Surgical outcome of extrahepatic portal venous obstruction: Audit from a tertiary referral centre in Eastern India.

Backgrounds/Aims: Extra hepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in Indian children. While endoscopy is the primary modality of management, a subset of patients require surgery. This study aims to report the short- and long-term outcomes of EHPVO patients managed surgically. Methods: All the patients with EHPVO who underwent surgery between August 2007 and December 2021 were retrospectively reviewed. Postoperative complications were classified after Clavien-Dindo. Binary logistic regression in Wald methodology was used to determine the predictive factors responsible for unfavourable outcome. Results: Total of 202 patients with EHPVO were operated. Mean age of patients was 20.30 ± 9.96 years, and duration of illness, 90.05 ± 75.13 months. Most common indication for surgery was portal biliopathy (n = 59, 29.2%), followed by bleeding (n = 50, 24.8%). Total of 166 patients (82.2%) had shunt procedure. Splenectomy with esophagogastric devascularization was the second most common surgery (n = 20, 9.9%). Nine major postoperative complications (Clavien-Dindo > 3) were observed in 8 patients (4.0%), including 1 (0.5%) operative death. After a median follow-up of 56 months (15-156 months), 166 patients (82.2%) had favourable outcome. In multivariate analysis, associated splenic artery aneurysm (p = 0.007), isolated gastric varices (p = 0.004), preoperative endoscopic retrograde cholangiography and stenting (p = 0.015), and shunt occlusion (p < 0.001) were independent predictors of unfavourable long-term outcome. Conclusions: Surgery in EHPVO is safe, affords excellent short- and long-term outcome in patients with symptomatic EHPVO, and may be considered for secondary prophylaxis.

Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis.

BACKGROUND: The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications. METHODS: All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality. RESULTS: Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP. CONCLUSIONS: Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes.

Distally based V-flap on the artery in an end-to-side anastomosis for arteriovenous fistula creation - A randomized controlled pilot study.

BACKGROUND: With an increasing number of chronic kidney disease (CKD) patients presenting at a young age, it is necessary to create a vascular access (VA) that is reliable, long-lasting, and has minimal complications. Despite improvements in anastomotic techniques, distal arteriovenous fistula (AVF) has a high failure rate. The successful use of a geometric design for the end-to-side anastomosis in free tissue transfer led us to consider whether V-flap technique can be employed to achieve consistent and earlier maturation in distal AVF and reduce the failure rates. METHODS: This was a prospective randomized controlled trial conducted between January and April 2022. Twenty CKD patients were randomized into two groups and underwent AVF creation using the slit-arteriotomy and the V-flap technique. Postoperative follow-up was performed on the 1st, 2nd, 4th, 6th, and 8th weeks. Cross-sectional area (CSA) and circumference of vein, linear and volumetric flow across the anastomosis, and the time taken to achieve AVF maturation were analyzed. RESULTS: There was a significant increase in the CSA and circumference in the V-flap group as compared to that in the slit-arteriotomy group. The volumetric flow across the anastomosis in the V-flap group was significantly higher than that of the slit-arteriotomy group. The median time to achieve AVF maturation in the slit-arteriotomy group was 8 weeks, whereas it was 4 weeks in the V-flap group. CONCLUSION: The V-flap technique creates an anastomosis with a greater CSA facilitating larger volumetric flow rate. This helps to achieve a consistent, reliable, and earlier maturation with successful initiation of hemodialysis.

Outcome of reoperative surgery for late failure of postcholecystectomy bile duct injury repair.

