surgery

A 35-year-old female, known case of complete spinal cord injury, presented with cervical pain and neck deformity that interfere with her physiotherapy and occupational therapy. Two years before admission, she had a car accident which result in a complete quadriplegia. That time at another center, she underwent surgery to anterior cervical fixation of C6-C7 through insertion of cage and plate without corpectomy. Based on current radiologic images, spondyloptosis was detected at the C6-C7 with bilateral locked facet, due to hardware failure. A three approaches in one stage was performed to maintain cervical alignment that includes posterior, anterior and again posterior approach. With this manner, anterior fusion through corpectomy and insertion of expandable cage and plate as same as instrumental posterolateral fusion were done. After surgery, she was pain free and the alignment of cervical spine was maintained so she could come back to ordinary rehabilitation programs.

Objective: Atlantoaxial subluxation (AAS) occurs when there is misalignment of the atlantoaxial joint. Several etiologies confer increased risk of AAS in children, including neck trauma, inflammation, infection, or inherent ligamentous laxity of the cervical spine. Methods: A single-center, retrospective case review was performed. Thirty-four patients with an ICD-10 diagnosis of S13.1 were identified. Demographics and clinical data were reviewed for etiology, imaging techniques, treatment, and clinical outcome. Results: Out of thirty-four patients, twenty-two suffered cervical spine trauma, seven presented with Grisel’s Syndrome, four presented with ligamentous laxity, and one had an unrecognizable etiology. Most diagnoses of cervical spine subluxation and/or instability were detected on computerized tomography (CT), while radiography and magnetic resonance imaging (MRI) were largely performed for follow-up monitoring. Six patients underwent cervical spine fusion, five had halo traction, twelve wore a hard and/or soft collar without having surgery or halo traction, and eight were referred to physical therapy without other interventions. Conclusion: Pediatric patients with atlantoaxial subluxation may benefit from limited 3D CT scans of the upper cervical spine for accurate diagnosis. Conservative treatment with hard cervical collar and immobilization after reduction may be attempted, but halo traction and halo vest immobilization may be necessary. If non-operative treatment fails, cervical spine internal reduction and fixation may be necessary to maintain normal C1-C2 alignment.

Systemic arterial air embolism (SAAE) is a rare but serious complication of CT-guided hook wire localization of pulmonary nodule usually with catastrophic and poor outcome. Hook wire needle localization is done pre-operatively by placing wire around or into the pulmonary nodule to provide the thoracic surgeon accurate location guidance of the target nodule for Video-Assisted Thoracoscopic Surgery (VATS) wedge resection with safety margins. Physicians should be aware of this possible complication during the procedure in order to rescue the patient promptly as it requires rapid diagnosis and management. We describe a 55-year-old male who underwent a CT-guided hook wire needle localization of left upper lobe lung cancer and left lower lobe pulmonary nodule prior to planned VATS wedge resection who developed altered mental status and bilateral lower extremities paralysis after wire placement was completed. His CT head demonstrated small air embolism in the left occipital area, confirming the diagnosis of cerebral air embolism and follow up CT and MRI of the head revealed multiple areas of brain infarction. In addition, he was diagnosed with anterior spinal cord syndrome (ACS), most likely due to anterior spinal artery ischemia from micro air embolism on the basis of clinical findings but with negative ischemic changes on MRI of the spinal cord. His mental status recovered but he remained paraplegic and transferred to inpatient rehabilitation service.

Aim: To assess the efficacy of decompressive craniectomy in patients with large basal ganglia (BG) bleed. To establish predictive criteria of mortality after surgery in patients with BG bleed. Materials: This prospective study includes all patients of large spontaneous BG bleed operated by decompressive craniectomy without hematoma evacuation from October 2012 to September 2015. Data was collected on patient age, gender, distribution of bleed, affected hemisphere dominancy, preexisting medical conditions, admission Glasgow Coma Score (GCS), midline shift on CT or MRI Brain, hematoma volume and anisocoria, duration (hours) between the onset of stroke and operation, post-operative complications, and the duration of hospital stay. This data was correlated with one month mortality of the patients. Results: Total number of patients were 27. Mean age was 51 years and mean GCS was 7.55(range 5-11). The mean volume of the bleed was 68.51 ml. Mortality was noted in 17 out of 27 patients (63%) in 30 days. Thirteen of the 16 patients with intraventricular extension of BG bleed had mortality. The factors that showed statistically significant correlation with one month mortality were age, GCS at admission, volume of the bleed and the intraventricular extension. Conclusion: Large BG bleed was associated with high mortality and morbidity. Age of 50 years or more and GCS ≤ 8 at presentation were poor prognostic factors for decompressive craniectomy in patients with BG bleed. Patients with large BG bleed of volume > 60 ml and intraventricular extension had poor prognosis.

