Linear Tear Research Articles

Traumatic gallbladder rupture in a 9-year-old child

We present gallbladder rupture following trauma. A 9-year-old boy admitted in 1.5 hours after injury. Considering clinical and ultrasound data, we diagnosed traumatic damage to the spleen and hemoperitoneum, biliary dyskinesia, cholestasis, sludge. Hemostatic therapy was carried out. After 3 days, signs of peritonitis appeared. Follow-up ultrasound revealed gallbladder enlargement with heterogeneous content, fluid in all parts of abdominal cavity. Intraoperatively, the gallbladder was enveloped in omentum soaked in bile. After mobilization of the gallbladder, we found longitudinal linear tear up to 3 cm clogged with omentum. Cholecystectomy was performed. Thus, we present a patient with combined injury and damage to the spleen. However, gallbladder wall thickening and heterogeneous content were interpreted as concomitant pathology. Delayed manifestation of peritonitis was due to gallbladder enveloped in omentum. The last one soaked in bile partially entered the gallbladder through perforation and prevented bile leakage into abdominal cavity. Timely diagnosis of gallbladder damage presents certain difficulties, especially in case of combined injury. Ultrasound signs of traumatic gallbladder rupture in this case were wall thickening, heterogeneous content and gradual gallbladder enlargement. It is necessary to analyze all organs at the damage site including computed tomography in patients with combined trauma.

Mallory-Weiss Syndrome with Oesophageal Tear: A Case Report

A 67-year-old male patient presented to the hospital with complaints of mild-grade fever, gradually progressive cough, and frequent episodes of vomiting. The initial diagnosis was acute gastritis with severe dehydration. The patient had a medical history of Type 2 Diabetes Mellitus (T2DM) for 2 years and Hypertension (HTN) for 20 years, for which he was already receiving treatment. Due to continuous bleeding, an urgent endoscopy was performed, revealing a linear tear in the mucous membrane of the oesophageal region, leading to a diagnosis of Mallory-Weiss Syndrome (MWS). The patient was treated with antibiotics, antipyretics, antiemetics, and antacids. Subsequently, The patient was symptomatically improved, leading to his discharge from the hospital. Keywords: Mallory Weiss Syndrome (MWS), Hypertension (HTN), Type 2 Diabetes Mellitus (T2DM)

A COMPARATIVE STUDY OF LATERAL SPHINCTEROTOMY AND 2% DILTIAZEM GEL LOCAL APPLICATION IN THE TREATMENT OF FISSURE IN ANO

troduction: Anal ssure is a non-healing linear tear in the distal anal mucosa below the dentate line and is a painful entity.Fissure in ano is a common proctologic disease affecting both men and womenparticularly young.They require surgery like manual anal dilation or lateral internal sphincterotomy which heal the ssure in more than 90% cases but with a signicant risk of impaired anal continence. Newer non surgical therapies such as topical 2% diltiazem gel, have shown good efcacy without impairing anal continence. The aim of the study is to compare the AIMefcacy of outcome of Lateral Sphincterotomy Versus 2% Diltiazem gel in the treatment of chronic ssure in ano. 70 Material and Methods: patients diagnosed with ssure in ano were randomly divided into 2 %Diltiazem and lateral sphincterotomy groups. Patient were followed up at regular interval for symptomatic relief and healing of ssure. Less 89.4% patients Result: in diltiazem group and 100% of patients in lateral internal sphicterotomy group ssure healed completely between 4-8 weeks. In the diltiazem group pain relief was fairly good. 42 patients (89.4%) had pain relief at the end of 14 weeks. But the pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks. Mild headache was experienced with diltiazem patients.1 patient complained of atus incontinence with lateral internal sphincterotomy. We conclude that lateral sphincterotomy is the gold standard t Conclusion: reatment for the ssure in ano but chemical sphincterotomy using 2% topical diltiazem gel can be considered a good second line treatment option in those unt for surgery or for those not willing for surgery

