147 Pancreatoduodenectomies: a Single Center's Perspective into the Epidemiology and Surgical Outcomes of Periampullary and Pancreatic Cancers in South India.

BACKGROUND: Pancreatoduodenectomy (PD) is the only curative procedure for resectable periampullary cancers. This study aims to survey the various outcome variables of the procedure at our institute, which is in the early process of evolving into a high-volume center for PDs. METHODS: Data of patients, who underwent PDs, was collected retrospectively from January 2010 to December 2017 and prospectively from January 2018 to December 2019. Various preoperative, intraoperative, and histopathological parameters were compared with the outcome variables-morbidity and mortality rates. RESULTS: A total of 147 patients underwent PDs over the last decade. From January 2010 to December 2014 (period A), 29 patients underwent PD, while 118 patients underwent PD from January 2015 to December 2019 (period B). Clinically relevant (CR) delayed gastric emptying (44.8% vs 23.7%), CR post-pancreatectomy hemorrhage (37.9% vs 18.6%), and blood loss (850 ml (400-5300 ml) vs 600 ml (150-2500 ml)) improved in period B with no improvement in CR postoperative pancreatic fistula (20.7% vs 28.8%). The rates of SSI (63.6%), pulmonary complications (29.9%), and mean postoperative stay (19.87 ± 11.59 days) were found to be higher than most of the major centers. Mortality rates decreased significantly from 27.6% in period A to 10.2% in period B (p = 0.029). Median overall survival was 30 months (95% CI 20.76-39.23 months) CONCLUSION: Over the last decade, there has been a significant improvement in the mortality rate, but morbidity remains high and must be looked into as the department enters the new decade as a young high-volume center.

Pathogenic potential of Parabacteroides distasonis revealed in a splenic abscess case: a truth unfolded.

Splenic abscess is a rare entity, however if unrecognised or left untreated, it is invariably fatal. We herein report a case of splenic abscess in a 40-year-old man presenting with fever, left-sided abdominal pain, altered sensorium and vomiting. On clinical examination, hepatosplenomegaly was noted and the ultrasound of the abdomen showed multiple hypoechoic regions in the upper pole of spleen, and the diagnosis of splenic abscess was made. The patient received antimicrobial therapy and underwent an open splenectomy with full recovery. Pus aspirated from the splenic abscess grew an unusual organism named Parabacteroides distasonis In the literature, there are only a few recorded cases of P. distasonis causing splenic abscess. Through this case report, we would like to emphasise the pathogenic role of P. distasonis in causing clinical disease, as this organism is typically known to constitute a part of the normal flora.

Polidocanol versus phenol in oil injection sclerotherapy in treatment of internal hemorrhoids: A randomized controlled trial.

BACKGROUND/AIMS: Management of Haemorrhoids is suboptimal and is largely based on traditional practices in the Indian population. Though injection sclerotherapy is a well-accepted treatment modality in early grade haemorrhoids, there is no consensus on the effectiveness of the drugs used for sclerotherapy. The study was done to compare the safety and efficacy of a standard sclerosant (polidocanol) and the conventionally used phenol in oil in bleeding grade-1 and 2 internal haemorrhoids. MATERIALS AND METHODS: All patients with grade-1 and 2 hemorrhoids, were selected and randomised into two groups, 3% polidocanol and 5% phenol group. All patients were followed-up for three months and observed for "free of bleeding" or "persistent bleeding." Pain, pruritus and patient satisfaction following the procedure was also assessed. RESULTS: A total of 150 patients were enrolled, 75 in each group. At the end of the first sclerotherapy session with polidocanol, 60.6% of patients versus 38.1% in phenol group had stopped per rectal bleeding (p=0.009). After the second sclerotherapy session, 94.7% of patients in the polidocanol group and 84% of patients in the phenol group were treated successfully. Polidocanol group required significantly fewer treatment sessions than the phenol group (1.39±0.49 vs. 1.62±0.49; p=0.035), and the total volume of injected sclerosant was also less (3.30±0.96 mL vs. 4.86±1.46 mL; p=0.001). The patient satisfaction was 87% in polidocanol group versus 73% in phenol group (p=0.040). CONCLUSION: 3% polidocanol is safe and more effective than 5% phenol in oil when used as injection sclerotherapy in the treatment of first and second-degree internal hemorrhoids.

Efficacy and Feasibility of Objective Structured Clinical Examination in the Internal Assessment for Surgery Postgraduates.

INTRODUCTION: Traditionally assessment in medical training programs has been through subjective faculty evaluations or multiple choice questions. Conventional examinations provide assessment of the global performance rather than individual competencies thus making the final feedback less meaningful. The objective structured clinical examination (OSCE) is a relatively new multidimensional tool for evaluating training. This study was carried out to determine the efficacy and feasibility of OSCE as a tool for the internal assessment of surgery residents. METHODS: This study was carried out on the marks obtained by surgery residents at different levels of training in a single tertiary center in India over the 4 OSCEs conducted in the years 2015 and 2016. The marks of the OSCE were collected from the departmental records and analyzed. Reliability was calculated using internal consistency using Cronbach's α. Validity was calculated by item total correlation. Content validation was done by obtaining expert reviews from 5 experts using a proforma, to assess the content and checklist of each station of the OSCE. RESULTS: A total of 49 surgery residents were assessed in small batches during the above mentioned period. Of the 4 OSCEs conducted by us, 3 had a high value of Cronbach's α of greater than 0.9, as opposed to the set standard of 0.7. Out of 23 stations used in the 4 examinations separately, only 3 stations were found to have a low correlation coefficient (item total correlation), and hence, a low validity. The remaining 20 stations were found to have a high validity. Expert review showed unanimous validation of the content of 17 out of the 23 stations, with few suggestions for change in the remaining 6 stations. The material and manpower used was minimal and easy to obtain, thus making the OSCE feasible to conduct. CONCLUSION: OSCE is a reliable, valid. and feasible method for evaluating surgery residents at various levels of training.

Retrograde jejunogastric intussusception following Braun's jejunojejunostomy.

Jejunogastric intussusception is a rare long term complication of Billroth II gastrectomy. The case reported here is a 50 year old man with history of a Billroth II gastrectomy and Braun's side-to-side jejunojejunal anastomosis who presented with hematemesis. On abdominal examination, there was a mass in the left iliac fossa. Computed tomography scan showed a retrograde jejunogastric intussusception across the gastrojejunostomy. On laparotomy, a retrograde intussusception of the distal jejunum through the jejunojejunal anastomosis and across the gastrojejunostomy with a gangrenous intussusceptum was found. The jejunojejunal anastomosis was taken down, the gangrenous segment was resected and bowel continuity was restored with two jejunojejunal anastomoses, proximal and distal to the gastrojejunostomy. The gastrojejunostomy was preserved. This case brings out an unusual type of retrograde gangrenous intussusception which occurred at two points of a previous anastomosis, i.e., jejunojejunostomy and gastrojejunostomy simultaneously, which could be managed with jejunal resection.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori.

AIM: To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT). METHODS: Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up. RESULTS: Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00. CONCLUSION: H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.