Tushar Subhadarshan Mishra

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.

Umbilical Pilonidal Sinus: A Report of Two Cases and Recent Update of Literature.

Umbilical Pilonidal Sinus (UPS) is a rare differential diagnosis of umbilical disease as encountered by general surgeons. They usually present with history of pain and umbilical discharge. Young active adolescent males with dense hairy abdomen with a deep naval are at risk of developing this disease. There are no consensus guidelines for the management of this disease probably because of its rarity. Treatment depends on the type of presentation. Most of the cases are managed by conservative treatment with hair extraction and personal hygiene. Surgery is indicated in case of failure of conservative management. Although umbilectomy is a commonly done procedure, complete sinus excision with reconstruction which can be done to have better cosmesis. Incomplete hair extraction from the sinus tract has been found to be the commonest cause of failure of conservative management. In this paper we have presented two cases of UPS, managed conservatively, with no recurrence after one year of follow-up. We have also presented a recent update on current literature about this uncommon disease.

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.

A Vasculitis-Associated Neuromuscular and Vascular Hamartoma Presenting as a Fatal Form of Abdominal Cocoon

Neuromuscular and vascular hamartoma (NMVH), also known as neuromesenchymal hamartoma, is a rare hamartomatous condition of the intestine. It usually presents with submucosal humps protruding in the intestinal lumen causing obstructive features. The other clinical manifestations are hematochezia or melena and protein-losing enteropathy. The etiopathogenesis of these lesions is not well known, although an association with small bowel Cröhn’s disease and diaphragm disease had been postulated, the latter related to chronic nonsteroidal anti-inflammatory drug intake. Only 24 cases of NMVH are reported in the English literature and all of them could be adequately cured by resection of the affected part of the bowel. Moreover, none of these cases presented with abdominal cocoon or showed any evidence of vasculitis. We describe a peculiar case of NMVH in a 45-year-old male who presented with abdominal cocoon with symptomatic recurrence and fatal outcome within a month of surgery. Histopathology revealed classical histomorphology of NMVH with evidence of vasculitis. This appears to be the first case of a fatal form of NMVH, presenting with abdominal cocoon and associated with vasculitis.

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.

Giant endometrioma of the ovary: a case report

Endometriosis is a common gynaecological condition, affecting between 6%-10% of women in the reproductive age group. Ovarian endometrioma is seen in approximately 17%-44% of women with endometriosis. While the ovaries remain the commonest site of endometriosis, the size of ovarian endometriomas is typically not large, usually ranging from 1-6 cm. Huge ovarian endometriomas are extremely rare, with only a few case reports being described. We report a case of giant ovarian endometrioma in a 38-year-old multiparous woman, and discuss the challenges in diagnosis and management.