Background: In developing countries, manual small incision cataract surgery is a better alternative and less expensive in comparison to phacoemulsification and thus the incision is an important factor causing high rates of postoperative astigmatism resulting into poor visual outcome. Thus, modifications to the site of the incision is needed to reduce the pre-existing astigmatism and also to prevent postoperative astigmatism. Modification to superotemporal incision relieves pre-existing astigmatism majorly due to its characteristic of neutralizing against-the-rule astigmatism, which is more prevalent among elderly population and thus improves the visual outcome.Aims: To study the incidence, amount and type of surgically induced astigmatism in superior and superotemporal scleral incision in manual SICS.Methodology: It is a randomized, comparative clinical study done on 100 patients attending the OPD of Ophthalmology at a tertiary care hospital, with senile cataract within a period of one year and underwent manual SICS. 50 of them chosen randomly for superior incision and rest 50 with superotemporal incision. MSICS with PCIOL implantation were performed through unsutured 6.5 mm scleral incision in all. Patients were examined post-operatively on 1st day, 7th day, 2nd week and 4th week and astigmatism was evaluated and compared in both groups.Results: It is seen that on postoperative follow up on 4th week, 77.78% of the patients with ATR astigmatism who underwent superior incision had increased astigmatism whereas, only 13.63% of the patients with ATR astigmatism who underwent supero-temporal incision, had increased astigmatism but 81.82% had decreased ATR astigmatism. However, 77.78% of the patients with preoperative WTR astigmatism who underwent supero-temporal incision, had increased astigmatism, whereas 44.45% of the patients with WTR astigmatism preoperatively, had increased astigmatism in contrast to 50% had decreased amount of astigmatism. It is also seen that the supero-temporal incision group had more number of patients (78%) with visual acuity better than 6/9 at 4th postoperative week than superior incision group (42%).Conclusion: This study concludes that superior incision cause more ATR astigmatism postoperatively whereas superotemporal incision causes lower magnitude of WTR astigmatism, which is advantageous for the elderly. Besides superotemporal incision provides better and early visual acuity postoperatively.

Introduction: A dermoid cyst is a developmental choristoma lined with epithelium and filled with keratinized material arising from ectodermal rests pinched off at suture lines. These are the most common orbital tumors in childhood. They are categorized into superficial and deep. Superficial orbital dermoid tumors usually occur in the area of the lateral brow adjacent to the frontozygomatic suture. Infrequently a tumor may be encountered in the medial canthal area [1], which is the second most common site of orbital dermoids. We report a case where a swelling presented in the medial canthal area without involving the lacrimal system. Case report: A 43 year old lady presented with complaint of swelling near the (RE; Right eye) since 2 years duration. She presented with a solitary 1.5 cm x 1 cm ovoid, non-tender, non-pulsatile, firm, non-compressible mobile swelling with smooth surface over the medial canthus of right eye. (MRI; Magnetic Resonance Imaging) brain and orbit showed right periorbital extraconal lesion and the (FNAC; Fine Needle Aspiration Cytology) suggested of Dermoid Cyst. RE canthal dermoid cyst excision was done under Local Anasthesia. Conclusion: Complete surgical excision in to be treatment of choice for dermoids. Since medial canthal mass can involve the lacrimal system, it becomes necessary to perform preoperative assessments using (CT; Computed Tomography), MRI or dacryocystography while planning the surgical approach. Silicone intubation at the beginning of the surgery is an easy and effective way of identifying canaliculi and of preventing canalicular laceration during dermoid excision if the lacrimal system is found to be involved.

