Forgotten biliary stents: ignorance is not bliss.

BACKGROUND: Endoscopic biliary stenting is a common procedure in routine gastroenterology practice. Plastic stents are the most common type of stents used and are indicated mainly for short-term biliary drainage. Prolonged indwelling plastic stents can result in disastrous complications. METHODS: We conducted a retrospective analysis of patients who presented with complications of forgotten biliary stents in a tertiary care hospital during January 2010 to October 2016. All patients were managed either by endoscopic or surgical means. Details of these patients were obtained from departmental patient database, endoscopy records, and surgical register. RESULTS: A total of 21 cases of retained biliary stents were managed in the study period and their outcome was analyzed. The median age was 47 years (range 17-70 years) and 17 (80.9%) patients were female. Primary indication of biliary stenting was stone disease in 76.2% (n = 16), while benign biliary stricture accounted for 19% of cases (n = 4). Mean duration at presentation to hospital after ERCP stenting was 3.53 years (range 1-14 years), with cholangitis being the most common presentation (66.67%). Definitive endoscopic treatment for forgotten stent and its associated complication was possible only in five patients (23.8%); in remaining 16 (76.2%) cases, surgical exploration was required. Despite life-threatening complications and major surgical interventions, no mortality was recorded. CONCLUSIONS: Instances of forgotten biliary stents presenting with serious complications are not uncommon in Indian setup. Patients either ignore advice for timely stent removal or are unaware of the presence of endoprosthesis or need for removal. Adequate patient counseling, information, and proper documentation are essential to avoid this condition.

Intraoperative ultrasonography of the biliary tract using saline as a contrast agent: a fast and accurate technique to identify complex biliary anatomy.

BACKGROUND: Intraoperative assessment of biliary tract anatomy is relevant for a number of benign and malignant hepatobiliary diseases. During biliary reconstruction, drainage of all relevant bile ducts is imperative to prevent atrophy of undrained segment, cholangitis and secondary biliary cirrhosis. Intraoperative cholangiography, though widely used for intraoperative imaging of the biliary tract, involves heavy equipment use, radiation risk and has a limited role in the evaluation of isolated segmental bile ducts. METHODS: We evaluated the use of a novel technique of intraoperative ultrasonography of the biliary tract using normal saline as a contrast agent. It involves injecting saline in any part of the biliary system while performing real-time intraoperative 2-dimensional ultrasonography. RESULTS: This procedure was carried out in intraoperative situations to delineate complex biliary anatomy involving segmental bile ducts. Excellent image quality was obtained in the form of opacification and demarcation of the liver segment to which the duct belongs. The flow of saline microbubbles was clearly visible on real-time ultrasound images, leading to accurate identification of the duct. CONCLUSION: Intraoperative ultrasonography with saline as a contrast agent can accurately identify small isolated segmental bile ducts and help in surgery of the biliary tract. It is a simple and inexpensive technique that can be performed with minimal resources.

CONTEXTE: L'examen anatomique peropératoire des voies biliaires est justifié pour un certain nombre de maladies hépatobiliaires bénignes et malignes. Durant la reconstruction biliaire, la vidange de toutes les voies biliaires concernées est nécessaire pour prévenir l'atrophie des segments non drainés, la cholangite et la cirrhose biliaire secondaire. Même si elle est couramment utilisée pour l'imagerie des voies biliaires, la cholangiographie peropératoire fait appel à des équipements complexes, comporte un risque d'irradiation et joue un rôle limité dans l'évaluation de segments isolés des canaux biliaires. MÉTHODES: Nous avons évalué l'utilisation d'une nouvelle technique d'échographie peropératoire des voies biliaires à l'aide de solution physiologique comme agent de contraste. La technique repose sur l'injection de solution physiologique dans n'importe quelle portion de l'appareil biliaire sous échographie bidimensionnelle peropératoire en temps réel. RÉSULTATS: La technique a été appliquée dans un contexte peropératoire afin de cerner l'anatomie biliaire complexe de certains segments des canaux biliaires. Des images d'excellente qualité ont été obtenues sous forme d'opacification et de délimitation du segment hépatique auquel le canal appartient. La circulation des microbulles de sérum physiologique était clairement visible sur les images échographiques en temps réel et a permis de visualiser les structures avec précision. CONCLUSION: L'échographie peropératoire avec sérum physiologique comme agent de contraste permet de visualiser avec précision de petits segments isolés des canaux biliaires et facilite la chirurgie des voies biliaires. C'est une technique simple et peu coûteuse qui peut être effectuée avec un minimum de ressources.

