Delayed Splenic Rupture due to an Occult Primary Injury.

Spleen, due to its unique position and relative mobility, is the most vulnerable organ in blunt abdominal injuries. After splenic trauma, hemodynamically unstable patients are treated with splenectomy. Delayed splenic rupture presents 48 to 72 hours after blunt abdominal trauma and is a rare entity. It is usually associated with low-velocity blunt injuries. The sequela is usually a minor trauma that is concealed initially and presents later as subcapsular hematoma, hemodynamic instability, abdominal pain, and positive Kehr's sign in most cases. Computed tomography is the investigation of choice in such cases. We discuss here a case of delayed splenic rupture that presented after eight weeks of a minor abdominal injury due to a fall. The patient presented with a tender left hypochondrium, positive Kehr's sign, and tachycardia. Computed tomography of the abdomen revealed delayed splenic rupture and hemoperitoneum. As the initial imaging is usually normal in these cases, a routine follow-up and close monitoring of trauma patients can help in the early detection of complications. Key Words: Splenectomy, Splenic rupture, Kehr's sign, Hemoperitoneum.

Transmuscular Quadratus Lumborum Block versus Infrainguinal Fascia Iliaca Nerve Block for Patients Undergoing Elective Hip Replacement: A Double-blinded, Pilot, Randomized Controlled Trial.

Purpose: Transmuscular quadratus lumborum (TQL) block has been described as an effective option for postoperative analgesia in patients undergoing hip replacement with single injection described as providing analgesia for up to 24 h. We hypothesize that a TQL block, when compared to fascia iliaca block (FIB), will provide better analgesia and less motor block in the initial 24-h postoperative period. Patients and Methods: Fifty patients undergoing elective hip replacement surgery, ASA I-III, were included in the study. Patients were randomized into two groups. Patients in group A received spinal anesthesia followed by FIB. Patients in group B received spinal anesthesia followed by TQLB. Postoperative pain scores and motor block were assessed at 6 and 24 hours. The primary outcome measure was 24 h total morphine consumption. Secondary outcome measures included pain score (VNS) and motor block (modified Bromage scale) at 6 and 24 h postoperatively. Results: There was no statistical difference in morphine consumption between the two groups (p-value 0.699). There was no difference in pain scores at 6 h (p-value 0.540) or 24 h (p-value 0.383). There was no difference in motor block at 6 h (p-value 0.497) or at 24 h (p-value 0.773). Conclusion: Transmuscular quadratus lumborum block along with spinal anesthesia for patients undergoing elective hip replacement surgery does not reduce opioid consumption or motor weakness when compared to fascia iliaca block. The results and conclusion apply to a dose of 20 mL of 0.25% bupivacaine used in each group.

Double Peptic Ulcer Perforation due to Cumulative Effects of Post-surgery Stress and NSAIDs: A Rare Event in Surgical Practice.

Peptic ulcer disease affects a large number of people around the world. Complications occur in 10-20% of patients and perforation develops in 2-14% of the cases. It can either be in the pyloric part of the stomach or in the first part of duodenum. Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) abuse and smoking are noted to be the most common risk factors in developing countries. Other risk factors are steroid abuse, post-surgery stress, burns and Zollinger-Ellison syndrome. Although small perforations can be treated conservatively but Graham patch repair is the treatment of choice. Double peptic ulcer perforation is a rare event with only a few cases reported worldwide. This patient presented with double peptic ulcer perforation in emergency due to post-surgery stress. She had cesarean section 10 days earlier with delayed recovery. Key Words: Peptic ulcer disease, Perforation, Graham patch repair, Cesarean section.

Dermatofibrosarcoma Protuberans Of Trunk In A Male Patient.

Dermatofibrosarcoma protuberans is a rare cutaneous malignancy. Usual sites of origin are trunk and extremities. Aetiology of the condition is not well understood but a genetic basis is explained as a reciprocal translocation t (17l;22) (q22; q13). Distant metastasis is quite rare as it is mostly a locally advancing tumour. Histopathology is the most accurate investigation to make a diagnosis. Imaging is still required to rule out distant metastasis. Surgical excision is the treatment option for stage I tumours. Imatinib, a tyrosine kinase inhibitor, has shown promising results in management of locally advanced and metastatic disease.

