Niladhar S. Hadke

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection: A Randomized Controlled Trial

BACKGROUND The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. METHODS The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone (Group A; n = 50) or physiologic saline as placebo (Group B; n = 50) after the induction of anesthesia. Patient demographics and clinical and surgical outcomes were recorded. RESULTS The incidence of SSI was similar in the two groups: 2 patients in group A and 4 patients in group B (chi(2) = 0.71; p = 0.40). None of the factors studied was associated with surgical site infection statistically, as shown by binary logistic regression analysis. CONCLUSION A single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.

PREDICTIVE FACTORS FOR SUCCESSFUL EARLY LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: A PROSPECTIVE STUDY

BACKGROUND Early laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis. However, the rate of intraoperative conversion to open surgery remains high and has provoked an interest in studying the predictive factors for better patient selection to minimize the conversion rates. MATERIALS AND METHODS 50 patients of acute cholecystitis were operated within 5 days of onset of symptoms. Comparative evaluation of the patient groups undergoing successful versus failed early laparoscopic cholecystectomy was done to identify preoperative factors predicting conversion/failure of the laparoscopic procedure. Predictive factors for intraoperative and histopathological severity of acute cholecystitis were also identified. RESULTS 40 patients underwent successful completion of early laparoscopic cholecystectomy, 8 required conversions to open, while in 2 patients the procedure had to be abandoned due to phlegmon formation. Male sex, preoperative duration of symptoms WBC counts, serum alkaline phosphatase, serum amylase, and serum C-reactive protein were significant predictors of histopathological severity of acute cholecystitis. Intraoperative and histopathological severity of acute cholecystitis had good association with conversion rate of early laparoscopic cholecystectomy. Male sex and serum C-reactive protein levels >3.6 mg/dl at admission were very strong predictors of conversion/failure of early laparoscopic cholecystectomy in acute cholecystitis. CONCLUSION Male patients of acute cholecystitis or patient with serum C-reactive protein levels of >3.6 mg/dl at admission have high risk of conversion in early laparoscopic cholecystectomy and warrant a conservative early management followed by delayed laparoscopic cholecystectomy.

Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging condition

BACKGROUND Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. METHODS In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. RESULTS The success rate was 100% in the study group compared with 30% in the control patients. CONCLUSIONS Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.

Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy

INTRODUCTION Although laparoscopic cholecystectomy appears to be less traumatic to the patients than open surgery, decreased venous return from lower extremities and hypercoagulability occurring in patients undergoing elective laparoscopic cholecystectomy with CO(2) pneumoperitoneum makes it a potent risk factor for deep venous thrombosis. METHODS The observational study of 50 patients undergoing elective laparoscopic cholecystectomy was designed to study alteration in PT, APTT, D-dimer and antithrombin III, which were measured preoperatively, 6 and 24h postoperatively. It was accompanied by color duplex ultrasound of bilateral lower limbs preoperatively and 7th day postoperatively to look for evidence of deep venous thrombosis. RESULTS Significant postoperative decrease in APTT and antithrombin III suggested activation of coagulation while decrease in d-dimer suggested activation of fibrinolysis. Values of PT had no statistically significant postoperative changes. Age, body mass index and duration of pneumoperitoneum were found to correlate with significant activation of coagulation and fibrinolysis. None of the patients developed clinical or radiological evidence of deep venous thrombosis in the postoperative period. CONCLUSIONS CO(2) pneumoperitoneum enhances the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. Patients with risk factors like old age, obesity or with expected long duration of laparoscopic surgery are likely to have significant activation of coagulation, making them a vulnerable risk group for development of postoperative deep vein thrombosis, warranting some form of thromboprophylaxis.

