Foreign body aspiration with iatrogenic right bronchus perforation - A case report and literature review

INTRODUCTION AND IMPORTANCE

Evacuation of obstructed trachea foreign body (FB) can be challenging and may have several life-threatening complications. Iatrogenic tracheobronchial injury (TBI) is a rare and devastating complication which need prompt diagnosis and management.

CASE PRESENTATION

An 11-year-old child was brought to the emergency with a history of cough and chest discomfort for the last 15 days. Chest x-ray and computed tomography (CT) chest were done which showed the presence of a FB in the right main bronchus. After all pre-operative investigations, rigid bronchoscopy and removal of the foreign body under general anesthesia was performed. After several attempts, the foreign body couldn't be removed and there was massive surgical emphysema of the chest. Immediately bilateral chest tube was inserted. A repeat CT chest was done which revealed a ruptured of the right main bronchus with migration of the foreign body to the right pleural cavity. Right thoracotomy was performed under general anesthesia. The foreign body was removed and the bronchus ruptured was repaired. The child's vital signs were normal throughout the procedure and she was discharged on the seventh post-operative day.

CLINICAL DISCUSSION

TBI can have devastating scenarios in the absence of quick diagnosis and treatment. Around 80 % of patients with TBI due to accidents have been found to have fatal outcomes before reaching the hospital, probably due to tension pneumothorax, hypoxia, or respiratory failure.

CONCLUSION

Prompt diagnosis and management of complications with definitive repair of the injury were key elements in saving lives after TBI.

Penetrating Chest trauma with right atrium rupture - A case report

Background

Penetrating chest trauma can have lethal consequences. Anterior chest wall penetrating injury can cause fatal lacerations over the chest wall, lungs, pericardium, and the heart. There are few reports on these kinds of injuries and operative management.

Purpose

To describe a case of penetrating chest trauma with right atrium ruptured, after a fall from height. The patient was successfully managed with prompt resuscitation and definitive surgical intervention.

Case presentation

A 48-years-old gentleman presented with history of fall from height and right sided penetrating chest injury. The patient had a penetrating injury to the right-fourth intercostal space in parasternal region. Chest X-ray showed massive right-sided hemothorax and chest tube drained more than 1700 ml upon insertion. Emergency right thoracotomy was performed, after initial resuscitation with fluids and blood transfusion in the emergency department. He had injury to the intercostal arteries, lacerations of the pericardium and the right atrium ruptured, which was managed successfully with definitive repair.

Conclusion

Survival is rare after penetrating chest trauma with right atrium ruptured if not intervened on time. Prompt diagnosis and resuscitation, along with the definitive surgical repair were the key elements for successful management of the patients.

Large posterior mediastinal ganglioneuroma with intradural cervical spine extension: A rare case report and review of literature

Introduction

Ganglioneuroma (GN) is a rare benign tumor of ganglion cell origin and can occur anywhere along the sympathetic chain. These tumors can grow to a significant size without any symptoms unless they exert a mass effect on the region they grow and start showing symptoms. Spinal extensions are rare and they may produce neurological symptoms warranting further investigation.

Case presentation

We described a case of posterior mediastinal ganglioneuroma in a 4-year-old boy with cervical extension who presented with quadriparesis. The radiological scan revealed large ganglioneuroma having an intradural extramedullary extension with a large posterior mediastinal component compressing and displacing the surrounding structures. He underwent consecutive surgeries for complete excision of the tumor following which he regained his power in his upper and lower limbs over the period of 2 months.

Conclusion

Para spinal mass with consistent radiological features suggests ganglioneuroma but confirmation should be done with biopsy. Complete excision of the tumor is the treatment of choice with close follow-up for clinical improvement and recurrence.

Intermediate syndrome following organophosphate poisoning: A case report in a low resource and poor socio-economic setting

Intermediate syndrome with respiratory failure is a serious complication that can be fatal as in our case of a 24‐year‐old‐man who developed intermediate syndrome requiring intubation and respiratory support. Furthermore, the patient's socio‐economic situation significantly impacts the illness's progress and prognosis.

With this case report, we want to stress how a patient's socio‐economic background affects the course and outcome of a particular disease condition.

Giant occipital encephalocele complicated with obstructive hydrocephalus: A case report

Introduction

and importance: An encephalocele is a type of congenital neural tube defect defined by herniation of intracranial contents via a cranial defect. When an encephalocele is greater than the size of the head, it is referred to as a "giant encephalocele." The occurrence of encephalocele has been documented to be 1–4 instances per 10,000 live births. Surgery is challenging.

