Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures

Background

Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures.

Methods

The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity.

Results

The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92).

Conclusions

PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair.

Clinical implications

This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair.

PROSPERO registration number

CRD42023409710.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis

Background

Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair.

Methods

This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis.

Results

Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67).

Conclusion

The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Techniques of staged laparoscopic orchidopexy for high intra-abdominal testes in children: A systematic review and meta-analysis

Background

Laparoscopic exploration is currently considered the gold standard for managing nonpalpable intraabdominal testes. The problem of short vascular pedicle is addressed in Fowler-Stephen (FS) technique by the division of testicular vessels and in Shehata technique (ST) by traction on testicular vessels. There is a lack of the consensus among pediatric surgeons on the choice of one technique over other. This analysis compares the reported outcomes of staged laparoscopic orchidopexy by ST with the time tested FS technique in managing high intraabdominal undescended testis.

Materials and Methods

The present systematic review and meta-analysis was conducted as per the preferred reporting items for the systematic review and meta-analyses guidelines. Only randomized controlled trials and comparative studies were included. The primary outcomes compared were the incidence of testicular atrophy, testicular retraction/ascent rate, and operative time of Stage I and Stage II orchidopexy.

Results

The present analysis was based on three randomized studies with a total of 119 undescended testes in 117 patients satisfying the inclusion criteria. The operative time was less in Stage I FS technique; however, there was no statistically significant difference in operative time of both procedures during the Stage II laparoscopic orchidopexy. Pooled analysis of postintervention testicular atrophy, testicular retraction rate, and duration of postoperative hospitalization showed no difference between both procedures.

Conclusion

Both FS and STs are comparable in terms of postintervention testicular atrophy, testicular retraction/ascent; however, the mean operative time is significantly less with FS technique in Stage I laparoscopic orchidopexy.

Clinicopathological profile of breast cancer from Chhattisgarh India: A single-center hospital-based study

Background

Global breast cancer incidence is increasing at an annual rate of 3·1%. Female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer, with an estimated 2.3 million new cases (11.7%). However, the data from different parts of India are still lacking and the study was conducted to assess the burden of disease at tertiary referral centers in central India.

Material and Methods

Retrospective record analysis (June 2013-June 2017) of data from outdoor clinics and pathology reports. The patients aged <15 yrs, nonresidence of Chhattisgarh, and diagnosed outside the study period were excluded. The triple assessment was used to diagnose all breast lumps (sensitivity 99%).

Results

Eighty patients were diagnosed having breast carcinoma. The mean age for breast cancer was 39 ± 3.028 years (ranged 31-50 years). Twenty patients had locally advanced breast carcinoma. The predominant religion was Hindu 55.00%. The referral pathway to seek medical care for breast cancer was via a gynecologist in 40% (32/80). Familial breast cancers were in 0.03% (3/80) of patients. None breast cancer patients have previous histology-proven benign breast disease. The mean size of the breast cancer lump was 3.56 cm (ranged 1.0-11.0 cm). Overlying skin ulceration (n = 2), skin infiltration/peau-d'- orange (n = 2), skin tethering (n = 4), and bloody nipple discharge were found in one patient. Breast cancer was diagnosed during lactation (postnatal period) in one patient. The maximum number of patients have tumor size >5 cm (72.6%). Immunohistochemistry and pathological analysis was done on core biopsy (n = 20) and surgical procedure (n = 60). Modified radical mastectomy was done in 52, breast conservative surgery with Sentinal Lymph node biopsy and axillary lymph node dissection in 6, and toilet mastectomy in two patients. The predominant tumors were solid (n = 79/80), with both solid and cystic types (1/80). The solid and cystic lesion on FNAC was of C3b type, and an excision biopsy revealed medullary carcinoma of the breast. Invasive ductal carcinoma-no special type (IDC-NST) was observed to be the most common histopathologic type (n = 70/80), followed by medullary carcinoma (n = 2), metaplastic carcinoma (n = 1), papillary carcinoma (n = 4), Paget disease with DCIS (n = 1), mucinous carcinoma (n = 1), invasive lobular carcinoma (n = 1). One male patient with breast cancer and two female patient having bilateral breast cancer also have IDC-NST.Scarff Bloom Richardson Grade was predominantly graded 2 in 46.25% (37/80) of breast cancer patients (Grade 1 = 9, Grade 2 = 37, Grade 3 = 34). Lymphovascular (LVI) and perineural invasion (PNI) were predominantly without LVI and PVI. (Lymphovascular present and perineural invasion present = 4, Lymphovascular present and perineural invasion absent = 32, Lymphovascular absent and perineural invasion absent = 42, Lymphovascular absent and perineural invasion present = 2). Histological examination of axillary lymph nodes showed the presence of malignant cells in all. Triple-negative breast carcinoma was 26.58% (21/79). Most breast cancer presented at stage II A = 37.5% (30/80) and II B = 28.7% (23/80) of the AJCC staging system.