A Portable, Vacuum-Operated, and Purely Mechanical Device for Extracting Feces by Suction to Cure Chronic Anal Fissures

Abstract An anal fissure is a common anorectal problem that affects men and women of all age groups. It initiates with an acute stage that presents as a linear or oval tear in the anoderm and may progress to a more complex chronic stage due to poor healing. Routine defecation causes overstretching of the injured anoderm which deepens the injury resulting in hypertonicty and ischemia, setting up a positive feedback loop that keeps the fissure from healing. Existing treatments can be invasive, expensive, and may include side effects. Here we present a novel vacuum-operated mechanical device to extract feces via suction. The device is designed to solve the problem of anodermal stretching by assisting in defecation. The device was tested in vitro on a benchtop model of the rectum and in vivo on live pigs. in vitro tests showed that the device could hold vacuum pressures for 12 h with negligible leakage. Further, the device could extract simulated human feces at a flowrate of 32 mL/s. in vivo tests on pigs showed that the device did not cause any trauma to the rectal wall, thus demonstrating its safety. Our results highlight the potential of this novel platform to circumvent the problem of anodermal stretching and improve the healing rate of anal fissures.

Anal Fissure: A Strong Treatment 15 Years of Evidence

Anal fissure is a very common disease and is defined as a linear tear or injury or ulcer, involving the anoderm perpendicular to the pectineal area at the edge of the anus. Anal fissure is classified as acute, less than 6 weeks duration of symptoms and chronic with a time greater than this. The objective is to describe the experience of the results obtained from the surgical treatment of chronic anal fissure in four different hospitals, second and third level care. Material and methods: it is described as a study with a retrospective, longitudinal, observational and descriptive design, with the presentation of the results carried out through descriptive biostatistical procedures. The results were 2,728 surgical procedures of fistulectomy with open lateral internal sphincterotomy, which were 1,853 women (68%) and 875 men (32%). With an age range of 17 to 81 years. No recurrence or surgical reintervention was documented, no patient readmission was reported 30 days after surgery, and there was no mortality. Discussion: the treatment of chronic anal fissure is multiple and varied, in the first place general management measures should be initiated, the use of multiple topics, chemical sphincterotomy, as well as surgical management with many of its variants. In conclusion, fissurectomy with open lateral internal sphincterotomy with a 33% cut of the internal anal sphincter achieves a high rate of success in healing, zero complications and no recurrence, with level II scientific evidence in regard to international medical literature.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures.

Per operatory finding of spontaneous rupture of the spleen: a case report

Spontaneous rupture of the spleen is an uncommon cause of haemoperitoneum. The diagnosis is difficult especially in premenopausal patient. We report a case of patient operated with an indication of ruptured ectopic pregnancy and whose peroperatory finding was a rupture of the spleen instead at the Centre Hospitalier Dominicain Saint Martin de Porrès, Yaoundé – Cameroon. She was a 28 years old, brought on consultation with acute abdominal pain, without amenorrhoea nor per vaginal bleeding. On physical examination, there was tachycardia and abdominal tenderness. The pregnancy test was negative and the pelvic ultrasound was relevant with a suspected ruptured ectopic pregnancy. We performed a laparotomy. The peroperatory findings were a haemoperitoneum and a linear tear of spleen capsule. We did a splenectomy and the post operatory follow up was unremarkable.

Spontaneous Intracranial Hypotension

(N Engl J Med. 2021;385:2173–2178) Spontaneous intracranial hypotension presents as below-normal cerebrospinal fluid (CSF) due to CSF leakage from an unknown cause. While spontaneous intracranial hypotension is treatable, it is difficult to diagnose. Imaging has identified 3 types of spontaneous spinal CSF leaks: linear tear in the dura posterolateral or ventral to the spinal cord; diffuse dilatations of the dural sac or leakage at the simple meningeal diverticula; or the space between the CSF-venous fistulas and proximal veins. It is estimated that spontaneous intracranial hypotension occurs in 4 to 5 cases per 100,000 population.

