Prevalence of Postoperative Deep Vein Thrombosis in Patients Undergoing Emergency Laparotomy: A Prospective Observational Study.

Background Deep venous thrombosis (DVT) is more common in the hospital population and has an estimated annual incidence of 67 per 100,000. Surgery is a risk factor for DVT and has been proven to cause morbidity and mortality in the postoperative period. The correlation between the frequency of DVT and major surgical procedures has been demonstrated. However, few studies have been conducted on the relationship between emergency surgeries and the incidence of DVT. Our study aims to determine the prevalence of postoperative DVT in patients undergoing emergency laparotomies. Methods This prospective observational study was conducted over 18 months, from January 2021 to July 2022. Patients who underwent emergency exploratory laparotomies were included in this study. Duplex ultrasonography was done preoperatively to exclude patients with DVT. A serial duplex ultrasound was performed to detect DVT until the seventh postoperative day. All the clinicopathological and surgical information of patients relevant to this study was collected and analyzed. Results Out of 146 patients, one developed DVT in the postoperative period. The patient who experienced DVT had no other known risk factors; however, his age of 60 was a risk factor for DVT. So, the reported prevalence of DVT in our study population was just 0.68% of emergency exploratory laparotomy patients. Conclusion Our study reports DVT in only one case out of 146 patients who underwent emergency exploratory laparotomy without routine pharmacological prophylaxis. We might, therefore, conclude that emergency exploratory laparotomy may be a separate risk factor for the emergence of DVT. More prospective studies with large sample sizes should be done to evaluate the prevalence of DVT in emergency exploratory laparotomies.

Intramuscular cysticercosis of the forearm mimicking a soft tissue tumour.

A man in his 20s presented with a painless, slow-growing firm swelling in the anterolateral aspect of his left forearm. The swelling had been present for 1 year and measured 10×12 cm. Clinically, a differential diagnosis of soft tissue sarcoma, lipoma, neurofibroma, dermoid cyst and hydatid cyst of the extremity was considered. MRI suggested a primary intramuscular hydatid cyst. However, fine-needle aspiration was inconclusive, and ELISA for immunoglobulin G antibodies to echinococcal antigen in serum was negative. A wide-local complete surgical excision of the lesion was planned. Intraoperatively, a well-defined, tense cystic swelling with surrounding dense adhesions was found within the intramuscular plane. Histopathological examination of the cyst wall revealed cysticercosis. The patient recovered uneventfully. This case highlights that solitary intramuscular cysticercosis, although rare, should be included in the differential diagnosis of an isolated soft tissue mass, particularly in endemic areas.

Cracking the silent gallstone code: Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones. While the treatment for symptomatic gallstones is clear, the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones. The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention, as it's uncertain when or which patients might develop complications. Consequently, risk stratification appears to play a critical role in guiding decisions about silent gallstones. However, there is no definitive evidence to direct management, and a consensus-based on high-quality evidence is yet to be established.

Duodenocolic and Cholecystocolonic Fistula: A Case Report of an Unusual Presentation.

Laparoscopic cholecystectomy is the established standard of care for addressing symptomatic gallstones, typically representing a straightforward and uncomplicated surgical procedure. However, patients exhibiting variant anatomy or local inflammation can present challenges to the surgeon, potentially leading to complications. In this context, we present the case of a 55-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease at a different medical facility. Postoperatively, she was diagnosed with a case of duodenocolic fistula and cholecystocolonic fistula. Conservative treatment ensued with intravenous antibiotic administration, as well as enteral and parenteral feeding. Diagnosing cholecystocolonic fistula before surgery proves challenging, even with modern diagnostic and imaging tools. Despite its significance, there is limited information in the literature regarding the management of this infrequent finding. The approach to diagnosis and management is elaborated upon in the case report.

Male Breast Cancer: An Updated Review of Patient Characteristics, Genetics, and Outcome.

