Gastrointestinal Pathology

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This document is a 14-chapter textbook on surgical pathology of the gastrointestinal tract written by Dr. Ketan Vagholkar. The chapters cover various diseases and conditions that affect the esophagus, stomach, small intestine, and colon, including carcinomas, ulcers, tuberculosis, diverticulitis, hemorrhoids, and more. The textbook provides an overview of the clinical presentation, diagnosis, and treatment of common gastrointestinal surgical diseases.

Gesundheit & Medizin

Surgical Pathology of the
Gastrointestinal Tract-I
by

Dr. Ketan Vagholkar
MS, DNB, MRCS, FACS
Consultant General Surgeon
&
Professor of Surgery

1

Surgical Pathology of the
Gastrointestinal Tract-II
by

Dr. Ketan Vagholkar
MS, DNB, MRCS, FACS
Consultant General Surgeon
&
Professor of Surgery

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Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for other age groups is advisable.

LITTRE’S HERNIA: A SURGICAL DILEMMA

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Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.

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Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management thereby reducing the morbidity and mortality associated with the disease.

Deep Vein Thrombosis

KETAN VAGHOLKAR

Background: Fluid collection in a femoral hernia sac designated as a femorocele is an extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and one case of bilateral femorocele have been reported in English literature. Objective: Thus making the case presented the second case of bilateral femorocele in English literature. Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease who had undergone dual valvular replacement with ascites due to cardiac cirrhosis is presented to highlight the surgical challenges in management of such a rare case. Discussion: Pathophysiology, clinical features, investigations and managemeny of femorocele are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is diagnostic. Open surgery in the form of dissection of sac with high ligation followed by obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.

Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...

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Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia. Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.

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Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.

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Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

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Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a great challenge to the attending surgeon. There are various variants of embryological abnormality of the processes vaginalis manifesting in different forms. Understanding the embryological development of the processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical option for treating these rare cases.

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Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical intervention in the form of debridement and desloughing followed by wound care is the next line of management. Patient education at the time of discharge is necessary for prevention of recurrence.

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Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.

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Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma patients. Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage. Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.

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KETAN VAGHOLKAR

Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair. Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the mainstay of surgical treatment.

ABDOMINAL WALL PSEUDOCYST COMPLICATING INCISIONAL HERNIA REPAIR

KETAN VAGHOLKAR

Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar hernia. He had a severe two wheeler accident. Following the accident he had undergone various surgical interventions for a fractured pelvis with a deglowing injury involving the right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia for which he had undergone open mesh repair. Subsequently he developed recurrence of the post traumatic right-sided lumbar hernia. After complete investigation he underwent open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles. They were double-breasted to cover the mesh. Postoperative outcome was excellent with no recurrence for the last six months. Discussion: The various anatomical and technical considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion: Bone fixation of the mesh with bone anchors is a viable option especially in cases where there is severe attenuation of adjacent muscles for mesh fixation.

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...

KETAN VAGHOLKAR

Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention. As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes. In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure. 10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic cholecystectomy is a safe and viable option for treating acute calculous cholecystitis

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...

KETAN VAGHOLKAR

Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.

Giant lipoma over the back

KETAN VAGHOLKAR

Background: Appendicectomy is one of the common procedures performed by a general surgeon. However, the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised 25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure for appendicectomy.

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical intervention for complications is the mainstay of treatment.

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed by clinical and radiological investigations were included in the study and studied prospectively. On admission to the hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented in an advanced stage developed complications. The majority of patients were males. The interval between the onset of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process, were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication. Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.

PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...

KETAN VAGHOLKAR

Background: Skin approximation is a very important step in a surgical operation. The quality of skin approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications. Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation). The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation) had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction. Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.

COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...

KETAN VAGHOLKAR

Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively. Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60 years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B. The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic requirement, early commencement of oral feeds, and shorter duration of hospitalization

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