Introduction: Hip fractures have become an increasing health problem throughout the world due to an increase in the aging population [1]. Hip fracture leads to pain and immobilization with numerous complications ranging from delirium to functional loss and even death. Objective: The objective of the study was to study the morbidity and mortality associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular) and identify the cause which increases the risk of mortality in postoperative period. Materials and Methods: All patients age more than 60 years of age who underwent surgery for proximal femur fractures from July 2015 to October 2017 at our tertiary care center were studied. A total of 120 patients (70 extracapsular and 50 intracapsular fractures) were included in the study. Patients were assessed at different intervals of follow-up. Mortality was assessed and identified the cause of mortality within 1 year treatment of the hip fracture. To measure the morbidity, we studied - mobility score, dependency on walking aids and degree of residual pain. Results and Observation: In intracapsular fractures mortality was at 1 month (6%) at 6 months (14%) and 1 year (16%) and compared to the extracapsular fractures at 1 month (7%) at 6 months (14%) and 1 year (20%). The most common cause of mortality in 1st year of post-operative period being a cardiovascular disease (41%), followed by respiratory disease (23%), hepatorenal disease (14%), surgical sepsis and cerebrovascular accidents (9% each), and other causes retrauma (4%). Reduction in mobility was observed both in intracapsular fracture (preoperatively 6.78 ± 1.47-5.57 ± 1.4 at 1 year) and extracapsular fracture (preoperatively 6.57 ± 1.41-5.50 ± 1.38 at 1 year). At 1 year, it was more in case of intracapsular fracture as compared to extracapsular fracture. Conclusion: During the 1st year of post-operative period mortality is higher in cases of extracapsular fracture in comparison to intracapsular fracture. Despite the fact that intracapsular fracture was mobilized early postoperatively, they are having less mobility at 1 year point of time, comorbidity such as cardiovascular disease respiratory disease hepatorenal disease, septicemia, and cerebrovascular accident being the major cause of death in there patient.

A 13-year-old girl, who did not receive any treatment for few hours following Road Traffic Injury (RTI), reported to the Casualty Department and found to have patent airway with clinically normal C spine, air-hunger (RR 42/minute), trachea deviated to left, distended neck veins and absent breath sounds on the right side. The chest X-ray she carried, done immediately after the injury, showed right sided tension pneumothorax. She was put on oxygen at 11 L/minute and an Intercostal chest tube drainage (ICD) was inserted on right side. Her oxygen saturation (40%) failed to improve. ICD bag showed continuous bubbling and air entry remained absent on the right side. An urgent right thoracotomy was done which revealed right main bronchus tear; the tear was repaired using interrupted Prolene (R) sutures. Patient recovered well and was discharged 10 days later in a stable condition.

CECT scan is considered essential for selective non-operative management (SNOM) of patients with abdominal trauma. However, CECT has its own hazards and limitations. We evaluated the safety and efficacy of selective non-operative management of patients with abdominal trauma without the mandatory use of CECT scan in a prospective study. Patients with peritonitis and ongoing intra-abdominal bleed were excluded. Consenting FAST positive, hemodynamically stable patients with blunt and penetrating abdominal trauma between 18 and 60 years of age were included and admitted for SNOM and detailed ultrasonography of the abdomen (in all) with or without CECT abdomen (selectively). Eighty-four patients with abdominal trauma were admitted during the study period. Twenty-two patients did not satisfy the inclusion criteria and 18 required immediate laparotomy based on primary survey. Remaining 44 patients were admitted for SNOM: mean ± SD age of these patients was 27 ± 8.7 years; 40 (89 %) were males. Thirty-five patients (79.54 %) sustained blunt trauma (RTI = 16, Fall = 16, others = 3) while nine patients (20.45 %) sustained penetrating trauma. SNOM without CECT was successful in 36 (81.82 %) patients. Five (11.36 %) patients underwent delayed emergency laparotomy based on clinical and detailed USG evaluation. CECT was not done in these patients. Three patients underwent CECT for various reasons; however, they were managed with SNOM. Thus, SNOM without abdominal CECT was successful in 36 (81.82 %) patients. SNOM failed in five patients but abdominal USG was sufficient. SNOM can be practised safely in patients of abdominal trauma with limited use of CECT scan.

Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.

