Endoscopic sistrunk using bilateral axillo-breast approach - A minimal access technique for thyroglossal duct cysts.

Sistrunk procedure for thyroglossal duct cyst (TGDC) includes removal of the thyroglossal cyst, middle portion of the hyoid bone and the tract towards the foramen caecum. Endoscopic approaches have surpassed the traditional open approaches for the treatment of benign thyroid swellings and TGDCs. Endoscopic Sistrunk procedure using bilateral axillo-breast approach is a safe and better alternative for the successful treatment of TGDC and provides excellent cosmetic results.

Minimally Invasive Management of Hemorrhagic Pheochromocytoma-A Rare Case Report.

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by its classic history, presence of a strong family history, or discovery of an incidental mass on imaging in an asymptomatic patient. Hemorrhage into an occult pheochromocytoma is a rare complication with ∼1 to 2 per 100,000 individuals diagnosed annually. We report a case of a 29-year-old woman, who presented with abdominal pain (with no other significant history) due to a right hemorrhagic pheochromocytoma. Computed tomographic imaging and magnetic resonance imaging revealed the source of retroperitoneal hemorrhage as the right adrenal mass. They lacked the typical features of a pheochromocytoma which was eventually proven by the biochemical tests. The patient underwent preoperative stabilization with α and ß adrenergic receptor blockers for 7 days following which laparoscopic adrenalectomy was performed successfully with an uneventful postoperative period. This is the eighth reported case in literature managed laparoscopically. Histopathology confirmed it as pheochromocytoma. The treacherous and deceptive nature of pheochromocytomas and its hemorrhage make it crucial to detect and treat it promptly; otherwise, it will almost certainly be fatal from cardiovascular complications or metastasis.

Laparoscopic versus Open Appendectomy: A Prospective Comparative Study and 4-Year Experience in a Tertiary Care Hospital.

Background The aim of this study was to validate the pros of laparoscopic appendectomy (LA) over open appendectomy (OA) and to compare various primary outcome measures in the management of acute and recurrent appendicitis. Study Design Prospective comparative study. Place and Duration Between June 2015 and October 2019 in JJ Hospital, Mumbai. Materials and Methods Total of 60 patients with acute and recurrent appendicitis were included in the study. Thirty patients underwent OA and 30 underwent LA. Both groups were comparable clinicopathologically and demographically. Various intraoperative and postoperative parameters were compared. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Mann-Whitney U test was used to compare continuous variables and chi-squared test was used to compare categorical variables. p -Value≤0.001 was considered to be statistically significant. Results The median age of patients undergoing OA and LA was 24.9 and 25.2 years ( p = 0.221), respectively. Female: male ratio in OA and LA was 1.30 and 1.14, respectively ( p = 0.795). Mean operative duration in LA and OA group was 47.17 ± 14.39 minutes and 36.9 ± 12.33 minutes ( p = 0.001), respectively. Mean length of postoperative stay in LA and OA group was 3.69 ± 0.71 days and 5.28 ± 0.63 days ( p = 0.000), respectively. Median visual analogue scale score in LA and OA group was 3.5 and 5 ( p = 0.001), respectively. Mean time to return to normal activity in LA and OA group was 8.13 ± 1.33 days and 10.10 ± 2.20 days ( p = 0.000), respectively. About 6.66% patients in LA group and 13.33% in OA group had postoperative wound infection ( p = 0.652). Mean scar scale scoring done on 30th postoperative day was 4.23 in LA and 8.23 in OA ( p = 0.000). Discussion and Conclusion LA is more promising than OA in the management of acute and recurrent appendicitis. LA offers lesser operative site pain in the postoperative period, shorter postoperative hospital stays, earlier recovery, and return to normal activities and cosmetically better scars on 30th day follow-up. No conversions or significant difference in wound related complications were seen in both groups. Prolonged intraoperative duration was the only drawback of LA.