Case presentation

A 1-month-old baby boy sustained a huge swelling on the back of his head since birth, and it increased gradually over time. On examination, he had a huge occipital swelling measuring about 20 × 15 × 17 cm in size. A diagnosis of giant occipital encephalocele was established. Surgical excision and repair was done. After 1 month, he developed obstructive hydrocephalus and a ventriculo-periotoneal shunting was performed. On regular follow-up, he is in a good state of health.

Discussion

Surgery imposes challenges for the anaesthesiologists and neurosurgeons due to its complex site, enormous size, intraoperative blood loss, and prolonged anaesthesia. A team approach is necessary for its successful treatment.

Conclusions

Based on our experience, we would like to deliver following recommendations in the surgical management of giant encephalocele. Surgery should be done quickly to ensure good prognosis. Proper positioning, efficient intubation, infections and sepsis control should be emphasized. Also, fortification of food with folic acid, as well as increased education and awareness of women on the need for antenatal care may also decrease the risk of this disease.

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An encephalocele is a type of congenital neural tube defect.

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Surgery imposes challenges for the anaesthesiologists and neurosurgeons.

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A team approach is necessary for its successful treatment.

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Proper positioning, efficient intubation, infections and sepsis control should be emphasized.

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Fortification of food with folic acid may also decrease the risk of this disease.

Von Hippel-Lindau disease: A case report

INTRODUCTION AND IMPORTANCE

Von Hippel-Lindau (VHL) disease is a rare autosomal dominantly inherited genetic condition. Von Hippel characterized the illness independently in 1911, and Lindau in 1926. Its prevalence is estimated to be about 1 in every 36,000 live births. VHL is characterized by the production of several benign and malignant tumors, as well as cysts in other organs. For proper prognosis, good clinical judgement and timely diagnosis is warranted.

CASE PRESENTATION

Herein, we report a case of a 50-year-old man with several central nervous system (CNS) lesions, retinal lesions, and renal cortical cysts with a diagnosis of VHL disease who was surgically treated. At a 3-month follow-up, he improved drastically with a marked alleviation of his signs and symptoms.

DISCUSSION

VHL is characterized by the creation of various benign and malignant tumors, as well as cysts in multiple organs, and is passed down through generations in an autosomal dominant pattern with near-complete penetrance. CNS lesions are surgically treated. Regular follow-up should be ensured.

CONCLUSIONS

VHL disease is an extremely complicated disease with the need for diagnosis and genetic tests in the patient and family members, as well as intensive supervision of carriers of the mutated gene, thereby improving early diagnosis and successful treatment of the malignancies. The high cost of diagnostics and surgical therapies is a severe issue. Government care and financial assistance are critical considerations.

Sebaceous carcinoma of trunk with bilateral axillary lymph node metastasis: a rare presentation of malignant adnexal tumor in young adult

Malignant adnexal tumors of skin are rare. Sebaceous carcinoma—a rare and aggressive cutaneous tumor—is frequently located in the periorbital region. Malignant adnexal tumors of sebaceous carcinoma type on trunk with axillary lymph node and distant metastasis in young adult is rare. The incidence of extraocular sebaceous carcinoma has been expected to be 0.06 per 100 000 person-years with an increased incidence in elderly patients and men. With a note of mimicking benign dermatologic conditions, definitive diagnosis of sebaceous carcinomas is often hindered, increasing morbidity and mortality for patients. Herein, we present a case of a 35-year-old man with a large ulcero-proliferating lesion of trunk region previously resected for a small swelling and eventually presented with the recurrent lesion and diagnosed as sebaceous carcinoma of trunk with bilateral axillary lymphnode and distant bone metastasis demonstrating several diagnostic and management challenges.

Pin-tract myiasis after external bone fixation: A case report and review of literature

Introduction and importance

Myiasis has been reported as a complication of fracture treatment with external fixation. Therefore, physicians should be aware of the possible re-emergence of myiasis as a complication of surgery and the use of metal fixators.

Clinical presentation

A 45-year-old male, non-diabetic, chronic alcoholic treated with external bone fixation and flap coverage for Gustilo-Anderson type IIIB comminuted fracture of shaft of left tibia and fibula with intact distal neuro-vascular system presented with multiple maggots with foul-smelling discharge from the pin tract. A diagnosis of abscess with pin-tract myiasis was made and managed with wound debridement and complete removal of maggots.

