Chellappa Vijayakumar

Effect of exercise on shoulder function and morbidity following mastectomy with axillary dissection in patients with breast cancer: a prospective randomized clinical study

Background: There are no guidelines for the exercises performed in physical rehabilitation after breast cancer surgery and, specifically, for how to minimize these postoperative complications. Hence this study was conducted to study the effect of exercise intervention on upper extremity range of motion, strength, lymphedema, pain and activities of daily living (ADL). Methods: A total of 75 patients were included in the study in accordance to inclusion criteria. They were randomized into exercise group (n=38) and no exercise group (n=37). Patients in the exercise group were given a set of 19 active or active assisted range of motion exercises and strengthening exercises with frequent follow up. The other group were did not receive any strict exercise, they were given a few free hand exercise when they had some shoulder complaints based on treating physician discretion. Apart from demographic data other parameters studied were pain, numbness, active shoulder range of motion, muscle strength, lymphedema and ADL. These were evaluated before surgery, 24 hours after drain removal and 3 weeks /6 weeks/ 3 months of post-surgery. Results: Demographic parameters were comparable between the groups. Pain score, shoulder ROM were better in the exercise group compared to no exercise group and this difference was found to be significant (p <0.001). More patients in no exercise group experienced numbness. There was no statistically significant difference in the grip strength between the two groups. The incidence of lymphedema was higher in no exercise group compared to exercise group and this was extremely significant. (p < 0.001). Patients in no exercise group had higher disability scores for ADL which was significant compared to exercise group. Conclusions: Exercise interventions resulted in significantly reduced pain, improved shoulder ROM and lowered ADL impairment. Exercise intervention significantly reduced the incidence of lymphedema, but there was no effect on strength.

Pediatric Primary Tuberculous Osteomyelitis of the Mandible Mimicking Parotitis

Tuberculosis (TB) is a worldwide public health problem; however, primary tuberculous osteomyelitis involving the mandible is extremely rare. Here, we report a 14-year-old boy who presented with a recurrent, generalized swelling of the cheek in the right side, mimicking parotitis. Fine needle aspiration cytology (FNAC) from the swelling was inconclusive. Contrast-enhanced computed tomography (CECT) of the head and neck revealed an osteolytic lesion of the mandible with a surrounding abscess. An intraoral incisional biopsy of the tissue showed a granulomatous lesion. The patient was started on anti-tubercular therapy (ATT) for six months. Our patient’s presentation underscores the clinical difficulty in establishing a diagnosis and considering tuberculous osteomyelitis in the differential diagnosis.

Stercoral Ulcer Not Always Indolent: A Rare Complication of Fecal Impaction

Stercoral sigmoid perforation is a dangerous surgical emergency. It is also a life-threatening situation because the spillage of fecal contents into the abdominal cavity leads to sepsis with many postoperative complications. Chronic, intermittent constipation can lead to fecal impaction, especially in older patients. An 80-year-old male patient presented with intestinal abdominal pain and distention for three days. His chest X-ray showed air under the diaphragm. On laparotomy, a small rent was discovered in the rectosigmoid junction with fecal contamination. The presence of a fecaloma is the speculated reason for the perforation. Primary closure of the defect with a diverting transverse colostomy was performed, and subsequently, the patient recovered well. A colostomy closure was performed six weeks after the primary surgery. It is imperative to understand the incidence of stercoral perforation in a normal bowel. Early treatment and intervention are the important aspects of stercoral pathology. We report a rare case of stercoral sigmoid colonic perforation with fecal peritonitis.

An Unusual Case of Penile Spindle Cell Malignancy

Sarcomatoid carcinomas are unusual high-grade tumors, predominantly composed of spindle cells. There appears to be no predilection for any specific site. A few cases of sarcomatoid tumors arising in the penis have been reported. We report a 60-year-old man with a pathological diagnosis of sarcomatoid carcinoma of the penis. This case reiterates the importance of including sarcomatoid carcinoma in the differential diagnosis, especially at uncommon sites.

