Is There an Association between Variceal Bleed and Helicobacter pylori Infection in Cirrhotic Patients with Portal Hypertension?: A prospective cohort study.

Objectives: This study aimed to determine the association between Helicobacter pylori infection and variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension. Methods: This prospective cohort study included patients with bleeding oesophageal varices and was conducted at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from August 2016 to July 2018. Results: A total of 190 patients were assessed for eligibility, of which 159 patients were included in this study. Among the 159 patients, 124 (78.0%) had alcohol-related liver disease and eight had hepatitis B virus-related liver disease. Seven patients with varices had bled neither at presentation nor during the follow-up period. A total of 78 (49.1%) patients were H. pylori infected. The primary outcome, which was correlation between prevalence of H. pylori and the incidence of bleeding/rebleeding from varices as well as encephalopathy found that patients with oesophageal varices (adjusted risk [AR] = 0.714) and H. pylori infection (AR = 0.682) had a lower risk of variceal rebleeding. Among H. pylori-negative patients, pepsinogen I was higher in patients with rebleeding (30.7 versus 14.4 ng/mL; P <0.001). The secondary outcome, which was correlation of the site of bleeding with H. pylori infection and the association of the ratio of pepsinogen I/II with bleeding showed that among H. pylori-positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 versus 1.3 ng/mL; P = 0.023). Conclusion: H. pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of the H. pylori infection, rebleeding was associated with increased levels of gastric acid output, as demonstrated by the level of pepsinogen.

Division of Fasciocutaneous Pedicled Flaps-Is It Time to Change Practice?: A Prospective Randomized Controlled Trial.

INTRODUCTION: The study was carried out to evaluate the safety of early division of the pedicled flaps and to identify the optimum day of division. METHODS: This prospective, parallel arm, open-label, noninferiority, randomized controlled trial was carried out from January 2019 to July 2020. All patients (age, ≥5 years) undergoing reconstructive procedures using pedicled flaps were randomized in 1:1 ratio to receive either early division or conventional division protocol. In the early-division group, the flap perfusion, if satisfactory on day 8 by clinical and thermographic methods, a clamp was applied on the pedicle. The clamp was gradually tightened to produce controlled delay, and perfusion assessment was repeated after complete tightening. If satisfactory, the flaps were divided. Primary endpoints were flap at 24 hours after division, day of division, and day of complete inset of the flap. Secondary end points included perfusion of the flap on day 8, morbidity parameters (wound infection/suture dehiscence, need for secondary surgery and donor site morbidity), quality of life, and function scores. RESULTS: Thirty-five patients were included in each group. The 2 groups were similar in terms of various demographic, clinicopathological variables, defect and flap characteristics. The flap survival rate was similar (P = 0.31) between the early (34/35) and standard (35/35) division groups. The early-division group had a significantly early mean day of flap division (mean difference of 12.74 days; P < 0.00001) and complete flap inset (mean difference of 12.09 days; P < 0.00001). All flaps had satisfactory perfusion on day 8. The wound infection rate was 1.33 times significantly higher in the conventional group (P = 0.033). There was a higher incidence of donor site morbidity (9% vs 0%) in the conventional group when compared with the early division group. The quality of life and function scores at 3 weeks (mean difference 2.37; P < 0.001) and 6 weeks (mean difference 3.76; P < 0.001) and adjacent joint stiffness were significantly higher in the early division group when compared with conventional group. CONCLUSIONS: The pedicled flaps can be divided significantly early at an average duration of 10 to 11 days after flap inset with increased patient satisfaction rate and with a reduced postoperative morbidity. The authors have included a diversity of pedicled flaps used in different anatomic locations. By using stratified block randomization, we could ensure that the distribution was similar between the 2 groups, thus minimizing the heterogeneity in the analysis. This could also potentially indicate the usefulness of the controlled delay technique, irrespective of the anatomic location and type of the flap.

Histological Analysis of the Effect of Nanofat Grafting in Scar Rejuvenation.

