Utility of Acute Normovolemic Hemodilution in Major Surgeries in Rural Area: A Prospective Comparative Study from North India.

INTRODUCTION: Easy availability of autologous blood is difficult in rural areas. Acute normovolemic hemodilution (ANH) has been found to be an effective alternative in major surgeries where we are expecting major blood loss. PATIENTS AND METHODS: A prospective comparative study was designed to evaluate the utility of ANH patients (patients receiving autologous blood) during major operations done at MRA Medical College Ambedkar Nagar, Uttar Pradesh, India. during from September 2015 to September 2016. A total of 60 patients undergoing major surgeries were randomly assigned into two groups of thirty patients' each. Group I received homologous blood intraoperative only when required. In Group II ANH was initiated to a target hematocrit of 30% after induction of anesthesia. Various parameters such as demographic, biochemical, and hemodynamic were compared. RESULTS: The mean value of blood withdrawn in ANH group was 650.5 ± 228 ml and it was replaced with an equal volume of 6% hydroethyl starch. There was no statistically significant variation in mean hemocrits levels in both the groups at various stages of the study. Hematocrits decreased significantly in both the groups at various stages as compared to preoperative values. The heart rate and mean blood pressure were almost similar and without statistically significant differences in both groups. Surgical blood loss in Group I was 895.29 ± 568.30 ml as compared to 765 ± 506 ml in Group II. The difference was statistically insignificant (P ≥ 0.05). The mean volume of homologous blood transfused in Group I was 850.71 ± 318.29 ml, as compared to nil in Group II which was statistically significant (P < 0.05). CONCLUSION: It concludes that ANH up to a target hematocrit of 30% is safe and effective in reducing the need for homologous blood in various major surgeries in institutes in rural areas.

Role of butorphanol and ondansetron premedication in reducing postoperative shivering after general and spinal anesthesia: A randomized comparative study from North India.

BACKGROUND: Postoperative shivering (PAS) is a common problem following general and spinal anesthesia and may lead to multiple complications. This placebo-controlled, randomized study was performed to evaluate the efficacy of Ondansetron and butorphanol premedication reduces shivering after general and spinal anaesthesia. AIMS: The aim of this study to highlight the efficacy of Butorphenol and ondosteron in controlling postoperative shivering. MATERIALS AND METHODS: This clinical trial included 180 patients scheduled for elective general surgery, E.N.T., Ophthamological operations, randomly divided to six groups. Three groups in which General Anaesthesia was used i.e. Group 1-ondansetron 8 mg intravenously(IV).Group 2 butorphanol 2 mg IV and Group 3 - saline 4 ml IV. And three groups where spinal Anaesthesia was used i.e. Group 4-Ondosteron 8 mg IV, Group 5 butorphanol 2 mg IV and Group 6 - saline 4 ml IV 3-5 minutes before anaesthesia. Patients were observed in terms of vital signs, side effects and shivering. SETTINGS AND DESIGN: The type of the study was double blind randomized trial. STATISTICAL ANALYSIS USED: Statistical Package for Social Sciences version 13.0 statistical analysis software. RESULTS: Postoperative shivering was observed in 15.5%, 22.2% and 60% in general anaesthesia groups I II and III respectively. The reduction of core and dermal temperature during the anaesthesia and recovery, changes in systolic and diastolic blood pressure and heart rate were similar in all three groups (i.e. Group I,II,III). In spinal anaesthesia groups, PAS occurred 10%, 13.3% and 43.3% in group IV, V, VI respectively. The reduction of core temperature is similar in all three groups of spinal anaesthesia. But heart rate and mean arterial pressure increase were significant in control saline group in post operative recovery time. No complication seen in any of the six groups. CONCLUSION: This study suggested that use of Butorphanol and Ondansteron both are effective in reducing the incidence of PAS after general and spinal anaesthesia.

Impact of hypothyroidism on primary anal malignant melanoma: a rare entity.

Primary melanoma of the anal canal is rare and highly malignant condition, which is 1% of all invasive tumors in this site. This condition is often mistaken for benign conditions as either hemorrhoids or rectal polyp. Thyroid-stimulating hormone stimulation causes high proliferation of malignant melanoma. The association of hypothyroidism with primary malignant melanoma of anal canal is very rare. We are reporting such a very rare case.

Difficult situations in laparoscopic cholecystectomy: a multicentric retrospective study.

INTRODUCTION: Difficult laparoscopic cholecystectomy (LC) is the most common "difficult" surgical procedure performed today, which possesses the potential to place the patient at significant operative risk. We present our retrospective study and experience of 8347 patients with LC since June 1995 to December 2011 at 2 large centers: Mariampur and GSVM Medical College, LLR Hospital, Kanpur, with discussions regarding the practical aspects of LC in difficult situations with respect to conversion to open cholecystectomy. METHODS: A retrospective analysis of patients who underwent LC from June 1995 to December 2011 was performed. The analysis was performed in relation to the need for conversion and the factors responsible for conversion. RESULTS: Out of 8347 cases, 2187 cases (26.2%) were identified as difficult. LC was performed successfully in 8265 cases (total completion rate, 99.02%). Of the 2187 difficult cases, LC was completed successfully in 2105 cases (completion rate in difficult cases, 96.25%) and converted to open cholecystectomy in 82 cases (conversion rate in difficult cases, 3.75%). CONCLUSIONS: Because of the increasing exposure and expertise of surgeons dealing with complex gall bladder laparoscopies, rates of conversion to open cholecystectomy are decreasing and many difficult cases are now handled laparoscopically. However, if required, conversion should not be considered as a failure for the benefit of the patient.

