Comparison of Short-Course versus Conventional Antimicrobial Duration in Mild and Moderate Complicated Intra-Abdominal Infections: A randomised controlled trial

Objectives: Studies have shown the feasibility of short-course antimicrobials in complicated intra-abdominal infection (CIAI) following source control procedure (SCP). This study was carried out to compare post-operative complication rates in short-course (5 days) and conventional (7–10 days) duration groups after antimicrobial therapy. Methods: This was a single-centre, open-labelled. randomised control trial conducted from July 2017 to December 2019 upon patients with CIAI. Patients who were haemodynamically unstable, pregnant and had non-perforated, non-gangrenous appendicitis or cholecystitis were excluded. Primary endpoints were surgical site infection (SSI), recurrent intra-abdominal infection (IAI) and mortality. Secondary endpoints included time till occurrence of composite primary outcomes, duration of antimicrobial therapy, the length of hospital stays, antimicrobial-free interval, hospital-free days at 30 days’ interval and the presence of extra-abdominal infections. Results: Overall, 140 patients were included whose demographic and clinico-pathological details were comparable in both groups. There was no difference in SSI (37% vs. 35.6%) and recurrent IAI (5.7% vs. 2.8%; P = 0.76), and no mortality was observed in either groups. The composite primary outcome (37% vs. 35.7%) was also similar in both groups. Secondary outcomes included the duration of antimicrobial therapy (5 vs. 8 days; P < 0.001) and length of hospitalisation (5 days vs. 7 days; P = 0.014) were significant. Times till occurrence of SSI and recurrent IAI, incidence of extra-abdominal infection and resistant pathogens were comparable. Conclusion: Short-course antimicrobial therapy for 5 days following SCP for mild and moderate CIAI was comparable to conventional duration antimicrobial therapy, indicating similar efficacy. Keywords: Abdominal Abscess; Antibiotic Prophylaxis; Antimicrobial Stewardship; Appendicitis, Perforated; Drug Resistance, Microbial; Intra-abdominal Infection; Peritonitis; Surgical Wound Infection

Double Trouble – Synchronous Primary Malignant Neoplasms: A Case Report

Synchronous primary malignancy (SPM) is rare. We herein present a case of gastric carcinoma (GC) and renal cell carcinoma (RCC) to highlight the fact that the occurrence of RCC as a synchronous tumor along with GC is rare and that a high index of suspicion of SPM should be considered before declaring it as a metastasis. A 60-year-old male presented with abdominal pain and vomiting for 4 months, and a mass was incidentally found in the lumbar region. The patient was diagnosed with SPM of the GC and RCC. Chemotherapy was given, followed by total gastrectomy; radical nephrectomy was performed. The patient is currently on follow-up. Complete history taking and thorough physical examination of patients with malignancy is instrumental in ruling out metastasis and other synchronous lesions, especially in GC. Synchronous malignancies should be treated with the multidisciplinary team, as there is no consensus in the treatment protoco

Broken stent of endoscopic retrograde cholangiopancreatography mimicking a common bile duct stone: a case report

Long standing biliary stent for biliary stricture may have complications like cholangitis, cholecystitis, stent fracture and stent migration. Treatment includes re-do endoscopic retrograde cholangiopancreatography, removal of fractured stent and restenting. Authors report a case of fractured biliary stent mimicking as distal common bile duct stone. Patient presented with features of cholangitis with history of endoscopic stenting 6 years back but lost follow up thereafter. Ultrasound showed 2cm calculus in distal common bile duct and the stent was seen on endoscopy through the papilla in the duodenum. Contrast enhanced computed tomography of abdomen showed radio opaque dense shadow in the distal common bile duct suggesting possibility of broken biliary stent. Redo endoscopic retrograde cholangiopancreatography failed to remove the fractured stent. A new stent was placed without complications. Patient underwent open common bile duct exploration and the fractured stent was removed. Patient recovered completely after the procedure

Sequential versus concomitant therapy for eradication of Helicobacter Pylori in patients with perforated duodenal ulcer: A randomized trial

