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Spigelian hernia is an uncommon hernia which occurs through a defect in the spigelian aponeurosis. An 84-year-old gentleman presented to us with uncomplicated bilateral spigelian hernia with bilateral direct inguinal hernia. The patient underwent an open pre-peritoneal mesh repair under spinal anesthesia. Bilateral spigelian hernia with bilateral inguinal hernia is a rare occurrence which led us to publish this case report. [ABSTRACT FROM AUTHOR]

The postbulbar segment also known as the distal duodenum is a separate clinical entity in terms of the intrinsic pathologies of this region and its varied anatomical relations. The common bile duct and the pancreatic duct open through the major papilla, which marks the beginning of this segment. Distal duodenal obstruction can be defined as a clinicoradiological entity that is characterized by features of gastric outlet obstruction with recurrent bilious vomiting and a radiological evidence of postbulbar obstruction. A Medline search for distal duodenal obstruction revealed 1409 entries, mostly in the form of case reports. In the last 10 years, 310 cases are reported. Clinical features like abdominal pain, nausea, and vomiting are non-specific and quite similar to gastric outlet obstruction. Clinical findings are also non-specific and do not aid in diagnosis. Laboratory findings also do not add much. Contrast-enhanced CT scan and MR enterography are diagnostic modalities of choice. Distal duodenal obstruction is a clinical entity that has a wide list of differential diagnosis which requires due consideration in terms of its management and follow-up. Most of these lesions require adequate workup with the help of a multidisciplinary team consisting of radiologists, gastroenterologists, and pathologists to adequately diagnose and stage the disease before a treatment plan is formulated. A thorough knowledge is a must regarding the treatment options available for each of the conditions so that the management can be personalized leading to better results. [ABSTRACT FROM AUTHOR]

Conventional hemorrhoidectomy for grade III and IV hemorrhoids is a tedious procedure associated with significant morbidity and a prolonged convalescence. We compared Ligasure™ hemorrhoidectomy with conventional 'closed' Ferguson's hemorrhoidectomy for the treatment of grade III and IV hemorrhoids. Forty-eight consecutive patients of grade III and IV hemorrhoids were randomized to either the Ligasure™ hemorrhoidectomy (28 patients) or Ferguson's hemorrhoidectomy (20 patients). The hemorrhoidal predicle was coagulated with Ligasure™ in the Ligasure™ group and transfied with 2/0 chromic catgut in Ferguson's method. In comparison with Ferguson's method, Ligasure™ hemorrhoidectomy had a shorter operating time (29 vs 12.5 min), less blood loss (22 vs 11.5 ml), less post operative pain as measured on VAS scale and less postoperative complications including hemorrhage (10% vs 3.5%), urinary retention (10% vs 3.5%) and wound breakdown (20% vs 14%). The submucosal dissection technique with Ligasure™ coagulation of the hemorrhoidal pedicle is safe and effective. The blood vessels and tissue are reduced to a wafer thin seal with good hemostasis. Suturing is not required as the mucosal tissue over the pedicle is sealed off with the current. There is minimal lateral spread of either thermal or electrical energy. The external components of the hemorrhoids can also be treated at the same time. Because of its ease of use and less postoperative pain and complication Ligasure™ hemorrhoidectomy can be preformed as a day-care procedure. [ABSTRACT FROM AUTHOR]

Objective To study the significance of nasal polyps on the symptoms of chronic rhinosinusitis (CRS) and their influence on surgical outcomes. Methods Retrospective analysis of prospectively collected data comparing two groups of patients diagnosed with CRS with and without polyps who underwent surgery with a minimum of 3 month follow up period. Subjective scoring was performed using the Sino-nasal Outcome Test (SNOT-20) questionnaire. Computed tomography (CT) scans were compared using the Lund--Mackay scoring system. Endoscopic findings were graded according to Lanza and Kennedy staging system. The two groups were analyzed for the need of revision surgery. Results 30 patients underwent surgical management of CRS over a period of one year. 20 were male, 10 were female and the average age was 26 years (range 15-55years). Polyps were present in 15 patients with CRS while, the other 15 did not have polyps. The average CT score was 10.13 for the polyp group and 9.79 for patients without polyp. The Polyp group SNOT-20 preoperative scores averaged 20.27 with improvement to 3.80 at 2 weeks, 2.67 at 1 month and 2.93 at 3 months (86.21% improvement p=0.001). Non-polyp group SNOT- 20 scores were 18.80 preoperatively with improvement to 4.67 at 2 weeks, 3.40 at 1 month and 3.27 at 3 months (81.83% improvement). Preop diagnostic endoscopy on polyp group was 5.27 which improved to 2.13 in 2 weeks, 1.33 in 1 month and 1.53 in 3 months (73% improvement). In the non polyp group it was 4.53 pre-operatively which improved to 1.20 in 2 weeks, 0.93 in 1 month and to 1.13 in 3months (69% improvement). 6 patients required revision surgery (20%), 3 (10%) belonging to polyp group and 3 (10%) who did not have polyps. Conclusion Nasal Polyp has a significant negative impact on the patients with CRS. Patients with polyps have higher symptom scores, worse objective findings compared with patients without polyp, but patients with polyp show more improvement after surgical intervention and need for revision surgery is equal in both groups. [ABSTRACT FROM AUTHOR]

