Chronic abdominal wall sinus secondary to missed spilled gallstones in laparoscopic cholecystectomy: a harrowing experience.

Gallbladder perforation with spillage of gallstones is not uncommon during laparoscopic cholecystectomy. Stone spillage can cause several complications. We report a case of recurrent discharging sinuses on the right back 4 years after laparoscopic cholecystectomy in a 44-year-old female patients. She suffered for 9 years to undergo empirical treatment for suspected tuberculosis, including repeated attempts at sinus tract excision done at different hospitals. We did a computed tomography sinogram, which revealed the tract extending from the right flank into a cavity in the right subpleural space. We proceeded with the sinus tract excision which extended between the tips of the 10th and 11th ribs, spreading to the right subpleural space where pus mixed with multiple gall stones were retrieved. Spilled stones may result in complications, making diagnosis difficult and seriously harming the patient physically, mentally, and economically. The need for accurate documentation and patient knowledge of missing gallstones cannot be understated.

Comparison of surgical site infection (SSI) between negative pressure wound therapy (NPWT) assisted delayed primary closure and conventional delayed primary closure in grossly contaminated emergency abdominal surgeries: a randomized controlled trial.

PURPOSE: NPWT has been tried in many surgical fields, including colorectal, thoracic, vascular, and non-healing wounds, for the prevention of SSI. However, its efficacy in the prevention of SSI-grade IV closed abdominal wounds is yet to be explored. METHODS: All patients with grade IV abdominal wounds were included in the study. They were randomized into the conventional arm and the VAC arm after confirming the diagnosis intra-operatively. The sheath was closed, and the skin was laid open in the postoperative period. In the VAC arm, the NPWT dressing was applied on postoperative day (POD)-1 and removed on POD-5. In the conventional arm, only regular dressing was done postoperatively. The skin was closed with a delayed primary intention on POD-5 in both arms. The sutures were removed after 7 to 10 days of skin closure. RESULTS: The rate of SSI (10% in the VAC arm vs. 37.5% in the conventional arm, p-value = 0.004) was significantly lower in the VAC arm, as were the rates of seroma formation (2.4% in the VAC arm vs. 20% in the conventional arm, p = 0.014) and wound dehiscence (7.3% vs. 30%, p = 0.011). The conventional arm had a significant delay in skin closure beyond POD5 due to an increased rate of SSI, which also led to a prolonged hospital stay (5 days in the VAC arm vs. 6.5 days in the conventional arm, p-value = 0.005). CONCLUSION: The VAC dressing can be used routinely in grade IV closed abdominal wounds to reduce the risk of SSI and wound dehiscence.

Statins abrogate gemcitabine-induced PD-L1 expression in pancreatic cancer-associated fibroblasts and cancer cells with improved therapeutic outcome.

A combination of chemotherapy with immunotherapy has been proposed to have better clinical outcomes in Pancreatic Ductal Adenocarcinoma (PDAC). On the other hand, chemotherapeutics is known to have certain unwanted effects on the tumor microenvironment that may mask the expected beneficial effects of immunotherapy. Here, we have investigated the effect of gemcitabine (GEM), on two immune checkpoint proteins (PD-L1 and PD-L2) expression in cancer associated fibroblasts (CAFs) and pancreatic cancer cells (PCCs). Findings of in vitro studies conducted by using in-culture activated mouse pancreatic stellate cells (mPSCs) and human PDAC patients derived CAFs demonstrated that GEM significantly induces PD-L1 and PD-L2 expression in these cells. Moreover, GEM induced phosphorylation of STAT1 and production of multiple known PD-L1-inducing secretory proteins including IFN-γ in CAFs. Upregulation of PD-L1 in PSCs/CAFs upon GEM treatment caused T cell inactivation and apoptosis in vitro. Importantly, Statins suppressed GEM-induced PD-L1 expression both in CAFs and PCCs while abrogating the inactivation of T-cells caused by GEM-treated PSCs/CAFs. Finally, in an immunocompetent syngeneic orthotopic mouse pancreatic tumor model, simvastatin and GEM combination therapy significantly reduced intra-tumor PD-L1 expression and noticeably reduced the overall tumor burden and metastasis incidence. Together, the findings of this study have provided experimental evidence that illustrates potential unwanted side effects of GEM that could hamper the effectiveness of this drug as mono and/or combination therapy. At the same time the findings also suggest use of statins along with GEM will help in overcoming these shortcomings and warrant further clinical investigation.

