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A female patient in her early sixties had problems of recurrent syncopal attacks and panic attacks over the last 5 years. She had been initially managed for an anxiety disorder with psychiatric medications. During one of those episodes, she was brought to our hospital in an unconscious state with a low blood sugar level of 43 mg/dL. She was suspected to have a neuroendocrine tumour and diagnosis was established by supervised fasting up to 72 hours and imaging. Her recorded blood sugar during fasting was 37 mg/dL. She underwent surgery and presently remains asymptomatic. Physicians should have a high suspicion of insulinoma in patients presenting with repeated episodes of hypoglycaemic symptoms in the absence of any cognizable cause.

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Anastomosing hemangioma (AH) are rare mesenchymal neoplasms affecting kidney with about 50 cases reported in English literature. In general, they are accidentally detected during examination or imaging done for nonspecific symptoms or wellness check-up. There are no key diagnostic features on the imaging modalities. The most common preoperative diagnosis has been a malignant primary renal carcinoma. Surgical resection remains the mainstay of treatment and of choice in symptomatic lesions. We are presenting a rare case of giant AH of the kidney mimicking a renal cell carcinoma on imaging. The lesions are characterized by anastomosing sinusoidal-like vascular spaces lined by banal endothelial cells with occasional hobnail morphology and associated with extramedullary hematopoiesis. The treatment of choice could be a conservative approach in small and asymptomatic lesions and patients with pre-existing renal dysfunction; hence, this entity should be in the differential of vascular renal neoplasms considering its proclivity to the urogenital tract. This is the first case in Indian literature to the best of our knowledge.

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The study aims to compare open intersphincteric resection (OISR) with laparoscopic intersphincteric resection (LISR) in terms of short-term oncological and clinical outcomes. This is a retrospective review of a prospectively maintained database including all the patients of rectal cancer who underwent intersphincteric resection (ISR) at Tata Memorial Centre between 1st July 2013 and 30th November 2015. Short-term oncological parameters evaluated included circumferential resection margin involvement (CRM), distal resection margin involvement, and number of nodes harvested. Perioperative outcomes included blood loss, length of hospital stay and 30-day postoperative morbidity and mortality. Chi-square test was used to compare the results between the two groups. Thirty nine cases of OISR and 34 cases of LISR were included in the study. Median BMI was higher in LISR group; otherwise, the two groups were comparable in all aspects. There were no conversions in LISR group. CRM involvement was seen in four patients (10%) in the conventional group compared to none in the LISR group. Median hospital stay was comparable between the two groups. Laparoscopic ISR is safe and can be performed with low conversion rate in selected group of patients.

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Perforative peritonitis is the most common surgical emergency in general surgical practice. Gastrointestinal perforation is the etiology in the vast majority of the patients. However, occasionally, other rare causes may be encountered. One such cause of peritonitis is spontaneous perforation of non-gravid uterus. Uterine perforation is a potential complication of any intrauterine procedure and may be associated with injury to surrounding blood vessels or viscera such as the urinary bladder or intestine. Spontaneous uterine perforation is rare and less than 50 cases have been reported in the English literature. We are presenting two such cases of spontaneous perforation of the uterus in elderly postmenopausal women which presented with generalized peritonitis and were clinically indistinguishable from gastrointestinal perforation.

