Showing papers in "Indian Journal of Surgery in 2018"

Incidental Findings in Routine Histopathological Examination of Appendectomy Specimens; Retrospective Analysis of 1970 Patients.

Abstract: Diseases and tumors of the appendix vermiformis are very rare, except for acute appendicitis. This study aimed to examine rare findings in the histopathologic examinations of specimens of patients undergoing appendectomy due to the diagnosis of acute appendicitis. The files of 1970 patients undergoing appendectomy due to the diagnosis of acute appendicitis between March 2012 and March 2016 were retrospectively investigated. Rare findings were found in 59 (3 %) patients, and these were evaluated in detail. Patients’ age, gender, pathology reports, and postoperation follow-ups were recorded. The rare histopathological findings of 59 patients were examined. Of these, 31 were female (52.5 %) and 28 were male (47.5 %). The average age was 33.1 ± 18.2 years. The unusual findings were as follows: 16 fibrous obliteration, 11 Enterobius vermicularis, 2 schistosomiasis, 3 appendiceal neuroma, 2 granulomatous appendicitis, 1 Crohn’s disease, 3 chronic appendicitis, 1 endometriosis, 2 hyperplastic polyps, 9 mucinous cystadenoma (+mucocele), 8 carcinoid tumors, and 1 lymphoma. All of the malignant tumors were localized in the distal end of the appendix, and all of the patients were treated with appendectomy. Patients with parasitic diseases also underwent anthelmintic treatment, while chemotherapy was administered to the patient with lymphoma. All of the patients diagnosed with malignancy were alive reported no problems at their follow-ups. Although all of the appendectomy samples were normal macroscopically, data from this study suggest that all specimens should be sent for routine investigation.

The Charlson Comorbidity Index as an Independent Prognostic Factor in Older Colorectal Cancer Patients

Abstract: High-age patients have higher rates of comorbidity that are associated with a poor prognosis. It is important to correctly evaluate their preoperative status to avoid mortality. The aim of this study was to clarify whether the Charlson comorbidity index (CCI) was useful for predicting postoperative outcomes. This retrospective study collected data from 250 consecutive patients over 75 years of age. The CCI takes into account 19 comorbid conditions. Inflammation-based scores, including the Glasgow prognostic score (GPS) and the platelet to lymphocyte ratio (PLR), are other preoperative scoring systems. The relationships among these scores and postoperative outcomes were evaluated. The patients were classified according to their vital status (dead, n = 30 or alive, n = 220). Comorbidities, the presence of double cancer, and lymph node metastases were significantly different between the groups (p < 0.01, p = 0.01, and p < 0.01). In regard to the scoring systems, the CCI, GPS, and PLR were significantly different (p = 0.02, p = 0.03, and p = 0.05). Multivariate analysis identified CCI ≥ 2 (hazard ratio (HR) = 5.24, 95 % confidence interval (CI) = 1.30–12.1, p = 0.01) as a significant determinant of postoperative outcome (p < 0.01). The overall survival tended to be lower in patients with high CCI scores group (p = 0.03). The CCI was useful to predict postoperative outcomes in high-age colorectal cancer patients.

Morgagni's Hernia: Analysis of 21 Patients with Our Clinical Experience in Diagnosis and Treatment.

Abstract: A Morgagni’s hernia is a congenital defect found in the anterior aspect of the diaphragm between the costal and the sternal portions of this muscle. This defect is also referred to as the space of Larrey. It has been reported that 70% of patients with Morgagni’s hernia are female, 90% of the hernias are right-sided, and 92% of the hernias have hernia sacs. This type of hernia is a rare clinical entity and accounts for 3% of all surgically treated diaphragmatic hernias. There are no large retrospective or prospective studies on this topic. This type of hernia is a rare type among adults without a well-described prevalence and without well-established definitive management strategies. There are also few clinical reports about this clinical entity and its surgical treatment. We treated 21 patients with Morgagni’s hernia in a 12-year period, and we report our experience while discussing the surgical treatment of this disease. We performed a retrospective review of the 21 patients who were operated between 2003 and 2015. These patients had undergone surgical repair of Morgagni’s hernia. For each subject, demographic data, symptoms of presentation, physical examination findings, preoperative imaging studies and diagnosis, and surgical procedures were documented. Location of the hernia sac and its contents, postoperative complications, and duration of hospital stay were recorded and evaluated. Twelve patients were females and nine were males. The mean age of patients was 63.85 years. Dyspnea was the most prominent symptom in our patients. Morgagni’s hernias were located on the right side in 19 patients and on the left side in 2 patients. Chest X-ray in 10 patients and abdominal computerized tomography in 17 patients were the major diagnostic tools. Four patients were operated as emergency while others underwent elective surgery (17 patients). Twelve patients were operated with laparoscopy and the remaining nine were operated with the conventional open abdominal technique. Hernia sacs were observed in all of the patients and removed except in four of them. The omentum and the transverse colon were the most commonly seen organs in hernia sacs. Hernia defects were repaired with primary sutures in four patients (all open cases) and primary closure supported with mesh in six patients (four laparoscopic, two open cases). In the remaining 11 patients, hernia defects were closed with synthetic meshes (eight laparoscopic, three open cases). Mean postoperative hospital stay was 9.8 days. No recurrence was observed in any patients. Only one of our patients died during follow-up. In Morgagni’s hernias, surgical intervention is necessary as the hernia may cause complications such as strangulation of the colon or intestines. A laparoscopic approach has increased its popularity in recent years because of the well-known advantages of laparoscopy.

