Foreign body aspiration with iatrogenic right bronchus perforation - A case report and literature review.

INTRODUCTION AND IMPORTANCE: Evacuation of obstructed trachea foreign body (FB) can be challenging and may have several life-threatening complications. Iatrogenic tracheobronchial injury (TBI) is a rare and devastating complication which need prompt diagnosis and management. CASE PRESENTATION: An 11-year-old child was brought to the emergency with a history of cough and chest discomfort for the last 15 days. Chest x-ray and computed tomography (CT) chest were done which showed the presence of a FB in the right main bronchus. After all pre-operative investigations, rigid bronchoscopy and removal of the foreign body under general anesthesia was performed. After several attempts, the foreign body couldn't be removed and there was massive surgical emphysema of the chest. Immediately bilateral chest tube was inserted. A repeat CT chest was done which revealed a ruptured of the right main bronchus with migration of the foreign body to the right pleural cavity. Right thoracotomy was performed under general anesthesia. The foreign body was removed and the bronchus ruptured was repaired. The child's vital signs were normal throughout the procedure and she was discharged on the seventh post-operative day. CLINICAL DISCUSSION: TBI can have devastating scenarios in the absence of quick diagnosis and treatment. Around 80 % of patients with TBI due to accidents have been found to have fatal outcomes before reaching the hospital, probably due to tension pneumothorax, hypoxia, or respiratory failure. CONCLUSION: Prompt diagnosis and management of complications with definitive repair of the injury were key elements in saving lives after TBI.

Chronic lymphedema reversal following arteriovenous fistula takedown: A case report.

INTRODUCTION AND IMPORTANCE: Lymphedema is a very rare complication of Arteriovenous Fistula. The commonly encountered complications following the arteriovenous fistula are thrombosis, stenosis, congestive heart failure, ischemic neuropathy, steal syndrome, aneurysm and infection. Hence, presence of Lymphedema is a rarity that must be managed vigilantly. The incidence of lymphedema following AV fistula is very rare. Presently there is lack of studies evaluating the outcome of fistula take down. The standard care for lymphedema is complex decongestive physiotherapy in most of other causes bur Fistula Take down also helps in reducing the swelling in our case. CASE PRESENTATION: Our case is of 53 years female presented to the surgical OPD with left upper limb swelling 5 months back which was non-pitting in nature. She was a known case of Acute kidney injury with no history of other comorbidities. The swelling started about 1 year ago involving the upper parts of the left arm which was intermittent and relieved spontaneously. She has a history of brachiocephalic fistula insertion for hemodialysis access 4 years ago with diagnosis of Acute Kidney Injury. However, the fistula was never used because of patient recovering from medical management. Investigations performed were doppler and other routine tests. CLINICAL DISCUSSION: The fistula was patent on examination confirmed by venous hum on auscultation. Fistula takedown surgery was planned after ruling out thrombosis and stenosis using doppler. Other alternatives were not considered because of lack of use of fistula. The swelling started to improve postoperatively and the patient was discharged. CONCLUSION: Our Case report highlights the fact that the rare complication like lymphedema could occur after the arteriovenous fistula which could be managed by fistula take down surgery if the fistula is no longer in use. Though very rare lymphedema should be kept in differential for complication which can be diagnosed by examination and ruling out other causes.

Penetrating Chest trauma with right atrium rupture - A case report.

Background: Penetrating chest trauma can have lethal consequences. Anterior chest wall penetrating injury can cause fatal lacerations over the chest wall, lungs, pericardium, and the heart. There are few reports on these kinds of injuries and operative management. Purpose: To describe a case of penetrating chest trauma with right atrium ruptured, after a fall from height. The patient was successfully managed with prompt resuscitation and definitive surgical intervention. Case presentation: A 48-years-old gentleman presented with history of fall from height and right sided penetrating chest injury. The patient had a penetrating injury to the right-fourth intercostal space in parasternal region. Chest X-ray showed massive right-sided hemothorax and chest tube drained more than 1700 ml upon insertion. Emergency right thoracotomy was performed, after initial resuscitation with fluids and blood transfusion in the emergency department. He had injury to the intercostal arteries, lacerations of the pericardium and the right atrium ruptured, which was managed successfully with definitive repair. Conclusion: Survival is rare after penetrating chest trauma with right atrium ruptured if not intervened on time. Prompt diagnosis and resuscitation, along with the definitive surgical repair were the key elements for successful management of the patients.

Sebaceous carcinoma of trunk with bilateral axillary lymph node metastasis: a rare presentation of malignant adnexal tumor in young adult.

Malignant adnexal tumors of skin are rare. Sebaceous carcinoma-a rare and aggressive cutaneous tumor-is frequently located in the periorbital region. Malignant adnexal tumors of sebaceous carcinoma type on trunk with axillary lymph node and distant metastasis in young adult is rare. The incidence of extraocular sebaceous carcinoma has been expected to be 0.06 per 100 000 person-years with an increased incidence in elderly patients and men. With a note of mimicking benign dermatologic conditions, definitive diagnosis of sebaceous carcinomas is often hindered, increasing morbidity and mortality for patients. Herein, we present a case of a 35-year-old man with a large ulcero-proliferating lesion of trunk region previously resected for a small swelling and eventually presented with the recurrent lesion and diagnosed as sebaceous carcinoma of trunk with bilateral axillary lymphnode and distant bone metastasis demonstrating several diagnostic and management challenges.