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BACKGROUND: Peritoneal carcinomatosis (PC) from colorectal cancers (CRC) either at initial presentation or at subsequent recurrence presents a significant treatment challenge. The aim of our study was to find its incidence and analyze outcomes of patients with PC from CRC origin managed by different treatment modalities. PATIENTS AND METHODS: A retrospective analysis of patients, from August 2013 to July 2014, presenting with metastatic peritoneal disease from CRC with or without metastasis to other sites was performed. PC was classified as limited (peritoneal carcinomatosis index [PCI] < 10) and widespread (PCI > 10). RESULTS: This study included 70 patients; 45 patients had peritoneum as the only site of metastasis and the remaining 25 visceral metastasis with peritoneum. Resections were performed in 23 patients (19 underwent R0 resection and 4 were R+). All patients received systemic chemotherapy (FOLFOX [Oxaliplatin with fluorouracil and folinic acid]/CAPOX [oxaliplatin and capecitabine]). At a median follow-up of 11 months, the median OS was 14 months. Patients with PCI < 10 had significantly better survival (median not reached) as compared with those with PCI > 10 (15 months). Patients undergoing R0 resection had better survival (24 months) versus those with R+ resection (16 months). The survival of patients receiving only systemic chemotherapy was 11 months. CONCLUSION: The incidence of peritoneal metastasis in CRC is about 10%. A select group of patients who have low PCI who undergo R0 resection of only the diseased portion, without entire peritonectomy, still do well. Where facilities for hyperthermic intraperitoneal chemotherapy are not available, cytoreduction followed by systemic chemotherapy should be considered. The added role of hyperthermic intraperitoneal chemotherapy in this subgroup needs to be evaluated.

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BACKGROUND: Locally advanced rectal cancers (LARCs) involve one or more of the adjacent organs in upto 10-20% patients. The cause of the adhesions may be inflammatory or neoplastic, and the exact causes cannot be determined pre- or intra-operatively. To achieve complete resection, partial or total mesorectal excision (TME) en bloc with the involved organs is essential. The primary objective of this study is to determine short-term oncological and clinical outcomes in these patients undergoing multivisceral resections (MVRs). METHODS: This is a retrospective review of a prospectively maintained database. Between 1 July 2013 and 31 May 2015, all patients undergoing MVRs for adenocarcinoma of the rectum were identified from this database. All patients who had en bloc resection of an adjacent organ or part of an adjacent organ were included. Those with unresectable metastatic disease after neoadjuvant therapy were excluded. RESULTS: Fifty-four patients were included in the study. Median age of the patients was 43 years. Mucinous histology was detected in 29.6% patients, and signet ring cell adenocarcinoma was found in 24.1% patients. Neoadjuvant therapy was given in 83.4% patients. R0 resection was achieved in 87% patients. Five-year overall survival (OS) was 70% for the entire cohort of population. CONCLUSIONS: In Indian subcontinent, MVRs in young patients with high proportion of signet ring cell adenocarcinomas based on magnetic resonance imaging (MRI) of response assessment (MRI 2) is associated with similar circumferential resection margin (CRM) involvement and similar adjacent organ involvement as the western patients who are older and surgery is being planned on MRI 1 (baseline pelvis). However, longer follow-up is needed to confirm noninferiority of oncological outcomes.

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BACKGROUND: To compare extra levator abdomino perineal resection (ELAPER) with conventional abdominoperineal resection (APER) in terms of short-term oncological and clinical outcomes. METHODS: This is a retrospective review of a prospectively maintained database including all the patients of rectal cancer who underwent APER at Tata Memorial Center between July 1, 2013, and January 31, 2015. Short-term oncological parameters evaluated included circumferential resection margin involvement (CRM), tumor site perforation, and number of nodes harvested. Peri operative outcomes included blood loss, length of hospital stay, postoperative perineal wound complications, and 30-day mortality. The χ(2)-test was used to compare the results between the two groups. RESULTS: Forty-two cases of ELAPER and 78 cases of conventional APER were included in the study. Levator involvement was significantly higher in the ELAPER compared with the conventional group; otherwise, the two groups were comparable in all the aspects. CRM involvement was seen in seven patients (8.9%) in the conventional group compared with three patients (7.14%) in the ELAPER group. Median hospital stay was significantly longer with ELAPER. The univariate analysis of the factors influencing CRM positivity did not show any significance. CONCLUSIONS: ELAPER should be the preferred approach for low rectal tumors with involvement of levators. For those cases in which levators are not involved, as shown in preoperative magnetic resonance imaging (MRI), the current evidence is insufficient to recommend ELAPER over conventional APER. This stresses the importance of preoperative MRI in determining the best approach for an individual patient.

