Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

BACKGROUND: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. PATIENTS AND METHODS: We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. RESULTS: A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) - the proportion increased significantly from 23% in 1996-2004 to 51.6% in 2013-2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). CONCLUSION: The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

Native oesophageal mucocoele: A rare complication of double exclusion of oesophagus.

INTRODUCTION AND IMPORTANCE: Native oesophageal mucocoele usually follows bipolar exclusion of oesophagus for various reasons and is very rare in literature. Though mostly asymptomatic, its symptoms can be divided into 3 groups - Compressive, Infective and fistulizing symptoms. The management options described in the literature are percutaneous drainage, chemical ablation, esophagectomy and internal drainage using Roux-en-Y reconstruction. CASE REPORT: A 40 year old female, presented with complaints of dysphagia, weight loss and chest pain for 6 month. She had history of retrosternal gastric pull-up for oesophageal stricture following corrosive injury. On evaluation with CT chest, there was a well-defined fluid attenuated tubular elongated lesion in the mediastinum in the region of oesophagus which was non-opacified with oral contrast and a diagnosis of giant oesophageal mucocoele was made. She underwent internal drainage of mucocoele by roux-en-Y esophagojejunostomy with placement of transanastomotic drain and discharged with an uneventful recovery with the trans-anastomotic drain in situ, which was removed on outpatient basis. Now she is asymptomatic in the subsequent follow up. CLINICAL DISCUSSION AND CONCLUSION: Though rare, mucocoele of oesophagus can lead to life threatening complication like respiratory distress, sepsis. Its diagnosis requires high index of suspicion and CT chest is helpful. Management options depend upon nutritional status of the patient and associated co-morbidities. Esophagectomy is the definitive form of treatment but not always possible and other options can be internal or percutaneous drainage.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience.

INTRODUCTION: The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. METHOD: We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. RESULTS: Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2-15 cm). The tumour extent was defined as 'borderline resectable' in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. CONCLUSION: SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report.

INTRODUCTION AND IMPORTANCE: Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. CASE PRESENTATION: A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. CLINICAL DISCUSSION: The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. CONCLUSION: The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

Cystic Lymhangioma of the Lesser Sac in Adult Presenting with Features of Gastric Outlet Obstruction - A Case Report.

Cystic lymphangioma is a paediatric benign tumour, occurs commonly in head and neck region. Adult intraabdominal lymphangiomas are uncommon and only few cases of lesser sac cystic lymphangioma are reported in the literature. We present a case of lesser sac cystic lymphangioma in a 26-year-old lady who presented with features of gastric outlet obstruction. Clinical examination revealed a 10x10 cm firm, non tender, mobile intraabdominal lump in the epigastrium. An upper gastrointestinal endoscopy showed possible external compression at the body of the stomach. Ultrasound demonstrated a multicystic lesion, with internal echoes in one locule. CECT showed a large multiloculated cystic lesion with hyper-dense content in the lesser sac extending up to the left lobe of the liver and indenting the stomach, lesser sac, and upper border of pancreas. On surgical exploration, a 10X8 cm multi cystic lesion with clear fluid was found in the lesser sac very close to the lesser curvature of stomach. Histopathological examination of the excised lesion showed features of cystic lymphangioma. Though very rare, intraabdominal cystic lymphangiomas should be considered in all atypical cases of gastric outlet obstruction. A reasonable knowledge about these benign lesions will aid in establishing the diagnosis and surgical management.