Sarath Chandra Sistla

Delay in surgery for acute appendicitis

Background:  The present study investigates the effect of delay in appendicectomy on the outcome of surgery and also examines the contribution of patient and physician related delay to the stage of appendicitis.

Minimizing Wound Contamination in a ‘Clean’ Surgery: Comparison of Chlorhexidine-Ethanol and Povidone-Iodine

Purpose: There is limited work analyzing the efficacy of different antiseptics in reducing wound contamination by the skin flora during hernia repair and its influence on the incidence of wound infection, which continues to be a major problem in the developing world. This study was designed to test if chlorhexidine-ethanol has superior antimicrobial efficacy compared with povidone-iodine. Methods: In a prospective randomized trial, the efficacy of chlorhexidine-ethanol and povidone-iodine in the reduction of colony counts of the skin flora and the incidence of surgical site infection was compared. Results: Both povidone-iodine and chlorhexidine-ethanol produced significant reduction in the skin bacterial colony counts, from 18.66 × 102 to 2.34 × 102 colony-forming units with povidone-iodine (59%) and from 12.34 × 102 to 0.93 × 102 colony-forming units (82%) with chlorhexidine-ethanol. Infection rates with the use of povidone-iodine and chlorhexidine-ethanol groups were not significantly different (9.5 vs. 7.0; p = 0.364). The reduction in colony counts in those who developed infection was only 15.6% compared with 77.1% in those who did not develop infection. Conclusions: The antibacterial efficacy of chlorhexidine-ethanol and povidone-iodine is comparable in open hernia repair.

Leiomyoma of the vagina: An unusual presentation

Vaginal leiomyomas are rare. They usually arise from the anterior vaginal wall. We report a case of a vaginal leiomyoma arising from the right lateral wall that presented as a gluteal swelling with pus discharging per vagina, creating a clinical dilemma in diagnosis. Preoperative imaging and biopsy may help to rule out malignancy. The size of the tumor necessitated abdominoperineal approach and hysterectomy for better surgical access. To the best of our knowledge such a clinical presentation of a vaginal leiomyoma has not been reported in the literature.

Effect of preoperative and postoperative incentive spirometry on lung functions after laparoscopic cholecystectomy.

This study was designed to compare the effects of preoperative and postoperative incentive spirometry on lung functions after laparoscopic cholecystectomy in 50 otherwise normal healthy adults. Patients were randomized into a control group (group PO, n=25) and a study group (group PR, n=25). Patients in group PR were instructed to carry out incentive spirometry before the surgery 15 times, every fourth hourly, for 1 week whereas in group PO, incentive spirometry was carried out during the postoperative period. Lung functions were recorded at the time of preanesthetic evaluation, on the day before the surgery, postoperatively at 6, 24, and 48 hours, and at discharge. Significant improvement in the lung functions was seen after preoperative incentive spirometry (group PR), P<0.05. The lung functions were significantly reduced till the time of discharge in both the groups. However, lung functions were better preserved in group PR at all times when compared with group PO; P<0.05. To conclude, lung functions are better preserved with preoperative than postoperative incentive spirometry.

Does single-dose preoperative dexamethasone minimize stress response and improve recovery after laparoscopic cholecystectomy?

Background Stress response after laparoscopic cholecystectomy (LC) is less compared with open cholecystectomy, but is still responsible for significant postoperative morbidity. Though preoperative glucocorticoids were found to be effective in reducing the response in open surgical procedures, their role in minimal access surgery is not clear. Aims and Objectives To evaluate the efficacy of single-dose preoperative dexamethasone in reducing the stress response and postoperative morbidity after LC. Materials and Methods In a prospective randomized, double-blind, placebo-controlled trial, 70 patients undergoing elective LC were randomized to receive either dexamethasone (8 mg intravenously), or placebo. The change in C-reactive protein levels after LC, pain scores at rest, and on exertion and narcotic requirements, the incidence and severity of postoperative nausea and vomiting (PONV), anti-emetic requirement, peak expiratory flow rate in both groups were compared. Results Dexamethasone was more effective in controlling late PONV (P=0.05). The antiemetic requirement was significantly less in the dexamethasone group (0.56 mg vs. 2.24 mg; P=0.02). Median pain scores were significantly less in the dexamethasone group at 24 hours at rest (P=0.002) and on exertion at 24 and 48 hours (P=0.03 and 0.001). Analgesic requirement was less in the test group (22.9 mg vs. 29.9 mg; P=0.054). The peak expiratory flow rate at 48 hours was higher in the dexamethasone group (315.28 vs. 285.8 l/min; P=0.04). The dexamethasone group showed significantly less elevation of C-reactive protein levels at 24 hours (7.17 μg/mL vs. 17.53 μg/mL; P=0.003) and 48 hours (10.65 μg/mL vs. 23.18 μg/mL; P=0.02) postoperatively. Conclusions Preoperative single-dose dexamethasone significantly reduces the pain scores, PONV, and antiemetic requirements while improving the respiratory function in the postoperative period after LC.

Primary retroperitoneal mucinous cystadenoma in a man.

