Ileostomy for Non-Traumatic Ileal Perforations: Is this the Beginning of the End?

INTRODUCTION: Ileal perforations are a common place of occurrence in emergency operation rooms around India. They are also significant contributors to mortality in our country. They are very distressing for patients because of the high morbidity of a laparotomy and in certain cases a stoma if its necessity is felt by the operating surgeon. The nature of the disease itself predisposes to a number of complications including wound infections, faecal fistulas and complications associated with a stoma. AIM: To evaluate the role of ileostomy in patients with non-traumatic ileal perforation. MATERIALS AND METHODS: A total of 192 cases of ileal perforation, diagnosed per-operatively, were prospectively studied between June 2012 and July 2014. Cases were treated according to standard resuscitation protocols and underwent repair of the ileal perforation either as primary closure or as a bowel resection and anastomosis with or without a proximal diversion ileostomy. Cases were followed up for a period of six months and immediate and late complications and outcomes were noted. RESULTS: A total of 192 patients were studied during the given study period out of which 170 (88.5%) were males. The disease was treated primarily without diversion stoma in 176 patients and in 16 patients a proximal diversion ileostomy was performed. The overall mortality was 15 (7.8%) that was noted to be not significantly different in patients with respect to the performance of a stoma. Enterocutaneous fistula was a complication seen exclusively in the non-ileostomy group whereas stomal complications were expectedly noted only in the stoma group. CONCLUSION: The authors found that though conventional ileostomy diversion may appear a safe option in patients with ileal perforations, it has its own additional morbidity, which at times can be very difficult to manage. An ileostomy is of use in a very small group of patients that is diminishing as better facilities and equipment are obtained to manage this dreaded disease.

Postoperative venous thromboembolism prophylaxis by general surgeons in a developing country: a survey.

Venous thromboembolism (VTE) is the most common preventable cause of hospital death. Several audits in the west have demonstrated that appropriate thromboprophylaxis is not being offered to a large number of surgical patients. Similar audits are lacking in the Indian population, and a perception exists among Indian surgeons that Indian patients are not susceptible to VTE. Hence we undertook a survey to analyze the existing knowledge and practice of VTE prophylaxis amongst general surgeons in India. A questionnaire-based survey was conducted on 100 active general surgeons. We found that 97% of surgeons had encountered VTE in their practice, and 49% had encountered mortality from pulmonary embolism. 64% of surgeons do not routinely score patients preoperatively for their VTE risk, and only 33% reported the presence of an institute-based protocol for the same. There was a wide disparity in the prophylaxis methods used for each risk group, particularly in the moderate-risk group. These findings suggest the need for adoption of institute-based protocols for prophylaxis and the evolution of Indian guidelines for VTE prophylaxis.

Hernia uteri inguinalis in a case of ovotesticular disorder of sexual differentiation.

An 18-year-old phenotypic male presented with an irreducible left inguinal mass, gynecomastia, and hypospadias. This mass on exploration was found to be a nonfunctional uterus with ipsilateral ovary and was excised. Further investigation confirmed the presence of a contralateral testis and a genotype of 46, XX. This confirmed the diagnosis of ovotesticular disorder of sexual differentiation (formerly true hermaphroditism) with obstructed hernia uteri inguinalis. The patient was raised as a male. Subcutaneous mastectomy for gynecomastia and neourethra construction with full thickness skin graft for hypospadias were performed. Hernia uteri inguinalis is rarely seen in this condition with only 2 cases being reported worldwide thus far, including our case.

Primary splenic lymphoma: a case report.

Primary splenic lymphomas (PSL) constitute a rare variety of splenic neoplasms. As a secondary lymphoid organ, the spleen is usually involved by lymphomas as part of the systemic illness. However, rarely it can be the exclusive site of disease burden. An elderly lady presented with symptoms and signs of splenomegaly. After evaluation she was found to have a splenic tumor. Splenectomy was done which revealed primary splenic lymphoma. This case report highlights the evaluation and management of this illness.

A case of giant advanced sebaceous gland carcinoma.

Sebaceous carcinoma is a highly aggressive, potentially lethal tumour arising from the sebaceous glands in the skin. It accounts for 3.2 % of all malignant skin tumours. An advanced case of sebaceous carcinoma with distant metastasis is very rare as most of them present in the periocular area and are easily visible. We present an elderly woman who presented with two large fungating exophytic masses over the right parotid/orbital region and right side of neck. FNAC showed cytological features suggestive of poorly differentiated carcinoma which on histopathological exam confirmed it to be sebaceous carcinoma. Unfortunately the patient succumbed to cardiac arrest before initiation of treatment. This is the largest case of sebaceous gland carcinoma of eyelid reported in the medical literature, confirming the local aggressive behavior of the tumor and highlighting the importance of early diagnosis.

Giant Tuberous Xanthomas in a Case of Type IIA Hypercholesterolemia.

Tuberous xanthomas are papulonodular skin lesions present in lipoprotein metabolism disorders. A patient presented with multiple large swellings (up to 20 cm in size) all over the body, which on excision were found to be tuberous xanthomas. Investigations revealed the diagnosis of familial hypercholesterolemia. This case is reported to document the unusual presentation of giant tuberous xanthomas.