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· WEEKLY BULLETIN OF SURGERY AND ALLIED SPECIALITIES· ISSUE III

THE TRIVIA
THEATRE
THE “EINSTEIN SIGN”
The famous physicist-Albert Einstein
suffered from abdominal aortic aneurysm.
He was operated upon by Dr Rudolph
Nissen (a fellow German, who escaped to
the US during World War II). Nissen is
known in the world of surgery for Nissen’s
fundoplication, developing the frozen
section technique and for performing the
first lung resection. Since no grafts were
available at that time he used
cellophane!!! Yes, the same thing we use
to wrap food in, to wrap the aneurysm.
Einstein survived for seven years post the
surgery.
At the time of presentation, Einstein had
presented with the complaints typical of
Acute Cholecystitis when the abdominal
aortic aneurysm dissected. The autopsy
revealed a normal gall bladder and a huge
abdominal aortic aneurysm. Dr Harveythe
pathologist, reported that the
compression of the gall bladder from the
hemorrhage had simulated an attack of
cholecystitis.
The presentation of patients of ruptured
abdominal aortic aneurysm with features
of acute cholecystitis was given the name
of “Einstein Sign” in his honour.
Department of General Surgery, AFMC
Pune
ACUTE LIMB ISCHEMIA DUE TO ULNAR ARTERY
THROMBOSIS:
A RARE SURGICAL CHALLENGE
A 56-year-old male presented to the MI Room with
complaints of acute onset pain and swelling over distal
phalanges of all fingers of the right hand for 7 days. On
examination pallor, paresthesia and diffuse bluish
discoloration of the distal phalanges was seen without any
demarcation. The ulnar artery was not palpable at the level
of wrist. Modified Allen’s test (MAT) of the non-dominant
hand showed ulnar artery dominance. Colour Doppler
ultrasound revealed a 07 cm long acute to sub-acute
thrombus extending from mid-forearm proximally to
beyond the wrist crease distally with no visualisation of the
superficial palmar arch. Cardiac, carotid artery imaging and
the thrombotic profile showed no abnormality. A trial of
conservative management with parenteral anticoagulants and oral anti-platelets was initiated.
After 1 week, in view of no positive clinical response, surgical management was undertaken.
An arteriotomy was performed 5 cm proximal to the wrist crease. The embolectomy could not
achieve complete distal clearance and the arteriotomy was extended distally beyond Guyon’s
canal till the first branch to the deep palmer arch. Reconstruction was done using a reverse
cephalic vein graft of 15 cm length. Reconstruction with interposition reverse venous graft showed
good response in decreasing symptoms and improving function and quality of life.
Dept. of General Surgery, AFMC Pune
A SPRAIN ANKLE TO GCT TALUS: A TALE OF SERENDIPITY
A 38-year-old male presented with complaints of pain and progressive swelling around the ankle.
He had sustained a twisting injury around ankle three months ago and was diagnosed and
managed conservatively as a
case of sprain ankle. The pain
became dull aching,
unrelated to activities of
weight bearing during this
course. On examination, he
was noticed to have a hard
globular swelling measuring
3cmx 3cm over the anterolateral
aspect of the ankle.
February 05, 2021 Pg. 2
Q-RIOSITY
1) Which of the following is an indication for
surgical treatment of a splenic aneurysm?
a) Pregnancy
b) Size>1.5 cm
c) History of thrombocytopenia
d) Neutropenia
2) Which of the following is not true for
emphysematous cholecystitis?
a) Usually associated with acalculous
cholecystitis.
b) Most common in diabetics.
c) Air is seen in the lumen of gall bladder
causing symptoms of acute
cholecystitis.
d) Clostridial organisms are the common
causative organisms.
3) Prophylactic cholecystectomy is not
recommended for?
a) Heart transplant recipients
b) Diabetes Mellitus
c) Incidental gall stones on laparotomy
d) Liver transplant donors
4) The most common symptom of a popliteal
aneurysm is?
a) Rupture
b) Thrombosis
c) Distal embolization
d) Adjacent nerve compression
5) The most common visceral artery
aneurysm is?
