Debajyoti Mohanty

Osteomyelitis of the ribs: a strategy for prompt diagnosis and effective management.

Seven patients were treated for osteomyelitis rib (OR). Discharging sinuses and painful swellings were the presenting symptoms. An initial chest X-ray was unremarkable in all patients. Fine needle aspiration cytology and microscopy of pus did not reveal acid-fast bacillus in any patient. Computerized tomography (CT) of thorax was consistent with the diagnosis of OR in five patients. The patients underwent a subperiosteal excision of the affected part of the ribs or an excision biopsy of the unhealthy granulation tissue. Histopathological diagnosis was consistent with the diagnosis of tuberculosis (TB) OR in six patients. The patients received anti-TB drugs or appropriate antibiotics following surgery. All responded to treatment except one with a non-TB OR, who required further excision of the unhealthy rib ends. Inclusion of a CT of the thorax and an excision biopsy in the diagnostic process facilitates prompt diagnosis and effective management of OR.

Safety and acceptance of non-sedated upper gastrointestinal endoscopy: a prospective observational study.

BACKGROUND The study was conducted to assess the patient acceptability of non-sedated upper gastrointestinal (GI) endoscopy and to study cardiorespiratory changes during the procedure. SUBJECTS AND METHODS This study was conducted in the outpatient endoscopy room of Department of Surgery of a teaching tertiary-care hospital in North India. The patients underwent diagnostic GI endoscopy under topical pharyngeal anesthesia using 5% lidocaine. No sedation was used. Pulse rate (PR), respiratory rate (RR), oxygen saturation (SpO(2)), and mean blood pressure (BP) were recorded immediately prior to endoscopy, during endoscopy, and 5, 15, and 30 minutes after endoscopy. Using a 10-point Likert scale, all the patients were asked to record their expected discomfort for the endoscopy as a pre-test score and their actual level of discomfort during endoscopy as a post-test score. Patients were also asked about whether they would opt for non-sedated upper GI endoscopy again in the future if required. RESULTS Sixty patients underwent diagnostic upper GI endoscopy during the study period. Post hoc tests using Bonferronis correction revealed that mean PR, RR, and mean BP changed significantly during endoscopy. However, these parameters normalized at 30 minutes following endoscopy. Mean SpO(2) did not differ significantly at the different time points. Pre- and post-endoscopy mean visual analog scale scores to assess the expected level of discomfort during endoscopy were not statistically different. Forty-four patients (73.3%) indicated their willingness to undergo repeat non-sedated endoscopy in the future if required. Binary logistic regression analysis identified young age, male gender, and long duration of procedure as significant factors for unwillingness to undergo repeat non-sedated endoscopy. CONCLUSION Non-sedated endoscopy is a feasible, safe, and fast office procedure and seems well tolerated by most patients.

Spontaneous rupture of the renal pelvis presenting as an urinoma in locally advanced rectal cancer

A 29-year-old gentleman underwent a transverse colostomy for intestinal obstruction caused by advanced rectal carcinoma. On the 5(th) postoperative day, the patient developed a painful swelling on the right side of the abdomen. The contrast enhanced computed tomography of the abdomen revealed a right sided hydronephrosis, a large rent in the renal pelvis, and a large retroperitoneal fluid collection on the right side. Percutaneous nephrostomy and pigtail catheter drainage of the urinoma led to resolution of abdominal swelling. Development of a urinoma as a consequence of rectal carcinoma is highly unusual. Prompt imaging for confirmation of diagnosis, decompression of the renal pelvicalyceal system, and drainage of the urinoma limits morbidity.

Quality of life after stapled hemorrhoidopexy: a prospective observational study.

Objective. The objective of the study was to assess the change in quality of life (QOL) of patients undergoing stapled hemorrhoidopexy (SH) using WHO Quality of Life-BREF (WHOQOL-BREF) questionnaire. Methods. The study sample comprised patients with symptomatic II, III, and IV degree hemorrhoids, undergoing SH. The patients were asked to complete WHOQOL-BREF questionnaire before and one month following the surgery. Result. There were 20 patients in the study group. The postoperative pain score measured by visual analogue scale at six hours postoperatively was 7.60 ± 1.23, which reduced to 0.70 ± 0.92 at 24 hours. The items in the WHOQOL-BREF had high-internal consistency or reliability as shown by high Cronbachs alpha coefficient which was 0.82 and 0.90 for pre- and postoperative questionnaires. There was significant improvement in the overall perception of QOL and health, and in physical and psychological domains. There was modest improvement in environmental domain, while no change was noted in social domain. Conclusion. SH improved the quality of life of patients treated for hemorrhoids.

