Effect of four-layer dressing on the microbiological profile of venous leg ulcer.

OBJECTIVE: Venous leg ulcer (VLU) is a chronic disease and has periods of exacerbation and remission. Various bandage systems-single-layered, double-layered and multiple-layered with elastic and non-elastic components-have been developed. The requirement for sustained pressure brought about the introduction of the four-layer bandage. We studied the bacteriology of VLUs and the effect of four-layer bandages on their healing. METHOD: Clinical details of all patients, with wound size measurement by gauze piece, wax paper and scale, were recorded. The wounds were initially debrided and photographic records of all patients were maintained. Patients were followed up every week, when the dressings and four-layer bandages were changed. RESULTS: A total of 60 patients were recruited to the study with four patients having bilateral disease and so a total of 64 VLUs were evaluated. Of these, 60 (93.8%) healed completely, one (1.6%) healed partially and three (4.7%) did not heal. After excluding the four VLUs that did not fully heal, 10 (16.7%) had recurrence while 50 (83.3%) had no recurrence in the follow-up period, which lasted for one year. During the first visit (baseline), meticillin-resistant Staphylococcus aureus (MRSA) was isolated in 29 (45.31%) VLUs and Pseudomonas spp. in 20 (31.25%) VLUs. With subsequent dressing, the VLU size decreased and the culture of the VLU was sterile from the third culture onwards in 45 cases. There was a significant correlation (p<0.001) between VLU size and the number of dressings. CONCLUSION: Compression therapy is the mainstay of treatment of VLU, with rapid healing and improvement in bacteriological profile. Compression in the range of 30-40mmHg is the most effective treatment for uncomplicated VLUs with adequate arterial competency.

Digital glomus tumor: An experience of 57 cases over 20 years.

BACKGROUND: Glomus tumors are rare tumors and may affect any area of the body, but digits, palms, and soles are commonly affected due to higher number of glomus body. We present our experience with the management of 57 cases of glomus tumors of the fingertips treated over a period of 20 years (2000-2019). MATERIALS AND METHODS: Medical records of 57 cases with glomus tumors treated over a period of 20 years were reviewed for patient demographics, presenting characteristics, duration, previous treatment history, physical examination, investigation, treatment, follow-up, and recurrence. RESULTS: In our study, the mean age was 49 years, with age 47 years among women and 53 years among men suggesting glomus tumor as a disease of past middle age. The total number of cases was 57 with 44 women and 13 men. Site of lesion was nail bed in 50 cases (87.7%) and tip of finger in 7 cases (12.3%). In clinical assessment pinpoint tenderness was present in all 57 cases (100%) and pain in 56 cases (98.8%). Other features at the time of presentation were nodularity in 38 cases (66.6%), deformed nail in 14 cases (24.6%), and cold hypersensitivity in 20 cases (35.1%). The mean duration of the disease was 2.3 years (1.2-5.6 years). CONCLUSION: One of the most painful clinical conditions confirmed by comprehensive clinical assessment and cured dramatically by complete surgical excision.

Study of association of varicose veins and inflammation by inflammatory markers.

OBJECTIVE: In varicose veins, increased levels of inflammatory markers are indicators of endothelial damage and increased procoagulant activity. These findings support the assumption that the constitution of blood in varicose veins differs from that of systemic blood. The purpose of the study was a correlative study of blood constituents in varicose veins and peripheral veins (normal vein) in same individual with varicose vein which was done by comparing the level of concentration of interleukin-6, fibrinogen, haemoglobin from blood of varicose veins and normal peripheral vein (antecubital vein). METHOD: Using citrated plasma samples withdrawn from arms and legs of same patient and plasma obtained by centrifugation of citrated venous blood at 5000 r/min for 10 min was used for correlation. Serum concentration of interleukin-6 and fibrinogen were determined by human enzyme-linked immunosorbent assay Kit for both interleukin-6 and fibrinogen, which is based on the standard sandwich enzyme-linked immunosorbent assay technology. This assay employs a monoclonal antibody specific for human interleukin-6 coated on a 96-well plate. RESULT: Expressed as median (interquartile range) in pg/mL, leg samples from patient having varicose vein has significantly increased interleukin-6 in cases as compared to controls (p value of <0.001). Leg samples from patient having varicose vein has significantly increased fibrinogen concentration than their arm samples (p value of <0.001). Concentration of haemoglobin significantly increased in leg samples as compared to blood withdrawn from arms (p value of 0.012). CONCLUSION: Blood withdrawn from the site of varicose vein appears to have significantly increased concentration of interleukin-6, fibrinogen and haemoglobin when compared to same patient's antecubital blood sample supporting the hypothesis that inflammation is increased in tissues drained by varicose vein.

