Rectal Bleeding: A Rare Complication of Abdominal Pregnancy

EDITORIAL COMMENT: We accepted this case report for publication not only because of its rare anecdotal interest, which is considerable, but also since it will warn readers that rectal bleeding in pregnancy may result from an abdominal pregnancy. It is strange that the ultrasonograph seems not to have identified the calcification as a fetus although we are not told that the latter was macerated or misshapen. The editor has never seen or heard of an ectopic pregnancy causing rectal erosion and bleeding although he has reported a primary abdominal pregnancy in which the placenta was implanted on the peritoneum of the pouch of Douglas posteriorly (A); this woman presented at 23 weeks' gestation when retroplacental haemorrhage resulted in a haematoma that bulged into the vagina causing acute urinary retention. One wonders why the placenta did not erode the anterior rectal wall in this more advanced case of primary placental implantment in the pouch of Douglas.
Summary: A rare case of abdominal pregnancy, causing massive rectal bleeding due to invasion of the rectal wall by the placenta, is reported.     

Radiotherapy with or without mitomycin c in the treatment of locally advanced head and neck cancer: results of the IAEA multicentre randomised trial.

BACKGROUND AND PURPOSE: Single agent mitomycin c (MMC) has been shown to improve the outcome of radiotherapy in single institution trials. In order to confirm these findings in a broader worldwide setting, the International Atomic Energy Agency (IAEA) initiated a multicentre trial randomising between radiotherapy alone versus radiotherapy plus MMC. MATERIAL AND METHODS: Patients with advanced head and neck cancer were treated with primary curative radiotherapy (66 Gy in 33 fractions with five fractions per week) +/-a single injection (15 mg/m(2)) of MMC at the end of the first week of radiotherapy. Stratification parameters were tumour localization, T-stage, N-stage, and institution. A total of 558 patients were recruited in the trial from February 1996 to December 1999. Insufficient accrual and reporting led to the exclusion of three centres. The final study population consisted of 478 patients from seven centres. Patients had stage III (n=223) or stage IV (n=255) squamous cell carcinoma of the oral cavity (n=230), oropharynx (n=140), hypopharynx (n=65) or larynx (n=43). Prognostic factors like age, gender, site, size, differentiation and stage were well balanced between the two arms. RESULTS: The haematological side effects of MMC were very modest (<5% grade 3-4) and did not require any specific interventions. Furthermore, MMC did not enhance the incidence or severity of acute and late radiation side effects. Confluent mucositis and dry skin desquamation was common, occurring in 56% and 62% of patients, respectively. The overall 3-year primary locoregional tumour control, disease-specific and overall survival rates were 19, 36 and 30%, respectively. Gender, haemoglobin drop, tumour site, tumour and nodal stage were significant parameters for loco-regional tumour control. There was no significant effect of MMC on locoregional control or survival, except for the 161 N0 patients, where MMC resulted in a better loco-regional control (3-year estimate 16% vs. 29%, P=0.01). CONCLUSIONS: The study did not show any major influence of MMC on loco-regional tumour control, survival or morbidity after primary radiotherapy in stage III-IV head and neck cancer except in N0 patients where loco-regional control was significantly improved.     