Introduction: The morphology and tissue response to macro- and micro-fat grafting have been widely studied in both clinical and experimental settings; the histological effects of the nanofat graft, however, remain largely unexplored. Aims: This study was carried out to evaluate the histological changes leading to scar rejuvenation in a fine scar following nanofat grafting. Materials and Methods: This was an experimental study carried out on guinea-pig fine-line scar models. Nanofat prepared from abdominal fat of the animal was injected into scar on right legs (NFG) at 1 month whereas left acted as controls (CG). Punch biopsies from all scars were analyzed at 2, 4, and 6 months by Hematoxylin&Eosin, Masson's trichrome, and Picrosirius red stains to evaluate dermal/epidermal regeneration, collagen fiber orientation, pattern of distribution, and amount of mature and immature collagen. Results: Nine animals were included in the final analysis of the study. On histological analysis, the amount of inflammatory infiltrate, collagen fiber orientation, pattern and total histological score at 2, 4, and 6 months were similar between the groups. There was an increased trend for earlier appearance of organized and mature forms of collagen in the NFG group. The distribution of collagen was similar at 2 months; however, there was a significant increase in collagen distribution in NFG at 4 months (NFG: 46.11±11.6, CG: 31.16±9.9; P = 0.010) and at 6 months (NFG: 63.48± 6.6, CG: 49.9 ±8.8; P = 0.002). Conclusion: Nanofat grafting is associated with an accelerated and increased production of mature collagen with proper alignment in fine-line scars.

The Impact of "COVID-19" and "Webinar Pandemic" on Plastic Surgery Practice in Teaching Institutes and Resident Training-A Multicentric Perspective.

Introduction The study was carried out to quantify the changes induced by the pandemic in plastic surgery practice and training and to study the impact of the webinars on plastic surgery education from a residents' perspective. Methods In this multicentric study, the number and type of surgeries, cause of injuries, and their regional variation during the coronavirus disease 2019 (COVID-19) period (February-September 2020) were compared with pre-COVID-19 time. An online survey on the impact of webinars was conducted for plastic surgery trainees across the country. Results There was a significant reduction in total number of surgeries ( p = 0.003). The procedures for hand ( p = 0.156), faciomaxillary injuries ( p = 0.25), and replantations ( p = 0.46) were comparable; there was a significant reduction in combined orthopedic-plastic-surgical procedures ( p = 0.009) during the pandemic. There was a significant reduction in road accidents ( p = 0.007) and suicidal injuries ( p = 0.002) and increase in assault ( p = 0.03) and domestic accidents ( p = 0.01) during the COVID-19 period. A usefulness score of >8 was given for the webinars by 68.7% residents. There was no significant difference in perception of utility when correlated with the academic program at their institutes ( p = 0.109); 92% opined webinars should continue in post-COVID times. Conclusion There was a drastic reduction in number of elective and emergency procedures during the COVID-19 time, negatively affecting resident training program. Majority of residents felt that webinars could prove a useful adjunct to training in formal training program in post-COVID-19 scenario.

Clinical Outcomes of Surgical Management of Primary Brachial Plexus Tumors.

Introduction This study evaluates the clinical presentation, tumor characteristics, and clinical outcomes of surgically treated benign and malignant brachial plexus tumors (BPTs). Methods A prospective study of patients with BPTs from June 2015 to August 2020 was conducted. All patients underwent surgical resection with microneurolysis and intraoperative electrical stimulation to preserve the functioning nerve fascicles. Results Fourteen patients with 15 BPTs underwent surgical resection. Mean age was 37.8 ± 12.3 years; with male to female ratio 4:10. The clinical presentations were swelling (100%), pain (84.6%), and paresthesia (76.9%). The lesions involved roots (5/15), trunk (5/15), division (1/15), and cords (4/15). Thirteen patients had benign pathology (8 schwannomas, 3 neurofibromas, 2 lipomas) and two had malignant neurofibrosarcoma. Gross total resection was achieved in all cases except a dumbbell tumor. The mean follow-up period was 24 ± 5 months. Postoperatively, all patients reported improvement in pain and paresthesia with no new sensory deficit. All patients had developed initial motor weakness (Grades 2-4); however, full power (Grade 5) was recovered by 3 to 5 months. Conclusion Total resection can be achieved by appropriate microneural dissection and electrophysiologic monitoring and is potentially curative with preserving function.

Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial.