The aim of the study is to report the outcomes of reoperative surgery for late failure of postcholecystectomy bile duct injury (BDI) repair. All the patients, who underwent a reoperative surgery for late failure of postcholecystectomy BDI repair at our institution between August 2007 and July 2020, were retrospectively reviewed. Of the total 262 patients of BDI repair, 66 underwent reoperative surgery for late failure. Median duration between last attempt repair and the onset of recurrent symptoms was 18 months. Eighty-five percent of patients with failed repair became symptomatic within 5 years of attempt repair. The most common type of BDI was E3. All the patients underwent Roux-en-Y hepaticojejunostomy. Twenty-nine postoperative complications developed in 23 (35%) patients. Postoperative mortality was 1.5%. Median postoperative hospital stay was 9 (5-61) days. Over a median follow-up of 80 (12-150) months, 5.2% (3/58) of patients developed clinically relevant anastomotic stricture. Three patients with secondary biliary cirrhosis died in the follow-up period due to decompensated liver disease. Overall, excellent or good long-term outcome was achieved in 83% (48/58) of patients which was significantly less satisfactory than primary repair patients (82.8% vs 92.7%, p = 0.039). Reoperative surgery is safe in patients with failed repair after postcholecystectomy BDI and good long-term clinical success can be achieved in most of the patients. The long-term results were less satisfactory in failed-repair group than those who underwent primary repair at our institution. Early referral to a specialized unit for BDI repair may improve long-term outcome.

Clinical profile and outcome of solid pseudopapillary neoplasm of the pancreas: A retrospective study on 28 patients.

BACKGROUND: Solid pseudopapillary neoplasms (SPN) of the pancreas are rare tumors accounting for 0.9-2.7% of all exocrine pancreatic tumors. Very few studies comprising of more than 10 patients have been published. The aim of the present study is to report on our experience with SPNs over a period of 14 years from a tertiary center of Eastern India. METHODOLOGY: Data of all patients whose histopathology reports of surgically resected specimen confirmed SPN were retrospectively reviewed in the present study. RESULTS: Twenty-eight patients had a pathologically confirmed diagnosis of SPN. Twenty-five (89.3%) patients were females with a median age of 26 (15-45) years. Abdominal pain (89.2%) was the most common presenting symptom. Abdominal mass was palpable in 12 (42.8%) patients. The mean size of the tumor was 9.03 cm (range, 4-25 cm). The most common location of the tumor was in the body and tail of pancreas (35.7%). The most commonly performed operation was distal pancreaticosplenectomy (n = 17, 60.7%), followed by Whipple's procedure (n = 8, 28.5%). Thirty postoperative complications developed in 23 (82.1%) patients. The operative mortality was 3.5% (n = 1). The median hospital stay was 10 (5-25) days. Over a median follow-up period of 36 months (range), no patient developed recurrence. CONCLUSION: Although the size of tumor was quite large at the time of initial presentation, complete surgical resection was possible in all the patients. In experienced hand, surgery can be performed with acceptable perioperative mortality and excellent long-term outcomes.

Duodenal Adenocarcinoma Versus Foreign Body Granuloma in the Background of Postcholecystectomy Migration of Endoclip Into Duodenum: A Histopathological Surprise.

A surgical endoclip in the cystic pedicle rarely migrates to the duodenum and is considered a rare complication of laparoscopic cholecystectomy. Duodenal adenocarcinoma endoscopically mimicking a foreign body granuloma in the background of postcholecystectomy endoclip migration has never been reported before. A 53-year-old Indian male presented with progressive weakness and melena for the last three months. He underwent laparoscopic cholecystectomy a year ago with an uneventful clinical course and post-operative recovery. A complete hemogram revealed hemoglobin of 4.5g/dL. Upper gastrointestinal endoscopy revealed a large necrotic polypoidal mass arising from the lateral wall of the first part of the duodenum. Contrast-enhanced computed tomography (CT) of the abdomen showed an impacted surgical clip into the lateral wall of the first part of the duodenum. Intraluminal extension of the surgical clip was not appreciated in the imaging. We suspected the diagnosis to be foreign body granuloma in the duodenal wall. He underwent open duodenal wedge resection. Microscopic evaluation of resected specimens revealed poorly differentiated adenocarcinoma. All the resection margins were free. He had an uneventful recovery and was discharged on the seventh post-op day. He was symptom-free and doing well on follow-up at 12 months. The purpose of reporting the case was to make the readers aware of the delayed massive upper gastrointestinal hemorrhage as a rare complication of endoclip migration (ECM) post laparoscopic cholecystectomy. In our case, the duodenal adenocarcinoma mimicked a foreign body granuloma endoscopically, and hence a possibility of duodenal adenocarcinoma as a potential delayed complication of ECM cannot be ruled out. Although rare, in case of upper gastrointestinal hemorrhage in the background of the previous history of laparoscopic cholecystectomy, endoclip migration should be kept as a differential diagnosis.

