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   2014| January-April  | Volume 4 | Issue 1  
    Online since July 14, 2014

 
 
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CASE REPORTS
Primary ALK positive Anaplastic large cell lymphoma of T-cell type of jejunum: Report of a rare extranodal entity with review of literature
Niamathullah Sadiya, Mitra Ghosh
January-April 2014, 4(1):50-53
DOI:10.4103/2278-9596.136716  
The gastrointestinal tract (GI tract) is the most common site for extranodal lymphomas with the majority of the non-Hodgkin's B-cell type. It involves any part of the GI, the most frequent sites in the order of occurrence are the stomach, small intestine, and ileocecal region. A 17-year-old male presented with intermittent abdominal pain, altered bowel habits associated with vomiting of 1 month duration. Computerized tomography of the abdomen revealed an eccentric mass in the jejunum with significant luminal narrowing. Limited resection of jejunum showed an intraluminal polypoidal growth with a homogenous cut surface. Microscopic examination of the mass revealed a diffusely infiltrating monotonous population of large lymphoid cells with round to oval vesicular nucleus, prominent nucleoli and moderate to scanty cytoplasm, admixed with few multinucleated giant cells with wreath like arrangement of nuclei, binucleated cells, and atypical mitosis. The tumor was involving the submucosa, infiltrating the muscularis propria and extending into the sub serosa. Immunohistochemistry showed diffuse positivity for CD45, CD30, anaplastic lymphoma kinase-1 (ALK-1), and focal positivity for CD43. The immunohistochemical stains for B-cell lineage CD20, CD79a, T-cell markers CD3, CD2, CD4, CD8, CD7, and other markers namely bcl2, bcl6, CD5, CD138, CD56, Mum1, and PAX-5 were negative. Six lymph nodes isolated showed features of reactive follicular hyperplasia and were free of tumor. A diagnosis of primary ALK positive anaplastic large cell lymphoma of T-cell type of jejunum was made. Patient has completed three cycles of chemotherapy comprising of cyclophosphamide, prednisone, vincristine, and doxorubicin and is in remission until the last follow-up.
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ORIGINAL ARTICLES
Adult intussusception: An institutional experience and review of literature
Sunil Kaval, Basant M Singhal, Sanjeev Kumar, Chandra P Singh
January-April 2014, 4(1):25-30
DOI:10.4103/2278-9596.136706  
Background: In adults, intussusceptions represent an uncommon form of intestinal obstruction, diagnosed in only 1-5% of cases. It can be idiopathic or secondary to a pathology in the bowel, which may be a malignancy in 9.75% of small bowel intussusceptions and 50-60% of large bowel intussusceptions. The aim of this study was to make a 15 year institutional review of adult intussusceptions. Materials and Methods: Over a period of 15 years from January 1998 to December 2012, a total of 17 patients were diagnosed and managed as intussusceptions in our institution. A retrospective analysis of clinical, imaging and management data along with specimen and histopathological analysis was carried out. Results: The age range was 21-58 years (mean 35 years) with a male preponderance (11 males: 6 females). Intussusceptions affected the small bowel in 12/17 (70.59%) and the large bowel in 5/17 (29.41%) of cases. The most common clinical presentation was insidious abdominal pain with sub-acute obstruction in 15/17 (88.24) of cases. Computed tomography scan was diagnostic in 88.23% cases. Intestinal tuberculosis (TB) was the most common etiology in 23.53% of the patients. Small bowel intussusceptions were not associated with malignancy, but all cases due to post-operative causes or TB affected small bowel only. Malignancy was responsible for intussusceptions only in the large bowel. Conclusions: On analysis of our cases, we found that malignancy is responsible for intussusception only in the large bowel. Small bowel intussusceptions were not associated with malignancy, but all cases due to post-operative cause or TB affected small bowel only.
