Satyendra K. Tiwary

Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis

Background. Multifactorial scorings, radiological scores, and biochemical markers may help in early prediction of severity, pancreatic necrosis, and mortality in patients with acute pancreatitis (AP). Methods. BISAP, APACHE-II, MOSS, and SIRS scores were calculated using data within 24 hrs of admission, whereas Ranson and Glasgow scores after 48 hrs of admission; CTSI was calculated on day 4 whereas IL-6 and CRP values at end of study. Predictive accuracy of scoring systems, sensitivity, specificity, and positive and negative predictive values of various markers in prediction of severe acute pancreatitis, organ failure, pancreatic necrosis, admission to intensive care units and mortality were calculated. Results. Of 72 patients, 31 patients had organ failure and local complication classified as severe acute pancreatitis, 17 had pancreatic necrosis, and 9 died (12.5%). Area under curves for Ranson, Glasgow, MOSS, SIRS, APACHE-II, BISAP, CTSI, IL-6, and CRP in predicting SAP were 0.85, 0.75, 0.73, 0.73, 0.88, 0.80, 0.90, and 0.91, respectively, for pancreatic necrosis 0.70, 0.64, 0.61, 0.61, 0.68, 0.61, 0.75, 0.86, and 0.90, respectively, and for mortality 0.84, 0.83, 0.77, 0.76, 0.86, 0.83, 0.57, 0.80, and 0.75, respectively. Conclusion. CRP and IL-6 have shown a promising result in early detection of severity and pancreatic necrosis whereas APACHE-II and Ranson score in predicting AP related mortality in this study.

Phyllodes Tumor of Breast: A Review Article

Introduction. Phyllodes tumours are rare fibroepithelial lesions. Accurate preoperative pathological diagnosis allows correct surgical planning and avoidance of reoperation. Treatment can be either wide local excision or mastectomy to achieve histologically clear margins. Discussion. The exact aetiology of phyllodes tumour and its relationship with fibroadenoma are unclear. Women aged between 35 and 55 years are commonly involved. The median tumour size is 4 cm but can grow even larger having dilated veins and a blue discoloration over skin. Palpable axillary lymphadenopathy can be identified in up to 10–15% of patients but <1% had pathological positive nodes. Mammography and ultrasonography are main imaging modalities. Cytologically the presence of both epithelial and stromal elements supports the diagnosis. The value of FNAC in diagnosis of phyllodes tumour remains controversial, but core needle biopsy has high sensitivity and negative predictive value. Surgical management is the mainstay and local recurrence in phyllodes tumours has been associated with inadequate local excision. The role of adjuvant radiotherapy and chemotherapy remains uncertain and use of hormonal therapy has not been fully investigated. Conclusion. The preoperative diagnosis and proper management are crucial in phyllodes tumours because of their tendency to recur and malignant potential in some of these tumours.

A Case Series Describing 118 Patients With Lower Limb Necrotizing Fasciitis

Necrotizing fasciitis of the lower limb is not uncommon, with poor outcome. This study reviewed 118 cases (78 males and 40 females) with mean age of 45 + 16.5 years (range 12-95 years) of lower limb necrotizing fasciitis admitted to the Department of Surgery, BHU in India between 1995 and 2007. Most patients (n = 97) presented with fever. Other presenting symptoms included painful swelling, bullae, erythema, ulcer, and necrosis. Comorbid conditions such as diabetes, tuberculosis, malignancy, and immunosuppressive therapy were associated in 72 (61%) cases. Amputations were done in 24 patients. Thirty one patients developed septic shock. Renal dialysis was done in 16 patients and ventilatory support was needed in 12 patients. The most common organism identified was β-hemolytic streptococci (n = 42). Eighteen patients died, a mortality of 15%. The authors consider early diagnosis and aggressive surgical intervention to be crucial for the successful treatment of disease.

IATROGENIC FEMORAL ARTERY ANEURYSMS IN ORTHOPAEDIC PRACTICE

Background:  Iatrogenic injury to the femoral vessel is a rare complication after fracture of hip. Pseudoaneurysm formation of superficial femoral artery or profunda femoris artery is detected quite late. We present our experience for surgical management of pseudoaneurysm of femoral artery after iatrogenic trauma during management of fracture of femur.

An introduction of Tertiary Peritonitis.

Intraperitoneal infection known as peritonitis is a major killer in the practice of clinical surgery. Tertiary peritonitis (TP) may be defined as intra-abdominal infection that persists or recurs ³48 h following successful and adequate surgical source control. A planned or on-demand relaparotomy after an initial operation is probably most frequent way to diagnose TP, but is a late event to occur. Hence it is desirable to have timely and nonoperative diagnosis of TP after the initial operation and subsequent initiation of an appropriate therapy to reduce the complications and to improve the outcome.