Pre-operative Intraperitoneal Drainage Under Local Anesthesia: A Promising Resuscitation Tool in Peritonitis Secondary to Hollow Viscus Perforation During the Corona Pandemic.

Introduction To study the role of intraperitoneal drainage in the resuscitation of patients with perforation peritonitis during the corona pandemic. Materials and methods This retrospective study was conducted in the general surgery department of Nishtar Medical University/Hospital Multan from April 2020 to September 2020. Patients of peritonitis who presented with bilateral pulmonary crepitations, SpO2 less than 92%, PaO2 less than 60 mmHg on arterial blood gas (ABG), and chest x-ray (CXR) finding of bilateral infiltrates are included. Due to high suspicion of associated coronavirus infection such patients needed polymerase chain reaction (PCR) for virus detection and special measures were required for resuscitation before any definitive treatment. A delay of six to eight hours is usually encountered while ensuring proper safety measures and dedicated operation theaters. Initial resuscitation started with intravenous fluids and broad-spectrum antibiotics were given to all patients. Twenty-seven patients were resuscitated with preoperative intraperitoneal drainage while waiting for PCR and 13 patients were resuscitated without drainage. Data analysis was carried out using the statistical package for the social sciences (SPSS) version 19 software. The mean was calculated for age while frequency and percentages were calculated for gender, comorbidities, and causes of delay. The mortality was compared using the chi-square test. Results The mean age of patients was 43.73 ± 16.04 years. The common cause of peritonitis were perforations due to duodenal ulcer, typhoid, tuberculous (TB), and biliary origin. The variables that led to suspicion of coronavirus were SpO2 < 92%, PaO2 <60mmHg and bilateral infiltrates on chest x-ray. PCR for coronavirus was positive in nine patients. Mortality was 29.6% in those resuscitated with intraperitoneal drainage before the definitive procedure and 54% in those not resuscitated with intraperitoneal drainage. Conclusions The surge of coronavirus infection has put the healthcare staff at great risk. This has led to strict protocols and precautionary measures in the management of patients with perforation peritonitis with suspected corona infection. The local guidelines for the management of patients with acute abdomen should include aggressive measures right from the start during the corona pandemic. Intraperitoneal drainage, early in the management of perforation peritonitis decreases morbidity and mortality in suspected corona infected patients.

Per-cutaneous dilatation tracheostomy (PCTD) in COVID-19 patients and peri-tracheostomy care: A case series and guidelines.

BACKGROUND & OBJECTIVE: COVID 19 patients with severe respiratory failure may require prolonged mechanical ventilation. Placement of a tracheostomy tube often becomes necessary for such patients. The steps of tracheostomy procedure and post tracheostomy care of these patients can be classified as aerosol generating. We wish to highlight our modified technique to address these issues. METHODOLOGY: We performed percutaneous dilation tracheostomy in three clinically challenging COVID-19 patients in our ICU and developed guidelines aiming to minimise aerosolisation during and after the tracheostomy procedure to safeguard healthcare workers. RESULTS: Percutaneous tracheostomy was performed by a team of three experienced anaesthetists and an ICU nurse. CONCLUSION: The decision of surgical or percutaneous tracheostomy should be dependent on the experience of the tracheostomy performer, health-care worker safety, resource availability, and patient-centred care. We believe our modified strategic approach of brief bronchoscopy, minimum PEEP and gas flows and step-wise planned approach for PCDT offers an extra level of safety to healthcare workers.

Chylous Ascites: A Rare Initial Presentation of Pancreatic Carcinoma.

Chylous ascites as first manifestation of pancreatic carcinoma is very rare. Usual presentations of pancreatic malignancy are abdominal discomfort, back pain, obstructive jaundice and duodenal obstruction. Development of chylous ascites during the course of the disease signifies poor prognosis. Malignancy and tuberculosis are the most common causes of this condition in developed and developing countries, respectively. Diagnosis is made on elevated triglyceride levels in ascitic fluid examination. Management is directed towards the treatment of primary cause and the chylous ascites. High protein and medium chain triglyceride diet is usually advised along with Orlistat for managing this condition. Peritoneovenus shunting can also be done but at the risk of complications. Our patient developed chylous ascites early in the course of the pancreatic carcinoma. CT scan abdomen was non-conclusive and cervical lymph node biopsy later on revealed that the primary disease was occult pancreatic carcinoma. Key Word: Chylous ascites, Triglyceride level, Pancreatic carcinoma.

