Abdominal packing for surgically uncontrollable haemorrhage.

Background: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. Patients and methods: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years) . The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were : liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). Results: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <340C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. Conclusion: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.

Complicated colonic diverticulosis: surgical perspective from an Indian Centre.

INTRODUCTION: Colonic diverticulosis was previously uncommon in India but its incidence seems to have increased recently. Patients with the disease in developing countries are also underdiagnosed and are therefore more likely to present with complications needing operation. However there is a paucity of surgical data on the condition. METHOD: Between August 1996 and February 2005 we operated on 32 patients (28 males, 4 females mean age 60 years) with colonic diverticulosis and analysed their characteristics from a prospective database. We here with describe our experience. RESULTS: Operations for diverticular disease constituted 3% of all the colorectal operations we performed. The diverticula were in the sigmoid colon in 28 (88%) and also in the descending colon in 4 (12%). Twenty-four patients were symptomatic. Twenty-two patients were diagnosed before surgery, 8 at operation and the rest from resected specimens. Emergency operations were performed in 23 and elective procedures in 9 patients. Ten patients were operated on for perforation and abscess, 8 for obstruction, 8 for colovesical fistula, 3 for peritonitis and 3 for haemorrhage. Emergency procedures were performed in 2 stages (resection plus a proximal diversion) in 20; unless done for bleeding in a stable patient where a primary anastomosis was done. One patient who had had an emergency procedure died of sepsis and ketoacidosis in the post-operative period. The 8 patients with colovesical fistulae were all males, had only sigmoid involvement and had had symptoms for a longer duration than the 24 without fistulae. CONCLUSIONS: Although operations for colonic diverticulosis still form a small proportion of the total number of colorectal operations, the diagnosis is often delayed till complications ensue and thus patients usually require emergency procedures. Males with long standing symptoms and sigmoid diverticula may develop colovesical fistulae.

Does exchanging comments of Indian and non-Indian reviewers improve the quality of manuscript reviews?

BACKGROUND: The quality of peer reviewing in developing countries is thought to be poor. To examine whether this was so, we compared the performance of Indian and non-Indian reviewers who were sent original and review articles submitted to The National Medical Journal of India. We also tested whether informing reviewers that their comments would be exchanged improved the quality of their reviews. METHODS: In a prospective, randomized, blinded study, we sent 100 manuscripts to pairs of peer reviewers (Indian and non-Indian) of which 78 pairs of completed replies were available for analysis. Thirty-eight pairs of reviews were exchanged and 40 were not. The quality of the reviews was assessed by two editors who were unaware of the reviewers' nationality and whether they had been told that their reviews would be exchanged. The quality of the reviews was scored out of 100 (based on a predesigned evaluation proforma). We also measured the time taken to return a manuscript. RESULTS: Overall, non-Indian reviewers scored higher than Indians (mean scores non-Indians first, 56.7 v. 48.6, p < 0.001), especially those in the non-exchanged group (58.4 v. 47.3, p < 0.001) but not the exchanged group (54.8 v. 50.0, p < 0.06). Being informed that reviews would be exchanged did not affect the quality of reviews by non-Indians (54.8 exchanged v. 58.4 non-exchanged) or of reviews by Indians (50.0 exchanged v. 47.3 non-exchanged). The editors' assessment of the reviewers matched well (r = 0.59, p < 0.001). Non-Indians took the same amount of time as Indians to return their reviews, although the postage time was at least eight days longer. CONCLUSIONS: We found that non-Indian peer reviewers were better than Indians and informing them that their views would be exchanged did not seem to affect the quality of their reviews. We suggest that Indian editors should also use non-Indian reviewers and start training programmes to improve the quality of peer reviews in India.

Multiple large pyogenic liver abscesses of the tropics: a new entity.

BACKGROUND: Pyogenic liver abscesses most commonly occur in males in -he sixth decade, are usually associated with biliary tract disease, malignancy and immunosuppression and the mortality rate is high. We describe another form of pyogenic abscess occurring in females which, if treated aggressively, carries a much better prognosis. METHODS: Between 1986 and 1993 we treated 8 patients with multiple pyogenic liver abscesses. Diagnosis was established by ultrasound and CT scan followed by needle aspiration to confirm pus. Amoebic aetiology was excluded by a serology, poor response to metronidazole and biopsy of the abscess wall. RESULTS: The mean age of our patients was 30 +/- 7 years and there were 2 males and 6 females. They presented with fever and abdominal pain for more than 2 months, tender hepatomegaly, a raised ESR and alkaline phosphatase. US and CT scans showed multiple large abscesses in the right lobe. Histology suggested chronic inflammation and with no definite organism isolated except for visceral larva migrans in one case. All patients underwent surgery--deroofing with drainage was done in four, segmental hepatic resection in three and right hepatectomy in one. One patient had a recurrence and underwent repeated resection. Only one patient died and 7 did well with no recurrence at a mean followup of 24 +/- 27 months. CONCLUSIONS: Large multiple cryptogenic pyogenic abscesses of the liver occurring mostly in young females, which respond well to aggressive excisional surgery may constitute a distinct clinical entity.

Encephalomyelopathy following portocaval shunt in noncirrhotic portal fibrosis: a case report.

A 30 year old male patient presented with the clinical picture of progressive encephalomyelopathy eleven years after a portacaval shunt for non-cirrhotic portal fibrosis (NCPF). The spinal cord involvement in this patient was restricted to the corticospinal and the spinocerebellar pathways. The clinical picture and neuropathology of encephalopathy and of myelopathy have been described in patients with cirrhosis. Cases of encephalopathy and myelopathy have also been reported following shunt surgery in NCPF. We report the first case of encephalomyelopathy developing eleven years after portacaval shunt in a patient with noncirrhotic portal fibrosis.