Most breast abscesses develops as a complication of lactational mastitis. The incidence of breast abscess ranges from 0.4 to 11 % of all lactating mothers. The traditional management of breast abscesses involves incision and drainage of pus along with antistaphylococcal antibiotics, but this is associated with prolonged healing time, regular dressings, difficulty in breast feeding, and the possibility of milk fistula with unsatisfactory cosmetic outcome. It has recently been reported that breast abscesses can be treated by repeated needle aspirations and suction drainage. The predominance of Staphylococcus aureus allows a rational choice of antibiotic without having to wait for the results of bacteriological culture. Many antibiotics are secreted in milk, but penicillin, cephalosporins, and erythromycin, however, are considered safe. Where an abscess has formed, aspiration of the pus, preferably under ultrasound control, has now supplanted open surgery as the first line of treatment.
Breast abscess; Mastitis; Breast feeding
Malignant peripheral nerve sheath tumors (MPNST) are rare spindle-cell sarcomas derived from Schwann cells or pluripotent cells of the neural crest accounting for less than 10 % of all soft tissue sarcomas. They arise from major or minor peripheral nerve fibers or their sheaths. The World Health Organization coined the term MPNST for tumors of neurogenic origin with similar biological behavior replacing all the previous heterogeneous and, often, confusing nomenclature including malignant schwannoma, malignant neurilemmoma, and neurofibrosarcoma. The retroperitoneum and the lower extremities are the most common sites, but MPNST may arise anywhere in the body. Its location in the retroperitoneum in a patient without neurofibromatosis is an exceedingly rare occurrence. Imaging is routinely performed to assess the extent of the disease and to plan surgical resection. Surgical resection is the first line of therapy, ideally with total removal of the tumor. Owing to a high risk of recurrence with incomplete resection, postoperative irradiation and chemotherapy are necessary; however, they are often used as adjuvant therapy even if the tumor is completely resected.
Malignant peripheral nerve sheath tumor; MPNST; Retroperitoneal sarcomas
Acromioclavicular dislocations are very common shoulder injuries. The optimal treatment for acute high-grade acromioclavicular joint injury remains a matter of debate. The purpose of this study was to evaluate the results of surgical treatment of complete acromioclavicular dislocation using coracoid process transfer and temporary K-wire transfixation. Twenty-one patients with complete acromioclavicular dislocation underwent coracoid process transfer and temporary K-wire transfixation. Patients were assessed at the follow-up based on visual analog scores (VAS), the Constant–Murley scoring system and the UCLA shoulder rating system. Radiographs were taken to check up vertical instability. The mean follow-up was 32.1 months (25–47 months). The mean Constant and Murley score and UCLA shoulder rating score was 89.9 ± 8.4 and 30.1 ± 4.4. There were fourteen excellent functional results and six results and one poor result. The overall rate of satisfaction, which means an excellent or good result, was 95.2 %. Nineteen patients (90.4 %) maintained their previous jobs or resume their daily activities. The mean final pain score, as measured from 1 to 10 on the visual analog scale, was 1.91 ± 1.09. The radiographic analysis revealed twenty patients had maintained reduction at the final follow-up. The coracoid process transfer and temporary K-wire transfixation is a reliable treatment for a complete acromioclavicular dislocation.
Coracoid process transfer; Acromioclavicular dislocation; K-wire
Surgeons are constantly looking for minimally invasive ways to treat their patients, as recovery is faster when a lesser trauma is inflicted upon a patient, scarring is lessened and there are usually fewer complications in the aftermath of the operation. Through nanotechnology, tiny biosensors could be constructed which could take these factors into account, thus shortening a patients recovery period and saving hospitals money, reducing infection rates within the hospital, reducing the waiting lists for operation and allowing doctors to treat more patients in the same period of time. One of the greatest achievements of nanotechnology in surgery will be what we call the “ideal graft”; that is, biocompatible and durable “repairs” of parts of the body like arteries, joints or even organs. At first, these repairs will be used for healing, but soon afterwards, they will be used for transcendence: to enhance current human abilities.
Nanotechnology; Surgery; Implants coatings; Nanobots; Nanosurgery; Nanosurgical tools
Traditionally, the knife has been used to make surgical incisions on the skin, but recent data suggest that diathermy blade allows the incision to be made more quickly, with less blood loss, less postoperative pain and no adverse effects on wound healing or cosmetic effect.