Male breast cancer (MBC) is a rare entity, underrepresented in population studies and clinical trials, resulting in management of MBC to be informed by current research on female breast cancer (FBC). A literature review was conducted by accessing relevant articles on 2 databases, by searching keywords "male breast cancer". A total of 29 articles from year 2011 to 2022 were selected for this review. The authors found that male breast cancer generally occurs later in life with higher stage, higher grade, and more estrogen receptor (ER) positive tumours. Most of the studies noted the mean age for MBCs at the time of presentation as >60 years. Risk factors for male breast cancer include family history, obesity, lower physical activity, and syndromes like the Klinefelter syndrome. Positive family history is much higher in MBC compared to FBC (30.9 vs. 18.4%). BRCA 2 cancers constitute a higher proportion compared to FBCs. A lot of genetic mutations have been observed. Some show promise to assess disease-specific survival and proliferative rate like TWIST1 and RUNX3, among others. MBCs usually present with a palpable lump in central region, with a bigger size and chance of nodal involvement and metastasis compared to FBCs. They are mostly infiltrating ductal type and hormone receptor positive, with worse histological grade. Treatment usually follows the same principles as FBCs (systemic therapy, surgical excision, and radiotherapy), with poorer prognosis to same treatment approach, possibly owing to its advanced stage at presentation. This is a rare entity which requires further research to ascertain need for different management approach than FBCs.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report.

Background: Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition. Clinical Case: A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy. Discussion: Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment. Conclusion: High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Current standards of surgical management of gastric cancer: an appraisal.

PURPOSE: Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC. METHODS: We conducted a systematic search on the PubMed database for studies on the management of GC. RESULTS: Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach. CONCLUSION: Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Emergence of Unusual Microorganisms in Microflora of Pilonidal Sinuses: A Multiple Case Series.

PURPOSE: Recent reports have noted an emergence of unusual organisms in microflora of pilonidal sinus (PNS); this study was undertaken to identify the primary microbial flora associated with infected primary PNS over a period of 1 year. DESIGN: A prospective multiple case series. SUBJECTS AND SETTING: A case series of 20 patients with primary PNS in a tertiary care center in Varanasi, India, was studied. The study was conducted at the Department of Microbiology and General Surgery, Institute of Medical Sciences, Varanasi, over a period of 1 year (September 2016 to July 2017). METHODS: Purulent exudate (pus) samples were collected from 20 patients with primary PNS from the discharging sinuses by aseptic methods. Samples were assessed for aerobic and anaerobic flora by conventional culture and molecular methods. Antimicrobial susceptibility testing was done for bacterial isolates. Bacterial diversity was compared with the demographic and clinical profile of the sinuses by multiple correspondence analysis. RESULTS: Of the total cases, 11 (55%) had purulent discharge, among which all showed polymicrobial flora. The ratio of aerobic to anaerobic organisms was 1:2 (16/32). Escherichia coli (E. coli, 4, 36.36%) and Enterococcus faecalis (E. faecalis, 4, 36.36%) were commonly isolated. Bifidobacterium was the most frequent anaerobe. Detailed molecular analysis revealed the presence of Kocuria flava as an unusual pathogen. On statistical analysis, factors like male gender, increased body mass index, absence of hair in sinus, presence of features of hirsutism, and absence of Fusobacteria were closely associated with one another in these PNS cases. CONCLUSIONS: The case series revealed the predominance of anaerobes in primarily infected PNS cases. Bifidobacterium spp and unusual pathogens like K. flava were among the emerging pathogens in infected PNS. Use of better molecular diagnostic facilities in addition to the conventional methods might enhance the verified diversity of microorganisms in such cases.

"Hurricane-like" Presentation of a Recurrent Marjolin's Ulcer in a Young Female.

Marjolin's ulcer (MU) with rapid progression and multiple distant metastases is rare. We report a case of an MU of the thigh developing in a postburn scar, which after successful R0 resection developed multiple bony and visceral metastasis to femur, vertebra, skull, lung, and liver within 3 months of excision. We highlight the "hurricane-like" recurrence in an MU, which is unusual for the metachronous disease. We stress that MUs, unlike conventional wisdom, need a thorough metastatic workup at presentation, and prognostication of a possible rapidly progressive course after surgery which may lead to grave prognosis and mortality.

Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives.

The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.

Predictors of Postoperative Outcome in Emergency Laparotomy for Perforation Peritonitis; a Retrospective Cross-sectional Study.

Introduction: Hollow viscus perforation is a significant cause of surgical mortality. Various attempts have been made to identify high-risk patients preoperatively and optimize and manage such patients more aggressively. This study aimed to evaluate the predictors of outcome in patients undergoing emergency laparotomy for perforation peritonitis. Methods: This retrospective cross-sectional study was conducted on perforation peritonitis cases admitted to the Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, India. The association between preoperative patient variables with postoperative complications, anastomotic leaks, need for intensive care unit (ICU) admission, and 30-day mortality were evaluated. Results: Tachycardia at the time of admission (t = 2.443, p = 0.020), hypotension (χ2 = 18.214, p = <0.001), lower haemoglobin (t = -4.134, p = <0.001), higher blood urea nitrogen levels (W = 1967.000, p = 0.012), International Normalised Ratio (INR) ≥ 1.5 (χ2 = 17.340, p = <0.001), the mean albumin level 2.89 ± 0.77 g/dL (t = -2.348, p = 0.027), and delay in surgery (χ2 = 28.423, p = 0.008) were significant associate factors of mortality. The association between need for ICU admission and higher pulse rate on admission (W = 2782.500, p = 0.011), lower systolic blood pressure (W = 1627.500, p = 0.029), higher blood urea nitrogen (W = 2299.000, p = 0.030) and serum creatinine levels (W = 2192.500, p = 0.045), preoperative coagulopathy (χ2 = 6.773, p = 0.017), hypoalbuminemia (t = -2.515, p = 0.016), and delay in surgery (χ2 = 17.780, p = 0.016) was significant. Conclusion: Based on the results of this study, hypotension, azotaemia, coagulopathy, and delay in surgery, increase the risk of postoperative mortality of patients undergoing emergency laparotomy for perforation peritonitis. Tachycardia, hypotension, azotaemia, hypoalbuminemia, and pre-operative coagulopathy were good predictors of need for ICU admission. Shock at presentation, deranged renal function and coagulopathy were associated with an increased risk of postoperative complications.

Risk factors of surgical site infection in elective laparotomy in a tertiary care center: an observational study.

INTRODUCTION: Surgical site infections (SSI) encompass 20-25% of all hospital-acquired infections with their prevalence ranging from 2.5 to 41.9% across the world. Prevalence and risk factors of SSI vary greatly between countries and between healthcare institutions within a country. There is limited data on the pattern and risk factors of SSI in the Indian healthcare scenario. This study is an attempt to identify risk factors of SSI in patients who underwent elective laparotomy in the general surgery department of a tertiary care hospital in India. METHODOLOGY: This is an observational cross-sectional retrospective study, conducted over 5 years from January 1, 2015, to December 31, 2019. A total of 112 patients who underwent elective laparotomy in the department of general surgery, were enrolled in the study. Data collection was done from hospital case records and discharge summaries of patients. RESULTS AND DISCUSSION: Out of the 112 patients, a total of 16 patients (14.29%) developed surgical site infections. Preoperative serum total protein (W-465.500, P 0.012) and length of hospital stay (W=1235.000, P≤0.001) were found to have a significant association with surgical site infection. Age, gender, smoking, comorbidity, class of surgical wound and, preoperative albumin did not show any significant association with the development of SSI. Escherichia coli was the predominant organism isolated in culture. CONCLUSION: Measures to curtail SSI can only be adopted after a thorough understanding of its prevalence and predictors. The characteristics and pattern of SSI will help identify prevalent organisms, their resistance pattern and will aid in formulating antibiotic policy tailor-made for the healthcare institution.

Recurrent retrorectal tailgut cyst mimicking deep pelvic abscess: A diagnostic dilemma.

