Efficacy and outcome of indocyanine green-based intraoperative cholangiography using near-infrared fluorescence imaging: A prospective study.

INTRODUCTION: The most dreaded complication during laparoscopic cholecystectomy still remains to be injury to the common bile duct. The primary cause for bile duct injury during LC is misinterpretation of the biliary anatomy. Intra-operative cholangiography was introduced as a means of reducing the chances of biliary injury, done using Fluoroscopic imaging or Near-infrared fluorescence imaging method. NIRF is one of the most popular imaging methods in biomedical sciences. Indocyanine Green is sterile and water soluble which completely binds to albumin and is excreted in bile. PATIENTS AND METHODS: This prospective study was conducted among 70 patients between July 2020 and December 2021. Subjects were administered 5mg of ICG dye pre-operatively and procedure performed using Karl Storz HD image S1 system with a D-light P light source for NIRF imaging. RESULTS: The average duration of surgery was 58.10 minutes. After calot's dissection, the CBD was visualized in 88.71 % patients, with a mean time to visualization at 26.33 minutes. The cystic duct was visualized in 87.3% cases with a mean time of visualization of 32.10 minutes. The hepatic duct was visualized in 28.57% and the hepatic duct-CBD confluence was visualized in 34.28% patients. CONCLUSION: Near infrared imaging based intra-operative cholangiography, using Indocyanine Green dye, during Lap. Cholecystectomy is an easy, useful and inexpensive method of visualizing the biliary ductal anatomy.

Evaluation of Preoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy.

Context: Laparoscopic cholecystectomy (LC) is established as the gold standard for benign gallbladder disease. This study was done for the evaluation of preoperative scoring system given by Randhawa and Pujahari considering various preoperative parameters to predict difficulty in LC. Aims: Preoperative prediction of difficult LC using a scoring system considering various preoperative factors in elective/interval LC to predict difficult gallbladder. Settings and Design: A prospective study of 120 patients admitted for LC from January 2020 to June 2021 was analyzed. Subjects and Methods: All the patients were evaluated on the basis of Randhawa and Pujahari scoring system with the following variables: age >50 years, male sex, body mass index 25.1-27.5 and >27.5 kg/m2, previous abdominal surgery, prior hospitalization for gallstone disease, palpable gallbladder, gallbladder wall thickening, impacted stone, and pericholecystic collection. Each variable had given a score. Based on these findings, the surgical procedure was defined as easy, difficult, and very difficult. Results: One hundred and twenty cases satisfying the inclusion criteria were studied comparing different variables and assigned preoperative scoring. A score >5 was considered significant and compared with intraoperative findings. Out of 53 patients having preoperative scores >5, 40 were difficult gallbladders and 13 were easy to operate. Prediction came true in 93.0% of difficult cases and 83.1% of easy cases. Conclusions: From this study, we can conclude that the preoperative scoring system is statistically reliable to predict difficulty in LC in the majority of the cases (area under receiver operator characteristics = 0.935).

Management of no Reflow during Percutaneous Transcoronary Angioplasty with Catheter-Directed Intracoronary Thrombolysis: A Retrospective Observational Study.

Background: Intracoronary thrombus is common in patients with ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) is the treatment of choice for these patients. Intracoronary thrombus is still a challenge during PCI in STEMI, even with dual antiplatelets, glycoprotein IIb/IIIa inhibitor, and anticoagulation. Intracoronary thrombus can cause distal or nonculprit vessel embolization and no-reflow state. No reflow results in large infarct size, adverse left ventricular remodeling, arrhythmias, and death. Recently, catheter-directed intracoronary thrombolysis (ICT) is gaining acceptance in patients with no-reflow due to a large thrombus burden. Aim: Evaluation of catheter-directed ICT in patients with acute STEMI who develop no reflow due to large thrombus burden during PCI. Materials and Methods and Results: This was a retrospective observational study conducted after approval of the institutional ethics committee in a tertiary care hospital of north India from April 15, 2021 to April 14, 2022, included 1020 adult patients who had undergone coronary evaluation. 37.25% patients had PCI, among these 10% had PCI for acute STEMI. Thrombolysis in myocardial infarction (TIMI) Grade 5 in 79.17% and Grade 4 in 20.83%. ICT was done with low-dose tenecteplase (15 ± 5 mg). The TIMI flow III in 91.67% and II in 8.33% of patients was achieved after intracoronary thrombolysis. Major risk factor was tobacco smoking in 41.67%, and the major complication was left ventricular failure in 33.33%. Conclusions: Catheter-directed ICT is safe and effective in reducing thrombus burden, thus improving myocardial reperfusion in STEMI. This condition has a grave prognosis and can lead to adverse cardiac outcomes. There are many drugs that have been tried to manage no reflow. The use of ICT to treat no-reflow state can be life saving with minimal systemic side effects.