Pancreatic Pseudocyst: Therapeutic Dilemma

Pancreatic pseudocyst develops in both acute and chronic pancreatitis. It is an entity likely to either remain asymptomatic or develop devastating complications. Despite being diagnosed easily, treatment exercise is still at crossroads whether in the form of internal or external drainage or endoscopic, laparoscopic, or open intervention with a good radiological guidance. The therapeutic dilemma whether to treat a patient with a pancreatic pseudocyst, as well as when and with what technique, is a difficult one. This paper is intended to get information about diagnostic and therapeutic exercises most appropriate for acute and chronic pancreatic pseudocyst.

Isolated splenic tuberculosis presenting with splenomegaly and pyrexia of unknown origin.

Isolated tuberculosis of spleen in young persons is an extremely rare condition. We report the rare presentation of isolated splenic tuberculosis in a patient who was young and immunocompetent, with no other organ was involved. A 15-year-old woman presented with fever of 11⁄2years. She was having pain in the abdomen off and on during last 8months. Moderate splenomegaly with fever (39.3 C) was noticed during physical examination. Ultrasound and computed tomography (CT) scan pictures were suggestive of abscesses or lymphoma. Fine-needle aspiration cytology from the splenic lesion showed Staphylococcus aureus. After 3weeks antibiotic treatment, splenectomy was carried out. Multiple small abscesses with thick, organized, purulent contents were noticed all over spleen. Gross examination of spleen showed multiple whitish nodules 1–3 cm by 1–2 cm in size, with splenic notch of 4.0 cm (Fig. 1) and histopathology confirmed tuberculosis. Splenic involvement in tuberculosis is common in miliary or disseminated tuberculosis,1 especially in AIDS patients with extrapulmonary tuberculosis.2 Pyrexia of unknown origin (PUO) is caused by tuberculosis in 5–11% of reported cases in a major series. Splenic abscess is associated with parenchymal liver disease and diabetes mellitus and affects age group >50 years.3 PUO as a result of tuberculosis is more common in patients >65 years old and those with HIV infection.4 Despite rapid advances in detection facility of tuberculosis, invasive techniques, for example, biopsy by endoscopy or operation, are needed in many cases to establish the diagnosis. Splenomegaly with PUO and investigations pointing towards abscess or lymphoma prompted us to do splenectomy, and histopathology was the final tool for diagnosing isolated tuberculosis of spleen. Diffuse hyperechogenity is shown on USG, but hypoechoic lesions are found if the lesion is necrotizing, as observed in our case. CT scan typically shows multiple rounded or ovoid lowdensity lesions 1–2 cm in diameter and without calcification. This appearance is, however, by no means specific as pyogenic splenic abscesses, lymphoma or primary or metastatic malignancies may also display similar features.5 Fine-needle aspiration under CT or ultrasound guidance is safe and often positive for acid-fast bacilli. For patients with splenomegaly and PUO, splenectomy is probably the diagnostic procedure of choice, which was carried out in our case. Our case was quite difficult to diagnose because of atypical presentations as the patient was young, immunocompetent presenting with PUO and splenomegaly without any dissemination, miliary involvement or extrasplenic foci.

Colonic carcinoma with multiple small bowel perforations mimicking intestinal obstruction

BackgroundCarcinoma of the colon may present with perforation proximal to the site of malignancy. Caecum is the commonest site of perforation if the ileocecal valve is patent and the jejunal and ileal perforations are very rare.Case presentationA 35 year male presented with intestinal obstruction. Emergency laparotomy revealed carcinoma of the transverse colon with multiple pinpoint perforations along antimesenteric border of ileum, which were wrapped with omentum, and no peritoneal contamination was present. Extended right hemicolectomy with jejunocolic anastomosis was done. Patient made uneventful recovery in postoperative period and was treated with adjuvant chemotherapy.ConclusionPatients with colonic carcinoma and incompetent ileocecal valve may present with intestinal perforation. Increased intraluminal pressure and closed loop obstruction may lead to ischemia and perforation of the small bowel.

Fibroadenoma in axilla: another manifestation of ectopic breast

Fibroadenoma of an accessory breast is a rare disease. The clinical significance lies in the fact that a number of cystic, inflammatory, neoplastic diseases similar to those of a normal breast have been reported in accessory breasts as well. Vigilant self-assessment and complete clinical examination are always encouraged to detect earliest malignancy in the axilla. We report two cases of ectopic breast fibroadenoma with the relevant literature.

Iliolumbar incisional hernia following iliac bone harvesting: a rare complication

Incisional hernia is a common post-surgical complication, but hernias through iliac bone defects after the harvesting of an iliac bone graft is rare. The common presentation includes swelling and discomfort, and sometimes features of intestinal obstruction. A computerized tomography (CT) scan is commonly used for the diagnosis and to define the anatomical defect in the bone. Surgery is recommended because of high risk of strangulation. While various methods of repairing this type of hernia have been described, we chose to perform mesh repair for an iliolumbar incisional hernia.