Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes Using Low-Cost Dual Dye Technique: Identifying Factors Associated with Adequate False Negative Rate Threshold.

Background: In this study, we evaluated the feasibility of the sentinel lymph node (SLN) identification rate (SLN-IR) of fluorescein-guided sentinel lymph node biopsy (SLNB) in combination with methylene blue dye (MBD) and factors which can lead to a false negative rate (FNR) threshold of 10%. Methods: This was a prospective cross-sectional non-randomized validation study in patients with post-neoadjuvant chemotherapy (NACT) clinically node negative axilla who were node positive prior to start of NACT. Patients underwent validation of SLNB using fluorescein (and blue LED light) and MBD. Axillary dissection was performed irrespective of SLNB histology. SLIN-IR and FNR were assessed and compared with various molecular subtypes. Results: The SLNs were identified in 102 out of 120 (85%) post-NACT patients. The median number of sentinel lymph nodes identified was 2 (range 1-3). The SLN-IR using MBD was 85%, FD was 82.5%, and combined MBD FD was 85%. Two or more SLNs were removed in 72 patients and 11 patients had tumor in the rest of the axilla, resulting in an FNR of 17.4%. An FNR was 25% in case only one SLN was found, and it was 11.42% if two or more than two SLNs were excised. Conclusions: This cohort study found that use of low-cost dual dyes in patients with positive axillary disease, rendered cN0 with NACT, with 2 or more negative SLNs with SLNB alone, results in an FNR of 11.4%. Her 2 positive and TNBC with 2 or more negative SLNs are associated with an FNR of <10%. However, the number of such patients was small and further studies with larger sample size are warranted to confirm these findings.

Pediatric Idiopathic Chylopericardium: A Case Managed with Thoracoscopic Window Pericardiotomy.

Idiopathic chylopericardium (CP) in the pediatric population is a rare entity with very few reported cases and is characterized by the accumulation of chyle in the pericardial cavity. There are no guidelines for the management of this rare entity. The present study reports a case of idiopathic CP in an infant and our experience of managing it by pericardial window creation using VATS and a multidisciplinary approach providing the optimum care for the child.

Evaluation of high-frequency ultrasonography for diagnosis of carpal tunnel syndrome.

The aim of this study was to assess the sensitivity and specificity of ultrasonography in the diagnosis of carpal tunnel syndrome. The cross-sectional area of the median nerve at the carpal tunnel for a positive diagnosis had a sensitivity of ∼ 98.6% but a specificity of 60%. The measure of the difference in cross-sectional area of the median nerve at the carpal tunnel and at the level of pronator quadratus had much better sensitivity and specificity of 97.1% and 80%, respectively. Signs of nerve flattening, palmar bowing and increased nerve vascularity were valuable in confirming the diagnosis. A positive predictive value of ultrasonography was found to be > 95% and a negative predictive value was ∼ 66% for a diagnosis of carpal tunnel syndrome. Ultrasonography is, therefore, an effective diagnostic tool in this regard.

Defunctioning ileostomy for typhoid ileal perforations: Out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries (LMICs). Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's malnutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later.

Effect of chewing gum in reducing postoperative ileus after gastroduodenal perforation peritonitis surgery: A prospective randomised controlled trial.

Chewing gum reduces the duration of postoperative ileus and early recovery of bowel function following elective abdominal surgery. However, its role has not been studied in cases of gastroduodenal perforation peritonitis, prompting us to conduct this study. Patients were randomised into two groups, 39 patients received chewing gum (study group) and 43 patients were in the control group. Sensation of hunger, appearance of first bowel sound, and passages of flatus and faeces were significantly early in the study group; their hospital stay was also shorter. Chewing gum reduces the duration of postoperative ileus in cases of gastroduodenal perforation peritonitis.Registration number: IEC/2020-23/3359 dated 13 December 2020, Institutional Ethics Committee, Netaji Subhash Chandra Bose Medical College, Jabalpur, India.

Low cost smart phone based laryngoscopy for the assessment of vocal cords in patients undergoing thyroid surgery: A pilot study.