Occurrence of polymelia in a female child.

We report a rare case of polymelia in a 6-month-old female child who presented with developed lower limbs and an additional underdeveloped left lower limb.

Evaluation of the Utility of the Fournier's Gangrene Severity Index in the Management of Fournier's Gangrene in North India: A Multicentre Retrospective Study.

OBJECTIVE: To study the utility of Fournier's Gangrene Severity Index (FGSI) with mortality predictive value in our tertiary institutes in North India. MATERIALS AND METHODS: A retrospective study of 95 cases of Fournier's Gangrene (FG), admitted from 2009 to 2011, was carried out. We analysed clinical and laboratory findings, various prognostic factors, surgical treatments and their outcomes in FG patients. FGSI was used as individual variable to estimate the severity of FG; the effects of these factors on mortality were also evaluated. RESULTS: The overall mean age was 46.5 ± 15.6 (range 24-82) years. Anorectal and urological regions were the main sites of the infection. The most common site of infection origin was scrotum in 81.3% in group A and 41.2% in group B. One or more predisposing factors such as diabetes mellitus (DM; 55%) malignancies (4.6%), chronic renal failure (4.5%) and previous surgery (9.2%) were detected. We observed mortality in 26.5% cases (17/65). The FGSI calculated averaged 5.95 ± 365 in group A and 9.44 ± 2.56 in group B, at the time of admission (P > 0.05). CONCLUSION: In FG, an early diagnosis and early surgical debridement are essential. The FGSI seems to be an excellent tool for the outcome prediction.

Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia.

The technique of Cervical Epidural Anesthesia (CEA) was first described by Dogliotti in 1933 for upper thoracic procedures. Administration of local anesthetic into cervical epidural space results in anesthesia of the neck, upper extremity, and upper thoracic region. CEA provides high-quality analgesia and anesthesia of above dermatomes and, at the same time, it has favorable effect on hemodynamic variable by blocking sympathetic innervation of the heart. CEA is not practiced routinely because of its potential complications. We selected this technique of CEA for excision of giant cervical lipoma on the back of the neck in an adult patient, as the patient was unwilling for general anesthesia. CEA was induced with 10 ml of 1% lignocaine-adrenaline mixture administered into C7-T1 space through 18G Tuohy needle. Our patient maintained vital parameters throught the procedure. The added advantage of epidural anesthesia was that the patient was awake and comfortable throughout the procedure.

Giant lipoma of posterior neck with bleeding decubitus ulcer: a rare entity.

Giant lipomas are benign soft tissue tumours. They are found relatively rarely on the posterior part of the neck. Bleeding pressure ulcer in this giant tumour is a rare presentation. Surgical interventions in these tumours are very challenging because, sometimes, extension to the spinal cord and malignant change may occur, especially in old age. Knowledge of the anatomy and meticulous surgical techniques are needed for such giant lipomas.

Extent of surgery in the management of phyllodes tumor of the breast: a retrospective multicenter study from India.

INTRODUCTION: Phyllodes tumor (PT) is a rare tumor of the breast. Usually, difficulty in making preoperative diagnoses and unpredictable clinical outcome of this disease leads to inappropriate management. Till date, no definite conclusion regarding the appropriate surgical procedure can be drawn. OBJECTIVES: The objective of this retrospective study is to study the clinicopathological correlation of phyllodes tumors in North-Central part of the India and also to evaluate efficacy of the various surgical options available for the management of phyllodes tumors of the breast. MATERIALS AND METHODS: A retrospective study of 24 cases from the archives of department of surgery of three tertiary institutes of North-Central part of India. We reviewed the clinical, pathological features of this disease entity with a view to highlight relevant features. We also analyzed various surgical options done for primary as well as recurrent PT. RESULTS: The breast masses in our study were particularly large. The mean size of the lump was 9.5 +/- 5.5 cm (range was 4.0-23 cm). Histopathological report was benign, borderline, and malignant PT in 62.4%, 20.8%, and 16.8% of the cases, respectively. Overall, 31 surgical procedures (24 in primary and 7 in recurrent) were performed. Simple lumpectomy, wide local excision and simple mastectomy were done in 25%, 27.4% and 27.4% of primary (non-recurrent) cases of PT, respectively. Modified radical mastectomy and simple mastectomy with LD flap reconstruction was done in 7.2% and 2.4% in primary cases, respectively in recurrent cases, simple mastectomy was done in four cases and modified radical mastectomy was done in one case. Overall, recurrence was seen in 29.2% of the cases. The median time for recurrence was 6 months (range 5.0-36 months). 90% (6/7) of recurrence occurred in lumpectomy patients. CONCLUSION: The unpredictable behavior of histological types and the disputable results of particular surgical procedures have contributed to the controversies. The therapeutic issue is further compounded by an imprecise preoperative diagnosis. This study shows that wide local excision for benign and borderline and simple mastectomy with or without reconstruction for the malignant PT of the breast are acceptable best surgical options.