Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration).

Context: The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries. Aims: To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India. Settings and Design: Multi-centric retrospective study. Methods and Material: A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period). Statistical Analysis Used: Microsoft Excel 2019 and SPSS Version 20. Results: The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent. Conclusions: The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

Effect of acute and long-term oral tobacco use on oesophageal motility.

BACKGROUND AND AIMS: Nicotine administration is known to decrease lower oesophageal sphincter (LOS) pressure. Although a few studies have assessed the effect of tobacco on the LOS, the effect of acute and long-term oral tobacco use on oesophageal motility is not known. The study was designed to investigate the effect of acute and long-term oral tobacco use on LOS and distal oesophageal motility. METHODS: Thirty-six healthy men (aged 18-65 years, median 34 years; 18 oral tobacco users, 18 non-tobacco users) underwent oesophageal manometry using a water-perfusion system. After baseline manometry, tobacco users were asked to keep 0.5 g tobacco in their mouth for 10 min; non-users of tobacco were kept in quiet surroundings for a similar period. Manometry was then repeated. RESULTS: The LOS basal pressures were similar in tobacco users and non-tobacco users (mean +/- SD 15.4 +/- 6.3 vs 13.4 +/- 5.3 mmHg). In the distal oesophageal body, the velocity (4.4 +/- 3.1 vs 4.9 +/- 2.6 cm/s), amplitude (92.7 +/- 38.3 vs 84.8 +/- 33.2 mmHg) and duration of contraction (2.1 +/- 0.7 vs 1.7 +/- 0.9 s) were similar in tobacco users and non-users. Acute tobacco use did not affect these parameters. The numbers of abnormal waves (triple peaks and non-transmitted contractions) were also similar in the two groups. CONCLUSION: Oral tobacco use does not appear to affect LOS pressures and distal oesophageal motility acutely or in the long term.

Acquisition of Helicobacter pylori infection and reinfection after its eradication are uncommon in Indian adults.

BACKGROUND: Eradication of Helicobacter pylori infection is known to decrease the recurrence rate of peptic ulcer disease. Data from India on the acquisition rate of H. pylori infection and reinfection after eradication are scant. AIM: To study the rates of acquisition of H. pylori infection and of reinfection after eradication in Indian adult patients. METHODS: We evaluated 116 consecutive patients with dyspepsia undergoing endoscopy. Sixty-four of them were H. pylori-positive on gastric antral biopsy (rapid urease test and histology). Patients diagnosed to have H. pylori infection were treated with a four-drug regimen (omeprazole, bismuth subcitrate, tetracycline, furazolidine) for 2 weeks; those failing H. pylori eradication were treated with a second regimen (lansoprazole, amoxycillin, secnidazole) for one week. Patients who were H. pylori-negative to begin with and those who had successful H. pylori eradication were followed up clinically and endoscopically every 3 months for a median of one year. RESULTS: Ninety-six patients (50 H. pylori-positive) were available for study; the other 20 were lost to follow up after the first endoscopy. Fifty of the 96 (52%) were H. pylori-positive; four of these 50 patients did not follow up after first treatment. The eradication rate with the four-drug regimen was 89.1% (41/46). Four of the 5 non-responders eradicated H. pylori with the second regimen. At the end of median one year follow-up (range 9-15 months), one of the 45 patients (2.4%) who eradicated the organism developed reinfection; none of the 46 patients who were initially H. pylori-negative acquired new infection. CONCLUSIONS: The risk of reinfection after eradication is low in Indian subjects at the end of one year. The rate of acquisition of new infection is also low in the adult population.

Predictors of response to pneumatic dilatation in achalasia cardia.

BACKGROUND: The role of esophageal laboratory testing in predicting response to balloon dilatation in patients with achalasia cardia has been evaluated in the West; data in Indian patients are scant. AIM: To study the predictors of response to pneumatic balloon dilatation in Indian patients with achalasia cardia. METHODS: Twenty-five patients with achalasia cardia who had earlier undergone esophageal manometry before balloon dilatation (Group A) were recalled for clinical evaluation. Another consecutive 25 patients with newly diagnosed achalasia (Group B) underwent esophageal manometry and isotope transit studies before and after dilatation. RESULTS: The overall symptom response to dilatation in the 50 patients at median (range) follow up of 26 (1-60) months was 64%. Pre-dilatation clinical and laboratory parameters did not predict outcome. All patients with 1-week post-dilatation lower esophageal sphincter (LES) basal pressure less than or equal to 10 mmHg and residual pressure less than 6 mmHg were asymptomatic at follow up. CONCLUSION: Post-dilatation LES basal pressure less than or equal to 10 mmHg and residual pressure less than 6 mmHg are predictors of symptom response to balloon dilatation in patients with achalasia cardia.

