The yesterday, today and tomorrow of liver transplant.

With a very long history of setbacks and successes, organ transplantation is one of the greatest medical achievements of the twentieth century. Liver transplantation is currently the most effective method for treating end-stage liver disease. From humble beginnings, improvements in surgical technique, perioperative management, and immunosuppressive therapy have yielded excellent graft and patient outcomes. Most established 'liver transplant' (LT) centres have a 1-year survival rate exceeding 90%, and a 3-year survival rate of over 80%. With immense success, the need for hepatic grafts substantially exceeds their availability. This problem has been partially addressed by using split grafts, living donor liver transplantation (LDLT), and extended criteria grafts (ECG). This article reviews the immense progress made in various aspects of LT including evaluation, increasing donor pool, surgical advances, immunosuppression and anaesthesia related aspects and the way forward. With ongoing cutting edge research in technologies like artificial liver devices, tissue bioengineering and hepatocyte 'farms', the future of LT is more exciting than ever before.

Wound Infection After Ileostomy Closure: An Interim Analysis of a Prospective Randomized Study Comparing Primary Versus Circumferential Subcuticular Closure Techniques.

Background: Circumferential subcuticular wound approximation (CSWA) of round shaped skin wounds after ileostomy take down is believed to lower the rates of surgical site infection (SSI). We performed this randomized trial to compare the rates of SSI and other short-term outcomes among primary linear skin closure (PC) and CSWA groups of patients. Patients and Methods: All patients undergoing ileostomy reversal during the study period were randomly assigned to either PC or CSWA. The primary outcome was the incidence of SSI as assessed by ASEPSIS scoring system. The secondary outcomes included healing time, length of post-operative hospital stay, and patients' satisfaction regarding cosmetic outcome, expectations, pain, time of healing, wound care, and activity on a five-point Likert scale. Results: Thirty-one patients (PC = 15; CSWA = 16) underwent ileostomy reversal during the study period. There was no SSI in the PC group whereas three patients developed SSI in the CSWA group but the result was not statistically significant (p = 0.23). The scores for time of healing (p < 0.001), wound care (p = 0.007), and activity (p < 0.001) were significantly better for PC compared with CSWA whereas there was no significant difference in the scores for cosmetic outcome, expectations, and pain. Healing time was shorter in the PC group (6.7 vs. 34.2 days; p < 0.001) whereas the post-operative length of stay was comparable (6.3 vs. 7 days; p = 0.27). Conclusions: Although there was no difference in the incidence of SSI among the two groups, the PC group fared better in terms of mean time to healing and requirement of wound care.

Abdominal Crunch Syndrome Creates a -Diagnostic Challenge in Treating a Pilot with Acute Upper -Abdominal Pain.

BACKGROUND: A diagnosis in acute abdomen may remain elusive especially when the cause is rare. We report this interesting case of a fighter pilot presenting with acute abdominal pain. The case posed significant challenges in reaching the correct diagnosis of abdominal crunch syndrome. The syndrome is rare with only seven reports in the literature so far. To the best of our knowledge, this is the first ever report of this condition in an aircrew.CASE REPORT: A 37-yr-old pilot presented with severe upper abdominal pain and sweating. During examination, he developed bradycardia and was admitted with a presumptive diagnosis of acute coronary syndrome. Investigations revealed no myocardial ischemia on ECG, transaminitis, raised CPK, CKMB, and LDH. A CECT scan of chest and abdomen was normal. A GI surgery consult was sought where we connected the transaminitis and raised CPK and considered the possibility of rhabdomyolysis. On specific inquiry, the aviator gave history of unaccustomed exercise with a vigorous session of abdominal crunches a day prior. Thus, a diagnosis of abdominal crunch syndrome was concluded.DISCUSSION: The aviator did not associate his vigorous exercise with the occurrence of pain and, therefore, did not mention it. It would have avoided unnecessary investigations and delay in treatment. From the aeromedical safety aspect, had the aviator flown on the day he developed pain, there was a possibility of developing severe pain exacerbated by the G force and G suit and sudden in-flight incapacitation. From the perspective of the aircrew, it is advisable that they avoid sudden, unaccustomed exercise.Kumar A, Kaistha S. Abdominal crunch syndrome creates a diagnostic challenge in treating a pilot with acute upper abdominal pain. Aerosp Med Hum Perform. 2023; 94(2):86-89.