An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center

Abstract: Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20–25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity.

Preoperative Fasting and Patients’ Discomfort

Abstract: Excessive fasting times before surgery continue to be a widespread practice in Turkey. The aim of the study was to determine the relationship between traditional fasting policies and preoperative patient discomfort. Patients included were undergoing breast, hernia, thyroid, or abdominal operations at a general surgery clinic. Participants were classified as American Society of Anesthesiologists physical statuses I and II. A Likert-type scale was used to describe the effects of midnight fasting. Peripheral blood sugar and vital signs were measured immediately before induction of anesthesia. Of 164 participants, mean age was 53.56 ± 13.47 years. Mean preoperative fasting times were 13.34 ± 3.07 h for solids and 12.44 ± 2.82 h for fluids. Immediately before surgery, 6.1% of patients were extremely thirsty, 5.5% were hungry, and 39% had mild dryness of the mouth. There was a weak positive correlation between total duration of solid fasting and thirst, hunger, mouth dryness, and weakness immediately preoperatively. Prolonged fasting before surgery was associated with patients’ discomfort. Current evidence-based guidelines for preoperative fasting may improve patients’ satisfaction.

Efficacy of the Evaluation of Inflammatory Markers for the Reduction of Negative Appendectomy Rates.

Abstract: Unnecessary appendectomy can cause complications; ways of reducing negative appendectomy rates (NAR) using biochemical and imaging methods are desirable. We retrospectively examined 640 patients who underwent appendectomy for suspected AA. Patients with histologically confirmed appendicitis were designated the positive appendectomy group (n = 565), whereas those with unconfirmed appendicitis were designated the negative appendectomy group (n = 75). The positive appendectomy group was subdivided into the non-perforated (n = 511) and perforated (n = 54) appendectomy groups according to pathology reports. We compared the age, sex, lymphocyte count, neutrophil percentage, pathologic positivity or negativity for appendicitis, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) of the patients. When the perforated, non-perforated, and negative appendectomy groups were compared, the highest CRP level, NLR, and PLR were evident in the perforated appendectomy group (p = 0.001), whereas the lowest neutrophil percentage was found in the non-perforated appendectomy group (p = 0.001). Multiple logistic regression analysis identified neutrophil percentage, CRP value, and NLR as independent variables and demonstrated that AA could be diagnosed with 88.9 % accuracy using the cutoff values determined. In patients with suspected AA, particularly in rural areas with limited access to advanced imaging modalities, the evaluation of neutrophil percentage, CRP level, and NLR, in combination with the findings of a physical examination, may aid diagnosis and reduce NAR.

Oral Plus Local Antibiotics Significantly Reduce the Need for Operative Intervention in Chronic Anal Fissure: a Novel Finding

Abstract: Up to 40% patients with chronic fissure-in-ano require operative intervention. As of today, antibiotics, local or oral, have no role in the treatment of chronic fissure-in-ano. In a prospective study, fissure-in-ano was classified as follows: acute 6-week duration with normal/low anal tone, and acute-on-chronic >6-week duration with high anal tone. The resting anal tone was assessed clinically on an objective scale—DRESS score—the digital rectal examination scoring system. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment was advocated for 6 months. For refractory cases, liquid paraffin and, for high anal tone, diltiazem cream along with sitz bath were prescribed. Non-responders underwent a MRI to look for fissure deepening (presence of sinus/fistula). Healing of fissure-in-ano was assessed by absence of pain, burning, itching, or spasm after defecation and absence of tenderness on per-rectal examination. Out of 109 fissure-in-ano patients recruited over 20 months, 90 (M/F—50/40) were finally included. Mean age was 37.6 ± 12.3 years. Conservatively managed, 86.7% (78/90) patients had significant relief and were cured without requiring any further intervention. Twelve out of ninety (13.3%) patients had no/minimal relief and underwent a MRI which revealed a fissure-sinus/tract in 10/90 (11.1%). MRI was normal in 2/90 (2%). Five out of ten patients with sinus underwent surgery (laying open of the sinus) and became alright subsequently. The rest of the five patients were lost to follow-up. In chronic fissure-in-ano, the regimen of local and oral antibiotics with avoidance of constipation significantly decreases the need for operative intervention.