Surgical treatment of tuberculous chronic constrictive pericarditis: A retrospective observational study from tertiary hospital of eastern Nepal.

BACKGROUND: Tuberculosis remains an important cause of chronic constrictive pericarditis (CCP) in developing countries. It is a surgically treatable cause of diastolic heart failure. Without surgery, it is associated with high morbidity and mortality. METHODS: We conducted a retrospective observational study of clinical presentations and perioperative outcomes of pericardiectomy in all patients operated from July 2015 to December 2018 for tuberculous CCP. RESULTS: A total 14 patients (mean age - 38 ± 13.3 years, 10 male), underwent pericardiectomy via median sternotomy without cardiopulmonary bypass. Eleven patients (79%) had completed treatment for pulmonary tuberculosis, and three (21%) were on anti-tubercular treatment at the time of referral for surgery. Ten patients (71%) had prior hospitalisation for cardiac failure. At the time of surgery, eight patients (57%) were in New York Heart Association (NYHA) class III-IV. The median duration of symptoms before surgical intervention was 15 months (range 11-24 months). Three patients (21%) had associated cardiac cirrhosis. Twelve patients (86%) underwent total pericardiectomy. Two patients (14%) underwent partial pericardiectomy. The mean operative time was 160 ± 33.8 minutes. The mean central venous press pressure before and after surgery were 28 ± 3.9 and 10 ± 2 mmHg respectively. The mean intensive care unit (ICU) and hospital stays were 4 ± 1.5 and 10 ± 2 days respectively. There was one (7%) 30-day mortality. There were two deaths (14%) due to non-cardiac causes at 10 and 16 months respectively. The remaining 11 patients (79%) are doing well (mean follow-up- 23 months), and are in NYHA class I. CONCLUSIONS: Tuberculosis is the most common cause of CCP in our region. Pericardiectomy provides definitive treatment to alleviate symptoms resolution and improve survival.

Open pleural decortication for the late stage empyema thoracis in children: a retrospective observational study from a tertiary hospital of eastern Nepal.

The management of late-stage empyema thoracis requires surgical intervention. We performed a retrospective descriptive analysis of open pleural decortication for late stage empyema thoracis in 55 children (age ≤ 15 years; median age = 6 years; age range = 1-15 years; 40 [72.7%] boys) over 42 months. The median time to thoracotomy from the onset of symptoms was 24 days, and the median duration of hospital stay before and after surgery was 15 and 4 days, respectively. Three (5.5%) patients had necrotising pneumonia, requiring debridement; 4 (7.3%) patients had superficial surgical site infection; 12 (21.8%) patients had perioperative pus culture positive for bacteria; and 3 (5.5%) patients had tubercular aetiology. There was no operative mortality. At median follow-up of 18 months, all patients are in good general health. Open pleural decortication leads to rapid resolution of symptoms and reduces hospital stay in paediatric late-stage empyema thoracis.

Behaviour of protein (BSA)-lipid (DMPA) mixed monolayer on the spreading order of the individual component.

Surface pressure (π) - mean molecular area (A) isotherms of protein (BSA) - lipid (DMPA) mixed films are examined by varying their ratio and altering the spreading order of BSA and DMPA on the water surface to study the protein-lipid interactions and the corresponding structures and patterns at different interfacial conditions. π-A isotherms and compression-decompression isotherm cycles of protein-lipid mixed monolayers below and above of the isoelectric point of BSA (pI ≈ 4.8) are also examined. Below the isoelectric point of BSA (pH ≈ 4.0), i.e., when BSA is weakly hydrophobic and has net positive charge shows low hysteresis irrespective of the spreading order of the molecules. However, at pH ≈ 7.0, i.e., when the overall charge of BSA is negative and is strongly hydrophobic the protein-lipid mixed films display higher hysteresis value. Besides the properties of the isotherms, the surface morphology and secondary conformations of protein inside the mixed films are obtained from X-ray reflectivity, atomic force microscopy (AFM) and Fourier transform infrared (FTIR) spectroscopy respectively after depositing the mixed films on solid substrates. Nearly similar information is obtained after altering the spreading order of BSA and DMPA, which indicates that the spreading of molecules on the water surface is one of the better ways of forming the lipid-protein mixed film at the air-water interface.

Simple Bone Cyst of Rib.

Simple bone cyst is a benign lytic lesion usually encountered in children and adolescents. It is a cystic, fluid-filled lesion that usually involves the metaphysis of the long bones. Simple bone cyst of the rib is very rare, with few cases reported in the literature. Here we describe an interesting case of a simple bone cyst of the sixth rib in a 15-year-old girl that was managed successfully with surgical excision.

Modification of hysteresis behaviors of protein monolayer and the corresponding structures with the variation of protein surface charges.

