ISA

Risk factors for postoperative pneumonia after esophagectomy for esophageal cancer

TAMAGAWA A, AOYAMA T, TAMAGAWA H, JU M, NUMATA M, YUKAWA N, MASUDA M, RINO Y

040115 TAMAGAWA A, AOYAMA T, TAMAGAWA H, JU M, NUMATA M, YUKAWA N, MASUDA M, RINO Y (Surgery Dep, Yokohama City Univ, Yokohama 236-0004, Japan, Email: t-aoyama@lilac.plala.or.jp) : Risk factors for postoperative pneumonia after esophagectomy for esophageal cancer. Indian J Surg 2020, 82(4), 632–8.

Few studies have investigated the risk factors for postoperative pneumonia after esophageal cancer surgery. The aim of the present study was to identify risk factors of postoperative pneumonia after esophagectomy for esophageal cancer. This study included 122 patients who underwent curative surgery for esophageal cancer between January 2005 and September 2018. The rate of postoperative pneumonia was measured by the revised Uniform Pneumonia Score. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for postoperative pneumonia. Postoperative pneumonia was found in 34 of the 122 patients (27.9 %). Among the factors examined (age, gender, preoperative chemotherapy status, operative type, operative duration, blood loss, lymph node dissection, smoking habit, and alcohol habit), the age (p = 0.038) and operative duration (p = 0.035) were identified as significant independent risk factors for postoperative pneumonia in the univariate and multivariate analyses. The incidence of postoperative pneumonia was 40 % (22 of 55) in patients ≥ 70 years old and 17.9 % (12 of 67) in those < 70 years old. The incidence of postoperative pneumonia was 45.2 % (28 of 62) in the operative duration ≥ 570 min group and 10.0 % (6 of 60) in the operative duration < 570 min group. The age and operative duration were risk factors for postoperative pneumonia in patients who underwent curative esophagectomy for esophageal cancer. To improve the survival of patients with esophageal cancer, it is necessary to carefully plan the surgical procedure, perioperative care, and surgical strategy.

4 tables, 21 ref

Mucosal melanomas of the head and neck-A tertiary cancer centre experience

SURESH S, GEORGE N A, JANARDHAN D, GEORGE P S, PATIL S, GEORGE C K, VARGHESE B T, AMMU J V

040114 SURESH S, GEORGE N A, JANARDHAN D, GEORGE P S, PATIL S, GEORGE C K, VARGHESE B T, AMMU J V (Head & Neck Surgery Dep, Regional Cancer Centre, Thiruvananthapuram, Kerala, Email: sndp_srsh@yahoo.co.in) : Mucosal melanomas of the head and neck-A tertiary cancer centre experience. Indian J Surg 2020, 82(4), 625–31.

Mucosal melanoma is a relatively rare tumour of the head and neck with a very poor prognosis. Managing this disease entity becomes more difficult due to high chances of disease failure locoregionally and at distant sites. This study assessed the treatment outcomes and factors affecting prognosis of head and neck mucosal melanomas. Forty-one cases of mucosal melanomas of head and neck (MMHN) treated in our institution during 10 years were retrospectively reviewed. Data regarding the clinicopathological parameters and treatment outcomes was collected. Survival was calculated using Kaplan-Meier method. The most common subsite of MMHN was upper alveolus and hard palate (39 %). Thirty-one of the 41 cases underwent surgery whereas 10 cases were treated with palliative intent. At presentation, 15 of 41 cases had lymph node involvement and majority of them had primary in the oral cavity: sinonasal region had low chances of lymph node metastasis. Seventy-four percent of cases underwent adjuvant post-operative radiotherapy. For surgically treated cases, 5-year disease-specific survival (DSS) was 35.7 %. Mucosal melanomas of nose and paranasal sinuses had a better overall survival than oral cavity. Distant metastasis was the most common cause of disease failure in 12 of 24 cases and had a significant association with disease-specific survival. The stage of the disease was a significant prognostic indicator. Sinonasal cavity mucosal melanomas have a better prognosis than mucosal melanomas in other subsites. Overall survival for surgically treated cases was significantly better than cases treated non-surgically. Presence of lymph node metastasis reduced the survival by 50 % in MMHN.

3 illus, 2 tables, 27 ref

Prospective randomized controlled study to compare the outcome of standard 4-port laparoscopic cholecystectomy with single-incision laparoscopic cholecystectomy in patients with gallstone disease

KRISHNA A, BANSAL V K, GUPTA S, MISRA M C

040113 KRISHNA A, BANSAL V K, GUPTA S, MISRA M C (Surgical Disciplines Dep, All India Institute of Medical Sciences, New Delhi, Email: dr.asurikrishna@gmail.com) : Prospective randomized controlled study to compare the outcome of standard 4-port laparoscopic cholecystectomy with single-incision laparoscopic cholecystectomy in patients with gallstone disease. Indian J Surg 2020, 82(4), 616–24.

Four-port laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallbladder disease. To reduce the invasiveness of standard four-port laparoscopic cholecystectomy, single-incision laparoscopic cholecystectomy (SILC) has come about an attractive option for the performance of laparoscopic cholecystectomy. There have been no studies on SILC from Indian subcontinent. The present study was designed to compare the outcomes of SILC with the standard four-port LC in a prospective randomized controlled trial. All patients with symptomatic gallstone disease were evaluated between May 2012 and April 2014. Patients were randomized to either standard four-port laparoscopic cholecystectomy (LC group) or single-incision laparoscopic cholecystectomy (SILC group). Demographic profile, preoperative and intraoperative variables, postoperative complications, hospital stay, and pain scores were recorded. WHO-QOL BREF was used for quality of life analysis. Patients were followed up at regular intervals, and satisfaction scores were recorded. Statistical analysis was done using STATA 12 and p value < 0.05 was considered significant. Out of 94 patients, 90 received the intended treatment, and four cases in SILC group were converted to standard four-port cholecystectomy. The demographic profile and preoperative WHO-QOL BREF scores were comparable between the two groups. Severity of adhesions, successful dissection of Calot’s triangle, ergonomics, and overall level of difficulty were also comparable. Operation time was significantly higher in SILC group, but the learning curve was seen to be achieved after 30–35 cases. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 6 months except for pain score during normal activity in immediate postoperative period which was significantly higher in SILC group. Overall complication rate was significantly higher in SILC group, however the incidence of SSI was not found to be significant among the two groups. There was one case of transient bile leak and one case of intraabdominal bleeding due to slippage of cystic artery clip. Postoperative quality of life outcomes were similar in the two groups. Although not significant, patients with SILC group had higher cosmetic score compared with the LC group. In conclusion, this study shows that SILC is a safe and feasible with a higher rate of complications but comparable cosmetic and QoL outcomes when compared with standard 4-port cholecystectomy.

2 illus, 3 tables, 20 ref

Missed inguinal cord lipoma may mimic recurrence following endoscopic repair of Groin Hernias

TOSUN S, EKINCI O

040112 TOSUN S, EKINCI O (General Surgery Dep, Istanbul Medeniyet Univ, Istanbul, Turkey, Email: drsalihtosun@yahoo.com) : Missed inguinal cord lipoma may mimic recurrence following endoscopic repair of Groin Hernias. Indian J Surg 2020, 82(4), 610–5.

To investigate the preoperative diagnosis, incidence rate, operation method, and recurrence as a cause of inguinal cord lipomas (ICL) in patients that were treated surgically due to groin hernia. This was a retrospective review of hernia repairs from January 2015 to January 2017 with open and endoscopic technique. Operative notes, pathologic reports, and demographic findings were evaluated in those patients. The same group of general surgeons performed all the procedures. A total of 722 patients were operated with the diagnosis of groin hernia. The patients were classified in two groups according to whether or not evaluation with the preoperative ultrasound (US). In total, 519 patients in group 1 had a preoperative US and underwent open surgery, whereas 203 patients in group 2 underwent endoscopic hernia surgery without a preoperative US examination. An US was performed before re-operation in recurrent cases. In group 1, 29 of 519 patients were identified as having ICL preoperatively through US with an incidence of 5.5 %. Pathologic reports were confirmed as ICL in all of them. Six recurrences were seen in group 1 (1.15 %) over at least 12 months follow-up period (12–48 months). ICL was not seen in these recurrences. Etiology of recurrence was mesh shrinkage in 5 and mesh migration in 1 patient. In group 2, 203 endoscopic hernia repairs were performed without a preoperative US. During the follow-up, 4 recurrences were diagnosed (1.9 %). Although there was no suspicion of ICL left reported during the surgery from the operation notes, ICL was mimicking recurrence in two (0.9 %) of them. Etiology of recurrence in the other 2 was mesh migration due to inadequate fixation. ICL could mimic recurrence if not removed or missed during hernia surgery. Preoperative US is a simple, useful, noninvasive, and cheap method in finding the ICL and preventing the re-operations.

