A randomised clinical trial to study postoperative abdominal and shoulder tip pain following low and standard pressure laparoscopic cholecystectomy.

Background: Laparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP). Methods: The present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques. Results: The demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%). Conclusions: Low-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

Development of a portfolio framework for implementation of an outcomes-based healthcare professional education curriculum using a modified e-Delphi method.

BACKGROUND: The explicit declaration of Entrustable Professional Activities (EPA) and milestones are an essential component of a competency based medical education curricula. The present study attempts to develop a portfolio framework to document them for adaptation in any healthcare professional education curriculum development. METHODS: A modified e-Delphi method was used after incorporation of a study group of medical education experts (MEDEX-G). Consensus was defined as 75% agreement. Both qualitative and quantitative data was collected and analysed to conduct three rounds of the Delphi. RESULTS: The draft template was prepared by the core faculty of medical education centre. The final template was approved by the experts after 03 iterations of anonymous online voting and presentation of summary results by the moderator. The final template lists out the milestones of each EPA separately with provision for expected expertise and level, suggestive teaching learning activities and assessments, reflections by the students and feedback by facilitator for each EPA. CONCLUSION: The MEDEX-G consensus template is an important development to encourage the adoption of portfolios in a competency based medical education curriculum. It can be freely adopted by various healthcare professional education bodies in various disciplines.

Superficial Temporal Artery Aneurysm in a Helicopter Pilot Operating at High Altitude.

BACKGROUND: Spontaneous aneurysm of the superficial temporal artery in a helicopter pilot while operating in the extreme cold climatic conditions of a very high altitude area led to a thorough search for etiological possibilities related to this case.CASE REPORT: A 38-yr-old military helicopter pilot, while flying at altitudes ranging from 4500 m to 6000 m (15,000 to 20,000 ft) reported with an acute onset of a subcutaneous swelling on his left temple. History and clinical profile did not suggest any traumatic, hematologic, or vasculitic etiology. His inflammatory markers, anti-nuclear antibody, anti-neutrophil cytoplasmic antibodies, complement levels, and whole-body PET scan did not suggest any evidence of vasculitis. Presence of any other intracranial aneurysms was also ruled out. He underwent curative excision biopsy, which showed perivascular inflammation. He was diagnosed as a case of left superficial temporal artery aneurysm. The recovery period was uneventful and the follow-up color Doppler flow imaging of the temporal artery and acute phase reactants was normal.DISCUSSION: Spontaneous aneurysms involving the superficial temporal artery is a very rare diagnosis. Occurrence of such an aneurysm in a young pilot without any identifiable predisposing factors led the authors to hypothesize a possible etiological combination of environmental and mechanical factors along with aviation stresses with the likely compounding role of the helmet. Management and aeromedical aspects of this unique case are discussed in this paper.Sekhar BM, Sheoran S, Routh D, Sharma S. Superficial temporal artery aneurysm in a helicopter pilot operating at high altitude. Aerosp Med Hum Perform. 2019; 90(1):53-57.

A study on outcome of binding pancreaticogastrostomy following pancreaticoduodenectomy: A prospective observational study.