Rectourethral fistula after injection sclerotherapy for haemorrhoids, a rare complication

Injection sclerotherapy is widely used for grade 1 haemorrhoids. We report possibly the first case of rectourethral fistula following its use. A 35-year-old male attended as an emergency, complaining of perineal pain and foul-smelling discharge from the anal orifice for 4 days. There was a history of haemorrhoidal bleeding for 5 months, for which he had received injection sclerotherapy (5% phenol in almond oil) a week previously. On digital rectal examination and proctoscopy, there was a small, irregular mucosal defect with indurated edges at 12 o’clock about 6 cm from the anal verge. The haemoglobin was 9.4 g ⁄ dl, the total leukocyte count 12 600 (polymorphs 90%), the urea 16 mg% and blood sugar 98 mg ⁄ dl. Microscopic examination of the urine showed three or four red blood cells and eight to 10 pus cells per high-power field. An indwelling catheter was inserted, but to our surprise, it came out of the anal orifice, thus confirming the diagnosis of rectourethral fistula (Fig. 1). A suprapubic cystostomy was carried out, and the patient was started on ceftriaxone 1 g i.v. every 12 h and metronidazole 500 mg i.v. every 8 h. The patient responded well to this treatment, and at 6 weeks contrast radiology was normal. The suprapubic cystostomy was removed, and the patient was well thereafter.

Correlation of D dimer and factor VIII levels with histopathology in patients with breast carcinoma.

INTRODUCTION There is evidence that the components of the coagulation/fibrinolytic system play a role in cancer biology and angiogenesis. Studies reveal that at the time of diagnosis, majority of the cancer patients have laboratory evidence of systemic coagulation activation. Our purpose was to investigate the significance of D-Dimer (product of fibrin degradation) and factor VIII levels in breast cancer and to evaluate its relationship with other variables such as histological characteristics, lymph node status and immunohistochemistry markers (ER, PR and Her-2neu). MATERIALS AND METHODS A prospective study was conducted in the Department of Surgery in collaboration with Departments of Medicine, Pathology and Radiodiagnosis & Imaging, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi. Fifty patients with diagnosed cancer breast who were treated in surgery department were evaluated for D Dimer and factor VIII levels. D-dimer and Factor VIII levels were measured three times i.e. at the time of commencement of treatment then after three cycles of Chemotherapy (CAF Regimen) and finally after six weeks of surgery. RESULTS Significantly higher levels of D Dimer and factor VIII were observed in tumors with significant lymphovascular and adipose tissue invasion in comparison to localized tumors. The reduction in D-dimer and Factor VIII values after Surgery was significant for both D-dimer (p value 0.000) and Factor VIII (p value 0.000). The reduction in D-dimer after 3 cycles of chemotherapy was significant for D-dimer (575.51 ± 572.47 ng/ml vs. 422.45 ± 363.58 ng/ml; p value 0.046) but not significant for Factor VIII (307.83 ± 184.47 ng/ml vs. 288.78 ± 163.02 ng/ml; p value 0.151). CONCLUSION D-dimer and factor VIII may be used as yardstick for systemic adjuvant therapy in node negative < 1 cm breast cancer. D-dimer may prove to be a safe, convenient and easily available biomarker which can be combined with conventional sentinel node biopsy in clinically node negative breast cancer to assess metastatic disease in axilla and reduce false negative results.

Breast cancer: Interaction between oxidant-antioxidant dynamics and inflammation in Indian females

OBJECTIVES Oxidative stress and pro-inflammatory mediators have been implicated in breast carcinogenesis. We attempted to evaluate the markers of oxidative stress, antioxidant mechanism and the inflammatory pathway in patients with breast cancer. METHODS This study was carried out in departments of Biochemistry and Surgery, Maulana Azad Medical College and associated Hospitals, New Delhi, India. A total of 60 cases of carcinoma of the breast and 60 healthy controls were included in the study. The parameters that were assayed include markers of oxidative stress-conjugated dienes, thiobarbitone reactive substances (TBARS), antioxidants-superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), glutathione (GSH) and markers of inflammation-interleukin-6(IL-6) and ferritin. RESULTS There was a significant decline in the antioxidant levels and a significant rise in oxidant levels in patients with carcinoma of the breast, compared to controls. The inflammatory markers-IL-6 and ferritin-were also significantly higher in patients with breast cancer. A significantly positive correlation was observed between the IL-6 levels and conjugated dienes with the stage of breast carcinoma; whilst a significantly negative correlation was observed between the levels of conjugated dienes and superoxide dismutase and superoxide dismutase levels with the disease staging. CONCLUSIONS This study underlines the interplay between inflammatory pathways and oxidative stress in the pathogenesis of breast cancer. MINI ABSTRACT: An intense research is underway to identify the possible risk factors and the molecular mechanisms involved in pathogenesis of breast cancer. Inflammation and oxidative stress are two such etiologies investigated in our study.