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Schwannomas are benign nerve sheath tumours arising from Schwann cells. Presacral schwannomas are rare with only case report and short case series being reported in literature. Complete surgical resection is the treatment of choice for these rare tumours. Approach to surgical resection depends on the type of the tumour. Type 3 tumours have conventionally been treated with open intra or extra peritoneal approach. With improvement in the laparoscopic surgical skills, more and more complex surgical procedures have been attempted via this approach. We are presenting a case of presacral schwannoma in an overweight lady treated by laparoscopic resection.

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BACKGROUND: Primary objective was to determine if sphincter preservation is possible with the use of neoadjuvant imatinib in cases of rectal gastrointestinal stromal tumor (GIST). Secondary objectives were to determine clinicopathological characteristics and intermediate term oncological outcomes of the cases of rectal GIST. METHODS: This is a retrospective review of 13 cases of GIST of the rectum diagnosed between January 1, 2010 and June 30, 2015 at Tata Memorial Centre, Mumbai, India. Clinical parameters that were assessed were duration of the neoadjuvant imatinib therapy, type of surgery performed as well as perioperative morbidity. Pathological parameters that were assessed included the size of the tumor, completeness of resection, mitotic count and mutational analysis. RESULTS: Of the 13 patients included, 11 were nonmetastatic at the time of presentation. All the patients received neoadjuvant imatinib in view of locally advanced nature of the tumors. Median distance from anal verge was 2 cm. Median duration of imatinib was 9 months. Of the 9 patients who underwent surgery, three had sphincter preserving surgery (33%) whereas the rest had abdomino-perineal resection. Two patients had perineal wound infections. All the operated patients received adjuvant imatinib therapy for 3 years. Median follow up period was 34 months. One patient developed distant metastasis; otherwise rest had no local or distant recurrence. CONCLUSIONS: In cases of rectal GIST, sphincter preservation may not be possible in spite of neoadjuvant therapy with imatinib.

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The primary objective of this study was to determine whether sphincter preservation is possible among patients who develop anastomotic leakage after rectal cancer surgery. The secondary objective was to determine the factors that may contribute to anastomotic leakage. This is a retrospective review of a prospectively maintained database. All patients with rectal cancer who underwent restorative proctectomy over 1 year were included in the study. The parameters analyzed were age, preoperative hemoglobin and albumin, neoadjuvant therapy, type of surgery, level of ligation of inferior mesenteric pedicle, technique of anastomosis, and defunctioning proximal stoma. In this study, 176 cases of anterior resection were included,of which15 (8.5 %) had anastomotic leakage. None of the factors contributing to anastomotic leakage reached statistical significance on univariate analysis. Among the patients who had proximal defunctioning ileostomy (n = 9), five (56 %) required re-surgery whereas other four were managed with antibiotics and presacral drainage alone (44 %). Among the patients who didnot have proximal defunctioning ileostomy (n = 6), all (100 %) required re-surgery. Among the 12 eligible patients, stoma reversal was successful in eight (67 %) patients. This study highlights the importance of defunctioning proximal stoma in reducing the incidence and severity of anastomotic leakage as well as the need and extent of re-surgery for low rectal cancer. Sphincter preservation is possible in majority of patients who develop anastomotic leakage after rectal cancer surgery.

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Complete surgical resection remains the primary goal of rectal cancer surgeries. However, in 10%-20% patients, rectal tumors invade adjacent pelvic organs and resection of such organs is essential to achieve an R0 resection. Seminal vesicle is the most commonly involved organ in males. Although laparoscopic surgery has been found to be safe and feasible for rectal cancer surgeries, multivisceral resection is considered complex, and hence majority of these patients are offered open surgical resection. However, with improved surgical expertise as well as better laparoscopic equipment, surgeons have been attempting more complex rectal surgeries through the laparoscopic approach. We are delineating the technical details as well as initial results of laparoscopic total mesorectal excision with enbloc resection of seminal vesicle.