Conclusion

We report this rare pin-tract complication to acknowledge how simple precautions, wound care, and avoidance of risk factors play a vital role in preventing such infestations. Therefore, physicians should be aware of the possible re-emergence of myiasis as a complication of surgery and the use of metal fixators.

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Pin-tract myiasis is a rare presentation of a neglected wound after external bone fixation.

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Myiasis is associated with poor hygiene which is still a public health problem in developing countries.

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Simple precautions, wound care, and avoidance of risk factors play a vital role in preventing this infestation.

Giant sacrococcygeal teratoma in a neonate: illustrative case

BACKGROUND

Sacrococcygeal teratomas (SCTs) are tumors that emerge in the sacrococcygeal area and contain tissue from all three germ layers. SCT affects about 1 in every 35,000–40,000 live births, with malignant transformation becoming more common as the patient gets older. Ultrasound helps in prenatal diagnosis. Surgical resection is the mainstay of treatment.

OBSERVATIONS

A couple gave birth to a neonate with a small mass over his sacral region that progressively increased in size. Diagnostic magnetic resonance imaging was performed, and a diagnosis of giant SCT was established. Complete resection with flap reconstruction was performed. In regular follow-up, he is in a good state of health.

LESSONS

One of the most common tumors in infancy, SCT should be carefully diagnosed. SCT is often confused with neural tube defects such as myelocystocele or myelomeningocele. Complete resection with appropriate reconstruction can ensure better treatment, and close follow-up until adulthood is recommended to keep a close view on its possible recurrence and to improve prognosis. Postoperative complications such as infection, bleeding, and urethral complications should be carefully watched.

Hyoscine butylbromide induced psychosis: A case report

Hyoscine butylbromide-induced pyschosis, though rare, should be considered in a child presenting with deteriorating cognitive functions and psychotic features acutely as evident in our case of a 9-year-old child taking hyoscine for her non-specific abdominal pain.

Ileosigmoid knotting: A case report of unique cause of acute abdomen in a Nepalese patient

Introduction and importance

Ileosigmoid knotting is a surgical emergency. Common in Asian males, it is presented with signs and symptoms of diffuse peritonitis. Aggressive resuscitation with intravenous fluids and antibiotics followed by workup enable the patient hemodynamically stable. Explorative laparotomy followed by colo-colic anastomosis and double barrel ileostomy is curative.

Case presentation

A 32-year-old-male from Nepal with a chief complain of diffuse abdominal pain for a day and signs of peritonitis presented to Emergency room. After assessing and stabilizing the patient, explorative laparotomy was performed. Ileal and sigmoid resection followed by colo-colic anastomosis and double barrel ileostomy was done. On regular follow-up, he is in his usual state of health.

Discussion

The incidence of ileosigmoid knotting is reported to be about 1.6 cases per year. It is often misdiagnosed as non-specific intestinal obstruction which confers poor prognostic value to the patient. It should be identified promptly and intervened timely.

Conclusion

Ileosigmoid knotting is a rare but dangerous differential of acute abdomen not to be missed. Early assessment and quick decision making is the key to provide excellent prognosis to the patient in need, provided adequate surgical skills are demonstrated.

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Ileosigmoid knotting is a surgical emergency.

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It is common in Asian males.

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Patient presents with signs and symptoms of diffuse peritonitis.

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Explorative laparotomy should be done.

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Ileal and sigmoid resection followed by colo-colic anastomosis with double barrel ileostomy was performed.

Benign rib tumors: a case series from tertiary care Centre of Nepal and review of literature

Rib tumors are rare. They can present with wide varieties of symptoms and differentiating benign from malignant lesions is challenging. A careful history and supporting investigations can help to reach the definite diagnosis. Surgical resection is the treatment of choice with excellent prognosis. A total of four patients were operated for the management of rib tumors over a period of 5 years at our institution. All four were benign lesions and included simple bone cyst, fibrous dysplasia with aneurysmal bone cyst, aneurysmal bone cyst and enchondroma. There were three male and one female. None of them is having recurrence till now. Surgical resection is the treatment of choice for benign rib tumors as it provides diagnostic and curative treatment.

Pulmonary sequestration presenting as a massive haemoptysis in adult: A case report

INTRODUCTION

Pulmonary sequestration is a rare congenital lung malformation characterized by non-functioning mass of pulmonary tissue that lacks normal communication with bronchial tree and receives one or more aberrant systemic arterial supply. It usually presents in children with recurrent chest infections. It is uncommon in adult and remains asymptomatic or present with recurrent chest infections, rarely with more severe symptoms like a massive haemoptysis as in seen in our case.

