Perforation peritonitis remains a life-threatening surgical emergency with widely varying aetiological profiles and outcomes across different geographic regions. While data from Western populations are abundant, large-scale Indian studies remain limited. This study aimed to assess the clinical profile, outcomes, and independent predictors of mortality in patients undergoing emergency laparotomy for perforation peritonitis. This prospective observational study was conducted at a tertiary care hospital in northern India from 1 September 2025 to 31 March 2026. A total of 200 patients aged > 18 years undergoing exploratory laparotomy for perforation peritonitis were enrolled. Data on demographic characteristics, clinical presentation, intraoperative findings, and postoperative outcomes were collected. Multivariable logistic regression was performed to identify independent predictors of 30-day mortality. The overall 30-day mortality was 24
Postoperative pancreatitis (POP) is a relatively underexplored condition and may contribute to postoperative pancreatic fistula (POPF). This study aimed to evaluate the association between vascular density at the pancreatic resection margin and POP; and determine the incidence of POP and its correlation with POPF. Consecutive patients undergoing pancreaticoduodenectomy in a single surgical unit of a tertiary care centre between February 2018 and October 2019 were included. Serum amylase (postoperative day 1) and drain fluid amylase (postoperative day 3) were measured. Vascular density scores were calculated from histopathological slides of the pancreatic resection margin. POP was defined as serum amylase exceeding the upper limit of normal on postoperative day 1. POPF was defined as clinically relevant fistula (Grade B or C) according to the ISGPF 2016 update. Among 33 patients (mean age: 56 years; 20 men), POP occurred in 54.5
The advent of obesity management medications have resulted in a noticeable fall in the number of metabolic and bariatric surgery. We believe that MBS will continue to play a key role as an adjunct therapy especially in stage 3 or 4 of Edmonton Obesity Staging System. We also predict the shift to less radical procedures like sleeve gastrectomy. With this letter we attempt to capture the ever-changing management in the advent of newer obesity-management-medications. We have ambitiously tried to predict the future of MBS in this light.
The effect of laparoscopic sleeve gastrectomy on gastroesophageal reflux disease remains controversial. Most published studies rely on symptom-based assessment rather than objective physiological testing. Data from Indian cohorts using gold-standard reflux monitoring are limited. In this small exploratory pilot study, 30 patients with morbid obesity undergoing primary laparoscopic sleeve gastrectomy at a tertiary centre in New Delhi between November 2019 and October 2021 were enrolled. All patients underwent upper gastrointestinal endoscopy and 24-hour multichannel intraluminal impedance-pH monitoring before surgery and again at three months. Resected sleeve specimens were tested for Helicobacter pylori by modified Giemsa staining and real-time polymerase chain reaction. Twenty-eight patients completed follow-up. Mean body mass index decreased from 40.95 (standard deviation 4.47) to 29.45 (standard deviation 3.74) kg/m² (p < 0.001). Non-acidic reflux episodes decreased significantly (median 4 vs. 1; p = 0.034). DeMeester score (p = 0.582), acidic reflux episodes (p = 0.461), and total gastroesophageal reflux episodes (p = 0.093) did not change significantly at the cohort level. Among 12 patients with a normal preoperative DeMeester score, 3 developed de novo pathological reflux postoperatively (25.0
As with all minimally invasive surgical techniques, maintaining the integrity of the specimen during laparoscopic appendectomy is of utmost importance. Laparoscopic appendectomy offers advantages such as smaller incisions, reduced pain, and shorter hospital stay. However, its impact on preserving the integrity of the surgical specimen remains unclear. Our aim is to evaluate the effect of laparoscopic appendectomy on surgical specimen integrity. This retrospective cohort study evaluated the effect of laparoscopic appendectomy on surgical specimen integrity. We retrospectively reviewed patients who underwent surgery for acute appendicitis in our clinic. Imaging findings, presence of perforation, pathology results, use of an endobag, surgical technique, and demographic/clinical characteristics were recorded. Based on these data, the impact of laparoscopic appendectomy on specimen integrity was assessed. In addition, risk factors associated with compromised specimen integrity were analyzed. Among the 1113 patients included in our study, 689 (61.9
Background: Vitamin D deficiency is prevalent among patients with obesity undergoing Metabolic Bariatric Surgery (MBS), potentially impacting surgical outcomes. This study aimed to investigate the prevalence of vitamin D deficiency and its association with factors such as body mass index (BMI), age, and sex in this population. Methods: This cross-sectional study included 217 patients (62.7
Cutaneous horn, also known as Cornu Cutaneum, is a clinical term describing a conical projection of hyperkeratotic material resembling an animal horn. It represents a morphologic reaction pattern rather than a distinct pathological entity and may arise from a wide spectrum of benign, premalignant, or malignant conditions. We report a case of a 60-year-old female who presented with a progressively enlarging, hard, keratinized growth over the anterior abdominal wall, just above the umbilicus. There was no associated pain or systemic symptoms. Clinical examination suggested a cutaneous horn, and routine investigations, including hematological profile, coagulation studies, and viral markers, were within normal limits. No evidence of regional lymphadenopathy or underlying induration was found. The lesion was excised under local anesthesia with a 3-mm margin of normal skin, ensuring complete removal. Histopathological examination confirmed a benign lesion showing hyperkeratosis and acanthosis without cellular atypia or malignancy. Cutaneous horn (Cornu Cutaneum), though predominantly benign, may overlie premalignant or malignant lesions. Early recognition and complete excision with histopathological evaluation are essential for accurate diagnosis and prevention of recurrence or malignant transformation. A high index of suspicion is necessary, particularly in lesions occurring over non-sun-exposed areas.
