Cystic Lymphangioma of Rectum-A Case Report and Review of Literature.

Colorectal cystic lymphangiomas are rare benign lesions. They are characterized by the presence of either single or multi-cystic spaces lined by endothelium. Though there are multiple case reports of right and transverse colonic lymphangioma; only around 10 cases of lymphangioma of the rectum have been reported. We present a case report of rectal lymphangioma with the relevant literature review.

Morphological and functional changes in colon after coloplasty for management of corrosive esophageal strictures.

BACKGROUND: The etiology of corrosive esophageal strictures is different from that reported in Western literature, with acid ingestion being a major cause. This study evaluated functional and morphological changes in the colon used as neoesophagus. METHODS: Functional changes in the neoesophagus were evaluated by symptom score of dysphagia and manometry. Barium study and fluoroscopy were done to evaluate the flow patterns and endoscopy with histopathological examination to study the adaptive changes in the colon. RESULTS: Thirty-five patients with corrosive injury presented between 2007 and 2010. Isolated esophageal involvement was seen in 22 patients; 11 of them underwent colonic replacement. The passage of barium was smooth, without any hold up at the upper or lower anastomotic line. Endoscopic biopsy at 6 months and 1 year did not show any change in the mucosal pattern or in the muscularis layer of the transposed colon. Functional evaluation showed relief of dysphagia in all 11 patients after surgery. The mean preoperative dysphagia score was 7.81 (range 5-10), at 1 month was 0.73 (range 0-2), and at 3 months post-surgery was 0.45 (range 0-2). Manometric study at 3 months after the surgery in all 11 patients and in five patients at the end of 6 months showed no evidence of peristalsis in the neoesophagus. Three of the latter five patients demonstrated a 4-5-cm zone with a high pressure in the intraabdominal part of the transposed colon compared with that in the intrathoracic part of the colon. On barium studies, reflux from the stomach into the neoesophagus was not seen in any of the 11 patients. CONCLUSIONS: Esophagocoloplasty was associated with symptom relief, and the reflux of gastric content was low because of 4-5 cm of the colon being intraabdominal in a positive pressure environment.

Structured training on box trainers for first year surgical residents: does it improve retention of laparoscopic skills? A randomized controlled study.

BACKGROUND AND AIM: Structured training on box trainers in laparoscopic skills in the initial years of residency has been used and found to be effective. Although there are studies that confirm immediate improvement after training, there is a lack of well-designed trials addressing the crucial issue of retention of these skills over time. The purpose of this study is to assess improvement in laparoscopic skills of surgical trainees after structured training on box trainers, compared with traditional training (observing and assisting laparoscopic procedures in the operation rooms) immediately and after 5 months. METHODS: Forty surgical residents in their first 2 months of residency training were randomized to either structured training on box trainers, in addition to traditional training, or to traditional training alone. Groups were equivalent with regards to demographics, previous operative experience, and baseline skills. Structured training consisted of 4 sessions with 6 tasks on box trainers under supervision and self practice. Task-based objective structured practical examinations (OSPE) were completed before and after each task. At the end of the training, residents were assessed by a blinded faculty member with the global operative assessment of laparoscopic skills (GOALS) rating scale. Residents also completed a satisfaction questionnaire. Focus group discussions were conducted for both groups. The GOALS were repeated for both the groups at the end of 5 months to assess retention of skills. RESULTS: The mean GOALS score was significantly higher for the structured training group (mean/SD 20.35 + 0.74) compared with the traditional training group (mean/SD 16.35 + 1.75, p < 0.01) at the end of 5 months. The mean global rating scale (GRS) score was significantly higher (Pre 7.55 + 0.99 vs. Post 16.4 + 0.68, p < 0.01) for the structured training group at the end of course. Residents in the structured training group had significantly improved skills immediately after the training and had better retention of skills at the end of five months. CONCLUSIONS: Structured training on box trainers, in addition to traditional training, compared with traditional training alone, leads to better skills and improved confidence of residents. There is significant retention of skills at the end of 5 months. These results provide support for incorporation of structured training with box trainers for laparoscopic skills into surgical training programs.

