The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.
Even though surgery for diastasis is controversial, we advocate repair for cosmesis and restoring function of the recti muscles. Our 'Venetian blinds' technique provides a solid repair and reduces the risk of seroma. The use of a prosthesis for the repair is mandatory to prevent recurrence. The adequacy of repair was assessed by measuring the IRD preoperatively and postoperatively with computed tomography (CT) scan. Laparoscopy provides all of the benefits of minimal access surgery.
It is well known that bronchogenic carcinoma frequently metastasises to the bony skeleton, but it is most unusual for it to present in the form of a musculoskeletal abscess. Presented here is the case report of a patient with what appeared initially to be a right sided gluteal abscess and which turned out to be the metastasis from a bronchogenic carcinoma. The Magnetic Resonance Image (MRI) scan carried out proved to be very helpful in arriving at a probable clinical diagnosis; however, it was histopathological studies of the abscess wall itself that ultimately gave the definitive diagnosis. We believe that this may represent one of the first documented cases in which on MRI scan has been used to confirm the presence of a gluteal abscess.
Laparoscopic cholecystectomy is the gold standard for managing cholecystolithiasis, despite being associated with a higher incidence of gallbladder perforations (10 % -40 %) [1] and spillage of gallstones (6 % -30 %) than is the open procedure. Although rare (0.08 % -0.3 %) [2], gallstone spillage could potentially lead to serious morbidity such as gallstone abscesses, which can present from as early as 1 month to as late as 20 years after the procedure, almost anywhere in the abdominal cavity [3]. A female patient underwent an apparently uneventful laparoscopic cholecystectomy 3 years back. She was referred to us with clinical and radiological signs suggestive of "residual" cholecystitis. Her magnetic resonance cholangiography showed an apparently anatomically intact gallbladder containing multiple stones and a low-inserting cystic duct with features suggestive of calculous cholecystitis (l " Fig. 1 and Fig. 2). The coronal section (l " Fig. 3) confirmed these findings. However, to our surprise, diagnostic laparoscopy revealed a walled-off abscess cavity at the gallbladder fossa containing 30 -40 ml frank pus with multiple gallstones giving a deceptively identical appearance to a "nonextracted" gallbladder. There was no trace of residual actual gallbladder or cystic duct. The patient recovered well after laparoscopic drainage of the abscess with removal of stones. This unique postcholecystectomy appearance of MR images could have confused the second surgeon while putting the previous surgeon at a risk of serious litigation. It could well be called a "pseudo" cholelithiasis. Such a deceptive appearance has not been reported before. In today's era of laparoscopic cholecystectomy, if this possibility were to be considered, it would reduce the number of false-positive diagnoses of "residual" cholelithiasis wherein a diagnostic laparoscopy and drainage (as in this case) could significantly reduce the access trauma. However, gallbladder perforation should be avoided as far as possible. If it occurs, all spilled stones should be retrieved and the patient informed. Moreover, routine use of endobags for specimen retrieval is strongly recommended in all laparoscopic cholecystectomies to avoid such potentially morbid sequelae.
Here, we discuss an unusual case of a pararectal tail gut cyst, initially misdiagnosed to be an ischiorectal abscess which was presented to us after being operated for incision and drainage. It was excised by a laparoscopic assisted approach. In such cases, a digital examination, transrectal ultrasound, CT scan, or MRI can help in the diagnosis. A combined approach is useful to locate and remove the cyst intact; however, a lower approach is useful for low-lying lesions. Histopathology can differentiate between a rectal duplication cyst and a tail gut cyst.Keywords Pararectal cyst . Laparoscopically assisted approach . Combined approach . Laparoscopy . Tail gut cyst Case ReportA 42-year-old lady presented to us after having undergone incision and drainage of ischiorectal abscess. During the surgery, minimal mucoid material was drained; however, there was no evidence of any pus. The operating surgeon had suspicion of intestinal herniation in left ischiorectal fossa. Hence, the surgery was abandoned, and she was referred to our institute for further management. Abdominal examination was normal. On per rectal examination, there was no significant tenderness in the pararectal region.CECT scan of the abdomen and pelvis was done which showed a heterogeneous collection in the left ischiorectal fossa and left pararectal region with supralevator extension (Fig. 1a).On exploring the ischiorectal fossa, a tubular fleshy mass was seen (Fig. 1b). A diagnostic laparoscopy was performed which did not reveal any herniation. After left ovarian cystectomy, the left pararectal plane was entered; levator ani fibers were then dissected. An elongated left pararectal cyst not in connection with the rectum, mostly confined to the left ischiorectal fossa, was seen. The cyst was then dissected as low as possible through an abdominal route. The rest of C. Palanivelu
Context: The importance of upper gastrointestinal (UGI) contrast study following sleeve gastrectomy (SG) is equivocal. It can, however, yield anatomical and functional details, the significance of which mostly remains unknown. Settings and Design: This prospective, single-center study included SG patients between January 2018 and January 2019. Materials and Methods: UGI contrast study was done on post-operative day 1. The findings of the study namely gastroesophageal junction (GEJ) holdup time, presence of fundus, gastroduodenal emptying (GDE) time, and sleeve shape were compared with weight loss, improvement of glycosylated hemoglobin (HbA1c) and gastroesophageal reflux disease (GERD) symptoms at 3, 6, and 12 months follow-up. Results: There were 138 patients with 100% follow-up. Radiological sleeve patterns observed were: tubular (62.3%), superior (16.0%), and inferior (21.7%) pouches. GEJ holdup time had no effect on percentage total weight loss (%TWL) ( P = 0.09) or HbA1c improvement ( P = 0.077). The absence of fundus led to greater %TWL at 6 months ( P = 0.048). GDE time <15 s led to higher %TWL ( P = 0.028) and lower HbA1c ( P = 0.010) at 12 months. Antrum size <2 cm was associated with higher %TWL ( P = 0.022) and lower HbA1c level ( P = 0.047) at 12 months. Vomiting and regurgitation were common with tubular sleeves. Conclusion: UGI contrast study can predict weight loss, HbA1c improvement, and GERD symptoms. The absence of fundus, small antrum, and rapid GDE are associated with better weight loss. HbA1c improvement is better with small antrum and rapid GDE. Tubular sleeve predisposes to vomiting and regurgitation.
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