2 illus, 1 table, 19 ref

Clinico-pathological evaluation and outcomes of emergency right Hemicolectomies in the HIV era

BUNDHOO G, KADER S, MANNEH C G, CHEDDIE S

Endoscopic Thyroidectomy Through Oro-Vestibular Route (ETOVR)

BHARGAV P R K, SABARETNAM M, AMAR V

Surgical results of the use of expanded polytetrafluor ethylene as an adhesion inhibitory membrane in Anastomosis surgery for total peripheral nerve cut

EROGLU U, YAKAR F, BOZKURT M, KAHILOGULLARI G, SHUKRIYEV B, UGUR H C, UNLU A

Rectal stump management after subtotal colectomy for severe colitis, in or out- A retrospective cohort study

BEDRIKOVETSKI S, LIU J, DUDI-VENKATA N N, KROON H M, LEWIS M, LAWRENCE M, ANDREWS J M, SAMMOUR T

040108 BEDRIKOVETSKI S, LIU J, DUDI-VENKATA N N, KROON H M, LEWIS M, LAWRENCE M, ANDREWS J M, SAMMOUR T (Adelaide Univ, Australia, Email: tarik.sammour@gmail.com) : Rectal stump management after subtotal colectomy for severe colitis, in or out- A retrospective cohort study. Indian J Surg 2020, 82(4), 585-91.

There is little evidence to guide optimal medical and surgical management of the rectal stump in patients undergoing subtotal colectomy (STC) for severe colitis (SC) and acute severe ulcerative colitis (ASUC). All patients undergoing an STC for SC and ASUC at the Royal Adelaide Hospital (RAH), Australia, between 1993 and 2018 were identified and included from the RAH inflammatory bowel disease database and hospital records. Patient demographics, postoperative medical and surgical outcomes, and second-stage procedures were analyzed. Sixty-one patients underwent an STC for SC including ASUC. In 21 patients, the rectal stump was left in situ, whereas in 40, the rectal stump was extra-fascial. Thirty-five of the 61 patients underwent surgery for ASUC, of whom 10 were in the in situ group and 25 in the extra-fascial group. Baseline patient characteristics were similar, except for a significantly higher American Society of Anaesthesiologists score (P 0.024) in the extra-fascial ASUC group. There were no statistically significant differences in the postoperative outcomes between the extra-fascial group and the in situ group for SC and ASUC. There was, however, a trend toward lower rates of systemic sepsis (1 (4 %) vs 3 (30 %), P 0.061) and pelvic sepsis (1 (4 %) vs 2 (20 %), P 0.190) in the extra-fascial compared with the in situ group in the ASUC subset. In our experience, exteriorization of the rectal stump after STC for ASUC may confer a lower systemic and pelvic sepsis rate compared with the in situ group; however, better powered prospective studies with larger numbers are required to confirm this.

1 illus, 4 tables, 28 ref

How do health anxiety, somatosensory amplification, and depression levels relate to non-cyclical mastalgia- A case-control study

HACIMUSALAR Y, TALIH T, KARAASLAN O

Computed tomography-assisted diagnosis of Meckel's diverticulum for adults in emergency

DONG D, XU W, ZHANG L, QIU X, CHEN X, WANG J

Prospective comparative analysis of total versus involved field parietal peritonectomy during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (crs-hipec) for peritoneal surface malignancies from colorectal cancer

SOMASHEKHAR S P, KUMAR C R, ASHWIN K R, RAMYA Y, RAUTAN A

040105 SOMASHEKHAR S P, KUMAR C R, ASHWIN K R, RAMYA Y, RAUTAN A (Surgical Oncology Dep, Manipal Hospital, Bangalore, Email: drrohit.life@gmail.com) : Prospective comparative analysis of total versus involved field parietal peritonectomy during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (crs-hipec) for peritoneal surface malignancies from colorectal cancer. Indian J Surg 2020, 82(4), 566-72.

Peritonectomy is the important component in management of peritoneal surface malignancies (PSM). The aim of this study was to assess the morbidity, recurrence pattern and oncological outcomes of extent of parietal peritonectomy done during CRS and HIPEC for colorectal carcinoma (CRC). Patients with PSM from CRC underwent total parietal peritonectomy (TPP) or IFP with CRS-HIPEC. Pre- and intra-operative data were analysed with main focus on postoperative morbidity, recurrence pattern and oncological outcomes. Of 40 patients in the study, 19 and 21 patients underwent TPP and IFP respectively. TPP group had longer duration of surgery (11 vs 9), more blood loss (1300 vs 835 ml), increased diaphragmatic resections (47.3 % vs 9.5 %) and multivisceral resection (47.3% vs 28.5 %). Overall, G3–G5 morbidity TPP versus IFP was 47.3 % versus 33.3 % and surgical morbidity was 30.7 % versus 23.8 %. With a median follow-up of 30 months, DFS was significantly higher in the TPP group (12 months vs 8 months, p < 0.01) and a median overall survival was 21 months in the IFP group (yet to be achieved in the TPP group). The TPP group had most of the recurrences in visceral liver and lung (50.0 %) followed by peritoneal (37.5 %) and nodal (12.5 %), whereas in IFP, it was peritoneum (42.8 %), visceral (38.4 %) and nodal (15.3 %). The TPP group had significantly higher DFS and trend towards improved OS. This indicates aggressive surgical resection has benefit with manageable postoperative morbidity. However, longer follow-up and a prospective multi-institutional randomised study need to be designed for more evidence of the same.

2 illus, 3 tables, 30 ref

Clinical and histological features of intraoral flap and a preliminary study of DNA methylation of mucosalization

CHEN X, LI Y, ZHOU Z, YU T, FAN W, ZENG C, TANG Q, LIANG F

Mortality and morbidity prediction for older patients undergoing emergency abdominal surgery-comparison of the possum, E-pass score and sasa score

JAKUB K, KINGA M, KINGA S, URSZULA S, KAMIL R

040103 JAKUB K, KINGA M, KINGA S, URSZULA S, KAMIL R (General Dep, Jagiellonian Univ Medical Coll, Krakow, Poland, Email: jkenig@cm-uj.krakow.pl) : Mortality and morbidity prediction for older patients undergoing emergency abdominal surgery-comparison of the possum, E-pass score and sasa score. Indian J Surg 2020, 82(4), 551-8.

Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are The Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM), the Estimation of Physiologic Ability and Surgical Stress (E-PASS), and the Surgical Apgar Score combined with the American Society of Anesthesiologists (SASA) physical status classification. The aim of this study is to compare the above scoring systems in the prediction of 30-day postoperative mortality and major morbidity in older patients undergoing emergency abdominal surgery. Patients ≥ 65 years were enrolled into the study. Pre- and intraoperative variables were used to calculate the scores and the ROC curve; logistic regression analysis was performed. The study sample comprised 427 older patients with a median age of 77 (range 65–100) years. The most frequent surgical indications were cholecystitis, followed by ileus, complication of colorectal cancer, complicated diverticulitis, and appendicitis. Decreasing SASA and increasing EPASS and POSSUM/P-POSSUM scores were significantly associated with both 30-day postoperative major complications and death. Multivariate analyses identified all the scores as independent variables to predict postoperative outcomes. The areas under the ROC curve were 0.66–0.81 for predicting mortality and 0.67–0.79 for predicting morbidity (p < 0.01). All the scores were confirmed to be predictive of 30-day postoperative morbidity and mortality. The SASA and the E-PASS scores demonstrated the highest discriminatory ability. However, SASA was found to combine effectiveness and simplicity. Based on this study, we therefore recommend SASA for postoperative risk evaluation in older patients undergoing emergency abdominal surgery.