The optimal long-term management of acute diverticulitis after initial conservative treatment remains uncertain. Elective sigmoidectomy may reduce recurrence and improve quality of life, but concerns persist regarding complications and stoma formation. We conducted a systematic review and Bayesian random-effects meta-analysis of randomized controlled trials comparing elective sigmoidectomy with conservative management in adults with previously conservatively managed acute diverticulitis. MEDLINE, Scopus, and Embase were searched from inception through March 2026. Eligible studies reported at least one long-term outcome, including recurrence, quality of life, or stoma formation. Odds ratios (ORs) and mean differences (MDs) were pooled with 95
Esophageal cancer, in advanced stages, may invade adjacent structures and lead to rare but fatal complications. A 57‑year‑old female patient was diagnosed with esophageal cancer two years ago, refused surgery, and subsequently underwent chemoradiotherapy. Due to progressive dysphagia, a self‑expandable metallic esophageal stent was placed two months prior. This case highlights the development of an aorto‑esophageal fistula following stent placement in esophageal cancer, a complication associated with extremely high mortality.
Stoma-related complications remain a significant source of morbidity, impaired quality of life, and increased healthcare costs despite advances in surgical techniques and perioperative care. Large-scale data describing complication patterns in centres with specialised stoma care services are limited. This study aimed to evaluate the hospital-documented frequency, distribution, and stoma-type–specific patterns of stoma-related complications over six years in a tertiary care hospital. A retrospective descriptive study was conducted including 1002 adult patients who underwent stoma formation between January 2019 and December 2024 in a tertiary care hospital. Data were obtained from hospital electronic records and standardised stoma follow-up forms completed by stoma and wound care nurses. Sociodemographic characteristics, stoma indications, stoma types, operative conditions, stoma site marking, and documented complication data were analysed. Descriptive statistics were used, and associations between stoma type and specific complications were evaluated using chi-square tests. The mean age of the patients was 62.21 ± 13.19 years, and 64.9
Operative difficulty in laparoscopic cholecystectomy (LC) is a major determinant of intraoperative judgment, bailout strategy, and perioperative outcome, yet it remains inconsistently defined across the literature. This systematic review evaluated operative difficulty in LC across risk stratification, intraoperative grading, bailout, and clinical outcomes. A systematic review was performed in adults undergoing LC for benign gallbladder disease. Eligible studies reported formal intraoperative difficulty grading systems, preoperative models predicting difficult LC, outcomes stratified by operative difficulty, or bailout decisions explicitly linked to difficult surgery. The final search was completed on 01 March 2026. Because of heterogeneity in target definitions, grading thresholds, and escalation constructs, the evidence was synthesized qualitatively using a domain-based approach. Twenty-seven primary studies were included. Operative difficulty was characterized using multiple non-equivalent frameworks, including the G10/Sugrue score, Nassar scale, Parkland Grading Scale, Tokyo Guidelines-related difficulty scores, bailout-oriented constructs, and composite difficult-LC endpoints. Greater operative difficulty was consistently associated with longer operative time, greater blood loss, increased use of subtotal cholecystectomy or other bailout strategies, longer hospital stay, and worse perioperative outcomes. Preoperative prediction studies repeatedly identified inflammatory burden, disease severity, gallbladder wall changes, obesity, stone impaction, prior biliary interventions, and selected imaging features as markers of difficult surgery or bailout-prone cases, although prediction targets varied substantially. Operative difficulty in LC is best understood as a continuum linking preoperative risk, structured intraoperative grading, and bailout-oriented escalation. Formal intraoperative grading systems provide the most coherent clinical anchor, whereas prediction models remain limited by target heterogeneity. Greater standardization is needed to improve comparability and support safer management of difficult LC.
