Polymorphous low-grade adenocarcinoma (PLGA) is a minor salivary gland tumor with a low malignant potential. It is twice more common in females, with a mean age of presentation at 59 years. It is a very slow-growing tumor with mean duration of symptoms that range from 27 months to as long as 40 years. We report a case of a male patient who was found to have PLGA with symptoms since birth. The patient was treated with wide local excision with good results. The lip is a rare location for PLGA, and its occurrence in adolescent age groups is even rarer.
Polymorphous low-grade adenocarcinoma; Tumor; Salivary gland
Subcuticular sutures have been extensively used for closure of wounds, particularly when good cosmesis is required. Both absorbable and nonabsorbable sutures are used in subcuticular sutures. Nonabsorbable sutures have some distinct advantages over absorbable sutures from cosmetic point of view, when used in subcuticular sutures. The challenge remains in keeping the nonabsorbable suture secure and in situ. We present six different methods of securing the suture in position while closing the wound with a nonabsorbable suture (2-0/3-0 polypropylene, polyamide, or polyethylene).
Subcuticular sutures; Nonabsorbable; Suture securing
Retrorectal tumors are extremely rare and heterogeneous, requiring complete surgical excision for definitive diagnosis and optimal outcome. We describe a patient presenting with chronic “tailbone pain” who was found to have a benign cystic teratoma in the presacral space. She underwent en bloc resection and recovered well. Radiographic and pathologic images from this unique case are depicted and clinical features discussed.
Teratoma; Retrorectal tumor; Congenital; Presacral cyst
The aim of our study was to evaluate the prognostic significance of blood transfusion on recurrence and survival in patients undergoing curative resections for colorectal cancer. Retrospective analysis of prospectively collected data of patients after elective resections for colorectal cancer between January 2001 and December 2009 was undertaken. The main endpoint was overall survival, disease-free survival, and recurrence rate. These data were evaluated in relation to blood transfusion (group A, no blood transfusion; group B, one to two blood transfusions; group C, three and more blood transfusions). A total of 583 patients met the criteria for inclusion in the study. Of these, 132 (22.6 %) patients received blood transfusion in the perioperative period. There were 83 (14.2 %) patients who received one or two blood transfusions and 49 (8.4 %) patients who required three or more transfusions. Patients with three or more transfusions had a significantly worse 5-year overall survival, disease-free survival, and increased incidence of distant recurrences in comparison with the group without transfusion or the group with one or two transfusions. Multivariate analysis showed that the application of three or more blood transfusions is an independent risk factor for overall survival (P = 0.001; HR 2.158; 95 % CI 1.370–3.398), disease-free survival (P < 0.001; HR 2.514; 95 % CI 1.648–3.836), and the incidence of distant recurrence (P < 0.001; HR 2.902; 95 % CI 1.616–5.212). Application of three or more blood transfusions in patients operated for colorectal carcinoma is an adverse prognostic factor. Indications for blood transfusion should be carefully considered not only with regard to the risk of early complications, but also because of the possibility of compromising long-term results.
Colorectal cancer; Blood transfusion; Survival; Recurrence
Superior mesenteric artery syndrome is a rare but well-known clinical entity characterized by compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery, resulting in chronic, intermittent, or acute, complete or partial, duodenal obstruction. The treatment for this arteriomesenteric compression includes conservative measures and surgical intervention. The aim of the study was to evaluate our surgical management and outcomes of the patients with superior mesenteric artery syndrome. The cases with superior mesenteric artery syndrome admitted between January 2000 and January 2010 were retrospectively investigated from the patients’ records. All six patients had a history of chronic abdominal pain, nausea, postprandial early satiety, vomiting, and weight loss. Diagnostic methods included barium esophagogastroduodenography, upper gastrointestinal endoscopy, and computed tomography. Medical management was the first step of treatment in all cases before surgery. Of those, four underwent Roux-en-Y duodenojejunostomy and two underwent gastroenterostomy. Postoperative periods were uneventful and mean duration of hospitalization after the operations was 7 days. Conservative initial treatment is usually followed by surgical intervention for the main problem that is the narrowing of the aortomesenteric angle in patients with superior mesenteric artery syndrome. This syndrome should be considered in the differential diagnosis in patients with chronic upper abdominal pain. Duodenojejunostomy is the most frequently used procedure with a high success rate.
