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   Table of Contents - Current issue
Coverpage
July-August 2020
Volume 53 | Issue 4
Page Nos. 123-158

Online since Thursday, August 20, 2020

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ORIGINAL ARTICLES  

Are immature granulocytes and derivatives early predictors of acute appendicitis and acute complicated appendicitis in adults? p. 123
Mustafa Korkut, Cihan Bedel, Fatih Selvi
DOI:10.4103/fjs.fjs_111_19  
Background: The aim of this study was to investigate the usability of immature granulocyte count (IGC), immature granulocyte percentage (IG%), and IGC to neutrophil ratio (IGC/N ratio), a new inflammatory marker, in both diagnosing acute appendicitis (AA) and differentiation of simple and complicated appendicitis (SA and CA). Materials and Methods: This study was conducted on 262 adult patients who underwent appendectomy. The patients were histopathologically divided into positive and negative appendectomy groups. The patients in the AA group were also divided into SA and CA subgroups. The demographic and laboratory data of the patients were compared. Results: The mean values of white blood cell count, neutrophil-to-lymphocyte ratio, IGC, IG%, IGC/N, and C-reactive protein (CRP) are the parameters that can be used both to diagnose AA and to differentiate CA from SA. In our study, the ability of IGC to predict AA was found to be greater than that of other parameters. For IGC, the area under the receiver operating characteristic curve (AUC) was 0.784, the sensitivity was 98.3% and the specificity was 80%. CRP and IGC/N ratio had the highest specificity predictive values in differentiating CA from SA. For IGC/N, the AUC was 0.702, the sensitivity was 63.9%, and the specificity was 72.3%. Conclusion: IGC is a reliable inflammatory marker in the diagnosis of AA but immature granulocytes and derivatives (IGC, IG%, and IGC/N) cannot be used for predicting CA because of low sensitivity and specificity.
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Modified bilateral thoracoscopy-assisted Nuss procedure for repair of pectus excavatum after previous thoracic procedure p. 128
Fu-Jung Lee, Po-Cheng Lo, Meng-Yu Wu, Min-Shiau Hsieh, Yeung-Leung Cheng
DOI:10.4103/fjs.fjs_9_20  
Background: Minimally invasive repair of pectus excavatum (PE) (Nuss procedure) was a transmediastinal procedure. Intrathoracic adhesion might increase the risks of this procedure. Patients after previous thoracic surgery might have the problem of intrathoracic adhesion increasing the surgical risks of Nuss procedure. PE after surgical repair was not a rare problem, especially in adults. In this study, we were to investigate the efficacy and safety of a modified Nuss procedure, using bilateral thoracoscopic approach, to repair recurrent or residual PE in adult patients. Materials and Methods: We retrospectively included all adults with PE corrected by modified bilateral thoracoscopy-assisted Nuss repair from January 2015 to December 2016. The clinical and surgical data of patients repaired with primary or secondary Nuss procedure were recorded and analyzed. Results: One hundred and fifty-one adult patients (136 men and 15 women) with a mean age of 26.3 years were included. Eleven patients (9 men and 2 women) were secondarily repaired due to prior failed Ravitch (three patients) or Nuss procedure (eight patients). The pectus repair was done using a single pectus bar (8.6%), 2 bars (81.5%), or 3 bars (9.9%). The rate of postoperative complications (6 months after operation) was significantly higher (P < 0.01) in the secondary repair group (two patients, 18.2%) compared to the primary repair group (seven patients, 9.3%), but it was still lower than most of the previous reports in the world (around 40%). Conclusion: All patients with PE had excellent postoperative outcomes in both the groups, even if with a slightly higher postoperative complication rate in the secondary repair group. The number of bar insertions was higher than previous data but with a lower complication rate. The modified bilateral thoracoscopy-assisted Nuss repair for adult patients after failed Ravitch or Nuss procedure was a safe and effective method and could have good early results.