Minimally invasive extended thymectomy for thymoma associated with pure red cell aplasia.

Anaemia characterised by near absence of red cell precursors in the bone marrow is referred to as "pure red cell aplasia (PRCA)." It has an unusual and intriguing association with thymoma and auto-immunity. Here, we report such a case which was successfully treated with extended thymectomy by minimally invasive approach. A 68-year-old anaemic lady presented to our institute with weakness and exertional dyspnoea for almost a year. She was transfused with blood for the same periodically but remained transfusion dependent. Apart from pallor, her systemic examination was unremarkable. Peripheral smear showed reduced haemoglobin (Hb) mass and reduced reticulocytes. Bone marrow biopsy implied PRCA. High-resolution computed tomography (HRCT) of thorax revealed a well-defined soft tissue lesion in the anterior mediastinum suggesting thymoma. Biopsy showed lymphocyte-rich type thymoma. Thymus along with fibrofatty tissue was resected completely using video-assisted thoracoscopic surgery (VATS) approach. Histopathological examination of the resected specimen revealed World Health Organisation (WHO) type B1-thymoma. Immediate post-operative period was uneventful. However, a fall in Hb which required blood transfusions necessitated initiation of immunosuppression with corticosteroids. Patient was given 6 weeks of adjuvant immunosuppression with corticosteroids. After 8 months post-thymectomy, she was leading a symptom-free life and no longer in need for blood transfusions. VATS thymectomy is a safe and feasible approach for the treatment of thymoma-induced PRCA with added advantage of minimal invasive approach. Long-term complete remission is possible with adjuvant immunosuppression.

Isolated primary tuberculosis of spleen-A rare entity in the immuno-competent patient.

INTRODUCTION: Tuberculosis is a global public health concern, with 9.6 million affected individuals worldwide. Current screening and diagnostic regimes focus primarily on smear positivity, and hence, the rising numbers of Sputum negative and Extra-Pulmonary Tuberculosis has become a significant set-back to adequate diagnosis, disease notification and treatment, due to the large number of false negatives. PRESENTATION OF CASE: We hereby describe an intriguing presentation of tuberculosis - A 23 yr old lady with no comorbid illness, came to us with ten month history of on and off pyrexia, weakness and left hypochondriac pain. On evaluation, two isolated hypodense lesions in the spleen were detected. Diagnostic laparoscopy and Splenectomy were performed and histopathology revealed features of primary tubercular abscess. DISCUSSION: Commonly, abdominal visceral involvement is seen as a part of miliary tuberculosis in the immuno-compromised patient. However, in the absence of any co-morbidity and preserved immune function, this case depicts the rare possibility of primary isolated Tubercular splenic abscess in the normal healthy individual. CONCLUSION: We require a close eye and a keen sense of clinical acumen to accurately diagnose and treat smear negative and uncommon forms of Tuberculosis. Considering the growing prevalence and difficulty in disease control, there is need for greater knowledge and awareness to help mitigate the global burden of Tuberculosis.

Triorchidism: Presenting as Undescended Testis in a Case of Indirect Inguinal Hernia.

Triorchidism is the commonest variety of polyorchidism, an entity with more than two testis is an extremely rare congenital anomaly of the testis. Although excision of the abnormal testis is a safer alternative proposed, recent literature suggests more conservative approach in normal testes with watchful regular follow up to screen for malignancy. This case presented as a left inguinal swelling diagnosed as indirect left inguinal hernia. The left side testis was of smaller size (about half) with normal sperm count, morphology and motility. Intraoperatively indirect inguinal hernia was noted with supernumerary testis at deep ring in addition to normal left testis in left scrotal sac. The ectopic testis were small (2.5×2.5×1 cm) lacking epididymis and with short vas deferens. An evident normal semen analysis and varied anatomy, the decision for orchidectomy of ectopic testis was taken. The histopathological finding was consistent with arrest in germ cell development.

