Vimal Bhandari

Prospective evaluation of risk factors for mortality in patients of Fournier's gangrene: A single center experience

Introduction: Fourniers gangrene is an aggressive disease with high morbidity and mortality. The aim of this study was to assess risk factors associated with mortality among patients of Fourniers gangrene. Materials and Methods: Between May 2011 and September 2012, all patients of Fourniers gangrene treated at our center were included in the study. All patients underwent emergency surgical debridement and received broad spectrum intravenous antibiotics. Their baseline characteristics, treatment, and follow-up data were recorded and analyzed. Results: A total of 30 patients were included in the study. Of these, six patients (20%) died during the treatment. Age <55 years, total leukocyte count <15000 cumm, extent of the area involved, septic shock at admission, visual analog scale (VAS) <7 at admission, and Fournier gangrene severity index (FGSI) score <8 at admission were significantly associated with increased mortality. Conclusion: In patients of Fourniers gangrene, increased age, total leukocyte count, extent of the area involved, septic shock at admission, VAS score, and FGSI score at admission have a significant association with mortality.

Intra-abdominal pressure in the early phase of severe acute pancreatitis: canary in a coal mine? Results from a rigorous validation protocol.

Background/Aims Intra-abdominal hypertension (IAH) is being increasingly reported in patients with severe acute pancreatitis (SAP) with worsened outcomes. The present study was undertaken to evaluate intra-abdominal pressure (IAP) as a marker of severity in the entire spectrum of acute pancreatitis and to ascertain the relationship between IAP and development of complications in patients with SAP. Methods IAP was measured via the transvesical route by measurements performed at admission, once after controlling pain and then every 4 hours. Data were collected on the length of the hospital stay, the development of systemic inflammatory response syndrome (SIRS), multiorgan failure, the extent of necrosis, the presence of infection, pleural effusion, and mortality. Results In total, 40 patients were enrolled and followed up for 30 days. The development of IAH was exclusively associated with SAP with an APACHE II score ≥8 and/or persistent SIRS, identifying all patients who were going to develop abdominal compartment syndrome (ACS). The presence of ACS was associated with a significantly increased extent of pancreatic necrosis, multiple organ failure, and mortality. The mean admission IAP value did not differ significantly from the value obtained after pain control or the maximum IAP measured in the first 5 days. Conclusions IAH is reliable marker of severe disease, and patients who manifest organ failure, persistent SIRS, or an Acute Physiology and Chronic health Evaluation II score ≥8 should be offered IAP surveillance. Severe pancreatitis is not a homogenous entity.

Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?

AIM To systematically review evidence on pathophysiology of intra-abdominal pressure (IAP) in acute pancreatitis (AP) with its clinical correlates. METHODS Systematic review of available evidence in English literature with relevant medical subject heading terms on PubMed, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved. RESULTS Intra-abdominal hypertension (IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital (prevalence increasing to 50% in those with severe disease). Abdominal compartment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-Biliary-Pancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums (such as fluid therapy, nutrition and antibiotic prophylaxis) with potential to further individualize treatment in AP. CONCLUSION We suggest that IAP be given its due place in future practice guidelines and that recommendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH.

Diagnostic dilemma in an unusual case of common bile duct obstruction.

Biliary obstructions are rarely caused by a foreign body and have received sparse attention. We present an unusual case with pruritis and abdominal pain caused by impacted full length surgical gauze within the common bile duct. The patient had previously undergone an open cholecystectomy. Radiological investigations were inconclusive and suggestive of either a calculus or a cholangiocarcinoma. Surgical exploration revealed full length surgical gauze within the common bile duct. Because imaging modalities are often non-determinant, the possibility of biliary tract obstruction from a foreign body should be borne in mind for patients with unusual presentations, especially those who have previously undergone surgery.

Giant dermatofibrosarcoma protuberans: A rare presentation over face.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive, soft tissue tumor. Its occurrence over face is very rare. We are presenting a case of giant DFSP over left cheek, which produces oncological, functional and esthetic challenges and deals by multidisciplinary team. We also reviewed the relevant literature in short.

