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   Table of Contents - Current issue
January-April 2020
Volume 3 | Issue 1
Page Nos. 1-31

Online since Friday, October 2, 2020

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Looking forward to a post-COVID era: A mentor's perspective p. 1
Brij B Agarwal, Sneh Agarwal, Kushal Mital
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Robotic transanal palliation of rectal tumors in frail patients: How i do it? p. 4
Aram Rojas, Mahir Gachabayov, Luis Quintero, Daniel M Felsenreich, Roberto Bergamaschi
Frail patients with malignant tumors of the rectum may be candidates for palliative robotic transanal surgery, given increased risks for perioperative morbidity and mortality. We, herein, described the surgical technique of robotic transanal surgery and attempted to provide readers with a concise insight into the current state of this procedure.
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Magnetic resonance imaging versus clinical examination in the diagnosis of fistula-in-ano: A comparison at a high-volume fistula center p. 7
Sandeep Mehta, Parvez Sheikh
Background: Proper treatment of fistula-in-ano is based on the accurate diagnosis. Digital rectal examination helps delineating the changes associated with the fistula, as well as helps in knowing the course of the same. Magnetic resonance imaging (MRI) is a well-tolerated, painless, and accurate diagnostic modality that helps in predicting the tract-course. Although MRI may be an accurate radiological assessment tool, it may not be accessible to the surgeon and the patients, especially in the interior parts of the country. Hence, we sought to compare the evaluation efficacy of MRI versus clinical examination in the diagnosis of fistula-in-ano at a high-volume fistula center. Aim and Objectives: 1. To analyze the sensitivity of clinical findings viz-a-viz, the operative findings in a prospective study in cases of complex fistula-in-ano 2. To analyze the sensitivity of MRI findings viz-a-viz the operative findings in a prospective study in cases of complex fistula-in-ano 3. To compare the sensitivity of clinical findings and MRI findings in cases of complex fistula-in-ano. Study Design: A prospective, observational study with clearance from the Institutional Ethics Committee was undertaken over the period of 2 years in a tertiary care hospital with a sample size of 50. Results: 1. Fifty patients with a mean age of 40.98 years were included in the study 2. Male predominance was seen in the study as 84% were males to 16% females 3. The most common type of fistula-in-ano detected by all the methods of assessment was anterior trans-sphincteric (19 out of 50 by clinical assessment, 16 out of 50 by intra-operative assessment, 14 out of 50 by MRI assessment) 4. Clinical examination was more sensitive (88%) than the MRI examination (72%) in accurately detecting the type of fistula-in-ano 5. The associated abscesses were more sensitively detected by MRI (75%) as compared to clinical examination (31.25%) 6. The most common location of internal openings of fistula-in-ano was 6 o'clock position (27 out of 50 on clinical examination, 27 out of 50 by intra-operative examination, and 21 out of 50 by MRI examination) 7. The locations of internal openings were detected by clinical examination with 100% accuracy. Conclusion: Clinical examination is a sensitive modality for the diagnosis and classification of fistula-in-ano. In places where MRI is unavailable, good technical skills on the part of the surgeon can help in accurately predicting the type and openings of fistula on clinical examination.
