Primary hepatic functional neuroendocrine tumor in an elderly female: Case report.

Key Clinical Message: Primary hepatic neuroendocrine tumor, an exceptionally rare subtype, poses a diagnostic challenge. Oncological resections should be considered, even in elderly patients after following protocolized pre-operative optimizations. Abstract: Neuroendocrine tumors (NETs) are rare tumors that primarily develop in the gastrointestinal and respiratory tracts. While the liver is commonly affected by NET metastases, primary hepatic neuroendocrine tumors (PHNETs) are an exceptionally rare subtype. The characteristic slow growth and nonfunctional nature of PHNETs pose challenges in their diagnosis. Furthermore, PHNETs often exhibit a lack of unique radiological characteristics that differentiate them from other liver tumors, leading to frequent misdiagnosis as hepatocellular carcinoma. We performed left hepatectomy for PHNET in an elderly lady with prolonged stormy postoperative course. This case report of a PHNET highlights the importance of histopathology and immunohistochemistry in the diagnosis and emphasizes that oncological resection, if feasible, is the preferred treatment even in the elderly population.

An incarcerated epigastric hernia with unusual contents.

Key Clinical Message: An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. This fact needs to be kept in mind by the operating surgeons. Abstract: An epigastric hernia usually contains preperitoneal fat, but rarely may contain colon. Experience with such a singular case is presented and discussed. This fact needs to be kept in mind by the operating surgeons.

Minimal access surgery of corrosive and thermal strictures of the foregut.

Background and Aim: : Conventional surgery for caustic/thermal strictures (CS/TS) entails considerable trauma, which may be mitigated by minimal access surgery (MAS). Experience with its use in CS/TS is both heterogeneous and limited, hence, warrants a comprehensive review. Methods: : Medical literature/indexing databases were systematically searched for pertinent articles published in English, from 1990 to 2021, and analysed. Results: : Fifty relevant articles, pertaining to over 200 patients, were found. They showed that MAS is feasible in CS/TS management. It reduces the access damage in chest and abdomen whilst facilitating resection or bypass of the affected gut segment through different combination of operations, sequence of steps, conduits and routes. The procedures range from completely minimal access to hybrid ones, with reduced complications and faster recovery. Hybrid procedures prove as expeditious as open ones. Conclusions: : MAS proves efficacious in restoring alimentary continuity in corrosive/thermal strictures of the foregut.

Evaluation of implantable Doppler probe continuous monitoring of hepatic artery anastomosis after liver transplantation.

BACKGROUND: Thrombosis of hepatic artery anastomosis (HAT) after liver transplantation is a catastrophic and dreaded complication. Early identification of HAT can salvage the situation. To monitor the anastomosis, conventional daily transcutaneous Doppler is performed. However, it has disadvantages of being noncontinuous, operator-dependent and technically difficult. Implantable Doppler probes wrapped around the anastomosed vessel giving continuous signal may be an important tool; however, very few studies are performed to study its efficacy after intra-abdominal vascular anastomosis, and its role is not clearly established. METHODS: Patients who underwent deceased donor liver transplant surgery were part of the study. On hepatic arterial anastomosis, implantable Doppler probe was fixed for monitoring. Conventional daily transcutaneous Doppler was also performed and the results were compared. RESULTS: A total of 40 hepatic arterial anastomoses were studied. The incidence of HAT was 10.53%. For the implantable Doppler probe monitoring, sensitivity and negative predictive value was 100%, whereas specificity was 94.44% and positive predictive value was 66.66% with an overall accuracy of 95%. A mean of 10 h of lead time was gained by implantable Doppler probe monitoring. CONCLUSION: Our study showed that there was high sensitivity and negative predictive value of implantable Doppler probe monitoring system, which makes it ideal for post-operative vascular anastomoses surveillance monitoring; however, abnormal positive finding on implantable Doppler probe monitoring needs to be confirmed by conventional transcutaneous Doppler. The implantable Doppler probe monitoring, because of its round the clock and continuous nature gives us a good lead time in identifying vascular complication, which translates into graft salvage and reduction in morbidity and mortality.

Evidence-based adoption of purse-string skin closure for stoma wounds.

BACKGROUND: Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure. METHODS: Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire. RESULTS: Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group. CONCLUSION: Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

Modified Makuuchi incision for major upper abdominal surgeries.

ackground: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. MATERIALS AND METHODS: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014-Dec 2018, was audited. RESULTS: 144 patients (76 Males, 68 Females) with an average age of 48.25 years underwent surgery using modified Makuuchi incision. 'J' and 'L' incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients (13.2%). Incisional hernias was observed in 6 patients (4.2%), on an average follow up of 27.78 months. CONCLUSIONS: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Primary Myoglobinuria: Differentiate Myoglobinuria from Hemoglobinuria.

