Raghunath Prabhu

Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: a prospective randomized study.

OBJECTIVE Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold standard of treatment. This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes. METHODS A prospective, randomized comparative study was conducted between October 2010 and August 2012. A total of 136 patients were randomly assigned to each of two groups. Patients were followed up postoperatively for more than 1 year to assess any complications. The outcomes were compared among the two groups using the Chi-square test and Student t test. RESULTS The mean age at presentation was 40.13 years. The male to female ratio was 1.47:1. The typical presentation was painful defecation. Fissures were most often located in the posterior midline and associated with a sentinel pile. Delayed postoperative healing was found in 4.4% of the group of patients undergoing open lateral sphincterotomy. The mean pain score and duration of hospital stay were lower with the closed technique. CONCLUSION Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective, safe, less expensive, and associated with a lower rate of complications than the open sphincterotomy technique.

Jejuno-jejunal intussusception: an unusual complication of feeding jejunostomy

The jejuno-jejunal intussusception is a rare complication of jejunostomy tube placement. We are reporting a case of 33-year-old man who was suffering from absolute dysphagia due to carcinoma of cricopharynx with advanced metastatic disease, who underwent Stamms feeding jejunostomy as a part of palliative care. After 1 month he presented with colicky type of pain in the abdomen and vomiting. Sonogram of abdomen revealed a target sign and a feeding tube in a dilated jejunum. Abdominal CT proved the sonographic impression of jejuno-jejunal intussusception. He, therefore, underwent exploratory laparotomy and resection and anastomosis of the intussuscepted bowel. New feeding jejunostomy (FJ) was done distally from the anastomotic site. As per the literature this complication has been reported in Witzels jejunostomy. In our case the patient had undergone Stamms jejunostomy with placement of a Ryles tube. Intussusception should be considered if a patient comes with abdominal pain and vomiting following FJ.

Iliac crest bone graft donor site hernia: not so uncommon

A 73-year-old man, who had undergone fracture fixation of humerus with LCP plating and bone grafting, presented again with a peri-implant fracture after 1 year. A repeat surgery was contemplated and replating was performed with tricortical bone graft harvested from the iliac crest. In the postoperative period the patient developed a tender swelling at the graft site with nausea and abdominal discomfort. It was managed conservatively thinking it to be a haematoma at the graft site. In the following 2 days his symptoms worsened. A CT abdomen showed the herniation of caecum from the bone graft donor site with obstruction. The patient was taken up for emergency surgical repair, the caecum was reduced and polypropylene mesh hernioplasty was performed. The patient recovered well without recurrence in the follow-up period. Iliac crest bone graft site hernia is not so uncommon and care has to be taken while harvesting.

Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians

A 49-year-old multiparous woman presented with a swelling in the left groin of 6 months duration. The swelling was associated with a dull aching pain. The patient reported increase in size of the swelling during lifting of heavy weights. Menstrual history was normal and there was no increase in pain over the swelling during menstruation. She underwent a caesarean section 20 years ago and the scar had healed by primary intention. She was provisionally diagnosed to have a left-sided inguinal hernia. Ultrasonography showed a multiloculated cyst measuring 5.3×1.5×5.2 cm within the inguinal canal. The patient had excision of the cyst under spinal anaesthesia. Intraoperatively the cyst was found to arise from the left round ligament. It measured 7×6 cm extending to the left lateral vaginal wall. Histopathology revealed endometriosis of the round ligament. Her gynaecological assessment was normal and they recommended no further treatment. On follow-up the patient was asymptomatic and wound had healed well.

Aggressive fibromatosis (desmoid tumour) of the head and neck: a benign neoplasm with high recurrence

A 50-year-old man presented with a 5-month history of swelling over the right side of neck. The swelling was associated with dull aching pain radiating to the forearm without associated weakness of upper extremity or sensory loss. There was no history of trauma. On examination a fixed mass approximately 8×6 cm in size, smooth, firm in consistency, with ill-defined margins was present in the right posterior triangle. MRI scan of the neck revealed well-defined, lobulated, heterogeneously enhancing altered signal intensity mass at the root of neck. Debulking of the tumour was performed in view of its close proximity to the brachial plexus. Histopathology revealed aggressive fibromatosis (AF). AF is a benign fibrous neoplasm arising from fascia, periosteum and musculoaponeurotic structures of the body. AF in the head and neck region tends to be locally aggressive with a nature to invade bone and soft tissue structures.