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Intraluminal bypass tube across colorectal anastomosis: An alternative to stomas p. 12
Navneet Mishra, Sakshi Goyal, Vishal Bansal
Introduction: Colorectal anastomotic leakage is a serious complication of colorectal surgery with high morbidity and mortality rates. Anastomotic leakage accounts for prolonged hospital stay and compromised postoperative quality of life, with aided psychological and economical burden to one's life. Currently, the most commonly used method to prevent leakage is by diversion ileostomy procedure, which has its own complications and morbidities. In recent decades, various studies that aimed at lowering the incidence of anastomotic leakage have been tried including the use of intraluminal bypass tube. In our study, we have introduced an intraluminal bypass tube through the anal canal reaching upto the proximal colon across the anastomotic site.The distal end of the tube was fixed with perianal skin to prevent the dislodging of the tube, thereby reducing intraluminal pressure as flatus follows the path of least resistance. Furthermore, it helps to prevent gush of the fecal stream coming in contact with the anastomotic site to some extent. Thus, we found this method as potentially simple and effective in reducing anastomotic leakage. Background: Currently, the only clinically valid method to prevent morbidity and mortality related to colorectal anastomotic leak (AL) is by construction of protecting ileostomy. The intraluminal bypass tube might also be a possible way to protect the anastomosis. Aims: The study aims to evaluate the usage of intraluminal bypass tube for the reduction of anastomosis-related morbidity and stoma creation in colorectal surgeries. Design: This was a prospective and observational study. Materials and Methods: The present study was conducted between January 2019 and December 2019. Twenty patients who underwent colorectal surgeries were studied. After completion of anastomosis, the latex tube was implanted and removed after 5 ± 1 days. Patients were followed for 10 days. Information about adverse events, ALs, and tolerance was collected. Results: In our study, there were twenty patients who underwent colorectal surgery and most of them were operated on due to colorectal malignancy 16 (80%). The postoperative period was uneventful. No anastomotic complications (hematoma, stricture, or abscess) or any adverse effects of the tube (ulceration of colon) were observed. Moreover, patients were discharged after 11–16 days of the surgery. Conclusions: Intraluminal bypass tube may provide a safe alternative for fecal diversion over a newly created anastomosis without the complications related to stoma creation and closure. However, larger randomized prospective studies should be performed in the future to confirm these findings.
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Colorectal surgery: Is there a need to recognize it as a separate super specialty in India? p. 16
Asif Mehraj, Nisar A Chowdri
Colorectal surgery is an established super specialty in most parts of the world. However, in India, this is yet to be recognized as a separate super specialty. Colorectal surgery has a vast scope and needs dedicated training to treat complex colorectal diseases. There is enough scientific evidence to prove that outcomes for such diseases are improved in the hands of dedicated colorectal surgeons. So far in India, the process of granting it the status of a separate super specialty has been initiated but it needs further efforts to formally do so and also start super specialty courses such as MCh/DNB in the field. In this review, we will give a brief historical background of the specialty of colorectal surgery, the scope of colorectal surgery, the scientific evidence to prove that better patient outcomes are achieved in the hands of dedicated colorectal surgeons and finally the journey of efforts that have been carried so far for recognizing this as a separate super specialty in our country.
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Should colorectal surgery be a separate superspecialty in India? p. 23
Subhashish Das, Samiran Nundy
Colorectal surgery is demanding and requires a certain degree of operative skill. The literature also suggests that the outcome of patients after colorectal surgery depends on the surgical expertise as well as the volume of colorectal cases in a hospital. Most parts of the world have already designated colorectal surgery to be a separate superspecialty, but in India, there is still little enthusiasm for this idea. However, considering the increasing incidence of colorectal cancer in India, especially in our younger population, we should consider whether it has become necessary to train doctors in such complex procedures from the beginning of their careers. However, whether colorectal surgery should be designated to be a separate superspecialty in this country is still debatable, but the initiative taken by the Association of Colon and Rectal Surgeons of India with their fellowship and instructional courses should be examined carefully.
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Rare presentation of congenital gut malrotation as adult cecal volvulus p. 26
Zubair Afzal Khan, Mudassir Ahmad Khan, Ghulam Ali Shah
Incomplete or faulty rotation and fixation of the gut during 5th–11th week of the fetal life results in intestinal malrotation. Cecal volvulus is a rare (1%–1.5%) cause of intestinal obstructions in adults. However, it accounts up to 25%–40% of all volvuluses involving the colon. Cecal volvulus due to malrotation presenting as an intestinal obstruction in an adult is very rare, and only few cases are reported in the literature. We present a case report of a 33-year-old adult male who presented to the emergency with a 2-day history of pain abdomen and vomiting with no significant past history. Per abdomen examination revealed a tender lump in the right paraumblical region. The diagnosis of intestinal obstruction was made on clinical and X-ray features. Emergency laparotomy was done. However, to our surprise, we found that the patient is having malrotated gut with cecal volvulus with the features of intestinal obstruction. The cecal volvulus was carefully de-torted, and right hemicolectomy with hand-sewn end-to-side ileotransverse anastomosis was done. Postoperatively, the patient behaved well and was discharged on the 8th postoperative day.
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Response to Quo Vadis COVID responder – Beat the Chinese virus, carpe diem p. 30
Rinelle Mascarenhas
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