Recurrent dermatofibrosarcoma protuberans: A report of two cases involving the trunk and abdominal wall.

In this paper, we report two cases of dermatofibrosarcoma protuberans (DFSP) who were treated with distinct surgical approaches. In the first case, a 50-year-old woman presented with a mass on her right shoulder and underwent local excision with subsequent reconstruction using a deltopectoral flap. The second case was of a young female who presented with a giant protuberant DFSP on the anterior abdominal wall who was treated with wide local excision along with inlay mesh repair of the defect. Early excision and adjuvant radiotherapy facilitates a low recurrence rate while also improving the prognosis of the patients.

Utility of Glasgow Microenvironment Score as a prognostic tool in colorectal carcinoma.

Background: Colorectal carcinoma (CRC) is third most common malignancy in the world. The presence of Lymphocytes particularly at the invasive margin of the tumor have been associated with good immune response indicating better prognosis. The relative tumor stroma is also important in deciding the course of the disease. The Glasgow Microenvironment Score (GMS) comprises of assessment of tumor cell infiltrate using Klintrup-Makinen (KM) grade and tumor stroma percentage. Aims: The aim of the present study is to evaluate the utility of GMS score in relation to parameters of adverse histopathological outcome in carcinoma colon that is grading, staging, LVI, PNI and nodal metastasis. Setting and Design: Colectomy specimens received over 3 year period were subjected to microscopic evaluation for LVI, PNI, grade, stage & lymph node metastasis. Materials and Methods: Lymphocytes at the deepest invasive margin of tumor were counted as per KM score in 5 HPF by two independent pathologists . Patients were classified as Low grade (0/1) or high grade (2/3) response. Tumor stroma percentage was calculated as stroma poor (<50%) and stroma rich (>/= 50 %). The GMS was scored by combining the two and scored 0, 1 and 2. Statistics and Results: Total 37 patients with no prior therapy were included out of which 23 were males and 14 females. 15 patients (40.54%) had GMS of 0, 6 (16.21%) had GMS 1 and 16 (43.24%) had GMS 2. A high GMS was associated with LVI (P = 0.02), PNI (P = 0.01) lymph node metastasis (P = 0.003). However, no significant association was found between GMS with Grade (P = 0.98) and Stage (P = 0.36). Conclusion: Low GMS was associated with good outcome and high GMS with poor outcome. This score can be used for risk stratification, can be of clinical utility and may be applied to pathological descriptions of CRC.

Microbial profile from peritoneal fluid and surgical wounds in patients with perforation peritonitis - A cross-sectional study from New Delhi.

Surgical site infection (SSI) remains one of the most common complications of perforation peritonitis, contributing not only to morbidity but also mortality. We studied the culture and sensitivity of intra-peritoneal fluid and post-operative laparotomy wounds, and found consistency in pathogen and sensitivity between the intra and post-operative samples in 25 cases (80.6%). Therefore, routine culture and sensitivity of peritoneal fluid and subsequently switching the empirical anti-microbial therapy accordingly is justified.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries.

OBJECTIVE: To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness. DESIGN: A mixed-methods approach using a multicentre online Delphi technique. SETTING: Two large tertiary hospitals in urban India. METHODS: Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments. RESULTS: 26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity. CONCLUSIONS: Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Basaloid squamous cell carcinoma of anal canal with adenoid cystic pattern and liver metastasis: A rare case report.

Anal malignancies are rare, and of these squamous cell carcinoma and basaloid squamous cell carcinoma are the most common types. Anal basaloid squamous carcinoma (BSC) can show a variety of patterns including unusual variants with cribriform areas resembling adenoid cystic carcinoma (ACC). BSC is reported more frequently in elderly females. Although the histopathology of BSC is characteristic, its cytomorphology is rarely described in the anorectal region. Due to overlapping morphological features, it is challenging to distinguish between ACC and BSC. Immunohistochemistry (IHC) is mandatory for this distinction and definite diagnosis, as it is a highly aggressive tumor with a tendency for distant metastasis. An interesting and rare case of BSC with ACC-pattern arising in the anal canal with liver metastasis in a middle-aged male is reported here. The aim is to highlight its cytological features, correlation with histology, IHC and its differential diagnoses.

Androgen insensitivity syndrome: Can cytology help?