Intraoperative localization of vascular malformation of small bowel by selective intra-arterial dye injection.

Angiomatous malformation is the most common vascular abnormality, accounting for 30-40% cases of obscure GI bleeding from small bowel. Surgical resection is the treatment of choice in severe or recurrent hemorrhage requiring multiple blood transfusions. However, the diffuse nature of the lesions poses a challenge to localize them accurately preoperatively, for exact resection. We present a case in which we have used selective mesenteric angiography with selective cannulation and exact localization of the lesion by injecting dye such as methylene blue, indigo carmine, and fluorescein, to localize the angiomatous malformation before surgical resection and also to determine the exact resection to be done.

Evaluating the efficacy of tumor markers CA 19-9 and CEA to predict operability and survival in pancreatic malignancies.

AIM: Using CA 19-9 and CEA (elevated > 2 times of normal) as predictors in determining operability and survival in pancreatic tumors. METHODS: Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. RESULTS: 16/24 (67%) patients with CA 19-9 levels (< 2 times) and 19/24 (79%) patients with CEA levels (< 2 times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p = 0.0002-t) and 17/25 (70%) patients having elevated CEA levels (p = 0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels > 1000 U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. CONCLUSION: Elevated levels of CA 19-9 and CEA (> 2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels > 3 times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (> 1000 U/ml) indicate a dismal survival in non-resectable group of patients.

Post-splenectomy response in adult patients with immune thrombocytopenic purpura.

UNLABELLED: Splenectomy has been the conventional surgical treatment for patients with Immune Thrombocytopenic Purpura (ITP). AIM: To define response to surgical therapy, pre operative factors influencing outcome and tolerability of surgery in adult patients undergoing splenectomy for ITP. METHOD: We analyzed prospectively maintained data of 33 patients who were diagnosed as ITP and underwent splenectomy over the last 10 years. The age, presenting complaints, bleeding manifestations, clinical details and other investigations were noted. Details of immediate pre-operative administration of blood transfusions, platelet transfusions and other forms of therapy were also recorded. Operative details with regards to blood loss and the presence of accessory spleens were obtained. Postoperative course in terms of clinical improvement, rates of complications and platelet counts was also noted. RESULTS: Skin petechiae and menorhhagia were common presenting symptoms in patients (mean age 26.5+/-10.5 yrs) with ITP. Eighteen patients underwent splenectomy for failure of therapy and fifteen for relapse on medical treatment. Mean platelet bags transfused in immediate pre-operative period were 2.8+/-0.8. Mean intra-operative blood loss was 205+/-70.5 ml. Accessory spleens were removed in 1 case (3.03%). The immediate postoperative response was complete in 19 cases (57.58%) and partial in 13 cases (39.39%). The platelet counts increased significantly from 23142+/-12680/ microL (Microliter) (mean +/- SD) preoperatively to 170000+/-66000/microL (Microliter) within 24-48 hours after splenectomy (P < 0.05). The mean platelet count was 165000+66000/microL (Microliter) at the end of one month when steroids were tapered off gradually. Four patients (12.12%) had complications (one each of wound hematoma, wound infection, splenic fossa collection and upper GI hemorrhage) in postoperative period but all responded to therapy. One relapsed patient was detected with accessory spleen and responded after re-surgery. Response to splenectomy was better in young patients and in those patients who had higher immediate post-splenectomy thrombocytosis. CONCLUSIONS: Splenectomy is safe and effective therapy in ITP patients with no response to steroids and relapse after medical therapy. Response to splenectomy was more in young patients and in those patients who had higher immediate post-splenectomy thrombocytosis.

Effectiveness of box trainers in laparoscopic training.