Microbiological Profile of Chronic Tonsillitis in the Pediatric Age Group

Introduction Tonsillitis is a very common disease in children. Understanding the microbiology and pathology of chronic tonsillitis is an important step in its management. The aim of the study was to describe the microbiological profile of core tonsillar tissue in chronic tonsillitis in children. Materials and methods Children under 16 years of age with chronic tonsillitis were recruited in the descriptive study. Children with recurrent tonsillitis and recurrent tonsillitis with obstructive symptoms were included. Children who underwent tonsillectomy for obstructive symptoms alone and those who received antibiotics for at least one month prior to surgery were excluded from the study. Dissection and the snare method of tonsillectomy were done on all children. The operated specimen was cut into two halves in a sterile container. The core of the tonsillar tissue was swabbed with two sterile cotton-tipped swabs and sent for the microbiological evaluation of aerobes and anaerobes. The tonsillar tissue was sent for a histopathological examination. Results A total of 106 children were operated for chronic tonsillitis in one year. The mean age of children included in this study was 9.4 years. The duration of symptoms due to tonsillar disease ranged from four weeks to 28 months. There were 48 males and 58 females. Recurrent tonsillitis was the most common indication for tonsillectomy in all children. A total of 301 aerobes and 171 anaerobic microorganisms were isolated from 106 children with chronic tonsillitis. The aerobic bacterial species most often isolated was Streptococcus viridans, which was present in 83 children followed by Group A, β-hemolytic Streptococci in 67 children. The anaerobic bacterial most often isolated was Peptococcus species in 49 children. Polymicrobial aerobic and anaerobic flora were present in all tonsillar specimens, yielding an average of 4.1 isolates per specimen. The histopathological examination revealed chronic tonsillitis with reactive follicular hyperplasia in all (100%) children. Actinomycosis was associated with non-specific reactive follicular hyperplasia in four specimens. Conclusion Polymicrobial aerobic and anaerobic flora are identified in deep tonsillar tissue in children with tonsillitis. The identification of bacterial isolates from the core tissue in recurrent tonsillitis could dictate the management of chronic tonsillitis. The histopathological examination of the core tissues of the tonsils helps in an accurate identification of organisms that are difficult to culture.

The Ideal Size of Mesh for Open Inguinal Hernia Repair: A Morphometric Study in Patients with Inguinal Hernia

Introduction This study was done to analyze the morphometric features of the inguinal canal with different types of inguinal hernias to determine the appropriate size of mesh required to cover potential sites of recurrence. A morphometric assessment in the particular population is essential to recommend the appropriate mesh size in inguinal hernias to cover all the potential sites of recurrence. Materials and methods This was a prospective observational study, including all consecutive patients undergoing open inguinal hernia repair under local/regional/general anesthesia over a period of three years. Surgeries that were done in emergencies for complicated hernias, laparoscopic repair, and recurrent inguinal hernias were excluded. Intra-operative parameters were studied to predict the appropriate mesh size, which included the position of the superficial and deep inguinal ring (SIR and DIR) with the diameter, the distance of SIR and DIR from the anterior superior iliac spine (ASIS), and the distance from the summit of the muscular arch to the inguinal ligament. The differences in morphometric details between the types of hernias and categorical variables were assessed using the chi-square test. Results The study included a total of 170 patients with a mean age of 50.67 + 17.59 years. An indirect hernia was the most common type in patients less than 60 years. The mean distance from ASIS to SIR was 10.2+ 1.9 cm, and in indirect hernia patients, it was found to be significantly increased (p=0.042). The mean distance from ASIS to DIR was 4.14+1.57 cm, where the indirect hernia patients had a significantly less distance (p=0.029). The mean length of the inguinal canal in a direct hernia was 5.66 + 0.5 cm, whereas, in an indirect inguinal hernia, it was 6.46 + 0.8 cm, which was significant (p=0.029). The mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch was 4.03 cm, and there was no significant difference between the indirect and direct hernia patients. Conclusion After considering the morphometric assessments of the length of the inguinal canal, the mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch, the mean distance from ASIS to DIR, the ideal mesh size for the population would be 9 X 15 cm to cover all the potential sites of recurrence.