a) Celiac
b) Splenic
c) Hepatic
d) Superior Mesenteric Artery
BILATERAL PREMACULAR SUB-HYALOID
HEMORRHAGEUNMASKING
COVID-19 INDUCED PANCYTOPENIA
A 40-year-old male presented with diminution of vision in both eyes of 05 days duration, along
with a history of fever, dry cough, and myalgia 20 days back. He tested positive for SARS-CoV-2
following which he was admitted and managed conservatively as a mildly symptomatic COVID-
19 positive case for 14 days. On ocular evaluation, his best-corrected visual acuity was 20/200 in
the right eye and 20/400 in the left eye. Dilated fundus examination revealed bilateral large
premacular “boat-shaped” haemorrhages with few superficial retinal nerve fiber layer
haemorrhages in the posterior pole of the retina. There was no evidence of any ischaemic
condition. The patient gave no history suggestive of a bleeding tendency or any concurrent viral
infection. His blood investigations revealed pancytopenia with a white blood cell count (WBC) of
1500/L, haemoglobin of 4g/L, and platelet of 31,000/μl. The patient was referred to a
haematologist for evaluation of pancytopenia and bone marrow biopsy showed normal
trilineage haematopoiesis with no sign of lymphoma, fibrosis, or myelodysplasia.
Fundus photo of right and left eye of the patient showing large “boat-shaped”
haemorrhages (blue arrows) in pre-macular area of both eyes typical feature of the
sub-hyaloid variety with few superficial haemorrhages in posterior pole of both eyes
with no evidence of neovascularization
The surface of the swelling was smooth and the margins were ill defined, with stable ankle
joint and no swellings elsewhere. He underwent ankle series radiographs and MRI of ankle
joint which revealed a lytic lesion originating from anterolateral aspect of talus.
Core needle biopsy revealed it to be a giant cell tumour, without any malignant transformation.
Through an anterolateral approach to the ankle extended curettage was performed using
phenol, motorized burr and electrocautery on tumour measuring 02x02 cm. Cavity was
managed with a bone cement block. The post-operative radiograph showed a complete
excision of the lesion and cavity defect completely obliterated by bone cement. Histopathology
of the excised specimen confirmed the diagnoses of giant cell tumour.
Follow up was done at 6, 12 weeks, 6 months and 1 year. At 1 year, the radiographs showed
no evidence of recurrence of the lesion or appearance of lesion elsewhere in the bone
Dept of Orthopedics, AFMC Pune
February 05, 2021 Pg. 3
Answers can be emailed to
[email protected]. Names of the top
3 people who answer correctly will be published
in the next issue along with the answer key.
Dept. of General Surgery, AFMC Pune
In view of preceding COVID-19 infection and absence of a secondary obvious cause of
pancytopenia, he was diagnosed as a case of COVID-19 induced pancytopenia and
immediately treated with double frequency Nd-YAG laser hyaloidotomy in both eyes for
premacular sub-hyaloid haemorrhage. Both eyes showed progressive resolution of premacular
haemorrhages and improvement in visual acuity to 20/30 in the right eye and 20/40
in the left eye at four weeks. He was also concurrently treated with packed cells and platelets
transfusion with subsequent improvement of haemoglobin levels to 9 g/dl and platelet count
to 80,000/μl at last follow-up with no recurrence of retinal haemorrhages or other signs of
bleeding manifestations.
Several ocular implications of COVID-19 have also emerged. Spontaneous sub-hyaloid
haemorrhages as the first presentation of pancytopenia are rarely reported.
Dept. of Ophthalmology, AFMC Pune
CONTACT ENDOSCOPY- THE OPERATING ROOM
PATHOLOGIST
Contact endoscopy is a procedure for in vivo and in situ visualization of mucosal blood vessels
and superficial cells of epithelium. It helps in pathological evaluation during endoscopic
procedure. This pathological evaluation is complimentary to Histopathological examination.
Epithelial cells show the superficial migration property thus most pathological changes can be
seen by examining superficial cells only.
Instruments required-
1) Contact endoscope (60x 150 magnification) 2) Topical anaesthesia 3) Methylene blue dye
Procedure-
The mucosal surface is cleaned using saline. After topical anesthesia administration, the surface
is stained with 1% methylene blue. The images are acquired by pressing the tip of the
endoscope firmly against the mucosa.
Applications-
Larynx and hypopharynx
• Identification of Squamous metaplasia, Increased N/C ratio, Dysplasia, keratosis and
Vascular loops as seen in laryngeal papillomata
• Nasal cavity
• Helps in identification of features suggestive of chronic rhinosinusitis, allergic rhinitis
• Helps in identification, screening and follow up of cases of nasal polyps
• Oral cavity and oropharynx
• Diagnosis of early cancer and study of tumour margins
• Assessment of response to Radio/chemotherapy
• Identification of subclinical stage of disease
Dept. of Otorhinolaryngology, AFMC, Pune
Winners of the previous quiz 🎉
Surg Lt Cdr Apphia Saphir Kathi (Resident
obstetrics and gynaecology)
Dr Chitrali Khanna (Resident General
Surgery)
Answer key:
1. c
2. b
3. b
4. b
5. c

THE MANY KOCHERS