2 illus, 3 tables, 21 ref

Development and evaluation of the airtight, minimal-invasive, and fast device harvesting adipose tissue for autologous fat grafting

HUANG H-L, LIAO X, LIU H-W, OU W-G, SHE W-L, XIE B, XIAO L-L, XIE G-H, HUANG Y-W

040102 HUANG H-L, LIAO X, LIU H-W, OU W-G, SHE W-L, XIE B, XIAO L-L, XIE G-H, HUANG Y-W (Plastic Surgery Dep, Innovative Technology Research Institute of Tissue Repair and Regenera, Guangdong, China, Email: liuhongwei0521@hotmail.com) : Development and evaluation of the airtight, minimal-invasive, and fast device harvesting adipose tissue for autologous fat grafting. Indian J Surg 2020, 82(4), 545-50.

Gastrointestinal (GI) metastasis from lung cancer generally suggests the end-stage of the disease because it is already part of the systemic dissemination, thereby indicating poor prognosis. Its symptoms, such as perforation and hemorrhage, are frequently emergent, and immediate clinical decision is warranted, given the patient’s poor prognosis. Herein, we reported 14 cases of GI metastasis from lung cancer who underwent surgery in our department. The mean age was 63 years. The most frequent site and symptom of GI metastasis were the small intestine (64 %) and hemorrhage (43 %), respectively. Perforation occurred in three of the patients (21 %), showing the worst prognosis compared with hemorrhage and obstruction. The median survival was 101 days (19–1651 days). The clinical and pathological factors of these patients were investigated. As evaluated in our case series, longterm survival might be achieved through resection with no residual tumor and with early detection of GI metastasis. Surgeons need to consider such insight when being consulted for patients who have lung cancer with abdominal symptoms. The present study was undertaken to develop the device that can be used to harvest adipose tissue for fat grafting with an airtight, minimal-invasive, and fast approach. The abdominal liposuction was performed in six women under local tumescent anesthesia. Fat from left abdomen was harvested by the classical 20-ml-syringe technique while fat from right abdomen was harvested by a reformative vacuum-assisted suction device (negative pressure, 25 to 35 kPa). This device includes a 1-L sterile canister, a cannula with 2.5 mm inner diameter, a conventional liposuction machine, and a one-way valve connected between the canister and the liposuction machine. The operative time of harvesting 200-ml fat grafts was recorded and calculated. The collected adipose tissue was used for adipose-derived stem cells (ADSCs) extraction and culture, glucose transport test (GTT), and bacteriological culture. First, we found that the operative time of harvesting 200-ml adipose tissue using 20-ml-syringe aspiration technique was 71.3 ± 4.3 min compared with 30 ± 3.5 min by the new device (p < 0.05). The sizes of the fat grafts obtained from both methods were similar. Second, the viability of harvested adipose tissue tested through GTT showed no significant difference between two harvesting methods (p > 0.05). Additionally, the samples harvested from both methods showed no bacterial growth. The results from the XTT test revealed that there was no significant difference on ADSCs growth between two methods (p > 0.05). In conclusion, the results support that the innovative device for adipose tissue harvesting is minimal-invasive, fast, and can prevent the fat grafts from contamination.

4 illus, 1 table, 18 ref

Surgical intervention and its clinical significance of gastrointestinal metastasis from lung cancer: A series of 14 cases

KOYAMA R, MINAGAWA N, MAEDA Y, SHINOHARA T, HAMADA T

Presentation and outcomes of papillary thyroid microcarcinomas

CAYIR D, KULAH B, BOZKURT M

040100 CAYIR D, KULAH B, BOZKURT M (Nuclear Medicine Dep, Health Sciences Dep, Ankara, Turkey, Email: drderyaors@hotmail.com) : Presentation and outcomes of papillary thyroid microcarcinomas. Indian J Surg 2020, 82(4), 533-9.

Despite the increased incidence of papillary thyroid microcarcinoma (PTMC), clinical importance is still controversial. Although risk factors for PTMCs have been identified previously, prognostic factors have not been established clearly. In this study, we aimed to review the presentation features and outcomes of the patients with PTMC. Our study included 144 patients that underwent thyroidectomy and were diagnosed with PTMC according to the postoperative pathology report. All data included age, gender, mode of diagnosis, preoperative ultrasonography and fine needle aspiration cytology (FNAC) results, tumor features (diameter, unilobar localization, multifocality, and stage), the presence of residual thyroid tissue, postoperative serum thyroglobulin (Tg) levels, and radioactive iodine (RAI) ablation were retrospectively reviewed. Only 29 patients (20 %) with PTMC could be diagnosed preoperatively with FNAC which was performed in 67 % of the patients. The diameter and the number of thyroid nodules were significantly related to the mode of diagnosis. The average size of the tumor diameter was 5 mm ± 2.87. An extrathyroidal extension (ETE) was observed in 10 patients (7 %). Lymph node metastasis (LNM) was diagnosed in 6 patients (16 %). There was a significant correlation between ETE and tumor diameter with LNM (p = 0.008 and p < 0.001, respectively). Residual tissue was noted in 110 patients (76 %). The presence of residual thyroid tissue was significantly related to the extent of surgery, unilobar location, and multifocality. Mode of diagnosis (incidental or non-incidental), tumor diameter, the number of thyroid nodules, unilobar location, and multifocality seem to be related to unfavorable outcomes of patients with PTMC.

1 illus, 3 tables, 30 ref

Alternative reconstruction after pylorus preserving pancreaticoduodenectomy

BABA A A, NAQASH S H, SHAH M A, KHAN B A

040099 BABA A A, NAQASH S H, SHAH M A, KHAN B A ( General Surgery Dep, SKIMS, Jammu and Kashmir-190 011, Email: drarshadbaba@gmail.com) : Alternative reconstruction after pylorus preserving pancreaticoduodenectomy. Indian J Surg 2020, 82(4), 527-32.

Pancreaticogastrostomy has been known as a method of reconstruction after pancreaticoduodenectomy. According to some published reports, the pancreatic fistula rate for pancreaticogastrostomy is significantly lower than pancreaticojejunostomy. The purpose of this study was to present the results of pancreaticogastrostomy after pancreaticoduodenectomy, feasibility of cannulating CBD after reconstruction and ability to control postoperative anastomotic bleed. Pylorus preserving pancreaticoduodenectomies were performed in 40 cases. The reconstruction was done by invaginating the cut end of the remnant pancreas into the posterior wall of stomach (end-toside pancreaticogastrostomy). The divided jejunum was taken retrocolically and anastomosed with the stomach at the divided pylorus (end-to-end gastrojejunostomy). Hepaticojejunostomy was done about 10 cm from gastrojejunostomy in an end to side manner. Pancreaticogastrostomy was the method of choice for pancreatic-enteric anastomosis. Data was analyzed and presented as mean and SD and chi square test were used with p < 0.05 conferring statistically significance. Out of total 40 patients operated 7 (17.5 %) patients developed postop complications. One (2.5 %) developed biliary leak, 3 (7.5 %) developed intraabdominal collection, upper GI bleed was seen in 1 (2.5 %) patient and pancreatic fistula developed in 1(2.5 %) patient and 1 (2.5 %) developed cardiac complication (bradycardia). CBD cannulation was attempted in all patients but was successful without any major difficulty in 37 (92.5 %) patients. One (2.5 %) patient required operative intervention for pancreatic fistula and one (2.5 %) patient died during the hospital stay.