Androgen insensitivity syndrome (AIS) is described as a patient's clinical (phenotypical) presentation as a female with male karyotyping. Classically, patients are normal looking females with complaints of primary amenorrhea. The gonads may be found as extra-genital swellings; rarely, the testes may undergo malignant transformation. Thus, gonadectomy is indicated in these patients on attaining puberty. A rare and interesting case of clinically unsuspected AIS in a young female who presented with primary amenorrhea and inguinal swelling is reported. The initial diagnosis was suggested on fine needle aspiration cytology (FNAC) from the inguinal swelling that showed the presence of Sertoli cells. Further family history revealed two similar siblings; karyotyping and histopathology confirmed the diagnosis of AIS in the patient. This case highlights the importance of FNAC in early diagnosis and a multidisciplinary approach to confirm the diagnosis and help in appropriate management.

Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice?

BACKGROUND: Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India. METHODS: A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS). RESULTS: With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%). CONCLUSIONS: Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Laparoscopically guided transversus abdominis plane block offers better pain relief after laparoscopic cholecystectomy: results of a triple blind randomized controlled trial.

BACKGROUND: Transversus abdominis plane (TAP) block is a regional anaesthetic technique providing analgesia to the parietal peritoneum, muscles and skin of the anterior abdominal wall innervated by somatic nerves T6 to L1. We present the results of our randomized triple blind study comparing laparoscopically guided TAP block with the commonly used port site local anaesthetic infiltration for pain relief after laparoscopic cholecystectomy. METHODS: A hundred patients with symptomatic gallstones planned for laparoscopic cholecystectomy were randomized into two groups of TAP block and port site infiltration. Group A received 4-quadrant TAP block with 10 ml of 0.25% bupivacaine at each of the four sites guided laparoscopically and port site infiltration with 10 ml of normal saline at each of the 4 ports for blinding the surgeon. Group B received port site infiltration with 0.25% bupivacaine, and infiltration with normal saline at TAP block sites for blinding the surgeon. Post-operative pain (at 3, 6, 24 h and 1-week post-operative) (VAS), time to return to activities of daily living and patient satisfaction (Capuzzo Score) were recorded by an observer blinded towards the groups of the patients. RESULTS: The median VAS at 3, 6, 24 h, at discharge, and 1-week post-operative were lesser in Group A compared to Group B (p ≤ 0.001 for all). The median duration of hospital stay was also lesser in Group A compared to Group B (p = 0.48, not significant) as was the time to return to activities (p < 0.05). The median Capuzzo score was higher in Group A compared to Group B (p < 0.001). CONCLUSION: This study shows that laparoscopically guided TAP block is a safe and easy-to-use technique. It reduces the severity of post-operative pain, helps in quick recovery, early discharge and improved patient satisfaction after laparoscopic cholecystectomy. Clinical Trials Registry of India 020227.

Development and validation of a recommended checklist for assessment of surgical videos quality: the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool.

INTRODUCTION: There has been a constant increase in the number of published surgical videos with preference for open-access sources, but the proportion of videos undergoing peer-review prior to publication has markedly decreased, raising questions over quality of the educational content presented. The aim of this study was the development and validation of a standard framework for the appraisal of surgical videos submitted for presentation and publication, the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool. METHODS: An international committee identified items for inclusion in the LAP-VEGaS video assessment tool and finalised the marking score utilising Delphi methodology. The tool was finally validated by anonymous evaluation of selected videos by a group of validators not involved in the tool development. RESULTS: 9 items were included in the LAP-VEGaS video assessment tool, with every item scoring from 0 (item not presented in the video) to 2 (item extensively presented in the video), with a total marking score ranging from 0 to 18. The LAP-VEGaS video assessment tool resulted highly accurate in identifying and selecting videos for acceptance for conference presentation and publication, with high level of internal consistency and generalisability. CONCLUSIONS: We propose that peer review in adherence to the LAP-VEGaS video assessment tool could enhance the overall quality of published video outputs.

Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.

Does tumor stroma ratio of breast cancer trucut biopsy determine response to neoadjuvant therapy?