The biological behavior and prognosis of breast cancer is often unpredictable with a number of factors contributing to the outcome. Nottingham's Prognostic Factor (NPI) takes into account the tumor size, nodal status, and histological grade of tumor. The receptor status considers the hormone receptor and HER2 status. The aim of the study was to correlate the NPI score with the receptor status expression in Indian women with breast cancer. A total of 78 breast cancer patients who underwent upfront modified radical mastectomy were recruited. NPI score and receptor status assessment was done at histopathological examination of the specimen. Hormone receptor negative breast cancer tended to have a higher NPI score compared to hormone receptor positive patients. However, this difference did not achieve statistical significance. NPI score parameters except for the histological grade are a reflection of the duration or time span of the tumor. On the contrary, the receptor status is indicative of the tumor biology and not of its time duration. A scoring system which incorporates the three parameters of the NPI as well as the receptor status would be the best prognostic index as well as predictive regarding the choice of adjuvant therapy. [ABSTRACT FROM AUTHOR]

Jejunojejunal intussusception with internal herniation of the stomach through a gastrojejunostomy stoma is one of the rarest complications of the previous gastric surgery. The incidence is reported to be less than 0.1 %. An elderly male presented to the emergency room with signs of intestinal obstruction for 1 day. There was also history of appearance of a lump in the mid-abdomen. A primarily healed midline scar of the previous surgery was present; the details of which were not known. X ray abdomen in the erect posture showed multiple air fluid levels. Ultrasonography (USG) revealed dilated stomach with central hyperechogenicity with a peripheral rim of decreased echogenecity. Contrast-enhanced computed tomography (CECT) scan showed jejunojejunal intussusception with internal herniation of the stomach. On laparotomy, it was found that there was a previous gastrojejunostomy with jejunal invagination leading to gangrene of a segment. Resection anastomosis was done. The postoperative period was uneventful. [ABSTRACT FROM AUTHOR]

Fibroadenomas are the most common benign breast lesions in adolescents. Fibroadenomas larger than 5 cm, weighing more than 500 g, or replacing at least 80% of the breast are termed giant fibroadenomas. Giant fibroadenomas usually warrant surgical excision as they alter the normal breast architecture. We report a case of probably the largest described bilateral juvenile giant fibroadenomas in a young 12-year-old girl managed with subcutaneous mastectomy and free nipple areola complex full thickness graft. The case highlights the rarity of disease presentation and difficulty in decision-making in selecting the best surgical option for such patients. [ABSTRACT FROM AUTHOR]

Background: Most centers use lymphoscintiscan for identification of a sentinel lymph node (SLN) and frozen section for its evaluation. The aim of the present study was to assess the accuracy of peritumoral methylene blue dye injection for SLN identification and the technique of touch imprint cytology (TIC) for its evaluation. Patients and Methods: One hundred and eight fine needle aspiration cytology (FNAC)-proven breast cancer patients with clinically N0 axilla were recruited for the study. Prior to the induction of anesthesia, 5 ml of 1% methylene blue was injected in the peritumoral region to stain the sentinel node, following which conventional modified radical mastectomy was performed. Touch imprint cytology was obtained from the cut surface of the SLN, and then the SLN along with all nonsentinel nodes were sent for histopathology. Results: Intraoperative identification of a blue node was possible in 102 of 108 patients (94%). Touch imprint cytology had a sensitivity of 88%, specificity of 98%, and overall diagnostic accuracy of 94% for diagnosing metastasis in the SLN. The false positive rate for malignancy of TIC versus histology was 2.5% and the false negative rate 7.8%. Conclusions: Blue dye lymphatic mapping by peritumoral injection of methylene blue was found to be accurate and cost effective for SLN identification. It avoids the expenses of lymphoscintiscanning, which requires special infrastructure and expertise with a significant learning curve. The identified SLN can, with reasonable accuracy, be assessed for metastasis by TIC. The frequently used method of frozen section requires a cryostat and a pathologist trained in the technique. Additionally scanty SLN tissue can be wasted in the cryostat and freezing artifacts can be introduced in the imprint, both of which are avoided by TIC. [ABSTRACT FROM AUTHOR]

An integral part of management of breast cancer is the appropriate treatment of the involved lymph nodes. While axillary nodes are always assessed and managed by sentinel node biopsy or an axillary clearance, the extra-axillary nodes do not receive equivalent attention even though they may influence staging, treatment, and prognosis. The purpose of this study was to assess the extra-axillary nodes by Doppler ultrasonogram in 228 patients with breast cancer over an 8-year period from January 2012 to January 2020. It is a case series analysis to evaluate axillary and extra-axillary lymph node basins in newly diagnosed breast cancer patients using linear array transducer ultrasonogram. It was found that while patients with T1 and T2 lesions did not have extra-axillary nodal involvement, 12% of T3 lesions (102 patients) and 50% of T4 lesions (48 patients) exhibited extra-axillary node involvement. Among the extra-axillary sites, internal mammary nodes were most often involved (24 patients) followed by infra-clavicular (8 patients) and supra-clavicular (4 patients) sites. Clinical examination by palpation could detect only the supra-clavicular nodes but was false negative in all patients who had an internal mammary or infra-clavicular node detected on ultrasound. Failure to identify internal mammary, supra-clavicular, and infra-clavicular lymph nodes can result in erroneous understaging in breast cancer patients leading to inadequate treatment and worse than anticipated prognosis. Therefore, all breast cancer patients as part of their pre-treatment protocol should undergo focused ultrasonogram evaluation of their axillary as well as extra-axillary lymph nodes. [ABSTRACT FROM AUTHOR]