Jejunal stricture complicating acute mesenteric venous thrombosis secondary to protein C deficiency and factor V Leiden gene mutation.

We report a patient with high small intestinal obstruction due to ischemic stricture, secondary to acute mesenteric venous thrombosis. Tests done for hypercoagulability revealed dual etiology (protein C deficiency and factor V Leiden gene mutation). The patient underwent surgical resection and has been on anticoagulation treatment. At 2 years' follow up, she remains asymptomatic.

Profile of extrahepatic portal venous obstruction in Mumbai.

AIM OF THE STUDY: To study the clinical profile of extrahepatic portal venous obstruction (EHPVO) in a tertiary referral centre in Mumbai. METHODOLOGY: Retrospective analysis of records of 113 patients with EHPVO, treated between January 1984 and May 1996. RESULTS: Thirty eight of 54 (70.4%) patients in whom information was available were delivered at home. Eleven of the 50 (22%) had umbilical sepsis after birth. Median disease duration was 5 years (range 4 months-31 years), with age at initial presentation 13 (range 0.5-45) years; 24 (20%) patients presented after age 20 years. Eleven presenting initially with splenomegaly bled after 3 (1-14) years. Number of bleeding episodes per patient was 2.5 (1-12). 13 of 44 (29.6%) patients bled (first bleed or recurrence) after age 20 years. Twenty five (22.3%) had ascites at some time, 17/102 (16.7%) had hypersplenism, and hypoalbuminaemia was present in 20/103 (19.2%). Endoscopic sclerotherapy obliterated varices in 47/52 (90.4%) in 10.5 (3-40) sessions over 7 (1-100) months. Twenty three patients underwent surgery: devascularisation in 20 (with splenectomy in seven), distal lieno-renal shunt in two, and meso-caval shunt in one patient. Follow-up was available in 68 (60.2%) patients. Rebleeding after sclerotherapy occurred in 27/64 (42.2%), with median one (1-5) per patient; recurrence of varices was noted in 15/35 (42.9%) patients over 12 (3-39) months. Varices were present in 12 patients 163 (33-305) months after surgery. CONCLUSIONS: Home delivery and umbilical sepsis may be risk factors in the development of EHPVO. A significant number of patients present or continue to bleed from varices after age 20. Variceal sclerotherapy is effective for eradication of oesophageal varices.

Multiple cutaneous metastases from laryngeal carcinoma.

A case of laryngeal squamous cell carcinoma recurrence presenting as multiple cutaneous metastases is presented. Such metastases are rare and are associated with a poor prognosis. Treatment is usually aimed at providing pain relief in these patients with a limited life expectancy.

Pancreatic ascites.

Pancreatic ascites is rarely considered in the differential diagnosis of exudative ascites, and is in fact missed in a majority of patients. Eleven cases of pancreatic ascites are described. 63.6% were chronic alcoholics. The clinical diagnosis was cirrhosis of liver (5/11), tuberculous peritonitis (5/11) or malignant peritonitis (1/11). In all patients ascites was exudative and the ascitic fluid amylase was markedly elevated (mean +/- SD: 7815 +/- 6507 SU/dl). Endoscopic retrograde pancreatography (ERP) performed in 4 patients demonstrated the site of leak in 3. Laparoscopy performed in 8 patients helped in the diagnosis of pancreatic ascites in all, which was confirmed on histology. Laparoscopy ruled out other causes of exudative ascites in all. We conclude that pancreatic ascites should be suspected in any patient with exudative ascites, especially chronic alcoholics and that ascitic fluid amylase should be routinely performed in all such cases. High ascitic fluid content is virtually diagnostic of pancreatic ascites. ERP is essential in preoperative assessment or planning endoscopic treatment. Laparoscopy is an invaluable investigation to rule out other conditions such as tuberculous or malignant peritonitis and cirrhosis of liver.

Ankylosing spondylitis in females. Similarities and differences with male spondylitics.

Ten female and seventy two male patients suffering from ankylosing spondylitis were studied to evaluate differences between the two sexes. Low lumbar backache and inactivity stiffness were the commonest presenting complaints in females (8/10) as compared to males (34/72). They also had a later age of onset (25.4 + 6.16 yrs) compared to males (20.56 + 6.57 yrs). Females were found to be symptomatically milder with a more benign course of the disease. There were no significant differences in the frequency of extra-articular features and HLA B27 between males and females. A positive family history was more often seen in female ankylosing spondylitis (50%) than male (31.94%) patients.