Emergency surgery amid ongoing pandemic in suspected COVID-19 with D1 perforation

The COVID-19 pandemic has affected working patterns of all emergency and regular surgical services. We report a case of emergency surgery amid this ongoing pandemic, in a suspected COVID-19 patient with D1 (duodenal) perforation. We did not wait for the real time polymerase chain reaction (RT-PCR) report for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to come, and proceeded with surgery with all safety protocols. We intend not to delay, for the better outcome of patient’s condition, the life-saving response alike we follow routinely. The pandemic scenario is expected to sustain for longer time. We assume, patients requiring acute care surgery with COVID-19 like symptoms (suspected or confirmed), should definitely be proceeded with surgery as earliest, following all safety protocols, and prevent undue and added morbidity and mortality during this pandemic crisis.

A rare scenario of perforated gastrointestinal stromal tumours of ileum

Gastro-intestinal stromal tumours (GIST) are among the common mesenchymal tumours of the gastro-intestinal (GI) tract. It varies in location and presentation. GIST are reported in the stomach frequently (60-70%), followed by small intestine (20-25%). Mainly GIST manifest typically with bleeding or vague abdominal pain and discomfort. The spontaneous perforation of GIST is very rare. We report case of a middle-age male patient who presented in emergency with pain in right lower abdomen associated with features of peritonism. After clinical evaluation and preliminary radiological investigations, a working diagnosis of perforated appendix was made. Patient was undertaken for emergency surgery. A diagnostic laparoscopy followed by midline laparotomy was done. Intra-operatively, a perforated and necrotic outpouching at antimesenteric border of terminal ileum was found. Histopathological examination of the resected part of ileum revealed compatibility with GIST. It was strongly positive for cluster of differentiation 117 (CD117) and smooth muscle actin. Patient received adjuvant therapy with Imatinib. A complete surgical resection without extensive lymph node sampling is the primary treatment option. As GIST are rare, a high index of suspicion is warranted for diagnosis and appropriate treatment.

Laparoscopic management of appendicular lump

The surgical management of an appendicular lump remains controversial. With the revolution and advancement of laparoscopic instrumentation and technical learning curve, it is possible to remove an inflamed appendix in presence of lump. This retrospective study was performed between August 2018 and August 2019 in AIIMS Raipur, 86 patients were treated for appendicitis laparoscopically, in these 14 patients had appendicular lump at the time of admission. 12 patients (total 14; 2 patients were excluded) underwent laparoscopic intervention for appendicular lump. Average operative time were 90 minutes. Average post-operative hospital stay were 5 days. Post-operative complications were seen in 2 patients (surgical site infection). In histopathology report, appendicular inflammation suggestive of appendicitis were present in all operated cases. We conclude, early laparoscopic appendectomy confirms the diagnosis. It is safe and feasible in patients with appendicular lump. It reduces the treatment cost, early recovery and satisfactory overall outcome.