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   Table of Contents - Current issue
January-April 2019
Volume 2 | Issue 1
Page Nos. 1-23

Online since Saturday, May 30, 2020

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Quo vadis COVID responder – Beat the chinese virus, carpe diem p. 1
Brij B Agarwal, Nayan Agarwal
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Transanal minimally invasive surgery p. 3
Mohammad Taha Mustafa Sheikh
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Effect of colon care bundle on surgical site infections in colorectal surgery p. 6
Ajaz Ahmad Bhat, Gowhar Aziz Bhat, Nisar Ahmad Chowdri, Zamir Ahmad Shah, Fazl Q Parray, Rauf Ahmad Wani
Objectives: Surgical site infection (SSI) has been recognized as the third most common health-care-associated infection. Colorectal surgeries are consistently associated with higher SSI (4%–45%) relative to other surgeries. SSI not only increases morbidity but also causes severe economic impact throughout the world. The aim of the present study was to study the effect of colon care bundle on SSI and identify the risk factors involved in SSI in colorectal surgeries. Methods: Two hundred and seventy patients who underwent elective colorectal surgery between July 2015 and June 2017 were included in the study. Patients were assigned to bundle care group (n = 150) and control group (n = 122). In the colon care bundle group, patients received aseptic cleaning of skin with chlorhexidine (night before and morning), clipping of hair before surgery, nonabsorbable oral antimicrobial agents, maintenance of normothermia during surgery, and high-inspired oxygen intra- and postoperatively. Both groups received parenteral antibiotics for 24 h. SSI was defined as per the Centers for Disease Control and Prevention. Patients were followed for 30 days postoperatively. Results: Both groups were comparable with respect to age, gender, comorbidities, obesity, and other variables. SSI in the colon care bundle group (8.7%; n = 13) was less than in the control group (18.9%; n = 23), which was statistically significant (P = 0.014); however, effect on deep and organ/space infection was not statistically significant. The incidence of SSI increases with age and superficial SSIs were more common than deep or organ/space infection in both groups. SSIs were more common in wounds of rectal surgeries than colon surgeries (46% vs. 15%, P = 0.926). SSIs were more common in patients with diabetes mellitus (39.1% vs. 23.1%), patients with increased body mass index (BMI) (43.5% vs. 38.5%), patients with decreased serum albumin (69.6% vs. 53.8%), smokers (60.9% vs. 53.8%), and patients with preoperative chemoradiation (65.2% vs. 61.5%) in both groups (control group vs. bundle group), but did not reach statistical significance. Out of 36 SSIs in two groups, 24 were culture positive with Escherichia coli, followed by Enterococcus faecalis as common organisms. Conclusion: Colon care bundle is an effective method of reducing SSI in colorectal patients. Overall SSI was found to be significantly less in the study group than in controls. On subanalysis, superficial SSI was seen more in the control group. The infections were seen more often in diabetics; smokers; and patients with increased BMI, decreased serum albumin, preoperative chemoradiation, and rectal operations, though statistically not significant. However, efficacy of individual component of care bundle on SSI remains unanswered.
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Endoluminal negative pressure therapy (Endo-SPONGE) for anastomotic leaks following transanal total mesorectal excision: Our experience p. 12
Diwakar Ryali Sarma, Pratik Bhattacharya, Howard Joy
Introduction: The management of anastomotic leaks in rectal cancer surgery poses a huge challenge, especially in patients developing a leak post transanal total mesorectal excision (taTME). Endoluminal negative pressure therapy is a minimally invasive method of managing the situation effectively and most times preventing a highly morbid reoperation. Aim: The aim was to study the effectiveness and safety of Endo-SPONGE therapy in the management of anastomotic leaks following taTME. Methods: We looked at our data spanning 4 years of patients developing anastomotic leaks following taTME and their management. The primary outcome measure was complete closure of the anastomotic leak and/or abscess cavity. The secondary outcome measures included the length of stay, stoma closure, and complication rates. Results: Nine patients from our series had anastomotic leak following taTME, four of which had endoluminal negative pressure therapy and were included in the study. These were all male patients and had either T2 or T3 tumor. The median age was 59 years, with a median American Society of Anesthesiologists grade of II and the most common comorbidity being diabetes mellitus (75%). The mean average body mass index of these patients was 25, and the initial (taTME) preoperative P-POSSUM morbidity and mortality median was 49 and 3%, respectively. The median distance of the anastomosis was 4 cm from the external anal sphincter. A median of six Endo-SPONGE was used per patient with a 100% success rate. Low negative pressure was advocated in all cases (80–110 mmHg). The average length of stay was 57 days. The most frequent complication of the Endo-SPONGE was a presacral abscess, followed by stenosis of the anastomosis. There were no mortality in the Endo-SPONGE group and no local recurrence of cancer. Conclusion: Introduced in the early 21st century, endoluminal negative pressure therapy is a viable option to consider for the management of anastomotic leak following low rectal anastomosis in taTME. Our initial experience with Endo-SPONGE is promising and was able to prevent high-risk redo operations or Hartmann's procedures in the select group of patients, thereby not impairing the quality of life significantly.
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A new modification of limberg flap for correction of severe anal stenosis p. 16
Ajitkumar Shripad Borkar, Ulhas Yashwant Kulkarni
This case presents two new concepts. First, a new modification of Limberg flap is introduced where the flap is raised by extending the long axis of the rhombic defect. It is particularly useful for correction of contracture with the vector of release lying along the short axis. Second, we are introducing a novel method for surgical treatment of moderate or severe anal stenosis. This flap brings an ample amount of skin with excellent blood supply and mobility with the least amount of tension at the suture line. It also allows the excision of the cicatrix and can avoid internal sphincterotomy. Donor site closure scar does not add to the vector of contracture.
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Giant solitary cecal diverticulum p. 20
Ipseet Mishra, Rohan Kumar, Washim Mollah, Arup Kumar Dutta
Right iliac fossa (RIF) mass is a common case scenario in surgical practice with a wide range of differentials. Colon carcinoma, appendicular lump, ileocecal tuberculosis, and tubo-ovarian mass are among the common diagnoses. Diverticulosis of the colon presents as an abdominal mass when complicated by perforation, abscess formation, obstruction, or giant transformation. This report describes the case of a giant colonic diverticulum at cecum in a 30-year-old male presenting as a huge RIF mass.
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