Particulate pollution in Ulaanbaatar, Mongolia

The World Health Organization (WHO) listed the air pollution in Ulaanbaatar (Mongolia) among the top 5 cities with the worst air quality in the world. Air quality in the winter season reaches highs of 750 μg/m³ for daily average fine particulates (PM) due to increased coal combustion and lower mixing heights (<200 m), coupled with the city’s geography surrounded by mountains, which further restricts the vertical and horizontal dispersion of the pollutants. The annual average concentrations in 2010–2011 ranged 136?±?114 μg/m³ (the WHO guideline for fine PM is 10 μg/m³). The single largest source of particulate pollution in Ulaanbaatar is coal and biomass combustion in households and heat-only boilers, followed by power plants. In this paper, we present sector-specific emissions for 2010 accounting for 62,000 tons of fine PM, 55,000 tons of sulfur dioxide, and 89,000 tons of nitrogen oxide emissions. The inventory is spatially disaggregated at 0.01° resolution on a GIS platform for use in a chemical transport model (ATMoS). The modeled concentrations for the urban area ranged 153?±?70 μg/m³, when overlaid on gridded population, resulted in estimated 1,000–1,500 premature deaths per year due to outdoor air pollution. This study also highlights the linkages between indoor and outdoor air pollution. In these harsh temperate conditions, with 50 % of the emissions originating from Ger households, they are as big a health risk for indoor air quality as they are for outdoor air quality. Any intervention improving combustion efficiency or providing clean fuel for these stoves will have a combined benefit for indoor air quality, outdoor air quality, and climate policy. The analysis shows that aggressive pollution control measures are imperative to protect the population in Ulaanbaatar from excess exposure levels, and implementation of control measures like the introduction of heat efficient stoves, clean coal for heating boilers, and urban transport planning will result in significant health benefits, which surpass any costs of institutional, technical, and economic interventions.     

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy

BackgroundBalloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV].Materials and methodsStudy consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0–4. Outcome of BMV was correlated with commissural score and Wilkins score.ResultsThe commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3–4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0–2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3–4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result.ConclusionsA higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.     

Hepaticoduodenostomy versus hepaticojejunostomy after resection of choledochal cyst: A systematic review and meta-analysis

Background

Excision has been established as a standard management practice for choledochal cysts in the last few decades. The two most commonly performed methods of reconstruction after excision are hepaticoduodenostomy (HD) and Roux-en-Y hepaticojejunostomy (HJ), of which the HJ is favored by most surgeons. Evidence concerning the optimal method of reconstruction is, however, sparse.

Materials and Methods

Studies comparing outcomes from HD and HJ after choledochal cyst excision were identified by searching Medline, Ovid, Search Medica, Elsevier Clinicalkey, Google Scholar and Cochrane library. Suitable studies were chosen and data extracted for meta-analysis. Outcomes evaluated included operative time, hospital stay and incidence of postoperative bile leak, cholangitis, reflux/gastritis, anastomotic stricture, bleeding, intestinal obstruction and re-operative rate. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables.

Results

Six retrospective studies were included in this meta-analysis, comprising a total of 679 patients, 412 of whom (60.7%) underwent HD, and the remainder, 267(39.3%) underwent HJ. Although, HD group had slightly shorter hospital stay (MD: 0.30; 95% CI: −0.22–0.39; P < 0.00001) it showed a higher incidence of postoperative reflux/gastritis (OR: 0.08; 95% CI: − 0.02–0.39; P = 0.002). However, the other outcomes such as bile leak, cholangitis, anastomotic stricture, bleeding, operative time, reoperation rate and adhesive intestinal obstruction did not differ between HD and HJ groups.

Conclusions

HD shows higher postoperative reflux/gastritis than HJ but a shorter hospital stay. There are few good-quality studies that compare the outcomes from HD and HJ, meaning that caution should be exercised in the generalization of the results of this meta-analysis, which suggests HD to be comparable with HJ in terms of other complications, operative benefits and outcomes.     

Gossypiboma Presenting as Coloduodenal Fistula – Report of a Rare Case With Review of Literature

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.Key words: Surgical sponges, Intestinal fistula, Multidetector computed tomographyThe first report of a coloduodenal fistula was by Haldane in 1862, and it was malignant from the hepatic flexure.¹ Coloduodenal fistula is caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease, but isolated coloduodenal fistula due to gossypiboma has not been reported in the literature to the best of our knowledge. Gossypiboma is known to present as intra-abdominal abscess, intestinal obstruction, and fistulization, but coloduodenal fistula has not been reported as a mode of presentation. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.