Can a smart phone application be reliably used for laryngoscopy? This thesis was tested for peri-operative evaluation of vocal cords in patients undergoing thyroid and parathyroid surgery.

A systematic review and meta-analysis of diagnostic performance of fluorescein-guided sentinel lymph node biopsy in early breast cancer.

BACKGROUND: Evaluation of axillary lymph nodes status in cN0 axilla is performed by sentinel lymph node biopsy (SLNB) utilizing a combination of radioactive isotope and blue dye or alternative to isotope like Indocyanine green (ICG). Both are very resource-intensive; which has prompted development of low-cost technique of Fluorescein Sodium (FS)-guided SLNB. This systematic review and meta-analysis evaluate the diagnostic performance of FS-guided SLNB in early breast cancer. OBJECTIVES: The objective was to evaluate the diagnostic performance of FS for sentinel lymph node biopsy. METHODS: Eligibility criteria: Studies where SLNB was performed using FS. INFORMATION SOURCES: PubMed, EMBASE, Cochrane library and online clinical trial registers. Risk of bias: Articles were assessed for risk of bias using the QUADAS-2 tool. SYNTHESIS OF RESULTS: The main summary measures were pooled Sentinel Lymph Node Identification Rate (SLN-IR) and pooled False Negative Rate (FNR) using random-effects model. RESULTS: A total of 45 articles were retrieved by the initial systematic search. 7 out of the 45 studies comprising a total of 332 patients were included in the meta-analysis. The pooled SLN-IR was 93.2% (95% confidence interval [CI], 0.87-0.97; 87% to 97%). Five validation studies were included for pooling the false negative rate and included a total of 211 patients. The pooled FNR was 5.6% (95% confidence interval [CI], 2.9-9.07). CONCLUSION: Fluorescein-guided SLNB is a viable option for detection of lymph node metastases in clinically node negative patients with early breast cancer. It achieves a high pooled Sentinel Lymph Node Identification Rate (SLN-IR) of 93% with a false negative rate of 5.6% for the detection of axillary lymph node metastasis.

A comparison of swallowing related quality of life in patients undergoing transoral endoscopic versus open thyroid surgery.

INTRODUCTION: It is important for the endoscopic thyroid surgeon to understand the pros and cons of trans-oral endoscopic thyroidectomy-vestibular approach (TOETVA) vis-à-vis, open conventional thyroidectomy (OTx) so he/she can help patients in making informed choices regarding the type of procedure to opt for. Swallowing related quality of life (SWAL-QoL) has not been compared between the two approaches. Using a rigorous qualitative methodology and validated reliable tool, this study set out to compare the swallowing related quality of life in patients undergoing TOETVA versus OTx. METHODS: Prospective study at 3 time points in patients planned for hemithyroidectomy (Preoperative, 1 week and 12 weeks). Data were collected on patients at a tertiary teaching institute in India. Participants ranged from age 18-60 years with a diagnosis of benign euthyroid nodule undergoing hemithyroidectomy. Exclusion criteria were-(1) pre-existing vocal cord abnormalities, (2) undergoing surgery for recurrent nodules, and (3) any neuro-muscular disease affecting swallowing ability. Main outcome measure was comparison of swallowing related quality of life domain scores between patients undergoing hemithyroidectomy via either endoscopic trans-oral or open approach. RESULTS: Of the 82 included patients, 40 underwent TOETVA and 42 OTx. Both the groups were comparable in terms of demographic and clinicopathological profile. The mean preoperative SWAL-QOL scores were comparable in all domains. Mean SWAL-QoL scores for all domains on postoperative day 7 were significantly better in TOETVA group with domains burden, eating desire, mental health and communication having medium effect sizes. Physical symptom domain was better in the OTx group but had a small effect size. The difference in SWAL-QoL domains between the two groups persisted for 3 months also. CONCLUSION: Swallowing related quality of life after trans-oral endoscopic thyroidectomy compared to conventional open surgery has not been reported in the literature. Our findings suggest that trans-oral endoscopic thyroidectomy results in significant superior swallowing related quality of life in the majority of domains.

Flap blood glucose measurement for flap monitoring and early detection of circulatory problems.

