Soumika Biswas

Jejunojejunal intussusception caused by a jejunal gastrointestinal stromal tumour (GIST)

IntroductionAdult intussusception represents a challenge to the surgeon as it can cause acute, subacute or chronic non-specific obstruction and presents with dubious clinical features.Case ReportA forty-six-year-old female presented with progressively worsening abdominal pain, mild abdominal distension, anorexia, profuse vomiting and constipation that had begun thirty six hours earlier.DiscussionPrimary or metastatic malignancies are responsible for 14–47% of all small bowel intussusceptions; in the large bowel 66% of cases have malignant aetiology. In contrast, abdominal X-rays display an intussusception as stacked coins or a coiled spring in the upper GI series and cup-shaped defect in contrast enema. The treatment of choice in adult intussusception is always surgical.ConclusionAdult intussusception is a rare entity that may present a diagnostic dilemma due to its non-specific symptoms. However, controversy surrounds the need for reduction and extent of surgical resection.

Concurrent papillary carcinoma of thyroid in a case of primary hyperparathyroidism

IntroductionAlthough the pathological association between thyroid and parathyroid diseases is not rare, simultaneous presence of thyroid carcinoma and parathyroid adenoma is regarded as a rare entity [1]. Concurrent thyroid and parathyroid pathology was first described by Kissin et al in 1947 [2].Case ReportAn Indian woman presented with recurrent attacks of pain abdomen, polyarthralgia, psychiatric complications and a palpable right anterior neck mass without any cervical adenopathy. Sonography revealed a solid oblong hypoechoic lesion postero-inferior to the right lobe of thyroid with internal necrosis/cystic changes. FDG avid lytic lesions were seen in calvarial vault, clivus, fascial bones, mandible, bilateral humerii, bilateral clavicles, bilateral scapulae, sternum and few bilateral ribs. CECT revealed a well-defined low attenuating lesion at the postero-inferior aspect of right lobe of thyroid gland.ConclusionCareful assessment of thyroid gland is advocated in all patients of primary hyperparathyroidism and vice versa.

Syringocystadenoma papilliferum on the breast: An unusual location

IntroductionSyringocystadenoma papilliferum (SCAP), otherwise known as naevus syringocystadenomatosus papilliferus, is a skin hamartoma originating from apocrine or exocrine sweat glands [1], microscopically characterized by papillary invaginations lined by bi-layered epithelium and decapitation secretion rich in plasmacytes [3].Case ReportA 29-year-old female presented with a cluster of large fleshy, irregular, sessile, moist, pinkish tumours located over her left breast, with pain, itching, discharge and bleeding upon friction with undergarments.DiscussionSCAP is an uncommon skin tumour usually seen in children or adolescents as a firm plaque of skincoloured to pinkish-brown hairless grouped nodules or a solitary nodule. Verrucous, papillary, hyperkeratotic, fleshy transformations are often seen in puberty [4,5]. Uncommon sites, such as the buttock, vulva, scrotum, pinna, eyelid, outer ear canal, postoperative scar, thigh, axilla, arms, lower limb, inguinal and perineal regions, have also been reported [6–9].ConclusionSCAP is a rare adnexal tumour commonly arising in association with congenital Sebaceous Naevus of Jadassohn. A watchful alertness is mandatory as adulthood malignancies can occur in more than one-third of this deceptively docile tumour.

Complication and management of intestinal stomas: In Indian perspective

IntroductionComplications associated with stomas are frequent and run the gamut from the technical, mechanical, physiological and psychological aspect. The impact of these complications ranges from simple inconvenience to life-threatening situations [1].Materials and MethodsThe study was conducted with 50 patients who underwent surgery and had a resultant stoma (ileostomy/colostomy) between Jan 2012 to September 2013.DiscussionIn our study, the most common complication observed was skin excoriation (66%), followed by wound infection (60%), transient oedema (56%), ileostomy diarrhoea(52%), mucocutaneous separation and retraction (26% respectively), wound gaping and incisional hernia (32% respectively), peristomal fistula (16%), burst abdomen (14%), dermatitis (24%), stomal ischaemia (4%), and superficial bleeding (6%).ConclusionGood care of a stoma includes a careful surgical technique, perioperative management and close attention to stoma care to minimize stoma-related complications.

