A Case Report of Familial Medullary Carcinoma Thyroid—Seldom Seen by Surgeons Abstract Medullary thyroid carcinoma (MTC) constitutes around 5% of all thyroid cancers with a worse prognosis. It accounts for 13% of thyroid cancer–related deaths. Twenty-three-year-old male presented with 4-year history of progressively increasing thyroid swelling with similar family history. On examination, butterfly-shaped firm swelling of size 7 × 3 cm in the right and 7 × 4 cm in the left can be seen on the anterior aspect of neck with regular margins and nodular surface moving with deglutition extending from the thyroid cartilage to clavicle head and laterally beyond the sternocleidomastoid into the posterior triangle muscle. Pemberton’s sign is negative. CT neck showed enlarged both thyroid lobes with areas of cystic degeneration and 15 mm retrosternal extension of left lobe of thyroid with bilateral IB, II, and V lymphadenopathy. Serum calcitonin level was 4435 pg/ml. FNAC favoured the features of MTC. Total thyroidectomy with central compartment neck dissection was done. Intraoperative frozen sections of bilateral level III were found to be tumour-free, so proceeded with thyroid excision and central compartment neck dissection. Histopathology revealed MTC with bilateral multifocal capsular and lymphovascular invasion and metastatic foci in the right central compartment lymph node. Hence, early diagnosis in family members offers a higher likelihood of cure and long-term survival.

Purple Urine Bag Syndrome: a Rare Benign Condition Associated with Chronic Indwelling Urinary Catheter and Bacterial Infection in an Elderly Man Abstract Purple urine bag syndrome is a benign condition presenting with purple urine in a urinary bag in chronically catheterised elderly individuals. It is associated with constipation, chronic kidney disease and urinary infection with bacteria like Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Morganella morganii, Providencia, Enterococcus species and other bacteria that alkalinise the urine. Since co-occurrence of all factors is unusual, the condition is rarely encountered and rather unknown. In the aetiopathogenesis, tryptophan, an amino acid in the food, is metabolised by tryptophanase enzyme of infecting bacteria to indole. Indoxysulphate is produced from indole by hepatic conjugation and is excreted in urine. The microbes causing urinary infection that produce the enzyme indoxylsulphatase catabolise indoxysulphate to indoxyl. This in turn forms indigo, a blue substance, and indirubin, red in colour. The two mix to produce the colour purple thus accounting for purple urine. The condition is easily treatable but lack of awareness is a cause for alarm amongst the patient and the treating doctor. Thus, the present case will help create understanding of purple urine bag syndrome.

Abdominal Actinomycosis Mimicking Malignancy Abstract A 76-year-old woman presented to our emergency department with hard periumbilical mass around irreducible umbilical hernia. Abdominopelvic computed tomography scan revealed large abdominal wall tumor, adherent to the small and large intestine, with a solitary 4-cm liver lesion in the right lobe. En bloc resection including umbilical skin, rectus muscle, infiltrated jejunum, and transverse colon was made with direct closure of the abdominal wall defect. Simultaneous excision of the liver lesion was also performed. The diagnosis was made but not until histopathological analysis. It revealed chronic inflammation and the presence of Actinomyces in the abdominal mass as well as in the liver lesion. The purpose of this report is to introduce readers to the differential diagnosis of this rare disease and thus enable them to recognize findings which would lead them to interpret this condition as actinomycosis.

Patchy Necrosis of Small Bowel Abstract Sepsis, vasopressors and infective endocarditis have been usually implicated as a causative factor for small bowel ischaemia. We present intra-operative image showing multiple necrotic patches over small bowel in a patient of traumatic superior mesenteric vessel injury.