RATIONALE AND OBJECTIVES: Various devices are used to aid in the education of laparoscopic skills ranging from simple box trainers to sophisticated virtual reality trainers. Virtual reality system is an advanced and effective training method, however it is yet to be adopted in India due to its cost and the advanced technology required for it. Therefore, box trainers are being used to train laparoscopic skills. Hence this study was undertaken to assess the overall effectiveness of the box-training course. STUDY PROCEDURE: The study was conducted during six-day laparoscopic skills training workshops held during 2006. Twenty five surgeons; age range of 26 to 45 years, of either sex, who had not performed laparoscopic surgery before; attending the workshop were evaluated. Each participant was given a list of tasks to perform before beginning the box-training course on day one and was evaluated quantitatively by rating the successful completion of each test. Evaluation began when the subject placed the first tool into the cannula and ended with task completion. Two evaluation methods used to score the subject, including a global rating scale and a task-specific checklist. After the subject completed all sessions of the workshop, they were asked to perform the same tasks and were evaluated in the same manner. For each task completed by the subjects, the difference in the scores between the second and first runs were calculated and interpreted as an improvement as a percentage of the initial score. STATISTICAL ANALYSIS: Wilcoxon matched-paired signed-ranks test was applied to find out the statistical significance of the results obtained. RESULTS: The mean percentage improvement in scores for both the tasks, using global rating scale, was 44.5% ± 6.930 (Mean ± SD). For task 1, using the global rating scale mean percentage improvement was 49.4% ± 7.948 (Mean ± SD). For task 2, mean percentage improvement using global rating scale was 39.6% ± 10.4 (Mean ± SD). Using Wilcoxon matched-paired signed-ranks test, 2-tailed P-value<0.0001 which is extremely significant. CONCLUSION: This study confirms that a short-term, intensive, focused course does improve laparoscopic skills of trainees. Box-trainers can be used to change the present day didactic training into objective and competency-based. Global rating scale and checklist provide an inexpensive and effective way of objective assessment of performance of laparoscopic skills.

Cadaver as a model for laparoscopic training.

BACKGROUND: Though minimally invasive techniques now are routine world over, there is need to develop facilities for training surgeons. Laparoscopy performed on anesthetized animals is an established model but is costly and is not easily available. We report on human cadaver as a training modality for surgeons participating in a laparoscopic training course. METHODS: Unembalmed cadavers were used for training surgeons to appreciate anatomy, practice laparoscopic techniques, and deploy equipment and instruments during a laparoscopic training course. Trainees carried out procedures such as cholecystectomy, appendicectomy, splenectomy, intestinal explorations, mesenteric lymph node biopsy, and varicocele-vein occlusion. We analyzed the trainees' perspective regarding cadaver as a model using the 5-point Likert scale. RESULTS: Thirty-two trainees from five consecutive training courses held at our institution expressed general satisfaction over cadaver as a training model, and 96.9% (31/32) rated the training model as highly satisfactory. The trainees ranked as highly satisfactory their understanding of surgical anatomy (29/32; 90.6%), understanding of laparoscopic technique (29/32; 90.6%) and use of instruments (32/32; 100%). The trainees thought such an approach improved spatial perception of anatomy and they perceived it as a valuable educational experience. CONCLUSIONS: Human cadaveric laparoscopy may offer an ideal surgical environment for laparoscopy training courses, allowing dissection and performance of complicated procedures.

Early morphological and functional changes in pancreas following necrosectomy for acute severe necrotizing pancreatitis.

INTRODUCTION: Morphological and functional changes in the pancreas after surgical pancreatic necrosectomy have not been studied extensively. AIMS: To study morphological changes in the pancreas, and exocrine and endocrine pancreatic function following pancreatic necrosectomy. METHODS: Eighteen adult patients surviving at least one month after pancreatic necrosectomy for acute necrotizing pancreatitis were followed up. Contrast-enhanced computed tomography was done every six months. Stool fat was estimated at 3-month intervals, and need for and response to enzyme supplements were recorded. Blood sugar was measured every fortnight; in patients with hyperglycemia, need for oral hypoglycemic agents or insulin was recorded. Additional pancreatic imaging was done in some cases. RESULTS: Six weeks after surgery, nine of 18 patients had exocrine insufficiency. Thirteen patients developed endocrine insufficiency, including 5 who also had exocrine insufficiency. At the end of the study, 13 patients had endocrine insufficiency and 2 had exocrine insufficiency. Pancreatic size was subnormal in all patients at the end of six months. Pancreatography in three cases did not reveal any ductal abnormality. CONCLUSIONS: Necrotizing pancreatitis affects pancreatic exocrine or endocrine function in more than half the patients.