Carpal tunnel syndrome secondary to a giant lipoma of the wrist and distal forearm.

In up to 2% of the population, benign tumours called lipomas can develop. When they are more than 5 cm, they are considered giant lipomas. Giant lipomas of the distal forearm and hand may cause compression to the underlying tissues, nerves and muscles, even though they are typically asymptomatic. An older woman with soft tissue swelling in her right wrist and forearm, and numbness and pain in her right hand presented to the general surgery outpatient clinic. Her numb fingers indicated that the median nerve was compressed, and an MRI scan of her wrist and forearm revealed median nerve compression due to a giant lipoma with a dimension of about 9.2×3.4×4 cm. A surgical excision was done with an intraoperative nerve stimulator, and the specimen sent for histopathology confirmed the diagnosis of lipoma. Pain, numbness and motor power improved within 1 week postoperatively, and the patient was discharged.

Unilateral Enlarged Right Accessory Axillary Breast Tissue in a Male: A Case Report.

Accessory breast tissue, associated with polymastia and polythelia, presents challenges and concerns, particularly when patients fear malignancy. While occurring in 1-6% of cases, accessory breasts, often located bilaterally in the axillae, necessitate careful examination. We report a 35-year-old male with painful axillary swelling who underwent high-resolution ultrasonography (HR-USG) and fine-needle aspiration cytology (FNAC), revealing proper axillary breast tissue. Subsequent excision biopsy confirmed accessory axillary breast without malignancy. In conclusion, surgical removal of accessory axillary breasts is advisable, addressing cosmetic concerns and minimizing cancer risks.

Agenesis of the Dorsal Pancreas: A Rare Cause of Diabetes and Recurrent Upper Abdominal Pain.

Agenesis of the dorsal pancreas is a rare congenital disorder with only a handful of cases described in the literature. It presents a diagnostic dilemma. Cross-sectional imaging is the cornerstone for diagnosis. It could have a syndromic association with polysplenia and cardiac anomalies. Pancreas divisum and chronic pancreatitis may present with similar symptoms and must be ruled out. We present a case of a 55-year-old male with recurrent non-specific abdominal pain and diabetes mellitus. He was managed with insulin and painkillers for symptomatic relief. We also reviewed approximately 68 cases described in the literature to date.

Comparison Between Closed and Open Methods for Creating Pneumoperitoneum in Laparoscopic Cholecystectomy.

Background: To study the efficacy of closed and open methods for creating pneumoperitoneum in laparoscopic cholecystectomy by comparing the two in terms of their outcome and complication. Study Design: Single-centre, prospective, observational study. Materials and study: Purposive sampling method where the inclusion criteria were all patients with cholelithiasis who were advised and consented to laparoscopic cholecystectomy of age 18-70 years were included in the study group. Exclusion criteria include patients with a paraumbilical hernia, a history of upper abdominal surgery, uncontrolled systemic illness, and local skin infection. Sixty cases of cholelithiasis satisfying exclusion and inclusion criteria who underwent elective cholecystectomy during the study period were included. Thirty-one of these cases underwent the closed method, while in the remaining 29 patients open method was adopted. Cases in which pneumoperitoneum created by closed technique were grouped as group A and those by open technique as group B. Parameters comparing the safety and efficacy of the two methods were studied. The parameters were access time, gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia. Patients were assessed on the first postoperative day, the seventh postoperative day, and then two months after surgery. Some follow-ups were done telephonically. Results: Out of 60 patients, 31 underwent the closed method, while 29 underwent the open method. Minor complications like gas leak during the procedure was observed more in the open method. The mean access time in the open-method group was less than in the closed-method group. Other complications like visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia were not observed in either group during the allocated follow-up period in the study. Conclusion: Open technique for pneumoperitoneum is as safe and effective as the closed technique.

Giant Plexiform Schwannoma on the Medial Aspect of the Left Thigh.

Plexiform schwannoma (PS), or neurilemmoma, is an uncommon benign tumor originating from a peripheral nerve sheath. It consists of Schwann cells organized in an intricate, web-like pattern. A male farmer in his 50s from rural India sought medical attention for a painless mass on his left thigh, present for 30 years. Physical examination revealed a firm, non-tender mass with restricted mobility. Imaging, including X-ray and ultrasound, indicated a neoplastic lesion. Fine needle aspiration (FNA) cytology revealed spindle-shaped cells, prompting a provisional diagnosis of a spindle cell lesion. Surgical excision was performed successfully, with histopathological examination confirming PS. He experienced no postoperative complications, and at the one-year follow-up, the complete resolution of symptoms and normal daily activities were observed.