Rational Use of Antibiotics: Time to Join the War Against Superbugs

I have read with interest the article comparing mesh fixation versus non-fixation in totally extra peritoneal (TEP) repair of inguinal hernia by Kumar et al. [1]. The study analyzed data of 171 TEP repairs performed over a period of three and a half years. Minimal access intervention is fast gaining popularity over conventional open repair in the management of groin hernia. The tiny incisions of minimal access surgery account for negligible postoperative pain, reduced incidence of wound infection, and abscess formation. The key benefits for the patient are faster postoperative recovery, short duration of hospitalization, and early return to normal activity. Inguinal hernia repair is considered as a prototype of clean surgical intervention. Apprehensions regarding increased risk of infection in presence of prosthesis in inguinal hernia surgery have not yet been substantiated. Antibiotic prophylaxis is indicated only in patients scheduled for open hernioplasty in a high-risk environment having > 5% incidence of wound infection, and having significant comorbid factors such as diabetes and immunosuppression. Antibiotic prophylaxis is not recommended in patients undergoing laparoscopic inguinal hernia surgery [2]. The recent CDC guidelines additionally recommend against administration of parenteral antibiotics following closure of surgical incision in both clean and clean-contaminated procedures [3]. Hence, administration of three intravenous doses of amoxicillin and clavulanic acid preparation in this study can be considered as redundant. The authors had reported statistically significant increased operative time for TEP with mesh fixation in both unilateral and bilateral hernia repairs; however, they had not mentioned the incidence of indirect and direct hernia in both groups. The type of hernia defect can act as a confounding variable as dissection of indirect sac from the cord structures consumes considerable time in contrast to straightforward reduction of direct sac. Two patients also required conversion in the fixation group. Conversion of TEP to transabdominal preperitoneal approach invariably prolongs the duration of surgery independent of the time taken for mesh fixation. Exclusion of these patients is essential to minimize bias in outcome analysis. Representation of the percentages against the absolute number of events is confusing in the table depicting intraoperative factors and complications. In the fixation group, a single patient with testicular vessel injury accounted for 1.7% of total 43 patients, while the sole patient having extensive surgical emphysema in the same group was reported to constitute 2.3% of the study population. I believe established guidelines backed by robust scientific data should take precedence over individual preference and prejudice in this era of evidence-based medicine. While mesh infection continues to be a dreaded complication in laparoscopic inguinal hernia surgery, preventive measures such as scheduling hernia patient as the first case of the day, use of disposable sterile drapes, having a dedicated set of instruments for hernia surgery or proper sterilization of reusable instruments, and minimum handling of sterile mesh can curtail the overdependence on antibiotics to allay the fear of infection. Practice of rational use of antibiotics is the only means to curb the growing menace of multidrug resistant microorganisms.

Acceptance of Fibrin Glue Fixation in Lichtenstein Hernia Repair: a Faraway Dream

Sir, we have read the article comparing fibrin glue with polypropylene suture for mesh fixation in patients undergoing open inguinal hernia repair by Karigoudar et al. with interest [1]. Short operative time, less post intervention pain, reduction in postoperative hospitalization period, and prevention of chronic groin pain were the benefits attributed to fibrin glue fixation in this study. Elective Lichtenstein repair was carried out in 64 adult patients having uncomplicated inguinal hernia. Fibrin glue was used for mesh fixation in half of the randomized patients. The mesh was fixed with polypropylene suture in rest of the patients. The protocol for the type of anesthesia (local or regional) and the administered anesthetic agents was lacking in this article. We believe that the procedures were carried out under local anesthesia as the first postoperative analgesia dose was administered at 40 min to a patient with suture fixation of mesh. The postoperative discomfort was more pronounced following suture fixation. All the patients in the suture group required analgesic supplementation within 85 min of the intervention. The trauma inflicted by multiple passage of suture needle through the tissue planes coupled with ischemic compression of tissue incorporated in the suture knots could be the explanation for this adverse outcome. Maximum four doses of analgesia in the form of intravenous tramadol (100 mg) were needed by the patients in the fibrin glue group. In contrast, 15 out of 32 patients in the suture group required more than four doses of intravenous analgesia for symptomatic relief. Since tramadol can be administered at six hourly intervals, the duration of postoperative hospitalization in these 46% patients should have been more than 24 h. Conflicting observations were made in this study regarding the duration of hospitalization of the enrolled patients. The use of fibrin glue was noted to shorten the hospital stay in BAbstract,^ but the mean duration of hospitalization in both the groups was reported to be similar in BResults.^ Post intervention pain at the inguinal area usually disappears within 3 months of the surgical procedure. Groin pain continued to be experienced by the patients at or beyond 3 months following inguinal hernia repair is considered as chronic groin pain [2]. So, a sufficient duration of follow-up is essential for evaluation of the incidence of chronic groin pain following inguinal hernioplasty. The follow-up period in this study was only 3 months, and the incidence of groin pain was not significantly different (p = 0.11) in both group of patients at the end of follow-up period. So, it was premature to conclude that use of fibrin glue is beneficial in reducing the incidence of chronic groin pain. * Debajyoti Mohanty debajyoti.mohanty@gmail.com

Plan of Anti-tuberculosis Treatment in Patients with Abdominal Tuberculosis.

