Satyajit Rath

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.

Port site infection in laparoscopic surgery: A review of its management

Laparoscopic surgery (LS), also termed minimal access surgery, has brought a paradigm shift in the approach to modern surgical care. Early postoperative recovery, less pain, improved aesthesis and early return to work have led to its popularity both amongst surgeons and patients. Its application has progressed from cholecystectomies and appendectomies to various other fields including gastrointestinal surgery, urology, gynecology and oncosurgery. However, LS has its own package of complications. Port site infection (PSI), although infrequent, is one of the bothersome complications which undermine the benefits of minimal invasive surgery. Not only does it add to the morbidity of the patient but also spoils the reputation of the surgeon. Despite the advances in the field of antimicrobial agents, sterilization techniques, surgical techniques, operating room ventilation, PSIs still prevail. The emergence of rapid growing atypical mycobacteria with multidrug resistance, which are the causative organism in most of the cases, has further compounded the problem. PSIs are preventable if appropriate measures are taken preoperatively, intraoperatively and postoperatively. PSIs can often be treated non-surgically, with early identification and appropriate management. Macrolides, quinolones and aminoglycosides antibiotics do show promising activity against the atypical mycobacteria. This review article highlights the clinical burden, presentations and management of PSIs in LS as shared by various authors in the literature. We have given emphasis to atypical mycobacteria, which are emerging as a common etiological agent for PSIs in LS. Although the existing literature lacks consensus regarding PSI management, the complication can be best avoided by strictly abiding by the commandments of sterilization techniques of the laparoscopic instruments with appropriate sterilizing agent.

Pathophysiology of Oxidative Stress and Antioxidant Therapy in Acute Pancreatitis

Acute pancreatitis is an inflammatory disease of pancreas with varied clinical presentation ranging from mild self limiting disease to severe necrotising pancreatitis with high mortality. The exact pathogenesis of the disease is unclear despite extensive research. Recent studies have shown the role of oxidative stress in the pathogenesis of the disease. Many experimental studies have proven the role of oxygen free radicals in the initiation and progression of the disease. Antioxidant therapy has shown promising results in experimental animal models, whereas conflicting result has been seen in clinical studies in humans. This may suggest existence of different pathogenetic mechanism in humans. This review gives an overview of the role of oxidative stress in the pathophysiology of acute pancreatitis and outcomes of antioxidant therapy as a therapeutic agent in the treatment of acute pancreatitis.

Opioid-free anesthesia for breast cancer surgery: An observational study

Background and Aims: Opioids are associated with postoperative nausea, vomiting, drowsiness, and increased analgesic requirement. A nonopioid anesthesia technique may reduce morbidity, enable day care surgery, and possibly decrease tumor recurrence. We compared opioid-free, nerve block-based anesthesia with opioid-based general anesthesia for breast cancer surgery in a prospective cohort study. Material and Methods: Twenty four adult American Society of Anesthesiologists grade I–III patients posted for modified radical mastectomy (MRM) with axillary dissection were induced with propofol and maintained on isoflurane (0.8–1.0 minimum alveolar concentration) through i-gel on spontaneous ventilation and administered ultrasound-guided PECS 1 and 2 blocks (0.1% lignocaine + 0.25% bupivacaine + 1 mcg/kg dexmedetomidine, 30 ml). Postoperative nausea, pain scores, nonopioid analgesic requirement over 24 h, stay in the recovery room, and satisfaction of surgeon and patient were studied. Twenty-four patients who underwent MRM and axillary dissection without a nerve block under routine opioid anesthesia with controlled ventilation were the controls. Results: MRM and axillary dissection under the nonopioid technique was adequate in all patients. Time in the recovery room, postoperative nausea, analgesic requirement, and visual analog scale scores were all significantly less in the nonopioid group. Surgeon and patient were satisfied with good patient quality of life on day 7. Conclusion: Nonopioid nerve block technique is adequate and safe for MRM with axillary clearance. Compared to conventional technique, it offers lesser morbidity and may allow for earlier discharge. Larger studies are needed to assess the long-term impact on chronic pain and tumor recurrence by nonopioid techniques.

Torsion of a Large Appendix Testis Misdiagnosed as Pyocele

Torsion of the appendix testis is not an uncommon cause of acute hemiscrotum. It is frequently misdiagnosed as acute epididymitis, orchitis, or torsion of testis. Though conservative management is the treatment of choice for this condition, prompt surgical intervention is warranted when testicular torsion is suspected. We report a case of torsion of a large appendix testis misdiagnosed as pyocele. Emergency exploration of it revealed a large appendix testis with torsion and early features of gangrene. After excision of the appendix testis, the wound was closed with an open drain. The patient had an uneventful and smooth postoperative recovery.

