Anatomical mapping of the biliary tree during laparoscopic cholecystectomy by using indocyanine green dye.

Background: Fluorescent cholangiography using intravenous indocyanine green (ICG) is a noninvasive technique that enables real-time intraoperative imaging of biliary anatomy. The objective of this study was to visualise the biliary anatomy in routine and complicated cases of laparoscopic cholecystectomy (LC). Methods: This was a prospective observational study of patients undergoing LC for various indications. After obtaining consent, 5 mg/1 ml of ICG dye was administered intravenously in each patient, 2 h before the incision time. LC was performed by standard critical view of the safety technique. The biliary tree was visualised using near-infrared (NIR) view before clipping any structure. Intra-operative findings, visibility of ducts in the NIR view, conversion, adverse reactions to ICG and post-operative outcomes in all patients were recorded. Results: Out of 43 patients undergoing LC, 24 had cholelithiasis, 10 had acute cholecystitis, 3 had chronic cholecystitis, 1 had mucocele of the gall bladder, 1 had gall bladder polyp and 4 cases had common bile duct (CBD) stone clearance with endoscopic retrograde cholangiopancreatography. Cystic duct (CD) and CBD were visualised in 100% of cases among all groups except for those with acute cholecystitis where CD and CBD were visualised in 90% and 80% of cases, respectively, and in chronic cholecystitis CD and CBD were visualised in 66.6% and 80% of patients, respectively. There was one elective conversion in the chronic cholecystitis group due to dense adhesions and non-progression. Only the CBD was visualised in this case. There were no cases of CBD injury or any allergic reactions to the dye. Conclusions: Fluorescent cholangiography during LC is a safe and non-invasive method, allowing superior anatomical visualisation of the biliary tree in comparison to simple laparoscopy. This method can correct misinterpretation errors and detect aberrant duct anatomy, thus increasing the confidence of the operating surgeon enabling safe dissection. This simple technique has the potential to become standard practice to avoid bile duct injury during LC.

Effectiveness of inspiratory muscle training (IMT) on pulmonary function and functional capacity in chronic smoker's v/s non-smokers patients undergoing open abdominal surgery - A study protocol.

BACKGROUND: Abdominal surgeries are performed for the treatment and diagnosis of many diseases. Smokers undergoing abdominal surgery, are high risk population, having underlying pathological changes in lung parenchyma due to inflammatory effect of smoking. Site of incision and history of smoking may significantly affect pulmonary function such as FVC and FEV1. Respiratory muscle training pre-operatively has shown significant improvement of pulmonary function compare to only conventional therapy and has led to reduction of PPCs, length of hospital stay and cost. This study aims to find effectiveness of IMT in chronic smokers undergoing abdominal surgery and its significance in reduction of PPC and in pulmonary function and functional capacity as compared to non-smokers. METHODOLOGY: This study protocol is observational cohort study comparing smoker and non-smoker participants undergoing abdominal surgery. The participants will be assessed for pulmonary function test and functional capacity (6MWD); pre-operatively and post-operatively day 1 till the day of discharge. Both the groups will receive IMT and conventional chest Physiotherapy from POD1 and increment of IMT will be done by assessing MIP each day. DISSEMINATION: We plan to publish this review in a peer-reviewed journal. We may also present this review at local and/or national conferences.

Short-term response to phenytoin sodium in Andersen-Tawil syndrome-1 with a cardiac-dominant phenotype.

BACKGROUND: Andersen-Tawil syndrome (ATS) is a rare familial periodic paralysis that typically also affects the heart and skeletal system. Ventricular arrhythmias (VAs) are profound and difficult to control, but minimally symptomatic. In this report, we describe an atypical phenotype of ATS in two related families. We also report our experience with phenytoin sodium for the control of resistant VAs in these patients. METHODS AND RESULTS: Between 2014 and 2018, seven siblings were diagnosed with ATS on the basis of cardiac arrhythmias and genetic evaluation. Heterozygous mutation with c.431G > C (p.G144A) in exon 2 of KCNJ2 gene was observed in all patients. Characteristic cardiac manifestations were noted in all patients but periodic paralysis or objective neurological involvement was distinctly absent. Phenytoin was considered for control of symptomatic VA in three patients. Intake of oral phenytoin (5 mg/kg/day) for 1 month completely suppressed VA (<1% in 24-h Holter monitoring) in two patients, and significantly in the third (8% per 24 h) patient. Phenytoin was well-tolerated in all three patients. CONCLUSIONS: We describe a cardiac-predominant phenotype in ATS. ATS should be suspected in patients with typical cardiac manifestations even in the absence of periodic paralysis. Our initial experience with short-term use of phenytoin for control of resistant VAs is encouraging.

Clinical and microbiological profile of diabetic foot ulcer patients in a tertiary care hospital.