Efficacy of Cytokeratin 19 expression on fine needle aspiration cell blocks in pre-operative diagnosis of malignant thyroid neoplasms

Context: Accurate diagnosis of malignant lesions of thyroid remains a challenge, especially when classical features are lacking on cytological examination. Aims: To evaluate the expression of Cytokeratin 19 (CK 19) on cell blocks made from thyroid swellings diagnosed as papillary carcinoma or follicular adenoma/carcinoma on fine needle aspiration cytology (FNAC) smears. Materials and Methods: Aspirates from fifty patients diagnosed as papillary or follicular lesions on FNAC were enrolled in the study. Cell blocks were simultaneously made along with aspiration using standard cell block techniques. These cell blocks were subjected to Cytokeratin 19 immunoassay using immunoperoxidase ABC (avidin biotin complex). Statistical Analysis Used: Chi-square test for statistical significance and Goldman test for sensitivity and specificity. Results: Evaluation of the expression of Cytokeratin 19 on cell blocks revealed that almost all papillary thyroid carcinomas stained strongly positive while all follicular adenomas and follicular carcinomas were found to be negative for CK 19 immunostaining. The difference in frequency of Cytokeratin 19 positive papillary carcinoma and follicular adenomas was statistically significant. The predictive value of a positive CK 19 test was found to be 100% while that of a negative test was 93.9%. Conclusions: Cytokeratin 19 immunostaining in conjunction with fine needle aspiration cell blocks can be a valuable marker in pre-operative diagnosis of papillary thyroid carcinoma along with its variants (sclerosing and follicular). This can help the clinician in formulation of treatment as papillary thyroid carcinoma is treated by radical measures as against the more conservative approach for benign follicular lesions.

A prospective randomized comparative trial between open subinguinal and loupe assisted subinguinal varicocelectome: A single center experience

Introduction: In our study, we reviewed efficacy and complication rates of open subinguinal varicocelectomy (OSV) and loupe assisted subinguinal varicocelectomy (LASV) using seminal and hormonal parameters in a prospective randomized study. Materials and Methods: We prospectively studied 60 males with Grade 2 and Grade 3 varicocele. Thirty patients underwent OSV and the other 30 patients underwent LASV. Intra-operative and post-operative complications along with pre-operative and post-operative seminal, hormonal parameters and testicular volume were compared between the groups. Results: Sperm count, motility and morphology increased significantly in both groups, but the improvement was significantly better in LASV group. (Group A – improvement in sperm count, motility and morphology by 25%, 8.5%, 10.3%, respectively and in Group B – improvement in sperm count, motility and morphology by 110%, 68.59%, 71.1%, respectively. Decrease in serum follicular stimulating hormone (FSH), luteinizing hormone (LH) and increase in serum testosterone were significant in both groups, but the improvement was significantly better in LASV group. (Group A – serum FSH and LH decreased by 17.2%, 23%, respectively and serum testosterone increased by 13.7% and in Group B – serum FSH and LH decreased by 56.9%, 56.65%, respectively and serum testosterone increased by 95.9%). The recurrence (OSV = 13.2% and LASV = 0, P = 0.01) and complication rates were significantly lower in LASV group. Conclusion: Our study shows that LASV is significantly better than OSV regarding efficacy and complication rates.

Gallstone ileus- An uncommon cause of bowel obstruction: A case report and review of literature.

Gallstone ileus occurs when gallstone migrates from the gallbladder to the bowel through a cholecysto-enteric fistula, causing mechanical bowel obstruction. It is an uncommon cause of bowel obstruction. It occurs almost exclusively in the elderly, and accounts for 25% of mechanical small bowel obstruction in patients over the age of 65 years. Clinical diagnosis of gallstone ileus is difficult and usually depends on the radiographic findings. We present a case of 70 year old female with history of unstable angina,