Tanveer Iqbal Dar

Stentless laparoscopic pyeloplasty: A single center experience

Aim: To assess the effectiveness of laparoscopic stentless pyeloplasty for congenital ureteropelvic junction obstruction. Materials and Methods: This was a prospective comparative study conducted over a period of 5 years. The study included 35 cases of primary ureteropelvic junction obstruction (UPJO) with mean age of 29.5 years, divided in two groups- Group A (stent-less, 18 patients) and Group B (stented, 17 patients). Follow up ranged from one to 4years (mean 2 years). Transperitoneal laparoscopic Anderson- Hyenes pyeloplasty was standard for both the groups. Perioperative and postoperative complications were prospectively collected and analyzed by Statistical Package for Social Sciences (SPSS) 17 version using Pearson chi square test. Results: Both the groups were comparable with respect to preoperative differential renal function (DRF) and time required for maximum activity in minutes (tmax.min). Average post operative DRF was significantly higher than preoperative DRF in both the groups. Average tmax was significantly lower after pyeloplasty than pre operative tmax. Mean operative time, mean duration of urethral catheter, and mean duration of drain removal were comparable in both the groups. However bothersome irritative lower urinary tract symptoms (LUTS) and hematuria were significantly more in group B patients (P < 0.0001 and <0.013 respectively). Conclusion: In experienced hands, laparoscopic stentless pyeloplasty is as effective method for treating UPJO as its stented counterpart. It is cost effective, avoids stent-related morbidity, and could be performed without compromising the success rate. However, more randomized studies are needed to evaluate the safety of stentless pyeloplasty.

Decompressive craniectomy in head injury

Decompressive craniectomy has been used to treat severe intracranial hypertension secondary to various causes like trauma, cerebral infarction, subarachnoid hemorrhage, and spontaneous hemorrhage, refractory to medical treatment. There are many different approaches grouped under the term ‘decompressive craniectomy’ with all of them aiming at reduction of raised intracranial pressure. We have reviewed the literature and tried to describe the mechanism, various types, indications and complications of this procedure.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries.

Background: The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain. Methods: All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO). Results: We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome. Conclusions: In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Low molecular weight heparin in prophylaxis of deep vein thrombosis in Asian general surgical patients: A Kashmir experience

Background and Objectives: Deep vein thrombosis (DVT) occurs at a lower rate in Asia than in the rest of the world. We wanted to study the significance and efficacy of low molecular weight heparin (LMWH) in prophylaxis of DVT in major general surgical patients in the Kashmir Valley (India, Asia) so as to make it a routine in our patients. Patients and Methods: This was a prospective study in which the effect of LMWH was compared with no prophylaxis. Results: LMWHs are more effective than no prophylaxis in the prevention of DVT and pulmonary thromboembolism in highest-risk general surgical patients (odds ratio = 16.64; 95% confidence interval = 3.63–1130.03; P-value = 0.014). Conclusion: LMWHs have a significant prophylactic effect on DVT in general surgical patients, with a higher benefit to risk ratio, and, in spite of the low incidence of DVT in Asia, its prophylaxis should routinely be considered in this part of the world as well, preferably in the form of LMWHs.

Jejunogastric intussusception presenting as tumor bleed

Jejunogastric intussusception (JGI) is a rare but serious complication of previous gastrectomy or gastrojejunostomy, and a delayed diagnosis can lead to catastrophe. It can present as hematemesis, and an endoscopist aware of the condition can diagnose it early. We present a case of JGI presenting as hematemesis and diagnosed as tumor bleed on endoscopy. Diagnosis of JGI was confirmed on laparotomy, gangrenous efferent limb was resected and a fresh gastrojejunostomy performed.

Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: a prospective study.

AIM To compare the results of subcutaneous internal lateral sphincterotomy under local anesthesia and nitroglycerin ointment treatments in acute and chronic anal fissures. METHODS This was a comparative, prospective study of 340 patients of acute and chronic anal fissure. The patients voluntarily opted either for the surgical procedure under local anesthesia, or the nitroglycerin treatment. All the patients were followed with regular checkups and complaints were documented. RESULTS Except for 1.75% patients having bleeding/hematoma formation, and with a dropout of 2.60% patients, no failure, recurrence or long term complications like incontinence, were observed in patients who underwent subcutaneous internal lateral sphincterotomy after a mean follow up of 28 months. With surgical treatment pain, bleeding per rectum and constipation showed significant improvement as compared to nitroglycerin treatment. Fissure healing was 100% in surgical group as compared to 56.90% in medical group (P=0.000, odds ratio=344.6). Nitroglycerin was equally effective in acute and chronic fissures (P=0.096). CONCLUSION Subcutaneous internal lateral sphincterotomy under local anesthesia is more curative, easy and safe, in the hands of a beginner as well as an experienced surgeon, with highest patient satisfaction, and should be considered as the first line of therapy in both chronic and resistant/recurrent acute anal fissures.