Superior mesenteric artery syndrome; Intestinal obstruction; Diagnosis; Surgical management
Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.
Exploratory laparotomy; Emergency surgery; Perforation peritonitis; Primary repair; Stomas; Resection and anastomosis
Although accounting for 90 % of the intestinal surface area, small bowel adenocarcinomas are not common. The majority of these lesions are incidentally detected during laparotomy for intestinal obstruction or perforation. The symptoms associated with these lesions are not very specific and preoperative diagnosis is rare. We report two cases of jejunal adenocarcinomas detected in patients undergoing laparotomy for acute abdomen and review the literature for small bowel adenocarcinomas.
Small bowel adenocarcinoma; Intussusception; Perforation; Diagnosis
Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.
Single port laparoscopic cholecystectomy; Single incision laparoscopic surgery; X cone®; Patient assessed cosmesis; Patient satisfaction scores; Learning curve
Internal hernia may either be congenital or acquired. Acquired internal hernias are usually complications of previous abdominal surgery. Congenital internal hernia is a rare entity and it being a cause of small bowel obstruction is still rare. We report a case of congenital internal hernia presenting as acute intestinal obstruction and its surgical management.
Congenital internal hernia(CIH); Small bowel obstruction (SBO)
We report an unusual presentation of inguinal TB lymphadenitis in a 16-years old unmarried female with multiple discharging sinuses.
Tuberculous inguinal lymphadenitis; Multiple discharging sinuses; Citric acid treatment
Anamolous Course of Carotid Artery is one of the rarest of the rare anamoly, we describe one such case of anamolous Course of Right Common Carotid Artery.
Anamolous carotid artery; Anamolous artery
Extrarenal teratoid Wilms’ tumor is a rare variant of Wilms’ tumor. Literature shows only 17 reported cases. We present this right-sided teratoid Wilms’ tumor in a 3-year-old boy for its rarity in association with the horseshoe kidney. The tumor was found in the anterior aspect of the right kidney and consisted of triphasic Wilms’ tumor element along with the presence of heterologous components.
Electronic supplementary material
The online version of this article (doi:10.1007/s12262-012-0606-5) contains supplementary material, which is available to authorized users.
Extra renal teratoid Wilms’ tumor; Complete excision; Wilms’ tumor; Horseshoe kidney
Primary anorectal malignant melanoma is an exceptionally rare neoplasm associated with poor prognosis. Anorectal malignant melanoma has been very rarely described with coexisting primary tumors of the colorectum. A 56-year-old female patient was admitted with a history of rectal bleeding. She had experienced increasing constipation and a sense of obstruction in the rectum for 6 months. Flexible rectosigmoidoscopy showed a large, pedinculated polypoid lesion extending from the anal canal to the rectum. She underwent a transanal local excision and was diagnosed with a melanoma of the anorectum with positive margins. Therefore, a formal abdominoperineal resection was performed. In addition to multiple synchronous anorectal malignant melanoma, we incidentally found another primary tumor in the proximal surgical margin of the resected specimen. Histopathologically, the lesion was an intramucosal adenocarcinoma of the sigmoid colon. Postoperatively, the patient received adjuvant chemotherapy of six cycles duration. At present, the patient has completed 18 months of follow-up.
