Role of specific nutritional biomarkers in predicting post-operative complications among patients undergoing elective abdominal surgery.

PURPOSE: Nutritional biomarkers like serum prealbumin, transferrin, retinol-binding protein (RBP), C-reactive protein (CRP), leptin, and insulin-like growth factor 1 (IGF1) have the inherent ability to diagnose undernutrition objectively before it is clinically manifested. The primary objective of the study was to evaluate the diagnostic efficacy of the specific nutritional biomarkers in predicting post-operative complications. METHODS: A prospective cohort study was conducted in the department of surgery and included all patients aged 18 years and above who underwent elective abdominal surgery. Demographic details and clinical and surgical details were documented from the case records. Nutritional biomarker assay was done at admission. The post-operative complications occurring until discharge were graded using the Clavien-Dindo classification. The diagnostic accuracy of the specific nutritional biomarkers in predicting post-operative complications was assessed. RESULTS: A total of 320 patients were included in the study. Of these, 126 (39.38%) developed post-operative complications. Major complications accounted for 19.05% of the complications, while 80.95% were minor complications. Patients with blood prealbumin level less than 17.287 mg/dL had a higher incidence of complications (p < 0.001). Serum transferrin levels less than 168.04 mg/dL and IGF1 levels less than < 44.51 ng/ml showed increased incidence of complications (p < 0.001). The AUC was found to be the highest for serum IGF1 with 0.7782. Sensitivity was equally high for IGF1 and serum transferrin, with 76.98% for the former and 76.19% for the latter. CONCLUSION: Specific nutritional biomarkers, like serum prealbumin and transferrin, were efficient in predicting postoperative complications of patients before undergoing elective abdominal surgeries even after adjusting for confounders. This can facilitate preoperative corrective measures to lower the overall postoperative complications.

Diagnostic Utility of NLR, PLR and MLR in Early Diagnosis of Gastric Cancer: an Analytical Cross-Sectional Study.

PURPOSE: Inflammatory markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR) are linked with the pathogenesis of gastric cancer (GC). However, the clinical significance of the combination of these markers is unclear. Hence, this study was carried out to determine the individual and combined diagnostic accuracy of NLR, PLR and MLR among patients with GC. METHODS: In this prospective, cross-sectional study, patients were recruited into three groups, GC, precancerous lesions and age and gender-matched controls. The primary outcome was to determine the diagnostic accuracy of inflammatory markers in the diagnosis of GC. The secondary outcome was to determine the correlation of inflammatory markers with the stage of gastric cancer, nodal involvement and metastasis. RESULTS: A total of 228 patients, 76 in each group, were enrolled. The cut-off value of NLR, PLR and MLR were 2.23, 146.8 and 0.26, respectively, for the diagnosis of GC. The diagnostic abilities of NLR, PLR and MLR were significantly high at 79, 75 and 68.4, respectively, to predict GC compared to precancerous and control groups. All the models of inflammatory markers showed excellent discrimination between GC and the controls with an AUC > 0.7. The models also showed acceptable discrimination between GC and the precancerous lesion group with AUC between 0.65 and 0.70. No significant difference was found in correlating inflammatory markers with clinicopathological features. CONCLUSION: The discrimination capacity of the inflammatory markers could be used as screening biomarkers in diagnosing GC, even in its early stages.

Comparison of Tissue Adhesive Glue with Subcuticular Absorbable Suture for Skin Closure Following Thyroid Surgery: A single-blinded randomised controlled trial.