Large Epiphrenic Diverticula: A Rare Case Presentation.

A 70-year old female was admitted to hospital with heartburn and chronic halitosis since 5 years. She was on proton pump inhibitors for the same. Her complaints worsened during the last one-year. Workup comprising of esophago-gastro-duodenoscopy, esophageal manometry, 3D computed tomography scan showed right-sided epiphrenic diverticula measuring 10x10 cm with wide mouth about 5 cm with hypertensive lower esophageal sphincter. Patient underwent a video assisted thoracoscopic surgery for esophageal diverticulectomy using two 45 mm staplers. On day 5, the patient developed leak, which was managed by a covered esophageal stent placement. Patient started on oral feeds from day 3 and the esophageal leak healed completely within 2 weeks. Literature suggests that esophageal leaks treated conservatively took approximately 30-40 days on an average for healing. Literature search did not reveal esophageal leak managed by stent with faster recovery (2 weeks). This is one of the largest epiphrenic diverticuli reported in literature.

Laparoscopic excision of mesenteric cyst of sigmoid mesocolon.

Mesenteric cysts are rare abdominal tumours. They are found in the mesentery of small bowel (66%) and mesentery of large intestine (33%), usually in the right colon. Very few cases have been reported of tumours found in mesentery of descending colon, sigmoid or rectum. Mesenteric cysts do not show classical clinical findings and are detected incidentally during imaging due to absent or non-specific clinical presentation or during management of one of their complications. Ultrasonography (USG)/computed tomography (CT)/ magnetic resonance imaging (MRI) are used in diagnosing mesenteric cyst but they cannot determine the origin of cyst. Laparoscopy not only helps in diagnosing the site and origin of the mesenteric cyst but also has a therapeutic role. Laparoscopic treatment of mesenteric cyst is a safe, preferred method of treatment and is a less-invasive surgical technique. Here, we present an unusual case of mesenteric cyst arising from the sigmoid mesocolon treated by laparoscopic excision.

Impact of laparoscopic Nissen's fundoplication on response of disease specific symptoms and quality of life.

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen's fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.

Retroperitoneal approach for recurrent benign multicystic peritoneal mesothelioma.

Benign multicystic peritoneal mesothelioma (BMPM) is an uncommon lesion. It presents as a lump in abdomen or a finding seen on imaging modalities. Surgery is the primary modality of treatment. However, it has a high recurrence rate; this results in adhesions and subsequent surgeries difficult. We present a case of recurrent BMPM in a female operated twice earlier in a rural centre. Imaging modalities showed majority of the lesion in paracolic and retroperitoneal region. Hence, retroperitoneal approach for surgery was taken. This avoided previous surgical adhesions. A brief case report on this novel approach and review of literature is presented.

Primary neuroendocrine tumor of the left hepatic duct: a case report with review of the literature.

Primary Biliary Tract Neuroendocrine tumors (NET) are extremely rare tumors with only 77 cases been reported in the literature till now. We describe a case of a left hepatic duct NET and review the literature for this rare malignancy. To the best of our knowledge the present case is the first reported case of a left hepatic duct NET in the literature. In spite of availability of advanced diagnostic tools like Computerized Tomography (CT) Scan and Endoscopic Retrograde Cholangio Pancreaticography (ERCP) a definitive diagnosis of these tumors is possible only after an accurate histopathologic diagnosis of operative specimens with immunohistochemistry and electron microscopy. Though surgical excision remains the gold standard treatment for such tumors, patients with unresectable tumors have good survival with newer biologic agents like Octreotride.

Mortality pattern of the 26/11 Mumbai terror attacks.

