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   Table of Contents - Current issue
September-December 2019
Volume 2 | Issue 3
Page Nos. 53-100

Online since Tuesday, September 22, 2020

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President's message p. 53
Niranjan Agarwal
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Academics and training of residents in pandemic norm of physical distancing and restrained surgeons – Remembering Osler and Halsted! Highly accessed article p. 55
Brij B Agarwal, Sneh Agarwal, Neeraj Dhamija, Roy V Patankar, Niranjan Agarwal
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Complete mesocolic excision for colon cancer p. 58
Puvvala Sriphani, Kotagiri Sreekanth, Gogineni Tarun Chowdary, Vasureddy Challa, Ajay Chanakya Vallabhaneni, Deepak Yadlapalli
Background: The aim of the present study was to define the complete mesocolic excision (CME) in conjunction with central vascular ligation (CVL) as the defined surgical treatment for colon cancer. Methods: A prospective study was conducted between August 2014 and August 2017, at GSL Medical College and General Hospital. A total of 46 patients (31 cases in open and 15 in the laparoscopic arm) demographic data, operative details, and postoperative outcomes, follow-up, the pathologic results were reviewed. Results: All patients (n = 46) underwent an elective CME + CVL for colon cancer. The mean age of patients was 57.8 ± 16.6 years. Of the 46, 28 were male, and 18 were female. The mean operation time was 61.2 ± 155.2 min. The mean blood loss was 88.6 ml. The mean number of total harvested lymph nodes was 28.6. The mean length of the hospital stay was 12.9 days. Conclusion: Based on the data presented in this study, CME with CVL is a feasible and safe procedure for treating colon cancer. Although the present study had certain limitations, like its small study, patients from a single center, CME with CVL was found to lead to better oncological outcomes for the colon surgery.
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Surgical site infection in colorectal surgery p. 63
Arshad Ahmed Baba, Afshan Anjum Wani, Asif Mehraj, Nisar Ahmad Chowdri, Fazl Qadir Parray, Rauf A Wani, Mudassir Ahmad Khan
SSI is a common complication following colorectal surgeries. We present data on the incidence of the same and the factors attributed for its causation at our centre which is a tertiary care centre and a high volume centre for colorectal surgeries. Of the total 538 patients, 316 (58.7%) were males while 222 (41.3%) were females. Mean age of the patients was 47.36±15.57 years, with a minimum age of 18 years and a maximum of 85 years. Elective procedures contributed for 84.01% (452) while 15.98% (86) cases were performed as emergency procedures. Of the total 538 patients 452 patients were electively operated, of which 67 (14.8%) developed SSIs. In emergency procedures 86 patient were operated, of which 31 (36.0%) developed SSI. In our study, total SSI was observed in 67 cases, of which superficial SSI were 46 (68.65%), and deep SSI cases, were11 (16.4%), and organ space SSI cases were 10 (14.9%).
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Pilonidal sinus in South India: A retrospective review p. 71
Dilip Rajasekharan, Jayanth Bannur Nagaraja, Srinath Subbarayappa
Introduction: Pilonidal sinus means a cavity or sinus in the subcutaneous tissue with a tuft of hair embedded in granulation tissue which communicates with the skin surface by a track lined usually by squamous epithelium which is continuous with the epidermis. We aim to identify the demographic and clinical characteristics and treatment modalities in patients with pilonidal sinus (PS). Materials and Methods: This was a retrospective analysis involving records of patients diagnosed with pilonidal sinus in Apollo BGS Hospitals, Mysore, from January 2007 to January 2019. Results: One hundred patients were identified with maximum cases in the age group of 16–25 years (61%). The male-to-female ratio was 2.98:1, with an increase in prevalence in those with sedentary occupations. The most common location was the natal cleft (94%), and risk factors included hirsutism. The maximum duration of hospital stay was 2 days (65%), and the most common presenting symptoms were discharge (77%), pain (74%), and swelling (52%). The average duration of symptoms was 7.82 days. Obesity (19%) was not found to be a significant risk factor. Maximum cases (73%) underwent excision and laying open technique. The recurrence rate of the study was 19%. Conclusion: Despite advances in medicine, pilonidal sinus still remains a bane. While numerous treatment modalities exist, there is no one ideal method for management, and the choice of surgery relies largely on the treating surgeon.
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Jivaka: The great surgeon and physician of ancient India p. 77
Ajaya Kashyap
Background: Indian civilization has been home to some of the greatest surgeons since antiquity. Jivaka has been one of the greatest. Three different systems of medicine including Indian, Thai and Chinese look up to him as one of the greatest physicians and surgeons in antiquity. Aims and Objectives: The aim of the present article was to study his contributions to modern medicine and specifically to surgical techniques. Results: Jivaka's approach to surgery was quite modern in giving due importance to pre and post surgical care. His famous cases and innovations include the surgery for fistula in ano, surgical treatment of a volvulus as well as surgery for hydrocele. He was the physician to Lord Buddha and took care of him for several ailments. Conclusion: While we study about the great surgeons in the medevial and modern times we only have to look back at great surgeons like Jivaka in antiquity to realize how it all started.