Objectives: This study aimed to compare the skin closure time, postoperative pain and the scar outcome between tissue adhesive and sub-cuticular sutures in thyroid surgery. Methods: This study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, a tertiary care hospital in India from March 2017 to December 2019. Adult patients undergoing thyroid surgery were included while those with previous neck surgery, history of keloids/hypertrophic scars and those undergoing concomitant neck dissections were excluded. Following platysma closure, patients were randomised into two groups (tissue adhesive and subcuticular sutures) using the Serially Numbered Opaque Sealed Envelopes technique. A sample size of 64 in each group was calculated for this prospective, single-blinded and randomised controlled trial. The primary outcome was the skin closure time. The secondary outcomes were postoperative pain at 24 hours and scar scoring at 1st and 3rd postoperative month. Statistical analysis was done using SPSS software. Results: A total sample of 124 patients were included in this study, with 61 patients assigned to the suture group and 63 assigned to the tissue adhesive group. The median skin closure time and postoperative pain was significantly lower in the tissue adhesive group as compared to the suture group (P <0.01). There was no statistically significant difference in scar outcome at the 1st or 3rd months between both groups (P = 0.088 and 0.137, respectively). There were no wound-related complications in either group. When a subgroup analysis was conducted, no difference was seen in the scar outcome or wound-related complications in patients with comorbidities. There were no instances of allergic contact dermatitis to the tissue adhesive. Conclusion: The use of tissue adhesive leads to lower operative time and less postoperative pain in thyroid surgeries. The scar outcome is comparable between tissue adhesives and subcuticular sutures.

Impact of Covid-19 on gastrointestinal cancer surgery: A National Survey.

PURPOSE: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers. METHODS: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era. RESULTS: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase, there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by oesophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3 (18%) centres reported higher morbidity, while the rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however, 6 (37%) centres reported slightly higher mortality in the active Covid phase. CONCLUSION: Covid-19 pandemic resulted in significant reduction in new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid 19 exposure.

A Rare Case Report of Non-toxigenic Corynebacterium diphtheriae Bloodstream Infection in an Uncontrolled Diabetic With Peripheral Vascular Disease.

Corynebacterium diphtheriae usually causes respiratory diphtheria, which is considered as a disease of toxemia but never bacteremia. Over the last few decades, cutaneous diphtheria has been increasingly reported owing to the emergence of the non-toxigenic strain, which causes locally necrotic and ulcerative lesions. Bacteremia is very rare, but the existing evidence in the literature suggests that the organism can rarely cause invasive infections such as septicemia, endocarditis, and osteoarthritis. Here, we present a rare case of C. diphtheriae causing bloodstream infections in an elderly diabetic with peripheral vascular disease, which was diagnosed incidentally on routine blood culture owing to automated identification systems viz matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) confirmed with conventional methods, and susceptibility was performed using automated VITEK 2 system (BioMérieux, Marcy-l'Étoile, France), which has aided in the timely management.

Coinfection of Typhoid Fever With Tuberculosis: A Challenge to Surgical Management.

Ileal perforation is one of the most dreaded complications of abdominal tuberculosis. It is more common in immunodeficient patients, where ulcerative type of intestinal tuberculosis predominates. Various factors play role in the outcome of these patients, such as age and comorbid illness, though the lag period (advent of symptoms to time of admission to hospital) correlated directly to the mortality in these patients. Herein we present a 28-year-old male who had a coinfection of typhoid fever along with intestinal tuberculosis. The patient presented with abdominal pain and fever for one-week duration. On examination, he had diffuse tenderness of his abdomen with guarding. X-ray revealed free air under diaphragm. The patient underwent limited resection of terminal ileum and cecum with end ileostomy for ileal perforation. The patient's serum Widal test was positive and blood culture grew Salmonella Typhi, and the patient was started on intravenous (IV) antibiotics based on culture and sensitivity. The patient's general condition worsened after two weeks with bile leak from the surgical site. The patient succumbed to severe sepsis. Postoperative histopathology of the resected ileo-cecal segment showed features of ileo-cecal tuberculosis. As typhoid is a common cause of ileal perforation in the developing countries, the co-existence of typhoid fever in this patient lead to the delay in the diagnosis and appropriate management of tubercular ileal perforation. Knowledge about various causes of typhoid perforation is essential for treating surgeons.

A Rare Case of Large Bowel Obstruction Secondary to Bone Grafting.

Anterior abdominal wall incisional hernias can occasionally present as acute intestinal obstruction. Incisional hernias occurring at uncommon sites or after uncommon surgeries may contribute to diagnostic dilemmas. Herein, we report the case of a 53-year-old lady who presented with obstructed incisional hernia following autologous iliac bone grafting. We report this as a rare case of obstructed incisional hernia following an orthopedic procedure.