Purpose: The sinusoidal obstruction syndrome (SOS) of the liver is an obliterative vasculitis that involves the terminal branches of the hepatic venules and sinusoids. When it is not treated, it will be a serious risk of mortality. Here, we aim to present our patient who has been associated with recurrent cholangitis attacks due to cholelithiasis and choledocholithiasis and is associated with sinusoidal obstruction syndrome with the literature.Description of the case: A 30 years old male patient had complaints of abdominal pain and nausea for a long time. The patient had a history of choledocholithiasis and cholangitis attacks. Although ERCP was performed and a stent was placed in the biliary tract, his jaundice did not disappear. Liver function tests were high. Tumor markers were negative.Methods: We could not make a definitive diagnosis with imaging methods and biopsy and we planned surgery. We performed segmental liver resection and biliary diversion in the surgery. Histopathological examination of the resected liver tissue was compatible with SOS.Conclusion: Many studies have been done on the etiology of SOS and different causes have been revealed. Accompanied with clinical findings, a definitive diagnosis is made with the exclusion of the presumptions considered. Surgery can be performed for both diagnostic and therapeutic purposes. If patients with elevated liver function tests and bilirubin have long-term abdominal pain, SOS should be bear in mind.

Cleft lip and palate is one of the most common congenital anomalies occurring round the world varying with the race, ethnicity and geography. Cleft lip and/or palate problems tends to worsen as the individual grows older. Although it occurs as a different entity in itself but its presence can hamper aesthetics as well as functions by effecting growth, dentition, speech, hearing and overall appearance resulting in social and psychological problems for the child as well as the parents. Cleft lip and palate is of a multifactorial origin such as inheritance, teratogenic drugs, and nutritional deficiencies and can also occur as syndromic or non-syndromic cleft. Treatment of Cleft Lip and Palate comprises of different specialists having an individual insight in a particular case ultimately reaching to a consensus for a successful culmination of the treatment. Although appropriate timing and method of each intervention is still arguable. An orthodontist plays a role in pre surgical maxillary orthopaedics, in aligning the maxillary segments and dentition, in preparation for secondary alveolar bone grafting and finally in obtaining ideal dental relation and preparing the dentition for prosthetic rehabilitation or orthognathic surgery if required. Therefore, for efficient treatment outcome and refinement of individual techniques or variations of the treatment protocol a highly able team of specialists from different specialities is a must, preferably on a multicentre basis.

Background: Diabetic retinopathy (DR) is one of the most common causes of preventable blindness. Patients with Diabetes Mellitus (DM) develop not only DR but also corneal endothelial damage leading to anatomical and physiological changes in cornea. Central corneal thickness (CCT) is a key parameter of refractive surgery and Intraocular pressure (IOP) estimation. The role of CCT and higher glycemic index in DR needs to be researched upon.Objectives: To identify the corneal endothelial morphology in patients with type 2 DM, to measure the Central Corneal thickness (CCT) in patients with type 2 Diabetes Mellitus, to assess the relationship of CCT with HbA1C levels in the study group and to correlate the CCT with the severity of Diabetic retinopathy in the study group.Methods: A cross-sectional observational study was conducted between January 2018 and June 2019 in Vydehi Institute of Medical Sciences and Research Centre, Bangalore. The study included 100 subjects with type 2 DM for 5 years or more. Patients with comorbidities that may affect the severity of DR or alter CCT and other corneal endothelial parameters such as glaucoma, previous ocular surgery or trauma, corneal degenerations and dystrophies, chronic kidney disease and Hypertension were excluded. DR was assessed by dilated fundoscopy, fundus photography and optical coherence imaging of the macula and graded as per the Early Treatment of Diabetic Retinopathy Study (ETDRS) classification. CCT and other corneal endothelial parameters were measured through specular microscopy. Relevant blood investigations including blood sugar levels were done for all patients.Statistical analysis: Relationship between CCT and grades of DR and HbA1c levels were established using the Chi-Square test. The level of significance was set at p < 0.05.Results: The mean CCT in patients with no diabetic retinopathy, very mild and mild non-proliferative diabetic retinopathy (NPDR), moderate NPDR, severe and very severe NPDR and PDR was 526.62 ± 8.084 μm, 542.07 ± 8.713 μm, 562.16 ± 8.255 μm, 582.79 ± 7.368 μm and 610.43 ± 18.256 μm respectively. Analysis of the relationship between CCT and severity of DR showed a statistically significant positive correlation between the two parameters (Pearson r = 0.933, p = 0.001). Beyond this, a correlation was found between all the corneal endothelial parameters and severity of DR. Multivariate analysis showed that advanced DR was positively correlated with CV (r  = 0.917) and CCT (r = 0.933); while it was negatively correlated with ECD (r = -0.872) and Hex (r = -0.811). A statistically significant correlation was also found between CCT and HbA1c. Also increasing age, duration of DM and higher glycemic index were positively correlated with severity of DR. Conclusion: This study, by demonstrating a strong correlation between the central corneal thickness to the severity of DR and HbA1c levels emphasizes the importance of evaluation of corneal endothelial morphology in the early screening and diagnosis of microvascular complications of DM.