Role of Heparin Irrigation in the Management of Superficial Burns with Special Reference to Pain Relief and Wound Healing: A Pilot Study

Introduction The objective of this study was to assess the effect of heparin irrigation in the management of superficial first and second degree burns with special reference to pain relief and wound healing. Materials and methods This pilot study was carried out over a period of 12 months in a tertiary care centre in South India. The study patients were divided into two groups: the heparin group and the saline control group. In the control group, the burn wound was irrigated with 100 mL of normal saline before the conventional dressing with silver sulfadiazine. In the heparin irrigation group, the wound was irrigated with heparin solution before the conventional dressing. Wound healing was assessed in terms of necrotic tissue score and granulation tissue score. Patient satisfaction in terms of patient satisfaction score, visual analogue scale (VAS) score, and length of hospitalization were compared between the two groups. Results A total of 40 patients were analysed in the study, 20 patients in each group. Both the groups were comparable with respect to age, gender, co-morbidities, body mass index (BMI), and degree of burns. Wound healing parameters like necrotic tissue score of six [40% vs. 50%; p = 0.024] and granulation tissue score of four [85% vs. 65%; p= 0.06] were significant in the heparin group compared to the control group. However, the difference was not statistically significant. The mean length of hospitalization between the two groups [10.5 days vs. 12.6 days; p = 0.74] were not statistically significant. Similarly, there was no statistically significant difference between the two groups with respect to the VAS pain score on the seventh dressing day [6.9 vs. 7.3; p= 0.321]. Conclusion In comparison to saline irrigation, heparin irrigation would result in better wound healing in superficial first and second-degree burns. The length of hospital stay in days and VAS pain score on the seventh dressing day were not statistically significant between the two groups.

Comparing Surgical Site Infection and Scar Cosmesis Between Conventional Linear Skin Closure Versus Purse-string Skin Closure in Stoma Reversal - A Randomized Controlled Trial

Introduction Stoma closure is one of the most frequently performed surgeries. The common complications are surgical site infection (SSI) and poor scar cosmesis. Purse-string sutures are expected to have less incidence of SSI due to the free drainage of secretions from the wound and possibly the early detection of a wound infection. Compared to the conventional linear closure, the purse-string closure technique is expected to have less wound infection, improved scar cosmesis, and good patient satisfaction because of a smaller size scar. Hence, a well-structured study is required to substantiate the advantage of this technique. Methodology This randomized control trial was carried out for two years in a tertiary care centre in Southern India. Patients with various stoma reversals, including colostomy, as well as ileostomy reversal, were included in the study. Patients were divided into Group I - conventional linear skin suturing (n = 40) and Group II - purse-string closure (n = 40). After the closure of rectus muscle, the skin is closed using the purse-string method (subcuticular) in the experimental group. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), the presence of co-morbidities, and indication for surgery. Stomal procedures were done (26.3%) for malignant cases. The difference in mean hospital days for both groups were statistically insignificant (11.95 vs. 9.9; p = 0.927). The incidence of SSI between the groups were statistically significant (17 vs. 3; p = 0.003). The mean Patient and Observer Scar Assessment Scoring (POSAS) scores between the groups (65.30 vs. 83.40; p = 0.012) were statistically significant. This proved significant improvement in scar cosmesis in purse-string skin closure. At one month postoperative, the purse-string group had better patient satisfaction (3.08 vs. 4.48; p = 0.001), which was evidenced by a mean Likert 3 scale score. The mean visual analogue scale (VAS) score did not show any significant difference in pain between the groups. Conclusion Purse-string skin closure for stoma reversal had significantly less incidence of SSI. The duration of antibiotic therapy was also less in purse-string skin closure patients as compared to linear skin closure patients. Purse-string skin closures significantly improved the scar outcome and patient satisfaction.