This study evaluated the diagnostic value of the delta neutrophil index and related hematological parameters in distinguishing acute appendicitis between pregnant and non-pregnant women. This retrospective single-center analysis conducted between January and October 2024 included 34 pregnant and 81 non-pregnant patients with histopathologically confirmed appendicitis. Preoperative hematological and biochemical parameters, including white blood cell count, neutrophil and lymphocyte counts, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, delta neutrophil index (DNI), C-reactive protein, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase were compared using the Mann–Whitney U test. Median age did not differ between groups (27 [22–30] years vs. 27 [22–30] years; p = 1.000). Pregnant patients had higher neutrophil percentages (81.8 [78.7–86.3] vs. 78.9 [73.3–83.9]; p = 0.020), higher neutrophil-to-lymphocyte ratio (7.68 [5.36–12.65] vs. 5.80 [3.96–7.61]; p = 0.008), and higher delta neutrophil index values (0.06 [0.04–0.10] vs. 0.05 [0.04–0.06]; p = 0.023; DNI
Pediatric papillary thyroid carcinoma (PTC) often presents with aggressive, advanced disease. When a tumor completely engulfs the recurrent laryngeal nerve (RLN), surgeons face a tough choice: shave the tumor to save the nerve, or cut the nerve to ensure all cancer is removed. Clear guidelines for this surgical dilemma in very young children are currently lacking. A 5-year old girl presented with a large goiter and palpable lymph nodes on both sides of her neck. Cytology confirmed PTC. She underwent a total thyroidectomy with bilateral central and lateral neck dissections. During the operation, we found the tumor completely wrapping around the left RLN. To make sure no microscopic cancer was left behind (stage pT3bN1b), we made the intentional decision to sacrifice the nerve. After surgery and radioiodine therapy, her scans showed no remaining cancer. Remarkably, despite losing the left recurrent laryngeal nerve, the child's voice recovered very well and is near-normal. Her wound was healed, and she is currently on thyroxine replacement. In young children with highly aggressive thyroid cancer, prioritizing complete tumor removal by sacrificing an involved RLN is a safe oncological choice. Because children have excellent vocal cord adaptation and neural plasticity, they can achieve impressive voice recovery even after a nerve is permanently removed.
Perforated appendicitis remains one of the most important causes of preventable morbidity in pediatric surgery. Despite substantial advances in diagnostic imaging, laboratory biomarkers, and clinical scoring systems, delayed diagnosis continues to contribute significantly to perforation, postoperative complications, prolonged hospitalization, and increased healthcare utilization. Emerging evidence suggests that delayed diagnosis is a multifactorial process involving patient-related, physician-related, and healthcare system-related factors rather than a single-point clinical failure. To critically evaluate the multidimensional causes of diagnostic delay in pediatric appendicitis and to develop a clinically applicable framework aimed at facilitating earlier recognition and reducing the risk of perforation. A structured narrative review was conducted using PubMed, Scopus, and Web of Science databases. Studies published between January 2000 and March 2026 evaluating pediatric appendicitis, perforation, diagnostic delay, imaging strategies, biomarkers, and clinical decision-making were reviewed. Eligible studies included original research articles, systematic reviews, clinical practice guidelines, and relevant peer-reviewed studies involving pediatric populations. Evidence was synthesized using a thematic framework encompassing patient-related, physician-related, and healthcare system-related determinants of delayed diagnosis. Diagnostic delay in pediatric appendicitis results from the cumulative interaction of multiple factors. Patient-related contributors include young age, atypical symptom presentation, communication limitations, and delayed healthcare-seeking behavior. Physician-related factors include diagnostic uncertainty, cognitive bias, and overreliance on isolated laboratory or imaging findings. Healthcare system-related factors such as limited access to pediatric surgical expertise, emergency department crowding, imaging delays, and variability in institutional pathways further prolong diagnostic timelines. Based on the synthesized evidence, a clinically applicable diagnostic framework emphasizing risk stratification, serial reassessment, timely imaging, and early surgical consultation was developed. Missed perforated appendicitis should be viewed as the consequence of cumulative delays occurring across multiple stages of care. Reducing perforation rates requires an integrated approach combining heightened clinical vigilance, structured diagnostic pathways, repeated clinical assessment, and timely access to pediatric surgical expertise. The proposed framework may help standardize evaluation and reduce preventable morbidity in children with suspected appendicitis.
