ABSTRACT
Background Enhanced recovery after surgery (ERAS) protocols are nowadays considered the standard of care for various elective surgical procedures. However, its utilization remains low in tier-two and tier-three cities of India, and there exists a significant variation in the practice. In the present study, we have investigated the safety and feasibility of these protocols or pathways in emergency surgery for perforated duodenal ulcer disease. Methods A total of 41 patients with perforated duodenal ulcers were randomly divided into two groups. All the patients across the study were treated surgically with the open Graham patch repair technique. Patients in group A were managed with ERAS protocols, while patients in group B were managed with conventional peri-operative practices. A comparison was established between the two groups in terms of the duration of hospital stay and other postoperative parameters. Results The study was conducted on 41 patients who presented during the study period. Group A patients (n=19) were managed with standard protocols, and group B patients (n=22) were managed with conventional standard protocols. As compared to the standard care group, patients in the ERAS group showed quicker postoperative recovery and lesser complications. The need for nasogastric (NG) tube reinsertion, postoperative pain, postoperative ileus, and surgical site infections (SSI) were all significantly lower in the patients of the ERAS group. A significant reduction in the length of hospital stay (LOHS) was found in the ERAS group when compared to the standard care group (relative risk {RR}=61.2; p=0.000). Conclusions The application of ERAS protocols with certain modifications in the management of perforated duodenal ulcers yields significant outcomes in terms of reduced duration of hospital stay and fewer postoperative complications in a selected subgroup of patients. However, the application of ERAS pathways in an emergency setup needs to be further evaluated to develop standardized protocols for a surgical emergency group of patients.
ABSTRACT
Background Ventral hernias are commonly encountered problems in the field of general surgery. Incisional hernia is a common complication following abdominal surgery that requires reoperation. This study was conducted to understand the incidence of various types of ventral hernia in both sexes and various age groups, predisposing factors, clinical features, and complications. Methods This prospective observational study was conducted in the Department of Surgery, Dr. Hedgewar Hospital, Aurangabad, Maharashtra, India, on a total of 100 patients diagnosed with anterior abdominal wall hernia between September 2020 to February 2021. Data collection included thorough history taking and clinical examination along with relevant investigations. The data collected was entered in a proforma, tabulated, and analyzed with the IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States). Results Incisional hernia (43%) was the most common of all ventral hernias. Females were much more affected than males. Out of these types studied, epigastric hernia showed more incidence among males. The average age of presentation was 52 years. Obesity was the most common predisposing factor (34%) with female preponderance. Obese patients were also associated with a higher rate of postoperative complications like wound infection and seroma. In the cases of incisional hernia, 32.6% of the patients gave a history of previous surgery complicated by a wound infection. Incisional hernias were more common in lower midline incisions (34.9%) and after gynecological surgery (55.81%) like total abdominal hysterectomy, cesarean section, or tubal ligation. In the majority of the patients (62.8%), the incisional hernia occurred within three years of the previous surgery. Wound infection following ventral hernia repair occurred in 11% of the cases, wound dehiscence in 3%, and seroma in 2 % of the cases. Conclusions The most common ventral hernias in decreasing order of their frequency are incisional hernia, umbilical hernia, para-umbilical hernia, and epigastric hernia. Epigastric and umbilical hernias are more common in males whereas incisional hernia is more common in females. Obesity and constipation were found to be the major predisposing risk factors. Incisional hernia is more common in females after gynecological and obstetrics surgery. The lower midline segment is the most common site for developing an incisional hernia.
ABSTRACT
Pilomatrixoma is a benign adnexal skin tumor involving the hair follicle matrix. It is found in children, predominantly involving the face. We report here an interesting and rare case of a 52-year-old male presenting with a large, firm, and painless mass over the scrotum considered to be a sebaceous cyst. The mass was completely excised and a biopsy report revealed it to be a pilomatrixoma of the scrotum. The patient recovered well postoperatively with no recurrence over two years.
ABSTRACT
STUDY QUESTION: Does a differential abundance of high mobility group box 1 (HMGB1) protein in uterine fluid (UF) have a functional significance? SUMMARY ANSWER: In rats, an excess of HMGB1 in UF during the receptive phase is detrimental to pregnancy. WHAT IS KNOWN ALREADY: The identification of constituents of the human uterine secretome has been a subject of renewed interest, due to the advent of high throughput proteomic technologies. Proteomic-based investigations of human UF have revealed the presence of several proteins such as mucins, host defense proteins S100, heat shock protein 27 and haptoglobin, etc. The present study reports on the presence of HMGB1, a nuclear protein, in human UF. Activated macrophages/monocytes, natural killer cells, mature dendritic cells, pituicytes and erythroleukemic cells are also known to secrete HMGB1. Existing data suggest that extracellular HMGB1 plays a role in inflammation. STUDY DESIGN, SIZE, DURATION: The human part of this study was cross-sectional in design. UF and endometrial tissues were collected from regularly cycling women in the early secretory (i.e. pre-receptive phase, Day 2 post-ovulation, n = 7) or secretory phase (i.e. receptive phase, Day 6 post-ovulation, n = 7) of their menstrual cycles. Samples were also collected from cycling rats in the proestrous (n = 8) or metestrous (n = 8) phase of their estrous cycles. Uteri were also collected from HMGB1-treated pregnant (n = 7) and untreated pseudo-pregnant (n = 7) rats and from pregnant rats at Day 3-5 post-coitum (p.c.) (n = 18, 3 each for six-time points). PARTICIPANTS/MATERIALS, SETTING, METHODS: In each group of human samples, four samples were used for isobaric tag for relative and absolute quantification (iTRAQ) analysis and three samples were used for immunoblotting experiments to determine the abundance of HMGB1 in pre-receptive and receptive phase UF samples. HMGB1 levels in rat UF and endometrial tissue samples were estimated by ELISA and immunohistochemical studies, respectively. The expression of inflammation-associated molecules, such as nuclear factor kappa B (NFκB), receptor for advanced glycation end products (RAGEs), tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6), was analyzed by immunohistochemistry in HMGB1-treated and pseudo-pregnant rats. MAIN RESULTS AND THE ROLE OF CHANCE: HMGB1 was identified as one of the differentially abundant proteins in the list generated by 8-plex iTRAQ analysis of receptive and pre-receptive phase UF samples. In both humans and rats, secreted and cellular levels of HMGB1 showed a similar pattern, i.e. significantly (P < 0.05) lower abundance in the receptive phase compared with that in the pre-receptive phase. A significant (P < 0.05) decline was also observed in the endometrial expression of HMGB1 on the day of implantation in pregnant rats. Exogenous administration of recombinant HMGB1, on Day 3 p.c., led to pregnancy failure, whereas administration of recombinant leukemia inhibitory factor or saline had no effect on pregnant rats. Further investigations revealed morphological changes in the endometrium, an increase in the expression of luminal epithelial NFκB and significantly (P < 0.05) higher expression levels of endometrial RAGE, TNF-α and IL-6 in HMGB1-treated rats, compared with untreated pseudo-pregnant rats. LIMITATIONS, REASONS FOR CAUTION: The mechanisms, contributing to a decline in the cellular and extracellular levels of HMGB1 during the receptive phase, remain to be ascertained. WIDER IMPLICATIONS OF THE FINDINGS: An excess of HMGB1 in the UF may be associated with infertility in women.