An interesting case of a left paraduodenal hernia with peritoneal encapsulation presenting as acute intestinal obstruction

Internal hernias commonly present as left duodenal, right duodenal, mesocolic, or retrocolic, intersigmoid hernias, as well as herniation through the foramen of Winslow and lesser sac herniation through an abnormal orifice [1]. Paraduodenal hernias are extremely rare entities, which may prove dangerous because of the high risk of bowel obstruction, strangulation and gangrene. These hernias are notorious because of non-specific signs and symptoms that can lead to diagnostic difficulties. We report the case of a left paraduodenal hernia with peritoneal encapsulation presenting as acute intestinal obstruction in a patient without any history of prior abdominal surgery. The patient underwent bowel reduction, adhesiolysis, resection of the sac, and repair of the defect. The patient’s recovery was uneventful.

An unusual case of mixed polydactyly of foot

BackgroundA common congenital anomaly, polydactyly refers to supernumerary digits of the hand or foot, the incidence of which varies widely according to race, geographical location, familial syndromes and other environmental factors. The foot tends to be more rarely involved than the hand.Case DescriptionThese images depict a 60-year-old Hindu male with polydactyly of the right foot since birth. Digital radiography of the right foot showed a combination of Y-shaped metatarsal, T-shaped metatarsal, block metatarsal and duplicated rays. There was no sign or symptom of a syndromic anomaly. The disorder appeared to be purely sporadic in nature. The patient displayed unilateral polydactyly with eight digits that included a combination of Yshaped metatarsal, T-shaped metatarsal, block metatarsal and duplicated rays; this is an uncommon presentation.ConclusionPolydactyly of the foot is a rare disorder which may present sporadically, or in conjunction with familial syndromes; hence, accurate, genetic diagnosis is essential for proper management. Thorough preoperative radiological and anatomical evaluation is mandatory for effective reconstruction of the digit.

Multimodality approach: A revolutionary concept in the management of diabetic limb ulcers

AimThe aim of the study is to evaluate the results of the multimodality approach to diabetic limb ulcers.BackgroundManagement of diabetic limb ulcers requires a multisystem approach that addresses the component problems of the nervous, vascular, skeletal, immune and integumentary system.Materials and MethodThe study period was from January 2012 to September 2013, and involved 60 patients with both type 1 and type 2 diabetes that also had limb ulcers.ResultsMean duration of healing in controls was 23.1564 ± 6.7859 weeks and in cases 15.6723 ± 4.0084 weeks. Ulcers converted from grade 2 to grade 1 in 18 cases, from grade 3 to grade 1 in five cases, and from grade 3 to grade 2 in three cases. Five controls and two cases had to undergo amputation.DiscussionDiabetes is the prime cause of non-traumatic amputations in the United States accounting for 54,000 to 55,000 limbs lost every year [5]. Hunt T K et al found that PDGF gel healed a greater percentage of patients after 10 weeks of application [19]. Edmonds M E et al (1986) observed that the recurrence rate of ulceration was 26% among those with special footwear and 83% among those who returned to using their regular footwear [23].ConclusionAlthough limb problems in diabetics cannot be completely eradicated, it is evident that a number of hospitalizations and health costs directly attributable to such problems can be reduced by adopting a multimodality approach.

A rare image of post-CTRT iatrogenic tracheoesophageal fistula

A tracheoesophageal fistula may occur due to direct extension of tumour tissue in the trachea and oesophagus, pressure necrosis by a tracheostomy tube in apposition to a nasogastric tube, or tracheoesophageal injury due to other sorts of instrumentation. Bevacizumab is known to cause post-chemotherapy tracheoesophageal fistulae. We present barium swallow x-rays of a female with squamous cell carcinoma of the middle third of the oesophagus; she was being treated weekly with a 6-week regimen of concurrent chemoradiotherapy (CTRT). The x-rays show the formation of a tracheoesophageal fistula at the mid-oesophagus with dye traversing in both directions. It is likely that the tracheoesophageal fistula was formed by trauma due to food matter on a friable sloughed off post-CTRT oesophageal mass. In the majority of cases, these fistulae do not form during chemoradiotherapy, but manifest about six months later. However, in the case presented herein, the fistula was formed in the immediate post-radiation phase.