Cutting of sphincter in fistulectomy with primary closure in complex fistula-in-ano: is it feasible?

Introduction: Treatment of complex fistulas such as inter- or transsphincteric, recurrent, and high fistulae have high rate of recurrence or incontinence. Fistulectomy with primary sphincter reconstruction might represent an effective and safe alternative to reduce rate of recurrence and incontinence. The aim of this study is to assess incontinence and recurrence after fistulectomy with primary sphincter reconstruction for management of complex fistulas. Material and Methods: There were 60 patients with complex fistulae involving the sphincter, with 56 male and 4 female, mean age 40.6 years, operated by fistulectomy and primary sphincter repair over a period of 7 years. Patients were followed up for 6months for any complications, recurrence, and incontinence. Results: The majority of patients (50, 83.3%) had complete wound healing in 2 weeks, while 4 (6.6%) patients had hematoma and superficial wound dehiscence, which were managed conservatively and healed in 4 weeks. There was one recurrence. All patients had good continence postoperatively, except for mild fecal incontinence (FI, score 3), seen in 6 (10%) patients. However, all these patients regained continence within 6 weeks. Conclusions: Primary reconstruction of anal sphincter with fistulectomy is a safe option for complex fistula-in-ano. (AU)

Personal financial literacy among Indian postgraduate residents

BACKGROUND Postgraduate residents’ ability to understand and effectively manage their finances is variable. We conducted this study to assess the awareness of personal financial literacy among Indian residents. METHODS We circulated a web-based cross-sectional Google Forms multiple-choice questionnaire having questions in three categories including financial awareness, current financial status and plans among 400 Indian residents. RESULTS A total of 215 Indian residents (53.75%) responded to the survey (men 80.9%, unmarried 74.4% and pursuing broad specialties 83.3%). The majority were unaware of stocks, special student/doctor loans, tax planning, life insurance, professional indemnity and tax/financial planning. The majority opined that personal finance and investing should be taught at medical school/residency. A financial pyramid based on the hierarchy of needs is proposed. CONCLUSION Lack of financial literacy and planning was seen among the majority of Indian residents. Our study highlights this gap in the medical curriculum and the need for formal structured financial education during training.

An observational single-center study of nivolumab in Indian patients with recurrent advanced non-small cell lung cancer

Purpose: Limited treatment options are available for patients with advanced non-small cell lung cancer (NSCLC) after failure of first-line platinum-based chemotherapy. The treatment of recurrent advanced NSCLC progressed with the arrival of nivolumab and other immunotherapeutic agents. Our single-center prospective study aimed to present the effectiveness and safety of nivolumab in second-line setting after first-line platinum doublet in Indian patients with advanced NSCLC. Patients and Methods: Twenty-nine adult patients with stage IV NSCLC treated with nivolumab after failure of first-line platinum-based chemotherapy at Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, India, between October 2016 and January 2018, were included in the study. Overall survival (OS), hematological, and nonhematological toxicities were evaluated. Results: A total of 29 patients (mean age of 59.6 years at enrollment) were evaluated. Histological evaluation revealed adenocarcinoma (44.8%) and squamous (55.2%) type of cancer. The Eastern Cooperative Oncology Group performance score was II in 7 patients (24.1%) and I in 22 (75.9%) patients. Patients received an average of four cycles of nivolumab. The median survival duration was 101 days, and OS rate in the study was 51.7%. Six patients (20.7%) had stable disease response, five patients (17.2%) had partial response, and three patients (10.3%) were lost to follow-up. Asthenia and cough were the most common nonhematological toxicities. Only three patients developed hematological toxicities (anemia and thrombocytopenia). Conclusion: Data from our study suggest nivolumab is well-tolerated and effective in Indian patients with recurrent advanced NSCLC after failure of the multiple first lines of platinum-based combination chemotherapy.

Repair of duodenal fistula with rectus abdominis musculo-peritoneal (RAMP) flap.

INTRODUCTION: Large duodenal defects/fistulae are difficult to repair, due to complex duodenal anatomy. Musculo-epithelial flaps are conventionally used for reconstruction of large soft tissue defects. We report the clinical use of rectus abdominis musculo-peritoneal (RAMP) flap for repair of duodenal fistulae. METHODS: Eight patients with duodenal fistulae underwent repair using right RAMP flap, based on the position of the superior epigastric artery. Feeding jejunostomy was done routinely to start early enteral feeding. RESULTS: Duodenal fistulae healed within 3-5 days in all the cases except one, in whom bile continued to leak for 30 days. One patient died within 12 hours of second surgery. Superficial wound infection was a common (n=3) cause of morbidity. CONCLUSION: RAMP flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed quickly in critically ill patients. It can be used for repair of large duodenal defects with friable edges when omentum is not available or when other conventional methods are impractical.