Systemic Melioidosis With Ruptured Splenic Abscess.

Melioidosis is a severe systemic disease caused by the bacterium Burkholderia pseudomallei, commonly found in soil, ground water, and ponds of endemic regions. It is transmitted to humans via percutaneous inoculation while working in these areas without protective clothing and footwear giving rise to the disease which has a high case fatality rate. It has a wide range of clinical manifestations, varying from asymptomatic infection to localized abscess formation to fulminating disease with multiple organ involvement and even death. Currently, there are no known pathognomonic features or specific criteria which can lead to a confident diagnosis of melioidosis. The gold standard diagnostic test is culture sensitivity of blood, pus, or bodily fluids, which itself has a low sensitivity. Imaging findings are not specific and can mimic other bacterial infection. However, awareness of these radiographic manifestations in multiple organs can raise the possibility of diagnosis and lead to more early proper treatment and thereby lower the high mortality associated with this disease. We here present a rare case of systemic melioidosis with ruptured splenic abscess managed laboriously with antibiotics and splenectomy and wish to review the literature.

Unwanted Diagnosis of a Subcutaneous Swelling.

Subcutaneous swelling is one of the common cases seen in surgical practice. The pathology of the subcutaneous swellings is varied ranging from epidermal inclusion cyst to malignant swelling. Fungal infections producing subcutaneous swelling are relatively rare. They occur in immunocompromised patients. We report a case of phaeohyphomycosis (PHM) which is characterized by the presence of pseudohyphae, hyphae, brown yeast-like cells, and melanin in their cell walls, presenting as subcutaneous swelling. A 34-year-old male presented with a swelling over the anterior aspect of left knee joint for three months, which was initially painless. He gave a history of purulent discharge from the swelling 20 days back. He was a known case of myasthenia gravis on regular treatment with steroids. On examination, the swelling was firm, nontender, and mobile in subcutaneous plane. The skin over the swelling showed a healed puckered scar, fine needle aspiration cytology (FNAC) of the swelling showed slender, septate hyphae with variable branching bulbous ends, and few of the hyphae showed pigmentation morphologically suggestive of PHM. The swelling was excised with clear margin. Subcutaneous mycosis is common in tropical and subtropical countries like India. Strong suspicion of this diagnosis is warranted especially in immunocompromised patients. Surgical excision is the treatment of choice to achieve early cure.

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.

An Unusual Presentation of Pseudomembranous Colitis.

Pseudomembranous colitis, also called antibiotic-associated colitis, is caused by the gram-positive anaerobic bacterium Clostridium difficile (C.difficile). The infection is common in elderly patients on chronic antibiotic use and in immunosuppressed patients. We report a rare case of pseudomembranous colitis in a 49-year-old male who presented with cramping abdominal pain, abdominal distension, and loose stools, without any pre-existing immunosuppression or chronic drug intake. The computed tomography (CT) picture was suggestive of fulminant ulcerative colitis and the patient underwent total colectomy in view of severe disease. This patient also had rectal bleeding caused by a bleeding pseudoaneurysm of the right internal pudendal artery, which posed diagnostic and therapeutic challenges. Embolization of the pseudoaneurysm was done in the post-operative period. Though the clinical and radiological pictures were suggestive of ulcerative colitis in our patient, this was disproved in the histopathological examination and by the negative serum anti-Saccharomyces cerevisiae antibodies (ASCA) testing. The presence of extensive pseudomembranous colitis in this patient masked the bleeding pseudoaneurysm of the internal pudendal artery, as bleeding is a common presentation in fulminant colitis, leading to a delay in the management of the pseudoaneurysm. Such a presentation was not reported in the literature to the best of our knowledge. Considering co-existent pathologies, especially in patients who present with an unobvious clinical picture, can prevent delay in the definitive diagnosis of these conditions.

Gastric Carcinoma in a Patient with Chronic Lymphocytic Leukemia: Coincidence or Consequence?

