Telescopic dissection versus balloon dissection during laparoscopic totally extraperitoneal inguinal hernia repair: A prospective randomised control trial.

BACKGROUND: Totally extraperitoneal (TEP) repair involves creating a preperitoneal space. The preperitoneal space can be created by balloon or telescopic dissection (TD). Nevertheless, these techniques may have some complications. However, there are very few studies that compare these two techniques. This study aims to assess the impact and comprehensively compare the TD and balloon dissection (BD) methods in patients undergoing laparoscopic TEP inguinal hernia repair. PATIENTS AND METHODS: This was a single-centre, double-blinded, prospective, randomised, controlled trial comparing BD and TD for the creation of the preperitoneal space. The primary end point was to compare the post-operative pain score, intraoperative complications and surgical site occurrence between the two groups. The secondary end point was to assess the impact of the dissection technique on operative time for the creation of extraperitoneal space during laparoscopic TEP inguinal hernia repair. RESULTS: A total of 46 patients were included in the study (23 in each group). Baseline parameters were comparable between the groups. The total operative time between the groups (120 min vs. 160 min; P < 0.005) was statistically significant. The incidence of the peritoneal breach was statistically less in the BD group (43% vs. 13%; P < 0.005). Other short-term and long-term complications were less in the BD group but not statistically significant. CONCLUSIONS: BD in TEP inguinal hernia repair reduces the operative time and peritoneal breach. When compared to TD in terms of operative time, routine use of BD can be proposed. It will be beneficial in the early part of the learning curve.

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

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

Evaluation of Acoustic Radiation Force Impulse Imaging in Differentiating Benign and Malignant Cervical Lymphadenopathy.

Background: The aim of this study was to assess the diagnostic role of acoustic radiation force impulse imaging (ARFI) in differentiating benign and malignant cervical nodes. Methods: This was a diagnostic accuracy cross-sectional study. All patients who underwent ultrasound-guided fine-needle aspiration cytology (FNAC) of cervical nodes were included. Patients without FNAC/biopsy and patients in whom cervical nodes were cystic or completely necrotic were excluded. FNAC was used as reference investigation to predict the diagnostic accuracy. In all cases, FNAC was carried out after the B-mode, color Doppler and the ARFI imaging. In patients with multiple cervical lymph nodes, the most suspicious node based on grayscale findings was chosen for ARFI. ARFI included Virtual Touch imaging (VTI), area ratio (AR), and shear wave velocity (SWV) for each node, and the results were compared with FNAC/biopsy. Results: The final analysis included 166 patients. Dark VTI elastograms had sensitivity and specificity of 86.2% and 72.1%, respectively, in identifying malignant nodes. Sensitivity and specificity of AR were 71.3% and 82.3%, respectively, for a cutoff of 1.155. Median SWV of benign and malignant nodes was 1.9 [95% confidence interval (CI), 1.56-2.55] m/s and 6.7 (95% CI, 2.87-9.10) m/s, respectively. SWV >2.68 m/s helped in identifying malignant nodes with 81% specificity, 81.6% sensitivity, and 81.3% accuracy. ARFI was found to be inaccurate in tuberculous and lymphomatous nodes. Conclusion: Malignant nodes had significantly darker elastograms, higher AR and SWV compared to benign nodes, and SWV was the most accurate parameter. ARFI accurately identifies malignant nodes, hence could potentially avoid unwarranted biopsy.

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

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

Outcomes from Early Experience with Laparoscopic Inguinal Hernia Repair Versus Open Technique: Navigating the learning curve.

Objectives: This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR). Methods: This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed. Results: A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group. Conclusion: Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

Volvulus of the Transverse Colon Herniated Through Drain Site.

Herniation of the transverse colon and volvulus of it occurring through the previous surgical drain site, presenting as intestinal obstruction, has never been reported. We present an 80-year-old female who complained of abdominal swelling for 10 years. She started developing pain abdomen for 10 days and obstipation for three days. Abdominal examination showed a tender mass in the right lumbar region, with all borders being distinct, and there was no cough impulse. There is a lower midline scar from the previous laparotomy and a small scar over the swelling (drain site). Imaging studies were diagnostic of large bowel obstruction due to the herniation and volvulus of the transverse colon through the previous surgical drain site. She underwent laparotomy, derotation of transverse colon with hernia reduction, and onlay meshplasty. She had an uneventful postoperative course and was discharged.

The Incidence and Severity of Patient-Reported Side Effects of Chemotherapy in Routine Clinical Care: A Prospective Observational Study.