  4 5,303 366
CASE REPORTS
Wandering spleen as acute abdomen
Basant Kumar, Vijai D Upadhyaya, Sheo Kumar, Ram N Rao
January-April 2014, 4(1):54-56
DOI:10.4103/2278-9596.136719  
Wandering spleen is a rare clinical entity that accounts for only 0.1-0.2% of all splenectomies. Early diagnosis and intervention is necessary for the preservation of the spleen, especially in children. However, most of the times in acute settings a precise clinical diagnosis is difficult because of its similarity of presentation with other causes of acute abdomen resulting in delayed diagnosis. We present a 12-year-old boy with left-sided abdominal pain following a fall from a bed. His abdominal examination revealed an enlarged tender spleen. Abdominal ultrasound and computed tomography showed enlarged spleen with multiple areas of infarction and thrombosis of the splenic vein. At laparotomy a diagnosis of torsion of a wandering spleen with infarction was confirmed and splenectomy done. We present the management of the patient with wandering spleen that presented as acute abdomen with lower abdominal mass and briefly review the literature.
  2 5,379 330
ORIGINAL ARTICLES
Assessment of the efficacy and safety of methylene blue dye for sentinel lymph node mapping in early breast cancer with clinically negative axilla
Arindam Mukherjee, Suman Kharkwal, KS Charak
January-April 2014, 4(1):6-10
DOI:10.4103/2278-9596.136689  
Background : The benefits of sentinel lymph node (SLN) biopsy in breast cancer patients with clinically negative axillary nodes are now well established. SLN biopsy has been performed using different techniques including injection of isosulfan blue dye (IBD), radioactive colloid, and methylene blue. The aim of this study was to assess the safety and efficacy of methylene blue dye (MBD) as a mapping agent for SLN biopsy in axillary node negative breast carcinoma. Materials and Methods: Between February 2010-2012, a total of 27 female patients of 18 years and above, with established diagnosis of breast carcinoma with clinically negative ipsilateral axillary lymph nodes were studied. After induction of anesthesia, 5 ml of 1% methylene blue was infiltrated into the subareolar tissue on the affected side. The lymph nodes receiving the blue dye were excised as the SLN. Modified radical mastectomy (MRM) was completed and the excised breast with the axillary tissue was sent for histopathological examination to correlate with the findings of the SLN biopsy. Results: The incidence of breast cancer was highest at 41-50 years. Of 27 cases, SLN was identified in 24 cases using MBD. The identification rate was 88.9%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 81.8, 100, 100, and 86.7%, respectively. Conclusion: This study confirms the safety and efficacy of methylene blue as a mapping agent for SLN biopsy in axillary node negative breast cancer.
  2 6,140 444
Determination of prostatic volume and characteristics by transrectal ultrasound among patients with lower urinary tract symptoms in Zaria, Nigeria
Ahmed Mohammed, Ahmed Bello, Hussaini Y Maitama, Hafees O Ajibola, Ahmad T Lawal, Mohammed J Isah, Abdullahi Alhassan, Babagana M Abubakar, Hassan M Dogo, Sadiq A Muhammad, Abdullahi Sudi, Mudi Awaisu
January-April 2014, 4(1):31-35
DOI:10.4103/2278-9596.136707  
Background: To determine the average volume and ultrasonographic characteristics of the prostate with transrectal ultrasound (TRUS) among adult male patients presenting with lower urinary tract symptoms (LUTS). This is because the size and characteristics of the prostate may suggest the specific pathology and guide the urologist on subsequent investigations and the choice of the most appropriate treatment. Patients and Methods: All male patients, 30 years or older, presenting with LUTS in the absence of non-prostatic causes of LUTS between 2006 and 2010 were included in the study. Patients with clinical suspicion or confirmed cause of LUTS other than the prostate were excluded from the study. They were all evaluated by TRUS and the findings recorded. Results: A total number of 602 patients met the inclusion criteria. The mean age of the patients was 62.5 years with a standard deviation (SD) of 13.70. The average prostate volume for all patients was 56.2 (12.5-325) and SD 42.70, while the average prostate volume among patients with suspected benign prostatic hyperplasia (BPH) (317) was 68.7 g and SD 47.52. Diagnosis based on ultrasound features was BPH (52.7%, 317) in majority of the patients, 27.6% (166) suggested carcinoma of the prostate (CaP). The TRUS characteristics of patients with suspected BPH was predominantly mixed echo (51.7%), CaP commonly appeared hypoechoic (70.5%), while prostatitis appeared hyperechoic in most patients (69.4%). Conclusion: The mean prostate size of 68.7 g among patients with BPH is consistent with most studies among Nigerians, but greater than the mean volume among Caucasians. Thus, open prostatectomy remains relevant in our environment and accurate prostate volume estimation by TRUS is required for proper patient's selection for endoscopic treatment. The predominant ultrasonic features of BPH and CaP are mixed echo and hypoechoic appearance, respectively.