Non-functioning Aortocaval Paraganglioma Masquerading as Celiac Lymphnodal Metastasis

An extra-adrenal paraganglioma is a rare tumour derived from chromaffin cells of sympathetic ganglia. This report documents a rare case of a non-functional aortocaval paraganglioma in a 24-year-old woman with persistent abdominal pain. Computed tomography revealed a solid mass, measuring 2.5x3cms, localized between the celiac trunk and superior mesenteric artery in aortocaval location along with right ovarian cystic mass. A clinical diagnosis of malignant ovarian tumour with celiac nodal metastasis was made. Excision and pathological analysis of both revealed an aortocaval extra-adrenal paraganglioma and benign ovarian cyst. On serial follow-up the patient was in a good health, asymptomatic and without evidence of tumour recurrence. This case emphasizes the necessity of including extra-adrenal paraganglioma in the differential diagnosis and management of retroperitoneal tumours, despite its rarity.

Small bowel carcinoid: a rare cause of bowel obstruction

Carcinoid tumours though commonly affect the appendix, are a rare cause of small bowel obstruction, causing a diagnostic dilemma. We presented a 70-year-old man with small bowel obstruction, not responding to conservative management, which required an emergency laparotomy and was found to have a mass encasing the mid-jejunal loops and mesentery that was resected and reported to be a carcinoid tumour.

Non-pancreatic retroperitoneal pseudocyst: a benign disease with non-specific symptoms.

A 76-year-old man presented with abdominal pain and constipation for 1 month. The pain was dull aching in nature and over the right upper abdomen. He also reported decreased appetite. The patient had no previous attacks of acute pancreatitis or history of trauma. There was no history of fever or melena. On visual inspection of the abdomen, there was a mass effect protruding out of the right mid-abdomen. The mass was approximately measuring 15×15 cm, firm in consistency, non-tender, non-mobile and not moving with respiration. Haematological investigations were normal. Both amylase and lipase were within normal limits. A CT of the abdomen revealed a large well-defined thin-walled cystic lesion measuring 10.3×13.9×14.3 cm in the right lumbar and iliac region without calcification or haemorrhage. A diagnosis of retroperitoneal cyst was made and the patient was taken up for surgery. Histology of the cyst showed the absence of epithelia and was reported as pseudocyst.

Pancreatic cancer presenting as a Sister Mary Joseph's nodule

A 69-year-old man presented with a painful umbilical nodule of 1 month duration. On examination the nodule was blackish in colour with a serous discharging fluid and was 2×2 cm in size, tender and fixed to the skin. There were no scars or sinuses at the umbilicus and no palpable mass or organomegaly on systemic examination. The patient underwent wide local excision of the skin nodule and on histopathology was reported as metastatic adenocarcinoma of the skin. A CT of the abdomen was performed to look for the primary site, which showed a 5×4 cm lesion in the tail of the pancreas. A biopsy from the pancreatic lesion was taken which was reported as an adenocarcinoma. CA19–9 was more than 1000 U/mL. The patient was advised palliative chemotherapy with gemcitabine. He was unwilling to take any further treatment in view of the advanced nature of the disease.

Be Careful with an IV Line.

Obtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intra-arterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those who try to obtain an IV access should always be on the lookout for possible clues that can prevent an inadvertent IA injection, especially if cannulation is in an area where an artery is in close proximity to a vein; these clues include but are not limited to the following: a bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at the site of injection. These signs, as well as educating the patient on early symptoms of ischaemia, may allow early action to be taken, to prevent irreparable damage. We always have to be careful when we insert an I.V line.