Malignant melanoma; Anorectal melanoma; Synchronous tumors; Abdominoperineal resection; Transanal local excision
Preoperative laboratory markers of primary hyperparathyroidism including serum parathormone (PTH), calcium and phosphate level may have some predictive value about the size and volume of the abnormal parathyroid gland tissue which needs to be resected in primary hyperparathyroidism. In a Prospective study from 2003 to 2010, 69 patients with parathyroid adenoma were enrolled. The correlation between preoperative serum PTH, calcium and phosphate level with adenoma’s weight and volume was analyzed separately. Adenoma volume was calculated via an equation for the volume of a spheroid object. The data were analyzed via a multiple analysis of variance, and a correlation coefficient was calculated. The level of significance was set at p _ .05. There was a significant correlation between adenoma weight and serum calcium and parathormone levels (p = .0001 and p = .0001, respectively). There was no significant correlation between adenoma weight and serum phosphate. With respect to adenoma weight, there was a significant relationship with parathormone levels and serum calcium (p = .0001 and p = .0001, respectively). There was no significant relationship between serum phosphate and aden2oma weight. Preoperative serum PTH and calcium levels may be valuable in predicting parathyroid adenoma volume and weight in primary hyperparathyroidism for a single adenoma.
Primary hyperparathyroidism; Adenoma; Weight; Volume; Biochemical markers
Liposarcomas are the most common retroperitoneal soft tissue tumors. We here in report a case of giant retroperitoneal sarcoma which weighed 24 kgs. Renal autotransplant of right kidney was done for organ preservation. The patient has done well after a follow up of 63 months. Complete surgical resection with organ preservation is the goal of treatment in patients with retroperitoneal liposarcomas.
Giant retroperitoneal liposarcoma; Renal preservation; Autotransplantation
Private surgery; Private practice; Surgical education; Surgical training
To compare and determine a credible method of measurement of wound surface area by linear, transparency, and photographic methods for monitoring progress of wound healing accurately and ascertaining whether these methods are significantly different. From April 2005 to December 2006, 40 patients (30 men, 5 women, 5 children) admitted to the surgical ward of Shree Sayaji General Hospital, Baroda, had clean as well as infected wound following trauma, debridement, pressure sore, venous ulcer, and incision and drainage. Wound surface areas were measured by these three methods (linear, transparency, and photographic methods) simultaneously on alternate days. The linear method is statistically and significantly different from transparency and photographic methods (P value <0.05), but there is no significant difference between transparency and photographic methods (P value >0.05). Photographic and transparency methods provided measurements of wound surface area with equivalent result and there was no statistically significant difference between these two methods.
Transparency method; Photographic method; Linear method
It is believed that sigmoid volvulus (SV) in Brazil is a frequent complication of megacolon caused by Chagas’ disease (CD), differing in some characteristics from volvulus found in other countries. Bowel obstruction in patients with CD, principally when the cause is SV, may be sometimes difficult to diagnosis exclusively with plain abdominal radiograph. Fecaloma impacted in retossigmoidal area is one of the differential diagnoses. In addition, the huge amount of gas and feces, and distension of the colon normally increase the difficulty to make the correct diagnostic. The use of computer tomography (CT) scan can easy elucidate the picture of SV, and can be a great tool in cases of patients with CD and suspicion of this entity. A 62-year-old man showed bowel distention and stop disposal of gas for 5 days. He had previous diagnosis of CD. He also had been suffering from chronic constipation for several years, including impacted fecaloma, with the necessity of manual extraction. Plain abdominal radiographs showed an important colon dilatation and gross amount of feces in the sigmoid colon. Abdominal computer tomography sacan revealed dilated colon filled with feces, as well, the “whirl sign” composed of mesentery and twisted colon. When abdominal radiograph films reveal gross colonic dilatation of unknown etiology in patients with CD, a whirl sign on CT scans raises the possibility of colonic volvulus.