Objectives: Comparison of Helicobacter pylori eradication rates, side effects, compliance, cost, and ulcer recurrence of sequential therapy (ST) with that of concomitant therapy (CT) in patients with perforated duodenal ulcer following simple omental patch closure. Methods: Sixty-eight patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori positive on three months follow-up were randomized to receive either ST or CT for H. pylori eradication. Urease test and Giemsa stain were used to assess for H. pylori eradication status. Follow-up endoscopies were done after 3 months, 6 months, and 1 year to evaluate the ulcer recurrence. Results: H. pylori eradication rates were similar in ST and CT groups on intention-to-treat (ITT) analysis (71.43% vs 81.80%,P = 0.40). Similar eradication rates were also found in per-protocol (PP) analysis (86.20% vs 90%,P = 0.71). Ulcer recurrence rate in ST groups and CT groups at 3 months (17.14% vs 6.06%,P = 0.26), 6 months (22.86% vs 9.09%,P = 0.19), and at 1 year (25.71% vs 15.15%,P = 0.37) of follow-up was also similar by ITT analysis. Compliance and side effects to therapies were comparable between the groups. The most common side effects were diarrhoea and metallic taste in ST and CT groups, respectively. A complete course of ST costs Indian Rupees (INR) 570.00, whereas CT costs INR 1080.00. Conclusion: H. pylori eradication rates, side effects, compliance, cost, and ulcer recurrences were similar between the two groups. The ST was more economical compared with CT

Gastric outlet obstruction and intussusception following Frey's procedure in a patient with chronic pancreatitis - A case report

Most commonly reported postoperative complications of Frey's procedure include sepsis, delayed gastric emptying, and endocrine insufficiency. Here, we report unusual complications such as gastric outlet obstruction and intussusception following Frey's procedure in the late postoperative period. A 40-year-old patient with chronic pancreatitis with common bile duct stricture who underwent Frey's procedure, presented with recurrent vomiting episodes 3 months postoperatively. Contrast-enhanced computed tomogram (CECT) abdomen showed features of gastric outlet obstruction. A gastrojejunostomy was carried out. The patient was asymptomatic for 2 months following which the patient presented with features of jejunojejunal intussusception confirmed on CECT, which was managed conservatively. The patient remains asymptomatic on follow-up for the past 9 months. Our experience reveals that although reports of such complications following Frey's procedure are rare, gastric outlet obstruction and intussusception can occur following Frey's procedure, and hence, the surgeon should have an index of suspicion in patients with atypical presentation

Low serum 25-hydroxy vitamin D levels are associated with aggressive breast cancer variants and poor prognostic factors in patients with breast carcinoma

ABSTRACT Objective: This study was conducted to assess the serum 25-hydroxy (OH) vitamin D levels in patients with breast cancer compared to healthy controls and to identify its association with aggressive breast cancer phenotypes. Materials and methods: Serum 25-OH vitamin D levels of 78 breast cancer patients and 78 matched healthy controls were estimated using ELISA. The cases and controls were matched with respect to age, menopausal status, parity, weight, height and co-morbidities. Prognostic factors like grade of tumour, hormone receptor status, HER2 neu status and lymphovascular invasion were compared with 25-OH vitamin D levels. Results: The mean serum 25-OH vitamin D levels of cases were significantly lower compared to the controls (22.33 ± 8.19 vs. 37.41 ± 12.9 ng/mL; p = 0.0001). Patients with higher grades of tumour, non-luminal types of breast cancer and breast cancers with estrogen receptor negativity had significantly lower serum 25-OH vitamin D levels than their opposing groups. Patients with excellent and good Nottingham's prognostic Index (NPI) had significantly higher serum 25-OH vitamin D levels than the moderate and poor NPI groups. Conclusion: Newly diagnosed breast cancer patients have significantly lower serum 25-OH vitamin D levels than healthy controls. Lower level of serum 25-OH vitamin D correlates with aggressive breast cancer phenotypes

Helicobacter pylori eradication in complicated peptic ulcer: Beneficial in most?