Simplified Laparoscopic Suture Rectopexy for Idiopathic Rectal Prolapse In Children: Technique and Results.

BACKGROUND: Laparoscopic suture rectopexy is safe and effective treatment option for pediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR). MATERIAL AND METHODS: The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications. RESULTS: 19 patients from MLSR and 22 patients from CLSR were evaluated. The mean operative time in MLSR group was 41.5 ±â€¯6.2 min which was significantly lesser than CLSR group with a mean operative time of 78.6 ±â€¯14.2 (p = 0.001). The blood loss was also less in MLSR group compared to CLSR group (p = 0.013). At three months of follow up, the constipation was less in MLSR group compared to CLSR group (p = 0.041). CONCLUSION: The modification makes the procedure technically easy, minimizes the chances of complications and retaining all the advantages of suture rectopexy. LEVEL OF EVIDENCE: Level II.

Assessment and grading of pigmentation in chronic venous insufficiency.

INTRODUCTION: Chronic venous insufficiency causes skin pigmentation of the leg ranging from small patches of mild dyschromia to extensive areas of severe skin pigmentation. It is thought that the pigmentation is mainly due to haemosiderin or melanin deposition. Erythrodiapedesis which occurs as a result of venular hypertension causes erythrocytes to migrate across the microvascular network into the dermis. METHODS: We categorized the grading of pigmentation into four grades: +, few spots; ++, pigmentation over gaiter area; +++, pigmentation involving leg and ankle; ++++, heavily pigmented (dark). Skin biopsies were taken from the patient while undergoing surgery; two biopsies were taken from each patient, one from apparently normal skin and other from the site of pigmentation. A total of 45 patients diagnosed as chronic venous insufficiency with pigmentation were included in the study and five patients included in control. The biopsy specimens were sent to pathology department for H&E, Perls stain and IHC for S100. RESULTS: Majority of cases, i.e. 62% of limbs fall under (++) grade of pigmentation, followed by (+) grade of pigmentation in 20%, while (+++) and (++++) constitute 9% of the cases each. Increased melanin deposition was seen in 40 pigmented skin biopsies and 3 normal skin biopsies from the case group, and normal melanin deposition was seen in all the non-varicose controls. CONCLUSION: We have tried to categorize pigmentation in chronic venous insufficiency into four grades. As the grade of pigmentation increases the per cent of cases with ulceration is increasing. It was observed that presence of melanin deposition irrespective of the grade of pigmentation was distributed more towards the advanced clinical classification (C5 and C6).

Evidence-Based Clinical Practice Points for the Management of Venous Ulcers.

Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan. Venous ulcers generally persist for weeks to many years and are typically recurrent in nature. This consensus aims to present an evidence-based management approach for the patients with venous ulcers. Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF). Compression therapy is the mainstay treatment for venous ulcer. However, in failure cases, surgery can be preferred. Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer. In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer.

Correction to: Evidence-Based Clinical Practice Points for the Management of Venous Ulcers.

[This corrects the article DOI: 10.1007/s12262-018-1726-3.].

Squamous cell carcinoma arising from pilonidal sinus.

Pilonidal sinus is usually present in the sacrococcygeal region. The common presentations are cellulitis, abscess or sinus. Rarely malignant change may be seen in chronic pilonidal sinus. We report a case of chronic pilonidal sinus complicated with squamous cell carcinoma.

Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis.

Background. Multifactorial scorings, radiological scores, and biochemical markers may help in early prediction of severity, pancreatic necrosis, and mortality in patients with acute pancreatitis (AP). Methods. BISAP, APACHE-II, MOSS, and SIRS scores were calculated using data within 24 hrs of admission, whereas Ranson and Glasgow scores after 48 hrs of admission; CTSI was calculated on day 4 whereas IL-6 and CRP values at end of study. Predictive accuracy of scoring systems, sensitivity, specificity, and positive and negative predictive values of various markers in prediction of severe acute pancreatitis, organ failure, pancreatic necrosis, admission to intensive care units and mortality were calculated. Results. Of 72 patients, 31 patients had organ failure and local complication classified as severe acute pancreatitis, 17 had pancreatic necrosis, and 9 died (12.5%). Area under curves for Ranson, Glasgow, MOSS, SIRS, APACHE-II, BISAP, CTSI, IL-6, and CRP in predicting SAP were 0.85, 0.75, 0.73, 0.73, 0.88, 0.80, 0.90, and 0.91, respectively, for pancreatic necrosis 0.70, 0.64, 0.61, 0.61, 0.68, 0.61, 0.75, 0.86, and 0.90, respectively, and for mortality 0.84, 0.83, 0.77, 0.76, 0.86, 0.83, 0.57, 0.80, and 0.75, respectively. Conclusion. CRP and IL-6 have shown a promising result in early detection of severity and pancreatic necrosis whereas APACHE-II and Ranson score in predicting AP related mortality in this study.