3 illus, 2 tables, 23 ref

Video Assisted Thoracoscopic Surgery (VATS) for all stages of empyema thoracis: A single centre experience

THORI R, DESAI G S, PANDE P, NARKHEDE R, VARDHAN A, MEHTA H

The use of paraspinal transposition flap for recurrent pilonidal sinus, a new histological basis for management of pilonidal sinus disease

FARAG A, NASR S E, FARAG A A, ELBARMELGI M Y

040097 FARAG A, NASR S E, FARAG A A, ELBARMELGI M Y (Cairo Univ, Giza, Egypt, Email: dr.yeho@yahoo.com) : The use of paraspinal transposition flap for recurrent pilonidal sinus, a new histological basis for management of pilonidal sinus disease. Indian J Surg 2020, 82(4), 514-9.

The ability of the pilonidal sinuses to spread laterally into both gluteal regions, governed by the skin vulnerability, raises the theoretical probability of a similar skin characteristic of the donor site from which most of the flaps used for repair of the PNS are taken. The present study aimed at a clinical outcome and histologic study of the use of paraspinal transposition flap for treatment of recurrent pilonidal sinus disease. This was a prospective clinical study that enrolled all patients who presented to our General Surgery Clinic, Kasralainy Hospital, Cairo University, with recurrent pilonidal sinus in the period from July 2007 till August 2017. They underwent excision of their pilonidal sinus and the use of paraspinal transposition flap to cover the defect. Histologic studies were done for the skin from both areas. This study ended up with 84 adult patients with recurrent pilonidal disease. The follow-up period ranged from 9 to 108 months (mean 70.45 months). All the patients reported pain scores from 0 to 3 during the first postoperative week. Incidence of early minor complications including mild wound dehiscence, sloughing at the tip of the flap, wound infection, and edema occurred in 21 patients (25 %). Three patients developed recurrence (3.57 %). Histological examination revealed deep pits lined by stratified squamous epithelium (SSE) at the macroscopic healthy skin at the edge of resection. Those changes were absent in biopsies from the flap skin. The paraspinal flap has good results in management of recurrent pilonidal disease. Also, histological findings suggest that the skin over both glutei is as vulnerable as the skin of the excised sinus which is different from the skin over the lower back. This explains that use of that skin to cover the defect is more prone to develop recurrence.

3 illus, 2 tables, 13 ref

Does scoring system help us in the diagnosis of acute appendicitis? A prospective clinical trial

GULER Y, DOGAN P, SENGUL S, CALIS H, KARABULUT Z

A new preoperative scoring system to predict difficulty of laparoscopic cholecystectomy and risk of conversion to open surgery

ABDELDAYEM M, OSGOOD L, ESCOFET X, FARAG M

040095 ABDELDAYEM M, OSGOOD L, ESCOFET X, FARAG M (General Surgery, Prince Charles Hospital, UK, Email: Magedfarag76@yahoo.com) : A new preoperative scoring system to predict difficulty of laparoscopic cholecystectomy and risk of conversion to open surgery. Indian J Surg 2020, 82(4), 501-6.

To develop a preoperative scoring model to assess difficulty of laparoscopic cholecystectomy (LC) and risk of conversion to open cholecystectomy (OC), retrospective analysis of patients who underwent elective LC and LC converted to OC between 01/06/ 2013 and 01/06/2014. LC difficulty assessment was based on operative time (OT) and conversion to OC. Preoperative factors included age; ultrasound scan (USS) findings; “gallbladder (GB) wall thickness; other acute inflammatory signs, e.g. pericholecystic fluid collection, common bile duct (CBD) diameter, and size of gallstones (GS)”; previous pancreatitis; endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Preoperative weighted score for LC difficulty was formulated based on the degree of significance of preoperative factors. A total of 280 patients were included, and 3.9 % had open conversion. Univariate analysis revealed highly significant (HS) association between prolonged OT and USS findings, thick GB wall (P = 0.003) and other acute inflammatory signs (P = 0.0001). Significant (S) association with pancreatitis (P = 0.05), ERCP (P = 0.027) and MRCP (P = 0.016). Conversion to OC had HS association with thick GB wall (P = 0.001) and other acute inflammatory signs (P = 0.0001), S association with age > 62.3 (P = 0.015) and large GS (P = 0.035). Score was formulated as follows: 2 points for HS factors on the multivariate analysis (thick GB wall and other acute inflammatory signs) (P = 0.027 and 0.007, respectively) and 1 point for each S factor (age > 62, large GS, pancreatitis and ERCP/MRCP). Sensitivity and specificity using ROC curve showed that patients scoring < 2 had a straightforward LC with OT < 63 min and no conversions to OC; score ≥ 2 had a difficult LC with prolonged OT ≥ 63 min (sensitivity 46 %, specificity 70 %, P = 0.03) but no conversion to OC, and score ≥ 4 had more difficult LC with OT ≥ 63 min and with possible conversions to OC (sensitivity 73 %, specificity 87 %, P = 0.001). The scoring system could be helpful in preoperative planning to improve efficiency of theatre time, better utilisation of day surgery lists and assignment of the appropriate surgical grade/experience.

1 illus, 6 tables, 19 ref

Incidence of pulmonary embolism in surgical patients: Hospital-based

PRASERTCHAROENSUK S, WONGKONKITSIN N, CHANTAWIBUL S

The effect of nutritional status on quality of life in palliative care patients

SERDAR K A, CAN S M, GOKCE A, YÜCE B H, FEZA Y K

The incidence of agenesis of Palmaris longus muscle among multiracial medical students of University Malaya, Malaysia

KASSIM N M, ZULKAFLI I S, ZAMIN R M, SALIM M A, DANAEE M, ZIN S R M

Open, laparoscopic and microsurgical varicocelectomy for male infertility: A systematic review and meta-analysis

WANG Q, LIU Y, WANG L

040091 WANG Q, LIU Y, WANG L (Pediatric Gastroenterology Dep, The First Hospital of Jilin Univ, Jilin-130 021, China, Email: yiyi20141223@163.com) : Open, laparoscopic and microsurgical varicocelectomy for male infertility: A systematic review and meta-analysis. Indian J Surg 2020, 82(4), 478–85.

The objective of the present systematic review and meta-analysis was to assess the effect of open, microsurgical, and laparoscopic varicocelectomy on the number of patients with improved sperm parameters (sperm concentration, motility) 6–12 months after surgery, spontaneous pregnancy rates ≥ 12 months after surgery, and postoperative sperm parameters in infertile males with a varicocele. We searched the Cochrane Library, PubMed, MEDLINE, and EMBASE databases from inception to December 2018 for randomized controlled trials (RCTs) comparing open, microsurgical, and laparoscopic varicocelectomy for male infertility. The meta-analysis demonstrated a significantly higher number of patients with improved sperm parameters 6–12 months after microsurgical varicocelectomy compared to laparoscopic varicocelectomy (OR = 1.63, 95 % CI 1.03–2.56; p = 0.04) or open varicocelectomy (OR = 2.06, 95 % CI 1.57– 2.70; p < 0.0001), a significantly higher spontaneous pregnancy rate at ≥ 12 months after microsurgical varicocelectomy compared to open varicocelectomy (OR = 1.47, 95 % CI 1.10–1.98; p = 0.01), a significant increase in postoperative sperm motility and concentration in patients that had undergone microsurgical varicocelectomy compared to laproscopic varicocelectomy or open varicocelectomy. These data suggest that, compared to laproscopic or open varicocelectomy, microsurgical varicocelectomy provides the greatest benefit to the most patients, results in a higher spontaneous pregnancy rate, and causes greater improvements in postoperative sperm parameters in males with a history of infertility. More high-quality large studies are needed to better illustrate the effects of the various surgical methods used to treat varicocele.

3 illus, 2 tables, 27 ref

Hybrid treatment for ischemic limb salvage in patients with subacute complex infrainguinal arterial occlusions

ELBADAWY A, HASABALLAH A

040090 ELBADAWY A, HASABALLAH A (Vascular and Endovascular Surgery Dep, Assiut Univ, Assiut- 71515, Egypt, Email: ahmedhassan.bakr@gmail.com) : Hybrid treatment for ischemic limb salvage in patients with subacute complex infrainguinal arterial occlusions. Indian J Surg 2020, 82(4), 472–7.