Tailgut cysts are congenital anomalies that are rare and arise from incompletely regressed primitive hindgut. These are more commonly found in women and are usually asymptomatic. When symptoms develop, these can present with pain, infection, hemorrhage, difficulty in defecation, and rarely malignant change. We report a middle-aged married woman who presented with deep-seated perineal pain for a couple of months, which increased during defecation and sexual intercourse. Although abdominal examination was unremarkable barring deep tenderness in the hypogastrium, rectal and vaginal examinations suggested a tender pelvic swelling. An abdominal ultrasonographic examination diagnosed a cystic swelling in the pelvis extending until the Levator ani muscles. Considering her symptoms, a pelvic abscess was diagnosed and transvaginal drainage was done. Due to persistence of symptoms and recurrence after a month, she was further investigated and was diagnosed to have a presacral benign cystic tumor based on CT and MRI scans of the pelvis. The lesion was completely excised through a combined abdomino-perineal approach and histopathological report suggested a benign tailgut cyst. That a cystic presacral swelling with features of inflammation can be confused with a deep pelvic abscess is hereby highlighted in this report. An MRI scan is diagnostic of these lesions. Failure to differentiate it from a pelvic abscess may result in drainage, which may be of concern if the lesion is malignant.

An appraisal of vascular endothelial growth factor (VEGF): the dynamic molecule of wound healing and its current clinical applications.

Angiogenesis is a critical step of wound healing, and its failure leads to chronic wounds. The idea of restoring blood flow to the damaged tissues by promoting neo-angiogenesis is lucrative and has been researched extensively. Vascular endothelial growth factor (VEGF), a key dynamic molecule of angiogenesis has been investigated for its functions. In this review, we aim to appraise its biology, the comprehensive role of this dynamic molecule in the wound healing process, and how this knowledge has been translated in clinical application in various types of wounds. Although, most laboratory research on the use of VEGF is promising, its clinical applications have not met great expectations. We discuss various lacunae that might exist in making its clinical application unsuccessful for commercial use, and provide insight to the foundation for future research.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background.

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.

STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery.

INTRODUCTION: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. METHODS: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. RESULTS: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. CONCLUSION: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery.

A Giant Sacrococcygeal Teratoma in an Adult Male: A Case Report.

Sacrococcygeal teratoma (SCT) in adults is very rare with only a few cases reported in the literature. Its presentation in the adult is asymptomatic to a slow-growing cystic tumor with a 1-2% chance for malignant transformation and may attain a huge size causing pressure effect on pelvic and intra-abdominal organs. It can present unusually as a perianal abscess which needs to be evaluated radiologically. We present a giant, long-standing SCT in an adult male patient which presented as a tender fluctuating swelling with spontaneous rupture and whitish discharge in the perianal region masquerading as a perianal abscess. Diagnosis of our case was suspected by clinical examination, ultrasound, and magnetic resonance imaging of the pelvis and histopathology confirmed the diagnosis. It was excised en bloc with coccygectomy and primary wound closure and had a good postoperative recovery. Long-standing perianal swelling in an adult should raise the suspicion of SCT and should be kept in the differentials. The author prefers the posterior perineal approach for excision in Altman type 2, as it has convenient control over the mass during surgery with good cosmetic results as in our case, but the role of coccygectomy to prevent recurrence needs long-term data.

Covid-19 and surgery: Challenging issues in the face of new normal - A narrative review.

This review aims to outline the current perspectives of surgery in the COVID 19 pandemic associated with the pitfalls in implementing the emerging guidelines to continue patient care without compromising safety, both from the surgeons' and the patients' points of view. The fight between the surgeon and the pandemic will be a dragging one since the post-pandemic infflux of surgical patients coupled with the 'new normal' practices to prevent COVID 19 spread requires pertinent resources, well-trained personnel, and co-operation among different departments. Emergency surgeries and cancer care have continued all this while, undoubtedly, with unwanted delays and distress. While we continue to prepare ourselves and work in a whole new environment, surgeons are facing the increased chances of litigations and compromised safety. We review what we have come to understand about safe surgical practices during and after the pandemic and the unanswered questions.