Outcomes of Arteriovenous Fistula Creation in Patients Undergoing Hemodialysis: An Indian Experience.

Introduction Creating an arteriovenous fistula (AVF) to provide a patent and long-term vascular access (VA) for hemodialysis (HD) still remains a challenge. A methodical approach to choosing the appropriate HD access in accordance with patients' end-stage kidney disease (ESKD) life plan will help them achieve their goals safely. This study summarizes the impact of various factors on the AVF outcomes in an Indian population as well as the necessary considerations before choosing the site of AVF creation. Materials and methods This study involved a single-center, retrospective evaluation of all patients who had undergone arteriovenous (AV) access creation for maintenance HD from October 2018 to August 2019 at a center in India. Results In our study of 216 cases, the average age at presentation was 43.9 years and the difference in age between the successful and unsuccessful group was not significant. The successful outcomes in males were significantly higher than those in females (p=0.005). The mean venous diameter in the successful group was significantly larger than that in the unsuccessful group. The distal arterial and vein diameter was higher in both males and females of the laborer group compared to the clerical group; however, the outcomes were comparable. The overall complication rate was 22.22%. We had primary patency rates of 83% at the end of one year with a primary failure rate of 8.80%. Conclusion Vein diameter was the most important predictive factor for a successful outcome in our study. Factors like age and life expectancy, gender, comorbidities, occupation, and type of anastomosis may not be individually predictive of outcomes but need to be considered before choosing the appropriate site of access creation according to the life plan of the patient. This will reduce morbidity associated with an additional procedure and facilitate the initiation of HD as early as possible. Occupation can be considered as a surrogate for preoperative forearm exercises with the increased caliber of vessels found in people performing heavy/manual labor favoring a more distal AVF creation.

Management of recurrent post-traumatic seroma of thigh (Morel-Lavallée lesion) by percutaneous aspiration and sclerotherapy using tetracyclines (PAST).

Morel-Lavallée lesion is a chronic, recurrent collection of serous fluid in the soft tissues and usually occurs following injury. The most common sites are thigh, hip and pelvic region. This presents as a local or diffuse swelling and may cause discomfort to the patient besides being a potential site for bacterial contamination. So, early diagnosis and timely management is crucial for an early and successful outcome. The investigation modality of choice for diagnosis of these lesions is MRI. Definitive management ranges from percutaneous aspiration with or without sclerotherapy to open debridement and irrigation. Although recurrences are common with conservative management, it can be minimised with judicious use of sclerotherapy.

Successful microsurgical replantation of an amputated penis.

Penile amputation is an uncommon injury for which immediate surgical replantation is warranted. Microsurgical replantation is the "standard" method for penile replantation. Early replantation yields a high success and low complication rate. We report a case of a 34-year-old male who presented with amputation at the proximal penile shaft which was successfully replanted using microsurgical techniques. Minor skin necrosis was noted post-operatively which was debrided and covered with skin graft. Follow-up at 6 months showed satisfactory cosmetic appearance, normal voiding, return of sensations and erectile function. The level of evidence was V.

A new design of a dorsal flap in the rat to study skin necrosis and its prevention.

BACKGROUND: The Mcfarlane flap or dorsal pedicled flap has become the standard model for pedicled rat skin flap study but its reliability has been called to question. In the past, there were possible confounding variable with the McFarlane flap and various methods were used to adjust these variables. We have developed a new model for studying skin flap necrosis and its prevention that eliminates these confounding variables. METHODS: The flap is a significant modification of the McFarlane flap where we form a blind ended pedicled tube using a 3 cm x 9 cm dorsal flap. Survival area is measured using digital photography and computer assisted analysis. This new flap is compared with the standard McFarlane flap with n=25 in each group. RESULTS: The mean survival area of the new flap (15.673 cm(2)+SD3.37) is comparable with the McFarlane flap (18.904 cm(2)+SD3.79). The relative merit lies in the elimination of the confounding variable of the graft bed influence on our flap without a significant reduction in the survival area. CONCLUSION: A new rat model is presented that may be used in studying the effect of various treatment modalities on pedicled skin flaps. This model has the benefit of eliminating graft bed effect without the risk of flap and wound infection or desiccation that have been encountered using other models. The new flap also has better demarcation of necrosis area in this study.