To evaluate safety and efficacy of a hybrid technique using a Fogarty catheter and an angioplasty balloon to retrieve organized thrombosis then endovascular therapy for underlying chronic lesions in subacute ischemic limbs with complex long infrainguinal arterial occlusions. Retrospective study. Patients presented with Rutherford (4:6) critical limb threatening ischemia (CLTI) and reported acute pain onset or worsening of existing symptoms and presented between 15 days and 3 months duration. Included cases underwent hybrid management for limb salvage performing short time inflation with angioplasty balloon to disrupt fibrosis then passing a Fogarty catheter to retrieve thrombosis and finally treating the underlying arterial lesions. Patient characteristics and comorbidities were reported; degree of disease in the crural vessels was described using the Society of Vascular Surgery modified runoff score. Pedal runoff was assessed according to pedal arch state. Study outcomes included technical success, 1- year patency, limb salvage, and amputation free survival (AFS) rates. Fifty-four patients (mean age 57.2), with a mean symptom duration of 7.3 ± 2.6 weeks, underwent the described hybrid management protocol. Mean runoff score was 7.5 ± 1.3. Distal embolization was reported in 11 (20.4 %) cases. Technical success was 90.7 %. Primary, assisted primary, and secondary patency rates were 64.8 %, 75.9 %, and 79.6 %, respectively. The 1-year AFS was 77.8 %. Limb salvage rate was 88.9 %. This study suggests that reported hybrid revascularization modality is considered a safe and effective alternative for treating subacute ischemic limb patients.

3 illus, 1 table, 21 ref

A comparative prospective study of laparoscopic and open-mesh repair for ventral hernia

PHALGUNE D

Infectious complications of hemodialysis tunneled catheters-types, diagnosis, and treatment strategies

BORISOV B, LINKOVA S

A general overview of incidence, associated risk factors, and treatment outcomes of surgical site infections

KHAN F U, KHAN Z, AHMED N, REHMAN A U

Curative efficacy of fosfomycin tromethamine versus ciprofloxacin in the initial therapy of uncomplicated uti-a prospective open-label randomised controlled clinical study

SINGH I, MURTAZA S M, KAUR I S, AGRAWAL V

040086 SINGH I, MURTAZA S M, KAUR I S, AGRAWAL V (Surgery (Urology) Dep, Medical Sciences Univ Coll (Delhi Univ) & GTB Hospital, Delhi-95, Email: iqbalsinghp@yahoo.co.uk) : Curative efficacy of fosfomycin tromethamine versus ciprofloxacin in the initial therapy of uncomplicated uti-a prospective open-label randomised controlled clinical study. Indian J Surg 2020, 82(3), 331–7.

The precise current role of fosfomycin in the management of uncomplicated UTI (uUTI) is not well defined in the published English literature (PubMed( ™) ). We aim to compare the overall curative efficacy, safety, and outcome of fosfomycin tromethamine vis-a-vis Ciprofloxacin therapy in the initial management of uncomplicated UTI in a select group of patients. After obtaining prior institutional ethical clearance and written informed consent, 120 consenting patients with uUTI were selected as per protocol (based on symptoms of uUTI, positive urine culture sensitivity (c/s), urine routine/microscopy (r/m) or positive urine leukocyte esterase dipstick (LED) test) and enrolled in this study. They were randomized by computer draw of lots, into two groups of 60 each, randomised to receive initial empirical therapy with either fosfomycin (F-intervention arm) or Ciprofloxacin (C-comparator arm), pending the urine culture report. Patients were followed up with urine culture analysis and other parameters. The primary outcome measures were clinical/bacteriological response/resolution of UTI documented by negative urine culture (sent on day 3), absence of pyuria, and negative urine LED on 3rd day. Urine c/s was sent at day 0, but treatment was started (based on randomization) for those with urine r/m positive and positive LED test, pending the result of c/s. If the urine c/s turned out to be negative, the patient was excluded from the study. For the patients who satisfied the inclusion criteria, urine c/s was again sent on day 3, based on which report, bacteriological cure was defined. Secondary outcomes included bacteriological spectrum, antimicrobial sensitivity pattern, incidence of UTI caused by extended spectrum beta-lactamase (ESBL) producing strains of Escherichia coli, possible risk factors for UTI, side effects, ADRs, and ADEs of the drugs. E. coli and Klebsiella were the commonest cause of UTI while ESBL uropathogens were detected in 14/120 (11.67 % 11 and 3 in F/C groups, respectively) patients. The sensitivity of uropathogens to F and C was 86 and 50% respectively while the overall clinical curative efficacy (CCE) of same was 83 and 43 % respectively. In the subset of 14 patients with UTI due to ESBL, the CCE of F and C was 91 and 67 % respectively. Side effects (minor and self-limiting) were significantly more common with the F group (p < 0.001), with diarrhoea being the commonest. Hospitalization was the commonest risk factor for UTI (27 %) though the association of risk factors with UTI was not significantly different (p = 0.609). Fosfomycin was safe and significantly more efficacious in treating uncomplicated UTI (p < 0.001) versus ciprofloxacin. The overall incidence of UTI due to ESBL strains was 12% in which the CCE of fosfomycin was significantly higher (p = 0.023).

2 illus, 6 tables, 30 ref

Neutrophil to lymphocyte ratio (nlr) and platelet to lymphocyte ratio (plr) versus laboratory risk indicator for necrotizing fasciitis (lrinec) as predictors of outcome in necrotising fasciitis

RAVINDHRAN B, RAJAN S, KERKETTA D, BALACHANDRAN G, MOHAN L N

040085 RAVINDHRAN B, RAJAN S, KERKETTA D, BALACHANDRAN G, MOHAN L N (General Surgery Dep, St. John’s Medical Coll Hospital, Karnataka - 560 034, Email: sendhil1986@gmail.com) : Neutrophil to lymphocyte ratio (nlr) and platelet to lymphocyte ratio (plr) versus laboratory risk indicator for necrotizing fasciitis (lrinec) as predictors of outcome in necrotising fasciitis. Indian J Surg 2020, 82(3), 325–30.

Necrotizing fasciitis (NF) is an aggressive infection with substantial morbidity and mortality despite advanced medical care, possibly due to non-specific clinical features in the initial stages. Prognostic indicators help in early diagnosis, risk stratification and decision-making. We analysed a historical cohort of 122 patients with biopsy-proven NF. Receiver operating characteristic (ROC) curve analysis was performed to find the cutoff levels for neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) as predictors of mortality, need for re-debridement and intensive care unit (ICU) stay. Patients were grouped according to cutoff levels of NLR, PLR and Laboratory Risk Indicator for NECrotizing fasciitis score (LRINEC) and their outcomes were compared. A multivariate logistic regression analysis was performed to assess the association between significant independent predictors of outcome in NF. Of the 122 patients who were studied, the mean age was 59.9 ± 14.1 years, with 81 (66.3 %) patients being male. Among them, 112 (91.8 %) were survivors and 9(8.2 %) were non-survivors. Non-survivors were diabetics (100 %), hypertensive (100 %), had ischemic heart disease (77 %) and had higher values of CRP (p < 0.001), creatinine (p = 0.003), LRINEC (p < 0.001), and NLR (p = 0.005). Patients who required repeat surgeries were older (p = 0.032), had higher white cell counts (p = 0.002), CRP (p = 0.01), LRINEC (p < 0.001), NLR (p < 0.001) and lower haemoglobin (p = 0.02). A multivariate logistic regression analysis revealed that NLR (p = 0.001), LRINEC (p = 0.002), creatinine (p = 0.002) and the presence of IHD (p = 0.002) were reliable predictors of poor outcome. LRINEC is a reliable predictor of outcome according to our study. The preoperative NLR (but not PLR) may be used as a potential and easy biomarker for prognostication in patients with necrotising fasciitis.

1 illus, 4 tables, 21 ref

Comparison of transanal minimally invasive surgery (tamis) and transanal endoscopic operations (teo)

KAYMAK S, SINAN H, SAYDAM M, AKTAS H H, GECIM E, DEMIRBAS S

040083 KAYMAK S, SINAN H, SAYDAM M, AKTAS H H, GECIM E, DEMIRBAS S (General Surgery Dep, Health Sciences Univ, 06010 Ankara, Turkey, Email: sahinkaymak@hotmail.com) : Comparison of transanal minimally invasive surgery (tamis) and transanal endoscopic operations (teo). Indian J Surg 2020, 82(3), 319–24.

