A rare presentation of midgut malrotation as an acute intestinal obstruction and perforation in an adult

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Ventral hernia from routine repairs to abdominal wall reconstruction: our initial experience

Background: Loss of continuity of abdominal wall significantly affects the functions of protection of viscera, postural stabilization, and maintenance of intra-abdominal pressure. The newer understanding of abdominal wall reconstruction (AWR) aims at restoring abdominal wall anatomy and function, instead of simply patching the defect. We want to showcase the changing trends and results in hernia repair at a Medical Institution.Methods: This is an observational retrospective study conducted in RRMCH, Bengaluru from July 2018-2019 including all patients with ventral hernia undergoing the specified hernia repairs.Results: A total of 54 patients with ventral hernias undergoing routine hernia repairs/AWR surgeries were retrospectively analysed. The overall mean age was 46.62±12.44 year. Majority subjects were females (n=37; 68.5%), and overweight (Mean BMI=28.07±3.01/m2). 14 patients (25.92%), all males, had history of tobacco consumption. There were 38 (70.37%) primary ventral hernias and 7 recurrent hernias. Overall mean defect size was 10.2±0.4 cm. Most frequently performed was open retro rectus Hernioplasty (n=18; 33.33%), followed by open Preperitoneal Hernioplasty (n=17; 31.48%), laparoscopic intraperitoneal onlay mesh (IPOM) (n=16; 29.62%) and open transversus abdominis release (TAR) (n=3; 5.5%). On statistical analysis, it was found that Open repairs had higher post-operative pain (p=0.0005), longer hospitalization (p=0.0002) and higher incidence of surgical site events (p=0.0134) when compared to Laparoscopic repairs.Conclusion: As known already, minimally invasive techniques of hernia surgeries are shown to have acceptable outcomes when compared to radical open surgeries. Newer techniques of AWR are being employed to routine cases in larger numbers, and not just for complex reconstruction, at most centres with acceptable outcomes.

A rare cause of gastric outlet obstruction

Gastric outlet obstruction is the clinical and pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying. It may be acute from inflammatory swelling and peristaltic dysfunction or chronic from cicatrix. Chronic inflammation of the duodenum may lead to recurrent episodes of healing followed by repair and scarring ultimately leading to fibrosis and stenosis of the duodenal lumen. We would like to present a unique case of an elderly lady presenting with intractable vomiting over 3 months, gradually progressive which aggravated on consuming solids initially to consuming liquids later. After thorough investigations a provisional diagnosis of chronic duodenal ulcer with gastric outlet obstruction probably due to cicatrix was made. On laparotomy there was a chronic scarred duodenal ulcer following a previously contained perforation which was causing the gastric outlet obstruction. Cholecystectomy, duodenoplasty and loop gastrojejunostomy was performed with no complications post-operatively. This is a rare case of previous contained duodenal perforation causing gastric outlet obstruction.

A comparative study of primary cellulitis and its local complications in lower limbs in diabetics and non-diabetics through the new Amit Jain’s staging system from India

Background: The objective of the study was to validate Amit Jain’s staging system for cellulitis in diabetic and non-diabetic lower limbs and to predict the outcomes associated with cellulitis and surgical procedures done in them.Methods: We conducted a prospective study in department of surgery at Raja Rajeswari Medical College and Hospital Bengaluru, India. The study period was from December 2018 to November 2019. Statistical analysis was done using SPSS 22 and R environment ver.3.2.2.Results: A total of 36 patients were included in this study of which 21 were diabetics and were in placed in group A and 15 were non diabetics and placed in group B. 83.3% of the patients were males. 73.3% of non-diabetics had stage 1 cellulitis and 33.3% of diabetics had stage 1 and 2 each. 47.2% of patients underwent debridement and it was significantly common in diabetics (p=0.037) and also it was common in higher stages of cellulitis (p=0.001). 8.3% had amputation in this series. All the major amputations were done in stage 4 cellulitis (p=0.002).Conclusions: In this validation study, it can be seen that cellulitis is common in both diabetics and non-diabetics but it is severe in diabetic patients. Stage 3 was more common in diabetics compared to non-diabetics. Amit Jain’s staging system of cellulitis is a simple, easy, practical, focal classification that guides therapy and predicts amputation.