Hyperhidrosis is sweating in excess than that is required for normal thermoregulation. It begins in either childhood or adolescence. Although any site on the body can be affected by hyperhidrosis, the sites most commonly affected are the palms, soles, and axillae. Hyperhidrosis exists in 3 forms: Emotionally induced hyperhidrosis (in which it affects the palms, soles, and axillae,Localized hyperhidrosis, Generalized hyperhidrosis. Hyperhidrosis often causes great emotional distress and occupational disability for the patient, regardless of the form.It affects both sexes and affects persons of all ages.In a study of 850 patients with palmar, axillary, or facial hyperhidrosis, 62% of patients reported that sweating began since before they could remember; 33%, since puberty; and 5%, during adulthood.
A team of Surgeons in the Dept of Minimally Invasive Surgery at VPS Lakeshore Hospital, Kochi, has successfully removed a cyst from inside the upper neck without any cut on the neck. This was a Thyroglossal cyst. Its a very rare keyhole surgery of its kind – first time in the state of Kerala was performed on a 30-year-old person from Wayanad.
Said Ahmad Said Al Hadidi, a 12-year-old Omani boy, presented to KIMS Cochin with severe hypertension and resultant cardiac issues. He was found on evaluation to have large tumours of the adrenal gland bilaterally. These tumours called Pheochromocytoma are rare in children, especially bilateral tumors can be very rare. The boy’s blood pressure was temporarily controlled with three types of drugs in large doses. Sudden blood pressure rises due to these tumours can cause heart attack, stroke or even sudden death.
Adrenal glands also called suprarenal glands are endocrine glands which are located above the kidneys on both sides and has got the major function of secreting a variety of hormones. The Pheochromocytoma is a neuroendocrine tumor which affects the inner layer of the gland that can lead to uncontrolled secretion of Adrenalin and nor-adrenalin which cause dangerous levels of blood pressure.
The patient was prepared for surgery by Dr Seenaj Chandran and Dr Sathyapalan. The Anesthesiology team led by Dr Rajeev took care of his vitals during this complex surgery which lasted five hours. The team was led by Laparoscopic Surgeon Dr R Padmakumar and they successfully removed the tumour on both sides completely without blood loss. Dr Madhukar Pai, Dr Khaleel, Dr Zuhail, Dr Arun and Dr Anurag were also actively involved in this major surgery as it was very high risk for patient’s life.
The patient was kept in the ICU for five days to counter the fall in blood pressure with drugs. The patient is presently doing well. It is very happy to note that even foreigners are choosing our hospitals and experts for such advanced and complex procedures opined Dr Ashok Thiakarajan, COO of KIMS Cochin. Medical Director, Dr Jose T Pappanacherry, also spoke on the occasion.
Pheochromocytoma Surgery Team
Dr. R Padmakumar, Chair- Minimally Invasive Surgery
Liposarcoma is a rare type of cancer and starts in the fat cells. Under a microscope, it resembles fat cells. It is considered to be a type of soft tissue sarcoma. Liposarcoma can affect the fat cells in any body part, but mostly occurs in the limb muscles or in the abdomen.
Symptoms of Liposarcoma
You may notice a lump that can be usually painless, but growing slowly. Unfortunately, abdominal tumors can grow to be quite large before they are found. Liposarcoma forming in the abdomen can cause abdominal pain, swelling of the abdomen, blood in the stool, constipation, feeling of fullness sooner when eating.
Types of Liposarcoma
There are four types of liposarcoma
A Case Study
82-year-old man came in with onset of pain in the abdomen since one week, inability to have food since few days, and gradually increasing abdominal distension for past six months.
On physical examination, his general condition okay, abdomen grossly distended with huge mass.
CECT (High-dose Contrast-Enhanced Computed Tomography) revealed mass extending from diaphragm to pelvis: ? Liposarcoma.