AIMS AND OBJECTIVES: We examined the prognostic value of Tumor stroma ratio (TSR) in breast tumor core biopsy (TCB) specimen to determine response to neoadjuvant therapy (NAT) prior to modified radical mastectomy (MRM). METHODS: This was a retrospective analysis of patients with breast cancer who underwent TCB before NAT between August 2016 and July 2018. TSR in TCB was studied independently by 2 pathologists ( VM, VS) defined as stroma rich (TSR≤50%) or stroma poor (TSR>50%). MRM specimen of these patients were subsequently studied .Residual cancer burden (RCB) was calculated using the MD Anderson RCB calculator, categorized as complete (0), good (1) Partial (2) and no response (3). Statistical analysis was done to assess correlation of TSR to RCB. RESULTS: A total of 62 patients were analyzed. Mean(SD) age was 48(11) years.Twenty eight (45%) and 34 (55%) patients were stroma rich and stroma poor respectively. Twenty six (42%) patients were responders and 36 (58%) non-responders to NAT. Among stroma rich patients, only 3 (10%) were responders (Class 0 &1)and 25 (90%) non-responders(Class2&3)to NAT, among stroma poor patients 23 (68%) responded well and 11 (32%) did not.TSR had a moderate negative correlation with RCB (-0.6). On univariate analysis, only TSR had a significant effect on RCB class (<0.001). CONCLUSIONS: TSR on TCB is a useful prognostic factor to determine response of breast carcinoma patients to neoadjuvant therapy.It is cost effective, simple and quick. Larger multi-centric studies would be useful to study its clinical implications.

Giant villous adenoma of rectum- what is the malignant potential and what is the optimal treatment? A case and review of literature.

INTRODUCTION: Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential. CASE REPORT: A 62-year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. DISCUSSION: Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose risk of malignancy is especially high up to 50% when greater than 2 cm in size. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas. Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases. CONCLUSION: Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. As per current data, the combined risk of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than 8 cm in size. Laparoscopic colorectal resection is safe and effective.

PTEN Genetic and Epigenetic Alterations Define Distinct Subgroups in North Indian Breast Cancer Patients

Background: Breast cancer is a heterogeneous disease that can be subdivided on the basis of histopathological features, genetic alterations, and gene-expression profiles. PTEN gene is considered an established tumor suppressor gene in different types of cancer including breast cancer. However, the role of PTEN alterations in north Indian breast cancer has not been explored especially in defining a group with distinct histological factors. Methodology: 181 sporadic breast cancer and their adjacent normal tissues were included in the present study. We analyzed methylation and LOH through MS-PCR and microsatellite markers respectively. While, for PTEN protein expression, we used immunohistochemistry. All the molecular findings were correlated with the clinicopathological parameters of the patients to underline clinical relevance. Results: We found that LOH and methylation of the PTEN promoter were significantly associated with loss of PTEN protein expression, while, PTEN mutation was a rare event. Furthermore, out of 46 double hit cases (i.e., having both methylation and LOH), 70% (32/46) cases showed complete loss of PTEN expression (P= 0.0249). Both LOH and PTEN promoter methylation were associated significantly with age and clinical stage, while, methylation and loss of PTEN expression were associated with high grade and Her-2 negativity. In addition, a quadruple (ER/PR/ Her-2 and PTEN) negative group with distinct features was found. Conclusion: The pattern of PTEN expression and its correlation with the clinical parameters indicates that loss of PTEN expression defines a clinical group with distinct features. Hence, PTEN expression provides differential therapeutic strategies for north Indian breast cancer.

Adrenal medullary hyperplasia with coexistent cerebral angiomas.

Sporadic adrenal medullary hyperplasia (AMH) is a rare entity and mimics pheochromocytoma clinically as well as pharmacologically. It is characterized by increase in adrenal medullary cells with the expansion of cells into areas normally not seen. A 59-year-old male presented with chronic hypertension and raised 24-h urinary normetanephrine levels. Radiological and clinical possibility of pheochromocytoma led to left transperitoneal laparoscopic adrenalectomy. Histopathology, however, showed increase in adrenal medullary to cortical ratio, further confirmed by immunohistochemistry. The absence of any well-defined lesion led to the diagnosis of AMH. Furthermore, on routine imaging, two asymptomatic cavernous hemangiomas were seen. We present this case to reiterate that AMH is an entity which should be considered as a differential for pheochromocytoma. Furthermore, the presence of asymptomatic cavernous hemangiomas in the cerebrum, in this case, makes it rarer since this sporadic association is seldom seen.