Surgical Management of Cystic Duct Stump Stone or Gall Bladder Remnant Stone.

Abstract: Retained calculi in the cystic duct or gall bladder remnant can present as a post-cholecystectomy problem Increased suspicion is necessary to diagnose this condition in a symptomatic post-cholecystectomy patient Ultrasonography usually detects this condition, but magnetic resonance cholangiopancreatography is the test of choice for diagnosis as well as for surgical planning Laparoscopic re-excision of the stump in most cases is feasible and safe It is increasingly becoming the treatment of choice

Garg Classification for Anal Fistulas: Is It Better than Existing Classifications?—a Review

Abstract: Classifying a disease is important as it helps in categorizing the disease according to its severity and also guide the treating physician regarding the management of the disease. There are three classifications in vogue for fistula-in-ano—Parks, St James university hospital, and Standard Practice Task Force classification. These existing classifications were compared with the recently proposed Garg classification. The grading of earlier three classifications do not correlate with the severity of the disease and also does not provide any input about the management. Garg classification correlate quite well with the disease severity and also guides the surgeon regarding the management of the disease (fistulotomy can be safely done in Garg grade I-II and should never be attempted in Garg grade III-V). Thus, Garg classification should be used by surgeons and radiologists.

Evidence-Based Clinical Practice Points for the Management of Venous Ulcers

Abstract: Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan Venous ulcers generally persist for weeks to many years and are typically recurrent in nature This consensus aims to present an evidence-based management approach for the patients with venous ulcers Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF) Compression therapy is the mainstay treatment for venous ulcer However, in failure cases, surgery can be preferred Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer

Postmastectomy Chronic Pain in Breast Cancer Survivors: an Exploratory Study on Prevalence, Characteristics, Risk Factors, and Impact on Quality of Life

Abstract: Chronic pain following surgery for breast cancer affects over 50% of patients and is one of the important issues adversely affecting the quality of life of breast cancer survivors. However, there is little information about this problem in Indian patients. Hence, this descriptive study was planned with the objectives to explore the prevalence, pain characteristics, risk factors of postmastectomy chronic pain (PMCP), and its impact on quality of life (QOL). During the period of February 2014 to January 2017, a total of 215 breast cancer survivors, coming for follow-up visits to surgery outpatients department, were evaluated for complaint of PMCP, defined as pain over anterior chest wall, axilla, or ipsilateral arm, which was persistent for more than 3 months after breast cancer surgery. Evaluation of pain severity was done by visual analogue scale (VAS), and characteristic of pain was assessed by Neuropathic Pain Symptom Inventory (NPSI). Body charts were used to define location of pain. Assessment of QOL was done by FACT-B questionnaire. Overall prevalence of PMCP was 41.4 and 19.5% patients had clinically significant pain scores of ≥3. Character of pain was mainly described as pins and needles (59.5%) and burning sensation (30%), and the most common site of pain (52%) was around the mastectomy scar. Younger age was significantly correlated with higher pain scores. Patients with higher pain scores had poorer QOL scores. (104.0 ± 19.27 with a VAS score of <3 vs. 85.26 ± 14.00 with a VAS score of ≥3, p < 0.001). Emotional distress was an important contributor to poor QOL. PMCP is a common problem in Indian breast cancer survivors, which causes considerable emotional distress and negatively impacts QOL. Treating physicians should evaluate and appropriately address this important survivorship issue.

To Determine Validation of RIPASA Score in Diagnosis of Suspected Acute Appendicitis and Histopathological Correlation with Applicability to Indian Population: a Single Institute Study.

