Giant Gallstone With Gallbladder Perforation and Hepatic Abscess in an Asian Patient.

Giant gallstone with a secondary hepatic abscess is a very rare phenomenon. We recently treated a patient with a giant gallbladder (GB) stone of size 11.5 cm with a hepatic abscess who presented with features of an acute abdomen. This was subsequently managed with an open subtotal cholecystectomy and concomitant hepatic abscess drainage. To the best of our knowledge and after a thorough literature search, this is one of the largest reported gall bladder (GB) stones with wall perforation and hepatic abscess in the Asian subcontinent.

Laparoscopic vs Endoscopic Management of Pancreatic Pseudocysts: A Scoping Review.

Pancreatic pseudocyst (PPC) and walled-off necrosis (WON) develop as late complications of acute pancreatitis that have been historically managed surgically. With the advancement in endoscopic equipment and the evolution of endoscopic surgery, the management of PPC has evolved considerably in recent years from surgical drainage to transmural endoscopic drainage. Till the end of the 20th century, a limited number of surgeons performed laparoscopic drainage of PPCs. Due to the steep learning curve needed for performing advanced laparoscopic suturing, a majority of studies conducted during this period have compared open surgical drainage with endoscopy. The efficacy of these modalities has largely been evaluated using retrospective studies and a few meta-analyses particularly due to the low-volume caseload of individual centres. Also, these studies include PPC and WON together in data analysis despite WON being a distinct entity. There are limited prospective well-designed clinical trials comparing endoscopic and laparoscopic management of pure PPCs. There is also a lack of specific recommendations for the management of PPCs. Considerable overlap of indications between these two modalities exists. The efficacy of endoscopic transmural drainage as an index intervention when compared to laparoscopy has not been proven in the research literature. Previous studies have not considered multiple endoscopic interventions within a four-week period of index intervention as a failure. We reviewed the literature using appropriate MeSH terms on the PubMed search engine for articles comparing laparoscopic and endoscopic transmural management of PPCs according to our inclusion and exclusion criteria. Seven articles were identified for inclusion in the qualitative synthesis. This scoping review was conducted to answer some pertinent unanswered questions, identify gaps in knowledge regarding the laparoscopic vs endoscopic management of PPCs, and guide further research.

High voltage electrical injuries: outcomes & 1-year follow-up from a level 1 trauma centre.

BACKGROUND: High voltage (>1000 V) electric injuries (HVEI) are rare, and dreaded due to profound myonecrosis and fatal arrhythmias. Trauma Centres are well equipped for acute and definitive treatment of injuries. Paucity of burn centres in Himalayan belt make trauma centres a prudent choice for management of HVEIs. We share our experience of HVEIs managed at our Level 1 Trauma Centre. METHODS: Study conducted at All India Institute of Medical Sciences, Rishikesh. Patients enrolled from prospectively maintained Trauma Registry. HVEI defined as an electrical shock from a source running current of or more than 1000 Volts. All patients admitted to department of Trauma Surgery with diagnosis of HVEIs, over 17 months (May 2019-Sept 2020) included. Demographics, clinical course, morbidity and management noted. Data is presented descriptively. RESULTS: Prevalence of HVEIs was 0.5% (n=8) among all trauma admissions; all patients were males with median age 25 years. Mode of injury accidental in 6 (75%). Seven patients (87.5%) had entry points in the upper extremity. All patients suffered thermal burns (median BSA 11%). Three patients (37.5%) had secondary fall, no concomitant injury found. Urine myoglobin & creatine kinase measured in all patients. No dysrhythmias detected in index or follow up ECGs. Four patients required emergent escharotomy, four underwent amputation. There was a median of 3 procedures per patient. Fasciotomy (n=6) and grafting (n=3) were commonest operative procedures. Multisystem involvement was seen in 3 patients. In-hospital mortality nil. CONCLUSIONS: HVEIs are rare injuries, predominantly affecting upper extremity of young males. Amputation rates approach 50% despite expeditious surgical management of extremity burn due to progressive myonecrosis. Creatine kinase and urine myoglobin did not correlate with renal failure; ECG monitoring wasn't advantageous in patients with normal index ECG in our study. Modest BSA doesnot rule out visceral damage. Delayed hollow viscus perforation is a possibility in HVEIs involving parietal wall. Vocational loss is common due to high amputation rates of affected extremity, most commonly upper limb. Trauma team is well trained to provide acute, definitive and intensive care, and level I trauma centres with their integrated services are well suited to manage victims of HVEIs in LMICs.

Head and neck injuries after leopard attack: Presentation and management.

Leopard attacks on humans are reported most often from the Indian subcontinent. The bite wounds are complex injuries infected with polymicrobial inoculum and may present as punctures, abrasions, lacerations or avulsions. The presentation and acceptable treatment of these injuries vary according to the wound. We hereby describe the clinical presentation and treatment of a male victim with leopard bite injuries on the head and neck region. As bite injuries are commonly found on and around the face, maxillofacial surgeons should be familiar with the therapy. Through thorough clinical and radiological examination, it is essential to prevent missing any hidden injuries, which can easily turn lethal. To benefit the rural population, more health facilities need to be established in remote areas.

Delayed bowel perforation in electrocution: An unpredictable foe.

Electrocution injuries, particularly high voltage, are uncommon, but can be devastating. Thermal burns, arrhythmias and myonecrosis are commonly known and monitored complications of electrical injuries. Direct thermal trauma to internal viscera is also known and almost all internal organs have been reported to be affected, bowel being the most common. However, bowel perforation occurring in a delayed fashion is one rare, dreaded and erratic complication of electrocution, making it a dangerous pitfall if missed. Alimentary tract perforations can present on a delayed basis in high voltage electrocution injuries; advise for clinical follow up must incorporate this possibility at the time of discharge. Presentation of delayed visceral injuries is subtle & atypical, and post burn immunosuppression may play a part for such presentation. We suggest that all victims of high voltage electrocution with abdominal wall burns receive diagnostic laparoscopy and/or CECT abdomen as part of workup of their injuries. Any non-enhancing segment of bowel on CECT, howsoever small, should be prudently evaluated with laparoscopy.