INTRODUCTION: The type of anastomosis of the pancreas following pancreaticoduodenectomy is often attributed to the reason for pancreatic leak. Results of various randomized trials comparing pancreaticojejunostomy and pancreaticogastrostomy are conflicting one suggesting advantage over the other and vice versa. In this study we intend to critically analyze a novel technique of binding pancreaticogastrostomy following pancreaticoduodenectomy. AIMS AND OBJECTIVES: The aim of this study is to see the outcome of binding pancreaticogastrostomy by evaluating the technical aspects of binding PG and study the incidence of post-operative complications. MATERIALS AND METHODS: The study included all patients who had undergone binding pancreaticogastrostomy from Mar 2012 to Mar 2016 at a tertiary care hospital. Patients' data, including patients demographics, type of procedure performed, complications, mortality, hospital stay, postoperative interventional procedures or reoperations were all documented. RESULTS: There were 60 men and 37 women (mean age was 55.4 ±â€¯11.6 years) with a mean BMI of 22.6 Kg/M2. 16% of the patients had evidence of cholangitis and 14 of them had to be stented preoperatively. Ninety-four percent of the patients were operated for malignant cause of obstructive jaundice. The mean operative time was 283 min s and average blood loss during surgery was 352 ml. 36% of the patients were operated by the senior residents undergoing training in Gastro intestinal surgery with the assistance of the available faculty. 60% of the patients had a pancreatic duct diameter less than 3 mm. 72% of the pancreatic stump were soft in consistency. In our study we had 3% patients with pancreatic leak. The most frequent complication was DGE, which was seen in 22% patients. The mean duration of DGE was 13.5 ±â€¯2.6 days. We had 2 deaths within 30 days of surgery of which one was due to massive intraabdominal bleed due to pancreatic leak. None of the parameters like pre-operative and operative parameters like age, bilirubin, total leucocyte count, preoperative stenting, pancreatic duct diameter, texture of pancreas and surgery performed by residents were found to be responsible for pancreatic leak. CONCLUSION: This novel method of binding PG is simple, secure, and reproducible. It possesses several advantages over the conventional PG: it is very easy to perform, it is less traumatic to the pancreatic stump, can be performed in all types of pancreatic stump irrespective of the texture and diameter of the pancreatic duct without any statistically significant adverse outcomes.

Comparison of outcomes in ideal donor and extended criteria donor in deceased donor liver transplant: a prospective study.

INTRODUCTION: The number of patients who could benefit from liver transplantation markedly exceeds the number of available donors. This increasing gap has fuelled efforts to maximize existing donor pool and identify new avenues. AIMS AND OBJECTIVES: To compare the outcome in deceased donor liver transplant (DDLT) based on extended donor selection criteria. MATERIALS AND METHODS: Donor and recipients' data were analyzed following DDLT from Mar 2007 to Feb 2013. Donors were grouped into either ideal donor (ID) or extended criteria donor (ECD) based on donor and graft related characteristics. Primary nonfunction (PNF) and patient survival were the primary endpoints while early graft dysfunction (EGD) and incidence of major postoperative complications were the secondary endpoints of the study. RESULTS: We had a total of 6 mortalities (13%) at the end of 1 year. The Kaplan Meier survival analysis at 7 days, 3, 6 and 12 months were not statistically different (p > 0.05). PNF occurred in three (6.5%) patients and was not significantly different nor influenced by cumulative number of risk factors in the subgroup analysis (p < 0.3). However, the incidence of EGD was significantly influenced by the cumulative number of risk factors (p < 0.005). A total of 12 (26.1%) patients were graded with 3 or more complications according to the 'Clavien Dindo Grade' for major post operative complications, although it did not reach a statistical significance in the various subgroups. Univariate analysis of the donor risk factors showed that none of these factors were predictive for PNF and mortality in deceased donor liver transplant recipients. CONCLUSION: Although the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.

Changing pattern of donor selection criteria in deceased donor liver transplant: a review of literature.

During the last couple of decades, with standardization and progress in surgical techniques, immunosuppression and post liver transplantation patient care, the outcome of liver transplantation has been optimized. However, the principal limitation of transplantation remains access to an allograft. The number of patients who could derive benefit from liver transplantation markedly exceeds the number of available deceased donors. The large gap between the growing list of patients waiting for liver transplantation and the scarcity of donor organs has fueled efforts to maximize existing donor pool and identify new avenues. This article reviews the changing pattern of donor for liver transplantation using grafts from extended criteria donors (elderly donors, steatotic donors, donors with malignancies, donors with viral hepatitis), donation after cardiac death, use of partial grafts (split liver grafts) and other suboptimal donors (hypernatremia, infections, hypotension and inotropic support).