Comparison of Postoperative Chronic Groin Pain After Repair of Inguinal Hernia Using Nonabsorbable Versus Absorbable Sutures for Mesh Fixation.

BACKGROUND: Inguinal hernia repair is one of the most common operations performed in general surgery. Lichtenstein mesh hernioplasty is a commonly practiced technique for open inguinal hernia repair. Out of many other complications postoperatively, chronic groin pain is one of the patients' most common postoperative complaints. There is no direct evidence to explain the cause of post-mesh hernioplasty pain. Only a few studies have been done to judge the effect of suture material used for mesh fixation on chronic groin pain. AIMS AND OBJECTIVES: To compare the postoperative groin pain level in mesh hernioplasty using nonabsorbable versus absorbable sutures for mesh fixation at predetermined intervals using a visual analog scale (VAS) score. METHODS:  A prospective, single-center, non-randomized, observational study was conducted. All patients per inclusion and exclusion criteria of inguinal hernia planned for surgery were admitted electively on the day of surgery and were operated on in minor OT under local anesthesia for open mesh hernioplasty. The VAS score assessed the postoperative pain level. RESULTS:  This observational study was done to look for any difference in postoperative chronic groin pain after mesh fixation with either nonabsorbable, prolene sutures (PS) or absorbable vicryl sutures (VS). One hundred and ten patients fulfilling the department of general surgery inclusion criteria were admitted to the study. In our study, postoperatively, the incidence of chronic groin pain was assessed and followed up to six months. After six months, 25%of patients had pain. Of this 25%, the majority (70%) of patients had mild pain, 15% had moderate pain, and 15% had severe pain. There was no statistically significant difference between the two groups of mesh fixation by nonabsorbable versus absorbable sutures. CONCLUSION: Inguinal hernia is one of the most typical conditions seen in general surgery clinics with male predominance. Definitive management of inguinal hernia is surgery. There is no difference in postoperative chronic groin pain with either type of suture material i.e., nonabsorbable or absorbable (prolene vs vicryl) sutures. To conclude, fixation material for mesh does not influence chronic inguinodynia. However, further studies are required for the same.

Demography, Spectrum, and Characteristics of Symptoms Associated With Post-operative Relief After Cholecystectomy.

Background Cholecystectomy is one of the most commonly performed surgical procedures, and it is indicated for symptomatic gallstone disease. Symptoms of gallstone disease vary; many patients complain of the persistence of symptoms post-operatively. Hence, it is imperative to know the characteristics of symptoms that predict post-operative resolution. Methodology A prospective cross-sectional study was performed at a tertiary care centre. Patient demography and pre-operative symptoms were noted. Post-operative persistence or relief of symptoms was also documented. The occurrence of any new symptoms was noted. Data were collected at three and six months after surgery. Results Pain was the most common (85%) symptom. The mean frequency of pain was 2.45 per year (range 0-10). The mean duration of pain was 39.7 minutes (range 15-90 minutes). The right hypochondrium (39%) and the epigastric region (42%), along with 8% of patients who experienced pain in both places, were the most frequent locations of pain. The radiation of pain to the right-side scapula is present in 48% of patients. The pain persisted after one-week follow-up in 28 (34%) of patients, 26 (22%) at the end of one month, and 18 (21%) at the end of six months. Dyspepsia was unresolved in 25%, 20%, and 13% of individuals after one week, one month, and six months, respectively. Upper abdominal discomfort was still persistent in 29%, 26%, and 24% of study subjects at the time of follow-up periods, respectively. Similar persistence is found in symptoms of post-prandial fullness and nausea, where unresolved complaints of post-prandial fullness were present in 18%, 13%, and 10% of patients, respectively, and 26%, 14%, and 10% of patients complained of nausea. Conclusion The persistence of symptoms such as upper abdominal discomfort, dyspepsia, post-prandial fullness, and nausea is present, which gradually decreases in severity and presentation over the course of time after the surgical procedure. Some symptoms present after surgery, such as flatulence. Such persistent symptoms might lead to a decreased outcome in terms of patient satisfaction. Patients with atypical pain or dyspepsia need to be counselled pre-operatively regarding the poor resolution of such symptoms.

