Effect of Synbiotics in Reducing the Systemic Inflammatory Response and Septic Complications in Moderately Severe and Severe Acute Pancreatitis: A Prospective Parallel-Arm Double-Blind Randomized Trial.

AIM: This study aimed at evaluating the efficacy of synbiotics in reducing septic complications in moderately severe and severe acute pancreatitis. METHODS: This was a prospective, parallel-arm, double-blinded superiority randomized control study. All patients with moderately severe and severe acute pancreatitis were included in the study. Acute on chronic pancreatitis, pancreatitis due to trauma, ERCP and malignancy were excluded. 1 g of synbiotic containing both pre- and probiotics was administered to the cases twice a day for 14 days and a similar-looking placebo to controls. Patients were followed for 90 days. Primary outcomes were reduction of septic complications and inflammatory marker levels. Secondary outcomes were mortality, non-septic morbidity, length of hospitalization (LOH) and need for intervention. RESULTS: A total of 86 patients were randomized to 43 in each arm. Demographic profile and severity of pancreatitis were comparable. There was no significant difference in septic complications between the groups (59% vs. 64%; p 0.59). Total leucocyte and neutrophil counts showed a significant reduction in the first 7 days (p = 0.01 and 0.05). No significant difference was seen in other inflammatory markers. There was a significant reduction in the LOH (10 vs. 7; p = 0.02). Non-septic morbidity (41% vs. 62.2%; p 0.06) and length of ICU stay (3 vs. 2; p 0.06) had a trend towards significance. The need for intervention and mortality was comparable. CONCLUSION: Synbiotics did not significantly reduce the septic complications in patients with moderately severe and severe acute pancreatitis; however, they significantly reduced the LOH. There was no reduction in mortality and need for intervention. Clinical Trials Registry of India Number: CTRI/2018/03/012597.

Hunger-Based Versus Conventional Oral Feeding in Moderate and Severe Acute Pancreatitis: A Randomized Controlled Trial.

BACKGROUND: The length of hospitalization is prolonged in patients with acute pancreatitis due to delay in feeding. The present study aimed at evaluating hunger-based early feeding for its efficacy in reducing length of hospitalisation. AIMS AND METHODS: This was a parallel arm superiority randomized control trial. Patients with moderate and severe acute pancreatitis were randomised into hunger-based feeding and conventional feeding groups. Patients in hunger-based feeding group commenced feeding once they felt hungry and in conventional feeding group after normalization of biochemical parameters and resolution of symptoms. Patients were followed up till their discharge and were analyzed for length of hospitalisation, fasting duration, feed intolerance, incidence of infective morbidities and invasive procedures. RESULTS: Hunger-based feeding and conventional feeding group included 56 and 54 patients, respectively. Hunger-based feeding led to a decrease in length of hospitalization (6.3 days in hunger-based feeding vs 7.3 days in conventional feeding group, P = 0.041) and fasting duration (1.6 days in hunger-based feeding vs 2.7 days in conventional feeding group, P = 0.001).The incidence of feed intolerance (P = 0.098), infective morbidities and invasive non-surgical procedures were similar in both the groups. CONCLUSION: Hunger-based feeding significantly reduces length of hospitalization and fasting duration in cases of moderate and severe acute pancreatitis without any significant rise in the incidence of complications. Registration number of Clinical Trails Registry India CTRI/2019/01/017,144.

Effect of perineural bupivacaine infiltration on reducing inguinodynia in patients undergoing inguinal meshplasty - a randomized controlled trial.

INTRODUCTION: Inguinodynia after inguinal meshplasty is a notable complication with an incidence of 13-37%. We wanted to determine if a perineural infiltration of bupivacaine given intraoperatively would reduce the incidence of immediate postoperative pain and inguinodynia. METHODOLOGY: We have conducted a single-blinded randomized controlled trial including 100 patients with inguinal hernia. Patients in the control group received only spinal anaesthesia. The intervention group received perineural bupivacaine infiltration in addition to spinal anaesthesia. Intraoperatively Ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve was identified and 2 mL of 0.5% bupivacaine was given perineurally along these identified nerves. Presence of inguinodynia, immediate post-operative pain scores using the Wong-Baker faces pain scale, duration of analgesics use, use of additional analgesics along with Paracetamol 500 mg tablet, and the length of hospital stay between the groups were recorded. RESULTS: 100 patients were randomized in the study, 49 in control and 51 in the intervention group. Both the group was comparable in terms of demographic characteristics. The intervention group had significantly lower median pain score at 3 h [4 ± 1.662 vs. 6 ± 1.55; p = .0001] and 6 h [4 ± 1.33 vs. 6 ± 1.307; p = .0001]. The incidence of inguinodynia did not significantly differ between the two groups (p-value = .12). CONCLUSION: Intraoperative Perineural bupivacaine infiltration significantly reduces the immediate postoperative pain. However, there was no significant reduction in the incidence of inguinodynia or additional analgesic requirement.