BACKGROUND: Mumbai, one of the industrial capitals cities of the world, has witnessed a series of terror attacks over the last two decades. The 2008 Mumbai terror attacks referred as "26/11" drew widespread global condemnation and killed 166 people, in addition to wounding more than 300 people. The mortality pattern and the pathophysiology of organ injuries are presented. The objective of this study was to determine the different patterns of injury in a terrorist attack of such magnitude and clinical implications in reducing mortality. METHODS: Data were collected from hospital records of 114 victims whose postmortems were conducted at the Sir JJ Group of Hospitals. The records were studied with respect to pattern and nature of injury. RESULTS: A total of 175 people were killed, 9 were terrorist with 166 victims. Of the 166 mortalities, postmortems were conducted on 114 predominately male victims ages 5 to 70 years old; 108 of these were dead on arrival. Sixty-eight people died from bullet injuries, 30 from blast injuries, and 10 had both bullet and blast injuries. Six were postoperative deaths (all bullet injuries), of which two were early postoperative deaths and four late postoperative deaths due to septicemia. CONCLUSION: There was multimodal pattern of injuries with predominance of bullet injuries sustained to vital organs. The hostage crisis resulted in varied and delayed evacuation times, which led to the death of nine victims with non-severe organ injuries. Delayed implementation of Prehospital Trauma Life Support due to the unsecured site and the hostage crisis can also be one of the causes. LEVEL OF EVIDENCE: V, epidemiological study.

Comparative study of laparoscopic versus open appendicectomy.

UNLABELLED: Comparative Study of Laparoscopic (LA) versus Open Appendicectomy (OA) as a Cross sectional hospital based study for evaluation of: Postoperative quality of life Postoperative painAmount of Narcotics/Analgesics usedHospital stayTime to full recovery BACKGROUND: This underdeveloped residuum of the caecum has no known function and is commonly termed as a 'vestigial' organ, yet diseases of the appendix loom large in surgical practice; and appendicitis continues to be the most common acute abdominal condition that requires immediate surgical treatment. STUDY DESIGN: Study to be carried out over a period of two months included patient diagnosed with appendicitis and admitted to surgery ward at Sir J.J. Group of Hospitals, Mumbai, India and St. George Hospital, Mumbai, India and willing to be enrolled in the study.Demographic data, clinical features, investigations, Technique, reintroduction of diet, postoperative pain, use of analgesia, hospital stay were documented and outcome recorded in a predesigned case record form. Return to normal activity and work was determined by questioning during postoperative clinic. RESULTS: Proved that laparoscopic procedures cause less post-operative pain than their conventional counterpartsAnalgesic requirement for post operative analgesia was significantly less in LA (mean 4 inj. doses) compared to the OA (mean 5.9 inj. doses) Hospital stay was less for LA (2.23 days) than OA (3.4 days) Full recovery on the basis of return to normal activity was earlier in LA (6.53 days) as compared to OA (8.7 days). CONCLUSION: LA holds a promising prospect and may replace OA in the near future as the method of choice for effective and qualitative clinical management of appendicitis in emergency and in elective set up.

Anterior mandibular ameloblastoma.

Ameloblastoma is a benign odontogenic tumor. These are usually asymptomatic until a large size is attained. Ameloblastoma has tendency to spread locally and has a high recurrence rate. Majority of ameloblastomas (80%) arise from the mandible. Ameloblastoma arising from anterior mandibular region (symphysis-menti) is rare. Very few cases of midline anterior ameloblastomas are reported in the literature. They often require wide local excision. Reconstruction of mandible in these cases is challenging. We present a case of mandibular ameloblastoma arising from symphysis-menti. Patient underwent wide surgical excision of the tumor followed by immediate reconstruction using free fibular vascular flap, stabilized with titanium reconstructive plates. A brief case report ands review of literature is presented.

Primary hepatic choriocarcinoma: a rare cause of spontaneous haemoperitoneum in an adult.