Abstract: Although acute appendicitis is one of the most common surgical emergencies worldwide, timely accurate diagnosis is always difficult for a surgeon even after availability of recent diagnostic tools Our study is to determine validation of RIPASA score in diagnosis of acute appendicitis and histopathological correlation A prospective study of 200 patients presented to emergency or surgical opd with right iliac fossa pain and suspected to have acute appendicitis were included in our study RIPASA score calculated but appendectomy done on the basis of clinical assessment and hospital protocol and histopathological correlation done with a score A score of 75 is cut off threshold, results compared with previous studies In our study of 200 patients, M:F ratio of 156:1 Sensitivity of the RIPASA score was 9589℅ with specificity 7592% and diagnostic accuracy of 905%, expected and observed rate of negative appendectomy were 85 and 1235%, respectively So there is net reduction in negative appendectomy rate by 385% Data analysis done with Statistical Package for Social Science (SPSS) version 210 RIPASA score at a cutoff value of 75 is easier, cheap, and better diagnostic tool in equivocal case of right iliac fossa pain in Indian scenario of limited availability of recent diagnostic tool in remote areas and affordability of these tool in the available set up, simultaneously, it also helps to reduce negative appendectomy rates

Simultaneous Hybrid Operation Common Femoral Endarterectomy and Endovascular Treatment in Multilevel Peripheral Arterial Disease with Critical Limb Ischemia

Abstract: The purpose of revascularization in lower extremity arterial occlusive disease is to prevent amputation and improve walking ability. Many surgical techniques for peripheral vascular disease (PAD) have been reported. The hybrid operation composed of open surgery and endovascular procedure has been increasingly used for multilevel revascularization. The goal of this study is to evaluate feasibility of simultaneous hybrid femoral endarterectomy and endovascular treatment in patients who need multilevel revascularization with critical limb ischemia. Between March 2011 and July 2014, 38 consecutive patients (43 limbs) with multilevel peripheral arterial disease in critical limb ischemia were treated by simultaneous hybrid operation by single surgeon. The hybrid operation which combines common femoral artery endarterectomy and additive interventional procedure was simultaneously performed for multilevel revascularization. The measurements of primary outcome were primary patency rates, secondary patency rates, and limb salvage rates. Patients who underwent single procedure of surgery or intervention were excluded. The mean age was 72.48 years old and 92.1% were male. The primary and secondary patency rates at 24 months were 67.3 and 72.1%, respectively. The preoperative mean ABI of 0.51 ± 0.27 increased to postoperative mean ABI of 0.88 ± 0.35. The limb salvage rate was 95.3%. Major amputation was performed in 2 out of 43 limbs. There was no early postoperative mortality. The simultaneous hybrid operation for multilevel revascularization may be feasible to treat in multilevel PAD with high technical success and limb salvage rates, thus providing an attractive alternative to larger open surgery or endovascular procedures.

Appendicitis in the HIV Era: a South African perspective

Abstract: The relationship between HIV infection and the clinical spectrum of appendicitis has not been fully elucidated in the South African context The aim of this study is to compare the surgical management, histopathology, and outcomes between HIV-positive and HIV-negative patients undergoing surgery for appendicitis A retrospective chart analysis was performed of 50 patients who underwent surgery for appendicitis at King Edward VIII Hospital, Durban, South Africa between January 2012 and December 2012 Patients were stratified by HIV serostatus into HIV-positive and HIV-negative groups Fifty patients underwent surgery for appendicitis during the study period Of the 50 patients, 14 were HIV-positive (28 %) and 36 were HIV-negative (72 %) Perforated appendicitis was more frequent in the HIV-positive group (50 vs 25 %, p > 005) There was a significantly higher laparotomy rate in HIV-positive patients (71 vs 33 %, p 005) and no difference in the mean length of hospital stay (78 ± 489 vs 58 ± 394 days, p > 005) In this retrospective study, perforated appendicitis was seen to be more common in HIV-positive patients resulting in a higher laparotomy rate in this group Granulomatous inflammation was only found in HIV-positive patients There was no difference seen in the complication rate, length of hospital stay, and mortality between HIV-positive and HIV-negative patients

