A Remarkable rare case of fractured endodontic instrument in periradicular region compressing inferior alveolar nerve.

This study aims to present the management of a rare case of a separated endodontic instrument in the periradicular area. The broken instrument had penetrated within and along the mandibular canal from the periapical zone of mandibular second molar after endodontic treatment, leading to acute neurological symptoms. These subsided completely following surgical removal of the separated instrument. Because of the close anatomic relation between the second molars and the inferior alveolar nerve, careful clinical and radiographic examinations should always be performed before endodontic treatment of these teeth, so as to prevent iatrogenic injuries of the type described here. Dentists should also be aware of the anatomic characteristics of the mandibular canal (i.e., cribriform rather than solid), as well as the consequences of overinstrumentation.

Omentopexy for limb salvage in Buerger's disease: indications, technique and results.

Buerger's disease is a limb-threatening condition occurring in the young and productive age group and its management has always been a challenging problem. A large number of medical and surgical options have been suggested, but the quest for an ideal solution to this problem continues. Omentopexy for Buerger's disease is an attractive option, which is rapidly gaining popularity. We discuss the historical aspects, technical considerations and results of omental transfer for this limb-threatening condition. In doing so, the relevant literature on the subject has been extensively reviewed. In all published series, there has been marked improvement in intermittent claudication and rest pain. Ischaemic ulcers have healed and the progression of gangrene has stopped. If carried out with the complete understanding of the anatomy of the omental vascular arcade, the results of omentopexy are gratifying, thus avoiding amputation and conserving the limb.

Post-infarction ischaemic mitral regurgitation: what determines the outcome.

Ischaemic mitral regurgitation is an important determinant of survival in patients with coronary artery disease. A retrospective analysis was performed to evaluate the overall outcome and its determinants in patients with ischaemic mitral regurgitation. Over a period of 10 years, 72 patients underwent operations for mitral regurgitation of ischaemic origin. Age ranged from 37 to 68 years (mean 54.6 +/- 10.4 years), and 62 (86.1%) were male. Thirteen (18%) patients had acute and 59 (82%) had chronic ischaemic mitral regurgitation. Twenty-one patients were in New York Heart Association class II, 32 in class III and 19 in class IV. Moderate to severe left ventricular dysfunction was present in 42 patients. Valve prolapse was present in 35 (48.6%) patients and restricted leaflet motion secondary to myocardial dysfunction was present in 37 (51.4%) patients. All the patients were operated using standard cardiopulmonary bypass technique. Mitral valve was replaced in 33 patients and repaired in 39. Repair included a combination of techniques: chordal transposition (n = 2), chordal shortening (n = 18), leaflet resection (n = 2), posterior collar annuloplasty (n = 35) and annuloplasty with flexible Duran's ring (n = 3). Operative mortality was 18.1 percent (13/72). Low cardiac output was the cause of death in the majority (n = 10). Acute presentation and presence of restricted leaflet motion were the significant predictors of early mortality. Follow-up ranged from 3 to 84 months (mean 41.6 +/- 10.2 months). Late mortality was 46.2 percent. Actuarial survival in operative survivors at five years was 44.4 +/- 8.8 percent. To conclude, ischaemic mitral regurgitation carries a poor early and late outcome, with left ventricular dysfunction and presence of restricted leaflet motion being important contributors to it. In addition, acute presentation also reflects greater early mortality.

Choice of incision in surgical management of small bowel perforations in enteric fever.

Fifty six patients with typhoid enteric perforation who underwent operative treatment were randomly assigned to 2 groups. Twenty seven patients in group A underwent laparotomy via the Rutherford-Morrison incision while 29 patients in group B underwent the same procedure via a right paramedian incision. Surgical treatment consisted of two layer closure of the perforation with peritoneal lavage and tube drainage in all cases. Mean operating time in group A and group B was 45 +/- 10 minutes and 73 +/- 6 minutes respectively (p < 0.001). Postoperative wound dehiscence in group A and group B was observed in 2 and 11 cases respectively (p < 0.001). Incisional hernia developed in 8 patients in group B and none in group A (p < 0.01). Two patients in group A and 10 in group B developed adhesion-obstruction (p < 0.05). Differences in wound sepsis, pelvic abscess and mortality were not significant. Mean hospital stay in groups A and B was 12.4 days and 16.8 days respectively (p < 0.001). We conclude that in the presence of a confirmed preoperative diagnosis of typhoid enteric perforation, laparotomy via the Rutherford-Morrison incision may significantly reduce postoperative wound complications and morbidity without significantly altering the overall outcome.

Blunt trauma abdomen: a study of 63 cases.

63 cases of blunt abdominal trauma were studied. It was more common in males and in the age group 21-30 years. Majority of the injuries were due to automobile accidents. Commonly presenting feature was pain abdomen and vomiting. Abdominal paracentesis revealed haemoperitoneum in 40 cases which was subsequently confirmed on laparotomy in all the cases. 40 cases had no visible external injury but subsequent laparotomy revealed internal visceral injury in 29 cases. Exploratory laparotomy was carried out in 43 cases, remaining were treated conservatively. Liver was found to be the commonest organ injured. Post operative complications developed in 5 cases and deaths occurred in 7 cases mainly due to associated extra-abdominal injuries, poor pre-operative general condition, delayed diagnosis and management. We conclude that a multipronged approach towards early diagnosis and vigorous management should be adopted to reduce the morbidity and mortality in patients with blunt abdominal trauma.

Primary mesenteric fibromatosis.

Primary mesenteric fibromatosis is a rare condition. We report a 46-year-old man with this condition.

Ultrasonic evaluation of intra-abdominal abscesses.

This study describes the role of ultrasound in the evaluation of abdominal abscesses in children. A total of 41 abscesses were encountered in 36 patients (21 boys and 15 girls). The youngest patient was 1-month-old. Abscesses were localised at various sites (hepatic, renal, perirenal, paracolic, appendicular, pelvic, psoas, subphrenic, parietal), and of varied sonographic patterns (complex, anechoic, hypoechoic and containing uniform low level echoes). Most of them had irregular walls.

Role of ultrasound in the evaluation of blunt abdominal trauma.

Twenty nine cases of intra abdominal injuries who became stable after initial shock were selected for ultrasound examination. Ultrasound detected intra-abdominal hematomas in 19/29 (65.51%). These cases were managed conservatively. The different types of hematomas encountered were renal, hepatic, splenic, retroperitoneal and parietal.

Spina bifida occulta with atrophy of toes.

A case of lumbosacral spina bifida occulta presented with resorption of toes which started at six years of age. Its differential diagnosis with neural leprosy is discussed.