An audit to study the diagnostic yield of lymph node biopsies under local anaesthesia

Background: Surgical referrals for lymph node biopsies are common, majority for diagnostic purposes. The indications and the diagnostic yield vary for different sites. We conducted an audit of the lymph node biopsies done over a period of seven months.Methods: The audit included 547 patients who underwent lymph node biopsies under local anesthesia in the department of general surgery over a seven-month period. Parameters such as overall diagnostic yield of lymph node biopsies, disease specific yield of lymph node biopsies with a primary focus on tuberculosis; site specific yield of lymph node biopsies and  referral pattern for the request for lymph node biopsies were analysed.Results: 324 samples (59.2%) yielded a definite diagnosis, which included haematological malignancy 102 (31.5%), infectious diseases 131 (40.5%), and 59 (18.5%) malignancy. The diagnostic yield of supraclavicular lymph nodes was found to be highest (72.45%) and the axillary group the lowest (39.8%). The referral pattern seen was 314 (57.4%) from General medicine, 149 (27.2%) from General Surgery, and 84 (15.4%) from Haematology. 130 (23.8%) samples were tested for tuberculosis; the highest yield, acquired from the cervical group (52.8%), lowest from the inguinal region (4%).Conclusions: Our audit revealed significant diagnostic yield of lymph node biopsies from the supraclavicular region. Majority of them were of infectious aetiology and referred from General Medicine. This study supports the introduction of co-ordinated problem-based referral and management pathways for the management of patients with enlarged superficial lymph nodes, supported by regular audits of practice.

Endoanal ultrasound assessment of sphincter defects and thinning – Correlation with anal manometry

This study aims to determine if anal sphincter defects/thinning observed at endoanal ultrasound correlates with anal pressures recorded at anal manometry. A total of 30 consecutive patients with history suggestive of anal sphincter pathology underwent anal endosonography with documentation of internal and external sphincter defects/ thinning. The same patients underwent anal manometry with documentation of maximum resting and maximum squeeze pressures. Patients with a sphincter defect [SD] were compared to patients without a sphincter defect [NSD] and both groups were compared with respect to findings in manometry. The Mann-Whitney U test was used for statistical analysis. This study was approved by the Institutional Ethics Committee. A statistically significant correlation was found between decreased maximal resting pressure and decreased internal anal sphincter [IAS] thickness or an IAS defect. The correlation between MSP and external sphincter pathology was significantly less consistent in our study. Our study showed a statistically significant correlation between maximum resting pressure and observation of internal sphincter defects at endoanal ultrasound. The patients with documented internal sphincter defects have significantly reduced maximum resting pressures. There was however, no correlation between external sphincter defects and decrease in maximum squeeze pressure as has been observed in other studies. Until a manometry cut-off can be set to discriminate between the absence and presence of defects, both manometry and ultrasound should be offered to patients with history suggesting anal sphincter pathology

Anal sphincter repair for fecal incontinence: experience from a tertiary care centre .

Aim Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit. Methods Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria. Results Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH2O and 90.25 to 111 cmH2O in those with a good outcome. Conclusions Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

Selective histopathology in cholecystectomy for gallstone disease.

Background Incidental gallbladder cancer is found in upto 1% of cholecystectomy specimens for gallstone disease. Currently, in our institution, all gallbladder specimens are sent for routine histopathology, to rule out incidental gallbladder carcinoma. This study was aimed at assessing the need for routine histopathology of gallbladder specimens after cholecystectomy for gallstone disease. Methods Hospital records of all patients undergoing cholecystectomy for gallstone disease over a ten-year period, between 1998 and 2007, in a single surgical unit were reviewed. Results A total of 1312 patients underwent cholecystectomy for gallstone disease. Gallbladder carcinoma was detected in 13 patients. Macroscopic abnormalities of the gallbladder were found in all the 13 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. Conclusion Gallbladder carcinoma is associated with macroscopic abnormalities in all cases. Therefore histopathology should be restricted to only those specimens which reveal a macroscopic abnormality. This would identify all cases of incidental gallbladder carcinoma, at the same time decreasing cost and pathological work load.

Adult idiopathic ileosigmoid intussusception prolapsing per rectum.

Ileosigmoid intussusception can lead to ischemia and necrosis of either the ileum or sigmoid colon. Ileosigmoid intussusception as a mass prolapsing per rectum in an adult has not been previously reported. We report a 50-year-old man with such a presentation. He recovered uneventfully after subtotal colectomy.

Traction as a cause of gallbladder avulsion.

Following isolated blunt trauma to the abdomen, a 25-year-old man developed peritonitis. Laparotomy revealed a band between the transverse colon and gallbladder, with partial avulsion of the latter. Avulsion of the gallbladder is a rare injury and, to the best of our knowledge traction has not been described as a mechanism of injury.

Omental lymphangioma in an adult.

Lymphangiomas are commonly found in the head and neck region. They are commonly seen in children while mesenteric cysts are more common in adults. We report the case of a 34-year-old man who was diagnosed as having a lymphangioma.