Quality of Life Assessment After Bariatric Surgery—a Single-Center Experience

Abstract: Obesity is a current pathology with many clinical, molecular, and psychological implications. The number of obese people has doubled in the past 10 years and we can observe an early onset of obesity. We have used a modified BAROS and SF36TM questionnaire to conduct a descriptive study on 34 obese patients undergoing surgery for obesity—laparoscopic sleeve gastrectomy (LSG). The inclusion criteria were the embodiment of surgery for obesity: BMI (body mass index) >40 kg/m2 or BMI > 35 kg/m2 and associated comorbidities. The postoperative BMI was 25.7670 ± 3.74759 kg/m2 (mean ± SD). The average number of lost kilograms was 38.74 ± 12.526 (mean ± SD), and the average percentage of excess body weight loss (% EBWL) was 85.9952 ± 22.69028% (mean ± SD). Patients lost an average of 36.88–38.56 kg at 6–12 months after surgery, and they reach a % EBWL of 94.69 ± 30.02% and a normal BMI of 23.96 kg/m2 at 18 months postoperatively. All patients significantly reduced the amount of food eaten after surgery. More than 2 years after the surgery, patients increased their food intake by about 30%, but maintained their weight loss and a normal BMI. Related to quality of life, 77.78% of patients declared a vast improvement, 11% a good quality of life, and only 3.7% said that the quality of life is worse than before the surgery. Also, a relationship between quality of life and the improvement of sexual life, or with the increased frequency of physical exercise has been observed. Improving quality of life is directly related with the weight loss, with %EBWL, and with the postoperative BMI. Bariatric surgery should be understood in all the positive changes that it generates in everyday life.

First Ever Robotic Stage One ALPPS Procedure in India: for Colorectal Liver Metastases

Abstract: Twenty five percent of total liver volume (TLV) is considered as the ideal functional liver remnant (FLR) in major liver resections. In patients with macro-vesicular steatosis, early cirrhosis, and post-neoadjuvant chemotherapy (NACT), hepatocellular injury is common. In such instances, up to 40% of FLR may be required. So in cases of marginal FLR, pre-operative portal vein (PV) embolization or two-stage hepatectomy with PV occlusion is used. Both of which take up to 14 weeks between stages and 30% of patients fail to reach the second resection either due to inadequate FLR growth or disease progression. Associated liver partition and portal vein ligation (ALPPS) procedure has become the gold standard for those cases. A 57-year-old male presented with rectosigmoid growth + multiple right liver and segment 4B metastases. Post-NACT MRI showed interval progression of lesions. Preoperative CT (computed tomography) volumetric scan showed a FLR/TLV (future liver remnant/total liver volume) of 22%. Since patient received 10 cycles of NACT, ALPPS procedure was planned ahead of direct liver resection. Robotic ALPPS stage 1 sparing left lateral segment and 4A + anterior resection was done. We transected the parenchyma between the FLR and the diseased part of the liver with concomitant right portal vein ligation done robotically. CT abdomen done on POD7 showed hypertrophied left lateral segment. Second stage was performed on the eighth post-operative day with FLR/TLV increasing to 37%. Robotic ALPPS procedure for stage one is a safe and feasible technique in experienced centers with advanced robotic skills.

Importance of Spontaneous Choledochoduodenal Fistulas Detected During ERCP Procedure

Abstract: Choledochoduodenal fistula (CDF) is an abnormal passage between the choledochus and duodenum. The most common causes of CDF are cholelithiasis, duodenal ulcer, and tumors. There are mainly two types of fistulas depending on the location. Type 1 is usually present on the longitudinal fold just close to the papilla. Type 2 is present at the duodenal mucosa adjacent to the longitudinal fold and probably caused by larger stones, duodenal ulcer penetration, impacted cystic duct stones, and as a complication of laparoscopic cholecystectomy. In this study, we investigate the characteristics of our patients those were diagnosed with CDF. This is a descriptive study. We retrospectively obtained the data of 21 patients with spontaneous CDF out of 2430 endoscopic retrograde cholangiopancreaticography (ERCP) patients between 2000 and 2014. We analyzed the laboratory results, demographic and etiological features, major clinical presentations, diagnostic methods, and treatment modalities of the patients. The mean age of the 21 patients was 66.6 ± 2.2 years and a female to male ratio was 12:9. In ten patients, interventional procedures were performed via fistulotomy, not through the papilla. The eventual diagnosis was tumor in five patients and stone or sludge in bile ducts in 14 patients. In the remaining two patients, no reason was found as a cause of CDF. Whipple operation was performed in one patient and stents were placed in three patients for malignacy. Among the 14 patients with sludge or stone in bile ducts, ERCP has been therapeutic in ten. One of the remaining patients has been operated for proximal fistula and underwent choledochus exploration and repair of fistula over a T-tube. In the second patient, stone extraction and T-tube drainage were performed. In patients who had bile duct obstruction and got over of jaundice afterwards, one of the most important reasons of this recovery is the development of spontaneous choledochoduodenal fistula. Even if it is very rare, malignancy can be observed in this area. Therefore, it is extremely important to evaluate the papillary area with ERCP and to conduct biopsy; this will make early diagnosis possible in many patients. In these patients, ERCP can both be diagnostic and therapeutic.