Efficacy of Pregabalin and Antioxidants Combination in Reducing Pain in Chronic Pancreatitis: A Double Blind Randomized Trial.

BACKGROUND: In patients with chronic pancreatitis (CP), pain relief is a dilemma. Antioxidants with pregabalin therapy have been reported to be useful. Hence, this study was carried out to determine the efficacy of the combination of antioxidant and pregabalin therapy in reducing pain in patients with CP. METHODS: This was a prospective, double blind, superiority, and randomized trial in patients with CP. The treatment group received pregabalin with antioxidants therapy for 8 weeks, and a similar placebo was administered to the controls. Primary outcome was to determine the change in maximum pain intensity assessed by visual analog scale (VAS) and Izbicki pain score. Secondary outcomes were the number of painful days, opioid and non-opioid requirements, improvement in quality of life, number of hospital admission, and overall patient satisfaction. RESULTS: A total of 90 patients were randomized to 45 in each arm. Demographic profile and baseline pain score were comparable. Patients in treatment group when compared to placebo group had a significant reduction in pain intensity (VAS score 2 ± 0.8 vs. 1.3 ± 0.9; p = 0.007), non-opioid analgesic requirement in days (54.4±2.9 vs. 55.7±1.5; p = 0.014), and number of hospital admissions (0.2 ± 0.5 vs. 0.6 ± 0.7; p = 0.002), respectively. Significant proportion of patients was satisfied in the treatment group compared to placebo group (18% vs. 11%; p = 0.03). CONCLUSION: The combination of pregabalin and antioxidant significantly reduces the pain, requirement of non-opioid analgesics, and the number of hospital admissions in patients with CP. It also significantly improves the overall patient satisfaction. CLINICAL TRIALS REGISTER NUMBER: CTRI/2017/05/008492.

Prophylactic Negative Pressure Wound Therapy in Reducing Surgical Site Infections in Closed Abdominal Incision: A Randomized Controlled Trial.

Objective: This study aimed to evaluate the efficacy of prophylactic negative pressure wound therapy (PNPWT) in reducing the incidence of surgical site infection (SSI) and other wound complications in closed abdominal incisions. Approach: This was a prospective, single-center, open-label parallel arm superiority randomized controlled trial conducted over 2 years. Participants were randomly assigned to PNPWT and standard surgical dressing (SSD) group. The occurrence of postoperative SSI within 30 days, other wound-related complications, length of hospital (LOH) stay, and readmission within 1 month among both the study group were studied. Results: A total of 140 participants were included, with 70 each randomized to the PNPWT and SSD groups. In this study, 28.5% and 5.8% developed SSI in the SSD and PNPWT groups, respectively (relative risk = 0.26; 95% confidence interval = 0.08-0.80; p = 0.001). Similarly, the incidence of seroma (7.2% vs. 18.5%, p = 0.016), wound dehiscence (0% vs. 4.2%, p = 0.244), superficial and deep SSI (5.7% vs. 24.3%, p = 0.001) and (0% vs. 4.2%, p = 0.244), and LOH stay (days) (9 vs. 10.5, p = 0.07) were less in PNPWT compared to SSD group. Innovation: Despite the advances in surgical care, SSI rates continue to be high. The present findings might facilitate the use of PNPWT as a novel preventive strategy to reduce SSI in closed abdominal incision. Conclusion: The PNPWT in closed incisions following elective laparotomy can reduce the incidence of SSI when compared to SSD. The use of PNPWT was associated with a lower incidence of superficial SSI and seroma but without significant reduction in hospital stay. Clinical Trial Registry India: CTRI/2020/11/028795.