Conclusion

The clinico-epidemio and histological profile of breast cancer in Chhattisgarh is similar to other parts of India. Scarff Bloom Richardson Grade was predominantly grade 2 in 46.25% (37/80) contrary to Grade III (70%) in other series from India.

A Right-Angled Thorn in the Bowel: A Curious Case of Small Bowel Perforation

We present a 45-year-old man with small bowel perforation resulting from the inadvertent ingestion of a right-angled thorn of the Gum Arabic plant (Vachellia nilotica). The diagnosis was made, and an emergency laparotomy was performed for suspected enteric peritonitis. The thorn was found projecting from the terminal ileum with a minimal intra-peritoneal fluid collection. The thorn was removed, and the perforation site was repaired primarily with absorbable sutures. The lack of a reliable history of foreign body ingestion makes it impossible to arrive at an accurate preoperative diagnosis in patients presenting with perforation peritonitis. Radiological investigations have a low sensitivity for detecting radiolucent vegetative foreign bodies as the cause of bowel perforations. Primary repair should be preferred over resection procedures in the management of foreign body-induced small bowel perforations.

The comparison of interrupted and continuous suturing technique in Snodgrass urethroplasty in patients with primary hypospadias: A systematic review and meta-analysis

Background

Hypospadias is among the common congenital anomalies in boys. Snodgrass urethroplasty is one of the most popular techniques for correcting distal and mid hypospadias. Although there is consensus among pediatric surgeons on using absorbable sutures for urethroplasty, there are no established guidelines about the suturing techniques (interrupted suturing [IS] or continuous suturing [CS]) for neourethra creation in Snodgrass urethroplasty. This analysis aims to compare the reported outcomes of both the urethroplasty suturing techniques.

Materials and Methods

This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses guidelines. A systematic, detailed search was carried out by the authors in the electronic databases - MEDLINE, PubMed Central, Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected and compared based on primary outcomes - development of urethrocutaneous fistula (UCF), meatal stenosis, and secondary outcomes - wound infection, urethral stricture, and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio, and I2 heterogeneity.

Results

Five randomized studies with a total of 521 patients met our inclusion criteria. Pooled analysis for total complications, UCF, meatal stenosis, and wound infection showed no significant difference between the CS and IS groups. Subgroup analysis of patients with the use of polyglactin sutures showed a decrease in total complications and UCF in the IS group.

Conclusion

There is no difference in total complication rates among the CS and the IS group with the use of absorbable sutures in Snodgrass urethroplasty; however, there is a decrease in the incidence of total complications and UCF in the IS group when polyglactin was preferred over polydioxanone suture for urethroplasty.

Use of an Autologous Platelet-Rich Concentrate in Hypospadias Repair: A Systematic Review and Meta analysis

Background

There is unanimous agreement amongst hypospadias surgeons to use an intermediate layer to cover the neourethra. Dartos fascia and tunica vaginalis (TV) flaps are the most preferred tissues to be used. Tissue glue, sealants and biomaterials are also useful where there is a paucity of local tissue to cover the neourethra. But these blood-derived products have associated infectious and allergic risks. The autologous human platelet concentrate (APC) contains biologically active factors and is safe for wound healing and soft tissue reconstruction. It has been used by few surgeons as an intermediate layer in hypospadias repair. This systematic review and meta-analysis aim to systematically compare the outcomes of hypospadias surgery in children with or without using APCs.

