Rajesh Panwar

Principles of Physics in Surgery: The Laws of Mechanics and Vectors Physics for Surgeons—Part 2

In this sequel, to an earlier article, we discuss the laws of Mechanics, Thermodynamics and Vectors as they apply to soft and bony tissues. These include the Laplace’s Law as applied to colonic perforation, compression therapy, parturition, variceal rupture, disc herniations etc. The Pascal’s Law finds use in hernia repair and the Heimlich maneuver. Trigonometrically derived components of forces, acting after suturing, show ways to reduce cut-through; the thickness and the bite of suture determines the extent of tissue reaction. The heating effect of current explains the optimum gap between the prongs of a bipolar cautery and the use of law of transfer of heat in determining relation between healthy wound healing and ambient temperature.

Laparoscopic pericystectomy for hydatid cyst of the liver.

The greatest disadvantage of conservative surgical procedures in the management of hydatid cyst of the liver is their association with high recurrence rates. Radical surgical procedures such as closed total pericystectomy avoids spillage thereby minimizing recurrences. The use of laparoscopy in performing these radical surgical procedures further reduces the morbidity associated with the open surgery. This study has been carried out to assess the safety and feasibility of laparoscopic pericystectomy in the management of hydatid cyst of liver. Small, peripherally located cysts lying away from major vessels are amenable to laparoscopic pericystectomy successfully whereas, cysts larger than 10 cm, posteriorly located cysts and those lying in close proximity to the major ducts and vessels required conversion owing to bleeding. Therefore, laparoscopic pericystectomy can be regarded as a gold standard for the management of hydatid cyst of the liver in selected patients.

Technical challenges in laparoscopic cholecystectomy in situs inversus.

Laparoscopic cholecystectomy in patients with situs inversus can be a technically challenging procedure. Although laparoscopic cholecystectomy has been described in patients with situs inversus, no standard technique has been described. We are presenting our experience of laparoscopic cholecystectomy in two patients with situs inversus and discuss the problems encountered during surgery and likely remedies.

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Brauns entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

Nationwide study of early outcomes after incisional hernia repair (Br J Surg 2009; 96: 1452-1457).

Sir We would like to thank Mr Renzulli and colleagues, who put their best efforts into this systematic review of atraumatic splenic rupture (ASR). However, a few points need clarification. The authors defined survivors as those who died from underlying disease within 30 days of follow-up or during the hospital stay. Death within 30 days or in hospital means failure of the treatment unless the patient died from an unrelated cause. Those dying in hospital or within 30 days cannot be included in the survivor group as it will not be possible to judge the efficacy of different treatment modalities and this may have a significant impact on the ASR-related mortality. Considering this 30-day criterion, the statistical analysis of ASR-related death cannot be correctly compared with the type of treatment modality. In discussing diagnostic procedures, the authors have not highlighted the sensitivity and specificity of any diagnostic procedures. Ultrasonography was positive for free fluid in 24·6 per cent of patients compared with computed tomography in 23·0 per cent. We think this is a wrong interpretation of the collected data as this suggests that ultrasonography is more sensitive for free fluid. Similarly, peritoneal lavage was positive in 89 patients (10·5 per cent); does this mean that peritoneal lavage done in almost all patients?1 The data are presented in an ambiguous manner. In the discussion of treatment, the tabulated data do not match the written data. The mortality in the primary non-surgical group (five patients) also needs to be described in detail. Were these deaths in patients who underwent splenectomy because of rebleeding or who completed primary non-surgical treatment? R. N. Khan and V. Jindal Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India (e-mail: vikasjindaldr@yahoo.co.in) DOI: 10.1002/bjs.7052

Pancreatic mixed serous neuroendocrine neoplasm with clear cells leading to diagnosis of von Hippel Lindau disease.