Chronic lymphocytic leukemia (CLL) is a neoplasm of mature B-cells of unknown etiology. There is a site-specific increased incidence of second malignancy in patients with CLL. Leukemia and cancer can thus occur in the same patient either simultaneously or sequentially. We present a case of gastric adenocarcinoma in a patient with chronic lymphocytic leukemia. A 47-year old female presented with a history of abdominal pain for one year, along with nausea and vomiting for two months. On examination, she was pale and had generalized lymphadenopathy. Her abdominal examination revealed vague fullness in the epigastrium, but there was no definite palpable mass. The complete hemogram showed features suggestive of CLL, which was later confirmed by a lymph node biopsy and bone marrow examination. While upper gastrointestinal endoscopy revealed an ulceroproliferative growth in the body of the stomach, its biopsy revealed a well-differentiated adenocarcinoma. Gastric cancer developing in a patient with CLL may be due to the immunological impairment associated with other etiological factors, such as Helicobacter pylori infection, smoking, etc. The treatment of gastric cancer consists of a gastrectomy with regional lymphadenectomy followed by adjuvant chemotherapy. The co-existence of CLL and carcinoma stomach can pose a challenge in the management of such patients.

An Unwonted Complication of Percutaneous Endoscopic Gastrostomy: A Case Report.

Percutaneous endoscopic gastrostomy (PEG) is a commonly used minimally invasive procedure to provide safe and durable access for long-term enteral nutrition in patients when oral feeds are not possible. The reported complications of PEG range from minor wound infections to life-threatening complications like hemorrhage and peritonitis. The buried bumper syndrome is one of the uncommon complications with a reported incidence of 0.3 to 2.4%. Though it is considered to be a late complication, the buried bumper syndrome has been reported as early as two weeks following the procedure. A thorough knowledge about this unusual complication is important for the prevention, early recognition and successful management of this condition to avoid interruption of enteral nutrition to the patient. Here we report a case of buried bumper syndrome developed at four weeks after placement of PEG tube.

Anal Canal Gas Gangrene in Aplastic Anaemia: Rare yet Lethal Entity - A Caveat.

Gas gangrene is one of the most serious infections of traumatic and surgical wounds. The importance lies in the fact that, if not managed at the right time, the condition is fatal. Though perianal cellulitis and gangrene are commonly reported in immunocompromised patients, we report the case of a patient with gas gangrene involving only the anal canal extending to the rectum, a rare presentation to be reported in literature.  An 18-year-old lady, a patient of aplastic anaemia - immunodeficiency, developed gas gangrene of the anal canal possibly due to faecal contamination of anal fissures. The patient was managed with surgical debridement and intravenous antibiotics.  The clinical manifestations of gas gangrene are due to the liberation of toxins by Clostridium perfringens. The infection spreads rapidly and results in necrosis and devitalisation of tissues, unless intervened surgically. The clinical manifestations are more rapid and a high index of suspicion is needed for the diagnosis.

Factors Hindering Practice of Day Care Surgery in a Tertiary Care Centre in Southern India: A Patient's Perspective.

INTRODUCTION: Day care surgery offers cost containment, effective usage of hospital beds, reduced incidence of nosocomial infection and early recovery in home environment. In developing countries like India, there are various factors that influence the success of day care surgery. AIM: To assess the factors hindering the practice of day care surgery in a tertiary care centre in South India. MATERIALS AND METHODS: This observational study was conducted in the Department of General Surgery, JIPMER, Puducherry, India, from January 2013 to March 2014. All male patients with uncomplicated inguinal hernia who were admitted for elective surgery under one particular surgery unit and who were found fit for discharge on Postoperative Day 1 (POD1) based on clinical fitness were included in the study. A questionnaire containing the patient's acceptance decision, VAS (Visual Analogue Scale) pain score and the reason for non acceptance if any was used for assessment. RESULTS: Among the 89 patients who were fit for discharge on POD1, the decision for discharge was accepted by 57 patients. 32 patients were not satisfied of the decision for discharge on POD1. The common reasons for dissatisfaction with the decision were persistent pain at operated site (13 patients with mean VAS score 8.3), non availability of health care resources in their locality (12 patients) and unwillingness to travel on POD1 (four patients). CONCLUSION: A comprehensive and well presented preoperative counselling along with an effective primary health service would help in promoting day care surgery in developing countries.