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Obesity and surgical intervention: How acquainted are we? p. 135
Mallikarjuna Manangi, Bhagyashree Hegde, Santhosh Shivashankar, Premkumar Anandan, Sunilkumar Venkatappa, MV Ramya
DOI:10.4103/fjs.fjs_29_20  
Background: Obesity is one of the leading causes of worry due to the vital role it plays in pathophysiology of many metabolic diseases. Even though there are various approaches taken to treat obesity, bariatric surgery has been shown to be effective. There is still hesitancy among the medical fraternity to accept bariatric surgery. We aim, in this study, to evaluate the perceptions and awareness about obesity and bariatric surgery among the medical fraternity. Materials and Methods: A survey consisting of an anonymous questionnaire was conducted which included undergraduate students, house surgeons, postgraduate residents, and consultants from various specialties in various institutes across Karnataka as participants. The study was conducted in September 2019. The research tool was designed using www.surveymonkey.com, which consisted of questions regarding obesity and its surgical management and was circulated among medical colleagues through social networking websites such as WhatsApp and Facebook, Inc. The survey was made available for 10 days. Questions were framed using skip logic, wherein each set of participants had a selected set of questions. A total of 28 questions were circulated for each participant. Results: Six hundred and seventy-one participants took part in the survey, among which 53.57% were undergraduate students, 28.18% were postgraduate residents, and 18.25% were consultants. About 88.03% believe that obesity is a disease and has a high prevalence in India. Nearly 96.87% of them are of the opinion that obesity affects only the educated, high socioeconomic status, and urban population, and 25.3% of them believe that obesity is not seen in the rural, low socioeconomic status population. Only 7.12% of them are aware of the fact that obesity is a causative factor for cancer. About 46.3% of them opine that obese patients are discriminated in the health sector. However, 61.57% of them would not like to undergo the surgery in case they ever fall into the obese category nor would they recommend it to their relatives. Conclusion: By making simple models and flow charts to educate the healthcare professionals regarding obesity, pathophysiology and the treatment might reduce the stigmatizing attitudes and reduce the discriminatory attitude towards obese patients and would help in the efficient management of obesity and its associated comorbidities.
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Versatile rhomboid flaps in paediatric surgical practice p. 140
Digamber Chaubey, Sandip Kumar Rahul, Ramjee Prasad, Zaheer Hasan, Rupesh Keshri, Sujit Kumar
DOI:10.4103/fjs.fjs_61_20  
Background: Tension-free closure of large cutaneous defects after excision of primary pathology poses a challenge to the operating surgeon. The objective of the study was to review the use of rhomboid flaps (RFs) in the closure of surgical defects at different locations and of varying pathology. Materials and Methods: A retrospective study on all cases of surgical wounds closed with RFs from January 2014 to December 2019 was conducted in the department of pediatric surgery at a tertiary care center. Data regarding the demographic details of the patient, location of the wound with its shape and size, details of the primary lesion, and any postoperative complications were noted and analyzed. Results: RFs were used in 73 large defects with the ratio of transverse to longitudinal dimensions ranging between 0.67 and 1.49. These defects had variable pathology and different location (59 - neural tube defects; 9 - arteriovenous malformation; 2 - amniotic bands; 2-pilonidal sinus; and 1 - coccydynia with ulcer). Different modifications of RFs included variation in the direction towards which they were raised, multiplicity of the flaps, variation in the angle at which the flap was fashioned (Dufourmentel modification), and lessening the flap length to match the short diagonal of the wound (Quaba modification). Minimal complication in the form of wound infection (5/73), dehiscence at the tip of the flap (2/73), and hematoma (3/73) was observed which were managed conservatively. Conclusion: Versatile and universal RFs offer tension-free closure of large wounds at different anatomical locations with minimal complication and are indispensable tools in the hands of a pediatric surgeon.
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CASE REPORTS Top

A rare case of proliferating trichilemmal tumour of mons pubis in an elderly male p. 145
Mohamed Javid, Shanthi Ponnandai Swaminathan, Rajeswari Mani, Arun Victor Jebasingh
DOI:10.4103/fjs.fjs_112_19  
Proliferating trichilemmal tumour (PTT) is a rare skin lesion arising from the isthmus region of the hair follicle, with a potential for a malignant transformation. It has a predilection for the scalp (90%) and commonly occurs in elderly females after the age of 50. However, there are various case reports suggesting that PTT can rarely arise from other areas. Here we present the case of an elderly male who came to us with an ulceroproliferative lesion in the mons pubis. A wedge biopsy suggested that the lesion was a PTT. Histopathological examination following a wide local excision confirmed the diagnosis of PTT without any foci of malignant changes. We feel this case is of interest and deserving to be reported on account of the unusual location and differential diagnosis from other diseases.