Mixed serous neuroendocrine neoplasms are extremely rare tumors that are usually seen in female patients and are often associated with von Hippel Lindau (VHL) disease. We describe the case of a 38-year-old male who presented with complaints of anorexia, weight loss, and abdominal pain. CT abdomen showed a mass in the head of the pancreas, multiple small nodules in the body of pancreas, and bilateral adrenal masses. Fine needle aspiration cytology (FNAC) from the mass showed features of a neuroendocrine tumor, with many of the cells demonstrating abundant clear cytoplasm. Histopathological examination of the pancreaticoduodenectomy specimen showed a mixed serous neuroendocrine neoplasm with two components viz. serous cystadenoma and neuroendocrine tumor (NET) World Health Organization (WHO) grade 2. In addition, he was diagnosed to have bilateral pheochromocytomas and a paraganglioma. The synchronicity of these tumors suggested the possibility of VHL disease. Thus, identification of a NET with clear cells or of a mixed serous neuroendocrine neoplasm should raise suspicion of VHL disease. In a mixed tumor, FNAC may identify only one of the two components. Thorough processing of all pancreatic serous tumors for pathological examination is recommended, as NET may occur as a small nodule within the serous cystadenoma.

Abstract 3986: Diagnostic significance of cathepsin L and cathepsin B expression in human gallbladder cancer - A pilot study

Background: Gallbladder cancer (GBC) is the most common biliary tract malignancy worldwide. Cancer of gallbladder usually refers to as an Indian disease as it is more common in Indian subcontinent especially in north and central India. Incidence rate of GBC in women in Delhi is as high as 21.5 per 100,000 population. It is an aggressive malignancy, which spreads locally to liver, adjacent organs and lymph nodes as well as to distant organs. Cathepsin L (CTSL) and B (CTSB) are lysosomal cysteine proteases implicated in protein turnover and tissue remodeling. Deregulated expression of these proteases has been associated with invasion and metastasis in several solid tumors. Objective: To assess the expression and clinical significance of CTSL and CTSB in human gallbladder cancer. Methods: We assayed the activities of CTSL and CTSB via spectroflurometrically in whole tissue lysates of gallbladder cancer patients (N = 23) and normal gall bladder tissue samples with gallstones (N = 31) / without gallstones (N = 34), which served as controls. Activities of these proteases were correlated with several clinic pathological parameters in GBC patients. CTSL and CTSB mRNA levels were determined in tissues samples by Real time PCR. Furthermore serum levels of these proteases were also assayed using sandwich based ELISA in GBC patients and controls. Results: Significant increase in the enzymatic activities of CTSL+B, CTSL and CTSB was observed in gallbladder cancer tissue samples in comparison to normal gall bladder both with and without gallstones (p Conclusion: Our study for the first time demonstrated a significant increase in the levels of cathepsin L and B in GBC patients as compared to controls. Elevated levels of these proteases may serve as potential biomarkers for human gall bladder cancer. Citation Format: SIDDHARTH MEHRA, MANISH KUMAR, RAJESH PANWAR, NIHAR RANJAN DASH, RATNAKAR SINGH, RAJNI YADAV, SIDDHARTHA DATTA GUPTA, PEUSH SAHNI, SHYAM S. CHAUHAN. Diagnostic significance of cathepsin L and cathepsin B expression in human gallbladder cancer - A pilot study. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3986.

Development and validation of a new score for measuring post-operative complications