Comparison of osteogenic potential of calvarial bone dust, bone fragments, and periosteum.

INTRODUCTION: Bone dust is often used as a control when testing the potential of a new reconstructive graft material. Under microscopic examination, it would be expected to see the fully differentiated cellular components of bone, but instead only fusiform shapes characteristic of fibroblasts are mainly seen. This study aimed to compare the osteogenic potential of cells obtained from calvarial bone dust, bone fragments, and periosteum using 3 assays: collagen, calcium, and alkaline phosphatase. MATERIALS AND METHODS: Bone dust was harvested from the calvaria of 5 euthanized rabbits by drilling burr holes. Small pieces of intact, nondrilled bone, and periosteum were also obtained to serve as controls. The cells obtained from the bone dust, bone fragments, and periosteum were cultured for 5 weeks and then assayed for collagen (type 1), calcium, and alkaline phosphatase. RESULTS: Staining for calcium revealed that the greatest calcium deposition was achieved with periosteum, followed by bone dust and then bone fragments. Staining for alkaline phosphatase was similar for bone dust and periosteum, followed by bone fragments. Collagen assay demonstrated the presence of collagen in similar concentrations in all 3 preparations. CONCLUSIONS: Bone dust has most of the necessary components for osteogenesis, including the presence of osteoprogenitor cells that have the ability to lay down collagen type 1 and deposit calcium and can differentiate to form bone. Further studies that can accurately quantify the percentage of surviving osteoblasts in various bone components are needed.

Evaluation of polymethylmethacrylate adhesion: a comparison of direct onlay versus screw anchoring techniques.

UNLABELLED: Polymethylmethacrylate (PMMA) is still the most frequently used alloplastic material for calvarial reconstruction, especially when dealing with large bony defects. It is strong, provides good protection to the underlying cerebral structures, and is stable and minimally reactive. One of the disadvantages of this material is its tendency to become loose over time because of its poor adherence to bone. Onlay miniscrews in improving PMMA's adhesion to bone have been previously proposed. A series of experiments were conducted to evaluate whether placement of screw anchors will significantly improve the adhesion force between the polymer and bony surface. METHODS: Four fresh-frozen cadaver heads were used for this experiment. The PMMA preparation and setup time strictly followed manufacturer guidelines. Two experimental groups were created: (1) PMMA was placed on the subperiosteal bony surface with increasing surface areas (areas: 1-20 cm2), and (2) a standard area of 16 cm2 PMMA was placed on the bony surface with an increasing number of titanium miniscrews (number of screws: 0-5). The force required to separate the material from the underlying bone was assessed using a digital pull force gauge (Imada DPS-44) through vertical traction. The experiments were undertaken in triplicate; the results were statistically analyzed using Student t test. RESULTS: Experiment 1: increasing forces were required as the surface area of PMMA application increased (1.2-42.3 N). The most consistent measurements with a low SD were obtained on the 16-cm2 implant, which was chosen for experiment 2. A 16-cm2 area would allow for the placement of up to 5 screws without technical difficulty. Experiment 2: higher forces were needed to detach the material, with increasing screw placement (1, 79; 2, 132.5; 3, 194.2; and 4 and 5, >196.1 N). In 73 of 75 experiments, the screws remained attached to the PMMA after separation. When the PMMA alone on a 16-cm2 surface area was compared with the placement of one or more screws, the force of adhesion significantly increased for all groups (P < 0.01). There was a 2.6x increase in this force with 1 screw, 4.4x with 2, 6.4x with 3, and 6.5x with 4 or more screws. Three or more miniscrews provided sufficient stabilization to anchor an implant firmly in place while resisting large traction forces. CONCLUSION: Although greater surface areas of PMMA will increase the adhesion force between the polymer and bone, a clinically and statistically significant increase in this force may only be achieved with the use of miniscrews.