Journal of Surgery

With the widespread practice of laparoscopic cholecystectomy and the advancements in imaging and endoscopic therapy the management of bile leaks following cholecystectomy has evolved over the years. Majority of the bile leaks are detected post-operatively. A high index of suspicion should exist for a possible bile leak if a patient presents with abdominal pain, fever, and tenderness within a week following a complicated or converted laparoscopic cholecystectomy, or it may present as an overt external biliary fistula. Leaks which are detected intra-operatively and managed appropriately carry the best prognosis. Interventional radiologists along with expert endoscopists can successfully manage many of the minor bile leaks. Major bile duct injuries should be properly characterized by appropriate imaging studies. One should avoid undue haste while opting for surgical interventions which are invariably required for such major injuries. Such repairs should be undertaken by expert hepatobiliary surgeons as the first repair has the greatest chance of success and failed repairs raises the level of injury making subsequent repairs more difficult.

Abdominoperineal resection may be the only curative solution for invasive or recurrent malignant tumors in the pelvic-perineal region. Recent studies have established that immediate pelvic-perineal reconstruction following abdominoperineal resection is associated with superior primary healing, decreased postoperative complications, rapid recovery and reinsertion with increased quality of life for the patient. Currently, many reconstructive options for the perineal defect after abdominoperineal resection are available, ranging from primary direct closure to flap reconstruction. Better knowledge of the progress attained in the care of the perineal defect after abdominoperineal and rectal resection can help the surgeon make a better choice for each patient. There is no consensus on the optimal technique after abdominoperineal resection. In this article, various closure techniques are presented, from direct closure, closure fastened with meshes to the autologous reconstruction by musculocutaneous flaps, which until recently have been the "gold standard" for perineal reconstruction. The main donor sites for musculocutaneous flaps include the rectus abdominis, gracilis or gluteus maximus muscles. The reconstruction option should be carefully chosen to establish a significant balance between the reconstructive needs and the morbidity of the donor site. A review of these techniques and their development is provided to offer a general overview of what has been done, what can be done currently and what may be done in the future.

Introduction: Carcinoma of the rectum is not only a medical but a social problem. Adenocarcinoma of the rectum accounts for 30% of these cancers. Locally advanced cancers of the rectum i.e., stage 2 and 3 diseases prove to be a challenge with respect to its management. Present guidelines state that the use of neoadjuvant chemoradiotherapy to downstage the locally advanced carcinomas of the rectum to have a positive impact on not only the survival but also the quality of life post-treatment viz., by allowing better resection margins to preserve the sphincter mechanism by performing a coloanal anastomosis.
Objectives: To assess the locoregional response rates determined by the measurement of margin of clearance from the anal verge, organ preservation (sphincter-saving operations), and histopathological findings in post CRT surgical specimen.
Materials and methods: This study included a total of 33 patients which were diagnosed with locally advanced rectal cancer who presented in the department of General Surgery, Vydehi Hospital, Bangalore. The patients in this series were subjected to pre-operative CRT, loco-regional response rates and the number of sphincter preserving surgeries performed were assessed.
Results: Downstaging of the tumor was achieved in 91% of the cases.
Conclusion: From this study, an interpretation can be made that following CRT there is a significant downstaging and increased ability to perform sphincter-saving procedures.

