Utility of Serum L-lactate in Identifying Ischemia in Acute Intestinal Obstruction: A Prospective Observational Study.

Introduction In cases of intestinal obstruction, increasing luminal dilatation compromises bowel wall perfusion, eventually resulting in intestinal ischemia and bowel necrosis in advanced cases. Elevated L-lactate, as a biomarker of ischemia, may indicate the presence of bowel ischemia in cases of obstruction. The objective of this study was to evaluate the value of serum L-lactate measurement in predicting the presence of intraoperatively observed intestinal ischemia in patients with acute intestinal obstruction. Methods Patients diagnosed with acute intestinal obstruction were prospectively studied over an 18-month period. Serum L-lactate values were assayed twice: at the time of presentation and following appropriate fluid resuscitation. Receiver operating characteristic (ROC) curve analysis was applied to determine the predictive value of serum L-lactate in detecting intestinal ischemia. Results One hundred forty-four cases of intestinal obstruction were included in this study, of which 91 underwent operative intervention. Intestinal ischemia was identified in 52 cases and categorized intra-operatively as reversible (n = 33) and irreversible (n = 19). ROC analysis showed a good predictive value of serum L-lactate after fluid resuscitation for irreversible intestinal ischemia (area under the curve (AUC) = 0.884, 95% confidence interval (CI), 0.812-0.956). An L-lactate cut-off of 19.1 mg/dL following fluid resuscitation was determined to have a sensitivity of 89.5%, a specificity of 72.9%, a positive predictive value of 46.6%, and a negative predictive value of 96.3% for gangrenous bowel. Conclusion Serum L-lactate is a good predictive tool for identifying intestinal ischemia during the management of intestinal obstruction. Serum L-lactate after resuscitation showed better predictive value for ischemic bowel.

Laparoscopic management of an uncommon cause for right lower quadrant pain: A case report.

INTRODUCTION: Primary segmental infarction of the greater omentum is an infrequent cause for right lower quadrant pain. The exact aetiology is unknown and the right side is more commonly involved. It usually presents like acute appendicitis and the diagnosis is made during exploration. CASE REPORT: We report such a case which was diagnosed and managed by laparoscopy. A 27-year-old male presented with features suggestive of acute appendicitis. Preoperative imaging failed to diagnose the condition. Laparoscopy showed a segment of oedematous and haemorrhagic greater omentum adherent to the parietal wall over the right lower quadrant. The infarcted segment was excised and removed in a non permeable bag through the umbilical port. A short edited video of the operative findings and the procedure executed is also provided. CONCLUSION: Primary segmental infarction of the greater omentum is an uncommon cause of right lower quadrant pain mimicking appendicitis. Laparoscopy is both diagnostic as well as therapeutic.

Laparoscopic mesh splenopexy (sandwich technique) for wandering spleen.

BACKGROUND: Wandering spleen is a rare clinical condition caused by incomplete fusion of the 4 primary splenic ligaments, allowing the spleen to be mobile within the abdomen, predisposing to splenic torsion along the vascular pedicle leading to splenomegaly and infarction, often diagnosed in an emergency setting. METHODS: The wandering spleen diagnosis was achieved by ultrasound in our case. We successfully treated the patient with laparoscopic splenopexy because the size was almost normal, and no infarction or evidence of hypersplenism was present. We used the sandwich technique in which 2 meshes sandwich the spleen. RESULTS: This technique was found to be highly satisfactory as a treatment for wandering spleen. The patient was discharged on the third postoperative day with no intraoperative or postoperative complications. CONCLUSION: Laparoscopy usually confirms the diagnosis. Recommended surgical procedures are splenopexy or splenectomy. Splenopexy is feasible, less invasive, and does not diminish splenic function.

Laparoscopic repair of high rectovaginal fistula: is it technically feasible?

BACKGROUND: Rectovaginal fistula (RVF) is an epithelium-lined communication between the rectum and vagina. Most RVFs are acquired, the most common cause being obstetric trauma. Most of the high RVFs are repaired by conventional open surgery. Laparoscopic repair of RVF is rare and so far only one report is available in the literature. METHODS: We present a case of high RVF repaired by laparoscopy. 56-year-old female who had a high RVF following laparoscopic assisted vaginal hysterectomy was successfully operated laparoscopically. Here we describe the operative technique and briefly review the literature. RESULTS: The postoperative period of the patient was uneventful and after a follow up of 6 months no recurrence was found. CONCLUSION: Laparoscopic repair of high RVF is feasible in selected patients but would require proper identification of tissue planes and good laparoscopic suturing technique.

Secretory carcinoma of breast in a 17-year-old male.

BACKGROUND: Secretory carcinoma of the male breast (juvenile carcinoma) is a rare neoplasm. Only a few cases have been reported in the literature. CASE REPORT: We report here a case in a 17-year old male presenting with recurrent breast swelling. CONCLUSIONS: Though considered an indolent neoplasm, secretory carcinoma does metastasise to lymph nodes and recur after local excision. Surgery in form of mastectomy with axillary clearance is the treatment of choice.