Effect of preoperative oral carbohydrate loading on postoperative insulin resistance, patient-perceived well-being, and surgical outcomes in elective colorectal surgery: a randomized controlled trial.

BACKGROUND: Insulin resistance (IR) is one of the independent determinants influencing the length of hospital stay (LOHS) and postoperative complications in colorectal procedures. Preoperative oral carbohydrate loading (OCL) has emerged as a prospective countermeasure for IR. This study aimed to investigate the effects of preoperative carbohydrate loading on postoperative IR, inflammatory parameters, and clinical outcomes in patients undergoing elective colorectal surgery. METHODS: This was an open-label, parallel arm, superiority randomized controlled trial conducted over 2 years. Participants were assigned to conventional fasting and oral OCL groups. IR, insulin sensitivity, Glasgow Prognostic Score (GPS), and interleukin 6 levels were analyzed on the day of surgery and on the first postoperative day (POD-1) and third POD (POD-3). Clinical parameters, such as thirst, hunger, dry mouth, anxiety, weakness, pain, nausea, and vomiting, were compared in the perioperative period. In addition, surgical clinical outcomes, such as intestinal recovery, time to independent ambulation, postoperative morbidity, and LOHS, were studied. RESULTS: A total of 72 participants were included, with 36 in each group. In the OCL group, there was a statistically significant decrease in postoperative IR on the day of surgery, POD-1, and POD-3 (P = .0336). Similarly, inflammatory parameters and the GPS were found to be significantly lower in the OCL group (P < .001). Clinical parameters, such as thirst, hunger, and dry mouth, were significantly lower in the intervention group (P =.00), with a shortened LOHS. CONCLUSION: This study demonstrated that preoperative carbohydrate loading is associated with reduced IR and inflammatory markers, shortened hospital stays, and improved overall clinical outcomes in elective colorectal surgery.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial.

BACKGROUND: Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AIM: To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. RESULTS: Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. CONCLUSION: ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Association Between Helicobacter pylori and Periampullary and Pancreatic Cancer: a Case-Control Study.

INTRODUCTION: Helicobacter pylori has been implicated in the etiopathogenesis of various malignant conditions; however, there is a dearth of studies on the correlation between H. pylori infection and pancreatic cancers. Hence, this study was carried out to evaluate the association between H. pylori infection and periampullary and pancreatic cancer. METHODS: This was a single-centre, retrospective, case-control study in which all consecutive patients of periampullary or pancreatic cancer were included. The demographic details with tumour characteristics were recorded. Age and gender-matched controls were patients with other extra-abdominal benign conditions. H. pylori and the Cag A status were determined using IgG antibodies and Cag A antibodies respectively. The association between H. pylori infection and periampullary and pancreatic cancer was the primary outcome. RESULTS: A total of 155 patients, 61 in the study and 94 in the control group were included. The overall prevalence of H. pylori in the study group (78.6%) was similar to that of the control group (76.5%) (p = 0.76). Although a higher trend of IgG and Cag A seropositivity was seen in the study group, the difference was not significant. The correlation of H. pylori and Cag A seropositivity showed a higher trend with site-specificity, differentiation, and nodal status. However, the difference was not significant. CONCLUSION: There was no association between H. pylori infection and Cag A seropositivity with periampullary and pancreatic cancers. The various tumour characteristics were also not associated with H. pylori infection. Thus, routine eradication of H. pylori infection may not be recommended in periampullary and pancreatic cancers.

Procalcitonin and C-Reactive Protein as an Early Predictor of Infection in Elective Gastrointestinal Cancer Surgery-a Prospective Observational Study.

BACKGROUND: Postoperative infections are a common entity following elective gastrointestinal surgery among which intra-abdominal infection is notorious and life threatening. Early detection could reduce postoperative morbidity and permit safe and early discharge. This study was aimed to establish the usefulness of procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day 3 as reliable markers for early detection of intra-abdominal infection and other postoperative infections following elective gastrointestinal cancer surgery. METHODS: A total of 125 patients following elective gastrointestinal cancer surgery were prospectively observed until discharge from January 2018 to December 2019. The incidence of intra-abdominal infections and other postoperative infections was recorded. Serum PCT and CRP were estimated on postoperative day 3 for all the patients. ROC analysis of PCT and CRP was performed to establish their predictability in detecting these infections. Risk factors for postoperative infections were also studied. RESULTS: The incidence of intra-abdominal infection (IAI) was 24%. The difference in PCT between the infected and non-infected patients was statistically significant (p = 0.001) but not in CRP (p = 0.223). On ROC analysis of CRP and PCT in detecting IAI, the areas under the curve were 0.494 and 0.615 respectively. CONCLUSION: Raised serum PCT values on postoperative day 3 indicate the presence of infections and should prompt the surgeon to consider other investigations to confirm the presence of IAI and other postoperative infections and plan early intervention thus expediting the postoperative recovery. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2018/12/016695.