Background: Obesity is one of the most important public health; it seems that inflammation is a pathogenic pathway between obesity and its associated comorbidities. The aim of the study was to evaluate the status of serum inflammatory markers in a group of obese patients hospitalized for bariatric surgery.
Materials and methods: We performed a retrospective study on 64 obese patients successively hospitalised in our Surgical Unit between November 2014 and November 2016. All patients received a full evaluation including medical and personal history, complete clinical examination, and anthropometric measurements as well as general and special biological tests. The inflammatory status of each patient was evaluated by serum values of fibrinogen, CRP, Leptin and NLR and PLR scores. Insulin resistance was assesed by the homeostasis model assessment of insulin resistance index. We noted the presence of metabolic syndrome and its components and also the presence of obstructive sleep apnea syndrome.
Results: 62.5% of patients had ≤45 years and the number of male patients was significantly lower (23.4%) than the number of females. The mean value of BMI was 45.06 ± 6.67 SD and the mean value of waist circumference was 133.39 cm ± 17.47 SD. The mean values of serum inflammatory markers (fibrinogen, CRP and leptin) were abnormally elevated. There was a directly proportional relationship between the increasing of waist circumference and serum fibrinogen (p=0.04) and CRP (p=0.003) variation. Elevated fibrinogen values corelated with MS, DM II and OSA. Increased leptin values corelated with BMI, HOMA IR and OSA.
Conclusion: Elevated serum values of fibrinogen and CRP correlate especially with abdominal obesity, quantified by waist circumference, while increased pathological values of serum leptin correlates also with BMI. Of all inflammatory markers assesed in the study, elevated fibrinogen appear to be most sensitively related to the presence of MS, OSA and DM II.

A case of intestinal pseudo-obstruction (Ogilvie's syndrome) secondary to herpes zoster infection. We discuss the association of Ogilvie's syndrome with herpes zoster as well as investigations and course of treatment of these cases. An understanding of the rare association is important in correct management of such cases to prevent associated morbidity and mortality.

Background: Gastric cancer is an important cause of death in worldwide, despite the progress achieved through screening programs. Multivisceral resections are dictated by R0 resection gold, but also by the histopathological type of the neoplasm involved.
Case report: A 64-year-old patient was admitted in Surgery department for epigastric abdominal pain, haematemesis, anorexia, weight loss. Superior digestive endoscopy revealed a reduced stomach in size, inextensible at insufflation, with a malignant ulceration, unresponsive to proton pump inhibitor (PPI) treatment. The clinical and endoscopic context required surgery and intraoperative it was detected a tumor block that includes the stomach, transverse colon, spleen and pancreas, undergoing total gastrectomy, distal spleno-pancreatectomy, subtotal colectomy with eso-jejunal anastomosis on Y Roux loop, ileo-sigmoid anastomosis, suture of the proximal pancreatic tissue. Postoperative course was favorable with discharge of the patient on the 11th postoperative day. The histopathological examination revealed a diffuse carcinoma with linitis plastica appearance. After oncological treatment with imatimib, no endoscopic and imagistic signs of tumor recurrence are seen at 6 months apart.
Conclusions: Multivisceral resections in the advance gastric cancer T4 stage represent the only surgical procedure to obtain an R0 type resection. This should be done whenever technically is possible, but favorable outcomes in distance survival are recorded in mesenchimal forms and less in adenocarcinomas.

Although a disease with a particularly historical, war-related implication, gas gangrene still retains its importance in pathology through its highly severe prognosis and rapid death in the absence of immediate treatment. The most common occurrences of the infection in times of peace are traffic accidents and natural disasters, but this can also occur in a non-traumatic context, in carcinomas and digestive tract ulcers or diabetes. The most commonly cited etiological agent is Clostridium perfringens, but other anaerobic germs as well as various aero-anaerobic associations may be responsible for the appearance of gangrene. The accumulation of gas bubbles through the action of etiological agents, highlighted by the presence of crevices or radiological examinations, is the hallmark of this condition. In this paper, the authors present the case of a 26-year-old man who died as a result of the gas gangrene with a rapid evolution (60 hours), which occurred in the progress of a soil telluric wound in the right thigh despite doctors’ efforts. The authors emphasize the importance of suspicion of the possibility of the occurrence of gangrene in wounds contaminated with vegetal remains or soil, on the one hand because the pathognomonic sign appears at an advanced stage of the infection and on the other hand because the prophylactic, surgical and medicinal treatment together with the resuscitation measures may be life-saving when applied in a timely manner.