Helicobacter pylori eradication therapy has a role in minimizing the complications of peptic ulcer disease, namely, bleeding, perforation, and obstruction. However, the precise role of H. pylori eradication therapy in the complicated ulcers remains inconclusive, especially in perforation and gastric outlet obstruction. The prevalence of H. pylori in peptic ulcer bleeding patients has been widely underestimated owing to the differences in diagnostic tests and patient characteristics, and hence, it is recommended that an initial negative test should be followed up by a delayed repeat testing to rule out false negativity. It is well established now that eradication of H. pylori in patients with bleeding ulcers reduces rebleeding and ulcer recurrence. Multiple studies have attributed high recurrence rates of duodenal ulcer following simple closure to a high prevalence of H. pylori infection. Eradication therapy decreases the recurrence rate of perforated ulcers, thus justifying the role of H. pylori eradication therapy following the primary surgical management of perforated ulcers. The role of H. pylori in duodenal ulcer with gastric outlet obstruction is yet to be evaluated clearly. There are some reports of resolution of gastric outlet obstruction following therapy for H. pylori, obviating the need for surgery. Clarithromycin-containing regimens are recommended as first-line in areas of low resistance, whereas bismuth-containing quadruple therapy is the first-line empirical treatment in areas of high clarithromycin resistance. Treatment of H. pylori is beneficial in most of the patients with complicated peptic ulcer disease, especially in reducing recurrence of ulcer with or without complications

Early versus conventional stoma closure following bowel surgery: A randomized controlled trial

Background/Aim: To compare early stoma closure with conventional stoma closure following defunctioning diversion stoma surgery with respect to the frequency of complications, health-related quality of life (QoL), and length of hospitalization (LoH). Patients and Methods: This study was designed as a prospective parallel-arm randomized controlled trial. Patients who underwent temporary stoma following bowel surgery between February 2014 and November 2015 were included. The rate of complications (medical and surgical) following early and conventional stoma closure was assessed. Health-related QoL and LoH were also measured. Results: One hundred patients were included, with 50 cases in each group. Postoperative complications including laparostoma (6% vs. 2%;P = 0.307), wound infection (32% vs. 18%; P = 0.106), intra-abdominal collection (14% vs. 18%; P = 0.585), anastomotic leak (4%vs. 8%;P = 0.400), and medical complications were comparable (22% vs. 32%;P = 0.257). The length of hospital stay, overall mortality and morbidity (64% vs. 44%; P = 0.05) were similar across the two groups. There was a significant reduction in the cost towards stoma care (96% vs. 2%; P = 0.001) in the early stoma closure group. Patients in the early stoma closure group also had a significantly better QoL. Conclusion: Early stoma closure does not carry an increased risk of postoperative complications, reduces cost towards stoma care, and leads to better a QoL

The Diagnostic Dilemma of Ruptured Liver Metastasis in a Patient with Lung Cancer: A case report

Spontaneous rupture of a metastatic liver tumour is rarely documented in the literature when compared to hepatocellular carcinoma and other liver lesions, especially from a lung primary. We report a case of ruptured liver metastasis from an adenocarcinoma of the lung mimicking ruptured liver abscess, challenging the clinical diagnosis. A 42-year-female patient presented to a tertiary care institute in 2020 with complaints of abdominal pain, breathlessness and fever. On examination, the patient was tachypnoeic with a right hypochondriac mass. A contrast-enhanced computed tomography of abdomen and thorax revealed an ill-defined heterogeneously enhancing lesion in the liver with a communicating subcapsular collection and hypo-enhancing lesions in the left lobe and heterogeneously enhancing lesion in the left lung. Adenocarcinoma of the lung with hepatic metastasis was confirmed with a core needle biopsy. The patient was managed conservatively with intravenous antibiotics, intercostal drainage tube and gefitinib. However, despite best efforts, the patient succumbed to the disease. Keywords: Metastasis; Spontaneous Rupture; Hepatocellular Carcinoma; Thyroid Transcription Factor; Liver Abscess; Case Report; India