Ancient Schwannoma of Ansa Cervicalis: A Rare Clinical Entity and Review of the Literature

Ancient schwannoma is an uncommon variant of schwannoma, a benign tumor arising from the nerve sheath. It is reported to arise from any nerves except optic and olfactory. However, only six cases of ancient schwannomas arising from ansa cervicalis nerve have been reported to date in English literature. Proper preoperative evaluation is necessary to rule out other causes of neck mass such as thyroid lesions, lymphadenopathy, and carotid body tumor. We report a case of ancient schwannoma arising from the ansa cervicalis nerve. The origin of the lesion from ansa cervicalis was confirmed by intraoperative finding. Postoperative histopathological examination revealed degenerative changes including pleomorphism, cellular atypia, large nuclei with prominent nucleoli, and paucity of mitotic figures. Periphery of the mass showed nuclear palisading with characteristic verocay bodies. Immunohistochemical evaluation for S-100 showed diffuse positivity of the tumor cells, thereby confirming the diagnosis of schwannoma. We consider that schwannoma of cervical region can have origin from any nerve and should try to identify the origin pre- and intraoperatively. The postoperative complications depend on the nerve of origin and the precision of the surgery performed.

Phytobezoar (Mangifera Indica Seeds) Induced Acute Intestinal Obstruction

Bezoars are partially digested conglomerates of fibres and foreign materials found in the gastro intestinal tract. Although they are common in lower vertebrates but there incidence in human being is rare. Bezoars in human beings can present with varied clinical signs and symptoms like colicky abdominal pain or intestinal obstruction or they may be silent and asymptomatic. In this case study we report a case of acute intestinal obstruction in a 35 years old female caused phytobezoar. The patient was diagnosed to have bezoar intra-operatively only in the terminal small bowel and stomach. On exploration she had obstruction at the level of terminal ileum and underwent enterotomy of terminal ileum and gastrostomy for removal of two pieces of phytobezoars comprising of semi digested mango seeds (Mangifera Indica). A detailed history of dietary habit was taken in the post-operative period. It revealed that she was very fond of eating mango and was regularly eating mango seeds along with the fruit which might be the cause of the phytobezoar. Phytobezoars are commonly found in the stomach and small intestine. The most common presentation of a bezoar is with intestinal obstruction. They can easily be managed by endoscopic procedures or surgical exploration at times.

Quality of Life after Frey’s Procedure in Patients with Chronic Pancreatitis

INTRODUCTION Chronic pancreatitis is a debilitating disease, associated with excruciating abdominal pain, exocrine and endocrine pancreatic insufficiency. Different types of surgical techniques have been described for the management of complications of this disease. The most common procedure which has been adopted for improving the quality of life of the patients with chronic pancreatitis is Freys Procedure. It is an organ preserving procedure in which the main pancreatic duct is drained by lateral pancreatico-jejunostomy along with coring of the head of the pancreas. AIM In this study, we have assessed the outcome of Freys procedure in terms of quality of life in patients with chronic pancreatitis. MATERIALS AND METHODS This was a prospective observational study done at a tertiary care center in West Bengal, India. The study period was from 2010 to 2014. All the patients who have undergone Freys Procedure during the study duration and with the postoperative histopathology of chronic pancreatitis were included in this study. The preoperative and postoperative pain and quality of life assessment was done using VAS score (0-100) and EORTC QLQ-C30 (Version 3) respectively. The statistical analysis was performed with the help of Epi Info (TM) 3.5.3. RESULTS A total of 35 patients with chronic pancreatitis underwent Freys procedure during the study period. The mean age (mean ± s.e) of the 33 patients included in the study was 38.48±5.55 years with a range of 29-49 years. The mean preoperative Physical Functional Domain (PFD), Physical Domain (PD), Emotional Domain (ED), Social Domain (SD) and general health raw score with standard errors were 32.06±0.40, 37.86±0.36, 15.18±0.32, 8.63±0.31 and 4.48±0.26 respectively. ANOVA showed that there was significant differences in PFD, PD, ED, SD and GH values during different time period of follow up (p<0.0001) and as per Critical Difference the postoperative values of PFD, PD, ED and SD decreased while postoperative value of GH increased significantly in different months compared to the preoperative values. CONCLUSION We conclude that Freys procedure is a low risk surgery, which significantly improves the quality of life of the patients with chronic pancreatitis in all the domains and can be recommended as a surgical therapy for such patients.

Pericatheter encrustations: an unusual cause of a retained Foley catheter.

Urethral catheterisation is a common bedside procedure in hospitals. After they have served their purpose, indwelling Foley catheters can be removed by deflating their balloon. The incidence of a retained Foley catheter, however, is not uncommon, failure to deflate the intravesicular balloon being the most common reason. Causes of retained Foley catheters are many and the method to deal with each varies with the inciting cause. Pericatheter concretion or encrustation, an unusual cause of difficulty in removal of the catheter, is often difficult to recognise and hence is prone to faulty management. We report a case of a patient with a retained Foley catheter due to pericatheter encrustations; multiple attempts to remove it were made before the patient presented to our hospital. The case is being reported for the unusual location of retention, and the associated diagnostic and therapeutic dilemma.