Rectal lesions, benign or malignant, are one of the most encountered clinical entities in general surgery departments. Technological breakthroughs in local excision techniques have been occurring such as transanal endoscopic microsurgery (TEM), transanal minimally invasive surgery (TAMIS), and transanal endoscopic operations (TEO) during the last two decades. We compared the results between TAMIS and TEO for removing rectal lesions. The study was conducted on patients who underwent TAMIS and TEO interventions due to rectal lesions between 2010 and 2015 in the Department of General Surgery of Gulhane Military Medical Academy and the University of Ankara. The data for these patients relating to their age, gender, distance from the anal verge, operation time, occurrence of first bowel movement after surgery, initiation of oral intake after surgery, length of hospital stay, tumor size, follow-up, complications, free resection margin, recurrence, postoperative Fecal Incontinence Severity Index (FISI) and visual analog scale (VAS) scores, and pathologic specimen examination were taken from the hospital’s electronic database. All data were enrolled and analyzed statistically. The TAMIS group had 23 (54.8 %) patients, and the TEO group had 19 (45.2 %) patients. The TAMIS operation time was significantly longer than that of TEO (Z = 3.188; P < 0.001). Median time to first bowel movement in the TAMIS group was 36.0 h (interquartile range (IQR) = 12.0) vs. 24.0 h (IQR = 18.0) in the TEO group; the difference was significant (Z = 3.358; P = 0.001). No significant differences were found between the two groups in complication rate, recurrence, visual analog scale, or Fecal Incontinence Severity Index. TAMIS and TEO techniques have been found to produce almost similar results. These two techniques are considered to be good alternatives to conservative treatment methods with their reliability and feasibility in experienced hands for selected patients. For TAMIS and TEO techniques to qualify as “treatment of choice,” prospective randomized clinical trials are needed.

3 illus, 2 tables, 25 ref

Comparison of outer diameter of appendix, c-reactive protein, and serum bilirubin levels in complicated versus uncomplicated appendicitis

PAREKH D, JAIN D, MOHITE S, PHALGUNE D

040081 PAREKH D, JAIN D, MOHITE S, PHALGUNE D (Research Dep, Poona Hospital & Research Centre, Pune, Email: dphalgune@gmail.com) : Comparison of outer diameter of appendix, c-reactive protein, and serum bilirubin levels in complicated versus uncomplicated appendicitis. Indian J Surg 2020, 82(3), 314–8.

The primary objective of the present study was to compare outer diameter of the vermiform appendix on ultrasound, highsensitivity C-reactive protein (hs-CRP), and serum bilirubin in complicated versus uncomplicated appendicitis. Eighty patients with a diagnosis of acute appendicitis clinically and with confirmation on ultrasound undergoing operative management were included for this prospective, observational study. All the patients underwent transabdominal ultrasonography for measurement of diameter of the appendix. Total serum bilirubin and hs-CRP levels were measured. The operative findings were objectively classified as a complicated appendix if perforation of the appendix, empyema or abscess formation, faecal peritonitis, and gangrenous appendix were noted. Chi-square test or Fisher’s exact test and unpaired ‘t’ test were used to compare categorical and continuous variables respectively. Receiver operating characteristics (ROC) curve was used for different cut-off points of appendicular diameter and hs-CRP. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Mean appendicular diameter and mean hs-CRP level were significantly higher among the patients with complicated appendicitis compared with the patients with uncomplicated appendicitis. Sensitivity was 86.1 %, 94.4 %, and 100.0 % for appendicular diameter ≥ 7.95 mm, hs-CRP ≥ 6.60 mg/dL, and appendicular diameter ≥ 7.95 mm or hs-CRP ≥ 6.60 mg/dL respectively. Specificity was 88.6 %, 90.9 %, and 81.8 % for appendicular diameter ≥ 7.95 mm, hs-CRP ≥ 6.60 mg/dL, and appendicular diameter ≥ 7.95 mm or hs-CRP ≥ 6.60 mg/dL respectively. Appendicular diameter and hs-CRP levels were useful to diagnose complicated appendicitis preoperatively

2 illus, 2 tables, 19 ref

Long-term results and prognostic significance of non-anatomic liver resection for colorectal liver metastasis: Single center experience

CIVIL O, OKKABAZ N, SAHIN T T, TIRYAKI C, YAZICIOGLU M B, KEMENT M

040080 CIVIL O, OKKABAZ N, SAHIN T T, TIRYAKI C, YAZICIOGLU M B, KEMENT M (General Surgery Dep, Health Science Univ, Kocaeli, Turkey) : Long-term results and prognostic significance of non-anatomic liver resection for colorectal liver metastasis: Single center experience. Indian J Surg 2020, 82(2), 197-204.

Development of liver metastasis is a single poor prognostic indicator if left untreated, and therefore management of colorectal liver metastasis (CRLM) is a subject of active multidisciplinary approach. We aimed to evaluate the long-term results and poor prognostic indicators in patients undergoing liver resection for CRLM from a single center in Turkey. All patients who underwent hepatic resection due to colorectal metastasis between March 2007 and November 2011 in our institute were included. Demographic data, operative and postoperative parameters, and long-term follow-up data were analyzed. A total of 44 patients [29 (65.9 %) male, median age: 61 (32–81) years] were included to the study. Most of the patients [28 (63.6 %) had metachronous liver metastasis, and almost half of the patients [19 (45.2 %)] was oligometastatic. Major resection was performed in 18 (40.9 %) patients. Intraoperative US changed the operative strategy in 7 (19.4 %) patients. Thirty-day mortality was observed in 4 (9.1 %) patients. Reasons for mortality were uncontrolled sepsis [catheter infection (n = 1), anastomotic leak (n = 1), and intraabdominal abscess (n = 1)] and hepatic insufficiency (n = 1). Follow-up period excluding patients with early mortality was 30.4 (3–138) months. Kaplan-Meier survival analysis revealed that estimated median survival time after hepatic resection was 28 (95 % CI: 20.6–35.4) months. Five-year and 10-year survival probabilities were 20.5 % and 13.3 %, respectively. Multivariate Cox regression analyses showed that surgical margin positivity was the only significant factor affecting survival. Our results suggest that tumor margin and number of metastasis are the two determinant prognostic indicators in patients with CRLM. Surgery seems to offer a chance for cure, and surgeons in the field should try to perform liver resections in order to obtain negative margins. Major hepatic resections are justified provided that patient selection and preparation is thorough and surgical procedure can be performed safely.

2 illus, 3 tables, 30 ref

The association between mammographic density and molecular subtypes of breast cancer

KILIÇ M O, UÇAR A Y

Reliability of axis classification system for prediction of sigmoid volvulus severity

MOHAMED A A

040078 MOHAMED A A (Minia Univ, Minia, Egypt, Email: ashraf.azeem@yahoo.com) : Reliability of axis classification system for prediction of sigmoid volvulus severity. Indian J Surg 2020, 82(3), 310–13.

This study aimed at evaluating reliability of AXIS classification system in predicting severity of sigmoid volvulus. This retrospective study included 60 patients diagnosed as sigmoid volvulus in Minia University Hospital, Egypt, from January 2014 to January 2019. According to abdominal X-ray coffee-bean sign mesenteric axis, patients were classified into three groups: group 1, mesenteric axis of 0–90°; group 2, 90–135°; group 3, > 135° from horizontal. Treatment options included endoscopic detorsion followed by elective sigmoidectomy for patients without severe abdominal pain or intestinal necrosis; otherwise, open sigmoidectomy was performed. Analyzed patients’ data included: age, sex, body mass index (BMI), American Society of Anesthesiologists physical status (ASA) score, intestinal necrosis, need for surgery, 30 days mortality, and hospital stay. Sixty patients included 38 for group 1, 20 for group 2, and 2 patients for group 3. Mean age was 71.2 years. Forty-six patients were males, and 14 patients were females. ASA score was ≥ 2 in 56 patients (93.3%). Forty-eight patients (80 %) underwent endoscopic detorsion only. Four patients (6.7 %) underwent endoscopic detorsion followed by elective sigmoidectomy with primary anastomosis. Eight patients (13.3 %) underwent sigmoidectomy and Hartmann’s procedure without endoscopic intervention. Two patients (3.3 %) had complications. Intestinal necrosis and need for surgery were significantly associated with AXIS classification. AXIS classification can be used as predictive factor for severity of sigmoid vovulus in early stage of patient’s assessment. However, further prospective studies with large population number are needed to validate this system.