Parathyroid incidentaloma.

Incidentalomas are lesions which are asymptomatic and detected incidently during imaging or surgery. Parathyroid incidentalomas are a rare entity. Enlargement of gland without hyperfunction may be an early stage of disease. Symptomatology is usually non-specific or related to renal and skeletal system. Total serum calcium estimation may be used as a screening modality. Sestamibi scan is a more accurate imaging technique than USG. FNAB - PTH measurement is the most reliable minimally invasive nonsurgical test for parathyroid tissue verification. Incidently discovered enlarged parathyroid gland may be removed to avoid a re-do surgery.

Postthrombotic syndrome: surgical possibilities.

Postthrombotic syndrome (PTS) is a late outcome of deep vein thrombosis characterized by cramping pain, swelling, hyperpigmentation, eczema, lipodermatosclerosis, and ulceration in the leg due to increased venous outflow resistance and reflux venous flow. Newer surgical and endovascular interventions have a promising result in the management of postthrombotic syndrome. Early surgical or endovascular interventions in appropriately selected patients may decrease the incidence of recurrent ulceration and skin changes and provide a better quality of life. Duplex and IVUS (intravenous ultrasound) along with venography serve as cornerstone investigative tools for assessment of reflux and obstruction. Venous obstruction, if present, should be addressed earlier than reflux. It requires endovenous stenting, endophlebectomy, or open bypass procedures. Venous stripping, foam sclerotherapy, radiofrequency, or laser ablation are used to abolish superficial venous reflux. Valvuloplasty procedures are useful for incompetent but intact deep venous valves, while transposition or axillary vein autotransplantation is done for completely destroyed valves.

Simultaneous breast and ovarian metastasis from gallbladder carcinoma.

BACKGROUND: Gallbladder carcinoma is a common malignancy in the Indian subcontinent. It commonly metastasizes through lymphatics, direct invasion, and hematogenous spread. A common extra-abdominal site of metastasis is the lungs. Simultaneous metastasis to breast and ovary is extremely rare. METHOD: This report describes an unusual case of carcinoma gallbladder metastasizing to the breast and ovary at the same time. RESULTS: A 45-year-old woman came to us with complaints of flatulent dyspepsia associated with weight loss and anorexia. Ultrasound of the abdomen revealed hepatomegaly with thick-walled gallbladder with multiple stones and a mass at the fundus, but normal uterus and ovary. Contrast-enhanced computer tomography of the abdomen showed a gallbladder mass infiltrating the liver parenchyma. The patient underwent radical cholecystectomy. Histopathological examination revealed a poorly-differentiated adenocarcinoma with mar-gins free from tumor infiltration. One month after surgery she developed a breast lump. Ultrasound of the abdomen for metastatic workup revealed an ovary mass. Simple mastectomy and salphingo-opherectomy were performed, and histopathological examination revealed a metastatic adenocarcinoma. The patient is now on chemotherapy with gemcitabin. CONCLUSION: This is an unusual case of carcinoma of the gallbladder with metastasis to the breast and ovary, which has not been documented before.

Comparison of Ligasure Hemorrhoidectomy with Conventional Ferguson's Hemorrhoidectomy.

Conventional hemorrhoidectomy for grade III and IV hemorrhoids is a tedious procedure associated with significant morbidity and a prolonged convalescence. We compared Ligasure™ hemorrhoidectomy with conventional 'closed' Ferguson's hemorrhoidectomy for the treatment of grade III and IV hemorrhoids. Forty-eight consecutive patients of grade III and IV hemorrhoids were randomized to either the Ligasure™ hemorrhoidectomy (28 patients) or Ferguson's hemorrhoidectomy (20 patients). The hemorrhoidal predicle was coagulated with Ligasure™ in the Ligasure™ group and transfied with 2/0 chromic catgut in Ferguson's method. In comparison with Ferguson's method, Ligasure™ hemorrhoidectomy had a shorter operating time (29 vs 12.5 min), less blood loss (22 vs 11.5 ml), less post operative pain as measured on VAS scale and less postoperative complications including hemorrhage (10% vs 3.5%), urinary retention (10% vs 3.5%) and wound breakdown (20% vs 14%). The submucosal dissection technique with Ligasure™ coagulation of the hemorrhoidal pedicle is safe and effective. The blood vessels and tissue are reduced to a wafer thin seal with good hemostasis. Suturing is not required as the mucosal tissue over the pedicle is sealed off with the current. There is minimal lateral spread of either thermal or electrical energy. The external components of the hemorrhoids can also be treated at the same time. Because of its ease of use and less postoperative pain and complication Ligasure™ hemorrhoidectomy can be preformed as a day-care procedure.