Clinical Study on Middle Ear Diseases in Children with Orofacial Clefts

Introduction Orofacial clefts are associated with middle ear diseases, but the magnitude of this problem is not generally well appreciated. The aim of this study was to describe the middle ear findings and audiological profile in children with orofacial clefts. Materials and methods Children with orofacial clefts attending plastic surgery and otorhinolaryngology departments of a tertiary hospital over one-year duration were included in this study. Ninety-six children with orofacial clefts were identified. They were categorized age-wise as zero to five years, more than five years to 10 years, and more than 10 years to 15 years. They underwent a detailed ear, nose, and throat examination followed by audiological tests, including brainstem evoked response audiogram (BERA), pure tone audiogram (PTA), and tympanometry. Results Among 96 children with orofacial clefts, only 24 children (25%) had symptomatic ear problems, whereas on ear examination, 56 children (58.3%) had abnormal ear findings. Middle ear effusion (MEE) was the most common ear condition, and it was seen in 94 ears (48.9%). Cholesteatoma was noted in six children (3.1%). Out of 73 children in the zero to five age group, 58 children (79.5%) did not have any history of ear problem but 55.5% (81 ears) had features of MEE such as a dull tympanic membrane (TM). In the age group of more than five years to 10 years, only four children (28.5%) were symptomatic. Five children (55.5%) out of nine in the age group of more than 10 years had a symptomatic ear problem of which four children (44.4%) had chronic otitis media squamosal disease. The earlier age groups showed a trend of ear disease being asymptomatic compared to older children. Normal hearing was present in only 40 children (41.7%) and various degrees of hearing loss were seen in 56 children (58.3%). The mean air conduction threshold in the age group zero to five years, more than five years to 10 years, and more than 10 years were 33±8.3 decibels (dB), 25±6.2 dB, and 31.5±14 dB, respectively. Out of 144 ears (72 children) in the asymptomatic group, 67 ears (46.5%) had normal hearing. Seventy-seven ears (53.5%) had some degree of hearing loss. Mean air conduction hearing loss in the asymptomatic group was 29.8±7.3 dB. Conclusion This study highlights the higher incidence of middle ear diseases compared to the presenting symptoms in children with orofacial clefts. This stresses on the need for a detailed otological evaluation to identify any middle ear pathology so that timely intervention can be taken.

Harmonic Scalpel-Assisted Laparoscopic Cholecystectomy vs. Conventional Laparoscopic Cholecystectomy - A Non-randomized Control Trial

Introduction Laparoscopic cholecystectomy (LC) is the most commonly done, minimally invasive surgical procedure. Routinely used electrocautery produces more smoke, which masks the operating field, thereby prolongs the surgery and posing an increased risk of gallbladder (GB) perforation. The titanium clips used for clipping the cystic artery and cystic duct have a risk of slippage, which may lead to bleeding, and an increased risk for bile leakage. In addition, it may act as a nidus for stone formation. Advanced energy sources, such as the harmonic scalpel, though expensive, may provide the advantage of shorter operating time by reducing smoke, bloodless dissection in the GB bed, lower risk of bleeding from the cystic artery due to secure vessel sealing, and avoiding the use of a larger number of titanium clips. However, evidence to substantiate this advantage is limited. Aim To compare the operating time and perioperative complications between conventional laparoscopic cholecystectomy (CLC) and harmonic scalpel assisted laparoscopic cholecystectomy (HLC). Methodology All consecutive patients who underwent elective LC were included. Patients with acute infection, impaired liver function tests, concomitant common bile duct calculi, chronic liver disease/cirrhosis, suspected GB carcinoma, and pregnant women were excluded from the study. Patients were allocated into two groups. In the CLC group, both the cystic duct and the cystic artery were divided after conventional titanium clip application and electrocautery was used for thermal energy. In the HLC group, the cystic duct was clipped with a titanium clip and the rest of the procedure was carried out using Harmonic Ace (Ethicon, New Jersey, United States) and Harmonic Hook (Ethicon, New Jersey, United States). Outcome parameters analyzed were operating time in minutes, post-operative pain using visual analogue scale (VAS) scoring, frequency and route of analgesic requirement after 24 hours, and intraoperative complications, including bleeding, bile duct injury, GB perforation, and surgical site infection (SSI) in the postoperative period, per the Centers for Disease Control (CDC) criteria. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), and the presence of comorbidity and an indication of cholecystectomy. The duration of surgery did not significantly differ between the groups (67.3 vs. 64.3 mins; p = 0.30). Other parameters, such as analgesic required on postoperative Day 1 (3.2 vs. 3; p = 0.67), VAS scores on Day 0 (4.55 vs. 4.65; p = 0.59), VAS scores on Day 1 (2.3 vs. 2.2; p = 0.84), superficial SSI (15% vs. 10%; p = 0.63), intraoperative GB perforation (30% vs. 20%; p = 0.71), and intraperitoneal drain (30% vs. 20%; p = 0.71) did not significantly differ between the groups. Conclusion HLC has no significant advantage over CLC with respect to operating time, postoperative pain, and perioperative complications.