Necrotising fasciitis is a rare infection of the skin and underlying soft tissue. It primarily involves the extremities and rarely the breast. Primary necrotising fasciitis of the breast in a non-lactating, healthy female is rarer still. The authors present the case report of a patient presenting with primary necrotising fasciitis of the breast after sustaining a penetrating injury. The patient was managed successfully with serial debridement and negative pressure wound therapy (NPWT). To our knowledge only 19 such cases have been reported in the indexed literature so far. This is also the eighth case globally of primary necrotising fasciitis of the breast in a non-lactating female without any associated immunosuppression, which is the basis of reporting this case.
Gastroduodenal artery (GDA) pseudoaneurysm is a rare but potentially fatal complication in chronic pancreatitis. Managing GI bleed in chronic pseudocyst due to ruptured pseudoaneurysm having multiple feeding vessels and that too in a background of portal hypertension is a challenging task. A 43 year old male patient with chronic calcific pancreatitis presented to our department with 10 days history of malena and drop in hemoglobin. He under micro coil embolization of GDA 12 days before in another hospital for ruptured GDA pseudoaneurysm with upper GI bleed. Upper GI endoscopy revealed grade II-III esophageal varices with portal hypertensive gastropathy with blood in 2nd part of duodenum. CECT scan revealed features of chronic calcific pancreatitis with pseudocyst and GDA pseudoaneurysm with intracystic bleed. Patient again underwent coil embolization in our hospital. However, the patient again developed GI bleed. Patient was taken for emergency laparotomy and found to have bleed from splenic artery as well as GDA pseudoaneurysm into the pseudocyst. Transcystic pseudoaneurysm ligation with ligation of intracystic bleeding vessels and lateral pancreaticojejunostomy was done. Postoperatively patient recovered well. Rupture of pseudoaneurysm in chronic pancreatitis is associated with almost 100% mortality if untreated. Though radiological intervention should be the primary modality of treatment, low threshold for surgery should be kept, considering multiple feeding vessels to the pseudocyst pseudoaneurysm, which may be missed in angiography
Background: Chronic pancreatitis, a debilitating disease which affects the patient to an extent to render him bedridden sometimes and often make him/her unable to perform daily work, leading to poor quality of life, severe emotional stress and financial burden. Frey’s procedure one of the most commonly performed surgery in patient of chronic pancreatitis with stones in pancreatic duct and small inflammatory head mass. This procedure had shown promising results in terms of pain control with unclear outcome with respect to exocrine and endocrine status.Methods: Study was conducted in Government Kilpauk Medical College, Chennai during March 2016 to December 2019. Total 21 patients were followed up for 18 months and Post-operative pain was analysed using pain scoring system used by Bloechle et al. Exocrine status in terms of diarrhea, bloating sensation and Fecal Elastase level(preoperative and postoperative) were analysed. Patient glycaemic status were also analysed and compared. Patient Nutritional status was analysed in terms of weight gain.Results: In this study there was significant improvement in pain after surgery in terms of VAS pain Score (Preop Mean-82.14, Post-op Mean- 9.76, p<0.001) , frequency of pain (Preop Mean-78.57, Post-op Mean- 14.29, p<0.001), analgesia required (Preop Mean-15, Post-op Mean- 3.10, p<0.001), and inability to work due to pain (Preop Mean-80.95, Post-op Mean- 11.90, p<0.001). Overall total Pain score was significantly improved after surgery (Preop Mean-256.67, Post-op Mean- 39.05, p<0.001). There was significant weight gain and significant improvement in Fecal Elastase level in patients following surgery, however there was no significant difference in pancreatic exocrine status on the basis of symptoms.Conclusions: Frey’s procedure is very effective in pain control in properly selected patients of chronic calcific pancreatitis, and it also improves nutritional status of patient. Frey’s procedure might improve patient exocrine and endocrine status but further multicentre studies are needed to come to a conclusion.
Background: Visceral nociception is a significant source of the post-operative morbidity in Laparoscopic cholecystectomy and thus the idea of intraperitoneal local anaesthetic (IPLA) instillation was promulgated. The aim of the study was to evaluate the role of intra-peritoneal lignocaine instillation on post-operative morbidity in terms of post-operative pain and post-operative nausea and vomiting and also to establish if there is any difference exists between the timing of instillation of intra-peritoneal lignocaine (before and after completing the gall bladder dissection).Methods: Eighty patients randomized into two groups lignocaine group (lignocaine instilled in gallbladder bed) and placebo group (saline instilled in gallbladder bed). Lignocaine group further divided into subgroups i.e. pre-dissection lignocaine group (lignocaine instilled before gallbladder dissection) and post-dissection lignocaine group (lignocaine instilled after gallbladder dissection).Results: Post-operative pain was measured in terms of the VAS score. The score was less in lignocaine group. The difference was statistically significant (p<0.05) at 1, 2, 4, 6, 12 and 24hours between lignocaine group and placebo Group. No statistically significant difference between the mean of VAS scores of pre-dissections lignocaine and post-dissection lignocaine subgroups. In lignocaine group, 27.8%, 75%, 41% and 25% of the subject required rescue analgesia in 1st hr, next 1-8 hr, 8-16 hr and 16-24 hr respectively. In placebo group 33.3%, 97.2%, 83.3 % and 63.9% of the subject required rescue analgesia in 1st hr, next 1-8 hr, 8-16 hr and 16-24hr respectively. The difference was found to be statistically significant (p<0.05) except at 1st hour. Post operatively nausea perception, seemed to be slightly higher in placebo group as compared to lignocaine group but difference was statistically insignificant (p>0.05).Conclusions: Intraperitoneal lignocaine instillation is an effective method to alleviate post-operative pain in patients undergoing laparoscopic cholecystectomy, whether used as pre-emptive analgesia or instilled at the end of surgery. Intraperitoneal lignocaine instillation decreases post-operative analgesia requirement, especially after the 1st post-operative hour.
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