Shehtaj Khan

Analyzing intra-abdominal pressures and outcomes in patients undergoing emergency laparotomy.

Background: Studies have documented the impact of intra-abdominal hypertension (IAH) on virtually every organ. However, it still remains strangely underdiagnosed. The aims of the study were to assess, in patients undergoing emergency laparotomy, whether intra-abdominal pressure (IAP) is an independent predictor of morbidity and mortality, to evaluate the effects of IAH, and to identify hidden cases of abdominal compartment syndrome (ACS). Materials and Methods: The study comprised 197 patients undergoing emergency laparotomy. IAP was measured preoperatively and then postoperatively at 0, 6, and 24 hours. Duration of hospital stay, occurrence of burst abdomen, and mortality were noted as outcomes. Results: At admission, incidence of IAH was 80%. No significant association was found between IAP and occurrence of burst abdomen (P > 0.1). IAP was found to be a significant predictor of mortality in patients undergoing laparotomy (P < 0.001). Elevated IAP was found to affect all the organ systems adversely. The incidence of post-op ACS was 3.05% in the general population and 13.16% in trauma patients. The mortality rate for this subgroup was 100%. Conclusions: IAP is a significant predictor of mortality in patients undergoing laparotomy. IAH has detrimental effects on various organ systems. A more frequent monitoring with prompt decompression may be helpful in decreasing the mortality rate. Further studies are required to establish a screening protocol in patients undergoing laparotomy to detect and manage cases of IAH and ACS.

Role of parenteral testosterone in hypospadias: A study from a teaching hospital in India

Objectives: To evaluate the effect of parenteral testosterone on penile length, preputial skin and side effects in patients with hypospadias. Materials and Methods: 23 patients with hypospadias were included in this study. An oily solution, each ml of which contained testosterone propionate 25 mg, and testosterone enanthate 110 mg, equivalent to 100 mg of testosterone was given deep intramuscularly 4, 3 and 2 weeks before reconstructive surgery at the dose of 2 mg/kg body weight. Increase in penile length, transverse preputial diameter, and diameter at the base of penis were noted. Basal testosterone levels were obtained before the institution of therapy and on the day of operation. In addition, side effect such as development of pubic hair and delay in bone age was noted. Results: Following parenteral testosterone administration, the mean increase in penile length, transverse preputial diameter and diameter at the base of penis was 1.35±0.40 cm (P<0.001), 1.40±0.47 cm (P<0.001), and 0.72±0.47 cm (P<0.001), respectively. Serum testosterone level after injection was well within normal range for that age. Minimal side effects were noted in form of development of fine pubic hair. Conclusion: We conclude that parenteral testosterone can be safely used to improve the surgical outcome of hypospadias repair.

Biliary cystadenoma mimicking hydatid cyst

Sir, Biliary cystadenomas are rare hepatobiliary cystic tumors, more common in women. We report one such tumor that presented with obstructive jaundice and mimicked a hydatid cyst of the common bile duct (CBD). Cystadenoma was diagnosed only after biopsy but, due to wide excision, there was no residual or recurrent tumor. Biliary cystadenomas are rare cystic tumors that arise in the liver or less frequently in the extrahepatic biliary system. They are more common in middle-aged women, their most favored site being the right hepatic lobe. It is extremely rare for an intrahepatic cystadenoma to extend into the CBD. Less than 10 cases have been reported in the medical literature.[1] Presentation is frequently nonspecific: Patients may complain of abdominal pain, anorexia and nausea. Liver function tests are frequently abnormal and extrahepatic lesions tend to present with obstructive jaundice. A 20-year-old female was admitted with a 10-day history of jaundice and a 3-day history of increasing right upper quadrant colicky pain. She had also experienced previous intermittent episodes of jaundice. Liver function tests were abnormal on admission, with a serum bilirubin of 4.8 mg/dL and alkaline phosphatase of 22 KAU. An ultrasound scan revealed multiple coiled ascaris in the CBD, seen as bunches and also appearing calcified. Intrahepatic ducts and CBD were dilatated (16 mm). Periportal lymphadenopathy was present. There was a diagnostic dilemma with which an exploration was undertaken. At laparotomy, there were multiple cysts filling up the CBD and a perop diagnosis of hydatid disease was made. Excision of the cyst [Figure 1] with removal of an enlarged regional lymph node was performed and a T-tube was left in situ. Figure 1 Excised cystadenoma Histology showed the tissue to be cystadenoma. The patient had a smooth postoperative course with T-tube removal performed on the 14th postop day. She was discharged and closely followed-up. Biliary cystadenomas are rare and their similarity to hydatid disease can make them difficult to diagnose. The radiological appearance of biliary cystadenomas is quite specific. Ultrasound may show an anechogenic mass with internal septations that are highly echogenic, which, in our case, led us to think of it as calcified ascaris. Computed tomography helps with the finding of a smooth thick-walled cyst with fine internal septae,[2] but it could not be performed in this case due to financial constraints. At laparotomy, these lesions can be difficult to localize as they are usually soft, difficult to palpate and pose minimal or no resistance to biliary probes. Therefore, the use of intraoperative choledochoscopy and cholangiography[3] has been advocated. In 1892, the first case of successful resection for a biliary cystadenoma was reported.[4] Since this time several treatment strategies have been suggested: Simple enucleation, local excision either with a cuff of bile duct or liver and radical excision, including hemihepatectomy if appropriate. However, these tumors have a low malignant potential and unless excised completely, tend to reoccur. The largest reported series of 15 cases is by Lewis et al., who concluded that while formal lobar resection is frequently carried out, local complete excision is just as effective provided the neoplasm is entirely removed and is associated with low rates of morbidity.[5] In developing countries, a wide local excision with regular follow-up would be more appropriate considering the limited availability of adequate back up for a more radical procedure at most of the centers.