Breast lymphatic malformations are rare benign slow-flow vascular anomalies, usually presenting as localized cystic lesions amenable to limited excision. Diffuse breast involvement with extension into adjacent compartments is exceedingly uncommon. We report a 21-year-old woman presenting with progressive enlargement of the right breast over 10 months, with a history of recurrent swellings since childhood. Ultrasonography demonstrated a multiloculated cystic lesion involving the right breast and axilla. Magnetic resonance imaging revealed a large (24 × 17.5 × 9.5 cm) multiloculated cystic lesion replacing the breast parenchyma with extension into subcutaneous, intermuscular, axillary, intercostal, and supraclavicular regions. Given the diffuse nature, prior recurrence, and extensive infiltration, right total mastectomy was performed. Histopathology confirmed lymphatic malformation. This case highlights the role of MRI in delineating disease extent and the need for definitive surgical management in selected patients with extensive, recurrent disease who present late.
Anal stenosis (AS) is a condition characterized by the narrowing of the anal canal, commonly resulting from fibrotic changes after hemorrhoidectomy. This leads to difficult and painful defecation, reduced anal canal elasticity, and may impair continence. Moderate to severe AS often requires surgical intervention when conservative treatments fail. This study aims to assess the outcomes and efficacy of calibrated rhomboid-flap anoplasty in patients with moderate to severe anal stenosis following hemorrhoidectomy. Thirteen patients (8 males, 5 females; mean age 51.7 ± 4.2 years) with moderate (61.5
Situs inversus totalis (SIT) is a rare congenital condition characterized by mirror-image arrangement of thoracoabdominal organs, occurring in approximately 1 in 4,000–8,000 individuals. Choledochal cysts (CC) are also uncommon congenital anomalies of the biliary tree, with much higher prevalence in Asian populations. The coexistence of SIT and CC, particularly in children, is extremely rare, posing diagnostic and surgical challenges. We report a 15-month-old toddler who presented with intermittent abdominal discomfort, occasional non-bilious vomiting, and history of fever, without jaundice. Clinical examination revealed dextrocardia. Ultrasonography and magnetic resonance cholangiopancreatography (MRCP) confirmed SIT with a Type I choledochal cyst. No intrahepatic biliary dilatation was noted. Intervention: Laparoscopic excision of the choledochal cyst with hepaticoduodenostomy was performed using mirrored port positioning to account for reversed anatomy. The cyst and gallbladder were excised, the distal common bile duct was ligated, and an interrupted hepaticoduodenostomy was done with 4 − 0 Vicryl. The postoperative period was uneventful. At 30 months follow-up, patient remained asymptomatic with appropriate weight gain and normal development. Postoperative liver function tests were within normal limits. Conclusion: Laparoscopic choledochal cyst excision with hepaticoduodenostomy is feasible and safe in pediatric patients with SIT, though it requires meticulous preoperative imaging, careful operating room setup, and adaptation to mirror-image anatomy.
The purpose of this study was to evaluate the clinical history and hemodynamic changes of type B aortic dissection (TBAD) during 10 years of CTA-based imaging follow-up after thoracic endovascular aortic repair (TEVAR), with 12-year clinical follow-up, in a single patient. A 59-year-old TBAD patient was enrolled in this single-case longitudinal retrospective analysis. The patient initially presented with a thrombosed thoracic and patent abdominal dissection and was treated with optimal medical therapy. However, the patient underwent TEVAR 6 months later for a newly developed thoracic aortic dissection. The patient was followed up with serial computed tomographic angiography (CTA) for 10 years after TEVAR and by clinical follow-up for 12 years. Reintervention was performed for a distal stent-graft-induced new entry tear. We reconstructed the CTA images into three-dimensional models to measure the area and volume of the true lumen and false lumen and performed hemodynamic simulations using computational fluid dynamics to measure the pressure, wall shear stress, and blood-flow velocity within the true and false lumens. The area and volume of the true lumen increased postoperatively. The postoperative false lumen pressure gradually decreased and it dropped below the true lumen pressure in the 7th and 10th postoperative years. Focal areas of high wall shear stress were observed at branch/bifurcation or curved segments and in compressed true-lumen segments. There was a decrease in wall shear stress and velocity in the true lumen after TEVAR. In this single patient, TEVAR was associated with altered pressure distribution, including a relative increase in true-lumen pressure, and with decreased wall shear stress and blood-flow velocity in the true lumen. These findings are hypothesis-generating and should not be generalized without validation in larger cohorts.