PurposeAssigning a numerical value to post-operative morbidity may improve its usefulness as an outcome measure. The recently developed Comprehensive Complication Index (CCI) is a step forward in this process but assigns an inappropriately high score to a combination of complications.MethodsWe developed a new score called the complication severity score (CSS) using a mathematical process and compared it with the CCI using a questionnaire-based survey of 49 experienced gastrointestinal and hepato-pancreatico-biliary surgeons. The CSS was modified based on the results of this survey and was correlated with other patient-centered outcomes in a prospective cohort of consecutive patients undergoing elective surgery.ResultsOf the nine sets of scenarios, experienced surgeons’ opinion matched with CSS in 6, CSS as well as CCI in 1, and neither CSS nor CCI in 2 scenarios. Of the total 441 responses, 281 matched with CSS while 143 matched with CCI (p = 0.0001, odds ratio: 3.7; 95% CI: 2.8 to 4.8). The modified CSS significantly correlated with the post-operative length of stay (r = 0.76; 95% CI: 0.68 to 0.82; p < 0.001), the length of ICU stay (r = 0.61; 95% CI: 0.50 to 0.70; p < 0.001) and with the difference between pre-operative and post-operative quality of life scores in the physical (r = 0.29; 95% CI: 0.14 to 0.42; p < 0.001) and social (r = 0.29; 95% CI: 0.14 to 0.43; p < 0.001) domains.ConclusionsThe CSS more often matched the opinion of experienced senior surgeons compared to CCI. The modified CSS significantly correlated with other patient-centered outcomes.

Author’s reply to the Letter to the Editor for “Efficacy and safety of metallic stents in comparison to plastic stents for endoscopic drainage of peripancreatic fluid collections: a meta-analysis and trial sequential analysis”

We would like to thank Bazerbachi et al. for reading and commenting on our systematic review and meta-analysis regarding metal vs plastic stents for the internal drainage of peripancreatic fluid collections (PFCs). We would also like to congratulate them for their systematic review and metaanalysis on the same topic. In our meta-analysis of comparative studies [1], we found that metal stents had higher clinical success rate and lower complication rate as compared to plastic stents. Bazerbachi et al. [2] used a very different approach for their meta-analysis and included single-arm studies. They found that the metal stents were superior for walled-off necrosis resolution and were associated with lesser complications; the results that are very similar to our meta-analysis. The results of these two meta-analyses using different approaches strengthen the case for the superiority of metal stents for the drainage of PFCs especially the walled-off necrosis. As there are virtually no randomized trials with adequate sample size on this topic, these meta-analyses represent the best available evidence at present and can be used to guide the clinical practice. As far as the level of evidence and quality are concerned, the single-arm case series are considered inferior to the comparative or two-arm studies. We believe that a metaanalysis should be done using the highest quality studies only. If sufficient number of randomized trials are available, using non-randomized comparative studies is more or less inappropriate. Similarly, if sufficient number of comparative studies are available, using single-arm studies does not make sense. The problem with using single-arm studies for meta-analysis is that the results of same procedure or technique may be quite different in different centers. This may be related to the different level of technical expertise or a difference in patient profile at different centers. Thus, if the cases are from one center and the controls from the other, it may be difficult to ascertain whether they belong to the same “universe” or not. Such comparisons, where cases and controls come from different studies, are likely to yield fallacious results. A fitting example would be the meta-analysis by Bang et al. [3] which did not find any advantage of metal stents over plastic stents. The methods used by Bazerbachi et al. are interesting and we appreciate their approach for quality assessment of case reports/case series. However, we would recommend using such an approach only if higher quality studies are not available.

Pancreatic heterotropia in wall of extra-hepatic choledochal cysts: A retrospective analysis of thirteen of such cases from north India

INTRODUCTION Heterotopic pancreas (HP) has rarely been identified in the wall of choledochal cyst (CC). METHODS Retrospectively we screened 200 excised specimens of CC received at our Institute over a period of last eight years and looked for presence of HP rests in them. All the specimens were processed in their entirety. RESULT HP was identified in the wall of 13 (6.5%) CCs, out of which 11 were Heinrich Type 2, and two were Heinrich Type 1. In half of the cases peribiliary mucous glands were observed intermingled with the HP rests. Features of chronic fibrosing pancreatitis were identified in these rests, with ulceration of overlying cyst lining. CONCLUSIONS HP rests in the wall of CC though rare; their coexistence with peribiliary glands may possibly indicate their common embryonic origin. As a common site of inflammation, HP rest may be one of the common causes of CC.