Prognostic indicators in acute pancreatitis: Comparison of interleukin 6 and some selected severity scoring systems in acute pancreatitis

Background: It is important to predict the severity of acute pancreatitis as early as possible in order to optimize the therapy and to prevent organ dysfunction and local complications. Several scores of severity have been proposed. New biochemical markers are now available besides physiological and radiological markers. Our study was done to know the relation between interleukin 6 (IL-6) concentrations, Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and computed tomography (CT) severity index in acute pancreatitis. Patients and Methods: The study was done in Jawaharlal Nehru Medical College, Aligarh Muslim University from December 2011 to November 2013. Blood sample was taken between 24 and 48 h from the onset of symptoms and IL-6 was assessed using ELISA method and compared with physiological APACHE-II and CT Severity scores. Results: Mean IL-6 levels were found to be higher in higher APACHE-II score categories and the difference was significant statistically (P < 0.001). The correlation (Spearman′s rank coefficient) also indicated a strong bivariate correlation of APACHE-II scores with IL-6 levels (ρ > 0.7). However, the IL levels did not correlate with the modified CT severity index. Conclusion: APACHE-II scores show a strong correlation with IL-6 levels within the limitation of having patients of only lower order of APACHE-II scores. Nonsignificant correlation with CT severity index was found. This should encourage us to use biochemical parameters to determine the severity of acute pancreatitis instead of CT standards.

Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Background: The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome. Objectives: The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting. Materials and Methods: This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent. Results: Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%). Conclusion: A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Tubercular esophagocutaneous fistula: A rare case

Tubercular esophagocutaneous fistula is a very rare complication arising either due to erosion by caseating cervical lymph nodes or due to tuberculosis (TB) of the esophagus. Both of these conditions are themselves rather sporadic. A young male presented with a passage of “orally taken liquids” from an opening in the neck. He had no primary foci of TB detected whatsoever, which was unusual. He was started on antitubercular treatment (ATT) for 8 weeks, but due to nonclosure of tract, the fistula had to be excised. Histopathology confirmed the tubercular nature of tract. ATT was continued postoperatively. There has been no recurrence even after 1½ years of follow-up.

Experience with tubularized incised plate urethroplasty in distal and mid penile hypospadias

Background: Whilst hypospadias is a common congenital defect in boys its aetiology largely remains unknown. The objective of this study was to evaluate the results of tubularized incised plate (TIP) urethroplasty in distal and mid-penile hypospadias repair. Patients and Methods: This was a prospective clinical study conducted in the Department of Pediatric Surgery over a period of 42 months (January 2012 to June 2015). All patients with distal and mid shaft hypospadias who underwent TIP urethroplasty in our department were studied. The patients were followed up for a period of 1 year after surgery. Results: Fifty eight patients (N = 58) with hypospadias (29 distal and 29 mid penile) were included in the study. The mean age at presentation was 4.5 years (range 3–7 years). The mean operative time was 70 min (range 55–90 min). The mean duration of postoperative stay was 11 days (range: 10–14 days). Overall 15 patients (25.86%) developed complications. Urethrocutaneous fistula (UCF) developed in 10 (17.24%) patients. Meatal stenosis occurred in six (10.34%) patients. Five patients (8.62%) developed flap necrosis and dehiscence of glans occurred in two patients (3.44%). The difference in complication rate between different types of hypospadias was not statistically significant (P > 0.05). There was no statistically significant difference in cosmetic and functional outcome between two groups operated by TIP urethroplasty. Conclusion: TIP urethroplasty is a simple and effective technique of repair for distal and mid-penile hypospadias in properly selected patients. It offers good functional and cosmetic results.

Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study

Background: Preoperative mechanical bowel preparation (MBP) for elective colorectal surgery has been criticized, but is still in use because of fear of fecal load and peritoneal contamination. Experience with an indigenous low cost technique for on-table colonic lavage (OTCL) in obstructive left-sided colonic pathology has been described. OTCL would be a step towards discouraging MBP before colorectal surgery. Patients and Methods: Fourteen patients for elective colorectal surgery without preoperative bowel preparation were evaluated and found with impacted fecal matter and loaded colon intraoperatively. Instead of two-stage procedure, we did OTCL by our own devised method followed by a single-stage curative resection. Results: All patients had successful resection and primary anastomosis of their lesions. Mean time for lavage was 21 min. There was no peritoneal contamination. No postoperative anesthesia or procedure-related complication was encountered. No clinical anastomotic leak or mortality was encountered. In one patient, surgical site wound infection occurred. Conclusion: In cases where bowel preparation is not done preoperatively and single-stage procedure discredited only because of impacted fecal matter, OTCL should be taken into account. Our technique of OTCL should be employed as it is simple, safe, and cheap and would prove to be a step towards discouraging preoperative MBP for elective colorectal surgery, especially in resource limited setting.

A rare association of congenital lumbar hernia and giant congenital nevus.

Lumbar hernia is a rare hernia accounting for less than 1% of abdominal hernias. Approximately, 20% of all lumbar hernias are congenital in origin.1 Congenital lumbar hernia is a compressible soft mass that may occur in the lumbar region especially through the superior lumbar space of Grynfeltt– Lesshaft, the inferior lumbar space of Petit and diffuse, which occurs due to generalized deficiency of the lumbar muscles. It may be present at birth or may develop in older children. Congenital lumbar hernia is usually associated with other congenital abnormalities of spine, rib, and viscera, that is, costovertebral syndrome, undescended testis, and bilateral renal agenesis.2,3 We report a rare association of giant congenital nevocellular nevus (NCN) and discuss the problems in management of congenital lumbar hernia in association with giant nevus.