Solid Pseudopapillary Neoplasm - Case Series and Review of Literature

Solid-pseudopapillary neoplasm (SPN) is a variety of solid and cystic tumors of the pancreas. It was first described by Frantz in 1959. It is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, which accounts for about 0.17 to 2.7% of all pancreatic tumors. Here, we are describing 5 cases of pancreatic solid pseudopapillary neoplasm, out of 180 pancreatic tumors, operated in our institution in the 5-year period (2015-2020). Also, we have reviewed all available case series (from 2006 to 2020) in the literature, of pancreatic pseudopapillary neoplasm, for demographic information, etiopathogenesis, diagnosis, and extent of operation to establish the optimal management of this condition. Retrospective analysis of pancreatic tumors was carried out from February 2015 to January 2020. A total of 180 patients underwent pancreatic resection in this period for pancreatic tumor, out of which, the solid pseudopapillary neoplasm was confirmed in 5 cases (2.76%). Among these 5 cases, 4 cases (80%) were female and one (20%) male, with age group range from 14 to 45 years (mean age - 28 years). Abdominal pain was the most frequent presenting symptom (60%). Mean tumor diameter was 6.9 cm (range, 2-18 cm). Two patients were diagnosed preoperatively by CECT and MRI findings, and three patients were diagnosed preoperatively by percutaneous/USG-guided and CT-guided FNA cytology. Two patients underwent pancreatoduodenectomy; one patient underwent enucleation; and two patients underwent spleen preserving distal pancreatectomy. Four patients are alive and on regular follow-up, while one patient died on the 5th post-operative day due to post-operative sepsis.

Current Approach for Diagnosis and Treatment of Adrenal Tuberculosis-Our Experience and Review of Literature

Addison's disease was first described by Thomas Addison in 1855. He demonstrated the destruction of bilateral adrenal gland by tuberculosis (TB) in six patients. Since then, the incidence of TB has declined in the Western world, but in developing countries, it is still the most common cause of adrenal insufficiency. Because of the introduction of antituberculous chemotherapy, the incidence of adrenal TB has been declined in the past decades. The most common symptoms are nonspecific; therefore, diagnosis is often delayed, and patients may first present with a life-threatening adrenal crisis. The most commonly identified organism for adrenal failure in adrenal TB is Mycobacterium tuberculosis infection. Adrenal TB involves bilateral adrenal glands more frequently than unilateral glands. Computed tomography (CT) scan and magnetic resonance imaging (MRI) are useful investigations to differentiate between tuberculous Addison's disease and the other causes of adrenal insufficiency. In CT scans or MRI, features of adrenal TB are bilateral adrenal enlargement and peripheral rim enhancement with or without calcifications. Antituberculous drugs, biochemical monitoring of adrenal function, and steroid therapy are essential for the management of adrenal TB and adrenal insufficiency. Here, we describe a case of adrenal TB with abscess formation followed by a review of the current literature of adrenal TB for better diagnosis and management of this condition.

Evaluation of risk factors for prognosticating blunt trauma chest

<b>Introduction:</b> Blunt trauma chest contributes to significant number of trauma admissions globally and is a cause of major morbidity and mortality. Many scoring systems and risk factors have been defined in past for prognosticating blunt trauma chest but, none is considered to be gold standard. </br> <b>Aim:</b> This study was conducted to reassess the significance of available scoring systems and others indicators of severity in prognosticating blunt trauma chest patients. </br> <b>Materials and Methods:</b> In this prospective observational study from November 2016 till March 2018, 50 patients with age more than 12 years with blunt chest trauma who required hospitalization were included. Nine risk factors were assessed namely- age of the patient, duration of presentation after trauma, number of ribs fractured, bilateral thoracic injury, evidence of lung contusion, associated extra thoracic injury, need for mechanical ventilation, Revised trauma Score (RTS) and Modified Early Warning Sign Score (MEWS). Severity of blunt thoracic trauma was assessed on following outcomes-SIRS, ARDS and Death. The inferences were drawn with the use of statistical software package SPSS v22.0. </br> <b>Results:</b> The age of 50 patients included in our study with a range of 15 to 76 years, the median age was 35.5 years. Statistically significant association was observed between occurrence of SIRS and multiple ribs fractured (p-value- 0.049), associated extra-thoracic injury (p-value-0.016) and higher MEWS score (p-value-0.025). ARDS occurrence was statistically significantly associated with all the risk factors except age.Death occurred more in patients with delayed duration of presentation to hospital (p-value <0.001), multiple ribs fractured (p-value-0.001), bilateral thoracic injury(p-value<0.001), associated extra-thoracic injury (p-value-0.004), patients who required ventilatory support (p-value<0.001), low RTS (p-value-0.006) and high MEWS (p-value-0.005) on admission. This association was found statistically significant. </br> <b>Conclusion:</b> High MEWS, associated extra-thoracic injuries and multiple rib fractured can very well predict poor outcome in terms of SIRS, ARDS and death. Aggressive treatment protocols should be established for better outcome in these patients with blunt trauma chest.