A case report of coexistence of ectopic lingual thyroid with hypoplastic normal thyroid gland.

Ectopic lingual thyroid along with a normally located thyroid gland is an uncommon condition caused by an aberrant descent of thyroid during embryogenesis. It is more common among females and expresses during puberty, pregnancy and menopause. It is mostly associated with hypothyroidism. Patient usually presents with complaints of dysphagia, dysphonia and suffocation. Treatment of choice depends upon the primary complaint of the patient. We present the case of a young female who underwent tracheostomy to relieve respiratory tract obstruction during puberty and was later diagnosed as a case of ectopic lingual thyroid by radioactive iodine uptake and CT scan imaging. She had an associated hypothyroidism; patient was then put on thyroxine and after making her euthyroid she was operated by transoral route and her ectopic lingual thyroid was removed. She was discharged on a maintenance dose of thyroxin.

Spleenic Abscess As A Complication Of Extrapulmonay Tuberculosis.

Tuberculosis continues to be a fatal infectious disease in developing countries. Despite the advances in medical sciences and introduction of potent therapeutic regimes tuberculosis has still managed to survive and prevail worldwide. It can affect many organs of body. Isolated splenic tuberculosis is uncommon in immunocompetent host and only some cases are reported internationally. Extrapulmonary tuberculosis with splenic involvement is also rare and only comes after lungs and liver. We present a case of patient presented with complaints of prolonged fever, cough and insidious onset of abdominal pain and sepsis. Exploratory laparotomy revealed spleenic abscess as incidental finding associated with tuberculous perforation of colon. She underwent double barrel colostomy and spleenectomy followed by intensive care unit admission. Measures such as awareness about the disease, early medical assistance and good compliance regarding treatment can produce positive results in combating tuberculosis and its complications.

Impaction of Phytobezoar at Meckel's Diveticulum.

Small bowel obstruction secondary to phytobezoars is a rare presentation in surgery. These are masses of undigested food and vegetables, which obstruct the narrowest part of gut. We discuss a case of a young patient presenting in emergency department with history of acute abdominal pain, distension and constipation. Diagnosis of acute intestinal obstruction was made on the basis of history, examination, and initial investigations. Exploratory laparotomy revealed a phytobezoar at the origin of Meckel's diverticulum, which was an incidental finding. He underwent wedge resection with primary closure and removal of phytobezoar. The change in dietary habits, decreased fiber intake, and psychiatric evaluation can prevent recurrence.

Comparative evaluation of gastric pH and volume in morbidly obese and lean patients undergoing elective surgery and effect of aspiration prophylaxis.

INTRODUCTION: The anesthetic management of patients with morbid obesity is challenging. There is no consensus on the routine use of aspiration prophylaxis in morbidly obese patients undergoing elective surgery. AIM: The aim of this study is to assess the risk of pulmonary aspiration and effect of premedication with ranitidine and metoclopramide on gastric pH and volume in morbidly obese and lean patients. METHODS: Gastric volume and pH were measured in 3 groups of 20 patients each: group I (lean, no aspiration prophylaxis), group II (morbidly obese, no aspiration prophylaxis), and group III (morbidly obese; tablet ranitidine, 150 mg; and tablet metoclopramide, 10 mg administered the night before and 2 hours before surgery). Patients with critical gastric volume >25 mL and critical pH <2.5 (Roberts and Shirley criteria) were considered to be at risk for pulmonary aspiration. RESULTS: The percentage of patients with gastric volume >25 mL and pH <2.5 was 5%, 30%, and 0% in groups I, II, and III, respectively. Statistically significant difference existed between groups I and II (P = .04) and groups II and III (P = .006). Premedicated morbidly obese and lean patients were comparable (P = .46). CONCLUSION: Morbidly obese patients undergoing elective surgery are at a higher risk for regurgitation and pulmonary aspiration when compared with lean patients. Preoperative aspiration prophylaxis decreases gastric volume and increases gastric pH and thus should be routinely prescribed.