1 illus, 2 tables, 14 ref

The effects of thymoquinone (kalonji) on abdominal adhesion in experimental abdominal adhesive model

OZDEN H, SAYGUN O, DAPHAN C E, AYDINURAZ K, AYDIN O, TANRIKULU F B, DOM S

040077 OZDEN H, SAYGUN O, DAPHAN C E, AYDINURAZ K, AYDIN O, TANRIKULU F B, DOM S (General Surgery Dep, Ahi Evran Univ, Kirsehir, Turkey, Email: huseyinozden@ahievran.edu.tr) : The effects of thymoquinone (kalonji) on abdominal adhesion in experimental abdominal adhesive model. Indian J Surg 2020, 82(3), 305–9.

The aim of this study was to investigate the effects of thymoquinone on abdominal adhesion development in an experimental abdominal adhesion model. Forty-five female Wistar albino rats weighing 260–280 g were used in the study. The rats were randomized into 3 even groups. Control, serum physiological (SP), and thymoquinone (TQ) groups were formed. In the experimental abdominal adhesion model, caecum serosa was brushed until the petechial hemorrhages were seen. No additional procedures were performed in the control group except surgery protocol. SP was injected over the caecum in the SP group. In the thymoquinone group, the abdomen was closed after the application of prepared thymoquinone solution on the caecum surface. On the 21st day, tissue samples from sacrificed rats were examined macroscopically and microscopically, and statistically evaluated. There was a statistically significant difference between the control group and the thymoquinone group in the microscopic evaluation (p = 0.006). However, there was no statistically significant difference between SP group and control group, and between thymoquinone group and SP group. Macroscopic evaluation revealed a statistically significant difference between the thymoquinone group and the control group, and between the thymoquinone group and the SP group (p = 0.009, p = 0.027, respectively). In the microscopic and macroscopic evaluation, it was observed that thymoquinone had a decreasing effect on postoperative adhesions. We think that this effect of thymoquinone is due to its anti-inflammatory and antioxidant properties. However, the available data are not sufficient for this effect to be used in medical treatment. Furtherstudies are needed in the future.

2 illus, 2 tables, 22 ref

Prospective evaluation of perioperative biochemical tests to predict hypocalcemia after total thyroidectomy

PEKER Y, CIN N, KAR H, TATAR F, KAHYA M C, BARAN N G

040076 PEKER Y, CIN N, KAR H, TATAR F, KAHYA M C, BARAN N G (Surgery Dep, Izmir Katip Celebi Univ, Izmir- 35340, Turkey) : Prospective evaluation of perioperative biochemical tests to predict hypocalcemia after total thyroidectomy. Indian J Surg 2020, 82(2), 187-90.

Hypocalcemia is a common complication after total thyroidectomy. In these patients, the serum parathyroid hormone (PTH), calcium level decreases, and the phosphorus level increases. The level of fibroblast growth factor-23 (FGF-23), a phosphaturic hormone, increases in the serum to normalize the phosphorus level. In our study, we aimed to investigate the predictive value of PTH, calcium, phosphorus, 1,25-dihydroxy vitamin D (vitamin D), and FGF-23 tests in revealing patients who will develop hypocalcemia after thyroidectomy. Fifty-seven patients undergoing total thyroidectomy (fifty-two with multinodular goiter, three with Graves’ disease and two with papillary thyroid cancer) were included in this prospective study. Serum PTH, calcium, phosphorus, and vitamin D levels of the patients were measured preoperatively. Ten minutes after complete removal of the thyroid gland, intraoperative PTH (IOPTH) level was measured and the amount of decline in PTH level (PTH decline) was calculated. Postoperative PTH, calcium, phosphorus, vitamin D, and FGF-23 levels were measured 24 h after the operation. Postoperatively, hypocalcemia developed in 7 (12.3 %) of the 57 patients. IOPTH, postoperative PTH, calcium, and vitamin D levels were significantly lower and PTH decline was significantly higher in patients with postoperative hypocalcemia. Postoperative FGF-23 levels were similar between the groups (p 0.952). When the IOPTH and postoperative serum calcium values were evaluated together, the highest sensitivity and positive predictive values were obtained (93.5 % and 67.5 %, respectively), The postoperative FGF-23 test was found to be rather unsatisfactory to reveal development of hypocalcemia (sensitivity of 14.3 %). The success of detecting patients with hypocalcemia was highest when IOPTH and postoperative serum calcium levels were evaluated together. The FGF-23 measurements were found to be not sufficient in identifying hypocalcemic patients after total thyroidectomy.

4 tables, 19 ref

Comparison of length of postoperative hospital stay in pulmonary resection patients with and without autologous fibrin sealant: A retrospective descriptive study

ERSOZ H, SANLI A, KARAÇAM V, TASDOGEN A, OZDEMIR N

Management for hemorrhage from the gallbladder bed caused by injury to the middle hepatic vein during laparoscopic cholecystectomy

CHAOLIANG L, LAN F, QINGHUA T, PENG H

040074 CHAOLIANG L, LAN F, QINGHUA T, PENG H (Gastroenterology Dep, The First People’s Hospital of Jiangxia District, Wuhan- 430 200, China) : Management for hemorrhage from the gallbladder bed caused by injury to the middle hepatic vein during laparoscopic cholecystectomy. Indian J Surg 2020, 82(2), 182-6.

Hemorrhage from the gallbladder bed during laparoscopic cholecystectomy which is a risk factor for conversion to laparotomy remains a serious problem. And injury to branches of the middle hepatic vein is an important reason for bleeding from the gallbladder fossa. The aim of this study was to report our experience of laparoscopic management for hemorrhage from the gallbladder bed because of injury to the middle hepatic vein. This study involved 8 patients with injury to the middle hepatic vein during laparoscopic cholecystectomy, and their records were analyzed retrospectively. Compression hemostasis with gauze was firstly performed to reduce or stop bleeding from the gallbladder bed in each patient. An injured branch of the middle hepatic vein in a patient was sutured with 3/0 non-absorbable suture under laparoscopy. The hemorrhage in the other 7 patients was managed successfully by closing the injured branches of the middle hepatic vein with laparoscopic Hem-o-lok tip. The mean time spent to maintain hemostasis was 27.6 min. LC was finished in each case. No patient received blood transfusion. Serious complications such as bile duct injury and hepatic artery bleeding did not occur during LC and after operation; there was no obvious abnormality in liver function after surgery. All of the 8 patients were cured and discharged, and no complication occurred after 12 months of follow-up. Laparoscopic treatment for hemorrhage caused by injury to the branches of the middle hepatic vein is safe and effective, and calm operation and maintaining a clear surgical vision is the premise of effective control for bleeding. Compression on the bleeding area of source with gauze is the first choice to stop bleeding during LC. But when the laparoscopic treatment for bleeding is difficult, it still should be timely converted to open surgery.

5 illus, 16 ref

Impact of covid-19 on general surgical practice in India

NASTA A M, GOEL R, KANAGAVEL M, EASWARAMOORTHY S

040073 NASTA A M, GOEL R, KANAGAVEL M, EASWARAMOORTHY S (Wockhardt Hospitals, Mumbai, Email: amritnasta@hotmail.com) : Impact of covid-19 on general surgical practice in India. Indian J Surg 2020, 82(3), 259–63.