AIM: To evaluate the clinical and microbiological profile of diabetic foot ulcer patients admitted to a tertiary care hospital. METHODOLOGY: This study recruited 120 diabetic foot ulcer patients of all grade. Their medical records were evaluated retrospectively. RESULTS: We found that median age of patient was 60(52, 67.75) years. 68.3% of patients were males. Median duration of diabetes mellitus was 15(10, 20) years. Mean HbA1C and fasting glucose was 10.3±2.3 and 167.6±52.42 respectively. Neuropathy (35%) and peripheral vascular disease (23.3%) was major micro vascular and macro vascular complication associated. Different locations of ulcers were toe (23.3%), sole (20%), dorsum (18.3%), shin (16.6%), heel (13.3%), and ankle (8.3%). Bacterial infection was seen in 81.66% patients out of which 23.3% had poly microbial infection. CONCLUSION: Diabetic foot ulcer patient had poor blood glucose control with elevated HbA1C and fasting blood glucose level. Neuropathy and peripheral vascular disease, hypertension were major complications. Staphylococcus aureus, Pseudomonas aeruginosa were common infecting bacteria.

Development and validation of health related quality of life questionnaire (Indian scenario) in diabetic foot ulcer patients.

AIM: To develop and validate Health Related Quality of Life Questionnaire in Diabetic Foot Ulcer Patients (HRQLQDFU) for Indian scenario. MATERIALS AND METHODS: This study was conducted in two phases. First phase was Development of HRQLQDFU which included literature search and expert interview. Second phase was validation of HRQLQDFL which included face validation, content validation and construct validation. Face validation was done by ten diabetic foot ulcer patients, ten practicing nurses and ten care givers. They were asked to read and respond to questionnaire and report any difficulty in understanding the questions. Further they were asked to add any item to the questionnaire which according to them has a significant effect on quality of life. Content validation was done by six subject experts who judged the content relevance of questionnaire with score ranging from zero to four; zero being least relevant and four being most relevant. Content validity index was calculated for each question. Questions having content validity index≥0.8 were selected for the study. Reliability was tested by calculating Cronbach's alpha. RESULTS: In the development phase a questionnaire containing 37 questions with six domains was developed. None of patient had difficulty in understanding questions. After content validation a new questionnaire containing 20 questions was developed. Cronbach's alpha was 0.86 which shows good reliability. CONCLUSION: The new health related quality of life questionnaire on diabetic foot ulcer patients for an Indian scenario is validated and can be a reliably measure for quality of life in diabetic foot ulcer patients.

Topical honey for the treatment of diabetic foot ulcer: A systematic review.

Topical honey has been used for the treatment of wound since ancient time. But the medical evidence proving it is limited. Hence a systematic review was planned. An exhaustive literature search was done in PUBMED, COCHRANE, GOOGLE using 'topical honey', 'diabetic foot ulcer', 'chronic wounds' as key words. Literature search showed total of five clinical trials and about ten observational studies in various part of world. Out of five clinical trials three concluded that honey dressing is better than conventional dressing, all the clinical trials proved safety of honey for the treatment of diabetic foot ulcer. Observational studies included total of 320 patients which also showed safety of honey but efficacy cannot be considered from observational studies. This review showed that honey dressing is safer for treatment of diabetic foot ulcer but there is insufficient good quality data to realistically conclude on the efficacy of honey on diabetic foot ulcers.

Gastroduodenal intussusception due to pedunculated polypoid gastrointestinal stromal tumour (gist ): a rare case.

Gastrointestinal stromal tumours (GISTs) account for less than 3% of all gastrointestinal tract tumours and 5.7% of all sarcomas, and the majority of these tumours are gastric in origin. Patients commonly present with gastrointestinal bleeding or abdominal pain with 10-30% of patients presenting with symptoms of gastrointestinal obstruction. We report a rare case clinically presenting as gastric outlet obstruction, gastroscopy suspecting it to be organo-axial gastric volvulus, CECT(Contrast Enhanced Computerised Tomography) suggesting features of gastric malignancy (leiomyosarcoma) keeping the possibility of differential diagnosis of GIST. Eventually on exploratory laparotomy we discovered gastric outlet obstruction due to transpylorically herniated pedunculated polypoid GIST leading to gastroduodenal inussusception.

Giant scrotal lymphoedema - A case report.

INTRODUCTION: Giant Scrotal Lymphoedema is a rare disease. Such Scrotal elephantiasis presents multiple problems both to the patient as well as the treating clinician obstruction, aplasia, or hypoplasia of the lymphatic vessels. The most common cause world wide is lymphatic Filariasis. PRESENTATION OF CASE: We present a particularly grotesque where the resected scrotal tissue weighed 32kg which is one of the largest so far mentioned in literature. The lymphoedema was progressive over 8 years duration and the testes were not palpable with the penis deeply buried. DISCUSSION: Scrotum was explored and penis was recovered deep within the pit of lymphoedema. Careful dissection done with cautery to delineate penis circumferentially from the root of scrotal lymphoedema. Foleys catheterisation was done. After the separation of penis scrotal skin flaps were raised on either side by extending the incision horizontally. De bulking of lymphoedema was done and the remaining scrotal skin was closed in Y shaped manner with root of penis in centre. Meticulous technique of dissection, cautery and ligasure use of Ligasure enabled excision with minimal blood loss. CONCLUSION: Once fibrosis sets in resectional therapy will be needed in most cases. Successful reduction scrotoplasty with acceptable cosmetic results can be obtained in giant scrotal lymphoedemas weighing as large as 32kg as in our case.