Methods

This systematic review and meta-analysis was conducted as per the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Meta-analysis protocol was registered with INPLASY. A systematic, detailed search was carried out by the authors in the electronic databases, including Medline, Embase, CENTRAL, Scopus, Google Scholar and clinical trial registry. Studies were selected and compared based on primary outcome measures like urethra-cutaneous fistula, meatal stenosis, wound infection and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio and I2 heterogeneity.

Results

Four randomized studies with a total of 355 patients were included. Pooled analysis for outcome of urethra-cutaneous fistula (UCF) showed no significant difference between the groups with APC and without APC. Pooled analysis for the other outcome like meatal stenosis, wound infection and total complications showed a decrease in incidence of these complications in groups with APC.

Conclusion

This meta-analysis shows that there is a reduction in the incidence of wound infection, meatal stenosis and total complications in patients where APC was used to cover the neourethra, although no such difference was observed in UCF rates.

A Systematic Review and Meta-Analysis of Harmonic Scalpel Versus Conventional Techniques of Appendiceal Stump Closure in Laparoscopic Appendicectomy

Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy.

This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I² heterogeneity.

Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.

Information technology-based joint preoperative assessment, risk stratification and its impact on patient management, perioperative outcome, and cost

Background: Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing’s impact on patient outcome and cost. Methods: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant.  Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications. Conclusion: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.

Discharging loin sinus: Unusual manifestation of ruptured horseshoe kidney

We present a 20-year-old man with a chronic discharging sinus in the left loin arising from a horseshoe kidney with a large pelvicalyceal calculus on its left side. The left moiety was non-functional, so a left hemi-nephrectomy, together with excision of the whole fistula tract, was carried out. Histopathology was suggestive of chronic interstitial nephritis. Patients with horseshoe kidney are prone to development of renal stones and their associated complications. The unfamiliar anatomy of horseshoe kidneys may increase the complexity of any surgical procedure. Radiological investigations are pivotal in identification of the underlying renal pathology; they may also delineate a fistula tract as in our case.

A rare case of congenital ranula

Simple ranula is a cystic swelling confined to the floor of mouth while plunging ranula presents with extension to the neck. Congenital ranula presenting with symptoms of feeding difficulties is a very rare occurrence. There is paucity of literature regarding the management of large congenital ranula. Varied treatment options are described for the management of ranula with variable recurrence rate. In paediatric and adult patients, ranula is considered as a type of extravasation cyst and removal of sublingual gland is advocated to remove the sources of extravasation. Congenital ranula is usually a variant of retention cyst and should be treated with marsupialisation or simple excision of cyst while cyst excision with sublingual sialadenectomy should be reserved for recurrent cases.

Distribution of Apolipoprotein A1 Polymorphism (G-75A and C+83T) in Patients with Diabetic Foot Ulcers-A Parallel Group Hospital Based Observational Study