BACKGROUND: The study aimed at comparing restrictive and liberal transfusion strategy in reducing mortality in patients with upper gastrointestinal bleeding (UGIB). METHODS: This was a single-center, prospective, open-label, non-inferiority, randomized controlled trial conducted over two years. Patients presenting with UGIB were randomized into restrictive (hemoglobin (Hb) <7 g/dl) or liberal (Hb <8 g/dl) transfusion strategy groups. Transfusion was given till patients achieved target Hb of 9 g/dl in restrictive and 10 g/dl in the liberal arms. Patients with exsanguinating bleeding, transfusion within 90 days, recent history of trauma or surgery were excluded. Primary outcome was mortality rate and the secondary outcomes were morbidity, re-bleeding episodes and the need for intervention. RESULTS: A total of 224 patients were randomized to 112 patients in each group. Demographic characteristics were comparable. 45-day mortality was similar between the two groups (restrictive vs. liberal; 10/112 vs. 12/112; P = 0.65). The number of in-hospital bleeding episodes (12 vs. 9; P = 0.25), incidence of re-bleeding during the 45-day follow-up (13 vs. 14; P = 0.84), need for endoscopic banding for varices (37/112 vs. 39/112, P = 0.99), mean hospital stay (days) (3.21 ± 2.78 vs. 2.73 ± 1.29; P = 0.10) were similar between the two groups. CONCLUSION: Restrictive transfusion strategy is non-inferior to liberal transfusion strategy in patients with UGIB.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial.

BACKGROUND: Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures. AIMS: To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery. METHODOLOGY: This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed. RESULTS: Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001). CONCLUSION: Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.

Assessment of Clinical and Histological Changes in the Skin Paddle of Pectoralis Major Myocutaneous Flap in Intraoral Reconstruction: A Prospective Cohort Study.

PURPOSE: This study was carried out to characterize the clinical and histological changes in the cutaneous portion of the transferred pedicled pectoralis major myocutaneous flaps used in intraoral reconstruction in patients with head and neck malignancy. METHODS: This was a prospective cohort study carried out from July 2016 to 2018. All patients underwent ablative surgery for oropharyngeal cancers and primary reconstruction with pedicled pedicled pectoralis major myocutaneous flaps. The intraoral flaps were examined for color, texture, presence of hair, chronic inflammatory changes, and ulceration. At 12 months, incisional biopsies were taken from the skin paddle of the intraoral flap and contralateral normal buccal mucosa, and flap histology was compared with that of the contralateral buccal mucosa. RESULTS: Twenty patients were included in the final analysis (M/F, 4:1; mean ± SD age, 51.38 ± 6.76 years). Fourteen flaps resembled oral mucosa, 3 had a mixed appearance of both skin and mucosa, and 3 had appearance of normal skin at 1 year follow-up. The epidermis and stratum corneum were retained in all the flap biopsies; however, severe attenuation was noted in 7 patients (had mucosal appearance) but was significantly different from oral mucosa(P = 0.0003). Cutaneous appendages were found in all the flap epithelia. Thirteen flaps showed grossly attenuation, of which 11 patients had a gross appearance resembling oral mucosa and 2 had a mixed appearance. The biopsies showed varied degree of chronic changes like desquamation in around 35% (7 patients), hyperkeratosis in 35% (7 patients), and chronic candidiasis in 30% (6 patients). CONCLUSIONS: Although the intraorally transferred flaps demonstrate a morphological appearance similar to oral mucosa, there is a histological preservation of skin elements and architecture.

Idiopathic gigantomastia: newer mechanistic insights implicating the paracrine milieu.

PURPOSE: Gigantomastia refers to pathological breast enlargement usually occurring in the peripubertal or peripartum period. Idiopathic gigantomastia, however, is a rare entity with hypotheses citing local expression of hormones and growth factors in causing this disease, none of which have been systemically analysed. The purpose of this study was to delve deeper into the mechanistic pathways causing this condition. METHODS: Herein, we describe three patients of idiopathic gigantomastia, all of whom had had normal puberty and uneventful pregnancies. Further, one of the patients had postmenopausal gigantomastia which is extremely rare, with only four cases described in the literature. Serum markers of autoimmunity, incriminated hormones and growth factors analysed, were normal in all the cases. Breast tissue specimens were subjected to histopathological examination and immunohistochemistry for ER, PR and Her-2-Neu. Quantitative immunofluorescence for aromatase, IGF2, EGFR, TGF-ß, PDGFR-α, ß, IGF1 and PTHrP was also performed. RESULTS: Of these, the tissue expression of aromatase, IGF2, EGFR, TGF-ß, PDGFR-α and ß were found to be upregulated, whereas IGF1 and PTHrP were comparable to normal breast. CONCLUSION: This observation that paracrine overexpression of these factors is responsible for the pathogenesis of apparently idiopathic gigantomastia may have therapeutic ramifications in the future for patients with this debilitating condition.

Comparison of efficacy of silver-nanoparticle gel, nano-silver-foam and collagen dressings in treatment of partial thickness burn wounds.