Postoperative monitoring of skin flaps is subjective and cannot detect early circulatory problems in the flap. Early detection and rapid remedial re-exploration are important for flap salvage. We evaluated flap glucose measurement to monitor the flaps for early detection of circulatory problems. In total, 30 patients underwent cutaneous flap reconstruction. This is an easy, economic, objective, and reliable method for flap monitoring and can detect early venous congestion requiring remedial measures.

Duragen: A dermal substitute for the management of suboptimal wounds.

Using a flap in a large wound with a very small area of exposed vital structures may be an excessive intrusion and cause unnecessary donor site morbidity. Dermal matrix (DuraGen) was applied onto critical areas where bone or tendons were exposed and a split skin graft was placed thereon. All patients had satisfactory wound closure without the need for a flap. DuraGen appears to be a safe, single-stage alternative, to a flap for the healing of complex wounds.

Assessment of symptomatic response to intravesical alkalinized lidocaine, bupivacaine, heparin and steroids in patients with bladder pain syndrome.

Bladder Pain Syndrome (BPS) is a puzzling and complicated disorder. 12 such patients, with a mean age 48.3 years, were treated with weekly intravesical instillation of admixture of alkalinized lidocaine, bupivacaine, heparin and steroids for six weeks. Evaluating the benefits of this therapy, patients experienced 82.2% & 90.9% relief at 3rd & 6th week of instillation. After completion of six cycles of therapy, patients experienced 68.7% & 65.3% relief at 3rd & 6th month follow up, concluding the early and long term relief of BPS.

Double blind randomized controlled trial of efficacy of ormeloxifene for the treatment of fibroadenoma (The FIBROCENT study).

BACKGROUND: We evaluated the effectiveness of Ormeloxifene (Centchroman) on regression of Fibroadenoma in a double-blind randomized controlled trial. METHODS: Patients with biopsy proven Fibroadenoma were enrolled between March 2023 and October 2023 and divided in two arms- Ormeloxifene group and Placebo group. Effectiveness of the treatment was evaluated using USG. No residual mass was defined as complete regression and more than 30% decrease in size was considered as partial regression. RESULTS: A total of 130 consecutive patients with Fibroadenoma were randomized to Ormeloxifene group (n = 65) and Placebo Group (n = 65). Complete regression was observed in 9% (6/65) patients in Ormeloxifene group and 10.8% (7/65) in Placebo Group at the end of 12 weeks (p = 0.49). Twenty one patients taking Ormeloxifene reported adverse events as compared to none in the other group. CONCLUSION: In our study Ormeloxifene was not found to be effective in treatment of fibroadenoma and had concerning side effects.

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia.

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Low-Cost Radio-Opaque Tumor Marking Techniques for Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: a Systematic Review.

Current standard of care localization techniques used in breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) are expensive and may not be available in LMICs (lower-middle income countries). This review evaluated the efficacy of radio-opaque low-cost tumor markers. A systematic search was conducted as per PRISMA guidelines through November 30, 2022, for all studies using non-commercial radio-opaque tumor markers for patients undergoing BCS post NACT. Rate of unsatisfactory margin on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. After screening, 07 studies were included for data synthesis. For marking, four studies used LIGA clips, two used 5-mm cut pieces of K-wire, and one used cut pieces of 25-G needle. Incidence of unsatisfactory margins (positive/close) ranged from 0 to 11%. All studies found these low-cost markers to be feasible, with 100% pre-surgery visibility and 100% retrieval rate. Low-cost radio-opaque tumor markers (LIGA clips, 5-mm cut pieces of K-wire and 25-G needle) are effective methods of tumor localization especially for LMICs. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-023-01845-2.

US-Guided Hydrodissection and a Low-Cost Indigenous Retractor Facilitate Endoscopic Thyroid Surgery.

Hydrodissection of plane between thyroid and strap muscles and retraction of strap muscles using a low-cost indigenously made retractor are effective in overcoming technical difficulties in transoral endoscopic thyroid surgery. Laryngoscope, 134:993-994, 2024.

Correlation of thermal burn hepatic dysfunction with outcomes.