  2 11,064 590
CASE REPORTS
Retrograde jejunogastric intussusception: A case report and review of literature
Ravikumar Gopalakrishnan, Marimuthu Veerasamy, Naveen P.G. Ravikumar
January-April 2014, 4(1):47-49
DOI:10.4103/2278-9596.136715  
Retrograde jejunogastric intussusception ( JGI) is a rare but potentially serious complication of gastrectomy or gastrojejunostomy. Only about 200 cases have been reported in the literature. We present a case of retrograde JGI in a 50-year-old female patient with a history of gastrojejunostomy who had increasing abdominal pain and vomiting for 1 week and hematemesis for 1 day. Emergency endoscopy revealed JGI that was confirmed at laparotomy. The gangrenous efferent limb was resected and a partial gastrectomy with Roux-en-Y-gastrojejunostomy was performed. We present this case for its rarity and the diagnosis of retrograde JGI should be kept in mind when the patients have history of gastric surgery. In our case, the patient was treated as recurrent peptic ulcer and she was referred to us only after she had hematemesis. To avoid mortality, early diagnosis and prompt surgical intervention is mandatory.
  1 4,183 280
ORIGINAL ARTICLES
The role of appropriate footwear in the management of diabetic foot: Perspective of clinicians in a low resource setting
Tagang I Jerry, Pei Eujin, Chen C Robert, Higgett Nick, Dahiru L Ismail, Ibrahim Abdulrasheed
January-April 2014, 4(1):15-19
DOI:10.4103/2278-9596.136704  
Background: The use of appropriate footwear among patients with diabetes mellitus and those with diabetic foot problems has been documented to play a vital role in the prevention and treatment of the established foot disease. However, there is a paucity of literature on the role of clinicians in ensuring appropriate footwear among patients with diabetes mellitus. This paper explores current practice in the use of appropriate footwear in patients with diabetes mellitus among clinicians in Kaduna state, Nigeria. Materials and Methods: A self-administered structured questionnaire was developed. The questionnaire was divided into two sections: demographic (clinical area of specialization, number of years in practice) and footwear questionnaire. The footwear questionnaire focused on three themes: diabetic foot problems encountered, type of footwear worn, and the role of footwear in the prevention of diabetic foot complications. Data were processed and analyzed using Microsoft Excel 2007. Results: Almost all the participants, 41 (91%), reported that foot ulcers could be related to inappropriate footwear. Most participants, 37 (82%), reported that ill-fitting footwear could be a major problem that leads to amputation. The shoe type reported to be most frequently worn by men were sandals (35%), slippers (26%), and half shoes (17%). The three commonest shoe types that women were reported to wear were slippers (45%), sandals (24%), and half shoes (18%). Conclusion: This study shows that the use of appropriate footwear in the prevention of diabetic foot complications is suboptimal. It is important that healthcare professionals support and stimulate research in establishing a diabetic footwear program.