Myoglobin is dark red colour heme containing protein, stored in muscle. Change in permeability of myolemma causes myoglobin leak in plasma, which is cleared by kidney swiftly. Differentiating myoglobinuria from hemoglobinuria is important. Clinicians concern over myoglobinuria is to protect the patient from acute renal disease. We present a case of primary myoglobinuria, its clinical symptoms, diagnosis and treatment.

Annexin A2 and its downstream IL-6 and HB-EGF as secretory biomarkers in the differential diagnosis of Her-2 negative breast cancer.

Background AnnexinA2 (AnxA2) membrane deposition has a critical role in HB-EGF shedding as well as IL-6 secretion in breast cancer cells. This autocrine cycle has a major role in cancer cell proliferation, migration and metastasis. The objective of the study is to demonstrate annexinA2-mediated autocrine regulation via HB-EGF and IL-6 in Her-2 negative breast cancer progression. Methods Secretory annexinA2, HB-EGF and IL-6 were analysed in the peripheral blood sample of Her-2 negative ( n = 20) and positive breast cancer patients ( n = 16). Simultaneously, tissue expression was analysed by immunohistochemistry. The membrane deposition of these secretory ligands and their autocrine regulation was demonstrated using triple-negative breast cancer cell line model. Results Annexina2 and HB-EGF expression are inversely correlated with Her-2, whereas IL-6 expression is seen in both Her-2 negative and positive breast cancer cells. RNA interference studies and upregulation of annexinA2 proved that annexinA2 is the upstream of this autocrine pathway. Abundant soluble serum annexinA2 is secreted in Her-2 negative breast cancer (359.28 ± 63.73 ng/mL) compared with normal (286.10 ± 70.04 ng/mL, P < 0.01) and Her-2 positive cases (217.75 ± 60.59 ng/mL, P < 0.0001). In Her-2 negative cases, the HB-EGF concentrations (179.16 ± 118.81 pg/mL) were highly significant compared with normal (14.92 ± 17.33 pg/mL, P < 0.001). IL-6 concentrations were increased significantly in both the breast cancer phenotypes as compared with normal ( P < 0.001). Conclusion The specific expression pattern of annexinA2 and HB-EGF in triple-negative breast cancer tissues, increased secretion compared with normal cells, and their major role in the regulation of EGFR downstream signalling makes these molecules as a potential tissue and serum biomarker and an excellent therapeutic target in Her-2 negative breast cancer.

ED plaster-of-Paris jacket for infantile scoliosis.

BACKGROUND: There are various articles published in last few years which consider surgical methods like growing rod instrumentation and modulation of the growth as a "gold standard" for the treatment of early onset severe scoliosis. We emphasize orthopaedic correction with serial casting as another option for such progressive deformity. The key to the success of this treatment is to understand the strategy and the technique involved in the effective casting. METHODS: The conventional technique of elongation, derotation, flexion cast (named EDF by Cotrel) is described with some modifications like wedging the cast (gypsotomy) in order to produce the flexion component. RESULTS: Serial casting with ED casts for the treatment of progressive idiopathic infantile scoliosis is an effective tool for the benign types of curves (Mehta) and spinal fusion was not necessary in two-third of our cases. CONCLUSION: Surgical option for treatment of early onset scoliosis is not a "gold standard". Orthopaedic treatment with serial elongation, derotation casts remain the centerpiece of this treatment. Each detail to understand the technique must be known in order to obtain the best result.

Treatment of late-presenting developmental dislocation of the hip by progressive orthopaedic reduction and innominate osteotomy. Our results with more than 30 years of follow up.

BACKGROUND: The treatment of late-presenting developmental dislocation of the hip (DDH) is still controversial. A consecutive series of 32 patients not previously treated (43 hips, Tönnis grade 3 or 4) underwent progressive closed reduction followed immediately by innominate osteotomy between 1964 and 1976. They were between 1.5 and 5 years old at the time of pelvic osteotomy. This study was designed to check the outcome of these patients more than 30 years later. METHODS: Eight patients living outside of France (North Africa) could not be reached and one patient had died of an unrelated cause. The remaining 23 patients (32 hips) were reviewed with clinical assessment (Merle d'Aubigné, Harris and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores) and anteroposterior (AP) pelvic radiograph. This represents a 75% rate of follow up at 31 to 44 years post-operatively. RESULTS: In two patients, surgery was repeated due to residual subluxation. Only one patient needed a total hip replacement (THR) 33 years after initial treatment. The Merle d'Aubigné, Harris and WOMAC scores for the surviving hips were excellent or good in almost 80% of the cases. In four cases, radiographic signs "at risk for" osteoarthritis were present. Regularity of the femoral head was perfect in seven hips, regular in 18 and irregular in six. According to the Severin-Seringe classification, 25 hips could be classified as group I (14 group IA and 11 group IB), three group II and three group VII. CONCLUSION: The long-term results of non-previously treated late-presenting DDH by the technique of progressive closed reduction followed by innominate osteotomy are quite good and compare favourably with the long-term results of open reduction with the same osteotomy.