INTRODUCTION: Organ dysfunction and failure increase the morbidity and mortality following major burn. Alteration of liver morphology and function is common following major burns; however, it has not received much attention. In this study we have assessed the impact of thermal burn on liver in relation with mortality. MATERIAL AND METHODS: 55 patients (33 female and 22 males) with TBSA 10-90% and age ranged from 18 to 75 years were included. A bed side serial ultrasonography to assess the volume of liver and liver function tests was done on the 2nd, 9th and 16th day following burn. Baseline demographic and clinical information such as age, gender, burn size and outcome of patient were also collected. RESULTS -: 8 patients died during 2nd week following burn and 47 survived. The mean TBSA for survivors was 37% and for non survivors 80%. Mean liver volume in survivors steadily decreased from 1693.70 cm3 to 1631.31 cm3 over 3 weeks. Mean liver volume in non- survivors steadily increased from 1855.88 cm3 to 2028.50 cm3 over 2 weeks. Liver function test in survivors steadily improved while in non survivors it deteriorated over 2 weeks. CONCLUSION: There is a correlation between altered liver morphology and function with mortality among severely burnt patients however liver volume did not show statistical significance. A decreasing trend of liver dysfunction parameters and hepatomegaly following burn is associated with good prognosis.

Sputnik V vaccine perception and hesitancy in a tertiary health care centre transformed to Covid-19 vaccine centre: A case study.

BACKGROUND: Sputnik V vaccine was approved in India in April 2021 to tackle the pandemic situation. However, there was lack of information on the effects, side effects, and peoples' perception toward it. The present case study aims to evaluate the vaccine coverage, the awareness, and perception toward it and compare the adverse effects after each dose. MATERIALS AND METHODS: A unique case study was conducted in a sample of 200 participants comparing 2 groups of population who took first and second dose of Sputnik V vaccine during June to November 2021. The data were collected by a prevalidated questionnaire, follow-up telephonic interviews focused on knowledge, awareness, side effects of vaccine, and analyzed using descriptive statistics such as frequency, percentages, mean, and standard deviation. RESULTS: The vaccine coverage for first and second doses were 98.3% and 96.5%, respectively. The mean age of the participant was 29 + 9.5 years and majority 68.5% were males. Seventeen percent experienced the S/E for the vaccine with 9.5% from second dose. There were usual side effects; however, it was more after second dose of vaccination. Friends and healthcare workers were the main source of information (33.5%) and motivation (43%). Majority (73.5%) were aware of the side effects. Forty three point five percent took vaccine attributed to its protective role, availability, and peer pressure. There was no significant association between type of doses and side effects of the respective doses of vaccine. CONCLUSION: The vaccine coverage was >90%. Participants were well aware of the vaccine and side effects which were more in second dose. However, there was no significant difference between the two doses of vaccine.

Patient Perspectives After Surgery-Related Complications Among Breast Cancer Patients from a LMIC.

Long-term quality of life in breast cancer patients has been studied and published regularly. However, the lived experiences of patients who develop complications after surgery are not well understood. Determining this experience of patients is challenging in most low- and middle-income countries where the majority of patients belong to poor strata of society and are uneducated. We aimed to explore the thoughts, feelings, and experiences of patients with surgery-related complications after breast cancer surgery. Purposive sampling was used to identify patients who developed any postoperative complication, and semi-structured interviews were conducted. Common patterns of patient experiences were identified and analyzed using descriptive thematic analysis. Twenty-eight patients out of 210 developing complications postoperatively were identified. The median age was 48 years (range 32-65 years). The majority (n = 26) were housewives, educated below the primary level (n = 11) and below the poverty line (n = 13). Complications included seroma (n = 17), flap necrosis and infection (n = 5), and hematoma (n = 1). Seven domains emerged from the interviews-knowledge of complications, psychological impact, burden, disruptiveness, social impact, relationship with the surgical team, and suggestions to improve the experience. The themes identified in the present study provide insights into the lived experiences and can inform the future development of patient-reported outcome measures and quality improvement programs, including more effective pre-operative counseling and consent. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-023-01721-z.