Context: Thoracic trauma causes significant morbidity; however, many deaths are preventable and few patients require surgery. Intercostal chest drainage (ICD) for hemo/pneumothorax is simple and effective; the main problem is residual hemothorax, which can cause lung collapse and empyema. Aims: Our study aimed to analyze the relationship between radiological chest tube parameters (position and intrathoracic length) and the frequency of residual hemothorax. Settings and Design: This prospective analytical study was conducted in a large tertiary care hospital in north India over 2 years till March 2013. Materials and Methods: Patients of chest trauma aged 18-60 years, with hemothorax or hemopneumothorax requiring ICD insertion were included in the study. Bedside ICD insertion was performed as per current standards. Immediate post-ICD chest radiographs were used to record lung status and ICD position (chest tube zone and intrapleural length). Residual hemothorax was defined as any collection identified on radiological investigations after 48 hours of ICD placement. Statistical Analysis: Univariate analysis was performed with the chi-square test or Student's t-test as appropriate, while multivariate analysis using stepwise logistic regression; a P-value < 0.05 was significant. Results: Out of 170 patients of chest trauma, 154 underwent ICD insertion. Most patients were young (mean age: 31.7 ± 12 years) males (M:F = 14:1). Ninety-seven patients (57.1%) had isolated chest injuries. Blunt trauma (n = 119; 77.3%) and motor vehicle accidents (n = 72; 46.7%) were the commonest causes. Mean hospital stay was 9 ± 3.94 days, and mortality 2/154 (1.1%). Residual hemothorax was seen in 48 (31%). No ICD zone or length was significantly associated with residual hemothorax on univariate or multivariate analysis. Conclusion: Intrapleural ICD zone or length does not affect the frequency of residual hemothorax.

BACKGROUND:Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey.However, this is not evidence-based as there has been no randomized trial. METHODS:In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST.The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment).Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS:Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group.104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing.In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237,not significant).As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST.For non-operative decisions, positive FAST was significantly better than positive DPL.DPL was significantly better than FAST in detecting as well as not missing the bowel injuries.DPL took significantly more time than FAST to perform. CONCLUSION:This study shows that DPL is better than FAST.

Introduction: Rabies is an enzootic and epizootic disease caused by a RNA virus (Genus: Lyssavirus , Family: Rhabdoviridae), is of worldwide importance, and is a practically 100 percent fatal disease even today, if not treated appropriately and in a timely fashion but easily preventable. There are many myths and false beliefs associated with animal bite and its management. This study is undertaken to highlight the factors influencing animal bite cases and practices regarding animal bites. Objective: 1. To determine the factors influencing the Animal Bite cases attending ARC, DMCH Darbhanga, Bihar. 2. To find out the practices related to animal bites among the cases attending ARC, DMCH Darbhanga, Bihar. Material and Methods : Study design: This is a hospital based descriptive cross sectional study conducted among 822 animal bite victims attended Anti Rabies Clinic, DMC Darbhanga. Duration: The duration of the study was 6 months, from May 2012 to November 2012 including data collection, data analysis and report writing. Study Population: The patients attending Anti Rabies Clinic DMCH, Darbhanga (Bihar) during the specified period. Tools: Semi structured proforma. Data Collection: The data collection was done through in-depth interviews with the animal bite victims attending OPD. Results: Animal bite cases attending ARC, Darbhanga are mostly male, Hindu, rural people those provoked the animal and they belonged to category III. Among all 9 cases were admitted with frank symptom of Hydrophobia. Conclusion: Wound toileting after a bite was lacking in most of the subjects. Many myths and false beliefs associated with animal bites and its management were present.

Skeletal metastasis as a primary presentation of gall bladder carcinoma is rare. A 50-year-old lady presented with neck pain and weakness in her right upper limb of 3 months duration. Clinical and imaging work-up suggested locally advanced gall bladder carcinoma with metastasis to cervical vertebra and sternum. Only one case till date has been reported where the patient presented with neurological symptoms due to pathological fracture secondary to metastasis from an occult gall bladder carcinoma. Although rare, an occult gall bladder cancer may present with neurological symptoms due to pathological fracture of spine secondary to metastasis. We present a brief review of literature of patients who presented with skeletal metastases in clinically silent gall bladder malignancy. Palliative care issues in advanced gall bladder carcinoma have also been discussed.

Trocar site hernias (TSH) is a rare but potentially dangerous complication of laparoscopic surgery. It’s incidence is approximately 0.477% [1]. Among TSH, omental herniation is very rare [2]. We report two cases of omental herniation through the laparoscopic port sites.