Midline laparotomy was performed, there was a huge mass in the mesentery of the large bowel. The mass was carefully separated and resected weighing 4.2 kg. There was another mass attached to the small bowel by single vessel causing torsion and obstruction of bowel. Derotation of the bowel was carried out, division of the feeding vessel was done and the mass was resected weiging 1.2 kg.
Liver nodule was taken for biopsy and biopsy report confirmed Liposarcoma
Post-op recovery was good and the patient was taking normal diet.
Three years old girl weighing only 10 kg was operated successfully through endoscopic method. Girl child hailing from Oman was suffering from a rare congenital condition called branchial cyst of second branchial cleft. The swelling had grown in such a size that she was finding it difficult to bend neck.
She was successfully treated by endoscopic surgery by a team led by Dr. R Padmakumar. The procedure was carried out through a 10 mm cut in the axilla (armpit) and nearby two 3 mm cuts. The entire swelling closely adherent to the main blood vessels (the carotid and jugular veins) and nerve to diaphragm was safely and completely removed. This kind of operation in the neck; that too for such young kid, was performed for the first time in the world. “The team’s expertise in doing endoscopic thyroidectomies for many patients really helped in successfully completing this unique procedure” said Dr. R. Padmakumar. As there is no cut in the neck child revived fast and could go back to Oman in three days time. Dr. Madhukara Pai, Dr. Mary Varghese, Dr. Shaji P.G and Dr. Sayooj Mukundan were part of this historic surgical procedure.
This is the case report of a three-year-old female Arab child who presented with a neck swelling since one year of age. Physical examination was suggestive of a 6 × 4 cm swelling in the right lateral neck, which was dumbbell shaped, deep to sternocleidomastoid muscle on either side of the muscle. Ultrasound scan revealed a large cyst with internal echoes in the right carotid space anteriorly. The cyst was dissected endoscopically by an axillary approach and complete excision was achieved, thus avoiding the need for a large incision in the neck. No complications noted after treatment. The lowest age at which branchial cyst excision was carried out endoscopically was 18 years as per the available literature. Hence this case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group.
A branchial cyst is a congenital epithelial cyst on the lateral aspect of the neck, due to failure of obliteration of branchial cleft during embryonic development. It is the most common congenital cause of a neck mass. Though congenital, it may present at a later date due to secondary infection. The definitive treatment is surgical excision of the entire cyst wall.
Presently, the principles of remote access and endoscopy are combined together and are used regularly for removal of thyroid masses. In literature there is a case report of endoscopic branchial cyst excision in a patient aged 18 years . We hereby report a case of endoscopic branchial cyst excision in a 3-year-old child via axillary approach without a neck incision. This case seems to be the first ever endoscopic branchial cyst excision in the pediatric age group.
Dr. R. Padmakumar, Dr. Madhukara Pai,Dr. Shams Farish, Dr. Jayadevan Rajeev, Dr. Thampi Sanjeev, Dr. Thekke Veetil Sreevalsan, Dr. Binu Sheetal, Dr. Yesudas Santhakumari Sooraj, Shamna Safar Rowther
*Author contributions: Padmakumar R performed surgical operation, designed the report; Pai M and Farish S contributed to the surgical operation, review of literature, data collection; Rajeev J contributed to the attending doctor for the patients (colonoscopy), editing assistance; Sanjeev T, anesthesiologist for the procedure, was responsible for the literature review; Sreevalsan TV was critical care specialist; Sheetal B and Sooraj YS were attending doctors for the patient; Rowther SS organized the report, statistics, and manuscript preparation.