Aggressive Surgical Approach for Treatment of Primary and Recurrent Retroperitoneal Soft Tissue Sarcoma.

Abstract: To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25–79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

Applying Haddon Matrix for Evaluation of Road Crash Victims in Delhi, India

Abstract: Road traffic injuries are placing an increasing and disproportionate global health burden upon developing countries. An understanding of region specific epidemiological risk factors is imperative in order to plan appropriate prevention and control strategies. The objective of the study was to evaluate epidemiological risk factors of road traffic injury victims in Delhi, India with the help of Haddon injury analysis framework. The current study was conducted among crash victims admitted to the government hospital. Data obtained from the hospital, police records and crash victims was triangulated with geospatial analysis. Haddon matrix was utilized to understand the interplay of human, vehicle and environmental factors in pre-crash, crash and post-crash phases of an accident. A total of 544 victims were included as study participants with mean age of 30.8 years for males and 31.81 years for females and were from lower socio-economic groups. Pedestrians (36.2%) and two-wheeler riders, especially those on pillion vehicles (21.5%), were worst affected victims. The crude odds ratio for motorized road users for experiencing a crash was higher on slippery roads [p < 0.05; OR = 0.197 (0.082–0.474)]. Moderate to heavy traffic flow (p = 0.001; OR = 0.469 (0.317–0.696) was found to be a protective factor for accidents. Geospatial analysis revealed clustering of crashes near traffic lights, markets and schools. Integrated approaches addressing engineering, technological and environmental factors along with behavioural modifications is needed to produce definitive changes in road crash trends.

Anastomotic Failure in Colorectal Surgery: Where Are We at?

Abstract: Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases the costs and demands on health services. There is inevitable interplay between patient physiology and technical factors that predispose a patient to AL. Obesity, preoperative total proteins, male gender, ongoing anticoagulant treatment, intraoperative complication and number of hospital beds have been identified as independent risk factors. This has led to an online risk calculator for AL. Non-steroidal anti-inflammatory drugs and neoadjuvant chemoradiotherapy have also been implicated, but no significant evidence has yet been found to support causation. In addition, technical factors such as type of anastomosis, mechanical bowel preparation, drains, omentoplasty and faecal diversion have failed to show significant differences in AL rates. Early diagnosis and intervention in AL is essential in reducing the rates of morbidity and mortality. Clinical assessment has high sensitivity but low specificity and should be used in combination with imaging techniques to get a diagnosis. C-reactive protein is also a useful marker. The management will depend on the grade of AL and the clinical state of the patient. Management options include conservative measures such as antibiotics and/or percutaneous drainage to more invasion procedures such as open drainage and/or Hartmann's procedure. In conclusion, ALs will forever pose challenges to the surgeon in diagnosis and management. It is often the yardstick by which each surgeon is measured and is the source of significant morbidity to patients and health care services worldwide. As a result, a low threshold for investigation and intervention is mandatory to ensure better outcomes and lower overall mortality and morbidity.

Non-fixation Versus Fixation of Mesh in Totally Extraperitoneal Repair of Inguinal Hernia: a Comparative Study.

Abstract: Two major issues with laparoscopic inguinal hernia (IH) repair are recurrences and chronic groin pain (CGP). The procedure involves fixing the mesh with the tackers which is believed to increase the rate of CGP due to nerve injuries. Thus, non-fixation of mesh is being proposed but concerns remain regarding increased recurrences. We sought to look at our outcomes after we switched over to non-fixation of mesh in totally extraperitoneal repair (TEP). Retrospective review of prospectively maintained database of 171 repairs was done on 122 patients (fixation 59 and non-fixation 112) during a period of 4 years with an endeavor to complete a minimum of 1 year of clinical follow-up. The primary objective was to assess the recurrence rates and CGP and the secondary objective was to assess operative times, immediate post-op pain, incidence of urinary retention, duration of hospital stay, days taken to return to activity, and cost. The mean operative times for unilateral IH for the fixation and non-fixation groups were 41.8 ± 11.4 and 35.9 ± 9.7 min, respectively (p = 0.021), whereas for bilateral were 66.2 ± 15.6 and 55.3 ± 14.2 min, respectively (p = 0.018). The mean pain score was 3.44 ± 1.2 versus 3.01 ± 1.0; (p = 0.037) in the two groups, respectively. At a mean follow-up of 33.2 ± 17.0 and 18.7 ± 6.2 months, the incidence of CGP was 02 (3.4%) and 3 (2.7%) (p = 1.000) and recurrences were 02 (3.4%) in the two groups, respectively (p = 0.118). Non-fixation of mesh in TEP does not lead to increased recurrence though it does not decrease the incidence of chronic groin pain. Collateral advantage would be decreased operative times, lesser post-operative pain, and decreased costs.