Tracking tsunami propagation and Island's collapse after the Hunga Tonga Hunga Ha'apai 2022 volcanic eruption from multi-space observations.

The quantity and accuracy of satellite-geodetic measurements have increased over time, revolutionizing the monitoring of tectonic processes. Global Navigation Satellite System (GNSS) and satellite radar signals provide observations beyond ground deformation, including how earthquake and tsunami processes affect variations in the ionosphere. Here, we study the Hunga Tonga Hunga Ha'apai (HTHH) volcanic eruption 2022 and its associated tsunami propagation with the analysis GNSS derived Total Electron Content (TEC), Synthetic Aperture Radar (SAR) Sentinel-1 data, complemented with tide gauge observations. We utilize GNSS sites data within a ~ 5000 km radius from the volcanic eruption for estimating the ionospheric perturbation as Vertical TEC. We give evidence on the detection of acoustic gravity, internal gravity, and atmospheric Lamb waves signatures in the TEC perturbation. In particular, the internal gravity waves that concentrated in the southwest of Tonga, directly correlates with the observed tsunami propagation direction as accounted by the tide gauge measurements. However, the acoustic gravity wave signature in the TEC is dominant in the north direction suggesting a surface deformation, which could be verified using Sentinel-1A SAR amplitude data. The analysis presented herein shows that within 5 h of the volcanic eruption, the central part of the HTHH island landscape disappeared with the biggest explosion. The unprecedented detail resolved by integrating satellite data yields previously unknown details of the deformation of the 2022 HTHH volcano eruption.

Association of hormonal and reproductive risk factors with breast cancer in Indian women: A systematic review of case-control studies.

The incidence of breast cancer in India has seen a rapid increase in recent years. Hormonal and reproductive risk factors for breast cancer have been affected by socioeconomic development. Studies on breast cancer risk factors in India are limited by the small sample size and specific geographical area. The current systematic review was carried out to assess the association of hormonal and reproductive risk factors with breast cancer in Indian women. A systematic review of MEDLINE, Embase, Scopus, and Cochrane database of systematic reviews were done. Relevant case-control studies published in peer-reviewed indexed journals were analyzed for hormonal risk factors such as age at menarche, menopause, and first childbirth; breastfeeding; abortion; and oral contraceptive pills use. Younger age (<13 years) at menarche was associated with high risk (odds ratio 1.23-3.72). Other hormonal risk factors with strong association were age at first childbirth and menopause, parity, and duration of breastfeeding. Abortion and the use of contraceptive pills did not have a clear association with breast cancer. Hormonal risk factors have a higher association in premenopausal disease and estrogen receptor-positive tumors. There is a strong association between hormonal and reproductive risk factors and breast cancer in Indian women. The protective effect of breastfeeding is related to the cumulative duration of breastfeeding.

Rare observations of sprites and gravity waves supporting D, E, F-regions ionospheric coupling.

We report rare simultaneous observations of columniform sprites and associated gravity waves (GWs) using the Transient Luminous Events (TLEs) camera and All-sky imager at Prayagraj (25.5° N, 81.9° E, geomag. lat. ~ 16.5° N), India. On 30 May 2014, a Mesoscale Convective System generated a group of sprites over the north horizon that reached the upper mesosphere. Just before this event, GWs (period ~ 14 min) were seen in OH broadband airglow (emission peak ~ 87 km) imaging that propagated in the direction of the sprite occurrence and dissipated in the background atmosphere thereby generating turbulence. About 9-14 min after the sprite event, another set of GWs (period ~ 11 min) was observed in OH imaging that arrived from the direction of the TLEs. At this site, we also record Very Low Frequency navigational transmitter signal JJI (22.2 kHz) from Japan. The amplitude of the JJI signal showed the presence of GWs with ~ 12.2 min periodicities and ~ 18 min period. The GWs of similar features were observed in the ionospheric Total Electron Content variations recorded at a nearby GPS site. The results presented here are important to understand the physical coupling of the troposphere with the lower and upper ionosphere through GWs.

Ionospheric perturbation during the South American total solar eclipse on 14th December 2020 revealed with the Chilean GPS eyeball.