We were unable to find reports in the published medical literature of any cases of bowel surgery being successfully performed at such a low hemoglobin level, without blood transfusion or blood products pre or post-surgery, with the patient’s uncomplicated recovery. This study is about such a case. A patient presenting with severe gastrointestinal bleeding was diagnosed with enteric fever and multiple ileal ulcers. He had an extremely low hemoglobin level (2 g/dL) and mild renal and hepatic impairment. He was immediately admitted for right hemicolectomy under general anesthesia though he refused transfusion of blood or blood products prior to, during, or after surgery on religious grounds (Jehovah’ s Witnesses). After the surgery and having survived these potentially life-threatening circumstances, he left the hospital without major complications. In such circumstances, lives may be saved by prompt clinical decision-making, collaboration and swift surgical intervention coupled with the immediate consultation and input of the patient and family.
It is unheard of in the medical history to take up a patient with hemoglobin of 2 g/dL for anesthesia and major bowel surgery, without transfusing blood or blood products prior to, during or after surgery; and saving the life without complications. We would like to report regarding such a patient who was treated at our hospital.
Few, if any case studies in the published medical literature report on the successful, uncomplicated surgical outcome of a patient with hemoglobin of 2 g/dL for anesthesia and major bowel surgery, without blood transfusion or blood products pre or post-surgery. Thus, we would like to report our recent experience treating such a patient at our hospital.
A 39-year-old male patient was admitted to Sunrise Hospital, Cochin, Kerala, India; after being referred from a nearby hospital [from where he left against medical advice] with a history of severe lower gastrointestinal bleeding. The diagnosis was enteric fever with bleeding from the gastrointestinal tract. Salmonella typhi “O” and “H” titer was 1/640, which was confirmed by tube agglutination test (stained febrile antigen set, Manufacturer- Span diagnostics ltd, Sachin, Surat, Gujarat, India). His hemoglobin was extremely low (4 g%) at admission. On examination, he was very pale and icteric, with a pulse rate of 120/beats per minute and blood pressure of 110/70 mmHg and mild distension of the abdomen was present. Table 1 shows the blood investigations of the patient at admission. An immediately performed colonoscopy showed multiple terminal ileal ulcerations with diffuse active bleeding that was not amenable to either colonoscopic or radiological intervention at that stage. Hence, immediate surgical intervention was planned.
It was decided as absolutely necessary to transfuse blood and blood products to correct the hemoglobin level, which had dropped to 2 g/dL within 12 h of admission. We discussed with the patient’s relatives the urgent need for blood transfusion, before proceeding with surgery to arrest the ongoing bleeding. However, the patient, his wife and other relatives were firm in their decision not to receive blood or blood products, due to their religious beliefs. Giving erythropoietin alone at that time was not an option in this patient with active bleeding. Thus, we were faced with the option of not performing the surgery at all, but at the almost certain cost of the patient’s life. Wanting to give the patient the chance to survive, it was decided to offer the patient surgery, despite his clinical condition and the treatment constraints mentioned above that make for an extremely risky surgery. The patient was prepared for laparotomy with a high-risk consent that also listed the distinct possibility of death during surgery and the continued unwillingness to receive blood or blood products.
The patient was given general anesthesia, during which minimal intravenous fluids were administered to maintain the blood pressure at 100/60 mmHg, as overhydration could lead to a further drop of in hemoglobin levels. The bowel was found to be thickened at the ileocecal region. Enterotomy was performed and linear ulcers with bleeding base were observed at the terminal ileum. Limited right hemicolectomy was performed, excising the distal 21 cm of ileum including the ulcer, cecum, appendix and a portion of ascending colon. The entire bowel was edematous,and the blood that oozed during resection appeared thin and watery. To reduce the duration of surgery, reconstruction was attempted by side-to-side ileocolic stapler anastomosis, but staplers did not hold due to bowel wall edema. Revision of anastomosis with hand-sewn, end-to-end, ileocolic two-layer suturing was performed with 3-0 Vicryl (polyglycolic acid)-continuous all coat and 3-0 silk, intermittent seromuscular.
