Ovarian teratoma presenting as small bowel obstruction in an elderly lady-A case report.

Teratomas of the ovary are of the mature or immature type. The mature variety is called dermoid cysts, which is the most frequent benign germ cell tumour of the ovary in the reproductive age group. They are usually asymptomatic until they reach a significant dimension.(1) Pressure effect, torsion and rupture of an ovarian cyst may present as an acute abdomen. A case is presented where an elderly lady presented with small bowel obstruction due to a very large, non-adherent to the intestine, dermoid cyst.

Extraction of a rectal foreign body - an alternative method.

We present a case report of trans-anal extraction of a foreign body from the rectum using an unconventional instrument. Our patient presented with impacted retained rectal foreign bodies. As the patient suffered from psychosis, a laparotomy with a stoma would have been difficult to manage. It was thus decided to make every effort to retrieve the objects transanally. After failed attempts with retractors and endoscopy, Kielland obstetric forceps were used successfully to retrieve the foreign body transanally. The authors have found no other report describing use of Kielland obstetrical forceps to retrieve foreign bodies from the rectum.

Synchronous perforation of sigmoid diverticula: a rare presentation.

Diverticular disease affects more than 50% of the population over the age of 60 years in the west and becomes even more common as the population ages. Diverticulitis is one of the complications of diverticular disease and can culminate into colonic perforation. Though perforated diverticular disease is not uncommon, synchronous colonic perforations in diverticulitis is rare. Our patient was admitted with acute abdomen and exploratory laparotomy revealed two side-by-side perforations of the sigmoid colon. A Hartmann's procedure was performed. Macro- and microscopic evaluation confirmed the presence of two perforated sigmoid diverticula due to diverticulitis. Simultaneous perforation of two abreast sigmoid diverticula is uncommon; thus, a cautious surgeon should always take into account such a probable diagnosis.

Gallstone ileus and bowel perforation: a rare complication of therapeutic ERCP.

Gallstone ileus is rare following an Endoscopic Retrograde Cholangio-Pancreaticography (ERCP). We present a case where gallstones caused ileus and perforation of small bowel after a therapeutic ERCP. There was no previous history of instrumentation of the papilla or a cholecystoenteric fistula. This case points out a serious morbidity of therapeutic ERCP for large common bile duct stones.

Negative pressure therapy for laparotomy wounds--a word of caution.

Negative pressure wound therapy (NPWT) is being used for the management of laparotomy wounds. The device applies subatmospheric pressure to the open abdominal wounds. We suggest a modification in its application to prevent a leak from the bowel.

Injuries to the duodenum--prognosis correlates with body Injury Severity Score: a prospective study.

BACKGROUND: Duodenal injury is an important hollow viscus injury in the abdomen. The study analysed the factors related to the outcome of duodenal injuries presenting to the unit. PATIENTS AND METHODS: Prospectively collected data on a case series involving 23 patients over three years. It involved demographic details, Injury Severity Score, Revised Trauma Score, part of duodenum injured, duodenal injury severity according to the AAST, injury-operation time lag, mode of repair, and the extent of significant associated injuries. Patients with non-perforating injury were excluded. RESULTS: M:F ratio was 9:2. Median age was 33 years. All were operated by a senior registrar or senior. Seven out of 23 were blunt, 13/23 firearm and 3/23 stab injuries. D2 was involved in 87%. Duodenal injury severity was graded according to American Association for Surgery of Trauma-Organ Injury Scale (AAST-OIS). Seventeen/23 were Grade II/III, 3 Grade IV and 3 Grade V injuries. Four had injury-operation lag of >18 h. Two injuries were missed. All injuries up to Grade IV had simple repair. Two of them had T-tube duodenostomy. None had pyloric exclusion. Complex repairs were required for 3/23 patients. Five patients died. Duodenum-related mortality was zero. The mortality was related to body Injury Severity Score >45. One delayed repair developed duodenal fistula. Intra-abdominal abscess, septicaemia and wound dehiscence were seen in two patients each. Adverse prognostic factors towards morbidity was injury-operation lag >18 h.

Vacuum assisted closure of laparostomy wounds "a novel technique".

Management of a laparostomy wound is contentious. Specific pathologies like severe intraabdominal sepsis, trauma requiring damage control, abdominal compartment syndrome, staged abdominal repair and other complex abdominal pathologies can be managed with a novel technique of Vacuum Assisted Closure dressing. This device applies sub-atmospheric pressure that leads to reduced bowel wall edema, bacterial count and inflammatory burden found in open abdominal wounds. This leads to a reduced need for frequent dressing changes, maintaining intact skin and improvement in fluid management. Controlled clinical studies are needed to establish the safety and effectiveness of this treatment strategy. We present our experience with this technique suggesting it to be safe and effective. A brief outline of the working of Vacuum Assisted Closure dressing is also presented.

Metaanalysis of recurrence after laparoscopic repair of paraesophageal hernia.

BACKGROUND: Recurrence and reflux are 2 most important remote complications of lap-paraesophageal hernia (PEH) repair. However, the extent of recurrence remains unknown. We sought to determine the true incidence of recurrence after lap-PEH repair. METHODS: A meta-analysis was carried out. PubMed, EMBASE, Cochrane Library, hand search, and personal communication were used to access and appraise studies. The inclusion criteria were full-text papers published from 1991 to date that describe lap-PEH repair in >25 patients, have at least a 6-month follow-up, and address the issue of recurrence. "Wrap migration" papers were excluded. Papers were appraised and the data were isolated on summary sheets. MS Office Excel 2003 was used to plot the results and represent it in graphs. RESULTS: Thirteen studies were eligible (all retrospective case series). A total of 965 patients with 99 recurrences were noted. The overall recurrence rate (in all patients) was 10.2% and was 14% if only the followed up patients (n=658/965) were considered. However, when patients with objective evidence (follow-up Ba esophagogram) were used (301/965), the "true" recurrence rate was 25.5% (ie, 1 in 4 recurred). The learning curve did not appear to be an issue (P=0.27). The studies revealed broad 95 CI and touched the line-of-no-effect, thereby increasing the "chance factor." When an alternate model was applied, esophageal lengthening (by Collis-Nissen gastroplasty) revealed a significant protective influence (P<0.0001). CONCLUSION: The true incidence of lap-PEH recurrence is 25.5%. The learning curve is not an adequate explanation. Mandatory (protocol) follow-up esophagograms at 1 year are essential. Two emphasis points in the repair have emerged: hiatoplasty and (superadded) esophageal lengthening.