INTRODUCTION: Understanding patients' self-reported chemotherapy side effects is significant because it affects patients' quality of life (QOL) and compliance with treatment. Our current knowledge of chemotherapy side effects comes from available literature, whose external validity is questionable. Moreover, there are very few studies available in the literature that focus on various cancers and their associated side effects. METHODS: A single-center, prospective observational study was conducted at a tertiary care center from July 2019 to July 2021. After deriving the sample size, we interviewed 76 consecutive study patients with gastric, periampullary, colorectal, and breast cancer for six months after chemotherapy initiation with a structured patient-reported outcome tool adapted in English and Tamil to record the side effects like diarrhea, vomiting, chest pain, constipation, dyspnea, fatigue, mucositis, and rash. The grading of symptoms was done according to the Common Terminology Criteria for Adverse Events version 5.0. The frequency and prevalence of side effects were calculated as the number of patients who reported the side effect of any grade at least once during the follow-up period. The incidence rate of side effects was calculated in terms of person-time. The association between each side effect and cancer type was calculated using the chi-square test and Fisher's exact test as appropriate. RESULTS: Of the 77 patients in the study, 51.9% were male, 63.6% were between 40 and 60 years of age, 45.5% had stage-3 disease, and 44.2% received neoadjuvant treatment. During the six-month follow-up period, 97.4% of patients experienced at least one side effect. Fatigue was the most common side effect (87%), followed by loss of appetite (71.4%) and diarrhea (49.4%). Approximately 66.7% of patients experienced six or more side effects. There was a statistically significant difference in the frequency of side effects between cancer types. However, age, socioeconomic status, BMI, comorbidity, chemo-intent, and stage of disease did not affect the frequency of side effects. CONCLUSIONS: This study highlights the need to integrate patient-reported side effects into routine clinical practice. Identifying these side effects, even if they are mild in intensity, and managing them in a timely manner may improve the patient's emotional state, QOL, and compliance with chemotherapy.

A Randomized Controlled Trial Comparing Ultrasonography-Guided Needle Aspiration and Surgical Drainage for the Management of Breast Abscess.

Background A breast abscess is a localized collection of inflammatory exudate in breast tissue. It is more common in lactating women. Treatment of the breast abscess is usually by incision and drainage, which is accompanied by extensive trauma, lengthy surgical incisions, psychological distress, surgical scar, and discomfort during dressing changes. Recent research has shown that ultrasonography-guided needle aspiration is an alternative to incision and drainage for breast abscess treatment, has superior cosmetic outcomes, and has fewer costs. However, there are no clear guidelines for the same. The primary objective of this study was to assess and contrast the outcomes and efficacy of two approaches in the treatment of breast abscesses: ultrasonography-guided needle aspiration and conventional incision and drainage. Methods This was a single-center, prospective, randomized, controlled, non-inferiority trial. Patients with breast abscesses were randomized either to receive needle aspiration or incision drainage. Patients with lactational breast abscesses were encouraged to breastfeed from either breast. The antibiotic was given for 10 days to all the patients. The study's main focus was on the primary outcome, which was the failure rate. Additionally, several secondary outcomes were examined, including postoperative pain, time required for healing, presence of residual abscess or recurrence, formation of fistulas, and the assessment of scar appearance. Results A total of 44 patients were randomized to 23 and 21 in each arm. There was no statistical difference in treatment failure (p-value=0.862), fistula formation (p-value=1.00), and recurrence (p-value=1.00). There was a significant statistical difference in healing period (p-value <0.001), scar formation (p-value <0.0001), continuation of breastfeeding (p-value=0.005), and clinical resolution (p-value=0.002). There was a significant reduction in post-intervention pain in the needle aspiration group than in the other group (p-value <0.001). Conclusion This study showed a significant difference in postoperative pain, healing time, the continuation of breastfeeding, and scar formation in the needle aspiration group, favouring minimally invasive treatment for breast abscess. However, due to the small sample size, we could not conclude that ultrasonography-guided needle aspiration of the breast abscess is non-inferior to the conventional incision and drainage.

A study on prevalence, profile, and risk factors of developing fungal infection in patients with diabetic foot ulcer.

BACKGROUND: Many chronic nonhealing diabetic foot ulcers (DFUs) with increased rates of amputation are frequently associated with fungal infections. PURPOSE: To evaluate the prevalence, profile, and risk factors of developing a fungal infection in patients with DFU. METHODS: This prospective observational study was carried out from October 2018 to July 2020. All adult patients with DFUs admitted to the surgery ward were recruited. Patients on antifungal therapy or who received such therapy within 6 weeks prior to admission were excluded. Three deep tissue samples were sent for bacterial culture, fungal culture, and histopathological examination of fungal elements. RESULTS: A total of 251 patients were enrolled in the study. Of the 23.3% of patients with positive fungal growth (n = 47/202), 2% (n = 4/202) had pure fungal growth and 21.3% (n = 43/202) had mixed growth with bacteria in their ulcers (ie, non-contaminated samples). A significant association was found between wound grade (P = .027), ulcer duration (P = .028), and positive fungal growth in DFUs. CONCLUSIONS: In this study, the prevalence of fungal infection in DFUs was 23.3%; Candida tropicalis (27.08%) was the most common isolate, followed by C. albicans (20.83%). The rate of fungal infections was high in patients with mild diabetic foot infection or DFU of 7 to 14 days' duration.