Evaluation of the Component Separation Technique for the Treatment of Patients with Large Incisional Hernia.

BACKGROUND: Incisional hernia remains a frequent complication of abdominal surgery. Results of surgical repair are disappointing with recurrence rates of suture repair being in the range of 5%-63% depending on the type of repair used, with better results using mesh implantation. For the management of such large hernias, interest has been generated in the Component Separation Technique. This technique relaxes abdominal wall by translation of muscular layers without severing the innervation and blood supply, with or without the mesh augmentation. This can accommodate for defects up to 25-30 cm in the waistline. MATERIALS AND METHODS: The study was conducted on 20 patients with "Large Incisional Hernia" with defect size >5 cm at its maximum width or with a surface area >50 cm2 operated upon with Component Separation. Clinical outcome was measured over a follow-up period of 3 months from the surgery in terms of recurrence and other local complications. RESULTS: There were 20 patients (3 men and 17 women; 70% of cases above the age of 50 years). Mean defect size was 9.5 cm (range = 6-20 cm). Average body mass index was 28.97 kg/m2 (range = 22-37 kg/m2). Mean duration of hospital stay was 9 days (range = 5-21 days). Early complications occurred in 15% (3/20) cases and postoperative abdominal compartment or recurrence was not reported over a follow-up period of 3 months. CONCLUSIONS: Component Separation Technique is a safe, easy, and quick option for patients with large hernias.

Blunt Abdominal Trauma With Hollow Viscus and Mesenteric Injury: A Prospective Study of 50 Cases.

Introduction Hollow viscus injury following blunt abdominal trauma is an infrequent diagnosis. Blunt hollow viscus and mesenteric injury (HVMI) is not only an uncommon finding but its timely diagnosis is also difficult. Due to its less frequency, this injury has not been studied in detail prospectively. Aims and objectives The aim of this study is to determine the causes, pattern, management, and outcome of HVMI following blunt abdominal trauma. Methodology This study was conducted from January 2015 to June 2016 in a high-volume tertiary care trauma center and teaching hospital in North India. All patients with blunt HVMI admitted during this period were included in this study. Data were collected regarding medical history, physical findings, demographics, injury dates and times, laboratory results, diagnostic tests, delay in surgical intervention, type of surgical procedure performed, site of injury, complications, and mortality. Results Out of a total of 6,570 trauma admissions, 465 blunt abdominal injuries were identified, and HVMI was found only in 50 patients. The small bowel was the most common injury, with the jejunum being the most commonly involved segment. All patients were managed surgically. The mean time to operative intervention after hospital admission was 4.5 hours (IQR: 2-8 hours). Primary repair was performed in 54% of patients. Mortality rate was high in patients with HVMI (22% patients). Septic shock was the most common cause of death. Conclusion Hollow viscus injury in blunt abdominal trauma is not so common finding. Early diagnosis and treatment is an important but difficult task. Prognosis depends on age, associated injuries, co-morbid conditions, and delay in operative intervention.

Role of percutaneous catheter drainage as primary treatment of necrotizing pancreatitis.