Pancreaticogastrostomy After Whipple’s Surgery Avoids Pancreatic Fistula—a Large Case Series Analysis Abstract Various modifications of the reconstruction following pancreaticoduodenectomy (PD) have been described. Pancreaticogastrostomy (PG) was first described clinically by Waugh and Clagett from the Mayo Clinic in 1946. Despite recent randomized trials and meta-analysis, the literature is still ambiguous as to which is a safer procedure. We hereby describe our experience of more than 400 pancreaticogastrostomies. The legacy of performing only pancreaticogastrostomy (PG) started by the senior author (BMLK) continued from 1977 to date in this surgical unit of a tertiary care hospital. We present the results of this case series analysis of a total of 467 Whipple’s pancreaticoduodenectomy in whom PG was performed. The mean operative time was 260.8 ± 50.3 min (180–390 min) with an average blood loss of 1068 ± 606.19 ml (400–2600 ml). None of the patients had clinically significant POPF. Thirty-five patients had postoperative bleeding out of which 12 were early and 23 had delayed hemorrhage. The most common postoperative complication was delayed gastric emptying which was seen in 96 patients (20.5%). Transient bile leak was seen in 84 patients (18%). Wound infection was seen in 70 (15%) patients. The overall 30-day mortality was 2% (10 out of 400). PG as a reconstructive technique is a safe option following PD with minimal incidence of clinically significant postoperative pancreatic fistula (POPF) as shown in our series of more than 400 patients. This is the largest series to date of pancreaticogastrostomy following PD.

Retraction Note: Failed Gastric Pull up after Esophagectomy Managed by Colonic Interposition The Editor-in-Chief is retracting this article [1] because the authors have not been able to provide documentary evidence that they obtained consent to publish from the patient whose details are described in this case report

A Rare Case of Primary Gastric Melanoma Abstract Primary melanomas in the gastrointestinal tract are extremely rare, with an estimated prevalence of 0.5 to 1 case per million. Primary mucosal melanomas of gastric origin account for approximately 1–3% of all primary melanomas in the gastrointestinal tract. We present the case of a patient who underwent surgery due to primary gastric melanoma.

Gastric Diverticulum: as a Cause of Unspecific Abdominal Pain Abstract Gastric diverticulum is the rarest type of diverticular disease of the gastrointestinal tract, ranging from 0.02 to 0.11% in different series. We report the case of a 53-year-old male patient who presented with upper abdominal pain that was associated with gastric diverticulum and cholelithiazis. There was no specific health history or family history of disease, trauma, operation and drug use. He described having epigastric abdominal pain for a few days. An endoscopic evaluation revealed a round-shaped gastric diverticulum structure. Additional imaging studies such as abdominal ultrasonography and computerized tomography diagnosed two separate pathologies as follows: multiple millimetric cholelithiazis and 16 mm in diameter, located near the esophagogastric junction, gastric diverticulum. This patient was considered as mild symptomatic cholelithiazis and asymptomatic, small gastric diverticulum. Symptomatic anti-acid treatment was prescribed.

Primary Breast Angiosarcoma: a Case Report Abstract Breast sarcomas are histologically heterogeneous group of non-epithelial malignancies arising from mesenchymal tissue of the breast. Angiosarcoma of the breast constitutes 1% of all soft tissue tumors of the breast and primary angiosarcoma is an extremely rare entity with overall incidence of 0.05% of all malignant tumors of the breast. We report a case of primary angiosarcoma of the breast in a 30 years woman, with no previous radiotherapy, treated with breast conservation therapy.

Are the operation theatres being optimally utilized? – A prospective observational study in a tertiary care public sector hospital Abstract The study aimed to analyse the utilization of the operation theatres at a tertiary care teaching hospital. An observational study with time monitoring of various processes was carried out from January to December 2016 in the OT complex of a public sector tertiary care hospital. OT complex comprised of 12 operating rooms and all the elective OTs (11) were included in the study except the emergency OT. One OT for a full day per week was observed. Selection of operation theatre and weekday for data collection was done using simple random sampling without replacement using chit system. OTs were observed for 26 days spread over a period of 6 months with resource hours of 15,000 min (250 h). A total of 129 (69.34%) surgeries out of 186 scheduled surgeries were conducted with an average of 4.61 surgeries per day and an observed cancellation rate of 30.66%. Overall raw utilization of OT was observed to be 99.29%, while overall adjusted utilization was 128.53% with an idle time of 0.81% only. Total time spent on “anaesthesia preparation” was 1624 min (8.42%), “surgical preparation time” was 1930 min (10.01%), “actual surgery time” was 9554 min (49.56%), “room set-up and room clean-up time” was 4441 min (23.04%), “surgery finish and anaesthesia finish time” was 574 min (2.98%) and “turn over time” was 1000 min (5.19%). The operation theatres are being optimally utilized, however, an effort should be made to make the ancillary processes (room set up and clean up) more efficient.