BackgroundRight iliac fossa (RIF) pain is one of the most common modalities of presentation to surgical emergency. It remains a challenge to the treating clinicians to accurately diagnose or to rule out appendicitis.ObjectiveThe aim of the study was to compare the efficacy of clinical impression, biochemical markers, and imaging in the diagnosis of RIF pain with special reference to appendicitis and their implication in reducing the negative appendicectomy rates.MethodsAll patients presenting to casualty with RIF pain were included in the study. Blood investigations including C-reactive protein (CRP), serum bilirubin, white blood cell counts (WBC), and ultrasound (USG) were done. Based on the clinical impression, patients were either posted for appendicectomy or observed in equivocal cases. Patients who had recurrent pain on follow-up underwent appendicectomy or underwent contrast-enhanced computed tomography (CECT) in equivocal cases. Patients who only had a single self-limiting episode with no other alternative diagnosis or had a normal CECT report were included in a non-specific RIF pain group.ResultsThe negative appendicectomy rate was 8.2%. The mean value of WBC counts (9.57x109/L vs 7.88x109/L; p<0.05) and that of serum bilirubin (1.37 mg/dl vs 0.89mg/dl; p<0.05) in the appendicitis and non-appendicitis group, respectively, were statistically significant. The percentage of CRP positivity was higher in the appendicitis group (51.9% vs 15%; p<0.05). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for USG (84.2%, 77.17%, 85.4%, and 75.5%), for CRP (51.8%, 85%, 82%, and 57%), for WBC count (45.1%, 88%, 86.6%, and 48.3%), and for serum bilirubin (69.2%, 75%, 81.4%, and 60.5%) were statistically significant between the groups.ConclusionImaging and biochemical investigations including bilirubin can act as useful adjuncts to the clinical diagnosis of appendicitis.

Background: Corrosive injury resulting in gastric outlet obstruction (GOO) is fairly uncommon in world literature. We aim to study the socio-demographic variables of corrosive acid ingestion patients presenting as symptomatic GOO, along with the surgical procedure performed in these patients, post-operative complications and long term follow up data.Methods: We included all patients with clinical features of gastric outlet obstruction following acid ingestion, who were operated in our department between January 2006 and April 2017. We collected patient’s demographic data, parameters during surgery, body weight and nutritional status pre- and post-operatively, which were all derived from case records and outpatient records. Follow up data of the patient were collected when possible.Results: During the study period, 81 patients were enrolled in the study; 42 males, average age 35.76±3.53 years, 82% had suicidal intent of ingestion and 18% accidental; average follow-up period was 80.5 months. After an average period of 6 months, 94% underwent loop gastrojejunostomy. Approximately, 22% suffered complications like surgical site infections, postoperative fever, pulmonary infections and postoperative vomiting. Average follow up of 6.7 years done in 68 patients who underwent only bypass without resection, none of the patients developed any malignancy of upper gastrointestinal tract.Conclusions: Staged treatment for GOO patients was seen to be associated with good clinical outcomes and few complications. Bypass of cicatrised stomach without resection gives acceptable results.

Though endometriosis involving the intestines is well known, it causing ileocecal obstruction is a rare presentation. Etiology for ileocecal obstruction may not be known in all the cases preoperatively and may sometimes need resection and histopathology for diagnosis. Here we present a case of endometriosis presenting for the first time as an ileocecal obstruction in a 39-year-old lady who presented to us with complaints of intermittent abdominal pain. Contrast CT scan of the abdomen showed terminal ileal stricture and wall thickening. She underwent diagnostic laparoscopy, which showed dilated distal small bowel loops with suspicious stricturing growth at the terminal ileum and ileocecal valve region. A formal laparoscopic right hemicolectomy was done and post-operative histopathology revealed endometriosis with fibrosis, causing a luminal obstruction. In conclusion, endometriosis should be considered as a rare differential in patients presenting with ileocecal obstruction and having inconclusive features on imaging, endoscopic or biopsy, especially in women of childbearing age.

Background: Management of injuries sustained during cholecystectomy requires expertise and involves a patient who is troubled, usually drained of personal resources. There has been an increase in incidence with laparoscopic cholecystectomy. The standard surgical management done for major biliary injuries is Roux-en-Y Hepaticojejunostomy (R-en-Y HJ). Materials and Methods: Patients managed surgically for definitive management of biliary injuries in the form of R-en-Y HJ were included. Data were collected from prospectively maintained records and through outpatient follow-up. Demographic data, early and late surgical complications, long-term outcomes, and follow-up results were analyzed. Results: Among the 62 patients, 26 were males, with a mean age of 37.4 ± 13.5 years. A total of 24 patients presented with ongoing biliary fistula. The Strasberg–Bismuth type of injury included types E1 in 8 (13%), E2 in 31 (50%), E3 in 19 (30.6%), and E4 in four patients (6.4%). There were no postoperative mortality and morbidity in 27.4% of patients. Atrophy–hypertrophy complex was seen in four patients, vascular injury in six patients, and an internal fistulisation with duodenum in two patients. Presence of comorbidities ( P = 0.05), male gender ( P = 0.03), tobacco use ( P = 0.04), low albumin ( P = 0.016), and more proximal (E4-E1) type of injury ( P = 0.008) were independent predictors of postoperative morbidity ( P < 0.05). The mean duration of patient follow-up was 26.2 ± 21.1 months. Conclusion: Optimization of preoperative nutrition, avoidance of intraoperative blood transfusion, proper timing of repair, and tension-free R-en-Y HJ draining all the ducts which is done at an experienced hepatobiliary center provide the best outcome.

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