Cautery incision; Electrosurgical unit
Evaluation of platelet count and its significance in early detection of post burn septicemia for commencement of timely vigorous treatment against it. Studies investigating the role of platelets and platelet count in burn patients are rare, rather old and mostly presenting case reports. Septicemia is the most important cause of mortality in burns. Burn patients can only be saved if septicemia is detected early which requires very sensitive prognostic indicator. Total 594 adult burn patients were studied, by observing them for septicemia and studying their subsequent platelet counts using visual method. In non-survivors (256) gradual decline in platelet count was observed and minimal platelet count was observed before death of the patient, while in survivors (338) gradual rise in platelet count was observed. No significant variation observed in other laboratory parameters such as total neutrophil count and serum creatinine. In significant number of non survivor (62.11%) platelet count was low before their death and in significant number of survivor (86.09%) platelet count was normal before their discharge. Thus it is conclude that serial declining platelet count is a very sensitive prognostic factor in early detection of post burn septicemia.
Platelet; Burn; Septicemia
Varicose veins are the most common manifestation of chronic venous insufficiency (CVI) worldwide. They interfere with the patients’ daily activities and hamper their professional endeavors, and therefore need to be addressed at the earliest with the best tools. Eleven patients of varicose veins of the lower limb with below knee perforators underwent subfascial endoscopic perforator surgery (SEPS) from October 2010 to December 2011 in our institute. The procedure was successfully completed in all 11 patients. The mean operating time was 78 min (60–96 min). The results showed a favorable outcome for the patients in terms of faster recovery and less morbidity.
Communicating veins or perforators; Subfascial endoscopic perforator surgery
Hepatocellular carcinoma (HCC) is the seventh-most common malignancy in males and ninth in females with incidence of one million new cases every year. Situs inversus totalis (SIT) is a rare congenital condition, in which there is a mirror-image transposition of both the abdominal and thoracic viscera. There are very few reported cases of HCC developing in people with SIT. In this review, we present a new case of HCC with SIT, and a review of literatures published between 1983 and 2011 on it. The literatures in English were searched through PubMed and Google Scholar, while those in Japanese language were accessed through J-EAST and translated in English with the help of Google translator on 22 April 2012. There are 6 English and 6 Japanese literatures showing 12 published cases, of which 10 cases were from Japan, 1 from Taiwan and 1 from China. Our case is probably the first case in the world beyond these regions. The articles containing adequate information, such as patient age and sex, investigations, diagnosis, type of congenital anomalies and methods of surgery, were reviewed. On reviewing the literature, we observed that clinical manifestations, laboratory findings and etiology correlate well with HCC, while anomalous hepatic vascularity correlates well with SIT. The reason for high incidence of HCC with SIT in Japan is not well correlated, but may be explained by higher incidence of SIT. All varieties of hepatic resection were feasible in cases of SIT.
Situs inversus totalis; Hepatocellular carcinoma (HCC); Hepatectomy; Liver cancer
Achalasia cardia is the commonest esophageal motility disorder. Recently, a new endoscopic procedure—peroral endoscopic myotomy (POEM)—has emerged for treating this chronic and debilitating condition. It has shown comparable success rates in prospective studies with conventional Heller’s myotomy with lesser rates of postoperative reflux. Literature regarding this procedure from India is scarce due to its limited availability. This case report illustrates the use of POEM in a patient with a permanent cardiac pacemaker and demonstrates its safety and efficacy in such a situation.
Achalasia cardia; Cardiomyotomy; POEM; Heller’s myotomy; Endoscopic myotomy
Metastasis from follicular carcinoma is usually blood-borne. Here, we present a case of skull metastasis with intracranial extension presenting as a pulsatile scalp swelling from the follicular thyroid carcinoma.
Skull metastasis; Follicular carcinoma thyroid
The aim of this study was to evaluate the immunomodulatory effects of supplementing intravenous omega-3 fatty acids in fish oil (IVFO) in elderly patients undergoing hip surgery. This was a single centre, randomized, controlled, comparative, phase IV study in elderly patients undergoing hip surgery. The subjects, within the age range of 50–90 years, were assigned randomly to the group receiving intravenous omega-3 fatty acids in fish oil (IVFO, Omegaven®) or the control group not receiving intravenous fish oil (n = 20 in each group). IL-6, IL-8, IL-10, and HS-CRP levels were the inflammatory markers assessed in this study. The within-group comparison was done by paired t-test and between-group comparison by unpaired t-test. At day 4, IL-6 values in the IVFO group decreased as compared to day 0. At day 4, IL-8 mean values increased for both IVFO and control groups. This increase was highly significant in the control group (P = 0.0182). IL 10 values decreased at day 4 and increased at day 8 in the IVFO group. Increase in HS-CRP levels was nonsignificant at day 4 in the IVFO group (P = 0.60) and significant at day 8 for the control group (P = 0.0084) as compared to day 0. Various biochemical parameters including albumin, protein, SGOT, SGPT, blood glucose, and urea values generated evidence regarding the safety profile of IVFO. This study suggests a role for IVFO in the short-term suppression of inflammatory mediators for patients undergoing hip surgery. However, further, larger trials may be needed to establish its definitive role in this patient population.