CONTEXT:Veress needle insertion (VNI) at sub-umbilical fold (SUF) midline is associated with serious intra-abdominal injuries. AIM:The aim of this study has been to evaluate the safety and efficacy of lower left intercostal space (LICS) for VNI. SETTINGS AND DESIGN:This prospective observational study was conducted in three parts in Surgery-II, Department of Surgery, GTBH-UCMS, Delhi. MATERIALS AND METHODS:In part one, skin fold thickness (SFT) was measured in 32 patients at SUF, LICS, right iliac fossa (RIF) and Palmer's point. As part two, in these patients, VNI was carried out from LICS under laparoscopic guidance. As part three, same technique of VNI was employed in 43 patients with suspected intra-abdominal adhesions undergoing laparoscopy for various reasons. Observations were made regarding ease of insertion, attempts needed for successful entry, loudness or clarity of give-way feeling of Veress needle, intra-abdominal bleeding at point of emergence of Veress needle, hemopneumothorax, bowel or vascular injury. STATISTICAL ANALYSIS USED:SFT was expressed as mean (SD), and one-way ANOVA followed by Tukey's test were employed to find the statistical significance. RESULTS:SFT at LICS was significantly less as compared to SUF and Palmer's point. VNI at LICS was easy to carry out; it could be successfully done in first attempt in all patients, and was associated with very clear and loud give-way feeling. There were no instances of intra-abdominal bleeding at point of emergence of Veress needle, hemopneumothorax, bowel or vascular injury. CONCLUSIONS:VNI at LICS as described here is safe and effective.

Gastrointestinal stromal tumors (GIST) are mesenchymal tumors occurring anywhere along the gastrointestinal tract and are believed to originate from the interstitial cells of Cajal. They commonly arise in the stomach or small intestine. The usual growth pattern is exophytic invading adjacent organs or perforation into the peritoneal cavity which may result in bleeding or obstructive symptoms. Intussusception and obstruction is a very uncommon presentation of these lesions because of their tendency to grow in an extraluminal fashion. We report an unusual case of 59 yrs old man presenting with acute small bowel obstruction, which on exploration was found to be due to ileo-ileal intussusception and the lead point of intussusception was a tumor, which was histologically diagnosed as GIST.

Biliary cystadenoma (BCA) and cystadenocarcinoma are rare cystic tumours arising from the biliary epithelium. Their location is usually intrahepatic and they are characterized by large multiloculated macroscopic lesions. They rarely communicate with the biliary ductal system. Clinical features of biliary cystadenoma, due to its rarity, have been sparsely investigated, mostly from both surgical and radiological aspects. There have been fewer than 150 case reports of biliary cystadenoma and fewer than 50 cases of biliary cystadenocarcinoma in the literature so far.

Anaplastic thyroid carcinoma (ATC) is a rare and highly aggressive thyroid neoplasm. Bleeding from tumor is an uncommon, but potentially life-threatening complication requiring sophisticated intervention facilities which are not usually available at odd hours in emergency. We report the case of a 45-year-old woman who presented with exsanguinating hemorrhage from ATC and was treated by emergency total thyroidectomy. The patient is well three months postoperatively. Emergency total thyroidectomy is a viable option for palliation in ATC presenting with bleeding.

Emphysematous gastritis is a rapidly fatal and rare type of infectious gastritis. It may lead to involvement of esophagus, and organ necrosis, in its severe form. A 16-year-old, previously healthy, boy presenting with acute abdomen was diagnosed to have emphysematous gastritis on CT scan. During laparotomy, there was complete necrosis of the stomach, with patchy esophageal involvement. Aggressive management in the form of total gastrectomy, and later, transthoracic esophagectomy was done. However, it failed to alter the course of the illness, and the patient succumbed to the illness. Emphysematous gastritis is rare in young patients without known risk factors. Also, only two previous cases have been reported with esophageal involvement. We have presented this case with a brief review of literature.