To compare the outcomes of pancreaticojejunostomy and pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: A prospective observational study.

Background: We have been in constant search of novel innovations to decrease the high morbidity after Pancreaticoduodenectomy (PD). Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the two different methods of reconstruction after PD. However, the existing data is ambiguous in supporting either of them as the preferred technique of reconstruction. Methods: This was a single-center prospective observational study that included 64 patients who underwent PD over two years. We compared PG with PJ as a method of reconstruction after PD. The primary objective was to assess whether PG decreases the rate of postoperative pancreatic fistula (POPF) rates or not. Secondary objectives comprised analysis of perioperative outcomes, 30-day and 90-day mortality. Results: Pancreatic fistula was significantly lower in PG as compared to the PJ group (24% vs. 47%) with a p-value of 0.027. The incidence of clinically pertinent (grade B) fistula was only 3% in the PG group and 32% in the PJ group. PG group had a higher incidence of post pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE). No statistically significant difference was seen between either group need for blood transfusion, re-exploration, re-admissions, ICU stay, or length of hospital stay, and 30-day and 90-day mortality. Pancreatic texture and high BMI were independent predictors for pancreatic fistula. Conclusion: PG when compared to PJ for reconstruction after PD, decreases the rate of POPF significantly; however, it is associated with an elevated risk of DGE and PPH. There was no difference in 30-day and 90-day mortality between both the treatment groups.

Current practice of antibiotic prophylaxis in elective laparoscopic cholecystectomy among surgeons of the Armed Forces Medical Services of India.

Background: Laparoscopic cholecystectomy (LC) is the most common surgery done in general surgical practice worldwide. Despite clear guidelines recommending against the routine use of antibiotic prophylaxis (ABP) for elective LC by professional entities such as the Scottish Intercollegiate Guidelines Network (SIGN), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) etc., most surgeons are not convinced about omitting ABP in low-risk LC. Thus, this study aimed at capturing the practice of administering ABP in elective LC among surgeons of Armed Forces Medical Services (AFMS). Methods: This was a survey based on an electronic, cross-sectional, self-completion questionnaire that was designed and disseminated amongst 184 surgeons of the AFMS, online, and the data was collated centrally. Results: 64% of surgeons completed the survey. The majority (85%) of surgeons used ABP routinely in elective LC. In the univariate analysis, only the number of years of surgical experience and the total number of LC done in an entire career, and in the multivariate analysis age group of the surgeon, surgical experience and designation were significant factors for avoiding routine ABP in elective LC. Amongst the surgeons administering ABP, only 30% administered a single dose, 73% chose a single agent and Cefotaxime (57%) was the commonest antibiotic used. Conclusion: This study found that there is a high prevalence of use of antibiotic prophylaxis in elective laparoscopic cholecystectomy amongst the surgeons of the AFMS. There was a wide variation in terms of choice of antibiotics, administering single or multiple doses and as a single agent or combination therapy. Registered with clinical trials registry of India: CTRI/2019/03/018092.

Abdominal wall actinomycotic mycetoma involving the bowel: a rare entity.

Actinomycotic mycetoma is a disease of the tropical region and usually presents as a chronic, suppurative and deforming granulomatous infection. We present an unusual case of actinomycotic mycetoma of the abdominal wall that was found to infiltrate into the bowel. A 51 year-old man presented with pain and swelling in the left flank of 2-year duration. Even after comprehensive preoperative evaluation with advanced radiological imaging, biochemistry and pathology, the diagnosis could not be arrived at. Histopathological examination of the excised specimen after the surgery guided to the diagnosis of actinomycotic mycetoma, which entirely changed the management in the postoperative period. We propose that mycetoma should be kept as a possible differential diagnosis for anterior abdominal wall swelling in the indicated clinical setting and the investigations be done keeping the same in mind. Otherwise, a lot of valuable time may be lost allowing the disease to progress further.

Laparoscopic surgery in pancreatic diseases: Pushing the boundaries.