Omega-3 fatty acids; Omegaven; Interleukins; Inflammation; Hip surgery
Esophageal perforations are life threatening emergencies associated with high morbidity and mortality. We report on 22 consecutive patients (age 20–86; 13 female and 9 male) with an oesophageal perforation treated at the university hospital Duesseldorf. The patients' charts were reviewed and follow-up was completed for all patients until demission, healed reconstruction or death. Patients' history, clinical presentation, time interval to surgical presentation, and treatment modality were recorded and correlated with patients' outcome. Six esophageal perforations were due to a Boerhaave-syndrome, eleven caused by endoscopic perforation, two after osteosynthesis of the cervical spine and three foreign body induced. In 7 patients a primary local suture was performed, in 4 cases a supplemental muscle flap was interposed, and 7 patients underwent an oesophageal resection. Four patients were treated without surgery (three esophageal stent implantations, one conservative treatment). Eleven patients (50 %) were presented within 24 h of perforation, and 11 patients (50 %) afterwards. Time delay correlates with survival. In 17 (80.9 %) cases a surgical sufficient reconstruction could be achieved. One (4.7 %) patient is waiting for reconstruction after esophagectomy. Four (18.2 %) patients died. A small subset of patients can be treated conservatively by stenting of the Esophagus, if the patient presents early. In the majority of patients a primary repair (muscle flap etc.) can be performed with good prognosis. If the patient presents delayed with extensive necrosis or mediastinitis, oesophagectomy and secondary repair is the only treatment option with high mortality.
Esophageal perforations; Boerhaave-syndrome
Venous aneurysms are one of the rare causes of neck swellings. Among neck veins, external jugular vein aneurysms are uncommon. We present a case of a woman who presented with a nontender compressible swelling in the left lower neck region, which initially thought to be hemangioma, was later found to be external jugular vein aneurysm on Doppler ultrasound and CT angiography.
Venous aneurysm; External jugular vein; Neck swelling; MDCT; Angiography
There are not many injuries that rival the injured hand in complexity. A better understanding of biologic, behavioral, and socioeconomic risk factors potentially associated with hand injuries can help identify those individuals most at risk and define potential preventative measures to help reduce the incidence. We present a prospective study of 436 consecutive patients of hand and forearm injury treated over a period of 2 years. A serial recording of the demographic profile of the patient along with the type & cause of injury sustained, hand dominance, duration of hospital stay, time lag between injury and admission, type surgery preformed with intra-operative findings and the cost analysis was done. An expected male dominance in economically viable individuals of 21 to 30 years formed 50 % of the patients of which 22.9 % were labourers and students each. The malady was altercation (27.5 %) followed by industrial & road accidents. Post prandial period was most notorious with multiple neuro (27.05 %) vasculo (39.34 %) tendinous (60.66 %) injury common with even simple lacerations. Dominant hand injury was commonest. It is challenging to assess and treat an injured hand. This study defines the demography and the etiology behind the various cases of hand and forearm injury with the detailed trauma profile. The limitation of the study was absence of functional outcome. The necessity of hand trauma registry is a pre-requisite to quantify the burden of hand injuries and formulate a prevention strategy.
Hand injuries; Incidence; Demography; Tendon injury; Neuro-vascular injury; Hand dominance
Acute Biliary Pancreatitis is one of the commonest forms of pancreatitis in Nepal. Controversies exist as to the most appropriate way of management of these cases. The present study was carried out to evaluate the management and outcome of Acute Biliary Pancreatitis cases in a tertiary level hospital of Nepal. A retrospective analysis of the patients managed with Acute Biliary Pancreatits was done. All patients admitted with the diagnosis of Acute Biliary Pancreatitis over a period of 2 years were included in the study. The variables measured were age, sex, clinical presentation, laboratory investigations, mode of treatment and outcome. A total of 45 cases had Acute Biliary Pancreatitis suggesting a prevalence of 28 %. The mean age was 45 ± 10 year. 39 patients (86.6 %) were treated with conservative management. 23 patients (54 %) had an uneventful recovery without any complications. 21 patients (46 %) developed some form of complications but recovered successfully. Mortality was seen in only one patient in the conservatively treated group. In a resource poor setting such as Nepal, definitive management is not always possible. Conservative management of Acute Biliary Pancreatitis has a favorable outcome in the majority of our patients with acceptable morbidity and mortality. Definitive management can be safely performed during index admission where possible.