INTRODUCTION: This study was carried out to compare the efficacy of silver nanoparticle gel (SG), nanosilver foam (SF) and collagen (C) dressings in partial thickness burn wounds. METHODS: This was a single-center, prospective cohort study carried out over a period of 1 year on patients with 15-40% partial thickness thermal burns ≤48 h. Each patient received all three dressings (silver-nanoparticle gel, nanosilver foam, collagen) simultaneously at 3 randomly selected areas which were comparable in terms of burn depth and surface area. Efficacy of the dressings was assessed in terms of healing rates, time taken and ease of application, pain at dressing change, cost, wound-swab culture and scar quality (at 3 months). RESULTS: A total of 20 patients were included. In SF group, number of patients with 60%-80% re-epithelialization on day10 (SG: 10/20; C: 10/20; SF: 16/20; p = 0.042) and complete healing on day14 (SF: 11/20, C: 6/20, SG: 4/20; p = 0.032) was significantly higher. The time for dressing change was similar at admission (p = 0.918) and day 10 (p = 0.163), although majority of the patients in SF group needed less than 10 min. The time taken (<10 min) was significantly lower in SF group by 14th day (SF: 18/20 C: 6/20 SG: 6/20; p < 0.001). The ease of application rated by clinicians as "extremely easy" was significantly better in SF group (SG: 78%, C: 80%, SF: 95%; p = 0.011). There was a significantly faster decrease in pain scores in SF group by 5th day (VAS score SF: 6, C: 8; SG: 8; p = 0.038), however, pain scores were comparable at 2 weeks. The scar quality (p = 0.82), cost (p = 0.09) and infection rates (SG: 7/20; C: 4/20; SF: 3/20; p = 0.05) were comparable. The need for skin-graft cover was lower in SF group (SG: 5/20; C: 3/20; SF: 1/20). CONCLUSION: Nanosilver-foam dressings were found to be more efficacious for re-epithelialization, healing, ease of application, tolerance when compared to silver nanoparticle gel and collagen dressings in partial-thickness burns. All were found to be safe.

Effect of Perioperative High Oxygen Concentration on Postoperative SSI in Elective Colorectal Surgery-A Randomized Controlled Trial.

BACKGROUND: This study was carried out to investigate the effect of perioperative high oxygen concentration on surgical site infection (SSI) in patients undergoing elective colorectal surgery. METHODS: This was a single-center, prospective, parallel arm, double-blind, superiority randomized controlled trial. All patients more than 18 years of age undergoing elective colorectal surgery were included as per the inclusion criteria. Patients were randomized at the time of induction of anesthesia into high concentration and standard concentration oxygen group based on the concentration of oxygen. Incidence of SSI, day of the detection of SSI, grade of SSI, incidence of anastomotic leak, postoperative day of return of bowel functions, day of starting oral feeds, day of ambulation, and length of hospitalization were studied in both the groups. RESULTS: A total of 94 patients were included in the study, 47 patients each in high concentration oxygen group and standard concentration oxygen group respectively. The SSI rates were comparable between the two groups [55.3% (95% CI-4.012-69.83) vs. 40.4% (95% CI-26.37-55.73); p = 0.215]. There was no significant difference found with respect to mean day of detection of SSI [4.5(IQR-3.0-7.5) vs. 6.0 (IQR-3.0-9.0; p = 0.602], postoperative day of return of bowel functions (2.20 ± 0.542 vs. 2.13 ± 0.582; p = 0.540), oral feeds (3.62 ± 0.945 vs. 3.46 ± 1.048; p = 0.544), ambulation (4.17 ± 0.868 vs. 4.17 ± 1.270; p = 0.987), and the length of hospitalization [15(IQR-10-19) vs. 15(IQR-10.75-18.25); p = 0.862] between the two groups. CONCLUSION: There was no significant difference in the rate of SSI with the use of perioperative high oxygen concentration in patients undergoing elective colorectal surgery.

Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial.