Effect of Trendelenburg's Operation With Subfascial Ligation of Perforators in Clinical Improvement and Quality of Life Among Patients With Varicose Veins.

Background Assessing patients' quality of life has received increasing attention, mainly because questions have been raised regarding the direct benefits of the treatment provided. Hence, clinical outcomes and quality of life must be measured after chronic venous disease treatment. The primary objective of the study was to assess the improvement in clinical outcome and improvement in quality of life using the revised venous clinical severity score and chronic venous insufficiency questionnaire-14, respectively, in patients with varicose veins undergoing Trendelenburg's surgery and subfascial ligation of perforators. The secondary objective was to identify the relationship between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. Method The present study is a single-center, prospective cohort study to assess the clinical improvement and quality of life in patients with varicose veins undergoing Trendelenburg surgery and subfascial ligation of perforators. All the study participants were evaluated preoperatively with the clinical, etiological, anatomical, and pathophysiological stage of the disease, revised venous clinical severity score for the clinical severity, and the chronic venous insufficiency questionnaire-14 questionnaire for the quality of life. The study participants were reviewed 90 days after surgery and reassessed for clinical severity and quality of life, both scores. Results Of the 87 screened varicose vein patients, 52 were included in the study. However, one patient was lost to follow-up. There were 38 (74.5%) males and 13 (25.5%) females. There was a significant difference in the preoperative and postoperative mean revised venous clinical severity score of the C3, C4, and C6 stages of the disease (p-value = <0.01). There was a significant difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score in C3, C4, and C6 (p-value = <0.01). There was a significant difference in the median preoperative and postoperative revised venous clinical severity score (p-value = <0.01). There was a considerable difference in the mean preoperative and postoperative chronic venous insufficiency questionnaire-14 score (p-value = <0.01). The correlation coefficient between the preoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.26 (p-value = 0.58), and the correlation coefficient between the postoperative chronic venous insufficiency questionnaire-14 score and the revised venous clinical severity score was 0.42 (p-value = <0.01).  Conclusion Patients undergoing Trendelenburg's surgery and subfascial ligation of perforators for varicose veins significantly improved the clinical severity and quality of life. There was significant improvement among the overall revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score after surgery among the different clinical classes. There was no preoperative correlation between the revised venous clinical severity score and the chronic venous insufficiency questionnaire-14 score. However, there was a significant correlation between the postoperative revised venous clinical severity score and chronic venous insufficiency questionnaire-14 score.

Tension pneumoperitoneum following colonic perforation due to barotrauma.

Barotrauma of the colorectum is an uncommon entity that usually occurs after colonoscopy. Perforation of the colon by non-iatrogenic barotrauma of the colon, with tension pneumoperitoneum, is very rare. We present a case of a male patient in his 20s with colon barotrauma caused by industrial compressed air, causing perforation of the transverse colon, with multiple serosal tears throughout the colon. There was also evidence of contusion in the caecum and ascending colon. Primary repair of the perforation and repair of the serosal tears were done along with a covering loop ileostomy.

Fulminant Necrotizing Pyomyositis Tropicans.

Pyomyositis tropicans is a purulent invasive infection of the striated muscle tissues, usually caused by Gram-positive bacteria Staphylococcus aureus and Streptococcus in immunocompromised patients. We hereby report a case of fulminant necrotizing pyomyositis that occurred in a 16-year-old immunocompetent patient, and it is the first one of its kind to the best of our knowledge. The patient underwent imaging which suggested extensive intramuscular abdominal wall abscess formation, for which the patient underwent multiple surgical debridements of the lateral thoracic wall. Subsequent cultures grew Escherichia coli as the causative organism. Postoperatively, the patient went into catastrophic, irreversible septic shock ending in an eventual fatality.

Traumatic Diaphragmatic Rupture With Pericardial Tear and Transdiaphragmatic Herniation of the Stomach.

Traumatic diaphragmatic rupture is uncommon in blunt or penetrating abdominal trauma. Diaphragmatic injury associated with pericardial tear is even rarer. Here, we report a case of a 23-year-old female who presented with complaints of chest pain, abdomen pain, and breathlessness following blunt trauma abdomen. An imaging study showed the presence of transdiaphragmatic herniation of the stomach inside the thorax. Emergency exploratory laparotomy was done, and we found a large diaphragmatic defect with a pericardial tear with herniation of the stomach. Both diaphragmatic and pericardial tears were repaired primarily. Postoperatively, the patient improved well without any complications.