Post Traumatic Isolated Ureteropelvic Junction Avulsion in a Child

Isolated ureteropelvic junction injuries due to blunt trauma are very rare and are missed at initial presentation in more than 50% patients. Hence they need high index of suspicion for diagnosis which is the main aim of reporting this case.

Fosfomycin tromethamine. Antibiotic of choice in the female patient: A multicenter study.

Introduction The aim of this study was to evaluate oral single/multiple doses of Fosfomycin Trometamol with clinical and microbiological efficacy in: Asymptomatic bacteriuria in pregnancy. Endourological procedures. Lower urinary tract infections. Material and methods This prospective, uncontrolled, open label study was conducted in two tertiary hospitals over a period of three years. A total of 400 patients were included in the study. Group A (200 patients) with asymptomatic bacteriuria in pregnancy and Group B (200 Patients) with symptomatic lower urinary tract infections and with any day care endourological procedures were enrolled in our study. Efficacy end points like post- antibiotic urinalysis, microbiological efficacy and clinical improvement with adverse effects of the drug were evaluated. Results Of the 400 patients studied, 98% returned for follow-up. Out of the 304 urinary isolates in Table 2 (ASB and symptomatic LUTS) grown on urinary culture, majority of the isolates were Gram-negative Enterobacteriacae family. After oral single/multiple doses of fosfomycin, bacterial eradication, bacterial persistence, bacterial reinfection were 96.3%, 3.9%, 3.9% respectively (Figure 2). No isolates were grown in 8 cases (Table 2). However, on administration of the drug 23.5% patients noticed diarrhea (loose stools) followed by itching (19.7%) in genital area (Figure 1). Conclusions Fosfomycin Trometamol is a bactericidal antibiotic with a broad spectrum activity against Gram-positive also Gram-negative bacteriae. It has an advantage of oral single /multiple doses, higher eradication rate of bacteria after 48 hours, excellent tolerability and safety in pregnancy and other female age groups. We recommend Fosfomycin Trometamol as the drug of choice particularly in patients with poor drug compliance and for minor day care endourological procedures.

Robotic-assisted versus laparoscopic partial nephrectomy: An experience with a novel technique of suturing

This study was conducted to evaluate whether robotic-assisted laparoscopic partial nephrectomy (RALPN) is superior to laparoscopic partial nephrectomy (LPN) with regard to warm ischemia time and complications and, in addition, to report our novel technique of suturing in partial nephrectomy (PN). This was a prospective study carried out over a period of six years at our institute. A single surgeon performed PNs laparoscopically (17) and with robotic assistance (16). Only exophytic tumors were included and a novel technique of knotless and bolster-less suturing using Hem-o-loc clips was used to close the renal defect. There was no difference in intra-operative and post-operative blood loss between the two groups. However, LPN patients had significantly longer mean warm ischemia time (24.1 vs. 30.1 min, P <0.001) and operating time (157.5 vs. 192.5 min, P <0.001). Also, hospital stay was comparable between the two groups. RALPN is technically easier and also safer than LPN because of its advanced degrees of freedom, decreased warm ischemia time and reduction in the total operating time. However, these observations need further validation by larger and randomized trials. Based on our study, we recommend RALPN wherever there is availability of robot and if cost is not an issue.

A study to evaluate the effect of ratio of donor kidney weight to recipient body weight on renal graft function

Aim and Objectives: To study the effect of the ratio of donor kidney weight (dkw) to recipient body weight (rbw) on short and long term graft function in live donor kidney transplant patients. Materials and Methods: It was a prospective study of 79 live donor kidney transplant recipients. Patients were divided into three groups depending on the ratio of dkw in grams to rbw in kilograms. Serum creatinine in milligrams percent on the day of surgery, 7th day, 1 month, 6 months, 1 year, and 3 years after the surgery was recorded and their means compared. Results: The comparison showed that the decrease in mean creatinine level was more in group three patients as compared with group 2 and one patients at 7 days (1.04,1.44 and 1.59 in group 3,2 and 1 respectively) and 30 days (1.12,1.36 and 1.45 in group 3,2 and 1 respectively), showing that higher dkw/rbw ratio is beneficial with respect to the early graft function. However this decrease was not statistically significant (P value –0.256 and 0.358 respectively on 7th and 30th day). Furthermore long-term function was not different among these three groups. Conclusion: The ratio of dkw to rbw does not have a significant effect on long-term graft function inspite of an early improvement in the function with increased dkw to rbw ratio.