Role of suture material and technique of closure in wound outcome following laparotomy for peritonitis.

Background: There are no accepted guidelines for the closure of laparotomy incisions in patients of peritonitis. As these patients differ from the patients undergoing elective abdominal surgery, the same recommendations for closure may not be applicable in both groups. Aim: To compare wound outcome parameters following closure of the laparotomy incision with absorbable and non-absorbable suture material using the continuous and interrupted techniques in patients of peritonitis. Method: A single blinded randomised controlled trial using Polygalactin–910 and Polypropylene, number 1 sutures, to close midline vertical incisions, placed in continuous and interrupted manner, was performed on 174 patients. Patients were randomised into four groups: Group A (Polygalactin-910 continuous suturing, n=40), B (Polygalactin-910 interrupted suturing, n=47), C (Polypropylene continuous suturing, n=45) and D (Polypropylene interrupted suturing, n=42). The incidence of wound infection, dehiscence, suture sinus formation and incisional hernia was recorded. Patients were followed up for a period of four years. Statistical analysis involved the chi-square and Fisher’s exact tests. A ‘p’ value of <0.05 was considered significant. Results: The study included 139 male and 35 female patients between the ages of 10 and 75 years. The incidence of wound infection (p=0.656), dehiscence (p=0.997), and incisional hernia (p=0.930) at 3 months and four years (p= 0.910) was not statistically significant. There was no sinus formation in groups A and B, however 2 patients of group C and 6 patients of group D did develop suture sinus (p=0.003). Conclusion: Suture material and technique of closure does not influence wound outcome in patients of peritonitis except for a significantly lower incidence of sinus formation when non-absorbable sutures are used.

Lateral sacral meningomyelocele as a gluteal swelling--an unusual presentation.

Paravertebral meningoceles are rare examples of craniospinal dysraphism. A young boy presented with a cystic swelling over left gluteal region with lumbosacral scoliosis. On exploration, he was found to have a laterally placed sacral meningomyelocele. The presence of an unusually located meningocele should be suspected when a paravertebral mass is associated with neurological deficit or deformity of the spine.

Effect of partial ileal bypass on the lipid profile in the hyperlipedemic rabbits.

The hypocholesterolemic effect of partial ideal bypass was studied in two groups of healthy albino rabbits. Both groups of rabbits were made hypercholesterolemic by feeding them cholesterol suspended in groundnut oil (1 ml/kg bw) at a dose of 100 ml/kg bw/day for one week. Group I rabbits were subjected to partial ileal bypass and group II rabbits were sham operated. Weekly estimation of serum lipid profiles were done for four more weeks while continuing cholesterol feed. After end of 5th week, it was found that partial ileal bypass not only prevented but also brought down its level from 132.8 mg% to 44.8 + 2.24 mg%, as compared to sham operates group where cholesterol level was 279 + 5.84 mg%. There was improvement in other parameters of lipid profiles namely HDL-C & LDL-C + VLDL-C and TAG.

Urolithiasis : Screening for Hyperparathyroidism is Essential

Thirty two patients having complex renal stones in the age group of 10-60 years were studied to detect hyperparathyroidism (HPT). The clinical diagnosis varied from bilateral renal stones in 20 (62.5%),2 (6.22%) had large unilateral stone, 2 (6.622%) had recurrent bilateral renal calculi and 4 (12.5%) had unilateral recurrent calculi. Serum calcium was raised (> 10.5 mg%) in 9 (20%) cases. Parathyroid hormone (PTH) was found raised, ranging from 80-1330 pg/ml (N : 16-65 pg/ml) in 9 (28%) cases out of 32. Hypercalcemia (> 10:5 gm %) was found in 7 out of 9 cases of HPT whereas in other 2 cases it was normal (8.9 mg %) and upper normal (1 O.3mg %) respectively. Hypercalciuria (>250mgl24 hrs) was found in 5 patient ofHPT and rest 3 patients had normal levels. Serum phosphate was found in the range of 1.4-7.1mg% (N : 2.5-6.8mg %) in 30 cases, on patient had < 2.5mg % and one patient had >6.8mg %. One patient with hypercalcemia had both urinary calcium as well as PTH normal. Dual subtraction scan (thallium and technetium) was done in all 9 patients with raised PTH. Scan was positive with adenoma in 4 (12.5%) cases. One patient 15 years old girl with a positive scan had both serum calcium and 24 hrs. urinary calcium levels normal with raised PTH (90-100 pg/ml). Scan reported doubtful hyperplasia in one (3.12%) patient out of 32. This patient, a multiple stone passer had normal serum calcium as well as 24 hrs. urinary calcium with raised PTH (99.60) pg/ml). 4 cases (12.5%) had a normal scan. Four (12.5%) cases with positive scan underwent parathyroidectomy (PTX). Serum calcium and PTH concentration dropped to normal levels in the postoperative period. Rest of the cases of HPT with normal and doubtful scans are under follow up.