Impact of personal protective equipment on patient safety and health care workers.

Background: The study aims to assess the effect of personal protective equipment (PPE) on the physical and psychological well-being of health care workers (HCWs) and its impact on patient safety. Methods: After ethical approval, a 14-point questionnaire was circulated offline and online among the HCWs of ours institute, who were involved in performing invasive procedures while wearing a PPE. The responses were analysed using the SPSS software version 26. Results: Of 198 responses, the mean duration of PPE use was 4.6 ± 1.52 h. Seventy percent of respondents suggested <4 h of continuous use of PPE. Seventy-seven percent found difficulties during the procedures while wearing PPE and agreed to errors while performing a procedure. Poor visibility (95.5%), fogging (84.9%), communication difficulty (75.3%), sweating (74.2%), posture-related discomfort (56.1%) and poor concentration (51%) were major causes. Anxiety (39.9%) and fear of spreading an infection to the family (42.9%) were major psychological effects. Eighty percent of HCWs raised concern over the quality of PPE, N95 mask and eye protector. The HCWs felt the need to improve the quality of PPEs, use extra padding around the ears, sealing the N95 mask with adhesive tape, besides using sign language for communication for more safety. Fifty percent graded the procedure-related difficulty level >6 on a Likert scale of 1-10. Conclusion: PPE-related discomfort is common among the HCWs and could contribute to errors during an invasive procedure. Efforts to alleviate the physical and psychological well-being of the HCWs will be essential for reducing procedural error while wearing a PPE.

On-demand (SOS) analgesia through Transversus Abdominis Plane (TAP) catheter route for post-operative pain relief in Emergency Laparotomies-a non-randomised interventional study (STAPLE trial).

INTRODUCTION: This study aimed to compare the efficacy and safety of on-demand bupivacaine infusion via transversus abdominis plane (TAP) catheter in emergency laparotomy patients. METHODS: A non-randomised interventional study was conducted on patients undergoing emergency midline laparotomy. The intervention group received an on-demand infusion of 10 ml 0.5% bupivacaine through TAP catheters, whilst the control group received standard analgesic care. The primary outcome was the amount of rescue analgesic consumption. Secondary outcomes included the post-operative, measured by visual analogue scores (VAS), side effects, time to first flatus, post-operative nausea and vomiting, and pulmonary complications. RESULTS: One-hundred-twenty patients (58 in the TAP-SOS group, 62 in the control group) were included in the final analysis. The TAP-SOS group showed significantly reduced rescue analgesic requirement by 91% (p < 0.001) and lower VAS scores at 3, 6, 12, and 24 h (adjusted p < 0.00). Time to out-of-bed mobilisation was significantly shorter in the TAP-SOS group by 12.47 h (p < 0.001), and post-operative pulmonary complications were lower by 75% (p < 0.05). There were no significant differences in bowel recovery, catheter-related complications, or post-operative morbidity. No incidences of catheter-site infection were reported on follow-up; however, the catheter tip-culture was positive in 3 (5.17%) patients. CONCLUSION: On-demand bupivacaine infusion through a TAP catheter effectively reduced post-operative pain and opioid requirements in emergency laparotomy patients without complications. If an epidural is not an option, the TAP-SOS approach can be a helpful adjunct in implementing the ERAS protocol in an emergency since it allows for early ambulation and better pain management.

Comparison of laparoscopic port site skin closure techniques (CLOSA): transcutaneous suturing versus subcuticular sutures versus adhesive strips: a prospective single-blinded randomized control trial.