Introduction: Diabetic Foot Ulcer (DFU), a serious complications of diabetes mellitus is a result of persistent low grade infection. The Apolipoprotein A1 (ApoA1) has an anti-inflammatory role and therefore can influence the chronic inflammation associated with the DFU. Polymorphisms of ApoA1gene have been implicated as determinants of plasma HDL-C and Apo A1 levels. However, the influence of ApoA1 polymorphism on susceptibility to DFU has not been studied. Aim: To study the distribution of ApoA1 polymorphism (G-75A and C+83T) and association between the polymorphism and the risk of DFU in patients with Type 2 Diabetes Mellitus (T2DM) so that timely detection and prevention of DFU can be done. Materials and Methods: This was a hospital based observational study on patients of DFU (n=80), diabetes mellitus without ulcers (n=80) and normal controls (n=75). ApoA1 polymorphism (G-75A and C+83T) was detected by Real Time Polymerase Chain Reaction (RTPCR) technique and plasma ApoA1 by immunoturbidimetric assay using blood collected in EDTA. Data was analysed using IBM® Statistical Package for Social Sciences (SPSS) 21.0 software. A p<0.05 was considered as statistically significant. Results: The GA and CC were the most predominant genotype in all the groups. HDL and ApoA1 were significantly lower in GG (p=0.009, p=0.03) and CT (p=0.03, p=0.002) compared to GA and CC. The APOA1-75A allele and +83C allele were associated with raised levels of HDL and ApoA1 in T2DM and DFU (p<0.05). Conclusion: The two polymorphism G-75A and C+83T were found to be equally distributed across the study populations. These polymorphisms were associated with serum levels of ApoA1 and HDL in the DFU patients.

Primary hydatid disease of fallopian tubes: the risk of infertility looms large

A 45-year-old postmenopausal woman from a rural area presented with a painless lower abdominal lump. Contrast-enhanced computed tomogram of abdomen revealed a well defined hypodense pelvic cystic lesion with multiple daughter cysts suggestive of hydatid disease. The liver was free of cysts on imaging. On laparotomy, the cyst cavity was found to be communicating with the fimbriated ends of both the fallopian tubes. Cyst excision along with hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathology confirmed presence of hydatid disease by demonstrating daughter cysts and laminated membrane completely filling up the tube lumens. The uterus and ovary were uninvolved. While the management is straightforward in postmenopausal women, the risk of infertility looms large in young patients with bilateral fallopian tube hydatid disease. Proper preoperative counseling is thus essential in the patients with pelvic hydatid disease to safeguard against future litigations.

Necrotizing Fasciitis in Neonate and Use of Allograft

Necrotising fasciitis is a fulminant and rapidly progressive infection of the superficial fascia and subcutaneous tissue. It is rare in newborn. Trunk is the commonest site of involvement in newborns. Early diagnosis and prompt surgical debridement is the preferred treatment. Debridement in NF leads to a large raw area which may not heal by primary intention and may a split thickness skin graft for healing. Presence of minimum subcutaneous fat, loose skin and large raw area at donor site like back in some neonate poses difficulty for harvesting of skin graft. In such neonates allograft make a valuable option temporarily. Herein we report a case of a neonate with NF in whom post debridement raw area was covered with allograft from mother.

A New Platelet Aggregating Material (PAM) in an Experimentally Induced Rat Fibrosarcoma

The present work concerns our studies to search for factor(s) which may influence the hemostatic process in or around metastasis of tumours. We studied the platelet aggregating property of a methyl cholanthrene induced experimental tumour. Platelet aggregating material was found to be different from the known aggregating agents like thrombin, ADP, collagen, thromboxane A2 and trypsin. It depends on a critical level of calcium for its action. PAM is a high molecular weight substance which contains sialic acid. It is trypsin and plasmin insensitive. The activity of this substance is not being destroyed by phospholipase-C. Metabolic study indicates that PAM acts by mitochondrial energy metabolic pathway of the platelets.

Spontaneous Rupture of a Congenital Diaphragmatic Eventration in an Infant

Rupture of eventration of diaphragm is a rare entity that commonly presents as sudden onset respiratory distress. We report a case of a 7-month-old infant with congenital diaphragmatic eventration having spontaneous diaphragmatic rupture which led to secondary diaphragmatic herniation with gastric volvulus. Clinical diagnosis of gastric volvulus was suspected on the basis of imaging and failed entry of nasogastric tube into stomach. Exploratory laparotomy revealed rupture of eventration of diaphragm and gastrothorax with volvulus. Anatomical repair of diaphragmatic perforation followed by diaphragmatic plication resulted in successful outcome in our patient.

Centchroman vs tamoxifen for regression of mastalgia: a randomized controlled trial

INTRODUCTION

Several agents have been tried in the management of mastalgia. Centchroman (Ormeloxifene), a novel non-steroidal selective estrogen receptor modulator (SERM), has also been recently used in the management of mastalgia.