Value Assessment of Local Treatment (Diltiazem Hydrochloride gel/vs Glycerile Trinitrite ointment) in acute Anal Fissure

Background: Anal fissure is a linear tear in the distal anal canal, associated with spasm of internal anal sphincter. Acute anal pain with bleeding on defecation are the main symptoms. Different types of chemical treatment to relax the sphincteric muscles have tried. Objective: Assess the efficacy, side effects and recurrence rate of 0.2% glycerile trinitrate ointment (GTN) and 2% diltiazim hydrochloride gel (DTZ) in treatment of acute anal fissure. Methods: A prospective randomized trial of 112 patient with acute anal fissure over 1.5 years period at Al-Kindy Teaching Hospital. The diagnosis was entirely clinical. Setting of inclusion and exclusion criteria, ethical consideration respected.

Outcomes of Fissurectomy and Advancement Flap in Management of Chronic Anal Fissure

Chronic anal fissure is a painful linear tear in the mucocutaneous junction of the distal part of the analcanal and involves the full thickness of mucosa, causing severe pain may last even hours after defecation.Usually,it occurs along the midline either anterior or posterior,if it presents off the midline, other pathologymight be associated with. Unhealed anal fissure after 6-8 weeks is defined chronic, with the presence of othercriteria,it unlikely heals with medical treatment, and surgery is mandatory after pharmacological treatmentfailure. Lateral internal sphincterotomy had high healing rate, but unfortunately, with risk of incontinence.Fissurectomywithcomplete excision of the fissure keeping the internal anal sphincter intact,and anadvancement flap of well vascularized tissue is transferred to cover the base of fissure and improve healing.This study mainly aiming to analyze the outcome of fissurectomy with advancement flap procedure in thetreatment of chronic anal fissure and highlight its advantage in terms of healing rate and complicationsespecially anal incontinence.During a period of about 5 years 345 patients (260 males and 85 females), havebeen included in this study and were diagnosed as cases of chronic anal fissure. After administration of localanesthetic,fissurectomywith advanced flap was performed. Patients had been followed up regularly for 6-24months. Data collected and statistical analysesby using SPSS. About 75% ofpatients were males while, 25% were females, their ages were between 20-59 year, most of the patients werein thirties, nevertheless most of the females were in twenties.Mean time for wound healing was 10 days.Whilst complete fissure healing process lasting approximately one month. About 11.9% of the patients takemore than one month to complete healing process. Healing rate was 100% after the follow up period of 6-24months. Recurrence developed only in 2% of the patients. None of the patients developed incontinence,anal stenosis, key hole deformity, necrosis or urine retention. From this study concluded Fissurectomy withadvancement flap in the treatment of chronic anal fissure is cost effective procedure, can be done under LAwith least time-off work, with low complication, low recurrence,and no incontinence.

Prevalence Rate and Clinical Features of Fissure-in-Ano in a Private Surgical Clinic in Al-Diwaniyah Province, Iraq

Background: One of the most frequent causes of anal discomfort and pain is fissure in ano in which there isa linear tear in the squamous epithelium that lines the anal canal at location distal to dentate line. The diseaseis encountered in both male and female gender and no age is immune particularly middle age and youngage. Little is known about the prevalence rate and clinical presentation in our community of Al-DiwaniyahProvince, Iraq.Aim of the Study: The current study was aiming at identifying the prevalence and clinical Presentation ofFissure-in-Ano in a Private Surgical Clinic in Al-Diwaniyah Province, Iraq.Patients and Method: The current cross sectional study was carried out at a private surgical clinic in AlDiwaniyah Province, Iraq. The study duration extended from January the 2nd 2019 to December the 31st2019.During this period patients with an age between 20-60 years were enrolled based on their clinicalpresentation of an anorectal problem. Any patient with previous anal surgery, with malignant disorder,pregnancy or lactation was excluded from the study. All enrolled patients were examined by digital rectalexamination and proctoscopic examination. Sigmoidoscopy and colonoscopy were done as required.Result: The study included a total of 314 patients with anorectal complaint of whom 78 patients had fissurein ano making the prevalence rate as 24.8 %. Those patients with anal fissure were categorized into 57(73.1%) males and 21 (26.9%) females. Most patients were between 31-40 years of age and the mean ageof all patients was 34.98±7.81 years and the range was 20-60 years. Most of fissures were located in theposterior midline location and the minority of them was seen in an anterior midline location. The majorityof patients had acute disease and the minority of them had chronic disease with some having sentinel pile.Conclusion: It has been shown therefore, that anal fissure is a common problem in our community and thatyoung age and middle age men are the target of majority of cases. The clinical features vary according toage and gender