CASE PRESENTATION

A 22-year-old male presented with a chief complain of multiple episodes of massive haemoptysis. After evaluation with chest x-ray, CT chest and angiogram, he was diagnosed to have intralobar pulmonary sequestration. He underwent successful thoracotomy and left lower lobectomy. He is asymptomatic after one year of follow up.

DISCUSSION

Pulmonary sequestration is rare in adult and can present with various symptoms like chest pain, cough, sputum production, recurrent infection and rarely haemoptysis. Intralobar sequestration of left lower lobe is the most common as seen in our case. The diagnosis can be made by Computed Tomogram chest with angiogram. Surgical intervention is the definitive curative treatment. Post-operative outcome is excellent with early patient satisfaction and promising outcome in long term follow-up.

CONCLUSION

Bronchopulmonary sequestration can rarely present in adults presenting with massive haemoptysis. CT chest is the best modality for diagnosis. Early surgical intervention is definitive treatment with good long term outcome.

Single-stage hepaticojejunostomy for symptomatic portal biliopathy in a splenectomized patient: A report of two cases

Single-stage biliary decompression without prior shunt surgery, although risks for catastrophic bleeding, it is feasible to perform upfront hepaticojejunostomy in a splenectomized patient where shuntable vein is not available in patient with portal biliopathy.

Surgical treatment of tuberculous chronic constrictive pericarditis: A retrospective observational study from tertiary hospital of eastern Nepal

BACKGROUND

Tuberculosis remains an important cause of chronic constrictive pericarditis (CCP) in developing countries. It is a surgically treatable cause of diastolic heart failure. Without surgery, it is associated with high morbidity and mortality.

METHODS

We conducted a retrospective observational study of clinical presentations and perioperative outcomes of pericardiectomy in all patients operated from July 2015 to December 2018 for tuberculous CCP.

RESULTS

A total 14 patients (mean age - 38 ± 13.3 years, 10 male), underwent pericardiectomy via median sternotomy without cardiopulmonary bypass. Eleven patients (79%) had completed treatment for pulmonary tuberculosis, and three (21%) were on anti-tubercular treatment at the time of referral for surgery. Ten patients (71%) had prior hospitalisation for cardiac failure. At the time of surgery, eight patients (57%) were in New York Heart Association (NYHA) class III-IV. The median duration of symptoms before surgical intervention was 15 months (range 11-24 months). Three patients (21%) had associated cardiac cirrhosis. Twelve patients (86%) underwent total pericardiectomy. Two patients (14%) underwent partial pericardiectomy. The mean operative time was 160 ± 33.8 minutes. The mean central venous press pressure before and after surgery were 28 ± 3.9 and 10 ± 2 mmHg respectively. The mean intensive care unit (ICU) and hospital stays were 4 ± 1.5 and 10 ± 2 days respectively. There was one (7%) 30-day mortality. There were two deaths (14%) due to non-cardiac causes at 10 and 16 months respectively. The remaining 11 patients (79%) are doing well (mean follow-up- 23 months), and are in NYHA class I.

CONCLUSIONS

Tuberculosis is the most common cause of CCP in our region. Pericardiectomy provides definitive treatment to alleviate symptoms resolution and improve survival.

Unusual achalasic sigmoid esophagus

Achalasia cardia is a rare primary esophageal motility disorder with an incidence of about 1 in 100,000 individuals. If left untreated or inappropriately treated, the disease may progress to end-stage achalasia characterized by megaesophagus or sigmoid esophagus. The presentation as severe malnutrition, anemia, hypoalbuminemia, and asymptomatic tracheal compression has not been described in the setting of the sigmoid esophagus, in absence of underlying malignancy. Here we report an interesting case of a young male, who presented with the above features and managed excellently by open Heller’s myotomy under epidural anesthesia due to the poor performance status.