Background: Heparin-induced thrombocytopenia/thrombosis (HIT/T) is characterized by a fall in platelet count 5-10days after starting heparin therapy and is diagnosed with specific 4-T clinical features and laboratory tests. This complication is relatively common in Cardiothoracic surgery patients. Objective: To evaluate the positive and negative predictive value of various HIT laboratory tests and assess any correlation between HIT, the underlying diagnosis, underlying procedure, and mechanical cardiac devices. Patients and methods: The patient’s medical records were correlated with two laboratories HIT diagnostic tests, the pan-specific screening test with IgG, IgA, and IgM antibodies, followed by HIT specific IgG ELISA. Results: Total n = 80 patients were assessed, 48% (n = 38) were HIT screen pan-specific negative and 50% (n = 40) were HIT pan-specific positive and 2 cases were inconclusive. 17% (n = 14) were both pan-specific and specific HIT IgG ELISA positive. There were 5 atypical cases. One patient had Eosinophilic myocarditis and was HIT ELISA IgG neg. Argatroban was given on clinical grounds with successful recovery. One patient with Sarcoidosis had an aggressive course and received IV Immunoglobulin (IVIG) but succumbed secondary to liver failure. One patient progressed to gut ischemia and had surgical intervention but succumbed. Two patients with mechanical heart valves were on Argatroban but relapsed and responded to IVIG therapy. Conclusion: Our study indicates that 9/16 (> 50%) HIT-positive patients had valve replacement or cardiac devices suggesting that like knee arthroplasty there is a high incidence of HIT in patients with mechanical heart valves and cardiac devices and this warrants further prospective study. 

Intrasellar meningioma (IM) is a rare occurrence that is difficult to distinguish preoperatively from the most common non-functioning pituitary adenoma. Here we describe a case of psammomatous IM occurring in a 68-year-old woman, presented with visual defects. On magnetic resonance imaging (MRI) she was found to have an intrasellar mass with suprasellar extension that was approached with transsphenoidal surgery. Subtle radiological hints, namely dural tail sign, intralesional calcifications and a marked and homogenous early enhancement of IM on MRI after gadolinium administration, may aid clinicians in achieving an accurate pre-operative diagnosis and choosing the proper surgical approach. The clinical and neuroradiological features of IM described in the literature has been reviewed.

Background: Cervical choriocarcinoma is a malignant trophoblastic neoplasm that arises from pluripotent gonadal germ cells. Various manifestations are expected including vaginal bleeding and symptoms related to metastasis. Here, we report a case of primary choriocarcinoma in a post-menopausal woman. Case presentation: A 67-year-old woman presented with vaginal bleeding and lower abdominal pain. Ultrasound and laboratory results were normal except for a β-hCG titer of 14850 IU/L. Hysteroscopy revealed a polyp in the posterior wall of the cervix. hysterectomy and bilateral salpingo-oophorectomy were performed due to suspected choriocarcinoma. The β-hCG titer decreased immediately after surgery. However, the β-hCG titer increased again one month after surgery and treatment was continued with weekly methotrexate administration. Conclusion: Manifestations such as vaginal bleeding is very important in post-menopausal women. Although there are no specific guidelines for the treatment of choriocarcinoma in these patients, hysterectomy following chemotherapy based on response to treatment and β-hCG titration is favorable.