Primary retroperitoneal mucinous cystadenomas (PRMC) are rare benign cystic neoplasms commonly detected as asymptomatic incidental masses on routine imaging exclusively in women. We report the second case of PRMC in the world to be described in a man. A 45-year-old male presented with a progressively enlarging painful lump in his abdomen over the past 3 months. Per-abdominal examination revealed a huge bosselated fixed retroperitoneal mass involving the left half of the abdomen and extending across the midline, which was confirmed by ultrasonography. Plain and contrast-enhanced computed tomography (CT) scan of the abdomen revealed a large 23 20 cm multiloculated retroperitoneal tumor with calcifications in its wall, occupying the entire left side of the abdomen, pushing the bowel loops and the great vessels to the right (Fig. 1). The left kidney was compressed, elongated, pushed postero-medially, and was engulfed by the tumor. A provisional diagnosis of a primary retroperitoneal cystic teratoma infiltrating the left kidney was entertained and laparotomy was performed. Laparotomy revealed a huge 27 15 16 cm multiloculated mass occupying the retroperitoneum and engulfing the left kidney (Fig. 2). Rest of the abdominal viscera including the pancreas was normal. The tumor was resected along with the left kidney. Cut section of the tumor revealed a multiloculated cyst filled with thick gelatinous mucoid material engulfing the left kidney. Microscopic examination of the cyst wall revealed fibrocollagenous tissue with areas of calcification lined internally by a single layer of columnar mucin secreting cells (Fig. 3). A diagnosis of benign primary retroperitoneal mucinous cystadenoma was made. The cortical parenchyma of the

Clear Liquid Diet vs Soft Diet as the Initial Meal in Patients With Mild Acute Pancreatitis A Randomized Interventional Trial

BACKGROUND Patients recovering from mild acute pancreatitis are usually started on a liquid diet and advanced to a solid diet. Evidence suggests a soft diet as the initial meal is tolerated well by such patients. However, the results are controversial. OBJECTIVES To assess the safety of starting an early soft diet compared with a liquid diet in patients with mild acute pancreatitis as the initial meal. METHODS We randomized 60 patients with mild acute pancreatitis into 2 groups to receive either a clear liquid diet (CLD) or a soft diet (SD) as the initial meal, and parameters such as tolerance to diet, recurrence of pain, length of hospitalization (LOH), need to stop feeding, post-refeeding length of hospitalization (PRLOH), and postdischarge readmission rate within 30 days were analyzed. RESULTS The demographic and baseline parameters (amylase, total leucocyte count, Balthazar score) in the 2 groups were comparable. Patients in both groups tolerated the diet well except 1 patient in the SD group, who developed vomiting and diarrhea, not severe enough to stop feeding. LOH and PRLOH were significantly lower in the SD group (4.23 ± 2.08 and 1.96 ± 1.63 days, P < .0001) compared with the CLD group (6.91 ± 2.43 and 4.10 ± 1.64 days, P < .0001). PRLOH in the SD group was 2.14 days less when compared with the CLD group. CONCLUSION In patients with mild acute pancreatitis, a soft diet as the initial meal is well tolerated and leads to a shorter total length of hospitalization.

Biliary cystadenocarcinoma of the gall bladder: a case report

IntroductionWhile biliary cystadenoma and biliary cystadenocarcinoma involving the liver are not uncommon, biliary cystadenocarcinoma of the gall bladder is an extremely rare lesion and can be very difficult to diagnose.Case presentationA 50-year-old Indian woman presented with pain and swelling in the right hypochondrium. An ultrasonography revealed a cystic lesion arising from the gallbladder fossa. This lesion was initially managed with aspiration and antibiotics by the treating physician. The patient was referred for surgical management because the abscess was not resolved through conservative treatment. A diagnosis of an infected nonparasitic cyst was made and deroofing of the cyst was performed. A histopathological examination of the excised cyst wall showed cystadenocarcinoma. The patient subsequently underwent a successful surgical excision of the lesion.ConclusionInfective lesions of the liver are common in developing countries and are usually managed through aspiration and antibiotics. Cystadenocarcinoma of the gallbladder needs to be considered in the differential diagnosis of cystic lesions arising from the gallbladder fossa. A high index of suspicion and cytological examination from the wall of such complex lesions will help in the timely management of such lesions.

Comparison of standard-pressure and low-pressure pneumoperitoneum in laparoscopic cholecystectomy: a double blinded randomized controlled study.

Background and Objective: With the safety of laparoscopic cholecystectomy (LC) having been established, the current stress is on reducing the postoperative morbidity associated with this procedure. Hence, this study was undertaken to compare the effect of low-pressure (8 mm Hg) (LPLC) versus standard-pressure (12 mm Hg) (SPLC) pneumoperitoneum on postoperative pain, respiratory and liver functions, the stress response, and the intraoperative surgeon comfort in patients undergoing LC. Materials and Methods: Patients undergoing LC (n=43) were randomized into the LPLC (8 mm Hg) group (n=22) and the SPLC (12 mm Hg) group (n=21). Postoperative pain, changes in liver function, peak expiration flow rate, C-reactive protein level, and intraoperative surgeon comfort were assessed. Results: The postoperative pain scores (P=0.003, 0.000, 0.001, and 0.002 at 0, 4, 8, and 24 h), total analgesic requirement (P=0.001), and the number (total and good) of demands for analgesic in the first 24 hours (P=0.002 and 0.001) were lower in the LPLC group. The surgeon comfort in the LPLC group was significantly lesser (P=0.000). The liver function and peak expiration flow rate did not show any significant changes. C-reactive protein levels varied significantly only at 24 hours postoperatively (P=0.001). Conclusions: The use of low-pressure pneumoperitoneum (8 mm Hg) for LC is associated with a significantly lower postoperative pain. However, the use of this low-pressure pneumoperitoneum can jeopardize the surgeon’s comfort.

Pure neuritic leprosy with nerve abscess presenting as a cystic, soft tissue mass: Report of a case diagnosed by fine needle aspiration cytology

Pure neuritic leprosy (PNL) with nerve abscess manifesting as a huge, cystic, soft tissue mass is highly uncommon. Fine needle aspiration cytology can serve as an important initial diagnostic modality in such an instance.