The coronavirus disease 2019 (COVID-19) pandemic is a global health crisis, and surgeons are at increased occupational risk of contracting COVID-19. The impact of the disease on prevalent general surgical practice is uncertain and continues to evolve. The study aimed to study the impact of COVID-19 on general surgical practice in India and the future implications of the pandemic. A survey questionnaire was designed and electronically circulated 1 month after India entered a national lockdown during COVID19 pandemic, amongst members of Indian Association of Gastro-intestinal Endo-surgeons (IAGES), a surgical association with nearly eight thousand members from across the country. Survey questions pertaining to pre-COVID era surgical practices, impact on current practice, and financial implications were asked. Responses were collected and statistically analyzed. One hundred fifty-three surgeons completed the survey, of which only 9.2 % were women. Majority (41 %) were into practice for more than 20 years; 36.6 % were into private practice at multiple hospitals (free-lancers). Amongst the respondents, 41.8 % had mainly laparoscopic practice with mean outpatient consultation of 26 patients/day and elective surgeries of 43 cases/month prior to lockdown. Post-lockdown, daily outpatient consults reduced to 4 patients per day, and 77% had not performed a single elective procedure. Hydroxychloroquine (HCQ) chemoprophylaxis was reported by 52 % surgeons. Personal protective equipment (PPE) was used by 52 % for all cases, while 71.5 % stated there are insufficient guidelines for future surgical practice in terms of safety. A drop of more than 75 % of their monthly income was experienced by 52 % surgeons, while 22 % faced 50–75 % reduction. One third (33 %) of respondents own a hospital and are expecting a monthly financial liability of 2.25 million rupees (nearly 30,000 US dollars). COVID-19 has led to a drastic reduction in outpatient and elective surgical practices. There is a definite need for guidelines regarding safety for future surgical practices and solutions to overcome the financial liabilities in the near future.

5 illus, 12 ref

The effects of working hours on sleep quality and burnout in Turkish pediatric surgeons

TANGUL S U, HACIMUSALAR Y, KARAASLAN O

Breast cancer management guidelines during covid-19 pandemic

GOWDA S M, KABEER K K, JAFFERBHOY S, MARLA S, SOUMIAN S, MISRA V, NARAYANAN S, BRUNT A M

Elevation of thin pudendal artery flap using fat thickness data in vulvovaginal reconstruction

FUJIWARA M, SUZUKI T, OHTA Y, OKADA E, FUKAMIZU H, TOKURA Y

Quality improvement in laparoscopic donor nephrectomy by self-imposed proctored preceptorship model

BANSAL D, BANSAL V K, KRISHNA A, MISRA M C, RAJESHWARI S, SINGH S, MINZ M

040069 BANSAL D, BANSAL V K, KRISHNA A, MISRA M C, RAJESHWARI S, SINGH S, MINZ M (Surgical Disciplines Dep, All India Institute of Medical Sciences, New Delhi- 110 029) : Quality improvement in laparoscopic donor nephrectomy by self-imposed proctored preceptorship model. Indian J Surg 2020, 82(2), 163-8.

Initiation of an advanced laparoscopic surgery program requires skill and proper training. Despite description of multiple surgical training modules, an ideal method for training of surgeons for advanced laparoscopic procedures is lacking. We propose an abbreviated self-imposed proctored preceptorship training model as the optimum training method for training skilled laparoscopic surgeons in advanced laparoscopic procedures like laparoscopic donor nephrectomy. The laparoscopic donor nephrectomy program was started at the Institute using preceptorship-proctorship model. One hundred left laparoscopic donor nephrectomies were performed over the course of 2 years. Outcomes in terms of performance related (Surgeon) outcomes in the form of learning curve and patient outcomes in terms of donor outcomes and recipient results and were studied. Learning curve was calculated using the moving average method and calculation of mean operative time of every five consecutive cases. Mean operative time for laparoscopic donor nephrectomy was 108.1 ± 26.5 min, the warm ischemia time averaged at 3.5 ± 1.3 min and the mean blood loss was 130.1 ± 54.9 ml. Moving average analysis revealed that approximately 20 LDN cases were needed to complete the learning phase. According to the mean operative time of every five consecutive cases, learning phase of LDN was completed between 26 and 30 cases. We believe that the abbreviated self-imposed proctored preceptorship model of training is an optimum model for starting a new advanced laparoscopic surgery program and can help surgeons to overcome the initial learning curve.

1 illus, 3 tables, 20 ref

Residents feedback on faculty and working environment: The urology training program in India

PANDEY S, GOEL A

Small incision in lower posterior axillary wall combining multihole drainage technique for the treatment of axillary bromhidrosis

HE C, TAN L, ZHANG Q, CHEN Z, LIU Y, LENG X

040067 HE C, TAN L, ZHANG Q, CHEN Z, LIU Y, LENG X (Plastic Surgery Dep, The Affiliated Hospital of Qingdao Univ, Shandong- 266 07, China) : Small incision in lower posterior axillary wall combining multihole drainage technique for the treatment of axillary bromhidrosis. Indian J Surg 2020, 82(2), 151-6.

Surgical excision of apocrine glands is an effective method for the treatment of bromhidrosis. However, common postoperative complications such as skin necrosis can result in prolonged healing and unsightly scars, which are mainly caused by surgical injuries and seroma or hematoma formation. We have improved the traditional surgical methods, in the hope that the new method can not only ensure the surgical effect, but also minimize the surgical trauma and postoperative complications. Forty-four patients with bromhidrosis were included. A 1-cm incision was made in the posterior wall of the lower axilla. Tissue scissors completely separated the skin from the subcutaneous tissue of glandular distribution. Iris scissors were used to trim subcutaneous glandular tissue, until there was only full-thickness skin left. Residual glandular tissue was removed with serrated edge curettage. After adequate irrigation and hemostasis, a drainage strip was placed in the incision. Then, we evenly divided the surgical area into 8 sections. In the center of each section, a draining hole was made. Of the 88 axillae, malodor was eradicated in 84 and considerably reduced in 4. Although 6 arms had temporary edema, and 10 axillae experienced superficial epidermal necrosis, no full-thickness skin necrosis was observed. Complications like hematoma, seroma, and infection were not present in all cases. All the scars of the incision and drainage holes were inconspicuous. The use of small incisions in the posterior axillary wall could accomplish sweat gland elimination and simultaneously provide excellent drainage. Combining this with porous drainage can effectively prevent hematoma, skin necrosis, and scar formation.

2 illus, 5 tables, 20 ref

A bibliometric analysis of pectoral nerve blocks

YILMAZ F, BAS K

040066 YILMAZ F, BAS K (Anaesthesiology and Reanimation Dep, Health Science Univ, Turkey) : A bibliometric analysis of pectoral nerve blocks. Indian J Surg 2020, 82(2), 147-50.

Pectoral nerve blocks (Pecs I and Pecs II) are superficial thoracic wall blocks which block the pectoral and intercostal nerves. They can be used as analgesia/anesthesia for breast surgery and other procedures/surgeries involving the anterior chest wall (arteriovenous graft creation surgery, minimally invasive cardiac surgery and thoracotomy, etc.). The aim of this study is to evaluate publications in the scientific field of pectoral nerve blocks. ISI Web of Knowledge-Science was used for the analysis. All scientific works published included in the Science Citation Index Expanded (SCI-E) from 1975 to January 27, 2019, were analyzed. A retrospective search was performed using key words “pectoral nerve block,” “PECS I,” “PECS II,” “pecs block,” “PECS block,”“Pecs I,” “Pecs II,” “PECS 1,” “PECS 2,” and “modified pecs I block.” We further analyzed these results by the “analyze” function of the software in terms of number of papers for each country, type of documentation, number of publications per year, and name of journals and authors. The number of citations to published works was also calculated by using the citation function of the same software. 72 papers were found related to pectoral nerve block. The biggest contribution was from India (24.28 %), and followed by Japan (14.28 %), USA (14.28 %), Canada (7.14 %), Egypt (7.14 %), Italy (5.71 %), and South Korea (5.71 %). The total number of publications increased sharply in years from 2014 (n = 1) to 2018 (n = 28). We have detected that papers on the use of pecs block in breast cancer surgery, which is one of the most common surgical procedure in the world, are few in the literature. With this study, we hope to increase the awareness on this area. We believe that pecs block applications will become widespread with the increasing use of ultrasound in anesthesia and the increase in education in this field.

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