BACKGROUND: Cosmesis is an essential aspect of laparoscopic surgery. Various methods of skin closure techniques have been described. We conducted a study to evaluate the cosmesis and patient satisfaction with the scars three months after laparoscopic surgery using transcutaneous suture (TS) vs. adhesive strips (AS) and subcuticular suturing (SS). METHODS: A randomized, controlled, prospective study was conducted at AIIMS, Bhubaneswar. The included patients were randomly assigned among the three arms. The time for skin closure was measured. Wounds were assessed till discharge, at 14 days, one month, and three months. Cosmesis was measured by the Hollander Wound evaluation scale (HWES) for each incision separately, and patient satisfaction by a 10- point Visual analog scale (VAS). RESULTS: One hundred six patients were assessed for eligibility, and 90 patients were randomized. Three-month follow-up data was obtained from 83 patients (92.22%). Baseline characteristics were similar among the groups. Cosmetic outcome was assessed in 312 incisions across 83 patients, and 206 (66.03%) incisions had an HWE Score of 0, but there was no significant difference (p = 0.86). Patient satisfaction was highest in the TS group (TS = 1.29, SS = 1.79, AS = 2.04, p = 0.03). Time for skin closure was the least in the AS arm (41.4 secs, p = 0.00). Skin dehiscence was significantly more in the AS arm. Four (4.44%) patients had port site infections. CONCLUSION: This study demonstrates that skin closure by transcutaneous, subcuticular, or adhesive strip methods had comparable cosmetic outcomes at three months. However, the transcutaneous closure method showed better patient satisfaction and minimal post-operative complications.

Surgical Site Infections in Patients of Periampullary Carcinoma Undergoing Delayed Bile Duct Division (COMBILAST) in Whipple's Procedure: A Prospective Cohort Study.

Surgical site infections (SSIs) following a pancreaticoduodenectomy have been a significant cause of morbidity and even mortality. A modified sequence of the Whipple procedure, using the COMBILAST technique, may reduce SSIs and the patient's hospital stay. This prospective cohort study included 42 patients undergoing Whipple's pancreaticoduodenectomy for a periampullary malignancy. The modified sequence pancreaticoduodenectomy technique, COMBILAST, was used to estimate the incidence of SSI and explore other advantages. Of the 42 patients, seven (16.7%) developed superficial SSIs, and two patients (4.8%) had an additional deep SSI. Positive intraoperative bile culture had the strongest association with SSI (OR: 20.25, 95% CI: 2.12, 193.91). The mean operative duration was 391.28 ± 67.86 min, and the mean blood loss was 705 ± 172 mL. A total of fourteen (33.3%) patients had a Clavien-Dindo grade of III or higher. Three (7.1%) patients died of septicemia. The average length of a hospital stay was 13.00 ± 5.92 days. A modified sequence of the Whipple procedure, using the COMBILAST technique, seems promising in reducing SSIs and the patient's hospital stay. As the approach is only a modification of the operative sequence, it does not compromise the oncological safety of the patient. Moreover, it has an added surgical advantage in reducing the chance of injury to the aberrant or accessory right hepatic artery.

Ligation of Intersphincteric Fistulous Tract vs Endorectal Advancement Flap for High-Type Fistula in Ano: A Randomized Controlled Trial.

BACKGROUND: This study aimed to compare the postoperative outcomes and success rate of the endorectal advancement flap and ligation of intersphincteric fistulous tract (LIFT) in high-type fistula in ano. STUDY DESIGN: This randomized control trial included patients with high-type fistula in ano of cryptoglandular origin. The primary endpoint was complete fistula healing at the end of 6 months. However, the patients were followed up for 2 years. Other parameters studied were perioperative complications, duration of surgery, postoperative pain, hospital stay in hours, continence, and quality of life at 6 months. RESULTS: A total of 84 patients were recruited (42 in each group). The healing rate in the LIFT arm was better than that in the endorectal advancement flap arm (76.2.% vs 54.7%, p = 0.039). Four patients in the endorectal advancement flap group and two in the LIFT group had flatus incontinence at the end of 6 months, but all were continent at 2 years. At the end of the first week, the Visual Analog Scale score and quality of life at 6 months were better in the LIFT arm (3.7 ± 1.16 vs 4.7 ± 0.81 and 0.7 vs 0.6, p < 0.05). The mean duration of surgery was significantly less in the LIFT group (46.43 ± 9.32 vs 89.29 ± 10.90 minutes). None had any postoperative complications, and >80% were discharged within 24 hours. CONCLUSIONS: The shorter operative duration, better quality of life at 6 months, and higher healing rate make LIFT a superior treatment option for high fistula in ano. However, studies with a large sample size will be needed to verify these results.