Comparison of closed incision negative pressure wound therapy with conventional dressing for reducing wound complications in emergency laparotomy

OBJECTIVE

The aim of this study was to compare the post-operative effects of closed incision negative pressure wound therapy with conventional dressing in emergency laparotomy.

METHODS

This study was conducted from 1st November 2018 to 31st March 2020 in ABVIMS &amp; Dr. R.M.L. Hospital, New Delhi. The potential candidates for the study were patients of 18 years and above who were admitted in surgical emergency and underwent emergency laparotomy by a midline incision. Fifty random patients were alternatively allotted to group A (25 patients) and group B (25 patients). In the patients of group A, closed incision negative pressure wound therapy (ciNPWT) was applied on midline closed wound after an exploratory laparotomy procedure. The patients in group B, standard dry gauze dressing was done.

RESULTS

The mean age of patients in group A and group B were 46.76±12.20 and 41.96±8.33 years, respectively (p-value-0.11). The wound infection was present in 12% of cases in group A and 32% in group B, but when we calculate the p-value, it was found to be statistically non-significant (p-value-0.08). Similarly, seroma formation and wound dehiscence were found less in group A as compared to group B but not reached up to a statistically significant limit (p-value 0.55 and 0.38 respectively). The frequency of dressing change was 1-2 per week in 92% of cases in group A while it was 3-4 per week in 68% of cases in group B. The mean time of the frequency of dressing change was 1.24±0.72 per week and 4.28±1.90 per week in both the groups respectively (p-value &lt;0.001). There was no significant (p&gt;0.05) difference in the duration of hospital stay between group A (mean hospital stay 8.20±2.34 days) and group B (mean hospital stay 8.21±3.37 days).

CONCLUSION

Closed incision negative pressure wound therapy has no advantages over conventional dressing in terms of post-operative complications and hospital stay. However, it reduces the frequency of dressing change significantly, which reduces the mental stress of the patient and the burden of changing daily dressing.

Penetrating trans-abdominal bamboo stick injury: An unusual case report

Objective: Penetrating abdominal trauma secondary to bamboo stick injury is a rare entity in the developed world. Most of such kind of trans abdominal penetrating bamboo stick injury is associated with multiple solid and hollow viscus injuries. In developing countries like India, where nearly 70% of the population reside in rural areas, it is not that uncommon. Aim of this report is to recognition of risk factors and explain optimum surgical management in trans-abdominal bamboo stick injury. Case Presentation: Here we describe a case of penetrating trans abdominal bamboo stick injury resulting due to fall over a branch of bamboo stick with multiorgan damage, which was successfully managed by early surgical exploration in our institute. Conclusion: There are many factors which can prognosticate the penetrating trauma cases. The most important factors include a long interval between injury and surgical exploration, presence or absence of shock, and other associated organ injuries at the time of admission. Early recognition of the severity of injury with surgical management is utmost necessary. These patients have high morbidity and mortality rates due to multiorgan damage and post-operative infection.

Evaluation of Risk Factors for Septic Complications after Laparotomy for Abdominal Trauma: A Longitudinal Cohort Study

Introduction: Septic complications are the most common cause of death in trauma patients who survive beyond 48 hours. Early diagnosis and treatment of infectious complications is essential to prevent life-threatening complications like Systemic Inflammatory Response Syndrome (SIRS) and Multi-Organ Dysfunction Syndrome (MODS). Aim: To study the various risk factors for septic abdominal complications following laparotomy for trauma. Materials and Methods: A prospective longitudinal cohort single-center study was conducted from November 2016 to March 2018. Sixty patients above the age of 12 years, who underwent laparotomy for abdominal trauma in the Surgical Department of our hospital, were included in the study. Various patient variables were compared with postoperative septic abdominal complications like wound infection, wound dehiscence, anastomotic leak and intra-abdominal abscess. Data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In the total 60 patients (35.60±16.54), significant association was seen between wound infection and dehiscence with the time interval between trauma and surgery (p<0.001), lesser Revised Trauma Score (RTS) (p<0.001) and greater Injur Severity Score (ISS) (p<0.001). A significant association of all septic complications was seen with the need for Intensive Care Unit (ICU) stay (p<0.001) and the presence of associated injuries (p<0.001). Variables such as age, gender, co morbidities, Body Mass Index (BMI), pre-hospital care received, intraoperative findings and duration of ICU stay had no association with outcomes (p>0.05). Conclusion: In trauma patients, factors like low RTS score, high ISS score, need for ICU stay and the presence of associated injuries may help the surgeons to decide in which patients to go for techniques like delayed closure of the wound, stoma instead of bowel anastomosis, etc., which may help to reduce postoperative septic complications.