The influence of the South American total solar eclipse of 14th December 2020 on the ionosphere is studied by using the continuous Chilean Global Positioning System (GPS) sites across the totality path. The totality path with eclipse magnitude 1.012 passed through the Villarrica (Lon. 72.2308°W and Lat. 39.2820°S) in south Chile during 14:41:02.0 UTC to 17:30:58.1 UTC and maximum occurred ~ 16:03:49.5 UTC around the local noon. The vertical total electron content (VTEC) derived by GPS sites across the totality path for two PRN's 29 and 31 show almost 20-40% of reduction with reference to ambient values. The percentage reduction was maximum close to totality site and decreases smoothly on both sides of totality sites. Interestingly, the atmospheric gravity waves (AGWs) with a period ~ 30-60 min obtained using wavelet analysis of VTEC timeseries show the presence of strong AGWs at the GPS sites located north of the totality line. But the AGWs do not show any significant effect on the VTEC values to these sites. Our analysis suggests, possibly an interplay between variability in the background plasma density and eclipse-generated AGWs induced plasma density perturbation could explain the observations.

Tsunami detection by GPS-derived ionospheric total electron content.

To unravel the relationship between earthquake and tsunami using ionospheric total electron content (TEC) changes, we analyzed two Chilean tsunamigenic subduction earthquakes: the 2014 Pisagua Mw 8.1 and the 2015 Illapel Mw 8.3. During the Pisagua earthquake, the TEC changes were detected at the GPS sites located to the north and south of the earthquake epicenter, whereas during the Illapel earthquake, we registered the changes only in the northward direction. Tide-gauge sites mimicked the propagation direction of tsunami waves similar to the TEC change pattern during both earthquakes. The TEC changes were represented by three signals. The initial weaker signal correlated well with Acoustic Rayleigh wave (AWRayleigh), while the following stronger perturbation was interpreted to be caused by Acoustic Gravity wave (AGWepi) and Internal Gravity wave (IGWtsuna) induced by earthquakes and subsequent tsunamis respectively. Inevitably, TEC changes can be utilized to evaluate earthquake occurrence and tsunami propagation within a framework of multi-parameter early warning systems.

Ionospheric monitoring with the Chilean GPS eyeball during the South American total solar eclipse on 2nd July 2019.

The impact of total solar eclipse of July 2, 2019 on the Ionosphere is studied using 24 Chilean GPS stations north-south of the totality path. The total solar eclipse passed through Coquimbo region from ~ 16:38 CLT (~ 20:38 UTC) to ~ 16:40 CLT (~ 20:40 UTC) and maximum eclipse was observed ~ 16:39 CLT (~ 20:39 UTC). The total electron content (TEC) derived from GPS signals shows peculiar features. At the totality stations TEC variations are small (~ 0.39 TECu), but it shows significant decrease (maximum ~ 2.24 TECu) for stations located south and increase (maximum ~ 3.89 TECu) for the stations located north of totality of the surface. The wavelet analysis of VTEC timeseries shows the presence of strong atmospheric gravity waves (AGWs) of duration ~ 30 to 60 min at the stations located north of totality. Thus, the results suggest an interplay between eclipse effect on the ionosphere plasma density and eclipse generated AGWs induced plasma density perturbation provided the peculiar features.

Superior Mesenteric Artery Thrombosis in COVID-19 Pneumonia: an Underestimated Diagnosis-First Case Report in Asia.

The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in prothrombin time, fibrinogen, and D-dimers. Early recognition of abdominal symptoms, diagnosis of pathology, and timely surgical intervention may definitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.

Anomalous variations of VLF sub-ionospheric signal and Mesospheric Ozone prior to 2015 Gorkha Nepal Earthquake.

The subject of pre-earthquake ionospheric signatures has always been contentious and debatable. Some of the previous reports have documented unforeseen and unusual variations in some of the atmospheric and ionospheric parameters well before an earthquake. Here, we analyze the ionospheric response from the Indian Subcontinent to Nepal Gorkha Earthquakes occurred between April and May 2015, which were the most powerful and disastrous natural calamities in past ~80 years over the Himalayan region left ~9000 causalities and more than ~20000 people injured with the property damage of the order of several billion dollars. In view of severe earthquakes occurrences, their prior information on the shorter time scales are warranted for mitigation of associated disasters. Here, we report for the first time, a case which shows a strong link in anomalous variations between VLF sub-ionospheric signal and mesospheric ozone prior to both April 25, 2015 (Mw = 7.8) earthquake and its biggest aftershock on May 12, 2015 (Mw = 7.3). Observations show an unusual variation in VLF signals amplitude /shift in terminator time (TT) strongly linked with positive (negative) mesospheric ozone anomaly in D-region altitudes prior to the Gorkha Nepal earthquakes. It is surmised that simultaneous continuous observations of both VLF waves and mesospheric ozone can be considered as an important tool to identify the prior earthquake signatures in the vicinity of the extremely earthquake-prone zone such as Himalayan region. In this context, the current report opens up a new dimension in lithosphere-atmosphere-ionosphere coupling during the earthquake preparation processes itself.