A case of post-operative agranulocytosis which occurred in a 66-year-old woman following surgery for endometrial carcinoma is reported. The agranulocytosis had a rapid onset, being detected on the first post-operative day. The causative agent, cefazolin was given to the patient intraoperatively. The agranulocytosis persisted until the 22nd postoperative day. A bone marrow biopsy performed on post-operative day four showed a left-shifted myeloid maturation pattern but not a maturation arrest. The pathogenesis of drug-induced neutropenia/agranulocytosis is discussed. It is postulated that reversible binding of cefazolin to albumin accounts for the prolonged duration of agranulocytosis.

Laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) is a technically challenging operation that requires extensive surgical dissection, transection and restoration of intestinal continuity, and advanced laparoscopic suturing skills.

Objective: To report our experience in the management of gastric cancers at the Kara University Hospital (Togo).Materials and methods: This was a retrospective and prospective study which was conducted from January 1, 2018, to July 31, 2021, in the general surgery and hepato-gastroenterology department of the Kara University Hospital (Togo). This study involved all patients treated for gastric cancer during the study period at CHU Kara (Togo).Results: We recorded 32 gastric cancers out of the 218 cases of cancer diagnosed during the study period. We had 20 men and 12 women with a sex ratio (M/F = 1.7). The average age was 58 years with the extremes ranging from 17 to 85 years. The pattern of the consultation was dominated by epigastralgia (100%) and deterioration in general condition (100%). Upper digestive endoscopy with biopsies was performed in all our patients. The antral localization was the most found in 62.5% of cases. The most common macroscopic appearance was ulcers-budding (90.6%) and the dominant histological type was moderately differentiated adenocarcinoma (87.5%). The extension assessment found liver metastasis in 10 cases, multiple regional lymphadenopathies of the hepatic pedicle and celiac trunk in 26 cases, ascites related to peritoneal carcinomatosis in 26 cases. Therapeutically, a 4/5 gastrectomy with D1 dissection was performed in 6 cases; gastrojejunal anastomosis in one case and palliative treatment in 25 cases. Survival at 1 year is 50% (3 patients) among operated patients. All the other patients (78.1%) who received palliative treatment all died within 3 months.Conclusion: Improving the prognosis of stomach cancer like other cancers requires early diagnosis to perform a gastrectomy, the only guarantee of long survival.

Crohn's disease is a chronic syndrome of the gastrointestinal tract that produces idiopathic inflammation. Approximately half of the patients develop abscesses and/or fistulas throughout their history that are located, mainly, in the perianal region. Current treatments are based on individualized plans that generally use combined pharmacology for symptomatic relief based on glucocorticoids, immunosuppressants or immunomodulators, antibiotics, anti-inflammatories, probiotics, and antibodies, or surgical therapies such as intestinal resections or ostomizations (colostomy and ileostomy) that tend to cause notable side effects in a considerable percentage of patients and a significant decrease in their quality of life.Perianal fistulas consist of abnormal tracts, inflammatory tunnels, or chronic tracts of granular tissue that connect two surfaces lined with epithelium, have an external hole in the skin that borders the anus, and an internal hole located inside it around the anal canal, rectus and sphincters. Treatment is a complex process that requires a multidisciplinary approach and the combination of several treatments. In the short term, the goal is to drain abscesses, reduce inflammatory and infectious processes, guard the fistulous tract with seton or lax lines, facilitate patency, and hinder new formations. In the long term, a total cure and the avoidance of complications that require surgery or the creation of intestinal stomas are pursued.For this reason, new effective remedies with fewer adverse effects continue to be investigated, one of the most promising being the use of mesenchymal stem cells for the regeneration and cure of perianal fistulas and the remission of symptoms. The present bibliographic review delves into this new therapy and analyzes the current state of the situation regarding its efficacy and safety.