Colonic carcinoma with multiple small bowel perforations mimicking intestinal obstruction.

BACKGROUND: Carcinoma of the colon may present with perforation proximal to the site of malignancy. Caecum is the commonest site of perforation if the ileocecal valve is patent and the jejunal and ileal perforations are very rare. CASE PRESENTATION: A 35 year male presented with intestinal obstruction. Emergency laparotomy revealed carcinoma of the transverse colon with multiple pinpoint perforations along antimesenteric border of ileum, which were wrapped with omentum, and no peritoneal contamination was present. Extended right hemicolectomy with jejunocolic anastomosis was done. Patient made uneventful recovery in postoperative period and was treated with adjuvant chemotherapy. CONCLUSION: Patients with colonic carcinoma and incompetent ileocecal valve may present with intestinal perforation. Increased intraluminal pressure and closed loop obstruction may lead to ischemia and perforation of the small bowel.

Hemangiopericytoma of the spleen: unusual presentation as multiple abscess.

BACKGROUND: Hemangiopericytoma is a soft tissue vascular neoplasm arising from capillary pericytes and is found throughout the body in soft tissues and bone. It was first described in 1942. Primary vascular neoplasm of the spleen constitutes the majority of nonhaematolymphoid splenic tumors like haemangioma, lymphangioma, hemangioendothelioma, hemangiopericytoma etc. Splenic hemangiopericytoma is a rare tumor and probably first case was described in 1989. Uptill now only eight cases are reported in the English literature. CASE PRESENTATION: A-35-year old male presented with fever and dull aching pain in left hypochondriac region. Radiological evaluation showed presence of multiple abscesses in spleen. Investigations were done to rule out common causes of abscess in spleen. After failure of medical management, he was subjected to elective splenectomy. There were dense adhesions between the spleen and the adjacent structures and the diaphragm. The histopathology of the resected specimen showed hemangiopericytoma of spleen. CONCLUSION: The present case illustrate that the hemangiopericytoma of spleen can mimic as multiple abscess. Splenectomy is the treatment of choice.

AgNOR count and subjective AgNOR pattern assessment (SAPA) score in carcinoma of the pancreatic head including periampullary tumors.

CONTEXT: Only a few studies are available in the literature regarding the AgNOR (argyrophilic nucleolar organizer region) count in pancreatic adenocarcinoma but studies on the SAPA (subjective AgNOR pattern assessment) score are completely lacking. OBJECTIVE: We attempted to estimate the AgNOR count and the SAPA score in carcinoma of the pancreatic head including periampullary tumors and to correlate them with other various clinico-histological parameters. SETTING: Patients undergoing pancreatic resection at the University Hospital, Banaras Hindu University, Varanasi, India. PATIENTS: Twenty-four cases of carcinoma of the pancreatic head including periampullary tumors. In addition, on the resected specimen of the pancreas, the area which was normal was chosen and, in that normal tissue, the AgNOR was also studied. MAIN OUTCOME MEASURES: Patients were studied for the AgNOR count and the SAPA score, and the values were correlated with the size of the tumor, the type of tumor and histological type and grade of tumor. RESULTS: The values of the AgNOR count and the SAPA score were significantly higher in cases of pancreatic cancer than in the healthy pancreas. The AgNOR count was 1.6+/-0.1 in the healthy pancreas while it was 2.8+/-0.5 in cases of pancreatic carcinoma (P<0.001). The SAPA score was 5.6+/-0.2 in the healthy pancreas while it was 8.0+/-1.4 in pancreatic carcinoma (P<0.001). Tumors less than or equal to 2 cm in size had an AgNOR count of 2.6+/-0.08 while the AgNOR count was 3.4+/-0.02 in tumors larger than 2 cm (P<0.001). The SAPA score was also higher in tumors greater than 2 cm in size (7.3+/-0.2 vs. 9.4+/-0.8; P<0.001). Periampullary tumors had a significantly lower (P<0.001) AgNOR count (2.7+/-0.06) and SAPA score (7.8+/-0.2) as compared to carcinoma of the head of the pancreas (AgNOR count 3.3+/-0.03 and SAPA score 9.2+/-0.7). Well-differentiated carcinomas had significantly lower AgNOR counts as compared to other tumors except acinar cell carcinomas since acinar cell carcinomas are also well-differentiated tumors. The SAPA score was also higher in moderately-differentiated tumors and the difference between moderately-differentiated tumor and other types of tumors was significant although there was no significant difference between cystadenocarcinomas and unclassified tumors, and between acinar cell carcinomas and well-differentiated tumors on SAPA scoring. CONCLUSIONS: The values of the AgNOR count and the SAPA score are well-correlated with the size of the tumor, the type of tumor and the histological grade.