The Diagnostic Dilemma of Ruptured Liver Metastasis in a Patient with Lung Cancer: A case report.

Spontaneous rupture of a metastatic liver tumour is rarely documented in the literature when compared to hepatocellular carcinoma and other liver lesions, especially from a lung primary. We report a case of ruptured liver metastasis from an adenocarcinoma of the lung mimicking ruptured liver abscess, challenging the clinical diagnosis. A 42-year-female patient presented to a tertiary care institute in 2020 with complaints of abdominal pain, breathlessness and fever. On examination, the patient was tachypnoeic with a right hypochondriac mass. A contrast-enhanced computed tomography of abdomen and thorax revealed an ill-defined heterogeneously enhancing lesion in the liver with a communicating subcapsular collection and hypo-enhancing lesions in the left lobe and heterogeneously enhancing lesion in the left lung. Adenocarcinoma of the lung with hepatic metastasis was confirmed with a core needle biopsy. The patient was managed conservatively with intravenous antibiotics, intercostal drainage tube and gefitinib. However, despite best efforts, the patient succumbed to the disease.

Role of Sarcopenia in Predicting the Postoperative Morbidity and Perioperative Mortality in Patients Undergoing Elective Surgery for Gastric Cancer.

PURPOSE OF STUDY: This study was done to assess the effect of sarcopenia and other risk factors on the postoperative morbidity and perioperative mortality of patients undergoing elective surgery for gastric cancer. METHODS: This was a prospective cohort study comprising a single group of patients undergoing elective surgery for gastric cancer carried out in a tertiary care center in India. Patients diagnosed with gastric cancer underwent contrast-enhanced computed tomography preoperatively. Patients were considered sarcopenic when their skeletal muscle index (SMI) was < 34.9 cm2/m2 for women and < 40.8 cm2/m2 for men. Patients were planned for surgery ranging from gastrectomy with curative intent to palliative gastrojejunostomy. Postoperative complications including mortality were noted for 30 days following surgery and graded according to the Clavien-Dindo classification. The role of sarcopenia and other risk factors on the postoperative outcome of patients was noted. RESULTS: A total of 100 patients were included in the study. There was a high prevalence of sarcopenia (62%) among patients with gastric cancer who underwent elective surgery. However, sarcopenia was not associated with any postoperative complication (p > 0.05) including 30-day mortality (p = 0.155), prolonged postoperative hospital stay (p = 0.876), or 30-day readmission rate (0.524). Among the variables considered, only esophagojejunostomy (p < 0.001) was associated with a poor postoperative outcome. CONCLUSION: The present study showed that there was a high prevalence of sarcopenia (62%) in patients undergoing elective surgery for gastric cancer. However, it did not adversely affect the postoperative outcome. Among the variables considered, esophagojejunostomy alone was associated with a poor postoperative outcome.

A qualitative exploratory study of delay in the presentation of gastrointestinal cancer.

INTRODUCTION: Patients with gastrointestinal (GI) cancers often present late in the advanced stages, due to various reasons and may experience delays in treatment. Hence, we have attempted to find the factors leading to this delay. METHODS: This was an exploratory qualitative study, in a tertiary care hospital, including 20 patients with advanced GI cancers. They were interviewed to assess the reasons for delays in presentation, diagnosis and treatment, and the factors were analysed based on the interval of delay and the cause. RESULTS: This study found that there was an interval of delay of 8 months from the onset of symptoms till primary treatment, more than half of which occurred in the pre-hospital phase (56.4%). We classified the causes for the delay into different intervals such as the appraisal interval, health-seeking interval, diagnostic interval and the pre-treatment interval. Lapses at the individual, societal and institutional level lead to the delay. The major causes included ignorance, substance abuse, poverty, social stigma, vague symptoms and missed diagnosis, miscommunication, resource constrain, very poor doctor-patient ratio and delay in investigation and treatment. CONCLUSION: This study noted a significant delay in the treatment of patients with advanced gastrointestinal cancers. Reasons for delay have been noted at various levels. Further action based on this study, at the community and hospital level could potentially reduce the delay and result in better survival and improved quality of life.