OBJECTIVES: The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency simple closure of perforated duodenal ulcer (PDU). METHODS: This single-center, prospective, open-labeled, superiority, RCT was carried out from August 2014 to July 2016. Patients of PDU undergoing open simple closure were randomized preoperatively in 1:1 ratio into standard care and adapted ERAS group. Patients with refractory shock, ASA class ≥3, and perforation size ≥1 cm were excluded. Primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity. RESULTS: Forty-nine and 50 patients were included in standard care and ERAS group, respectively. Patients in ERAS group had a significantly early functional recovery (days) for the time to first flatus (1.47 ± 0.18; p < 0.001), first stool (2.25 ± 0.20; p < 0.001), first fluid diet (2.72 ± 0.38; p < 0.001), and solid diet (3.70 ± 0.44; p < 0.001). LOH in ERAS group was significantly shorter (mean difference of 4.41 ± 0.64 days; p < 0.001). There was a significant reduction in postoperative morbidity such as superficial SSI (RR 0.35, p = 0.02), postoperative nausea and vomiting (RR 0.28, p < 0.0001), and pulmonary complications (RR 0.24, p = 0.04) in the ERAS vs. standard care group with similar leak rates (1/50 vs.2/49). CONCLUSION: ERAS pathways are safe and feasible in select patients undergoing emergency simple closure of PDU.

External validation of scoring systems in risk stratification of upper gastrointestinal bleeding.

AIM: The aim of this study was to externally validate the four commonly used scoring systems in the risk stratification of patients with upper gastrointestinal bleed (UGIB). METHODS: Patients of UGIB who underwent endoscopy within 24 h of presentation were stratified prospectively using the pre-endoscopy Rockall score (PRS) >0, complete Rockall score (CRS) >2, Glasgow Blatchford bleeding scores (GBS) >3, and modified GBS (m-GBS) >3 scores. Patients were followed up to 30 days. Prognostic accuracy of the scores was done by comparing areas under curve (AUC) in terms of overall risk stratification, re-bleeding, mortality, need for intervention, and length of hospitalization. RESULTS: One hundred and seventy-five patients were studied. All four scores performed better in the overall risk stratification on AUC [PRS = 0.566 (CI: 0.481-0.651; p-0.043)/CRS = 0.712 (CI: 0.634-0.790); p<0.001)/GBS = 0.810 (CI: 0.744-0.877; p->0.001); m-GBS = 0.802 (CI: 0.734-0.871; p<0.001)], whereas only CRS achieved significance in identifying re-bleed [AUC-0.679 (CI: 0.579-0.780; p = 0.003)]. All the scoring systems except PRS were found to be significantly better in detecting 30-day mortality with a high AUC (CRS = 0.798; p-0.042)/GBS = 0.833; p-0.023); m-GBS = 0.816; p-0.031). All four scores demonstrated significant accuracy in the risk stratification of non-variceal patients; however, only GBS and m-GBS were significant in variceal etiology. Higher cutoff scores achieved better sensitivity/specificity [RS > 0 (50/60.8), CRS > 1 (87.5/50.6), GBS > 7 (88.5/63.3), m-GBS > 7(82.3/72.6)] in the risk stratification. CONCLUSION: GBS and m-GBS appear to be more valid in risk stratification of UGIB patients in this region. Higher cutoff values achieved better predictive accuracy.

Efficacy and Feasibility of Objective Structured Clinical Examination in the Internal Assessment for Surgery Postgraduates.

INTRODUCTION: Traditionally assessment in medical training programs has been through subjective faculty evaluations or multiple choice questions. Conventional examinations provide assessment of the global performance rather than individual competencies thus making the final feedback less meaningful. The objective structured clinical examination (OSCE) is a relatively new multidimensional tool for evaluating training. This study was carried out to determine the efficacy and feasibility of OSCE as a tool for the internal assessment of surgery residents. METHODS: This study was carried out on the marks obtained by surgery residents at different levels of training in a single tertiary center in India over the 4 OSCEs conducted in the years 2015 and 2016. The marks of the OSCE were collected from the departmental records and analyzed. Reliability was calculated using internal consistency using Cronbach's α. Validity was calculated by item total correlation. Content validation was done by obtaining expert reviews from 5 experts using a proforma, to assess the content and checklist of each station of the OSCE. RESULTS: A total of 49 surgery residents were assessed in small batches during the above mentioned period. Of the 4 OSCEs conducted by us, 3 had a high value of Cronbach's α of greater than 0.9, as opposed to the set standard of 0.7. Out of 23 stations used in the 4 examinations separately, only 3 stations were found to have a low correlation coefficient (item total correlation), and hence, a low validity. The remaining 20 stations were found to have a high validity. Expert review showed unanimous validation of the content of 17 out of the 23 stations, with few suggestions for change in the remaining 6 stations. The material and manpower used was minimal and easy to obtain, thus making the OSCE feasible to conduct. CONCLUSION: OSCE is a reliable, valid. and feasible method for evaluating surgery residents at various levels of training.