A Rare Case of Carcinoma in the Thyroglossal Duct Cyst of an Elderly Patient.

Thyroglossal duct cysts are the most common congenital abnormalities of the neck, constituting about 70% of all cervical neck masses in children and 7% of the adult population. The occurrence of carcinoma in a thyroglossal duct cyst is very rare (less than 1%). Malignancy of the thyroglossal duct cyst usually presents in the third or fourth decade of life. We report a case of carcinoma in the thyroglossal duct cyst, which presented for the first time in our elderly patient.  A 76-year-old male presented with a 6 x 5 cm swelling in the anterior aspect of the neck. The swelling had been present for three months and had a variegated consistency. It moved with deglutition as well as with protrusion of the tongue. Intra-operatively, the lesion was cystic and was adherent to the hyoid bone. Sistrunk operation was done. The post-operative histopathology showed papillary carcinoma in the thyroglossal duct cyst.  The standard treatment is Sistrunk procedure with close follow-up of the patient. Patients with metastatic disease require a total thyroidectomy and in the presence of neck secondaries, neck dissection has to be done. The diagnosis can be missed because of the rarity of this condition. Carcinoma should be suspected in a thyroglossal duct cyst when presenting for the first time in the elderly age group.

An Unusual Cause of Small Bowel Obstruction: A Case Report.

Small bowel obstruction is a common surgical emergency. The common causes are adhesions, malignancies, and hernias. We present a rare case of small intestinal obstruction caused by an enterolith in the distal ileum in a patient with an apparently normal gut.  A 59-year-old male who underwent gastrojejunostomy 15 years back presented with features of intestinal obstruction of five days' duration. After initial conservative management, the patient was taken up for laparotomy. An enterolith causing obstruction was found in the distal ileum, and it was crushed and milked into the colon. The patient made an uneventful recovery.  The chyme crossing the ileum is usually liquid or semi-solid and hence luminal obstruction by the faecal bolus in the ileum is very unusual. In patients with previous gastric surgeries where the pylorus is bypassed, the solid food particles enter the small intestine and can form a bezoar. This patient was managed with laparotomy and milking of the stool bolus into the colon. Other treatment options include enterotomy or resection of the diseased bowel and removal of the enterolith.  Small bowel obstruction due to an enterolith is very rare and can pose a diagnostic challenge.

Primary tuberculous appendicitis presented with caecal perforation: a case report.

Gastrointestinal tuberculosis accounts for 3% of the extrapulmonary tuberculosis with ileocaecal region being the common site of involvement up to 75%. Primary involvement of appendix is very rare and accounts for only 0.6% to 2.9% of gastrointestinal tuberculosis in the absence tubercular focus elsewhere. The pre-operative investigations usually give non-specific results. The diagnosis in most instances made only after histopathology. Here we report a case of primary appendicular tuberculosis in a patient presented with caecal perforation.

Palmar cutaneous metastasis from carcinoma cervix.

Carcinoma of the uterine cervix is the most common gynecological malignancy in developing countries. However, its cutaneous metastasis is a rare entity. The reported incidence of cutaneous metastasis ranges from 0.1 to 2%. Frequent sites of cutaneous metastasis in decreasing order are: abdominal wall, vulva and anterior chest wall. To the best of our knowledge, only three cases of cutaneous metastasis to the upper extremity have been reported in the world. We report a case of a 74-year-old postmenopausal lady diagnosed to have carcinoma cervix (stage IIIB) who presented with cutaneous metastasis to palm and thigh, 10 months after radical radiotherapy. At presentation, the primary disease had resolved completely. She had a small nodular growth in the left palm and left thigh. Fine needle aspirate cytology and core needle biopsy from both the nodular lesions were positive for squamous cell carcinoma.