METHODS

Eligible patients, who had mastalgia for more than 3 months, were randomized into two groups - Group A received centchroman 30 mg daily and Group B received tamoxifen 10 mg daily. Treatment was continued for a total of 12 weeks; thereafter, patients were followed for another 12 weeks without medication to assess the continuum of relief. Pain severity was measured with VAS score. Patients were considered to have complete pain relief if their VAS score decreased to 3 or less.

RESULTS

Patients, in both the groups, showed gradual improvement in mastalgia with passage of time up to 12 weeks. Following cessation of treatment at 12 weeks, partial relapse of pain was observed at 24 weeks. There was no significant difference between Group A and Group B in terms of mean VAS Score and proportion of women reporting pain relief at 4, 8, 12, and 24 weeks. Fifteen patients in Group A had side effects namely dizziness, menstrual irregularities and development of ovarian cysts. There was no side effect noted in group B.

CONCLUSION

Centchroman and tamoxifen were found to be of similar effectiveness in providing pain relief in mastalgia. High frequency of side effects, particularly development of ovarian cyst, in patients receiving centchroman is a matter of concern.

Potentially toxic elements in lignite and its combustion residues from a power plant

The presence of potentially toxic elements in lignite and coal is a matter of global concern during energy extraction from them. Accordingly, Barsingsar lignite from Rajasthan (India), a newly identified and currently exploited commercial source of energy, was evaluated for the presence of these elements and their fate during its combustion. Mobility of these elements in Barsingsar lignite and its ashes from a power plant (Bikaner-Nagaur region of Thar Desert, India) is presented in this paper. Kaolinite, quartz, and gypsum are the main minerals in lignite. Both the fly ash and bottom ash of lignite belong to class-F with SiO₂ > Al₂O₃ > CaO > MgO. Both the ashes contain quartz, mullite, anhydrite, and albite. As, In, and Sr have higher concentration in the feed than the ashes. Compared to the feed lignite, Ba, Co, U, Cu, Cd, and Ni are enriched (10-5 times) in fly ash and Co, Pb, Li, Ga, Cd, and U in bottom ash (9-5 times). Earth crust-normalization pattern showed enrichment of Ga, U, B, Ag, Cd, and Se in the lignite; Li, Ba, Ga, B, Cu, Ag, Cd, Hg, Pb, and Se, in fly ash; and Li, Sr, Ga, U, B, Cu, Ag, Cd, Pb, and Se in bottom ash. Hg, Ag, Zn, Ni, Ba, and Se are possibly associated with pyrite. Leaching test by toxicity characteristic leaching procedure (TCLP) showed that except B all the elements are within the safe limits prescribed by Indian Standards.

Delayed rupture of gallbladder following blunt abdominal trauma

A 29-year-old gentleman presented to surgery emergency with severe upper abdominal pain and vomiting. He reported to had been hit in his abdomen by a ball during a cricket match. Computerized tomogram of the abdomen revealed hematoma within the gallbladder lumen, laceration of segment six of liver, and hemoperitoneum. The patient did not agree for laparotomy advised to him, and so, managed conservatively. The patient reported back to us with high grade fever, jaundice, and painful abdominal distension after seven days of discharge from the hospital. His abdominal examination showed features of generalized peritonitis. Surgical abdominal exploration revealed a single perforation in the fundus of gallbladder with frozen calot'striangle. Subtotal cholecystectomy was done. Histopathology of excised gallbladder revealed xanthogranulomatous inflammation. The present case report highlights that early exploration and cholecystectomy should be considered in patients with gallbladder injury to obviate the risk of delayed perforation.

Male urethral diverticulum having multiple stones

Congenital diverticulum of male urethra is an uncommon entity. Neglected management complicates the process in the form of calculi formation and recurrent urinary infection. A 10-year-old boy presented with urinary voiding disturbances and development of a painless hard lump at the penoscrotal junction. Imaging demonstrated presence of anterior urethral diverticulum with contained calculi in it. Open urethral diverticulectomy, extraction of multiple calculi, and primary urethral reconstruction over a Foley catheter was carried out. Early diagnosis and individualized surgical management of congenital male urethral diverticulum is the key to a successful outcome.

