Youngest en-bloc kidney transplant recipient in India: defying the barriers and challenges with teamwork.

We received a call from a transplant coordinator about the availability of a consented deceased donor. En-bloc kidneys with the aorta and IVC (inferior vena cava) were harvested from a toddler weighing 8 kg. The recipient was of early childhood weighing 14 kg who had been on haemodialysis for the last 3 years for end-stage kidney disease. He received anti-thymocyte globulin as an induction immunosuppressant. The kidneys were transplanted en bloc in the right lower quadrant retroperitoneal region; an anastomosis was performed to the recipient's aorta and IVC, and two separate neocystoureterostomies were created. His serum creatinine reached 0.5 mg/dL on the seventh postoperative day, following a few days of delayed graft function. In this study, we describe the surgical and non-surgical challenges that we faced while performing en-bloc kidney transplant to the youngest recipient and how a multidisciplinary team approach helped us overcome them.

Expression analysis of MMP14: Key enzyme action in modulating visceral adipose tissue plasticity in patients with obesity.

Compromised adipose tissue plasticity is a hallmark finding of obesity orchestrated by the intricate interplay between various extracellular matrix components. Collagen6 (COL6) is well characterized in obese visceral adipose tissue (VAT), not much is known about MMP14 which is hypothesized to be the key player in matrix reorganization. Subjects with obesity (BMI ≥40; n = 50) aged 18-60 years undergoing bariatric surgery and their age-matched controls (BMI < 25; n = 30) were included. MMP14, Col6A3 and Tissue inhibitor of metalloproteinase 2 (TIMP2) mRNA expression was assessed in VAT and their serum levels along with endotrophin were estimated in both groups preoperatively and post-operatively in the obese group. The results were analysed statistically and correlated with anthropometric and glycaemic parameters, namely fasting glucose and insulin, HbA1c, HOMA-IR, HOMA-ß and QUICKI. Circulating levels as well as mRNA expression profiling revealed significant differences between the individuals with and without obesity (p < .05), more so in individuals with diabetes and obesity (p < .05). Follow-up serum analysis revealed significantly raised MMP14 (p < .001), with decreased Col6A3, endotrophin and TIMP2 levels (p < .01, p < .001 and p < .01, respectively). A rise in serum MMP14 protein, simultaneous with post-surgical weight loss and decreased serum levels of associated extracellular matrix (ECM) remodellers, suggests its crucial role in modulating obesity-associated ECM fibrosis and pliability of VAT.

Flash pulmonary oedema following arteriovenous fistula surgery: rapid assessment and treatment is key to break the vicious cycle.

An early adolescent boy with chronic kidney disease on haemodialysis was referred to the surgical clinic for the creation of an arteriovenous fistula. He was undergoing treatment for dilated cardiomyopathy and extrapulmonary tuberculosis. The patient was haemodynamically stable during the procedure, but he developed rapidly progressing dyspnoea, tachycardia and tachypnoea about 10 min after the vessels were declamped. His blood pressure rapidly rose above 220/120 mm Hg and saturation dropped below 90%. A multidisciplinary team (MDT) constituted of surgeons, nephrologists and intensivists was quickly activated. The patient was put on a mechanical ventilator and resuscitated with parenteral antihypertensives, diuretics, amiodarone and haemodialysis. The patient improved clinically and was discharged on the third postoperative day. Thus, a rapidly activated MDT approach was key in breaking the vicious cycle caused by hypertensive crisis, myocardial dysfunction and impending ventilatory failurethat occurred following access surgery.

Effect of supervised surgical training provided to general surgery residents on clinical maturation of arteriovenous fistula surgery: A retrospective cohort study.