Successive compression-decompression cycles of the surface pressure (π) - specific molecular area (A) isotherms of protein (BSA) monolayers show that reversible hysteresis persists if the protein molecules contain effective positive or negative surface charges. However, for neutral condition, i.e., close to the isoelectric point of the protein, irreversibility in the hysteresis behaviour dominates. Out-of-plane structures obtained from the X-ray reflectivity analysis suggest that at lower surface pressure monomolecular layer of BSA is formed on the water surface. With increasing surface pressure, molecules start to lift-up from the water surface in such a way that semi-major axis makes an angle with the water surface. Depending on the surface pressure and surface charge of BSA, monomolecular or bimolecular layer of tilted BSA molecules is formed on the water surface, however, formation of bimolecular layer is observed when the pH is relatively closer to the BSA isoelectric point. After complete decompression, tilted monomolecular or bimolecular structures again transform into monomolecular layer as evidenced from the structural analysis of the films deposited at lower surface pressures in the second compression, however, structural hysteresis varies depending upon the subphase pH or protein surface charge. Structures obtained from the films deposited at first and second compressions at lower pressure implies that although structural dissimilarity is present but structural hysteresis is only present near the isoelectric point of BSA and becomes negligible below and above that pH. Competitive electrostatic and van der Waals interactions are responsible for such hysteresis behaviours and structural modifications.

Cation-induced monolayer collapse at lower surface pressure follows specific headgroup percolation.

A Langmuir monolayer can be considered as a two-dimensional (2D) sheet at higher surface pressure which structurally deform with mechanical compression depending upon the elastic nature of the monolayer. The deformed structures formed after a certain elastic limit are called collapsed structures. To explore monolayer collapses at lower surface pressure and to see the effect of ions on such monolayer collapses, out-of-plane structures and in-plane morphologies of stearic acid Langmuir monolayers have been studied both at lower (≈6.8) and higher (≈9.5) subphase pH in the presence of Mg^{2+},Ca^{2+},Zn^{2+},Cd^{2+}, and Ba^{2+} ions. At lower subphase pH and in the presence of all cations, the stearic acid monolayer remains as a monolayer before collapse, which generally takes place at higher surface pressure (π_{c}>50mN/m). However, at higher subphase pH, structural changes of stearic acid monolayers occur at relatively lower surface pressure depending upon the specific dissolved ions. Among the same group elements of Mg^{2+},Ca^{2+}, and Ba^{2+}, only for Ba^{2+} ions does monolayer to multilayer transition take place from a much lower surface pressure of the monolayer, remaining, however, as a monolayer for Mg^{2+} and Ca^{2+} ions. For another same group elements of Zn^{2+} and Cd^{2+} ions, a less covered bilayer structure forms on top of the monolayer structure at lower surface pressure, which is evidenced from both x-ray reflectometry and atomic force microscopy. Fourier transform infrared spectroscopy confirms the presence of two coexisting conformations formed by the two different metal-headgroup coordinations and the monolayer to trilayer or multilayer transformation takes place when the coverage ratio of the two molecular conformations changes from the critical value (p_{c}) of ≈0.66. Such ion-specific monolayer collapses are correlated with the 2D lattice percolation model.

A prospective, randomized, controlled, trial comparing occult-scar incision laparoscopic cholecystectomy and classic three-port laparoscopic cholecystectomy.

BACKGROUND: This study was designed to evaluate the outcome of laparoscopic cholecystectomy by comparing a new technique using occult-scar incision for laparoscopic cholecystectomy (OSLC) with classic three-port laparoscopic cholecystectomy (CLC). In the occult-scar incision, we moved the subcostal and subxiphoid trocar insertion sites to the suprapubic area so that operative scars were hidden in the pubic hairs and below umbilicus. METHODS: Between July 2009 and 2012, patients undergoing laparoscopic cholecystectomy were randomized to the OSLC or CLC approach after obtaining informed consent. Outcome was measured by operative time, operative complications, hospital length of stay, cost, analgesia required after surgery, and cosmetic outcomes. The patient satisfaction score (PSS) and visual analog score (VAS) also were used to evaluated the level of cosmetic result and postoperative pain. RESULTS: A total of 75 patients were randomized into CLC (n = 35) and OSLC (n = 40) groups. No patient was converted to an open procedure in either the CLC or OSLC group. No operative complications were reported within 30 days in either group. The PSS of 7 and 30 days after surgery were both significantly higher in the OSLC group than in the CLC group (5.8 ± 1.5 vs. 8.0 ± 1.1, P = 0.03; 6.5 ± 1.2 vs. 9.2 ± 0.8, P = 0.02). The VAS for pain was significantly lower in the OSLC group on postoperative day 3 compared with the CLC group (2.6 ± 1.2 vs. 6.3 ± 0.9, P = 0.01). There was no significant difference in operative time, hospital stay, and cost between the two groups. CONCLUSIONS: The OSLC is a safe and feasible alternative compared with CLC in experienced hands, and it is superior for outcomes regarding pain control and cosmesis.