The Swimmers

The Swimmers Walt Hunter 1 This September morning it was snowing in Denver.I told you that I dreamed my face was being liftedoff my face. You told me that you couldn’t find your hat.The whirling wicker houses full of dreamshave never been ours, but the basements look the same:putting the lid down on the washer, turning the dialunder the bare bulb. The light falls where it canand makes a house we live in while the light lasts.It’s true what Jennifer said this morning on the docks:the shepherds in the ancient pastoral, unhoused, say “nevertheless”and share a meal together before parting.To have such sorwe and be not ded—a car honksto get us out of the way. And a pair of girls, faces masked,are running fast as they can down Harmony Street, towards the Sound. 2 Bobbing in the water talking to Ken about ChaucerI hold my hand up to block the sudden glareand go down under the chop.Our friends are swimming longer distancesnow that the days for swimming are almost over.What have I done the last twenty yearsbesides come to know you? First with laughterand deflection, then with anger and loss,now with truth hanging in the afternoonover our heads, and whispering somethingthat we strain to hear. There were yearsI thought I knew that language, sent backevery signal with my own reply. But now [End Page 170] it’s just me coming out of the water towards you,the day after the storm, when the surface moveswith the weeds and wrack, billowing up from the rocks. 3 This is the first evening when the summer changes,the water from the fog hangs onthe telephone lines. A full moon scabs and heals.The light is more hospitable to shadow now.The leaves record the intervals of wind,the light-strewn leaves and cigarette buttshere outside the United Church of Stonington.Last night Jonathan stopped talkingand pointed at the seabirds breaking piecesoff the harbor. Later, after everyone had gone,while coming up the stairs, I thought I heardthe swallows, but when I looked it wasthe blue and calmless sky, unbroken. 4 Never having wanted to be so thoughtless, neverso hopeless, never having wanted to drive thesenorthern distances without you, never havingto risk the end of myself, the ruin of the houseI kept inside my mind for you, the ruin of my mind,the linear tear the sky makes through itselfwhile the world burns, the ruin of the worldto shivering jets of toxin where Joannajerks her leg up from the murk. It could have beenthe algae. It could have been the warmth sending us outeach day, then into separate houses when the sunsetpiles its glamor into the table like a mirror and it willhave been the air that sabled the pine, the elm, the oak,the lawn, the air itself, the aim of the trail of the boat’swake. Endlessly the lights in houses flicker and come on. [End Page 171] 5 Alone on the deck, I watch for signs of lifein the cupola windows. It’s the panic hour:I can see my heartlessness in the ashen skythat’s neither ash nor cloud but somethingof pure temperature. I know that if I waitit will dissolve. The day slumps in a linefrom Westerly to Old Mystic, fracturing the current.But it makes a brightness anyway. You and Igrew up unnoticed on our front lawns, waitingfor the past to change to weather. Now the past is over.Walking under the mountains, you’re so far from herethat I’ve mistaken clouds for the snow falling.None of the things I ever asked you for you couldn’t do.I watch the trees grow dark with night, but slowly. [End Page 172] Copyright © 2021 Walt Hunter