Laparoscopic excision of a large adrenal pseudocyst: diagnostic dilemma and technical challenges.

A woman in her 40s attended the hospital with worsening left upper abdominal dull aching pain for the past 6 months. Clinical examination and radiological investigations with ultrasonography and contrast-enhanced CT of the abdomen confirmed it to be a cystic lesion of the left adrenal of size 13 cm × 12 cm × 11 cm. With the possibility of an incidental malignancy due to large size, laparoscopic cyst excision meticulously without spillage of cyst content was possible due to preoperative planning. It was a difficult task to mobilise the cyst intact due to the thin wall to prevent accidental rupture and gross spillage of the cyst contents. The cyst wall sent for histopathological examination confirmed it to be an adrenal pseudocyst without any malignant focus. Adrenal pseudocysts are rare and mostly benign. However, the index of suspecting a malignancy should be high in large cysts, and meticulous dissection is warranted.

MIF confers survival advantage to pancreatic CAFs by suppressing interferon pathway-induced p53-dependent apoptosis.

The presence of activated pancreatic stellate cells (PSCs) in the pancreatic ductal adenocarcinoma (PDAC) microenvironment plays a significant role in cancer progression. Macrophage migration inhibitory factor (MIF) is overexpressed in PDAC tissues and expressed by both cancer and stromal cells. The pathophysiological role of MIF in PDAC-associated fibroblasts or PSCs is yet to be elucidated. Here we report that the PSCs of mouse or cancer-associated fibroblast cells (CAFs) of human expresses MIF and its receptors, whose expression gets upregulated upon LPS or TNF-α stimulation. In vitro functional experiments showed that MIF significantly conferred a survival advantage to CAFs/PSCs upon growth factor deprivation. Genetic or pharmacological inhibition of MIF also corroborated these findings. Further, co-injection of mouse pancreatic cancer cells with PSCs isolated from Mif-/- or Mif+/+ mice confirmed the pro-survival effect of MIF in PSCs and also demonstrated the pro-tumorigenic role of MIF expressed by CAFs in vivo. Differential gene expression analysis and in vitro mechanistic studies indicated that MIF expressed by activated CAFs/PSCs confers a survival advantage to these cells by suppression of interferon pathway induced p53 dependent apoptosis.

Lithotomy versus prone position for perianal surgery: a randomized controlled trial.

PURPOSE: Studies objectively comparing lithotomy and prone positions regarding surgeon comfort, ergonomics, patient comfort, and position related complications are scarce. METHODS: The patients posted for surgery of either fistula in ano, hemorrhoids, or were included in this study. Subjective Mental Effort Questionnaire (SMEQ) and Local Experienced Discomfort (LED) scale were used to score the level of mental and physical stress among the operating surgeon, assistants, and the scrub nurse. Other parameters studied were the exposure of the operative site, patient comfort level, and position-related complications. RESULTS: Thirty patients were operated in each position. Mean±standard deviation of jackknife prone vs. lithotomy surgeon SMEQ score (15.6±10.4 vs. 107.0±11.5, P<0.05) and LED score (1.8±1.5 vs. 6.7±0.5, P<0.05) were found to be statistically significant. Prone vs. lithotomy assistant SMEQ score (29.1±13.1 vs. 100.6±8.7, P<0.05) and LED score (4.6±1.1 vs. 7.4±0.8, P<0.05) were also found to be statistically significant. SMEQ (10.0±0.0 vs. 20.6±2.5, P<0.05) and LED scores (1.1±0.3 vs. 3.3±0.5, P<0.05) of scrub nurses and LED scores (2.5±0.5 vs. 6.3±0.7, P<0.05) of patients were also statistically significant. Exposure of the operative site was significantly better in the prone position (5.0 vs. 2.1, P<0.05). CONCLUSION: Significantly better SMEQ, LED, and exposure score suggests the superiority of jackknife prone position over the lithotomy in terms of significantly less mental and physical stress to the operating surgeon, assistant, and scrub nurse; better ergonomics, and excellent exposure.