Postoperatively, the patient was kept in the intensive care unit for 10 d with nasal oxygen to enrich the available hemoglobin with oxygen. He had features of renal and hepatic impairment, which gradually improved (Table 2). Improvement in hemoglobin level is presented in Figure 1. Total parenteral nutrition and albumin infusion were initiated. He was given intravenous ferric carboxymaltose and recombinant erythropoietin. Small doses of frusemide were given intravenously for the benefit of hemoconcentration.
The patient was put on oral fluids on the fifth day of surgery, which was gradually switched over to soft diet by the seventh day. A high protein, high calorie diet was given together with oral iron supplementation. Gradually, his hemoglobin level improved, as shown in Table 2. The biopsy report showed linear ulcers in the distal ileum, with the largest measuring 1.5 cm. Microscopy showed a mucosal ulcer infiltrated by histiocytes, lymphocytes, plasma cells and occasional neutrophils consistent with typhoid ulcer ileum. No granulomas were present.
We were unable to find reports in the published medical literature of any similar cases of bowel surgery being successfully performed at such a low hemoglobin level with the patient’s uncomplicated recovery. Various reports of surgeries performed without blood transfusion in severely anemic patients (hemoglobin level less than 5 g/dL) showed mortality of approximately 50%, which further increased to 91% in the 2 to 3 g/dL group.
Hemoglobin is the major oxygen-carrying protein in blood. Low hemoglobin level is generally defined as less than 13.5 g/dL for men and less than 12 g/dL for women. Unless it is very severe, anemia, perse, does not cause any problems with anesthesia or surgery. Severe anemia can precipitate cardiac arrest due to (1) increased cardiac output; (2) vasodilatation associated with anesthesia; and (3) hemodilution during resuscitation of hemorrhagic shock using saline. The degree of hemodilution is directly associated with acid base imbalance and is proportional to the level of compromise of metabolic recovery, which in turn is projected on to mortality. In addition, tissue hypoxia due to reduced oxygen-carrying capacity of the blood leads to end-organ damage and systemic immune response syndrome. There also is a risk of surgical site infection, delayed wound healing and bowel leak at the site of the anastomosis.
Jehovah’s Witnesses are a Christian denomination with non trinitarian beliefs distinct from mainstream Christianity and have a worldwide membership of over 7.78 million people. Their beliefs are based on interpretations of the Bible and they prefer to use their own translation. They refuse blood transfusions, which they consider to be a violation of God’s law based on their interpretation of Acts 15:28, 29. Since 1961, the willing acceptance of blood transfusion by an unrepentant member has been grounds for expulsion from the religion. Watch Tower Society literature directs Witnesses to refuse blood transfusions, even in “a life-or-death situation”. They refuse transfusions of whole blood or of any of its four primary components – red cells, white cells, platelets and plasma (serum)[7,8].
It is always a dilemma for the surgeon to decide whether to urgently operate on a bleeding patient with hemorrhagic shock without blood transfusion. We believe that life-saving interventions should not be delayed for patients with active bleeding, even though blood transfusion may be refused. Atabek and colleagues have reported a case of active bleeding in a Jehovah’s Witness patient, where early surgery led to rescue of the patient. Initial conservative treatment with delayed surgery led to a 75% mortality rate, compared with a 20% mortality rate in patients who underwent emergency surgical intervention within 24 h of admission to the hospital[10,11].
Our patient was at high-risk for cardiac arrest due to oxygen depletion, but eventually survived without complications. Anastomotic site healing was also potentially in jeopardy, but he recovered without leak.
In conclusion, even in the rarest of situations, such as the one described, a successful attempt to save the patient’s life can be made, even though the general condition of the patient is clinically unstable. Prompt decisionmaking and effective communication among the treating doctors and with the patient and his relatives were important factors that helped the patient’s positive outcome. Had the clinical team refused to perform surgery on this patient, or even delayed the operation because of his extremely low hemoglobin, death would likely have been assured.
Le T, Bhushan V, Rao D. First aid for the USMLE step 1. McGraw-Hill Medical, 2008: 597