Association between serum 25-hydroxy vitamin D level and gastric adenocarcinoma - a cross sectional study.

INTRODUCTION: Vitamin D is found to have anti-cancer properties. Although the preventive role of vitamin D in cancer is proven, its role in gastric cancer is equivocal. AIM: To evaluate vitamin D deficiency in patients with gastric adenocarcinoma and its relationship with the disease characteristics. MATERIAL AND METHODS: This single-centre, prospective, cross sectional study was carried out from February 2017 to December 2018. Serum 25-hydroxy vitamin D levels of 94 patients with gastric adenocarcinoma and 94 age- and sex-matched healthy controls were estimated. Among cases, vitamin D levels and disease characteristics such as TNM stage, tumour grade, clinical stage and patient demographics were analysed. RESULTS: The vitamin D levels among cases (13.83 ±5.97 ng/ml) were significantly lower (p < 0.0001) than the control group (29.15 ±4.13 ng/ml). Vitamin D deficiency was found in 88% of cases and in 3% of controls. Among cases, age, T stage and clinical stage had a significant inverse relationship with vitamin D levels. Cases with distant metastasis and cases with pain had significantly lower levels of vitamin D compared to the cases without distant metastasis and without pain respectively. Other study parameters did not have a significant relationship with vitamin D. CONCLUSIONS: Vitamin D deficiency is associated with occurrence of gastric adenocarcinoma and correlates with the disease severity. However, to assign a causal relationship and to study the beneficial effect of vitamin D in gastric cancer, further research is needed.

Serial estimation of serum C-reactive protein and procalcitonin for early detection of anastomotic leak after elective intestinal surgeries: a prospective cohort study.

OBJECTIVES: Anastomotic leak can adversely affect the outcome of surgery especially if detected late. The present study was carried out to detect the anastomotic leak early in the postoperative period using serial estimation of procalcitonin (PCT) and C-reactive protein (CRP). MATERIAL AND METHODS: A single centre prospective cohort study was done on patients undergoing elective gastrointestinal surgery with anastomosis. Serial estimation of serum procalcitonin and C reactive protein was done on the first five postoperative days. Other parameters such as hemoglobin, total protein, albumin and WBC counts were noted perioperatively. Patients were followed up to 60th postoperative day to assess for anastomotic leak, wound infection and other septic foci. RESULTS: Eighty-four patients were included in the study. Anastomotic leak rate was 26.19% (22/84) and 3/22 patients died in the anastomotic leak group. Wound infection rate was 23.81%. The cut off value of CRP on third postoperative day in detecting anastomotic leak was 44.322 mg/dl with sensitivity of 72.73%, specificity of 66.13% and accuracy of 59.52%. The cut off value for WBC count measured perioperatively in detecting anastomotic leak was 9470 cell/mm3 with sensitivity of 72.73%, specificity of 56.45% and accuracy of 59.74%. Serum procalcitonin, haemoglobin, total protein and albumin measured were not sensitive enough to detect the anastomotic leak early. CONCLUSION: Measuring CRP on the third postoperative day can predict anastomotic leak with a cut off value of 44.32 mg/dl. Patients with raised CRP need careful evaluation to rule out anastomotic leak before deciding on early discharge.

Erratum: Serial estimation of serum C-reactive protein and procalcitonin for early detection of anastomotic leak after elective intestinal surgeries-prospective cohort study.

[This corrects the article on p. 022 in vol. 37.].

Xanthogranulomatous adrenalitis masquerading as a functioning adrenocortical malignancy: a case report.