Squamous Metaplasia in a Borderline Phyllodes Tumor-an Undocumented Histological Finding in Male Breast: Report of a Case and Review of Literature.

Phyllodes tumor is a paradigm of fibroepithelial neoplasm that accounts for <1% of the breast neoplastic lesions usually detected in females and uncommonly in the male breast. The World Health Organization classifies the tumor into benign, borderline, and malignant based on the predefined morphological criteria. Squamous differentiation in phyllodes tumor is epithelial metaplasia, which has been occasionally documented in English literature. We report the first undocumented case of a recurrent borderline phyllodes tumor with cystic squamous metaplastic change in a 32-year-old male patient. The histology was that of a fibroepithelial neoplasm with the typical leaf-like projections and cystic spaces lined by squamous epithelium containing keratin debris. The purpose of presenting this case is to elucidate the pathogenesis and discuss other malignant and benign breast lesions that may be included in the differential diagnosis when evaluating a breast lesion with squamous metaplasia, particularly in the context of fine-needle aspirates.

CT Imaging in Predicting Ovarian Torsion: Report of Two Cases, With and Without Infarction.

Ovarian torsion is one of the common abdominal and gynecologic surgical emergencies with serious morbidity in the form of ovarian infarct or necrosis. Various imaging modalities like USG, CT, and MRI have been used in the evaluation of ovarian torsion. Two middle-aged females presented with lower abdominal pain. Imaging showed an ovarian cystic lesion in the first patient and thickened and twisted ovarian pedicle or 'helical swirling' sign in the second. Intraoperatively, the first case turned out to be a 180* twist with mild ovarian edema and the second showed more than 720* torsion with ovarian infarction. The CT findings of twisted pedicle with pericystic fat stranding might be predictive of hemorrhagic infarction in cases of torsion.

Pure primary ovarian carcinoid tumor with carcinoid syndrome and cervical carcinoma: A rare concoction of dual primary malignancies.

Carcinoid tumors are defined as rare slow-growing neuroendocrine tumors. A majority of primary ovarian carcinoids occur in association with mature cystic teratoma or are metastatic to the ovary. A 48-year-old post-menopausal woman presented with progressive facial puffiness, and intractable diarrhea. Radiological imaging suggested a 10 × 9 × 9.2 cm right ovarian mass. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination revealed primary pure carcinoid tumor of the ovary with the synchronous presence of early invasive squamous cell carcinoma of the cervix, along with the icthyosis uteri. The patient is doing well on 5 years of follow-up post-surgery without any recurrence or metastasis. In this report, we intend to highlight the rare association of cervical carcinoma and ichthyosis uteri with this tumor. In addition, we present a short review of the literature, over a decade of ovarian carcinoids associated with carcinoid heart disease.

Mesh hernioplasty in emergency repair of traumatic abdominal wall hernia following bull horn injury.

Traumatic abdominal wall hernia (TAWH) is uncommon, mostly following motor vehicle accidents, fall from height and bullfighting. Bullhorn injury, common in rural areas, presents as either penetrating injuries to the abdomen or blunt injuries leading to internal organs injury. Rarely the bull horn injury may lead to TAWH. We report a 70-year-old female from a rural area who suffered bull horn injury to the abdomen leading to TAWH without penetrating the horn and was managed in the emergency by an open mesh hernioplasty. We suture closed the 10×5 cm size defect and reinforced it with a polypropylene mesh of 15×15 cm in the emergency setting. The patient recovered well without any complications or recurrence and doing well at 1 year of follow-up. Mesh hernioplasty can be considered a feasible and safe option in the emergency repair of traumatic abdominal hernia following bull horn injury.

Nicolau Syndrome: An Unforeseen Yet Evadable Consequence of Intramuscular Injection.

