustainable unless underlying patient factors and resource deficits are addressed.

Extranodal NK/T Cell Lymphoma of the Jejunum Complicated by Hemophagocytic Syndrome: Practical Problems Encountered by a Pathologist.

Extranodal NK/Tcell lymphomas (ENKTL) are rare, aggressive lymphomas. The most common primary site of involvement is the nasal cavity, nasopharynx and paranasal sinuses. The other sites of primary involvement are skin, gastrointestinal tract and testis. Advanced disease can show lymph node, bone marrow and peripheral blood involvement. We report a case of ENKTL of the jejunum, showing peripheral pancytopenia and haemophagocytosis in the bone marrow. The intestine showed multiple intestinal perforations, with evidence of infiltration by lymphoma with coexistent strongyloides infestation. The patient showed disseminated disease in the form of lymphadenopathy and had a rapidly downhill course and expired on 5th day of admission. We also discuss the problems encountered by the pathologist in diagnosing these uncommon lymphomas.