Sanoop Koshy Zachariah

Urachal cysts (UCs) are rare congenital anomalies, especially in adults. They often mimic a variety of intra-abdominal pathologies, making the diagnosis difficult. Laparotomy and excision of the cyst along with the umbilicus has been the traditional technique. A 33-year-old female presented with painful umbilical swelling. A CT scan was suggestive of a UC. We performed an umbilicus-preserving laparoscopic excision of the cyst. We describe this rare case and review literature related to the surgical treatment of UCs.

Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted. This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018. A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28–66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4–10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0–1, 22.7% for those who had scores of 2–3, 46.8% for those who had scores of 4–5, and 86.7% for those who have scores of 7–8. The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Internal hernias are rare cases of small intestinal obstruction of which Right Paraduodenal hernias through the Fossa of Waldeyer occur only in less than a quarter of all cases. A high index of suspicion and a good understanding about the pathological anatomy is pertinent for the detection and successful management of this condition which has non-specific symptomatology. The gold standard of diagnosis is computed tomography scan, which shows characteristic findings. Surgical correction is often necessary as mortality rates hover above 50% in unintervened cases. Here we present very rare case of an obstructed right paraduodenal hernia which presented as an abdominal mass.

Ganglion cysts (GCs) are one of the most common benign cystic lesions that commonly arise from joints of the wrist. The diagnosis is usually straightforward in these situations. Nevertheless, they have been reported to rarely arise in certain unusual anatomic locations leading to diagnostic difficulties. Here we report an atypical presentation of a ganglion cyst within the gastrocnemius muscle. To the best of our knowledge this is the second case of histologically proven intramuscular ganglion cyst presenting within the gastrocnemius muscle, to be reported in literature.

Background: Our aim was to determine the usefulness of hepatic transaminases as hematological markers to predict the presence and severity of liver injury in adult patients with abdominal trauma.Methods: This is a retrospective study of patients admitted with abdominal trauma (blunt and penetrating) over a three-year period. Grading of liver injury was based on CT-scan or surgical findings. Patients in whom liver enzymes were estimated in the first 48 hours were included.Results: Out of the 66 patients in the study, 23 (63.89%) patients had minor liver injuries, while 13 (36.11%) had major liver injuries. Injury was blunt in 63 (95.45%) and penetrating in 3 (4.54%) patients. The mortality rate was 7.57% (n=5). The median SGOT and SGPT levels in the liver injury group were higher than those in the non-liver injury group SGOT (209LI vs. 43.5) U/L and SGPT (283.22 vs. 72.97) U/L, respectively, (p=0.001). Receiver operating characteristic (ROC) curve assessment, showed the optimum SGOT and SGPT thresholds to be >112.5 and >120.5U/L respectively, which were strongly associated with the presence of liver injuries. There was significant correlation between liver transaminases with grade of liver injury, SGOT (p=0.013) and SGPT (p=0.004).Conclusions: SGOT and SGPT values >112.5 and >120.5U/L respectively, are strongly suggestive of liver injury. Hepatic transaminases are useful screening hematological markers for liver injuries and should be included in the initial trauma blood test panel and may guide in the decision making especially in medical centers with limited facilities.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.