An intramuscular (IM) injection is one of the common routes for administering drugs, commonly analgesics and vaccines. Nicolau syndrome refers to the rapid-onset painful, extensive cutaneous discoloration progressing to necrosis and ulceration, reported after IM injections. This case report highlights a rare but avoidable complication of such injections. An elderly man presented with extensive cutaneous necrosis and discoloration over the buttocks extending to the thigh, within few days after receiving a single shot of IM injection of diclofenac. Management involved wound care, biopsy, and cultures with supportive antibiotics to control superadded infection. After multiple sittings of extensive surgical debridement, the wound showed signs of healing and was ultimately amicable for skin grafting in a month. Health care workers need sensitization toward such a complication that can occur out of a routine procedure like an IM injection. They should follow standard IM injections techniques and take precautions to avoid this mishap, which adds to the patient's morbidity.

Iatrogenic injury of duodenum: malady of a therapeutic misadventure.

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

A Study of the Pattern of Injuries Sustained from Road Traffic Accidents Caused by Impact with Stray Animals.

BACKGROUND: The incidence of road traffic accidents (RTA) is increasing every day, especially in developing nations. Amongst various attributable factors, the menace of the stray animals remains one of the most underrecognized factors leading to animal-vehicle collision (AVC). Objectives: Our prospective cross-sectional study aims to survey the incidence of RTA attributable to stray animals and record the pattern of injuries along with other epidemiological parameters. METHODS: The present study was conducted at a tertiary care trauma centre located in a major city of eastern India, between June 2019 and March 2020. Variables like demographic details, type of vehicle and injury with severity score, use of safety gear including types of stray animals were collected and analysed. RESULTS: A total of 185 patients had suffered RTA due to AVC during the study period. The median age of occurrence was 29.0 years. The evening was the most frequent time of accidents (4 PM to 8 PM) with two-wheelers affected in 92% of cases. Stray dogs account for 69% of cases followed by cattle 21% cases. 41% of all RTA victims had polytrauma. Patients with RTA due to impact with ox were found to have higher injury severity score (ISS). The ISS comparison between two-wheeler drivers with and without helmet and influence of alcohol were statistically significant (P<0.01). CONCLUSION: The study highlights an alarming incidence of RTA due to stray animals roaming freely on roads, thus adding significant morbidity and costs to the society. There is a need of the hour for imposing stringent measures from the appropriate authority, including public awareness to make sustainable action plans to prevent animal homelessness and wander freely on streets and major roads.

Epidemiology and patterns of road traffic fatalities in India pre- and post-motor vehicle (Amendment) act 2019: An autopsy-based study.

BACKGROUND: Road traffic accidents (RTAs) are a preventable cause of death. The government of India enacted the motor vehicle amendment (MVA) act on September 01, 2019, to curtail the alarming trend of RTAs and their associated fatality. The study objective was to compare the epidemiology and pattern of fatal RTAs before and after the MVA Act 2019 of India. METHODS: An autopsy-based cross-sectional study was conducted at the Department of Forensic Medicine and Toxicology (FMT) of a tertiary-care hospital from March 2019 to February 2020. The sample comprised 75 fatal RTA victims who underwent postmortem at FMT. Patients were studied in two groups: One pre-MVA group (n = 47) and one Post-MVA group (n = 28). The data were obtained from medical records and inquest reports with autopsy correlation. Data pertaining to sociodemographic profile, mechanism, injury profile including injury-severity-score (ISS) and survival-time was recorded. RESULTS: There was a 40.4% decline in mortality among RTA victims (P = 0.057) in the post-MVA group. The case fatality rate also declined during post-MVA implementation months compared to pre-MVA months (1.61 vs. 1.96). A significant correlation was noted between the ISS and survival-time of victims (P < 0.001, r = -0.522). The mean age of patients was 39.87 ± 17.44 years. Heavy motor vehicles along with motorized two-wheeler were the most common offending-vehicle. The median ISS of all victims was 41 (33-57). Head injury was the most common cause of death (60%). CONCLUSION: Study results signal-toward early triumph of the new MVA act, probably due to enhanced adherence to safety gears and constructive behavioral change.