BACKGROUND: Laparoscopic surgery has expanded exponentially in the last two decades but, somehow it is limited in pancreatic surgery by virtue of the pancreas being a friable, retroperitoneal organ with difficult access and adjacent major vessels risking torrential bleed. It is thought to be unforgiving if not handled well. However, improvements in technology and surgeon's expertise have pushed the boundaries of minimal access surgery (MAS) to include pancreas in its domain. We present our series of laparoscopic pancreatic surgery (LPS) with an aim to look at the feasibility and outcomes. METHODS: This is a retrospective review of all LPS done at the Gastrointestinal Surgery (GIS) centre of a tertiary care Armed Forces Hospital over a period of 3 years. RESULTS: A total of 24 LPS were done during this period. The median age of the patients was 46 years (range; 13-81). There were 14 male and 10 female patients. Nine patients had at least one co-morbidity. Three patients underwent laparoscopic lateral pancreaticojejunostomy, 4 distal pancreatectomy, 4 laparoscopic Whipples pancreaticoduodenectomy, 6 laparoscopic pancreatic necrosectomy, 6 laparoscopic cystogastrostomy and 1 roux en y cystojejunostomy. CONCLUSION: LPS can be performed for almost all open pancreatic surgeries and can be done with reasonable outcomes. However, it has a steep learning curve and therefore, a hybrid approach leading to a totally laparoscopic approach may be the way forward.

Laparoscopic Access: Direct Trocar Insertion Versus Open Technique.

INTRODUCTION: Creation of pneumoperitoneum and laparoscopic entry into the abdominal cavity are crucial initial steps of laparoscopic surgery and associated with bowel and major vessel injuries. Various methods have been described in literature such as Veress needle, open access technique (OAT), direct trocar insertion (DTI), and optical port. There is no consensus on the safest method of gaining access to the peritoneal cavity to create a pneumoperitoneum. DTI technique appears to be not well accepted by many due to the fear of causing injuries as it is a blind procedure. OBJECTIVE: To compare the outcome of DTI in terms of feasibility and complications with a well-established and widely practiced OAT for a laparoscopic procedure. MATERIALS AND METHODS: Nine hundred fifty-five participants were randomized to be in either of the two groups, that is, Group "A" for DTI and Group "B" for OAT. The primary endpoint was major complications (bowel, major vessel, and solid organ injury) and the secondary endpoint was port access time and minor complications directly related to access. Patients were assessed on the first postoperative day, at the time of discharge, 3 months, 6 months, and a year after discharge, for complications. RESULTS: There was no statistical difference in major complications between DTI and OAT groups, however, DTI was found to be superior to OAT in terms of port access time (P = .01), umbilical port-site hernia, port-site infection, and port-site pain (P = .01). CONCLUSION: This study further strengthens the literature on DTI being a good and safe technique of laparoscopic access. The technique of DTI is still underutilized and needs to be adopted by surgeons without fear.

Non-fixation Versus Fixation of Mesh in Totally Extraperitoneal Repair of Inguinal Hernia: a Comparative Study.

Two major issues with laparoscopic inguinal hernia (IH) repair are recurrences and chronic groin pain (CGP). The procedure involves fixing the mesh with the tackers which is believed to increase the rate of CGP due to nerve injuries. Thus, non-fixation of mesh is being proposed but concerns remain regarding increased recurrences. We sought to look at our outcomes after we switched over to non-fixation of mesh in totally extraperitoneal repair (TEP). Retrospective review of prospectively maintained database of 171 repairs was done on 122 patients (fixation 59 and non-fixation 112) during a period of 4 years with an endeavor to complete a minimum of 1 year of clinical follow-up. The primary objective was to assess the recurrence rates and CGP and the secondary objective was to assess operative times, immediate post-op pain, incidence of urinary retention, duration of hospital stay, days taken to return to activity, and cost. The mean operative times for unilateral IH for the fixation and non-fixation groups were 41.8 ± 11.4 and 35.9 ± 9.7 min, respectively (p = 0.021), whereas for bilateral were 66.2 ± 15.6 and 55.3 ± 14.2 min, respectively (p = 0.018). The mean pain score was 3.44 ± 1.2 versus 3.01 ± 1.0; (p = 0.037) in the two groups, respectively. At a mean follow-up of 33.2 ± 17.0 and 18.7 ± 6.2 months, the incidence of CGP was 02 (3.4%) and 3 (2.7%) (p = 1.000) and recurrences were 02 (3.4%) in the two groups, respectively (p = 0.118). Non-fixation of mesh in TEP does not lead to increased recurrence though it does not decrease the incidence of chronic groin pain. Collateral advantage would be decreased operative times, lesser post-operative pain, and decreased costs.

Necrotizing Fasciitis: A Rare Complication of Acute Necrotizing Pancreatitis.

Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.