Hepatobiliary and pancreatic ascariasis (HPA) was described as a clinical entity from Kashmir, India in 1985. HPA is caused by invasion and migration of nematode, Ascaris lumbricoides , in to the biliary tract and pancreatic duct. Patients present with biliary colic, cholangitis, cholecystitis, hepatic abscesses and acute pancreatitis. Ascarides traverse the ducts repeatedly, get trapped and die, leading to formation of hepatolithiasis. HPA is ubiquitous in endemic regions and in Kashmir, one such region, HPA is the etiological factor for 36.7%, 23%, 14.5% and 12.5% of all biliary diseases, acute pancreatitis, liver abscesses and biliary lithiasis respectively. Ultrasonography is an excellent diagnostic tool in visualizing worms in gut lumen and ductal system. The rational treatment for HPA is to give appropriate treatment for clinical syndromes along with effective anthelmintic therapy. Endotherapy in HPA is indicated if patients continue to have symptoms on medical therapy or when worms do not move out of ductal lumen by 3 wk or die within the ducts. The worms can be removed from the ductal system in most of the patients and such patients get regression of symptoms of hepatobiliary and pancreatic disease.

Primary extrahepatic hydatid cysts are rare, and primary splenic hydatid cysts even more so, constituting 2% to 3.5% of all hydatid cysts. We report here a case series of isolated splenic hydatid cysts. Case records of 382 adult patients of abdominal hydatid cysts were analyzed; eight of them (2%; aged 23 to 45 years, 5 women and 3 men) had primary splenic hydatid cysts. Seven patients presented with dull dragging pain in the left hypochondrium. Four patients had splenomegaly. Diagnosis was made at ultrasonography and/or contrast-enhanced computed tomography. Enzyme linked immunosorbent assay for hydatid antibodies tested positive in all patients. One patient presented with hemoperitoneum. All patients underwent splenectomy. Primary splenic hydatid cyst is rare but should be considered in patients with cystic lesions of the spleen.

Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).

To compare elliptical excision with primary midline closure and rhomboid excision with limberg flap reconstruction techniques for the sacrococcygeal pilonidal sinus. This prospective randomized study of 80 patients of sacrococcygeal pilonidal sinus was performed in SKIMS medical college from 2004 to 2007. After assigning patients randomly to either of the surgical groups, group A patients (40/80) were operated by using rhomboid excision with limberg flap reconstruction whereas group B patients (40/80) were operated by using elliptical excision with primary midline closure. Data was compiled in terms of operative period required, immediate post operative complications, post operative pain (VAS scores), work-off period, hospital stay and recurrences over a follow up of 3 years for the two study groups. Data thereby collected was analyzed by using Microsoft excel. The parameters in which the two techniques were found to differ significantly were work-off period, immediate post operative complications profiles and recurrence rates. Rhomboid excision with limberg flap reconstruction technique surely outscores elliptical excision with primary midline closure in certain important parameters. While facing a patient with uncomplicated sacrococcygeal pilonidal sinus, instead of, which procedure for the patient? Surgeons should pose the question why not rhomboid excision with limberg flaps reconstruction?

Congenital midline swellings of nose are encountered rarely, and nasal gliomas constitute about 5% of such lesions. Various theories have been suggested to explain the pathogenesis. Imaging preferably by MRI is mandated to study the extent and to rule out intracranial extension. Treatment is complete excision, and the approach depends upon the extent of the lesion and availability of expertise. We present the management of one such case of congenital intranasal glioma without any intracranial extension that presented as a septal polyp.

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IntroductionPenetrating hand injuries are common and improper assessment can result in missed foreign bodies. These bodies can result in a wide range of complications.AimThe aim of our study was to study the profile of patients reporting with missed foreign bodies in the hand.Materials and methodsAll the cases treated in the Department of Surgery, Sheri Kashmir Institute of Medical Sciences (medical college), Kashmir, for missed foreign bodies in hands from June 2003 to May 2009 were studied retrospectively.ResultsA total of 61 cases with missed foreign bodies of different nature were treated over the period of six years. Wooden splinters were the most common foreign bodies missed. Preoperative localization was accomplished with plain radiographs and ultrasonograms. Most of the cases were treated on outpatient basis.ConclusionsForeign bodies should be suspected and ruled out in all cases of penetrating injuries of hands. Missed foreign bodies need to be removed after proper localization by imaging.

Subcutaneous internal lateral sphincterotomy under local anesthesia is more curative, easy and safe, in the hands of a beginner as well as an experienced surgeon, with highest patient satisfaction, and should be considered as the first line of therapy in both chronic and resistant/recurrent acute anal fissures.