  1 6,045 481
Evaluation of the role of omental transposition in chronic limb ischemia: A prospective study
Dharmender P Singh, Suhani, S Saha, Vivek Agrawal, Ravi Kashyap, Nitin Aggarwal, Sanjay Gupta
January-April 2014, 4(1):20-24
DOI:10.4103/2278-9596.136705  
Background: Surgical treatment options for thromboangitis obliterans (Burger's disease) and atherosclerosis where arterial reconstruction is not possible are limited. Omental transposition is one of the treatment modalities used in these patients. However, improvement in vascularity of the limb has been infrequently evaluated in previous studies. In this study, we evaluated the outcome of omental transposition in patients with chronic peripheral vascular disease in terms of clinical improvement and also objectively document the effect on limb vascularity using technetium 99 labeled methylene diphosphonate radionuclide scanning. Materials and Methods: This prospective study was conducted in the Department of Surgery in a Tertiary Care Hospital in North India. A total of 22 patients suffering from chronic peripheral vascular disease unsuitable for corrective arterial surgery underwent omental transposition. Patients were evaluated 1 month after the operation for the change in the clinical parameters and vascularity of the limb using radionuclide scan. Results: Five (22.7%) patients had complete relief, 12 (54.5%) patients had significant relief while 5 (22.7%) patients had no relief in the rest pain. Signs of healing of ulcer were present in 44.4% of patients having ulcers and coldness of the skin was decreased in 18 patients (81.8%). Radionuclide scan demonstrated increased vascularity in the thigh in 78.6% of patients, increased vascularity in calf in 86.4% and increased vascularity in the foot in 44.6%. Conclusions: Omental transposition increases the blood supply in the transposed limb and may be considered as an effective modality for management of chronic limb ischemia in cases where definitive revascularization cannot be carried out.
  1 4,333 333
CASE REPORTS
Isolated neurofibroma of the Thyroid Gland
Prakash K Sasmal, Kanakalata Dash, Raghumani Mohanty, Kumudini Devi
January-April 2014, 4(1):44-46
DOI:10.4103/2278-9596.136714  
Neurofibroma is a common benign tumor usually arising from a cutaneous or peripheral nerve. Neurofibromatosis involving only the thyroid gland is a rare phenomenon and so far only two cases have been reported in the literature. We describe neurofibromatosis in a 46-year old male presenting with a gradually increasing isolated swelling over left anterior triangle of neck for two years. No toxic or pressure symptoms were reported. Fine needle aspiration cytology (FNAC) of the swelling was suggestive of colloid goiter with spindle-cell component. The patient underwent a left hemithyroidectomy. Histology and immunehistochemistry data confirmed it to be neurofibroma of the thyroid gland. Since the last two years, the patient is doing well. Isolated neurofibroma of the thyroid gland is very rare. Surgical excision is the treatment of choice depending on the extent of involvement of the gland. The entity although rare has to be considered in the differential diagnosis of a thyroid swelling.
  - 4,299 291
Synchronous GIST of jejunum and neuroendocrine tumor of duodenum: A rare case report
Karpagam Janardhan, Vijaya S Kumar, Pradeep L Kumar
January-April 2014, 4(1):57-59
DOI:10.4103/2278-9596.136720  
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of gastrointestinal tract, although it comprises only 0.1-3% of all gastrointestinal neoplasms. The majority of the neuroendocrine tumors of small intestine occur in adults and most of them are located in ileum followed by jejunum and duodenum. We present a case of synchronous GIST of jejunum and neuroendocrine tumor of duodenum in an elderly adult male patient without any associated syndrome. Although a Synchronous occurrence of gastrointestinal tumors without any coexisting syndromes is rare, a complete workup should be done to rule it out in any gastrointestinal tumors. To the best of our knowledge this is the first case to be reported in literature.