Utility of Ultrasound in the Evaluation of Chronic Anal Fissure

Introduction: Anal fissure is a linear tear in the anal mucosa seen distal to the dentate line. The diagnosis of chronic anal fissure depends on clinical history, physical exam, anoscopy and other imaging modalities are uncommonly recommended unless an associated condition was suspected. Management is either by chemical sphincterotomy or surgery through lateral internal sphincterotomy when chronic anal fissure was resistant to treatment. Purpose of the Study: The current study aimed to evaluate the sonographic findings that can be observed in cases with chronic anal fissure and their significance. Methodology: 15 asymptomatic patients and 30 patients with chronic anal fissure were examined with 3 dimensional transperineal ultrasound and if females an additional transvaginal ultrasound was performed. Results: 26 patients (86.5%) showed diffusely thickened internal anal sphincter of mean thickness >3.5mm, ranging from 3.7 mm to 6.4mm and the mean value was 5mm. 3 patients (10%) with posterior fissure showed a lucent narrow defect in the internal anal sphincter at the midline of the distal aspect of the anal canal wall. One of them showed associated localized intersphincteric plane sepsis. Conclusion: Use of ultrasound in cases with chronic anal fissure may show gapping of the internal anal sphincter and an associated intersphincteric plane sepsis corresponding to the high morphological grade of anal fissure which predict poor healing response to chemical sphincterotomy and further studies that correlate between the thickness and texture of IAS and the healing response to chemical sphincterotomy recommended.

A comparison of efficacy between 0.2% of topical glyceryl trinitrate and lateral anal sphincterotomy

Background: Anal fissure is a linear tear in the lining of the anal canal below the dentate line. Among the conservative modalities glyceryl trinitrate (GTN) is emerging as first line of treatment since it breaks the vicious cycle and relaxes the sphincter. Surgery was considered as the first line of treatment if conservative measures such as bulk laxatives, stool softeners and local anaesthetics fail. Aim of this study was to study the aetiology and predisposing factors, age and sex distribution, clinical presentation, position of fissure, complications associated with medical and surgical management and comparison of efficacy of topical GTN (0.2%) and lateral anal sphincterotomy.Methods: The study was based on analysis of 60 patients who were treated for chronic fissure in ano at Malla Reddy Institute of Medical Sciences, Hyderabad from January 2018 to February 2020. Patients were divided into 2 groups. One group was managed by topical application of the ointment and other group was managed by surgery (lateral anal sphincterotomy). Statistical tool (software) used to analyse the data was SPSS 13.0 software.Results: Around 33.33% patients who were managed medically by 0.2% glyceryl trinitrate did not have relief of symptoms. Patients under surgical management had more relief of symptoms (86.6%). Almost all patients treated with glyceryl trinitrate had some form of headache. During the immediate post-operative period 13.3% patients treated with surgery had pain.Conclusions: It can be concluded that open lateral anal sphincterotomy is superior to topical 0.2% GTN with high rate of healing and very low rate of complications.

Dural Injury in Unilateral Biportal Endoscopic Spinal Surgery.

Study Design:Retrospective study.Objectives:Unilateral biportal endoscopic surgery (UBES) is a popular surgical method used to treat degenerative spinal diseases because of its merits, such as reduced tissue damage and outstanding visual capacity. However, dural injury is the most common complication of UBES with an incidence rate of 1.9% to 5.8%. The purpose of this study was to analyze the pattern of dural injury during UBES and to report the clinical course.Methods:We retrospectively reviewed the medical and radiographic records of surgically treated patients who underwent UBES at a single institute between January 2018 and December 2019.Results:Fifty-three patients, representing 67 segments, underwent UBES. Seven dural injuries occurred, and the incidence rate was 13.2%. Among 16 far lateral approaches, 2 dural injuries of the exiting roots occurred and were treated with fibrin sealant reinforcement. Among 51 median approaches, dural injury occurred at the thecal sac (n = 3) and traversing root (n = 2). A dural injury of the shoulder of the traversing root was treated with a fibrin sealant; however, a defect in the thecal sac required a revision for reconstruction. The other 2 thecal sac injuries were directly repaired via microscopic surgery.Conclusions:Dural injury during UBES can occur because of the various anatomical features of the meningo-vertebral ligaments. Direct repair of the central dural defect should be considered under microscopic vision. A linear tear in the lateral dura or root can be controlled with a simple patchy reinforcement under endoscopic vision.