BACKGROUND/AIMS: Necrotizing pancreatitis has morbidity and mortality rates exceeding most of the other acute medical emergencies despite the best possible medical and surgical care. Early surgical intervention has a high operative risk. MATERIALS AND METHODS: This prospective open-label study was designed to evaluate the role of percutaneous catheter drainage (PCD) of pancreatic necrosis as primary treatment of acute necrotizing pancreatitis. An ultrasound/computed tomography-guided drainage was performed with 10 or 12 Fr catheters using a 0.35 mm guide wire, irrespective of whether necrosis was infected or not. Patients were followed up for organ dysfunction, need for surgical intervention, and survival at week 8. RESULTS: A total of 20 (65% males) patients who had acute necrotizing pancreatitis with varied etiology were enrolled in the present study. Of these patients, 9 (45%) did not need surgery after PCD. The remaining 11 (55%) patients showed significant reversal of organ failure after PCD insertion (p<0.05 for improvement in serum creatinine, need for mechanical ventilation, and decline in C-reactive protein). Survival at week 8 was 95%. PCD was well tolerated with only two catheter-related complications being observed. CONCLUSION: Percutaneous catheter drainage can be a primary treatment option for necrotizing pancreatitis. In addition, it helps to stabilize critically ill patients and delay the surgical procedure to beyond 4 weeks to improve the surgical outcomes.

A Rare Case of Intra- Abdominal Bronchogenic Cyst- A Case Report.

Bronchogenic cysts are developmental foregut anomalies usually located in the mediastinum. A 90% of the bronchogenic cysts occur in the posterior aspect of superior mediastinum. Retroperitoneal location of a bronchogenic cyst is rare. We report a rare case of intra abdominal bronchogenic cyst. A CT scan was done for a 34-year-old female who presented with complains of heaviness in the right flank. CT scan revealed a large cyst of 10 x 6 cm in the right hypochondrium. Cyst was removed laparoscopically and the histopathology revealed a bronchogenic cyst.

Efficacy of topical application of beta urogastrone (recombinant human epidermal growth factor) in Wagner's Grade 1 and 2 diabetic foot ulcers: Comparative analysis of 50 patients.

INTRODUCTION: Diabetes mellitus is growing at epidemic proportions world wide and associated with this is an increase in incidence of diabetic foot ulcers. For better understanding and ease of management, diabetic foot ulcer severity is often classified using the Wagner system. In recent times, various treatment modalities have been put to test for getting early wound healing, including growth factors like human epidermal growth factor. MATERIALS AND METHODS: The present study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana. The patients were divided into two groups of 25 patients each. Group 1 was the study group and patients in this group received topical application of beta urogastrone (rhEGF) gel. Group 2 was the control group and patients in this group received betadine dressing. The patients were followed up after every two weeks for eight weeks. RESULTS: The age and sex were comparable in both groups. Mode of onset was either spontaneous or posttraumatic or following debridement. Initially in group A, 12 patients each had serous and seropurulent discharge respectively. I patient did not have any discharge. In group B, 15 patients had sero purulent discharge, 9 patients had serous discharge and 1 patient had purulent discharge. Initially, 13 patients in group A and 15 patients in group B had granulation tissue. Mean size at the beginning of the study in-group A was 19.56 sq cm and 21.20 sq cm in group B. Two patients from group A had incomplete healing at the end of the study as compared to 14 patients from group B. CONCLUSIONS: The application of rhEGF shortens the wound healing time significantly and the mean closure was significantly higher in the EGF group compared with placebo.

Experience with uroflowmetry in evaluation of lower urinary tract symptoms in patients with benign prostatic hyperplasia.

INTRODUCTION: Uroflowmetry is a non- invasive urodynamic tool which is widely used for most of the patients with suspected lower urinary tract dysfunction. The severity of lower urinary tract symptoms (LUTS) can be measured reliably by using a number of validated questionnaires, like International Prostate Symptom Score (IPSS). This study was designed to determine the relationship between the parameters of uroflowmetry and symptom severity. MATERIALS AND METHODS: Fifty patients with LUTS caused by benign prostatic hyperplasia were evaluated by using uroflowmetry, IPSS, prostate volume estimation. The correlations between these parameters were quantified by means of Spearman correlation co-efficients. RESULTS: Statistically significant correlations were found between the IPSS and results of uroflowmetry (peak flow rate and average flow rate) and post void residual urine. No correlation was found between the IPSS and results of prostate volume measurements. CONCLUSION: There was a positive correlation between peak flow rate, as was measured by uroflowmetry and lower urinary tract symptom severity.