Secondary malignant fibrous histiocytoma of thigh with surface ulceration following radiotherapy for carcinoma cervix

IntroductionRadiotherapy is known to cause rarely various malignancies including leukemia, sarcoma, and thyroid and lung carcinoma. Post-radiation sarcomas account for 0.5–5.5% of all sarcomas; and include extra skeletal osteosarcoma, fibrosarcoma leiomyosarcoma, and malignant fibrous histiocytoma. Reports on post radiotherapy malignant fibrous histiocytoma in cervical cancer patients are rare.Case reportWe present a case of 45-years-old female diagnosed with squamous cell carcinoma of the uterine cervix stage IIB; she underwent a radical hysterectomy with pelvic lymphadenectomy and postoperative radiotherapy and chemotherapy. Five years later, she presented with ulcerated nodular masses in right and left medial aspect of thigh. Cytological and histological diagnosis of the masses was malignant fibrous histiocytoma which was further confirmed by immunohistochemistry.ConclusionPost-irradiation sarcoma must be considered in patients of carcinoma cervix treated with radiotherapy, when soft tissue mass is seen in the previously irradiated area. It should be differentiated from metastasis from primary tumor with the help of appropriate markers as it has a grave prognosis.

Hemostatic factors in breast cancer as prognostic/predictive factors

We read the article “Relation between hemostatic parameters and prognostic/predictive factors in breast cancer” by Yigit et al. [1] with great interest. Though they have written that previous chemotherapy and/or radiotherapy could affect hemostatic parameters, they have still included those patients of breast cancer who had either of treatment. The rational of this could not be understood. Chemotherapy seems to cause activation of hemostatic markers by three possible mechanisms [2]. Firstly, chemotherapy leads to destruction of tumor cells causing release of cytokines which may activate hemostatic parameters. Secondly, it causes direct damage to vascular endothelium. And thirdly, it is the direct stimulation of expression of tissue factor procoagulant activity in macrophages and monocytes by some chemotherapeutic agents. So, inclusion of those patients who had chemotherapy earlier in this study requires further clarification.

Surveillance and pharmacoeconomics of antimicrobial use among inpatients in a tertiary care, teaching hospital in New Delhi, India: Assessing need for policy formulation

Objective: Although extensive use of antimicrobial medicines (AMMs) has been reported in India, there are limited data on AMM use and expenditure incurred on the same among inpatients. This study was conducted to determine (i) the pattern of AMM prescribed, (ii) adherence of AMM used with the hospital essential medicine list (EML), and (iii) expenditure incurred on AMM. Materials and Methods: An observational, prospective study was conducted among inpatients in Medicine and Surgery Departments of a tertiary care teaching hospital in New Delhi, India, who were receiving AMM. AMM use characteristics (name, dose, dosage form, frequency, duration, route) and expenditure incurred and ABC analysis was done. Results: AMMs were prescribed to 60.1% of patients. Of these, the indication for prescribing AMM was therapeutic in 76.1% patients. On an average, 2.52 antimicrobials were prescribed per patient. The most common route of antimicrobial administration was parenteral (71.9%). Biological samples were sent for bacterial culture sensitivity testing only in 21.1% cases, of which 23.6% were positive. A total of 46 different antimicrobials were prescribed. The most commonly prescribed AMMs were ceftriaxone, metronidazole, ciprofloxacin, amoxicillin-clavulanic acid, and levofloxacin. The number of AMMs prescribed from EML was 1125 (74.4%). Expenditure on antimicrobials accounted for 52% of the total expenditure on medicines. ABC analysis revealed that the maximum expenditure (72%) was on medicines used in a small (9.82%) percentage of patients. The parenteral use of newer, more expensive antimicrobials, not included in the hospital EML, accounted for a large proportion of expenditure on antimicrobials. Conclusion: There is an urgent need to develop a hospital antimicrobial policy, guidelines for use, and generate awareness among physicians to improve and rationalize the economy of antimicrobial use in the hospital.