Parameter Estimation for Evaporation-Driven Tear Film Thinning.

Many parameters affect tear film thickness and fluorescent intensity distributions over time; exact values or ranges for some are not well known. We conduct parameter estimation by fitting to fluorescent intensity data recorded from normal subjects' tear films. The fitting is done with thin film fluid dynamics models that are nonlinear partial differential equation models for the thickness, osmolarity and fluorescein concentration of the tear film for circular (spot) or linear (streak) tear film breakup. The corresponding fluorescent intensity is computed from the tear film thickness and fluorescein concentration. The least squares error between computed and experimental fluorescent intensity determines the parameters. The results vary across subjects and trials. The optimal values for variables that cannot be measured in vivo within tear film breakup often fall within accepted experimental ranges for related tear film dynamics; however, some instances suggest that a wider range of parameter values may be acceptable.

Recovery from hemorrhoids and anal fissure without surgery.

An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF. A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors. Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05). Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.

Traumatic Diaphragmatic Hernia

Traumatic diaphragmatic hernia (TDH) is uncommon and it can be a result from both blunt and penetrating trauma. About to 1% to 7% of patients with blunt trauma sustained TDH. Left sided traumatic diaphragmatic hernia are much common compared to right side.TDH can present acutely or delayed with signs of respiratory distress of intestinal obstruction. The diagnosis was made with the aid of chest radiograph and computed topography (CT) abdomen. A coiled nasogastric tube within the hemithorax is a pathognomonic for TDH. We are presenting a case of high impact injury resulting in a TDH in a 19-year-old, malay male with unsure mechanism injury. He presented with generalised abdominal pain and in respiratory distress with a clinical evidence of abdominal tenderness and type 1 respiratory failure. Subsequently, he underwent exploratory laparotomy and repair of left diaphragmatic hernia. Intraoperatively, noted large linear tear of left hemidiaphragm posterolaterally extending medially until the insertion of falciform ligament. Stomach, left lobe of liver, spleen and splenic flexure of colon were herniated into the left hemithorax. The left diaphragmatic tear was repaired in 2 layers using prolene. A left subdiaphgramatic drain and a chest tube were inserted. Post operatively, the patient was nursed in ICU and recovered well. Repeated chest x -ray showed left lung was fully expanded. With aggressive chest physiotherapy and incentive spirometry, he recovered well and was discharged home. In trauma, there should be a high index of suspicion in patients with both respiratory and abdominal symptoms. Conclusion: Prompt recognition and early definitive management can improve patient outcomes.

Use of 3D printing to create a bespoke repair of a Percutaneous Endoscopic Gastrostomy (PEG) tube in patient unfit for surgical replacement

We report a case of three-dimensional (3D) printing being used to solve a difficult bedside clinical problem and avoidance of substantial risk associated with alternative solutions. A 15-year-old male with...

Tennis Leg: A Unique “Strain”, Management Approach and Review of the Literature

The term tennis leg is often used to denote any pathology resulting from acute injury to the medial head of the gastrocnemius muscle. Management of such cases is usually conservative, with scarce evidence in the literature describing cases of surgical intervention for such patients. Authors performing surgical repair, have done so for complete ruptures of the medial gastrocnemius head, usually in the acute setting. In these cases reported outcomes have been encouraging. As our imaging capabilities evolve variations in the exact pathoanatomy denoting clinic tennis leg are now emerging. We present a unique case of a linear type myotendinous tear affecting the medial head of the gastrocnemius muscle in a 45-year-old athletic patient. Following failed conservative measures, we describe an approach to management in the non-acute setting, which successfully resulted in resolution of our patient’s symptoms and return to competitive activities. We also address the evidence available within the literature regarding the management options available for tennis leg.