Choricarcinoma is a beta human chorionic gonadotrophin secreting neoplasm pertinent to uterus and pregnancy mostly. It occurs primarily in gonads but rarely in extragonadal sites. Primary hepatic choriocarcinoma is an extremely rare tumor. Most of the reported cases are seen in infants representing metastasis from an occult placental choriocarcinoma. Till date, only 7 cases of primary hepatic choriocarcinoma in adults have been reported in literature. We present a case of a 40-yearold male presenting as haemoperitoneum due to ruptured hepatic tumor. He underwent emergency left lateral segmentectomy. He died on 10(th) postoperative day. The surgical specimen and autopsy findings confirmed it to be primary hepatic choriocarcinoma. This is the first case report from Indian Subcontinent. A brief case report and review of literature is presented.

Primary schwannoma of adrenal gland: a case report.

Primary schwannoma of the adrenal gland is a rare tumour and only one case is described in Indian literature. We report the clinical, pathological and radiological features of adrenal schwannoma discovered accidentally in a 34 years old female as part of gynaecology work-up.

Giant recurrent retroperitoneal liposarcoma presenting as a recurrent inguinal hernia.

Retroperitoneal liposarcoma presenting as an inguinal hernia is a rare entity. We present the first case of Giant recurrent liposarcoma presenting as a recurrent inguinal hernia in a 40-year-old male. Physical examination showed an irreducible lump in the right inguinal region and a scar in the right lumbar and right inguinal region. Computed tomography (CT) scan of abdomen revealed it to be a retro peritoneal mass extending into the right inguinal region along and involving the cord structures. Wide local excision of the tumour with right orchidectomy and inguinal hernioplasty was performed. Histo-pathology confirmed it to be a liposarcoma. Patient received postoperative radio therapy. Follow up of two years has shown him to be disease free. Retroperitoneal liposarcoma can grow along cord structures into the inguinal canal and mimic an irreducible indirect inguinal hernia.

Right posterior branch draining into intra-pancreatic common duct: the triple duct sign.

Simultaneous dilatation of pancreatic duct (PD) and common bile duct (CBD) is often seen on radio imaging in pancreatic head malignancy or chronic pancreatitis. This is called double duct sign. However, dilatation of aberrant bile duct along with PD and CBD resulting in triple duct sign on radio imaging has not been reported in literature till date. We report a case of 45 years old male with surgical jaundice due to pancreatic head mass. Computed tomography (CT) scan revealed three dilated ducts in the head of pancreas. Besides PD and biliary duct, the third duct was pre-operatively thought to be long cystic duct with low insertion in common hepatic duct (CHD). Intra-operative findings revealed an unusually long and dilated aberrant right posterior sectoral duct with low insertion into intra-pancreatic CHD. Patient underwent Whipple's procedure with two separate biliary anastomosis besides pancreaticojejunostomy. Histopathology of specimen revealed chronic pancreatitis. Retrospective analysis shows that Magnetic Resonance Cholangiopancreatogram (MRCP) should have been done for correct pre-operative delineation of this anatomical anomaly. In conclusion, pre-operative detection of triple duct dilatation on CT scan should be further investigated with MRCP for anatomical variations of the biliary tract. This can guide operative planning and prevent inadvertent biliary injuries.

Primary extra-ampullary duodenal neuroendocrine carcinoma in an adult male.

A primary extra-ampullary duodenal neuroendocrine carcinoma was found in a 40-year-old man who presented with upper abdominal pain and weight loss. Duodenoscopy and hypotonic duodenography revealed a protruding fungating mass with luminal occlusion at the third part of the duodenum (D3). Although the metastatic work-up was normal, the tumor was inoperable intraoperatively, hence a palliative bypass was carried out followed by chemotherapy with 5-fluorouracil and leucovorin. Examination of the biopsy by immunohistochemistry and ultrastructural study revealed it to be neuroendocrine in nature, expressing synaptophysin, chromogranin and cytokeratin and containing dense core cytoplasmic granules. However, there was no evidence of clinical endocrinopathy. The present case emphasizes the need for better detection, further analysis and evaluation of such rare cases to identify their clinical course and effective treatment modalities.