Ultrasonogram-guided fine needle aspiration cytology of the axillary lymph nodes using a 7–12 MHz linear transducer was carried out on 102 breast cancer patients in whom there was no clinically palpable lymph node in the axilla. Ultrasound was able to visualize an axillary node in 55 patients (54%) while in 47 patients (46%), no node was visualized. USG-guided FNAC on the 55 patients found 9 (16%) patients to be positive for metastases, 27 (49%) to be negative, and 19 (35%) in whom an inconclusive or inadequate sample was reported. On correlation with post-modified radical mastectomy (MRM) histopathology, the preoperative USG-guided FNAC had a sensitivity of 60%, specificity of 100%, and an overall diagnostic accuracy of 58%. It can be concluded that patients with a positive for malignancy USG-guided FNAC report on the axilla should be treated as such. Patients who have a negative for malignancy or inconclusive/inadequate FNAC report or in patients in whom no axillary node is visualized on USG should undergo a sentinel node biopsy procedure for further evaluation of the axilla. [ABSTRACT FROM AUTHOR]

Evaluation of expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor 2 (HER2/neu) receptor was carried out on 80 breast cancer patients before and after neoadjuvant chemotherapy (NAC). No differences in expression were noted in 89% with reference to ER, 95% with reference to PR, and 91% with reference to HER2/neu status. A change in receptor status from positive to negative was noted in 12% for ER, 5% for PR, and 21% for HER2/neu after NAC. A negative to positive shift was noted in 11% for ER, 4% for PR, and 4% for HER2/neu after NAC. The possible reasons ascribed for change in receptor status after NAC are as follows: (1) Selection of chemoresistant clones with different receptor expression after NAC. (2) Tumor heterogeneity with variable receptor expression in different areas. (3) Ovarian suppression during NAC leading to alteration in receptor expression. (4) Technical considerations such as staining techniques and intra-observer and inter-observer differences in IHC slide interpretation before and after NAC. [ABSTRACT FROM AUTHOR]

Triple negative breast cancer (TNBC) is characterized by absence of estrogen and progesterone receptors (ER and PR) expression and lack of amplification of HER2 gene expression. It accounts for 15-20% of all breast cancer worldwide. The aim of the study was to determine the prevalence of TNBC patients visiting Surgery Department of Banaras Hindu University and correlate various clinico-pathological parameters vis-a-vis non-TNBC patients. TNBC accounted for 64/196 (32.6%) of all breast cancer patients. TNBC patients presented at a younger age (49 versus 55 years) compared to non-TNBC patients. TNBC patients had a higher chance of lymph node involvement (84 versus 75%), more grade III lesions (64 versus 50%), higher chance of lympho-vascular invasion (62.5 versus 45.5%) compared to non-TNBC patients. On follow-up of 36 months, the incidence of locoregional recurrence was 26.5% and distant metastasis 17.2% among TNBC patients compared to 16.6 and 12% respectively for non-TNBC patients. None of the TNBC patients developed bone metastasis which was seen in 7 of the non-TNBC patients. Stage for stage TNBC tumors had a worse histological profile and higher incidence of locoregional and distant metastases compared to non-TNBC patients. Although the prevalence of TNBC in our study was three times higher than reported worldwide yet their biological behavior is by and large similar to those reported worldwide. [ABSTRACT FROM AUTHOR]

The etiopathological role of human papilloma virus (HPV) in the causation of oral cancer is till a subject of speculation. We used the technique of Southern blot hybridization to detect the presence of HPV types 16 & 18 in biopsy specimens from oral cancer and leukoplakia patients as well as normal oral mucosal biopsies. The prevalence of either HPV type 16 or 18 was found in 64.5% (29/45) of oral cancer, 40%(12/30) of leukoplakia and 20%(9/45) of normal oral mucosal biopsies. No association could be demonstrated between tobacco usage habits or a history of genital warts with HPV prevalence. A significant finding was that none of the oral cancer patients were negative for both: a history of tobacco usage as well as presence of HPV infection, on Southern blot hybridization. [ABSTRACT FROM AUTHOR]

Spontaneous common bile duct (CBD) perforation is an unusual cause of acute abdomen. It is rarely suspected or correctly diagnosed preoperatively. Clinical presentation is as biliary peritonitis. The common causes are CBD calculus disease, tumors of the bile duct, choledochal cyst and sometimes idiopathic. Treatment is surgical and consists of CBD exploration and repair over a T tube. [ABSTRACT FROM AUTHOR]