Introduction: With the advent of endovascular technique and the emergence of vascular surgery as a separate branch distinct from general surgery, there is a decrease in exposure of open vascular technique to general surgery resident. Vascular access surgery is a vascular subspecialty area and not all residents get similar exposure during training, and this has implications if one becomes a vascular consultant in the future and have to undertake access surgery. There is no established protocol or duration, following which a surgical resident can be named as "trained" in vascular anastomosis. Our study tries to address the aforementioned problems; in particular the actual training that a general surgery resident needs in vascular access. Objective: To study and compare the outcomes of AV Fistula surgeries, created by "trained" general surgical residents and consultant. Method: A single-institution retrospective cohort study comparing two groups of cohorts: trained residents (group A) and consultant (group B). Study has been done in accordance with the standards of ICMJE and registered with the Clinical Trial Registry of India. (CTRI/2021/12/038581). Result: Out of 238 patients recruited, 157 underwent surgery in group 'A' (the trained residents performing arteriovenous fistula surgery) and 81 underwent surgery in group 'B' (by consultant of general surgery). Clinical maturation noted after 8 weeks was 83.4% (131/157) in group A and 90.1% (73/81) in group 'B'; (p = 0.113). The mean duration of surgery in group 'A' was 99.8 ± 18.2 min and group 'B' was 56.2 ± 10.4 min; (p value < 0.0001). Conclusion: A structured training in vascular anastomosis provided to the newly recruited residents in general surgery for 6 months lead to outcomes that were comparable with the consultants.

Intra-arterial injection of Diclofenac by informal health practitioner: A rare complication of a common drug.

Introduction and importance: Intra-arterial injections (IA) though rare, cause acute limb ischaemia with often catastrophic outcomes. Symptoms could progress rapidly and early identification and intervention could help in preventing the limb gangrene. Methodology: The work has been reported in line with the SCARE 2020 criteria:Agha RA, Franchi T, Sohrabi C, Mathew G, for the SCARE Group. The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines, International Journal of Surgery 2020; 84:226-230. Operative procedure was performed by consultant of general surgery. Case presentation: 38-year-old male presented to surgery casualty with history of sudden onset of pain and paraesthesia in the left forearm and palm followed by progressive weakness and discolouration, 15 hours following injection of Diclofenac in the mid cubital region. Clinical discussion: On examination, limb temperature was lower, finger movements were minimal. However, distal pulses were palpable, and duplex ultrasound showed normal triphasic flow. In view of the equivocal clinico-radiological findings, the patient underwent CT-Angiography of upper limb, which showed non-opacification of radial and ulnar arteries. Fasciotomy of forearm, brachial artery exploration and removal of embolus was attempted in a doubtful viable left upper limb. No thrombus was noted. Subsequently, he was managed conservatively, and cervical sympathectomy was done. As there was progressive deterioration in the viability of the limb, the patient underwent an above elbow amputation. Conclusion: Intra-arterial injections can lead to limb threatening gangrene, the course of which can be rapid A multidisciplinary team approach was necessary to arrive at a diagnosis and provide optimum care.

Fracture of tissue dilator in the femoral vein during insertion of temporary dialysis catheter: a stitch in time can save nine.

A 48-year-old man presented to the surgery casualty with 1-day history of broken foreign body during the insertion of dialysis catheter and a failed surgical retrieval. A Doppler ultrasonography of the right groin and lower limb and a noncontrast CT of abdomen and pelvis were performed. Eventhough no intravascular foreign body could be identified on imaging, a decision to re-explore the wound was taken in view of definitive clinical history. A 9.5 cm-long, broken piece of tissue dilator was found inside the right external iliac vein, which was removed through venotomy of the femoral vein. Postoperative recovery was uneventful.

Accessory veins related hand ischemia: A case series.

INTRODUCTION: Arteriovenous fistula is considered as a lifeline for chronic kidney patients undergoing maintenance hemodialysis. OBJECTIVE: To study the outcome of ligation of the accessory vein causing hyperperfusion and ischemia of the ipsilateral limb. METHOD: ology: A single institution, single surgeon, in-hospital, retrospective case series of patients presented with alarm symptoms in postoperative period following arteriovenous fistula. RESULTS: A total of 800 AVF were created between 2016 and 2019, out of which 6/800 (0.75 %) patients presented with alarm symptoms related to venous hypertension and underwent accessory vein ligation. All showed normal recovery with complete resolution of symptoms postoperatively. CONCLUSION: Timely ligation of the accessory vein in patients with arteriovenous fistula with accessory vein related alarm symptoms showed salvage of lifeline and limb with no residual complications during follow-up.

Pleomorphic liposarcoma of the male breast: lessons from a rare malignancy during COVID-19 pandemic.

A 52-year-old man presented with a recurrent right side breast lump. He had undergone excision of a lump on the right breast followed by adjuvant chemoradiotherapy 1 year ago for a diagnosis of pleomorphic liposarcoma. Imaging revealed a 47×36 mm lesion on the right side of the chest wall involving the pectoralis muscle. The patient underwent right radical mastectomy. Histology of the specimen showed an undifferentiated pleomorphic sarcoma infiltrating into the underlying skeletal muscle. Therefore, he was planned for chemoradiotherapy. But due to lockdown during the COVID-19 pandemic, he was lost to follow-up and later presented with malignant pleural effusion. This case emphasises the impact of COVID-19 pandemic over such rare malignancies.