We have read the article BStudy of surgical emergencies of tubercular abdomen in developing countries^ by Wani et al. [1] with interest. Tuberculosis continues to be a major health hazard in our country due to the emergence of multidrug-resistant strains coupled with the increasing burden of human immunodeficiency virus infection. As per the WHO report on tuberculosis in 2014, India has the highest number of patients with extra-pulmonary involvement (n= 226,557, 16 % of all patients with tuberculosis) in the world [2]. In such a scenario, administration of proper antituberculosis treatment (ATT) and ensuring strict compliance by the patients during the entire course of therapy are of paramount importance. The authors had presented their experience in the management of 50 patients of abdominal tuberculosis over a period of 2 years. A positive history of pulmonary tuberculosis was available in ten patients. Six patients were properly investigated prior to elective surgical intervention while a total of 32 patients needed emergency exploration due to acute abdominal symptoms. Definitive intervention in the form of adhesiolysis, stricturoplasty, bowel resection and reconstruction, and appendectomy was carried out in 24 patients. In the remaining eight patients, peritoneal and lymph node biopsy was obtained without any definitive repair. It will be interesting to know whether recovery in these eight patients was at par with the 12 patients subjected to conservative management. Histopathological examination was not suggestive of tuberculosis in only one patient in this study; however, all the patients were advised ATT for a period of 6 months. The reason for ordering ATT in the patient in whom the histopathology was not indicative of tuberculosis should have been clarified. The authors were silent regarding the immune status of the included patients as well as the type of ATT regimen followed (daily versus thrice a week schedule). They have also used only three drugs (rifampicin, isoniazid, and pyrazinamide) for the intensive phase of treatment. The WHO guidelines recommend the use of four drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol) for the initial 2 months of intensive phase followed by two drugs (rifampicin and isoniazid) for 4 months in both pulmonary and extra-pulmonary tuberculoses. While either of the two regimens may be followed in immune-competent patients, daily regimen is desirable in immune-compromised individuals to minimize the incidence of relapse and failure of treatment [3]. The previous ATT status of the ten patients with positive history of pulmonary tuberculosis was not disclosed. Due consideration should have been given for an extended course of ATT with five drugs or use of second-line drugs against multidrug-resistant strains in the event of prior treatment failure or relapse in these patients. In conclusion, the operating surgeon should share the responsibility for the selection of appropriate regimen of ATTas * Debajyoti Mohanty debajyoti.mohanty@gmail.com

Study Methodology: Crux of a Research Article

We have read the article “A prospective randomized study comparing non-absorbable polypropylene (Prolene®) and delayed absorbable polyglactin 910 (Vicryl®) suture material in mass closure of vertical laparotomy wounds” by Pandey et al. [1] with interest. The authors had analyzed the two different types of suture materials in 100 patients randomly allocated to each intervention arm in terms of postoperative wound dehiscence. The inclusion and exclusion criteria of a study need to be stringent so that only the patients satisfying the predefined characteristics are enrolled and studied. This study had included five patients of obstructed umbilical hernia while listing presence of abdominal hernia as one of the exclusion criteria. The authors had included 22 patients with hemoperitoneum and 20 patients of blunt abdominal trauma. Blunt abdominal trauma is considered the leading cause of hemoperitoneum mandating emergency laparotomy. Whether hemoperitoneum in the 22 patients was secondary to blunt abdominal trauma or some other pathology needs to be specified. Further, estimation of sample size for this study on the basis of the primary outcome measure of postoperative wound dehiscence could have enlightened us about the precision of the observed results. Randomized trials are the current gold standard to compare the effect of different interventions. Proper outlining of the technique of randomization along with the method of blinding employed improves the credibility of a study. The authors had excluded 11 randomized patients from analysis as they were not explored via vertical laparotomy incision. Ideally, these patients should not have been enrolled for randomization at the first place as the defined inclusion criteria was patients undergoing elective or emergency midline laparotomy. At the same time, 13 patients were not included in randomization due to use of a different type of suture material. This creates confusion regarding the timing of randomization technique. Whether randomization was carried out at the time of admission, at the time of making the surgical incision, or at the time of abdominal fascial closure needs to be clarified. The study mentioned of increased incidence of wound dehiscence in the patients undergoing emergency surgery. This assumption was not supported with documentary evidence as we are unable to find any data regarding the incidence of wound dehiscence following emergency surgery in the “Results.” The increased incidence can be due to the simple fact that majority of included patients had undergone emergency intervention. Poor general condition of patients, malnutrition, increased risk of surgical field contamination, and surgeon fatigue are the known risk factors for the increased incidence of wound complication in emergency situations [2]. The authors had listed lack of proper sterilization in the emergency setup as one of the factors for this increased incidence. We believe that in this modern era of health-care delivery system, the practice of standard sterilization protocols should not be denied to the patients undergoing emergency surgery. Lastly, disclosure about the source of funding is essential in this article as the authors had chosen to incorporate the brand name of the suture materials in their work.