Comparing Hemodynamic Symptoms and the Level of Abdominal Pain in High- Versus Low-Pressure Carbon Dioxide in Patients Undergoing Laparoscopic Cholecystectomy.

Abstract: The laparoscopic cholecystectomy (LC) is the gold standard to treat gallstone To view the surgical site in this type of operations better, carbon dioxide is used with a certain pressure The current study aimed to compare the hemodynamic symptoms and the level of abdominal pain due to using high- and low-pressure carbon dioxide in patients undergoing LC The current double-blind randomized clinical trial was conducted on 60 patients with the age range of 20–70 years old undergoing LC The first and second groups experienced PaCO2 of 7–10 and 12–14 mmHg, respectively The hemodynamic symptoms, abdominal pain, shoulder-tip pain, nausea and vomiting after the surgery, and the mean of liver function tests were evaluated Data were analyzed using T test, Chi-square test, and repeated measures ANOVA by SPSS 16 Information of 60 patients in two groups was analyzed There was a significant difference between the groups regarding the mean of systolic blood pressure (P < 005) The mean of heart rate was significantly higher in the high-pressure group during surgery and 1 h after that (P < 005) The frequency of pain in shoulder-tip and abdomen was higher in the high-pressure group Frequency of nausea and vomiting 12 h after the surgery between two groups was significant (P < 005) The mean of alkaline phosphatase was higher in the low-pressure group than the high-pressure group (P < 005) Considering the good performance and low side effects of low-pressure laparoscopic cholecystectomy compared to those of high-pressure, this method can be replaced by high-pressure in LC

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience

Abstract: Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3–9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Sexuality in Surgically Treated Carcinoma Penis Patients and Their Partners.

Abstract: Most common treatment offered to carcinoma penis patients is surgery. This results in not only mutilation of the genitals but also affects their sexuality. The treating physician fails to address the issue due to the paucity of the data in this regard. Hence, we decided to evaluate sexuality in these patients after surgical treatment for penile cancer. Most of the times, their partners also face problems of sex and sexuality, regarding which there is no literature. Hence, we decided to include their partners also in the study. We retrieved records of the patients who underwent surgical treatment for carcinoma penis at our institute. After obtaining ethical committee approval, they were invited along with their partners for personal interview. After obtaining written informed consent from each of them, they were administered sexual functioning questionnaire (SFQ). Sexuality was evaluated based on the scores obtained. Performance anxiety was reported by majority of these patients. Their sexual interest, arousal and desire remained almost intact with reduction in satisfaction more so in total penectomised patients. Though the partners had accepted the global reduction in sexuality as their fate, their interpersonal relationship remained little disturbed. The study reveals that sexuality is more than the sexual intercourse alone. Proper pre-operative counselling of these patients and their partners by the treating urologist helps better post-treatment adjustment with regards to sexuality in these patients as well as their partners.

Effect of Varicocelectomy on Serum FSH and LH Levels for Patients with Varicocele: a Systematic Review and Meta-analysis.

Abstract: Varicocelectomy can improve the function of testicular Leydig cell for patients with varicocele. We carried out a systematic review and meta-analysis to assess effect of varicocelectomy on serum FSH and LH levels for patients with varicocele. A literature review was performed to identify all published randomized preoperation-postoperation clinical trials of assessing serum FSH and LH levels before and after varicocelectomy. The search included the following databases: PUBMED and EMBASE. The reference lists of retrieved studies were also investigated. A systematic review and meta-analysis were conducted. Five studies were selected from 149 studies, including 312 patients. The meta-analysis showed that serum FSH level (95% confidence interval 0.19–0.77, P = 0.001) and serum LH level (95% confidence interval 0.25–0.91, P = 0.0005) were higher preoperation than postoperation. Serum FSH level decreased by 0.48 ng/dL after varicocelectomy. The mean decrease of the serum FSH was from 0.1 to 4.8 ng/dL. And serum LH decreased by 0.58 ng/dL. The mean decrease of the serum LH was from 0.2 to 2.1 ng/dL. This meta-analysis proves that varicocelectomy perhaps can decrease serum FSH and LH levels in patients with varicocele. And it might be related to the improvement of the function of Leydig cell. But it remains to need a large-scale multicenter randomized controlled study to be further confirmed.