Regurgitation and prolapse of oesophageal mucosa: a dramatic presentation of the oesophagitis dissecans superficialis.

Oesophagitis dissecans superficialis is a rare benign entity that is usually self-limited, characterised by sloughing of the oesophageal mucosa. We preset a 38-year-old woman, known case of epidermolysis bullosa acquisita who presented to us with regurgitation and prolapse of the oesophageal mucosa from the mouth. Upper gastrointestinal endoscopy showed sloughing of the mucosa. The patient was managed conservatively and discharged.

An Observational Study of Anticipatory Coping Behavior of Women for Chemotherapy-Induced Alopecia for Breast Cancer Treatment.

Background It is necessary to explore patients' expectations of chemotherapy-induced alopecia, anticipate reactions to alopecia, and how women intend to prepare for an altered body appearance. Studies regarding women's critical aspects of anticipatory coping behavior (anticipate reactions to alopecia and how women intend to prepare for a modified body appearance) towards hair loss and factors influencing it are sparse, especially from India. This study helped identify the factors influencing the anticipatory coping behavior toward chemotherapy-induced alopecia. Methodology This was a cross-sectional analytic study carried out for three months, including all breast cancer patients admitted for neo-adjuvant chemotherapy. Anticipatory coping behavior before and during each chemotherapy cycle period (minimum one cycle) was assessed using the World Health Organization scale. Study patients received two sets of questionnaires. The first question is asked before the start of chemotherapy, and the second is requested at least four weeks after completing the first chemotherapy. The first question included baseline demographic data, disease details, and awareness about hair loss. The second question had hair loss pattern, severity of cancer-induced alopecia, and rated the degree of alopecia in a visual analog scale score. Individual psychosocial and social factors associated with the anticipatory coping behavior were documented using a self-administered questionnaire. Results A total of 40 patients were included in the study. All of the participants reported anticipating hair loss. Five percent of the patients came to terms with the inevitability of hair loss. Around 22.5% of them became ready, 67.5% of the patients took control and 52.5% of the patients felt shame in front of society due to a lack of anticipatory behavior. About 47.5% of the participants felt that not being willing to wear a wig is a reason for deficient anticipatory coping behavior. Conclusion The study patients' main reasons for lack of anticipatory coping behavior were shame in society, insecure thoughts about the future, and unwillingness to live with a wig. It should be advised to such patients that losing hair is not a health problem (though it is an emotional issue), and clinicians can encourage them to use hats. Further multi-institutional prospective studies are required to assess the poor motivation of health care professionals to achieve target anticipatory coping behavior.

Catastrophic Sequalae Following Percutaneous Intervention in Case of Sigmoidectomy for Sigmoid Volvulus.

Injury to the inferior epigastric artery is infrequent and iatrogenic in most cases, which can be fatal and life-threatening in some cases due to unnoticed excessive hemorrhage. We present a 23-year-old male who underwent sigmoidectomy, end-to-end colorectal anastomosis with covering loop ileostomy for sigmoid volvulus. He developed intra-abdominal pus collection one week following surgery, for which ultrasound-guided aspiration was attempted. Post aspiration, the patient developed abdominal distension, pain with a significant drop in hemoglobin. Imaging showed active bleed from the branch of the inferior epigastric artery with massive intra-abdominal hematoma. The hematoma was evacuated, and the bleeding artery was identified and ligated. Postoperatively, there was no further drop in hemoglobin, and the patient was stable and hence discharged.

A Rare Case of Occult Extra-Baudet Period in a Patient With Spontaneous Splenic Rupture.

Spontaneous splenic rupture in the extra-Baudet period is a rare phenomenon demanding a high clinical suspicion for diagnosis with prompt treatment. We present a case of a 39-year-old male presenting with left upper abdominal pain following six months after abdominal trauma. The patient underwent imaging studies showing a large subcapsular splenic hematoma with near-total parenchymal displacement and moderate hemoperitoneum. Sequential scans revealed a non-progressive resolving hematoma with no active extravasation. The patient underwent aggressive initial resuscitation followed by successful conservative management and was discharged.

Rare case of traumatic bilateral testicular dislocation.

Bilateral traumatic testicular dislocation is an uncommon condition and usually occurs after a direct impact on the scrotum. Herein, we report this as a rare case of a 21-year-old man presenting with bilateral traumatic dislocation of testes into the inguinal canal following a motorcycle accident. Imaging studies ruled out any other associated injuries. The patient underwent bilateral orchidopexy without any further complications.