  - 4,071 287
Spontaneous gastrocutaneous fistula
Subramanian Kaushik, BS Madhu, Shashi H.B. Kumar
January-April 2014, 4(1):60-62
DOI:10.4103/2278-9596.136722  
Gastrocutaneous fistula is an infrequent but a serious surgical complication confronting the surgeon. Isolated and spontaneous gastrocutaneous fistula is an entity which has received scant attention in the surgical literature. Herein, we report a 68-year-old patient who came to the surgical outpatient with a history of recurrent abdominal pain for 1 year and discharge from just above the umbilicus for 3 days. He had no past history of abdominal surgeries. There were no comorbid conditions afflicting him. On examination, there was a stoma above the umbilicus with surrounding hyperemia of the skin. Bile-tinged fluid noted discharging from the external opening. Abdominal contrast-enhanced computed tomography (CECT) showed a fistulous tract from the skin surface to the anterior surface of the stomach with extravasation of contrast into rectovesical pouch. Upper gastrointestinal endoscopy showed Grade 3 esophageal candidiasis. Clinical diagnosis of gastrocutaneous fistula was made. Laparotomy revealed a gastrocutaneous fistula from the anterior wall of the stomach to the anterior abdominal wall. The fistula was excised and the gastric defect closed. Edges of the gastric perforation were biopsied and a feeding jejunostomy was placed. The patient succumbed to acute respiratory distress syndrome (ARDS) in the postoperative period. Histopathological examination revealed normal gastric mucosal lining with fibrosis and chronic inflammation in the submucosa with no evidence of malignancy. The most likely cause for such a fistula appears to be a benign gastric ulcer causing chronic inflammation and erosion, which is a rare entity and must be borne in mind in elderly patients presenting with gastric ulceration.
  - 4,283 263
ORIGINAL ARTICLES
Early experience with laparoscopic surgical operations in Aminu Kano Teaching Hospital, Kano, Northwestern Nigeria
Abdurrahman A Sheshe, Ahmed A Yakubu, Sani U Alhassan, Ismail Tsauni
January-April 2014, 4(1):1-5
DOI:10.4103/2278-9596.136688  
Background: New knowledge in health sciences, advances in technology, and a greater awareness of human rights add up to the need for higher standards in medical training and health services. Laparoscopic surgery is a major breakthrough in surgical practice that is now virtually integrated into all surgical fields. Its benefits have been recognized over many conventional open surgical procedures. However, its appropriateness and our readiness for the practice of laparoscopic surgery in Nigeria is yet to be determined. The objective of this study was to describe early experience, challenges, and prospect with laparoscopic surgical operations in Aminu Kano Teaching Hospital Kano, northwestern Nigeria. Materials and Methods: The case notes of patients admitted into the Surgical Wards of Mallam Aminu Kano Teaching Hospital in Kano, northwestern Nigeria that had laparoscopic surgical operations from October 2005 to October 2013 were retrieved and studied. The data collected from these was entered into Minitab Statistical Software. Relevant statistical indices were calculated. Results: A total of 42 patients were the subject of this review. Their mean age was 37 years, ranged 13-62 years. The male:female (M:F) was 1:1.2. The most common indication of laparoscopic operation was gallbladder disease in 38 (90.5%) patients. Laparoscopic cholecystectomy was the most common laparoscopic procedure performed. Two patients were converted to open surgery. The average duration of post-operative hospital stay was 4 days and the average operating time was 3 h. Conclusion: Experience with laparoscopic surgery is still early in our center, nevertheless the prospect is enormous. There is need for further skills acquisition and effective organization in order to maintain these services. Involvement of the National Health Insurance Scheme should assuredly bring about technological developments and subsidize the services to meet the socioeconomic challenges and changing disease pattern in our environment.
  - 5,322 404
Clinicopathological and ultrasonographic correlation of acute appendicitis in emergency: A prospective and retrospective study
Rajat K Patra, Dilip O Gupta, Rohan R Patil
January-April 2014, 4(1):11-14
DOI:10.4103/2278-9596.136703  
Background: Evaluation of Acute Appendicitis needs a well conducted history and physical examination. But major factors contributing to high negative appendectomy rate are non-specificity of clinical findings, lack of readily available techniques allowing direct visualization of appendix. This study evaluated diagnostic accuracies of clinical and ultrasonographic in Acute Appendicitis. Materials and Methods: The study was carried out in the department of surgery, Kasturba Hospital, MGIMS, Sevagram. Total of 38 patients were selected for the study. In the emergency department of surgery thorough clinical assessment, laboratory investigations, ultrasound findings were recorded for each patient. After confirming the diagnosis of Acute Appendicitis the patients had operative intervention and specimens were sent for histopathological study. Results: Acute appendicitis was found more commonly among patients of 20-29 years of age with 37% in prospective and 42.9% in retrospective studies respectively. Modified Alvarado score (MAS) had sensitivity of 47.7% and 59.6%, specificity of 87.5% and 91.6% in both prospective and retrospective studies respectively. Ultrasonographic findings showed sensitivity of 82.1% and 92.7%, specificity of 76.4% and 72.7% in prospective and retrospective studies respectively. Conclusion: When the diagnosis of acute appendicitis is clinically obvious based on strongly positive clinical signs, it can be an indication for operative treatment. However in the cases of equivocal diagnosis Ultrasonography should be used as an adjunct to clinical diagnosis and thereby decreasing the rates of negative laparotomies.