Correlation Is Not Suitable for Comparison of Outcomes.

We have read the article comparing the role of hemorrhoidectomy and rubber band ligation in patients with second- and third-degree hemorrhoids by Gagloo et al. [1] with interest. Hemorrhoidal diseases account for bulk of the patients attending the surgical clinics. A wide array of management options are available for this common ailment that rangefromsimplelifestylemodificationtoinvasiveexcisional hemorrhoidectomy. The selection of appropriate management strategy depends on the classification of hemorrhoids. Higher degrees of hemorrhoids often necessitate more invasive interventions. Recently, efforts are being made to extend the benefits of minimal invasive methods to more and more patients with higher degree hemorrhoids. We beg to differ on the issue of assignment of patients into different degrees on the basis of proctoscopic examination. The Goligher classification of hemorrhoids takes into account the clinical presentation of the hemorrhoid mass, particularly the extent of prolapse. This can be ascertained by specific enquiry regarding the extent of prolapse as well as confirmation of the same onvisual inspection of the perianal area when the patient is requested to strain. Proctoscopy is an integral component of the evaluation process of hemorrhoids as internal hemorrhoids are always better seen than felt. Proctoscopy helps in documentation of the number, location, and appearance of the hemorrhoid mass. It also identifies coexistent lesions in the anorectum in need of intervention along with the hemorrhoids. The authors have compared postoperative complication rateandoverall patient satisfactionlevel for evaluationofboth the treatment modalities. Hemorrhoidectomy resulted in enhanced postoperative pain but reduced incidence of prolapse and bleeding episodes in comparison to rubber band ligation. The satisfaction level was reported to be higher in patients undergoing hemorrhoidectomy. We feel that selection of Chi-square test or Fisher exact test instead of correlation analysis would have better suited to this scenario. Correlation points to the extent of mutual relationship between two or more variables. Change in one variable is thus expected to bring about certain changes in the other variables. Increase in one variable in response to an increase in the other variable indicates a positive correlation while increase in one variable leading to decrease in the other variable denotes a negative correlation. The reduced incidence of prolapse and bleeding episodes following hemorrhoidectomy was associated with an increase in the satisfaction level pointing to a negative correlation. Correlation coefficient denotes the strength of correlation in either direction and varies between �1.0 and +1.0. The closer is this value to 1.0, the stronger is the association. In this study, both reduced prolapse and reduced bleeding contributed to increased patient satisfaction. Had a proper correlation analysis with calculation of correlation coefficient undertaken, then the factor more closely related to the greater acceptability of hemorrhoidectomy could have been identified. In conclusion, appropriate selection of statistical tests to complement documented observations is absolutely essential as they add reliability and respectability to conclusions.

Crafting a Research Article from Dissertation: the Arduous Final Hurdle

I have read the article comparing the outcome of minor anorectal surgeries under local anesthesia (LA) versus spinal anesthesia (SA) by Kulkarni et al. [1] with interest. The anorectal ailments indeed account for bulk of the patients reporting for surgical consultation. Favoring LA in the surgical management of these patients can tremendously cut down the requirement for general and spinal anesthesia in our already overburdened operation theaters. In this modern era of evidence-based medicine, randomized control trials (RCT) are considered the benchmark for comparing the outcome of different treatment modalities. The inherent strength of RCT design lies in the unbiased and unpredictable allocation of patients into the different intervention arms with the aim to abolish baseline imbalances. In this article, the authors have disclosed neither the basis of selection of a sample size of 60 patients nor the technique of randomization employed for enrollment of patients into the two intervention arms. The fairness of their randomization process is also under suspicion as the duration of symptoms was ≤6 months in all the 30 (100 %) patients of the LA group but in only 12 (40 %) patients of the SA group. The article is crammed with 12 colorful diagrams and 14 tables making it quite difficult to focus on the relevant outcome measures. In fact, there is duplication of presented data as both the figures and the tables depict the same set of observations. Reference to all the tables and figures is cited in the introduction while they should have been ideally Prima facie, it appears that this article has been hastily crafted from a postgraduate dissertation. The publication of the research work carried out during postgraduation period is highly rewarding for the resident and should be encouraged. Ideally, the research article should be a neatly packaged miniature form of the dissertation. Precise analytical representation of the relevant outcome measures in sync with the aim of the study while leaving out the insignificant observations is the key for converting the thesis into a good research article.