Management of Complicated Choledochal Cyst in an Adult with Situs Inversus Totalis: Diagnostic Difficulties and Technical Notes.

Situs inversus totalis is the mirror image of situs solitus, the normal position of abdominal and thoracic viscera. Many associated intraabdominal anomalies have been described with this condition. However, association of choledochal cyst with situs inversus has never been reported. Diagnosis and surgical procedures for abdominal pathology in patients with situs inversus totalis are technically more complicated and pose unique challenges because of left-right transposition of the visceral organs. The choledochal cyst is usually diagnosed in the neonatal period or during childhood. The clinical symptoms are nonspecific and usually include pain in the right upper quadrant and jaundice. The condition may also present with biliary colic, cholangitis, cholelithiasis or pancreatitis. In our case, the abdominal ultrasonography performed on a 55-year-old female who presented to us with jaundice, fever and pain in the left upper abdomen revealed presence of situs inversus with fusiform dilation of the common bile duct. Based on the magnetic resonance cholangiopancreatography (MRCP) images diagnosis of type I choledochal cyst was made. The aim of this case report is to illustrate an extremely rare association of situs inversus totalis with choledochal cyst along with the challenges faced in diagnosis and surgical management of this condition.

Assessment of Unusual Gigantic Jets observed during the Monsoon season: First observations from Indian Subcontinent.

Gigantic Jets are electric discharges from thunderstorm cloud tops to the bottom of ionosphere at ~90 km altitude and electrically connect the troposphere and lower ionosphere. Since their first report in 2002, sporadic observations have been reported from ground and space based observations. Here we report first observations of Gigantic Jets in Indian subcontinent over the Indo-Gangetic plains during the monsoon season. Two storms each produced two jets with characteristics not documented so far. Jets propagated ~37 km up remarkably in ~5 ms with velocity of ~7.4 × 106ms-1 and disappeared within ~40-80 ms, which is faster compared to jets reported earlier. The electromagnetic signatures show that they are of negative polarity, transporting net negative charge of ~17-23 C to the lower ionosphere. One jet had an unusual form observed for the first time, which emerged from the leading edge of a slowly drifting complex convective cloud close to the highest regions at ~17 km altitude. A horizontal displacement of ~10 km developed at ~50 km altitude before connecting to the lower ionosphere. Modeling of these Gigantic jets suggests that Gigantic Jets may bend when initiated at the edge of clouds with misaligned vertical charge distribution.

Laparoscopic ventral mesh rectopexy for complete rectal prolapse: A retrospective study evaluating outcomes in North Indian population.

AIM: To analyze the outcomes of laparoscopic ventral mesh rectopexy in the management of complete rectal prolapse (CRP) in North Indian patients with inherent bulky and redundant colon. METHODS: The study was conducted at a tertiary health care center of North India. Between January 2010 and October 2014, 15 patients who underwent laparoscopic ventral mesh repair for CRP, were evaluated in the present study. Perioperative outcomes, improvement in bowel dysfunction or appearance of new complications were documented from the hospital records maintained prospectively. RESULTS: Fifteen patients (9 female) with a median age of 50 years (range, 15-68) were included in the study. The median operative time was 200 min (range, 180-350 min) and the median post-operative stay was 4 d (range, 3-21 d). No operative mortality occurred. One patient with inadvertent small bowel injury required laparotomy on post-operative day 2. At a median follow-up of 22 mo (range, 4-54 mo), no prolapse recurrence was reported. No mesh-related complication was encountered. Wexner constipation score improved significantly from the preoperative value of 17 (range, 5-24) to 6 (range, 0-23) (P < 0.001) and the fecal incontinence severity index score from 24 (range, 0-53) to 2 (range, 0-53) (P = 0.007). No de novo constipation or fecal incontinence was recorded during the follow-up. On personal conversation, all patients expressed satisfaction with the outcome of their treatment. CONCLUSION: Our experience indicates that laparoscopic ventral mesh rectopexy is an effective surgical option for CRP in North Indian patients having a bulky redundant colon.