INTRODUCTION:Traumatic hernia of the abdominal wall is a rare entity. A large proportion of reported cases are in children with a particular type of injury, i.e. from a handlebar injury. In adults, the presentation can vary substantially and the diagnosis is difficult. We present two cases in adults, with widely varying presentations and management.CASE PRESENTATIONS:A 40-year-old woman from rural north India presented with a low-velocity blunt injury to the lower abdomen. She was attacked by a bull. She had a clinically evident abdominal fascial disruption with intact skin, and was hemodynamically stable. An emergency mesh repair of the defect was performed, and she recovered well. A 38-year-old man from rural north India presented with blunt trauma to the abdomen following a motor vehicle accident. He was stable, with a central abdominal parietal wall swelling and bruising. A computed tomography scan revealed herniation of bowel loops in the area with minor intra-abdominal injuries. A laparotomy, resection-anastomosis of the ischemic bowel, and primary repair of the defect was performed and he recovered well.CONCLUSION:Following blunt abdominal trauma, particularly high-velocity injuries, a high index of suspicion must be reserved for parietal wall swellings, as missed hernias in this setting have a high risk of strangulation. Computed tomography is the best aid to diagnosis. Management of each case needs to be individualized.

CONTEXT:Diffuse serous cystadenomas of the pancreas are extremely rare, with only 8 cases reported previously, and have been associated with neuroendocrine tumors in only two patients. Some have been seen in von Hippel-Lindau disease. The management of these tumors poses a challenge due to their rarity and uncertain malignant potential. We report a case of diffuse serous cystadenoma associated with neuroendocrine carcinoma in a 35-year-old woman.CASE REPORT:A 35-year-old woman with mild abdominal pain was diagnosed as having a cystic pancreatic mass on ultrasonography. On contrast-enhanced CT scan, MRI and MRCP imaging, a spongy lesion was found to replace the entire pancreas, and was diagnosed as diffuse serous cystadenoma. Serum biochemistry for amylase, lipase, CA 19-9 and CEA was normal. Screening for retinal and CNS lesions was also unremarkable. A total pancreatectomy was performed, and the patient recovered well. Histopathological examination of the specimen revealed microcysts and macrocysts replacing the entire pancreas, the largest being 3.5 cm. The cysts were lined with a single layer of cuboidal to flattened cells. An endocrine tumor abutting the cystic component was found, having neoplastic cells in a trabecular pattern. Metastasis of the neuroendocrine component was seen in the adherent lymph nodes. A diagnosis of diffuse serous cystadenoma associated with neuroendocrine carcinoma was made.CONCLUSION:Diffuse serous cystadenomas of the pancreas are extremely rare tumors. In young patients, they may harbour associated malignancy, and may be the first presentation of von Hippel-Lindau disease. Aggressive surgical resection with long-term follow-up may be worthwhile in this group of patients.

Background: Balloon dissectors (BD) find their use in totally extraperitoneal (TEP) and retroperitoneoscopic procedures. Commercial BD is prohibitively expensive. The author uses an indigenously assembled BD and describes the same. Material and Methods: The author assembles the BD by tying glove-fingers on an NG tube and then tying this assembly in the concavity of a Kelly′s clamp, premounted with peanut gauze (KC-BD). Results: The author has used it in the last 75 cases of TEP. A large working space is created, without any iatrogenic injuries or balloon rupture. This cheap indigenous BD can be assembled easily and in no time at all. Conclusions: KC-BD offers several advantages because of its unique design. It is effective, totally nontraumatic, inexpensive, and easy to assemble.

BACKGROUND:Appendiceal mass may be treated in several ways. However, no randomized trial has been conducted to find the best option.OBJECTIVE:To compare the three most commonly used methods for treating appendiceal mass.METHODS:Over a three-year period, 60 consecutive patients with appendiceal mass were randomly allocated to three groups: Group A--initial conservative treatment followed by interval appendectomy six weeks later; Group B--appendectomy as soon as appendiceal mass resolved using conservative means; Group C--conservative treatment alone. Short-term outcome measures included operative time, operative difficulty, postoperative complications, length of hospital stay, and duration of time away from work. Long-term outcome measures were: number of hospital visits made, presence of severe incisional pain, scar appearance, and patients with recurrent appendicitis.RESULTS:Baseline characteristics were comparable in the three groups. In patients in Group A, operative time was less, adhesions were encountered less frequently, the incision had to be extended less often and post-operative complications were fewer, as compared to Group B. Patients in Group C had the shortest hospital stay and duration of work-days lost; only 2 of 20 patients in this group developed recurrent appendicitis during a follow-up period of 24-52 (median 33.5) months.CONCLUSION:Of the three treatment modalities compared, conservative treatment without subsequent appendectomy appears to be the best.