INTRODUCTION: Xanthogranulomatous adrenalitis (XA) is a rare chronic inflammatory disease of the adrenal glands and resembles adrenal neoplasm in clinical and radiologic characteristics. There is no report on XA presenting as a functioning adrenal mass in the literature. We present a case of XA mimicking a functioning adrenocortical carcinoma. CASE REPORT: A 52-year-old man presented with right flank pain, fever, vomiting, and loss of appetite for 2 weeks. He had signs of dehydration and elevated blood glucose level. Ultrasonography revealed a right adrenal mass. Contrast-enhanced computed tomography showed lobulated and necrotic mass replacing the right suprarenal gland and encasing the right renal vein, adjacent inferior vena cava, psoas, and diaphragm. There was loss of fat planes with liver and upper pole of the right kidney. Biochemical evaluation indicated increased serum and urine cortisol levels. As a sequel to hypercortisolism-induced hyperglycemia, he developed spontaneous chest wall abscess and bilateral sudden vision loss due to vitreous hemorrhages. Pus and blood culture grew methicillin-sensitive Staphylococcus aureus. Adrenal suppressant ketoconazole was administered for better glycemic control. With a diagnosis of locally advanced adrenocortical malignancy, right radical adreno-nephrectomy was performed, and cut section revealed a pus collection of around 100 mL. Histopathology examination showed xanthogranulomatous inflammation involving adrenal gland, Gerota's fascia, psoas, and lymph nodes. Postoperatively, the patient recovered satisfactorily with favorable glycemic control. CONCLUSION: XA can mimic adrenal neoplasms both clinically and radiologically and is associated with staphylococcal infection. It warrants surgical excision and culture-based antibiotics and is mostly diagnosed on postoperative histopathology.

Negative Pressure Wound Therapy Compared to Petrolatum Gauze and a Bogota Bag to Manage Postoperative Midline Abdominal Wound Dehiscence: A Pilot, Nonrandomized Controlled Trial.

Treating postoperative abdominal wound dehiscence following abdominal surgery using negative pressure wound therapy (NPWT) has shown promising results. PURPOSE: A study was conducted to evaluate the efficacy of NPWT for fascial closure/cutaneous cover compared to non-NPWT treatment using petrolatum gauze and a Bogota bag in patients with postoperative laparotomy wound dehiscence. METHODS: A single center, prospective, nonrandomized pilot study was conducted. Using convenience sampling methods, consecutive patients on 6 different surgical units who were at least 18 years of age and who developed postoperative abdominal wound dehiscence following elective and emergency laparotomy from January 2017 to December 2018 were recruited. NPWT dressing with polyvinyl white foam sponge or loosely packed, saline-soaked petrolatum gauze followed by Bogota bag application were used and compared. Baseline patient demographics and history were collected, and patients were followed for an average of 6 months after surgery. Number of days until first signs of granulation tissue appearance, time until complete granulation tissue cover/fascial surgical closure, and hospital discharge were compared. Categorical variables (gender, comorbidities, presence or absence of stoma, exposure to prior radiotherapy) were expressed as proportions and analyzed using chi-squared test or Fischer's exact test. Continuous variables such as age, body mass index, albumin, postoperative hospital stay, and number of days required for decision for fascial closure were expressed as Mean ± standard deviation and analyzed using an independent t test or Mann Whitney U test based on whether the data followed normal distribution. Postoperative day of wound dehiscence, the number of days for the appearance of granulation tissue, and the number of NPWT placements required also were assessed using Mean ± standard deviation and analyzed using an independent t test. A P value <.05 was considered significant. RESULTS: Sixty (60) patients were included, but 4 in NPWT group and 10 in the non-NPWT group could not complete the study, leaving 26 patients in NPWT group and 20 patients in non-NPWT group. Demographic and surgical variables were not significantly different. Patients in both groups achieved complete wound coverage by surgical closure or healing by secondary intention. Days until first signs of granulation tissue (2.92 vs. 6.65; P <.001), number of days until fascial closure (15.50 vs. 29.50; P <.001), and length of postoperative hospital stay (24.30 vs. 37.90; P <.001) were significantly less in NPWT group. Two (2) patients (7.6%) in the NPWT developed a fistula during the 6-month follow-up period. No fistulas developed in the control group, and no intra-abdominal abscesses, ventral hernias, or wound dehiscence were reported in either group. CONCLUSION: Time until first signs of granulation tissue appearance and complete granulation tissue coverage was significantly shorter in the NPWT group, but time until definitive closure was not evaluated. Randomized, controlled clinical studies to compare definitive time to wound closure and long-term follow up to evaluate long-term complication rates, including the risk of developing fistulas, are warranted.

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.