Subacute Peristomal Necrotizing Fasciitis Detected During Adjuvant Chemotherapy for Adenocarcinoma Rectum: Case Report on a Unique Presentation and Description of a Simple Surgical Strategy for Treatment.

Necrotizing fasciitis (NF) is a rare entity with its subacute form being even rarer. The condition has also been described to occur in the peristomal area in relation to different clinical scenarios. However, it has not been described in the setting of adjuvant chemotherapy where these medications have already been given. While the diagnosis may be delayed or missed due to the subtle symptomatology of the indolent subacute form of NF, another reason for a delayed or missed diagnosis may be the excessive use of tape and the stoma belt around the stomal appliance to prolong the life of the appliance beyond its recommended days of usage due to economic constraints. This, in turn, covers a larger area around the peristomal skin and developing skin changes associated with necrotizing fasciitis. Despite the less aggressive presentation of the subacute form, it may still represent a unique surgical challenge in this setting, as the chemotherapy-induced neutropenia bound to occur a few days after the chemotherapy may expose the patient to serious complications at that time. As such, the surgical plan at the time of presentation may become the determinant of morbidity and mortality. Here, a case is presented of a young patient who underwent abdominoperineal resection for stage III adenocarcinoma of the rectum. He was referred to us on the day of the fourth cycle of adjuvant chemotherapy by the oncology service where he had received part of his chemotherapy regimen. On presentation, he was found to be having significant skin changes in the peristomal area consistent with necrotizing fasciitis despite being clinically stable. The authors present this unique case as a study from which many lessons can be learned. They also explain the thought process behind a well-planned but simple surgical strategy that was implemented with a successful patient outcome. In addition to describing this surgical strategy, the case report is concluded by highlighting some factors that may raise suspicion of this condition and by emphasizing routine history-taking for peristomal symptomatology and a thorough examination of the peristomal site prior to administration of chemotherapy in patients with stomata, as this condition, if overlooked, may lead to a fatal outcome.

Metabolic Syndrome: An Indicator of Complicated Gall Stone Disease?

Background Gallstone disease is a common surgical entity worldwide and accounts for a major portion of hospital admissions and surgeries. Metabolic syndrome is diagnosed when three of the following medical conditions are positive: central obesity, high blood pressure, increased fasting glucose levels, low high-density lipoprotein (HDL) levels and high serum triglycerides. Objective To compare the frequency of metabolic syndrome in patients with uncomplicated gallstone disease and complicated gallstone disease. Study design Observational, cross-sectional study. Methodology A total of 104 patients, above age 18 years, visiting the outpatient department (OPD) or the emergency department, diagnosed as having gallstone disease. The study was conducted in surgical unit VI, civil hospital Karachi from June 2014 to June 2015. Patients' demographics, abdominal waist circumference, blood pressure, serum fasting blood sugar, triglyceride level and HDL levels were recorded. Final outcome was labeled as presence or absence of metabolic syndrome. Presence of metabolic syndrome was compared in patients with complicated gallstone disease as well as in patients with uncomplicated gallstone disease. Chi square test was used to detect statistical significance and a p-value of <0.05 was taken as significant. Results The ages were comparable between the two groups, that is, the complicated and uncomplicated gallstone disease at 42.42 +/- 12.15 years in the former and 39.24 +/- 10.41 years in the latter group. Metabolic syndrome was more predominant in the complicated arm 40.38% when compared to uncomplicated arm 25% but it was not significant statistically with a p-value of 0.2. Conclusion Metabolic syndrome is associated with complicated gallstone disease though this study failed to reach statistical significance due to small sample size, it re-enforces the findings of previous studies. It is an easily assessable and useful measure to predict complications associated with gall stone disease.

Iatrogenic Non-Reconstructable Duodenal Injury Presenting without Peritonitis: An Indication of Pancreatoduodenectomy in the Presence of Safe Hands. A Case Report.

Iatrogenic duodenal injuries are rare complications of upper gastrointestinal endoscopic procedures, gallbladder, and right kidney operations. Management includes diverse options depending on a number of factors that include the size of the injury, timing of presentation, degree of peritoneal contamination, and presence of peritonitis and/or sepsis, etc. While most duodenal injuries are small, large complex non-reconstructable injuries may occasionally occur, requiring complex surgical procedures rather than primary repair which if done in the latter cases, may lead to further morbidity and mortality. Whipple's pancreatoduodenectomy has rarely been performed for complex duodenal injuries especially in the iatrogenic setting. Here a case is reported of an iatrogenic duodenal injury that presented 12 days after a right open nephrectomy, with a dehisced right lumber incision having greater than one liter per day bilious discharge, for which Whipple's pancreatoduodenectomy was performed. A discussion regarding factors which influenced per-operative decision making and probably led to a successful patient outcome is presented.