Massive amebic liver abscess--an unusual presentation.

A 40-year-old woman presented with a huge lump in the right half of the abdomen and irregular menses. Ultrasonography showed a cystic lump with septations, extending from the upper abdomen to the pelvis; the right ovary was not seen. On exploration, there was a large cyst arising from the right lobe of the liver; the aspirate was bilious. Since the cyst wall was adherent to retroperitoneal structures, complete excision was not possible. A roux-en-Y loop of jejunum was anastomosed to the cyst wall. Biopsy of the wall showed inflammatory granulation tissue with trophozoites of Entamoeba histolytica. She was treated with metronidazole, and recovered uneventfully.

Agenesis of the Gallbladder: Falacies of Ultrasonography

A case of the agenesis of gallbladder detected at laparotomy for symptomatoloy suggestive of gallbladder disease is described. The agenesis of gallbladder, diagnostic inaccuracies and fallacies of ultrasonography for gallbladder disease are discussed. The diagnosis of agenesis was substantiated on MRCP, done postoperatively.

Review of a hospital experience of enterocutaneous fistula.

A retrospective analysis of records of 46 patients with enterocutaneous fistulas treated over a period of three and half years has been done. There were 28 males and 18 females, with 80% of patients being in age group of 25-35 years. Forty-five patients were postoperative and in one patient fistula occurred spontaneously. Tuberculosis was the most common underlying pathology, seen in 32.6% followed by enteric fever in 23.9%. The small intestine was the most common site for the origin of fistula, seen in 34 patients (73.9%). There were 22 patients with high output fistula and 24 with low output. For high output fistulas, enteric fever was the most common cause (45%) and ileum was the most site of origin (82%). Low output fistulas were mainly of tubercular aetiology (62%) and involved ileum in 62% of cases. Nineteen out of 22 patients of high output fistulae had sepsis. Fourteen of these had generalised peritonitis (63%) and 5 had localized intra-abdominal collections (27%). Spontaneous closure occurred in 45.6% of patients on conservative management and 37% patients underwent surgical intervention. The overall mortality was 30.4%. High output fistulae had mortality figure of 54.5% and low output fistulas 8.4%. Mortality in relation to sepsis was 63%. No patient with sepsis and without surgical intervention survived. Following surgical intervention mortality was 50% in patients who showed evidence of sepsis. Early and effective control of sepsis is the most important factor determining outcome in patients of enterocutaneous fistula.

Chronic calcific pancreatitis associated with osteomalacia and secondary hyperparathyroidism.

A 22-year-old woman with chronic calcific pancreatitis had dramatic relief of pain after pancreaticojejunostomy. Four years later, she presented with steatorrhea with osteomalacia and secondary hyperparathyroidism, a rare occurrence in chronic pancreatitis. She improved with pancreatic enzyme supplementation and calcium and vitamin D therapy.

Malignant carcinoid tumor of the gallbladder: a case report and review of literature.

Carcinoid of the gallbladder and bile ducts is a rare tumor. Till date 20 cases have been reported. Here we report one more case and review all 21 cases collectively. The tumor affects elderly patients of either sex equally. Surgical obstructive jaundice (SOJ), followed by abdominal symptoms were the commonest presenting complaints. None of the patients presented with carcinoid syndrome. Bile duct carcinoids presented significantly earlier than gallbladder carcinoids because of strategic location causing SOJ. Gallstones were present only in 3 cases. Fifty per cent of these tumors were malignant, with liver followed by bone as the commonest site of metastasis. Surgery has been the mainstay of the treatment of these lesions. Old age, jaundice and metastasis at presentation and location of carcinoid in bile duct were found to be bad prognostic factors. In the absence of these features overall survival after surgical procedures like radical cholecystectomy was encouraging enough to undertake the surgical challenge.