An article by Baum, et al. “Unclear swelling in the region of a maxillary canine tooth” [1] caught our interest. A 14-year-old boy had developed an adenomatoid odontogenic tumor (AOT) without undergoing maxillofacial surgery. During an INTERPLAST-Germany mission [2] in Goma, Democratic Republic of Congo, we operated on a young man with an advanced odontogenic tumor. Since we are confronted with fist-sized odontogenic tumors (mostly ameloblastoma of the mandible) every time we operate in Africa, where they grow out of control due to a lack of experienced surgeons, it may be of interest to our colleagues in developed countries to know which grotesque tumors are prevented by early surgery.

Median arcuate ligament syndrome is a rare entity. This clinical condition develops by compression of the root of a celiac artery with the median arcuate ligament. The typical triad of this syndrome is the following; abdominal discomfort and pain, especially after a meal, and weight loss. In diagnosis, other causes should be ruled out and compression must be demonstrated by any type of imaging method. The main principle of treatment is cutting down the median arcuate ligament. A 54-year-old woman presented with untreatable recurrent abdominal pain and was diagnosed with median arcuate ligament syndrome by imaging with angiographic computed tomography. This patient was operated on. We performed laparoscopic division of median arcuate ligament with the retrograde surgical dissection technique. The patient was discharged from the hospital without any complaint on the third day after surgery. She was still symptom-free after 12 months.The laparoscopic retrograde dissection approach is a safe and feasible treatment modality for median arcuate ligament syndrome.

A 61 - year-old physically fit and athletic man presented to his dermatologist with a 10 mm raised, dark lesion on the left side of his neck. A complete skin examination did not show any other abnormal areas of skin. Pathology was found consistent with Merkel cell cancer, and the patient was referred to surgery for a wide local excision and sentinel lymph node biopsy. A PET scan did not show any other areas of concern. At surgery, one of two sentinel lymph nodes was found to be involved with Merkel cell cancer and the patient received postoperative radiation.

Background: Intracerebral hemorrhage (ICH) is one of the most feared complications after brain tumor surgery. Despite several factors being considered to influence bleeding, an increasing number of clinical studies emphasize that hemostatic disorders, developed during surgical aggression and tumor status, could explain unexpected ICH. The objective of this prospective study was to evaluate the influence of perioperative D-dimer levels on ICH after brain tumor surgery. Methods: This prospective, observational, 18-month study, at a single third-level hospital, included all consecutive adults operated on brain tumors and postoperative stay in an intensive care unit. Three blood samples evaluated D-dimer levels (A-baseline, B-postoperative and C-24 hours after surgery). The normal range considered was 0-500ng/ml. ICH, as a primary outcome, was defined as bleeding that generates radiological signs of intracranial hypertension either by volume or by mass effect on the routine CT scan 24 hours after surgery. Other tumor features and hemostasis variables were analyzed. Chi-squared and Fisher’s exact test were used in the inferential analysis for qualitative variables and Wilcoxon and T-Test for quantitative ones. P-value < 0.05 was considered significant for a confidence interval of 95%. Results: A total of 109 patients operated on brain tumor surgery were finally included, 69 male (63,30%) and 40 female (36,70%), with a mean age of 54,60 ± 14,75 years. ICH was confirmed in 39 patients (35,78%). Their average of DDimer was A-1.526,70 ng/dl, B-1.061,88 ng/dl, and C-1.330,91 ng/dl (A p0.039, B p0,223 C p0.042, W-Wilcoxon test). The male group was also associated with ICH (p0,030 X2 test). Of those 39 patients with ICH, 30 in sample A (76,9%), 20 in sample B (51,28%) and 35 in sample C (89,74%) had a D-dimer > 500 ng/dl (p0,092, p1, p0,761 X2 test) and the relative risk of developing a postoperative hematoma in this patients was increased 0,36-fold presurgery, 0,25-fold postsurgery and 0,40-fold 24hours after surgery. D-dimer variation, had no statistical significance (p0,118, p0,195, p0,756 T-test). Platelets and prothrombin activity were associated with D-dimer levels only in sample A (p 0,02 and p 0,20, W Wilson). Conclusion: High levels of perioperative D-dimer could be considered a risk marker of ICH after brain tumor surgery. However, more studies would be worthwhile to confirm this association and develop primary prevention strategies for stroke.