Laparoscopic total extraperitoneal (TEP) mesh repair for femoral hernia in a patient of child B liver cirrhosis with ascites. A case report.

INTRODUCTION: Femoral hernia is infrequently encountered in surgical practice and is even rare in patients with liver cirrhosis. Recurrent pain adds to the existing morbidity and affects the quality of life of these patients. Management of such cases had rather high rates of morbidity and mortality owing to hepatic decompensation. However, more recent studies have shown a significant improvement of the quality of life and improved rates of morbidity in cirrhotic patients with inguinal hernias post repair. These studies all included open hernia repair with preperitoneal approach with improved results in terms of morbidity and lower rates of recurrence postoperatively. However, when compared to laparoscopic repairs these have more postoperative complications, complication related re-operations, pain and recurrence rates. Keeping these in mind, the laparoscopic approach was considered in our patient which has not been described yet in literature for femoral hernia. The report is in line with the SCARE criteria. (Agha et al. (2018) [1]) The case report is registered with research registry (UID researchregistry5467). PRESENTATION OF CASE: A 40 year old female patient with Child B cirrhosis of liver with ascites was operated for a symptomatic left uncomplicated femoral hernia using standard three port laparoscopic total extraperitoneal repair with prolene mesh. She was discharged on postoperative day 2. She developed ascitic leak from the hypogastric port site in the late postoperative period which was managed conservatively. The patient has remained stable without recurrence at one year follow up. CONCLUSION: Laparoscopic TEP may be a safe option with no major adverse events in symptomatic femoral hernias. Further studies are needed to ascertain its role.

Intraductal papillary neoplasm of bile duct: all rare in one.

A 45-year-old woman was referred from Department of Dermatology to Surgery outpatient department with pruritus since 6 months and an episode of jaundice that lasted for 15 days about 6 months ago. She was referred with a contrast-enhanced MRI finding that showed a small lesion in the lower end of common bile duct. Endoscopy-guided biopsy was performed twice at our hospital, the second revealed low grade dysplasia. Consequently, she underwent pancreaticoduodenectomy. Intraoperatively, there were both vascular and biliary anatomical variations that were missed on preoperative images. On histopathological examination, it turned out to be a mixed variety of intraductal papillary neoplasm of bile duct (IPNB). As all findings were rare in one, hence, we present this case of IPNB that presented to us with variable clinical, radiological, surgical and pathological findings.

Incidental Carcinoma Gallbladder: Incidence, Risk Factors, and Factors Affecting Survival-5-Year Experience from a Tertiary Care Institute.

INTRODUCTION: Carcinoma gallbladder is a very lethal disease. It can get detected incidentally after laparoscopic cholecystectomy. The overall outcome of incidentally detected carcinoma gallbladder is a matter of debate in literature. AIM: To estimate the overall incidence of the incidental gallbladder carcinoma, the various risk factors associated with it and factors affecting overall survival in patients who underwent laparoscopic cholecystectomy with eventual histology turning out to be carcinoma gallbladder. METHODS: Data of all the patients undergoing laparoscopic cholecystectomies in one surgical unit under the Department of Surgery at All India Institute of Medical Sciences, New Delhi, India, between January 2014 and December 2018 was retrospectively analyzed. All patients with incidental carcinoma gallbladder were followed up and completion radical cholecystectomy was performed. The demographic profile, preoperative imaging, intra-operative finding, histopathology of primary surgery, and median interval between two surgeries were analyzed to look for various risk factors associated with incidental carcinoma gallbladder and factors affecting overall survival. RESULTS: Incidence of the incidental carcinoma gallbladder was 0.51% with a female/male ratio of 4:1 and mean age of 47.2 years. Preoperative imaging of most of them was suggestive of chronic cholecystitis; however, one patient had multiple gallbladder polyps. Six patients had uneventful laparoscopic cholecystectomy, while four had bile spillages intraoperatively. All the patients had adenocarcinoma on histopathology. Pathological staging of four patients was pT1b and six patients had pT2 tumor. The median interval between cholecystectomy and completion radical cholecystectomy in this series was 8 weeks. At the end of 19-month median follow-up, overall survival was 55.5%. CONCLUSION: Incidence of incidental carcinoma gallbladder is 0.51%, most commonly affecting middle-aged females. Risk factors associated with incidental carcinoma gallbladder were found to be multiple gallbladder calculi, single large stone, and gallbladder polyps. Survival is better in males, young patients with uneventful primary surgery and better-differentiated pathology.