  - 4,820 366
Pyogenic liver abscesses in adults: A 3-year study
Ramesh K Korumilli, Gautham R Ginjala, Srinivas A Mahesh
January-April 2014, 4(1):36-39
DOI:10.4103/2278-9596.136709  
Background: Pyogenic liver abscess (PLA), a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades. This study was undertaken to evaluate PLA in relation to age, sex, anatomical relation, etiological factors, and response to various lines of management. Materials and Methods: A prospective study was conducted during the period from September 2010 to September 2013. Amebic and hydatid liver abscesses were excluded. We recorded and analyzed the clinical presentations, diagnostic modalities, and treatment programs of PLAs. Results: A total of 423 patients were studied. The average age of patients was 42 years, ranged from 20 to 80 years. Of a total 423 patients, 386 patients (91.2%) were males and 37 (8.8%) were females. The most common symptom was fever associated with chills. The most common sign was hepatomegaly and tenderness in right hypochondrium 209 (49.4%). Alcoholism was identified as a major risk factor in 309 (73%) patients. Diabetes was present in 86 (20.3%), tuberculosis in 34 (8%), and HIV infection in 10 (2.3%) patients. Abdominal ultrasonography had a sensitivity of 97% in diagnosing liver abscess. There was a single abscess in 326 (77%) patients, the right lobe being involved in 282 (66.6%) patients. Multiple abscesses were found in 97 (22.9%). Most patients were managed conservatively with antibiotics and percutaneous drainage. 46 patients (10.8%) had ruptured liver abscesses and required peritoneal lavage at laparotomy. Death occurred in seven (2%) patients. Conclusion: Pyogenic liver abscess is a potentially fatal disease if untreated. Early diagnosis remains the cornerstone of management. Majority can be managed conservatively with antibiotics and percutaneous drainage.
  - 3,976 255
Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study
Jyoti Bansal, Shehtaj Khan, Rajkamal Jenaw, Reyaz Ahmad
January-April 2014, 4(1):40-43
DOI:10.4103/2278-9596.136712  
Background: Preoperative mechanical bowel preparation (MBP) for elective colorectal surgery has been criticized, but is still in use because of fear of fecal load and peritoneal contamination. Experience with an indigenous low cost technique for on-table colonic lavage (OTCL) in obstructive left-sided colonic pathology has been described. OTCL would be a step towards discouraging MBP before colorectal surgery. Patients and Methods: Fourteen patients for elective colorectal surgery without preoperative bowel preparation were evaluated and found with impacted fecal matter and loaded colon intraoperatively. Instead of two-stage procedure, we did OTCL by our own devised method followed by a single-stage curative resection. Results: All patients had successful resection and primary anastomosis of their lesions. Mean time for lavage was 21 min. There was no peritoneal contamination. No postoperative anesthesia or procedure-related complication was encountered. No clinical anastomotic leak or mortality was encountered. In one patient, surgical site wound infection occurred. Conclusion: In cases where bowel preparation is not done preoperatively and single-stage procedure discredited only because of impacted fecal matter, OTCL should be taken into account. Our technique of OTCL should be employed as it is simple, safe, and cheap and would prove to be a step towards discouraging preoperative MBP for elective colorectal surgery, especially in resource limited setting.
  - 5,373 282
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