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Pantaloon hernia with two sliding components: The appendix -ascending colon in lateral sac and the urinary bladder in medial sac p. 148
Abhinandan Milind Kadiyal, Thakut Gowtham, Mansingh N Ghatage, Rajat Kumar Singh, Vishwas Thimmegowda
DOI:10.4103/fjs.fjs_95_19  
An inguinal hernia is quite frequent in surgical praxis. One of the rare entities sliding type of inguinal hernia with an incidence of 2%–5%, which is difficult to diagnose preoperatively, most of the time, its diagnosis is made on the operational table. We report a rare case of pantaloon-type hernia with sliding components in either side of the hernia: the appendix, ascending colon onto the lateral, indirect hernia sac, and the urinary bladder onto the medial, direct sac, respectively. The two hernia sacs were saddled on either side of the inferior epigastric vessels. A 77-year-old presented with a right inguinoscrotal swelling for 5 years and increased frequency of micturition for 8 months. The indirect sac was opened very cautiously and was found to contain an appendix, the part of urinary bladder medially and ascending colon laterally forming the sliding component, small bowel, omentum are the contents of sliding hernia. The contents were attenuated and the sac was sealed cautiously. The posterior wall of the right inguinal canal was opened in total, contents were reduced, and neo posterior wall is formed by strengthening, and reinforcement did with prolene mesh. This entity is a diagnostic dispute due to its rarity and defined clinical presentation. Pantaloons hernia with two sliding components is uncommon. The hernia consisted of two parts: a laterally-located indirect sac containing the appendix and sliding ascending colon, and a medially-located direct hernia of sliding urinary bladder. A hernia of long duration in old patients should raise a suspicion of a pantaloon-type hernia. One should be very careful to identify the contents of the hernia to avoid inadvertent injury to the structures.
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Functional outcome in critical-size defect aneurysmal bone cyst of the distal humerus patient treated with curettage and nonvascularized autologous fibular graft p. 152
Rahadyan Magetsari, Yuni Artha Prabowo Putro, Rizky Admagusta
DOI:10.4103/fjs.fjs_16_20  
Aneurysmal bone cyst (ABC) is a rare benign expansive cystic lesion characterized by blood-filled cavernous spaces separated by septae containing osteoid tissue and osteoclast giant cells. Treatment goals are to stop progression of the lesion, relieve pain, stabilize pathologic fractures, and reduce recurrence rates. The standard of care for ABCs is curettage with or without bone graft depending on the resultant void. Despite best efforts at curettage, clinical series have shown highly variable recurrence rates, with some series showing rate ranges from 0% to 100%. Tumor resection may be associated with critical bone loss. Critical-size defects require reconstruction. Other than that, functional outcome after surgical treatment in patients with critical size defect is still a challenge even in benign tumor case. We reported a 32-year-old female presenting an entirely contained ABC to the distal metaphysis of the humerus treated with curettage and nonvascularized autologous fibular bone graft.
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“Drill holes” made on exposed scalp bone promotes secondary intention healing of extended scalp laceration wounds: A Mbabane Government Hospital approach in the Kingdom of Eswatini p. 156
Po-Hsun Chou, Chi-Cheng Tu
DOI:10.4103/fjs.fjs_103_19  
Granulation tissue growth over exposed bone may be facilitated by creating fenestrations on the exposed bone. We report the case of a 6-year-old girl with a large-sized scalp laceration (10 cm × 6 cm) with bone exposure (4 cm × 3 cm) due to a road traffic accident in the Kingdom of Eswatini. We treated the wound with saline-soaked gauze dressing and drilled several holes on the exposed bone to enhance secondary healing. The aim of this case report was to provide a successful application of “Drill holes” procedure or trephination of exposed calvarium for the treatment of exposed bone and large-sized scalp lacerations in resource-poor areas, where flaps or more complicated procedures are not feasible.
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