Pain management after laparoscopic cholecystectomy-a randomized prospective trial of low pressure and standard pressure pneumoperitoneum.

BACKGROUND: Abdominal pain and shoulder tip pain after laparoscopic cholecystectomy are distressing for the patient. Various causes of this pain are peritoneal stretching and diaphragmatic irritation by high intra-abdominal pressure caused by pneumoperitoneum . We designed a study to compare the post operative pain after laparoscopic cholecystectomy at low pressure (7-8 mm of Hg) and standard pressure technique (12-14 mm of Hg). Aim : To compare the effect of low pressure and standard pressure pneumoperitoneum in post laparoscopic cholecystectomy pain . Further to study the safety of low pressure pneumoperitoneum in laparoscopic cholecystectomy. SETTINGS AND DESIGN: A prospective randomised double blind study. MATERIALS AND METHODS: A prospective randomised double blind study was done in 100 ASA grade I & II patients. They were divided into two groups -50 each. Group A patients underwent laparoscopic cholecystectomy with low pressure pneumoperitoneum (7-8 mm Hg) while group B underwent laparoscopic cholecystectomy with standard pressure pneumoperitoneum (12-13 mm Hg). Both the groups were compared for pain intensity, analgesic requirement and complications. STATISTICAL ANALYSIS: Demographic data and intraoperative complications were analysed using chi-square test. Frequency of pain, intensity of pain and analgesics consumption was compared by applying ANOVA test. RESULTS: Post-operative pain score was significantly less in low pressure group as compared to standard pressure group. Number of patients requiring rescue analgesic doses was more in standard pressure group . This was statistically significant. Also total analgesic consumption was more in standard pressure group. There was no difference in intraoperative complications. CONCLUSION: This study demonstrates the use of simple expedient of reducing the pressure of pneumoperitoneum to 8 mm results in reduction in both intensity and frequency of post-operative pain and hence early recovery and better outcome.This study also shows that low pressure technique is safe with comparable rate of intraoperative complications.

Role of epidermal growth factor in healing of diabetic foot ulcers.

Diabetes mellitus may lead to amputation in 3 % of population. Risk for amputation is 15 folds in diabetics compared with nondiabetics. The aim of the study is to compare the outcome of dressing a diabetic foot ulcer with epidermal growth factor with that of conventional dressing with normal saline. The patients with diabetic foot were divided into study and control groups of 20 each. In the study group, epidermal growth factor (EGF) gel was used as dressing; in control group, dressing was done with normal saline. Treatment was given for 8 weeks or until ulcer healed, whichever occurred first. Evaluation of healing response was recorded on 1, 3, 5, and 8 weeks. After the first week of dressing 90 % of the study group and 30 % of the control group patients showed decrease in wound soakage, size, and increase in proliferation of healthy granulation tissue. After the eighth week of dressing in the study group, 80 % of the patients showed complete response to EGF application. Whereas in control group only 35 % of the patients showed complete response. Duration of hospital stay in the study group was lower as compared with the control group. EGF dressing causes early healing up to first 5 weeks as compared with conventional dressing. The results in healing were not significantly different in two study groups after 8-week duration. Hospital stay was lower in the study group as compared with the control group.

Gallbladder agenesis with common bile duct stone--a rare case with a brief review of the literature.

We present herein the case of a 45-year-old female who presented with obstructive jaundice and was diagnosed as agenesis of the gallbladder with choledocholithiasis. We discuss the radiological and operative features along with a brief literature review of this uncommon entity.

Port site metastasis after laparoscopic cholecystectomy.

We report a case of 62-year-old female, who developed port site metastasis one year after undergoing laparoscopic cholecystectomy for calculous cholecystitis. This is only second such report in Indian literature.