Spontaneous rupture of the renal pelvis presenting as an urinoma in locally advanced rectal cancer

A 29-year-old gentleman underwent a transverse colostomy for intestinal obstruction caused by advanced rectal carcinoma. On the 5^th postoperative day, the patient developed a painful swelling on the right side of the abdomen. The contrast enhanced computed tomography of the abdomen revealed a right sided hydronephrosis, a large rent in the renal pelvis, and a large retroperitoneal fluid collection on the right side. Percutaneous nephrostomy and pigtail catheter drainage of the urinoma led to resolution of abdominal swelling. Development of a urinoma as a consequence of rectal carcinoma is highly unusual. Prompt imaging for confirmation of diagnosis, decompression of the renal pelvicalyceal system, and drainage of the urinoma limits morbidity.

Amoebic anal fistula: new insight into an old disease

A 67-year-old gentleman underwent fistulectomy for low trans-sphincteric anal fistula along with curettage for an associated abscess extending proximally for half a centimeter into the intersphincteric plane. The roof of the cavity became clearly visible after satisfactory culmination of the surgical procedure. Histopathological examination of the fistulous tract and the curetted granulation tissue revealed presence of multiple trophozoites of Entamoeba histolytica exhibiting erythrophagocytosis in the background of mixed inflammatory infiltrate. This case report provides the outlook that yields the novel insight into the possible role of Entamoeba histolytica in the pathogenesis and persistence of the fistulous tract.

Colonic perforation with peritonitis in amoebiasis: a tropical disease with high mortality

BACKGROUND

Invasive colonic amoebiasis presents primarily with dysentery; colonic perforation occurs rarely. Cases of amoebic colonic perforations have been reported sporadically over the past 20 years.

METHODS

A retrospective study was done in the surgical unit of a tertiary care hospital in North India. The case records of those patients were reviewed who underwent exploratory laparotomy from January 2011 to September 2012 and were diagnosed with amoebic colonic perforation on histopathological examination. Details concerning the clinical presentation, investigations, intraoperative findings, operative procedures, and postoperative outcomes were retrieved.

RESULTS

Amongst, a total of 186 emergency exploratory laparotomies carried out during the study, 15 patients of amoebic colonic perforation were identified. The median age of the patients was 42 years (IQR 32.0-58.0) and the male to female ratio was 13:2. Previous history of colitis was present in only 1 patient. The preoperative diagnosis was perforation peritonitis in 12 patients; and intussusception, intestinal obstruction and ruptured liver abscess in 1 patient each. Ten patients had single perforation while 5 had multiple colonic perforations. All the patients except one had perforations in the right colon. Bowel resection was performed depending upon the site and extent of the colon involved-right hemicolectomy (8), limited ileocolic resection (6) and sigmoidectomy (1). Bowel continuity could be restored only in 2 of the 15 patients and a stoma was constructed in the remaining 13 patients. The overall mortality rate was found to be 40% (6/15).

CONCLUSION

Amoebic colonic perforation is associated with unusually high mortality.

External jugular venous aneurysm: A clinical curiosity

Jugular venous aneurysm is an extremely rare condition. The patients presented with a painless swelling in the neck that appears while coughing, straining, bending, or breath holding. Detection of a soft and compressible swelling in the course of an external jugular vein (EJV) superficial to the sternomastoid muscle, non-filling on compression of the EJV during Valsalva maneuver clinches the diagnosis of EJV aneurysm. Color Doppler ultrasound allows precise delineation of the lesion and is considered the gold standard for confirming the diagnosis. Surgical excision is indicated mostly for cosmetic reasons and symptomatic aneurysms. We, herein, report a patient with saccular external jugular venous aneurysm to highlight the typical clinical presentation and diagnosis of this rare entity.