Sigmoid volvulos; Chaga’s disease; Whirl sign; Computer tomography scan; Bowel obstruction
Serum procalcitonin (PCT) levels may have predictive value in the prognosis of postoperative sepsis in elderly patients who have undergone colorectal surgery for colorectal cancer in intensive care units (ICUs). A prospective study involving 90 critically ill patients who underwent colorectal surgery for colorectal cancer in ICUs was performed. Twenty-eight patients were diagnosed with sepsis, in accordance with the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria, and these patients were included in the sepsis group. Sixty-two patients, who were without evidence of sepsis, were enrolled in the control group. We measured the serum PCT concentrations preoperatively (immediately before induction of anesthesia), upon arrival in the ICU (ICU day 0), on the morning of the first postoperative day (postoperative day 1), and on the morning of the third postoperative day (postoperative day 3). The C-reactive protein (CRP) index, acute physiology and chronic health evaluation II (APACHE II) score, mechanical duration of ventilation, mortality rate, incidence of multiple organ failure, and usage of continuous renal replacement therapy were evaluated. The area under the curve for the receiver operating characteristic curve (AUC-ROCC) was measured to explore the association between the serum PCT and the prognosis. In the sepsis group, 12/28 patients died (mortality rate 43 %). In the control group, 6/62 patients died (mortality rate 9.7 %). On the first postoperative day, the serum PCT level was dramatically higher in the sepsis group than in the control group (2.71 ± 1.13 vs. 1.37 ± 0.57, P ≤ 0.05). The PCT level on the first postoperative day was distinctly higher than that measured upon arrival in the ICU (2.71 ± 1.13 vs. 1.31 ± 0.58, P ≤ 0.05). In the two groups, the CRP concentrations were both markedly higher on the first postoperative day than upon arrival in the ICU (138.89 ± 45.12 vs. 70.43 ± 23.54 in the sepsis group, and 133.13 ± 44.91 vs. 69.65 ± 24.98 in the control group, P ≤ 0.05). Linear regression analysis was performed. The results suggest that the PCT and APACHE-II scores were not significantly associated. On the first and third postoperative days, the PCT levels were associated with increased odds of sepsis (AUC-ROCC, 95 % confidence interval 0.817–0.973, P = 0.000, and 0.755–0.944, P = 0.000, respectively). The outcomes of patients in the sepsis group were worse than those in the control group. PCT levels appear to be early markers of postoperative sepsis in elderly patients undergoing colorectal surgery for colorectal cancer during the ICU course. These findings could allow for early identification of postoperative septic complications and be used for prognostic evaluation of these patients.
Elderly patients; Sepsis; Emergency colorectal surgery; Procalcitonin; Prognosis
We present a simple technique of nonanatomic resection of liver parenchyma for porcelain gallbladder infiltrating gallbladder bed, that is, segments IVb and V of the liver. The resection has been carried out with the use of straight 18-gauge stainless steel multi-use needle designed for hepatic resections (Chang’s needle). This simple, safe, and cost-effective technique can be used for nonanatomic liver resections by surgeons less experienced in liver surgery.
Porcelain gallbladder; Liver resection
Cystosarcoma phyllodes is an uncommon neoplasm of the breast, constituting 0.3–0.9 % of all breast tumors. The incidence of malignant phyllodes tumor is even lower. The tumor is similar to fibroadenoma in structure, but it is distinguished from it histologically by large leaf-like projections of stroma with increased stromal cellularity (Dyer et al. Br J Surg 53:450–455, 1966). Although surgical removal is the mainstay of treatment, the extent of surgery required (excision vs. mastectomy) and the need for additional local therapy, such as radiotherapy, are unclear (Chaney et al. Cancer 89(7):1502–1511, 2000). We report a case of a 52-year-old married woman who presented to our outpatient department with 45 × 35 × 20 cm ulcerative, foul-smelling, huge right breast mass weighing 12 kg, and involving nipple areola complex, which turned out to be a malignant phyllodes tumor. The malignant variant of phyllodes tumor is indeed a very rare mammary tumor.
Breast; Phyllodes tumor; Malignant; Excision