Gall Bladder Polyps : A Paradigm Shift – Need for Reappraisal of Guidelines

Background : Gall Bladder Polyps are mucosal lesions that project from the Gall Bladder wall into the Gallbladder lumen. They form morphologically distinct lesion/s with internal characteristics different than that of neighboring structures as verified by microscopic examination. About 4-6% are picked up clinically, 2-12% in Cholecystectomy specimens and 4% on Ultrasound. Materias and Methods : A three calendar year retrospective single surgical unit study compromised of 1442 cholecystectomies performed for benign Gall Bladder Disease. The patient were subjected to Ultrasound of abdomen for diagnosis and routine clinic work up. The Gall Bladders Harboring Polyps were examined grossly for site ,number, and microscopy for histological details. Results : In a total number of 40 cases of Gall Bladder Polyp, females outnumbered males. This series spreads over age groups of 3rd decade - 9th decade, most of the patients were seen in 6th decade of life. Youngest patients were 27 years old and oldest one was 85 years old. Incidentally, none of the old patients had evidence of malignancy on histopathology in their Gall Badder Polyp, only 2% were necessitated for a pre-operative diagnosis of Gall Bladder Polyps alone. Rest required it for presence of Gallstones with or without Polyp. None of >10mm size showed any malignant change on histopathological examination. On the Contrary, among the polypoid lesions <10mm size, one polypid lesion (7mm) showed a malignant change (Carcinoma in situ) Conclusion : A predictive model for neoplastic potential of Gall Bladder Polyp may support clinical decision to achieve an ideal therapeutic outcome. Hence a need for reappraisal of management guidelines.

Hand Assisted Laparoscopic Splenectomy (HALS) in a Case of Primary Solitary Unilocular Gaint Splenic Hydatid.

Hydatid disease, a zoonotic parasitic infestation mainly caused by Echinococcus granulosus is a significant problem in endemic areas. Primary splenic hydatidosis is rare. A case is described in a 52 year male who presented with left upper quadrant swelling and pain. Ultrasonography of the abdomen revealed enlarged spleen with span of 14 cm with intraparenchymal cyst measuring 93.1mm x 92 3mm x83.3mm with approximate volume of 378.3 cc. CT scan of the abdomen showed spleen enlarged in size and measures 14.1cm with well defined cystic lesion of 10.1 x 9.2 cm.cyst shows internal serpentine structure suggestive of membranes with no calcification and no liver involvement. Hand assisted laparoscopic splenectomy (HALS) was performed.

Recto-sigmoid neurofibroma presenting as rectal prolapse in an adult patient with neurofibromatosis - a rare presentation.

Neurofibroma occurs most frequently in the stomach and jejunum, but the colon may also be involved .Its association with rectal prolapse has not been reported yet. We are reporting here such a rare case report.

Unusual Presentation of a Rare Para Testicular Tumour in a Child.

Adenomatoid tumour epididymis usually present as painless scrotal mass during 2nd or 3rd decade of life. The case presented is a seven years old boy admitted with acute painful swelling of the scrotum. The scrotum was explored on the suspicion of torsion testis but testis was found to be normal and the epididymis enlarged. Biopsy from epididymis showed Adenomatoid tumour. Surgical exploration was performed through the same inguinal incision later and tissue sent for histopathological examination confirmed “adenomatoid tumour with surrounding inflammatory mass”.

Post ERCP Surgical Emphysema.

Endoscopic Retrograde Cholangio Pancreatography(ERCP) is increasing in popularity due to its obvious advantages. Therefore, as treating physicians and surgeons, we ought to be aware of not only its common but also uncommon complications. We report here a case of post-ERCP surgical emphysema on the right side extending from the umbilicus to the face.

A Giant Inguinoscrotal Hernia.

We report a case of giant inguinoscrotal hernia. Such hernial formations are rare (5% cases) and largely a problem of developing countries. Problems arise in the management for both the patient and the surgeon because of the rarity of the reported cases as there is no standard surgical procedure in place for their treatment. Surgical management of such giant hernias has to be individualised.