Rupture of Cystic Artery Pseudoaneurysm: a Rare Complication of Acute Cholecystitis

Abstract: Pseudoaneurysm (PA) of the cystic artery is rare. Most of the reported cases are iatrogenic and develop secondary to liver biopsy, laparoscopic cholecystectomy, ERCP, and liver transplant. Other reported causes include trauma, malignancy, arteriovenous malformations, and inflammation in the hepatobiliary and pancreatic system. Cystic artery psuedoaneurysm is usually asymptomatic but may also present as vague abdominal pain, intra-abdominal mass, and hemobilia. In the event of rupture, it may present as a catastrophic intra-peritoneal bleeding with hemorrhagic shock. Doppler ultrasound and contrast-enhanced CT scan are useful tools for the diagnosis of this condition. However, selective visceral angiography is confirmatory and offers the opportunity for therapeutic embolization. We report a case which presented with upper right quadrant abdominal pain, vomiting, and hypotension. Abdominal ultrasonography revealed subhepatic hematoma and pericholecystic fluid collection along with acute calculus cholecystitis and sludge in the bile duct. Subsequent contrast-enhanced CT and CT angiography confirmed the presence of ruptured cystic artery psuedoaneurysm with subhepatic hematoma. The patient after resuscitation underwent selective visceral angiography and successful coil embolization of the cystic artery pseudoaneurysm. During the same admission, ERCP and biliary stenting were also performed followed by laparoscopic cholecystectomy. This case reports a rare entity which was successfully treated using a multimodality strategy.

Robotic Pancreaticoduodenectomy: Technical Considerations

Abstract: Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low and controversial. We focused on some important technical details crucial for a safe robotic pancreatectomy. After performing 52 robotic pancreatic resections that included 10 pancreatoduodenectomies, the authors describe their technique. The review of literature on robotic and laparoscopic duodenopancreatectomy is also performed in order to evaluate possible benefits of the robotic platform. We describe the step-by-step surgical procedure, analyzing all possible troubleshooting occurring in an initial center experience. The estimated blood loss as well as the length of stay was reduced by the robotic approach. We did not observe any significant increase of pancreatic fistula rate and all other postoperative complications despite our initial learning curve. Robotic pancreatoduodenectomy is a technically advanced procedure that requires important laparoscopic and robotic skills but it shows to be safe, feasible with some clear advantages in the bleeding control and in the reconstructive phase of the procedure.

Transmural Migration of Gossypiboma: a Rare Cause of Acute Abdomen.

Abstract: Gossypiboma is the retained foreign body which is generally a cotton sponge/gauze after surgery. Incidence of gossypiboma is around one in 3000 to 5000 surgeries. This low incidence is mainly attributed to a low case reporting due to an associated medicolegal aspect. We are reporting a case of a 38 years old male, who presented with signs and symptoms of peritonitis. The patient had a history of open cholecystectomy 2 years back. A working diagnosis of perforation peritonitis was made, and the patient underwent exploratory laparotomy. Intraoperatively, a surgical sponge was present inside the ileal lumen causing intestinal obstruction with dense adhesion of bowel loops proximal to the site of obstruction with multiple ileal perforations. Even though the incidence of gossypiboma is very low, it should always be kept in mind as a cause of chronic abdominal pain and abdominal discomfort in a patient with previous abdominal surgery.

Mayer-Rockitansky-Kuster-Hauser Syndrome Presenting as Irreducible Inguinal Hernia.

Abstract: Inguinal hernia is the most common type of hernia experienced in the surgical OPD due to the muscular anatomy of the region being weak along with the natural weaknesses like deep ring with indirect hernia being more common than direct. Inguinal hernias may have varying unusual sac contents, a case presentation of rudimentary uterus and ovaries as contents of inguinal hernia in an adult female with Mayer-Rokitansky-Kuster-Hauser (MRKH) type II syndrome. This syndrome may be attributed to abnormal development of blastema of cervicothoracic somites and pronephriducts.

Ethics of Smartphone Usage for Medical Image Sharing.

Abstract: Technology advances in medicine have led to increased usage of smartphones and applications in facilitating provision of care. As the increased power of technology paves the way for advances, it is fundamental that ethical considerations are comprehensively explored. This paper explores the importance of consent, confidentiality, and data security in use of smartphone applications for transferring medical information.