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Gut malrotation is a congenital anomaly characterized by either lack of rotation or incomplete rotation of gut around axis of superior mesenteric artery. Most patients present within first year of life. Presentation during adult life is considered rare. Diagnosis of intestinal malrotation during adult life is most often by chance rather than by clinical acumen. Once diagnosed, treatment is based on the general principles of management of intestinal obstruction. We are presenting one such case in which CECT abdomen done to look for the diagnosis of acute pancreatitis leads us to the identification of intestinal malrotation.

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Cervical lymphadenopathy is one of the common presentations in present day surgical practise. The causes may vary from gastrointestinal malignancy indicating a grave prognosis to nonspecfic lymphadenopathy secondary to infection or trauma to the extremity which is self-limiting. Diagnosis most often requires contributions from pathologist as well as radiologist in addition to a detailed clinical examination. We are presenting a case of Kikuchi's disease which mimics tuberculosis and often leads to diagnostic dilemma.

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The incidence of rectal cancer in India is on the rise, and unlike in the West, predominantly younger individuals are affected. Surgery for rectal cancer has evolved over the years with the ultimate goals of sphincter preservation and better quality of life, besides oncological safety. With the routine use of magnetic resonance imaging for local staging, intersphincteric resection has become a viable alternative to abdominoperineal resection. Similarly, there is enough evidence to consider laparoscopic surgery as feasible and oncologically safe for rectal cancer. Thus laparoscopic intersphincteric resection fulfills all the objectives of modern-day rectal cancer surgery. Here we describe the technical points while performing the surgery as well as short-term results of our own series.

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INTRODUCTION: The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario. MATERIAL AND METHODS: All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay. RESULTS: Thirty-three patients with low rectal cancer and a median age of 38 years underwent ISR during the defined study period. Twenty-three patients (70 %) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300 mL and 7 days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes. CONCLUSIONS: Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

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Rectovaginal fistula [RVF] is a devastating complication of anterior resection whose incidence worldwide is on a rise with widespread use of staplers for the rectal anastomosis. It is a special surgical challenge for the treating surgeon with limited suitable options available to treat this difficult situation. As there is no consensus on its management, most often patient ends up with permanent stoma and overall inferior quality of life. We are presenting a case of post anterior resection RVF which was treated with intersphincteric resection followed by hand sewn coloanal anastomosis. An intersphincteric resection avoids dissection in a previously violated rectovaginal plane and improves chances of sphincter preservation. A well vascularized colonic graft with hand sewn coloanal anastomoses well below the site of fistula and omental interposition further avoids the chances of recurrence of fistula.

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Solitary adrenal metastasis from colorectal cancer is rare with reported incidence from 3.1% to 14.4% in the literature. Conventionally, adrenal metastasis is considered as indicative of widespread systemic disease and hence treated with palliative intent. Surgical resection remains controversial although a median survival of 32 months was found in the largest reported case series. It has been postulated that surgical resection should be offered when the adrenal metastasis develops more than 6 months after the treatment of the primary tumor. For the metastatic lesions and potentially malignant lesions, role of minimally invasive surgery is still considered controversial. We are presenting a case of metachronous, solitary adrenal metastasis from sigmoid colon carcinoma treated surgically with curative intent.

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Head injury is an important cause of mortality worldwide as the head is the most vulnerable part of the body involved in fatal road traffic accidents. The present study was undertaken on 682 victims of road traffic accidents who died due to injuries sustained to the head, which were autopsied at District Wenlock Hospital, Mangalore over a period of 5 years between January 1999 and December 2003. Most of the accidents had taken place during the afternoon and evening hours (1400-2200 h). There was a marked male preponderance (84.6%). The most vulnerable age group was found to be between 21 and 30 years. Two wheeler occupants were most commonly involved. Skull fractures were present in 88.88% of the cases. Fractures of the vault were found in 88%, base of the skull in 35.97% and a combination of both in 35% of cases. In most of the cases, fissured fractures were found (23%). Among intra-cranial haemorrhages, subdural haemorrhage was found in 52.63% and subarachnoid haemorrhage in 27.27% of cases. Contusions and lacerations of brain were found equally in 35% of cases.

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