Acute pancreatitis; Biliary; Conservative management; Outcome
Alleviating the agonizing pain of critical limb ischemia (CLI) in patients of Buerger’s disease (BD) has been challenging, due to lack of definitive treatment; “Heparin-Dextran” infusion has been tried in this study. Assessment of clinical improvement and vascular changes following therapy. Patients with CLI admitted to emergency surgical ward were studied prospectively. BD was diagnosed by Shionoya’s criteria, and confirmed by digital subtraction angiography (DSA). Heparin and Dextran intravenous infusion was administered for 10 days. Severity of rest pain, ischemic changes in the feet, claudication distance and ankle brachial index (ABI) were estimated prior to therapy, at completion and 3 weeks after therapy. Vascular changes were assessed by CT angiography (CTA) performed prior to and 3 weeks after therapy. Twenty consecutive patients were studied. Successful hemodilution reflected by decreased hematocrit (37.4 % to 32.6 %, p < 0.05) and increased mean ABI (0.46 to 0.83, p < 0.01), improved rest pain in 75 % patients (p < 0.001), increased claudication distance in 94 % (p < 0.05) and ulcers healing in 70 % patients. CTA revealed recanalised vessels (decreased length of occluded segments) in 10 (50 %, p = 0.005), increased collaterals in 12 (60 %, p < 0.01) and improved distal run-off in 13 (65 %, p < 0.01) patients. “Heparin-Dextran” therapy in patients of CLI from BD improves tissue perfusion by increasing collaterals and recanalisation of vessels, resulting in significant relief from rest pain and clinical improvements. CTA is as efficacious as DSA for evaluation of BD.
Buerger’s disease; Critical limb ischemia; Heparin-Dextran; Angiography
The objective of our study was to evaluate the role of splenic artery embolization (SAE) in the management of traumatic splenic injuries. From September 2008 to September 2010, a total of 67 patients underwent nonoperative management (NOM) for blunt splenic injuries. Twenty-two patients were excluded from the study because of associated significant other organ injuries. Twenty-five patients underwent SAE followed by NOM (group A) and 20 patients underwent standard NOM (group B). Improvement in clinical and laboratory parameters during hospital stay were compared between two groups using Chi-square test and Mann–Whitney test. SAE was always technically feasible. The mean length of the total hospital stay was lower in the group A patients (5.4 vs. 6.6 day, [P = 0.050]). There was significant increase in hemoglobin and hematocrit levels and systolic blood pressure (SBP) in group A patients after SAE, whereas in group B patients there was decrease in hemoglobin and hematocrit levels and only slight increase in SBP (pre- and early posttreatment relative change in hemoglobin [P = 0.002], hematocrit [P = 0.001], and SBP [P = 0.017]). Secondary splenectomy rate was lower in group A (4 % [1/25] vs. 15 % [3/20] [P = 0.309]). No procedure-related complications were encountered during the hospital stay and follow-up. Minor complications of pleural effusion, fever, pain, and insignificant splenic infarct noted in 9 (36 %) patients. SAE is a technically feasible, safe, and effective method in the management of splenic injuries. Use of SAE as an adjunct to NOM of splenic injuries results improvement in hemoglobin, hematocrit levels, and SBP. SAE also reduces secondary splenectomy rate and hospital stay.
Trauma; Splenic artery embolisation
Amniotic band syndrome is an uncommon congenital disorder without any genetic or hereditary disposition. It involves fetal entrapment in strands of amniotic tissue and causes an array of deletions and deformations. Primary treatment is plastic and reconstructive surgery after birth with in utero fetal surgery also coming in vogue.
ADAM complex; Amniotic band sequence; Streeter’s dysplasia; Congenital constriction bands; Pseudoainhum
It is unusual to encounter a patient who stabbed his abdomen with a kitchen knife. A 25-year-old man was in police custody for 2 days. He stabbed his abdomen with a kitchen knife. He was brought to casualty with a retained knife in his abdomen. The knife had torn gastrocolic omentum and caused contusion on the transverse colon. His postoperative period was fair.
Self-inflicted stab; Knife injuries; Abdominal injuries
A man was admitted to hospital due to a blunt injury on the right side of thoracic back. The computed tomography scanning showed absence of free air or fluid in the abdominal cavity, bleeding in the right hepatic lobe (segments 7 and 8), filling defect in the junction between the right hepatic vein and inferior vena and in the posthepatic inferior vena, nonvisualization and medium dose of pleural effusion in right chest; there was complete occlusion and thrombogenesis in the right renal artery, nonvisualization in the right kidney. Repair of the right liver and posthepatic inferior vena, partial excision of middle lobe of right lung, excision of right kidney, and internal fixation of rib were performed. The patient underwent an uneventful recovery without occurrence of complications.
Laceration; Posthepatic inferior vena cava; Right renal artery