Synovial hemangiomas of wrist and ankle joint: A report of two rare cases.

Synovial hemangioma is a rare, benign, vascular tumor of synovium leading to joint pain and swelling. The most common site is the knee joint, but rare cases involving other sites have also been reported. We report two rare cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint. Histopathology is the gold standard for diagnosis of these cases. Early treatment is warranted to prevent the risk of permanent joint damage.

LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery: A Joint Trainers and Trainees Consensus Statement.

OBJECTIVE: Consensus statement by an international multispecialty trainers and trainees expert committee on guidelines for reporting of educational videos in laparoscopic surgery. SUMMARY OF BACKGROUND DATA: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but there are no guidelines for video annotation or procedural educational and safety evaluation. METHODS: Delphi questionnaire of 45 statements prepared by a steering group and voted on over 2 rounds by committee members using an electronic survey tool. Committee selection design included representative surgical training experts worldwide across different laparoscopic specialties, including general surgery, lower and upper gastrointestinal surgery, gynecology and urology, and a proportion of aligned surgical trainees. RESULTS: All 33 committee members completed both the first and the second round of the Delphi questionnaire related to 7 major domains: Video Introduction/Authors' information; Patient Details; Procedure Description; Procedure Outcome; Associated Educational Content; Peer Review; and Use in Educational Curriculae. The 17 statements that did not reach at least 80% agreement after the first round were revised and returned into the second round. The committee consensus approved 37 statements to at least an 82% agreement. CONCLUSION: Consensus guidelines on how to report laparoscopic surgery videos for educational purposes have been developed. We anticipate that following our guidelines could help to improve video quality.These reporting guidelines may be useful as a standard for reviewing videos submitted for publication or conference presentation.

Gall bladder flip technique in laparoscopic cholecystectomy.

BACKGROUND: The precise steps for the removal of gall bladder from the gall bladder bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus creates a 'tug of war' like situation. MATERIALS AND METHODS: This is a description of a simple technique that aids in accurate dissection of the gallbladder from liver bed. As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, the medial and lateral peritoneal folds of gall bladder are further incised. The assistant is asked to leave the traction from the gallbladder fundus, while the surgeon holds the dissected surface of gall bladder around 2-3 cm away from its attachment with liver and flip it above the liver. Further dissection is carried out using a hook or a dissector till it is disconnected completely from the liver bed. RESULTS: We have employed 'Flip technique' in around 645 consecutive cases of laparoscopic cholecystectomy operated in the past 3 years. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in this study. Ease of dissection by surgeons was rated as 9.6 on a scale of 1-10. CONCLUSION: Gallbladder 'Flip technique' is a simple and easily reproducible technique employed for dissection of gall bladder from liver bed that reduces complications and makes dissection easier.

Laparoscopic Anterior Partial Fundoplication is Comparable With Nissen Fundoplication for Gastroesophageal Reflux Disease.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has been the gold standard for gastroesophageal reflux disease (GERD), but the side effects of dysphagia and bloating have lead to interest in partial fundoplication as an alternative. AIM: To compare the symptomatic and objective parameters after LNF and laparoscopic anterior partial fundoplication (LAPF) in patients with GERD. PATIENTS AND METHODS: The study was conducted in the Division of Minimal Access Surgery, Maulana Azad Medical College from June 2008 to October 2016. Patients with GERD with high score on 24-hour pH monitoring were selected for surgery (LAPF) and were compared with our historical control of 25 patients who underwent LNF. The preoperative and postoperative symptom score and objective parameters were analyzed. RESULTS: Of 50 GERD patients, 20 patients underwent surgery (LAPF) and these were compared with 25 patients who underwent LNF. Demester score, modified Visick grade decreased from 4.12, 3.23 in LNF; 4.35, 3.35 in LAPF to 0, 1 in both groups. There was significant and similar increase in lower esophageal sphincter (LES) length, intra-abdominal LES length, LES pressure. The 24-h pH) decreased from 10.18% and 8.08% to 0.85% and 1.09% in LNF and LAPF, respectively. At 1 year and 5 years of follow-up, symptom scores, manometric analysis, and pH metry evaluation remained to be improved in both the groups. CONCLUSIONS: LAPF is as effective as LNF for GERD, with less dysphagia.