Thyroid tuberculosis

Thyroid tuberculosis is a rare disease. Its incidence is low even in countries where prevalence of pulmonary tuberculosis is high (0.1-0.4%). In literature, there are only a few cases which were diagnosed as thyroid tuberculosis. It can be explained by a high resistance of the thyroid gland to infectious processes. However, the prevalence of tuberculosis has increased worldwide and thyroid involvement can be a primary manifestation of the disease. The incidence of extrapulmonary tuberculosis has been showing a progressive increase in the recent years(Barnes and Weatherstone, 1979). The most frequent clinical presentation is a solitary thyroid nodule that may present as a cystic nodule. It may also present as thyroid abscess with pain, fever and other non-specific signs and symptoms. ATT results in complete cure therefore it is important to differentiate it from other form of thyroiditis. Patients are usually euthyroid, but cases of hypothyroidism and hyperthyroidism are described. For accurate diagnosis of thyroid tuberculosis, clinical and radiological features are nonspecific and histological examination is required for confirmation of diagnosis. PCR may help in diagnosis. The authors encounter 3 cases of thyroid tuberculosis in last 5 year which are described in this article. The aim of this study is to review all the cases published in literature to describe clinical presentation, appropriate diagnostic method and possible treatment options of the disease.

Ileosigmoid Knotting Causing Double Lumen Acute Intestinal Obstruction and Gangrene: Review and A Case Report

Ileosigmoid Knotting is a rare cause of intestinal obstruction. It is also called as compound volvulus or double volvulus. It is caused by the wrapping of the ileum around the sigmoid colon and its mesentery or vice-versa. It is a rapidly progressive condition, leads to acute intestinal obstruction and gangrene in ileum as well as in the sigmoid colon. Early diagnosis and intervention is the key to a better outcome. Due to the rarity and unfamiliarity of this entity, diagnosis is usually made intraoperatively. Surgical removal of the gangrenous segment with either stoma formation or anastomosis is the only hope.An additional systemic search of the literature was done in PubMed, MEDLINE, ISIS, Embase, and CAS searches with the following free text keywords: ileosigmoid knotting, intestinal knotting, compound volvulus and double volvulus in English literature. Around 64 studies were identified, out of which 38 studies were selected for this article after the removal of duplicates and unrelated articles. These case series and reports were reviewed for aetiopathogenesis, presentation, diagnostic modalities, surgical interventions, and outcome.Along with this review article, there was a case report of ileosigmoid knotting in a 38-year-old male patient that presented in the surgical Emergency Department; with complaints of generalised pain and distention of abdomen for two days. Also, he had complained of not passing flatus and motion for two days. On examination, patient had generalised tenderness and bowel sounds were absent. X-ray abdomen showed dilated small and large bowel with multiple air-fluid levels. After resuscitation, an emergency exploratory laparotomy was done, and the diagnosis of ileosigmoid knotting with gangrene of both ileum and sigmoid colon was made intraoperatively. After resection of both gangrenous segment, colocolic anastomosis and double barrel ileostomy was performed. The postoperative course was uneventful, and patient was discharged on 7th postoperative day.

Characteristics of the positive ion source at reduced gas feed

The neutral beam injector of steady state superconducting tokamak (SST1-NBI) at IPR is designed for injecting upto 1.7 MW of neutral beam (Hº, 30-55 keV) power to the tokamak plasma for heating and current drive. Operations of the positive ion source (PINI or Plug-In-Neutral-Injector) of SST1-NBI were carried out on the NBI test stand. The PINI was operated at reduced gas feed rate of 2-3 Torr l/s, without using the high speed cryo pumps. Experiments were conducted to achieve a stable beam extraction by optimizing operational parameters namely, the arc current (120-300 A), acceleration voltage (16-40 kV), and a suitable control sequence. The beam divergence, power density profiles, and species fractions (H(+):H2(+):H3(+)) were measured by using the diagnostics such as thermal calorimetry, infrared thermography, and Doppler shift spectroscopy. The maximum extracted beam current was about 18 A. A further increase of beam current was found to be limited by the amount of gas feed rate to the ion source.