Spontaneous cholecystocutaneous fistula: empirically treated for a missed diagnosis, managed by laparoscopy.

A 70-year-old woman was referred to our hospital from primary health centre with complaints of pain in the abdomen, swelling and discharging sinus in the right hypochondrium since 2 years. She had received anti-tubercular treatment for 18 months as the wedge biopsy of the sinus tract suggested granulomatous lesion. As the symptoms did not subside she was referred to our hospital. Her blood investigation reports at our hospital were normal. Ultrasound of the abdomen suggested cholelithiasis with normal common bile duct. CT fistulogram findings were diagnostic of cholecystocutaneous fistula (CCCF). She underwent laparoscopic cholecystectomy and excision of the sinus tract. Postoperative recovery was uneventful. Indiscriminate usage of anti-tubercular drugs should be discouraged and possibility of CCCF should be considered in patients presenting with discharging sinus in the anterior abdominal wall. CT fistulogram is helpful in making diagnosis of CCCF. Cholecystectomy with excision of the sinus tract is the treatment of choice.

Combined caesarean with splenectomy in pregnancy with portal hypertension: defining plausibility.

24-year-old woman at 28 weeks gestation was referred from peripheral hospital with diagnosis of pregnancy with portal hypertension. She had received multiple transfusion for pancytopaenia in the past and had undergone endoscopic sclerotherapy for oesophageal varices. Initially, she was admitted in our hospital at 28 weeks gestation for blood transfusion and was evaluated by multispecialty team of doctors. She was advised splenectomy for transfusion-dependent pancytopaenia secondary to hypersplenism in non-cirrhotic portal hypertension. She was readmitted at 36 weeks gestation. A decision for caesarean was taken owing to failed induction of labour at 38 weeks gestation. She underwent combined caesarean with splenectomy. Mother and child had an uneventful postoperative recovery and were discharged on ninth postoperative day. Preconceptional counselling, treatment of oesophageal varices and multispecialty approach was paramount in the management. Combined caesarean with splenectomy is feasible and cost-effective treatment associated with improved quality of life. Prospective clinical trials are essential to prove safety and efficacy of treatment.

Penetrating cardiac injury: sustaining health by building team resilience in growing civilian violence.

Penetrating cardiac injury (PCI) is gradually increasing in developing countries owing to large-scale manufacturing of illegal country-made weapons. These injuries are associated with significant morbidity and mortality. Logistically it is difficult to have all organ-based specialists arrive together and attend every critically injured patient round-the-clock in developing countries. It is therefore important for doctors (physicians, surgeons and anaesthetists) to be trained for adequate management of critically injured patients following trauma. We report the approach towards 2 cases of haemodynamically unstable PCI managed by a team of trauma doctors. Time lag (duration between injury and arrival at hospital) and quick horizontal resuscitation are important considerations in the treatment. By not referring these patients to different hospitals the team actually reduced the time lag, and a quick life-saving surgery by trauma surgeons (trained in torso surgery) offered these almost dying patients a chance of survival.

Malrotation of the gut harbouring midgut volvulus in an adult with situs inversus totalis: a clinical delay and treatment dilemma.

A 22-year-old man experiencing infrequent episodes of abdominal pain, distension, non-bilious vomiting and constipation, was diagnosed with malrotation of the gut. He was treated conservatively over the past 10 years. He was referred to our hospital owing to recent aggravation of symptoms. He had no signs of peritonitis. On imaging, malrotation of the gut, with midgut volvolus and situs inversus totalis, was found. Diagnosis was confirmed during laparotomy. A large sac was present to the right of midline. Detorsion of the sac was performed and the sac was opened. The duodenum and caecum were found in the left upper abdomen adherent to the lateral abdominal wall. Adhesiolysis was performed and extrinsic compression at the duodenum relieved. The large bowel was placed on the right side and small bowel was placed on the left. Appendectomy and feeding jejunostomy were performed. Thorough analysis (clinicoradiological) is necessary before considering conservative management in patients known to harbour a congenital anomaly of the gut.