Notes

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The surgical approach of such patients is somewhat similar to those with situs solitus; however, the performing surgeon must take into consideration the anatomical orientation. Proper assessment of such patients prior to surgery with history, full physical examination, and fitting imaging modalities is essential.
Rectovaginal fistula (RVF) is a refractory complication that occurs after anastomotic leakage following low anterior resection for rectal disease. Due to its refractory nature, RVF is often managed with surgical treatment, such as stoma creation for fecal diversion, closure of the fistula and/or re-anastomosis, rather than conservative therapy.

A 72-year-old woman who underwent laparoscopic low anterior resection developed RVF on post-operative day (POD) 15. check details Conservative therapy with the administration of estriol and total parenteral nutrition was started. In addition, a polyglycolic acid (PGA) sheet was inserted into the fistula using colonoscopy, and fibrin glue was applied. However, this treatment with the PGA sheet and fibrin glue seemed to be unsuccessful. Therefore, an operation for simple closure of the RVF was performed on POD47. The PGA sheet was then removed, and primary closure of the RVF from both sides of the rectum and vagina was performed. Following re-operation, solid food with low dietary fiber content was started on original POD55 (POD14 after re-operation), and the dietary fiber content was gradually increased. The patient was discharged from the hospital on original POD 83 (re-operation POD42).

The administration of estrogen might result in increased vaginal compliance, decreased vaginal pH, increased vaginal blood flow and improved lubrication. Therefore, vaginal suture was made possible because the vaginal extensibility was restored.

Primary closure of the RVF following administration of estriol may be an effective treatment.
Primary closure of the RVF following administration of estriol may be an effective treatment.
Splenic artery embolization (SAE) is an accepted intervention for patients with traumatic injury AAST III-IV in hemodynamically stable patients, splenic artery aneurysm and pseudoaneurysm (Brian and Charles, 2012). Unusual circumstances may pose different challenges in individual cases.

A 52-year-old male on anticoagulants for past mitral valve replacement presented to us with history of blunt trauma sustained a month prior, was found to have grade IV splenic injury with delayed pseudo-aneurysmal rupture. In addition, his cardiac evaluation revealed an ejection fraction of 20%. A potential life threatening unstable cardiac status and hemodynamic irregularities accentuated due to the hemoperitoneum was an unusual challenge to deal with. After initial stabilization in ICU, the option of distal embolization of splenic artery was undertaken in a well-planned manner.

Unstable cardiac condition, anticoagulant therapy and delayed pseudo aneurysmal bleed led us into undertaking this procedure as a semi-emergency with calculated risks. We discuss this case due to the complexities and dilemmas on various aspects which we faced in his management.

Patient tolerated the procedure well and was discharged on the third day of embolization. Our experience taught us the judicious implementation of a viable and only lifesaving option for an otherwise inoperable patient due to multiple co-morbidities and would strongly recommend this interventional radiological, relatively innocuous procedure for salvaging such patients.
Patient tolerated the procedure well and was discharged on the third day of embolization. Our experience taught us the judicious implementation of a viable and only lifesaving option for an otherwise inoperable patient due to multiple co-morbidities and would strongly recommend this interventional radiological, relatively innocuous procedure for salvaging such patients.
Isolated complete pancreatic transection following blunt trauma abdomen is associated with very high mortality. Conservative management in such a scenario is a rare experience. Majority of the patients with American Association for Surgery of Trauma (AAST) grade III or IV pancreatic injury are treated with surgical options and have poor outcomes. As per the available literature we are reporting a rare case of isolated AAST grade III pancreatic injury managed conservatively in adult.

A 37-year-old female presented with complaints of severe epigastric pain with the alleged history of domestic violence. CECT of the patient suggested isolated pancreatic injury with complete transection of pancreas. Considering the clinical and hemodynamic status of the patient a trial of conservative management was started. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.

Operative procedures in patients with high grade pancreatic injury are associated with high risk of mortality and morbidity. Emergency surgeries can be avoided in patient with stable clinical and haemodynamic status. In selected cases decision on the basis of radiology may lead to unnecessary surgeries, whereas conservative approach may have better outcomes.

Tailored approach in cases of high-grade pancreatic injury will augment the decision taking between operative and non-operative management. Clinical and haemodynamic status should play a pivotal role and radiology should be used as an adjunct for deciding the management.
Tailored approach in cases of high-grade pancreatic injury will augment the decision taking between operative and non-operative management. Clinical and haemodynamic status should play a pivotal role and radiology should be used as an adjunct for deciding the management.
Musculoskeletal tuberculosis (TB) is a rare variant of the disease. Involvement of the chest wall is even rarer. This paper aims to report a case of primary chest wall TB mimicking gynecomastia.

An 11-year-old male presented with gradual left breast enlargement for one year duration, clinically diagnosed as a case of gynecomastia. On examination; there was a firm swelling involving left anterior chest wall elevating the nipple and areolar region. Ultrasound showed thick wall cystic lesion with internal debris and bone erosion. Computed tomography scan (CT scan) of the chest revealed a cystic lesion containing fluid with a similar cystic lesion in the substernal area. Under general anesthesia, through an anterolateral incision, a thick wall cystic lesion with a very thick pus content was found connecting to another similar lesion in the anterior mediastinum with a localized thickening of the pleura. Both of the lesions, and the fifth rib with a part of the fourth rib were resected and sent for histopathological examination which revealed multiple granulomas with caseating material, typical for tuberculosis.
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