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Experience of surgeon in training in COVID Era p. 80
Ravi Bhushan Jha Rajeev, Manish Kinra
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Experience of a Himalayan doctor couple during COVID-19 p. 82
Rakesh M Gautam, Sapna Sharma
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Handling of surgical cases in a forward military location: Experience during the corona times p. 84
SC Gupta, Manish Sharma
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COVID-19 global health security and costs: Up close and painfully personal! p. 86
Suviraj James John, Sudhir Kumar Kalhan, Mukund Khetan, Vivek Bindal
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The science, techniques, and art of anal fistula treatment p. 88
Arshad Ahmad
Anal fistula is a diverse disease. There is no single treatment which is effective for all types of anal fistulas. The management of simple anal fistula is straightforward, and a fistulotomy is recommended. However, in complex anal fistula if fistulotomy or fistulectomy is performed, it is combined with primary sphincter repair. Alternatively, a sphincter sparing procedure may be performed for complex anal fistula. The basic principle of sphincter preserving surgery for anal fistula involves three basic steps: disconnection of the tract from the anal canal, deepithelialization of the tract, and drainage from the external opening. The disconnection of the fistula tract from the anal canal can be achieved by direct closure of the internal opening, with endoanal advancement flap or with ligation of intersphincteric fistula tract procedure. After disconnecting the fistula from the anal canal, the remaining tract, which is now converted into a sinus is cleaned and deepithelialized. The tract is deepithelialized either mechanically by curetting or by using an energy source-like LASER or endocautery. The external opening of the tract is widened so that it does not close and continues to drain until the fistula is completely healed. The art of anal fistula treatment involves the assessment of the extent of the disease and selecting appropriate treatment strategy for a particular patient. None of the procedures are technically very demanding; however, selecting the right procedure for a particular patient is important.
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High versus low ligation of inferior mesenteric artery in the radical resection of rectal cancer p. 94
Rajiv Nandan Sahai
Background: Despite ongoing debates, there is still no consensus regarding where to divide the inferior mesenteric artery for oncological reasons in rectal cancer: at its origin from the aorta (high ligation) or distal to the origin of the left colic artery (low ligation). Objectives: The purpose of this study was to compare the outcomes of high and low ligation of the inferior mesenteric artery in rectal cancer surgery. Data Sources: Medline, embase, cinahl, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN Register were searched. Study Selection: Randomized controlled trials investigating outcomes of curative anterior resection in patients with cancer of the rectum were included. Interventions: High ligation of the inferior mesenteric artery was compared with low ligation technique. Main Outcome Measures: We measured the total number of lymph nodes harvested, anastomotic leak, postoperative complications, postoperative mortality, operative time, intraoperative blood loss, conversion to open surgery, overall survival, and disease-free survival. Results: Analysis of 1102 patients from 8 trials suggested no difference between high and low ligation of the inferior mesenteric artery in terms of total number of lymph nodes harvested (mean difference = –0.87; p = 0.26), anastomotic leak (OR = 1.39; p = 0.15), postoperative complications (OR = 1.39; p = 0.78), postoperative mortality (risk difference = –0.00; p = 0.48), operative time (mean difference = –1.99; p = 0.79), intraoperative blood loss (mean difference = –2.28; p = 0.77), conversion to open surgery (risk difference = 0.01; p = 0.48), 5-year overall survival (OR = 0.76; p = 0.32), 5-year disease-free survival (OR = 0.88; p = 0.58), overall survival at maximum follow up (OR = 0.80; p = 0.43), and disease-free survival at maximum follow-up (OR = 0.83; p = 0.35). Limitations: Limited data were available on functional and long-term survival outcomes. Conclusions: There is no difference between high and low ligation of the inferior mesenteric artery in terms of oncological outcomes or postoperative morbidity and mortality. The available evidence is subject to potential confounding by the use of neoadjuvant therapy, adjuvant therapy, disease stage, location of tumor, and use of protective stoma. Functional outcomes including postoperative bowel, urinary and sexual function, and long-term survival outcomes should be the outcome of study in future trials.
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Tuberculous fistula-in-ano p. 97
Parmeshwar Bambrule, Mohammad Taha Mustafa Sheikh, Tarun Mittal, Asish Dey, Anmol Ahuja, Bipul Agarwal, Deepak Patel, Vinod K Mailk
Perianal tuberculosis (TB) is a rare diagnosis in cases of fistula-in-ano, especially in cases where healing has not occurred despite multiple surgical interventions. One should consider a high level of possibility of harboring TB, which may be the reason behind the failure of treatment and multiple recurrences. The histopathological finding includes epithelioid cell granulomas, and caseation necrosis would be an essential guide in such cases along with the other tests such as acid-fast bacillus staining and culture and Mantoux test. The treatment of tuberculous fistula-in-ano includes not only surgical but also the full course of four-drug anti-tubercular treatment for at least 6 months and regular follow-up to cope up with recurrence.
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