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.

Effect of Candida infection on outcome in patients with perforation peritonitis.

Perforation peritonitis is treated with surgery and antibiotics. This study was conducted to identify bacterial and fungal microorganisms responsible for peritonitis in patients with hollow viscus perforation and to examine the influence of these microorganisms on the outcome. A prospective study was conducted from May 2005 to September 2006 involving 84 consecutive patients with spontaneous gastrointestinal perforation peritonitis, who were referred for surgery. Peritoneal fluid was analyzed by microbial culture and biochemical tests for bacteria and fungi. The Jabalpur Prognostic Score was calculated. Forty-two of the 84 patients had positive peritoneal fluid cultures. Escherichia coli was the most common bacterium (n=26) and Candida (n=13) the most common fungus isolated. Bacterial isolates were largely sensitive to amikacin while all the Candida isolates were sensitive to fluconazole. Mortality was significantly higher in patients with positive peritoneal cultures (15/42) compared with those with negative peritoneal cultures (0/42, p<0.001), and in patients with mixed bacterial and fungal-positive cultures (10/13) compared with those with isolated bacterial cultures (5/29, p<0.001). Using the Jabalpur Prognostic Score, positive fungal cultures were found to be associated with a significantly higher than expected mortality. Patients with gastrointestinal perforations and positive peritoneal cultures have a poor prognosis, which is significantly worsened by the association of positive fungal cultures. Early recognition and treatment of fungal infection is advisable.

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.

Quality of life after peptic perforation.

AIM OF STUDY: Quality of life (QOL) as outcome during treatment of acid peptic disease has been studied, but, peptic perforation, which is the commonest complication of acid peptic disease, has not been studied in the light of QOL outcome. The present-study addresses the important issue of QOL after peptic perforations. METHODS: This prospective study was carried on 51 adult consecutive survivors of peptic perforation managed in Gastrointestinal Surgery Unit, Department of Surgery, Government NSCB Medical College and Hospital, Jabalpur (MP) India. These underwent exploratory laparotomy with repair of perforation, and subsequently were discharged on anti-ulcer therapy (Pantoprazole 40 mg once a day) for 6 weeks. The instrument chosen to study their QOL was gastrointestinal quality of life index (GIQLI). Patients were assessed before they underwent surgery and 3 months and 6 months after operation. RESULTS: The overall GIQLI score (t = 20.1, p < 0.00 at 3 months; t = 8.2, p < 0.001 at 6 months) as well as its G I core (t = 14.5, p < 0.001 at 3 months; t = 7.3, p < 0.001 at 6 months), G I disease specific (t = 12.9, p < 0.001 at 3 months; t = 2.6, p < 0.02 at 6 months), psychological (t = 15.4, p < 0.001 at 3 months; t = 3.5, p < 0.001 at 6 months) and physical and social components (t = 10.9, p < 0.001 at 3 months; t = 4.2, p < 0.001 at 6 months) significantly increased over 3 and 6 months of follow-up, reflecting improvement in quality of life as perceived by the patients. Variations in the pattern of recovery, based on age and gender were not seen in the present study. CONCLUSION: Peptic perforation does not result in any long lasting impairment of QOL and the QOL improves to near normal in 6 months time after the perforation.

A simplified prognostic scoring system for peptic ulcer perforation in developing countries.

BACKGROUND: Several complex prognostic scoring systems are available for abdominal sepsis. We constructed and assessed a simplified scoring system for peptic perforation, which can be easily used in developing countries. METHODS: One hundred and forty consecutive patients with perforated pre-pyloric or duodenal ulcer undergoing Graham's patch omentopexy closure were studied prospectively. Each factor was given a score based on its severity in accordance with the APACHE-II scoring system to construct the simplified prognostic (Jabalpur) scoring system, and multiple regression analysis was used to identify risk factors. This system was prospectively validated in the next 50 consecutive patients and compared to existing systems. RESULTS: The factors associated with mortality were age, presence of co-morbid illness, perforation-to-operation interval, preoperative shock, heart rate, and serum creatinine. The mean score in survivors (4.9) was less than that in those who died (12.5; p<0.0001). This scoring system compared favorably with other scoring systems. CONCLUSIONS: The Jabalpur scoring system is effective for prognostication in cases of peptic perforation. It is simple and user-friendly as it uses only six routinely documented clinical risk factors.

Correlation of trauma scoring systems with abdominal septic complications in abdominal trauma.

INTRODUCTION: Anatomical trauma scoring systems can predict the occurrence of postoperative abdominal septic complications (ASC) after major abdominal trauma; however, this has not been validated in any Indian study. We attempted such an evaluation in patients attending a teaching hospital in central India. METHOD: A retrospective analysis of data from 169 patients who had undergone emergency laparotomy for penetrating or blunt abdominal injury between August 1996 and July 2001 was done. Every patient was scored using three trauma severity indices and the occurrence of ASC was identified. RESULTS: Patients who developed ASC had higher trauma severity scores than those who did not. Thirty-eight patients had isolated small bowel injury; trauma scores underestimated the occurrence of ASC in these patients. CONCLUSIONS: Trauma severity indices may serve as useful tools to predict the occurrence of postoperative ASC in patients with abdominal trauma, except in those with isolated small bowel injury. There is thus a need to modify the weight of small bowel injury in these scoring systems.

Esophago-gastric dissociation complicating devascularization procedure for portal hypertension.

Devascularization surgery for portal hypertension, indicated in selected patients, is considered safe. A 15-year-old boy with cirrhosis underwent elective modified Sugiura's devascularization procedure for secondary prophylaxis of variceal bleeding. He developed esophago-gastric dissociation, which was successfully managed with emergency feeding jejunostomy and restoration of gut continuity three months later.