A Prospective Comparative Trial of Post -Operative Pulmonary Function: Laparascopic versus Open Cholecystectomy

Gall stone disease is the most common biliary pathology and has plagued the mankind for over 2000 years. Since the National Institutes of Health Consensus Conference, in 1993, laparoscopic cholecystectomy has replaced open cholecystectomy as the gold standard in the treatment of patients with symptomatic gall stone disease. The present prospective study was conducted to evaluate and compare post- operative pulmonary dysfunction following laparoscopic and open cholecytectomy. A total of 60 patients, 30 each in laparoscopic and open cholecystectomy groups, respectively, were studied. Pulmonary function tests of the patients were determined by computerized spirometer, Medspiror, pre-operatively and post operatively on day 1 and day 6. Forced vital capacity (FVC), Forced expiratory volume in one second (FEV1), Peak expiratory flow rate (PEFR) and Mid-expiratory flow(FEF-25-75%) were determined The ultimate outcome showed a gratifying trend towards laparoscopic cholecystectomy which is discussed in detail in the article. Laparoscopic cholecystectomy causes significantly less impairment of post-operative pulmonary function.

An Unusual Presentation of Biliary Ascariasis

Ascariasis is one of the most common disease in human being worldwide. Ascariasis is 2nd to gall stone as a cause of biliary symptoms. The invasion of biliary tract by round worms during early post operative period is an infrequent but serious complication. We present 42 years old man operated for cholelithiasis with Choledocholthiasis on whom choledochotomy and T -Tube insertion was done. On 5th postoperative day Ascaris extruded peri-T-Tube and immediate T - Tube cholangiogram done that showed multiple filling defects in Common Bile Duct (CBD). Patient was managed with saline irrigation of CBD via T-Tube and anti-heliminthic was given. In view of its rarity and unusual presentation the case is being reported.

Pilonidal Sinus of Prepuce-An Unusual Presentation

Occurence of pilonidal sinuses under the prepuce of penis is being reported in a patient aged 62 years.

Surgical manifestations and management of ascariasis in Kashmir.

Amongst 876 cases suffering from ascariasis 662 cases were managed conservatively and 214 cases were treated by surgery. Surgical complications were found to be more common in males in the age group of 6-10 years. Principal clinical features included pain abdomen (99.54%), constipation (80.25%), vomiting (67.46%), abdominal distension (47.03%), palpable worm masses in abdomen (35.50%), visible peristalsis (27.63%), worms in vomitus (24.20%) and palpable worm clumps on rectal examination (20.09%). Principal clinical diagnosis were worm colics (48.74%), sub-acute intestinal obstruction (27.74%), acute intestinal obstruction (11.42%) and acute intestinal obstruction with strangulation (5.71%); rest of the cases included worm cholecystitis (2.63%), obstructive jaundice (1.71%), bile peritonitis (0.91%), intestinal perforation (0.68%) and acute appendicitis (0.46%). Surgical procedures performed were milking of worms (34.12%), resection anastomosis of small intestine (23.36%), enterotomy with removal of worms (16.36%), cholecystectomy with T-tube drainage (12.15%), cholecystectomy (8.41%), appendectomy (1.87%), resection anastomosis with excision of Meckel's diverticulum (1.40%), repair of intestinal perforation with peritoneal toilet (1.40%) and cholecystectomy with choledochoduodenostomy (0.93%). In surgically managed patients 35 cases died of septicaemia and in conservatively managed cases 3 died of encephalitis with an overall mortality of 4.34%.

Primary ascaridial perforations of small intestine and Meckel's diverticulum.

The clinical presentation of six cases with primary ascaridial perforations of the terminal ileum (4 cases) and Meckel's diverticulum (2 cases), without any associated underlying intestinal disease, is described. All the cases presented clinically as peritonitis and had worm masses in the intestinal lumen with maximal impaction in the terminal ileum. Ileal perforations were surgically closed in two layers after removal of the worms. Diverticulectomy after removal of the worms was performed for Meckelian diverticular perforations. Peritoneal toilet was done in all the cases. Pressure necrosis from the impacted worm masses probably resulted in these perforations.

Biliary ascariasis.

The clinical presentation of 12 cases with biliary ascariasis is reported. Ultrasonography was employed to demonstrate worms in the gallbladder and common bile duct preoperatively. Ten cases were operated upon and operative findings were compared to assess the accuracy of sonography in biliary ascariasis. Our results show that ultrasonography can be relied upon for the demonstration of biliary tract ascariasis.