Outcomes of Ligation without Revascularization in Pseudoaneurysms of Peripheral Arteries in Intravenous Drug Users

Introduction: Management of pseudoaneurysms in intravenous drug users is complex andchallenging due to an associated infection and unavailability of autologous vein grafts. Here weobserve the outcomes of ligation and local debridement as a primary modality of treatment in thissubset of patients with pseudoaneurysms. Methods: This is a descriptive cross sectional study of 15patients over a period of 4 years whopresented with pseudoaneurysm of peripheral artery from intravenous drug use. In this study,we describe the presentations and management outcomes in 15 patients with peripheral arterialpseudoaneurysmfrom IV drug use. Results: The most common site involved was common femoral artery among 12 (80%) patientsfollowed by superficial femoral artery among 8 (13.3%) patients and external iliac artery in 1 (6.7%)patient. Twelve (80%) patients were having signs of infection. All patients underwent surgicalintervention which comprised of excision of pseudoaneurysm and ligation of artery withoutrevascularization among 12 (80%) patients and with revascularization with autologous venous graftamong 3 (20%) patients. There was no mortality or a major bleeding requiring re-exploration. Noneof the patients developed limb ischemia necessitating amputation.One patient with femoral arteryligation without revascularization at one year of follow up is having claudication on brisk walking.There was one saphenous vein graft thrombosis in immediate postoperative period. Conclusions: With the use of ligation without revascularization technique, there was no mortality ormajor bleeding requiring re-exploration. None of the patients developed limb ischemia necessitatingamputation so this treatment modality seems promising in treatment of pseudoaneurysms inintravenous drug users.

Simple Bone Cyst of Rib

Simple bone cyst is a benign lytic lesion usually encountered in children and adolescents. It is a cystic, fluid-filled lesion that usually involves the metaphysis of the long bones. Simple bone cyst of the rib is very rare, with few cases reported in the literature. Here we describe an interesting case of a simple bone cyst of the sixth rib in a 15-year-old girl that was managed successfully with surgical excision.

Establishing Cardiac Surgery in Eastern Nepal: Early Results

BACKGROUND

Only few dedicated cardiac centres provide cardiac surgery service in Nepal. We are the only government affiliated centre outside the capital providing this service. In this study, we aim to present our early results of cardiac surgery.

METHODS

This retrospective study was conducted at B P Koirala Institute of Health Sciences with objective of analysing the early results of cardiac surgery in the patients operated from July 2016 to March 2017.The data were analysed for patient demographics, type of surgery and cardiac disease, mortality, hospital and intensive care unit stay, valve related complications.

RESULTS

Total 51 major cardiac surgeries (42 on pump and nine off pump) were performed. There were 27 (53%) males and 24 (47%) females with median age of 36 years (range: 1 to 70 years).The cardiac diseases consisted of 28 rheumatic heart disease, 12 congenital heart diseases, five coronary artery disease, five chronic constrictive pericarditis and one left atrial myxoma. The mean cardiopulmonary bypass and cross clamp times were 106 ±35 and 80±26 minutes respectively. The mean intensive care unit and hospital stay was 4±2 and 8±3 days respectively. Two (4%) patients required re-exploration for mediastinal bleeding. There was no prosthetic valve thrombosis or infection.Two patients (4%) had superficial wound infections.There were four (7.8%) in hospital mortalities. Remaining 47 patients (91.8%) are in NYHA class I aftermean follow up duration of five months.

CONCLUSIONS

Our early result of cardiac surgery is encouraging and has established the safety and feasibility of starting open heart surgery in other parts of Nepal.

Giant pseudoaneurysm of subclavian artery after blunt chest trauma

Subclavian artery (SCA) pseudoaneurysm after blunt chest trauma is rare and its delayed presentation months after the SCA injury is even rarer. Herein we discuss a case of SCA pseudoaneurysm in a 74-year-old man who presented to us 5 months after blunt chest trauma. He had been managed conservatively for the fracture of first rib and clavicle until presentation to our hospital. He had uncontrolled hypertension and a rapidly increasing large painful swelling (10 by 8 cm) in left clavicular region along with purplish discoloration of the overlying skin. The diagnosis was confirmed after computed tomography angiography and the patient was successfully treated with surgical evacuation of clots, primary repair of the rent in the SCA, and plating of clavicular fracture.

Fever of unknown origin: a rare presentation of giant hepatic hemangioma

Hepatic hemangioma is mostly asymptomatic and incidental finding on imaging. Fever of unknown origin as a sole presentation is rare. We present an interesting case report of a 49-year-old female, who presented with fever for three months. Extensive blood investigations and infectious workup failed to reveal the cause. Contrast computed tomography of abdomen revealed a giant (15 × 11 cm) hemangioma arising from left lateral segment of liver, and was attributed as a cause for fever. Surgical excision of hemangioma completely ameliorated the fever.

Extreme Small Bowel Enteroatmospheric Fistula

Small bowel enteroatmospheric fistula is a serious and devastating complication of open abdomen. We present an interesting image of a 40-year-old gentleman who developed multiple small bowel enteroatmospheric fistulae following open abdomen management for complicated intra-abdominal peritonitis.