Chronic mesenteric ischemia (CMI) is an underdiagnosed condition characterized by post-prandial pain resulting from progressive mesenteric arterial stenosis. Although traditionally regarded as rare, contemporary evidence indicates a greater prevalence, particularly among elderly females. While multi-vessel involvement is considered classical, symptomatic single-vessel disease is increasingly recognized in the setting of inadequate collateral circulation. Diagnostic evaluation relies on a combination of imaging modalities including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography and selective use of conventional angiography or functional studies in equivocal cases. Revascularization remains the cornerstone of definitive management. A paradigm shift toward endovascular-first strategies has occurred, driven by superior peri-operative safety, minimal invasiveness and shorter hospitalization. Endovascular therapy is indicated in most anatomically accessible lesions, especially ostial or short-segment stenoses of the celiac or superior mesenteric arteries. Covered stents are preferred in these settings due to enhanced patency. However, limitations include restenosis risk, technical failure in long-segment occlusions and contra-indications in extrinsic compression syndromes such as median arcuate ligament syndrome. Open surgical revascularization remains critical in patients with associated complex aortoiliac disease, long occlusions or failed endovascular attempts. Retrograde bypass from the iliac or infra-renal aorta is favored in high-risk patients for technical ease, while antegrade bypass from the supraceliac aorta may offer greater durability. Hybrid approaches such as retrograde open mesenteric stenting (ROMS), indicated in cases where aortic clamping is not feasible and in acute-on-chronic mesenteric ischemia with bowel gangrene, offer high technical success and favorable mid-term outcomes. Early diagnosis and tailored revascularization strategies remain central to improving long-term clinical outcomes in CMI. Continued refinement of endovascular techniques and hybrid interventions holds promise for optimizing outcomes in anatomically and physiologically diverse patient populations.

Abstract Background Thoraco-abdominal endovascular aortic repair [(T)EVAR] of thoracic (TEVAR) and abdominal aorta (EVAR) has surpassed open surgical repair for thoraco-abdominal aortic diseases. Objectives We describe the long-term outcomes of 101 (T)EVAR patients treated over the last eleven years. Methods A retrospective analysis of 101 consecutive (T)EVAR patients was performed. The primary endpoints were in-hospital and 30-day outcomes, while the secondary endpoints were long-term outcomes and re-intervention rates. Results Out of 101 patients, EVAR and TEVAR were performed in 40 (39.6%) and 61 (60.3%) patients, respectively. Mean age was 58.04 ± 15.7 years. Technical success rates were 100% and 95% in the EVAR and TEVAR groups, respectively. Intraoperative endoleak was observed in 17 patients. Major perioperative complications (n=16) included retrograde aortic dissection (n=1), stent graft migration (n=2), paraparesis (n=1), device system entrapment in iliac vessels (n=1), acute renal failure (n=2), acute limb ischemia (n=3), and aorto-enteric fistula (n=2). The 30-day mortality rate was 7.9% (8 patients). Kaplan Meyer survival estimates at 1 and 5 years were 79% (95% CI 66.0-87.0, SE 0.053%) and 71% (95%CI 56.0- 81.0, SE 0.065%) for TEVAR and 84% (95% CI 67.0-92.0, SE 0.061%) and 69% (95%CI 46.0-83.0, SE 0.094%) for EVAR, respectively. Diabetes and smoking were associated with increased all-cause mortality in EVAR (p=0.018) and TEVAR (p=0.045) cases, respectively, following Cox regression analysis. Conclusions We observed favorable short- and long-term outcomes in 101 (T)EVAR patients, proving its safety and long-term efficacy for management of thoracoabdominal aortic disease.

Background: Peripheral Arterial Disease (PAD) is a progressive vascular disorder that compromises blood flow to the extremities, leading to ischemic symptoms such as claudication, rest pain, and tissue loss. Infrared thermography (IRT) is a non-contact imaging modality that detects cutaneous temperature changes, reflecting tissue perfusion status. This study explores the utility of smartphone-based infrared thermography in assessing perfusion before and after revascularization in PAD patients. Methods: A prospective observational study was conducted from July 2020 to September 2021, including 52 patients with PAD undergoing revascularization. Baseline and post-intervention perfusion assessments were performed using Ankle-Brachial Index (ABI) and Thermal Ankle-Brachial Index (TABI), calculated from temperature readings obtained using the FLIR One Pro infrared thermal camera. Measurements were taken pre-intervention, at discharge, and one-month post-intervention. Statistical analysis was performed to evaluate correlations between ABI, TABI, and limb temperature. Results: A strong positive correlation was observed between ABI and lower extremity (LE) temperature pre-intervention (r = 0.973, P < 0.001) and post-intervention at discharge (r = 0.682, P < 0.001). Post-revascularization, there was a significant improvement in ABI (Δ0.38 ± 0.20, P < 0.001), TABI (Δ0.09 ± 0.053, P < 0.001), and LE temperature (Δ10.2 ± 5.4℉, P < 0.001). These improvements persisted at one-month follow-up, validating smartphone-based IRT as a reliable perfusion assessment tool. Conclusion: Smartphone-based thermography is a promising, non-invasive, cost-effective adjunct to ABI for evaluating revascularization outcomes in PAD patients. Its portability and real-time assessment capability make it a viable alternative in clinical practice for rapid perfusion assessment.

Angioleiomyomas are rare, benign, smooth muscle tumors that occur predominantly in the lower limbs and infrequently in the upper limbs. We present a case of angioleiomyoma arising from the distal ulnar artery, presenting as a painful lesion with a 20-year history of diagnostic uncertainty. It was preoperatively misdiagnosed as an ulnar artery aneurysm. Surgical excision with primary end-to-end arterial repair was performed. Histopathological examination confirmed features consistent with a leiomyoma arising from the distal ulnar artery wall. The patient became asymptomatic following the surgery and remains pain-free at 6 months of follow-up.

Introduction Diabetic foot ulcers (DFUs) are a significant complication of diabetes mellitus, often leading to major lower extremity amputation. Identifying predictive factors for amputation can guide interventions to prevent this severe outcome. This study aimed to identify predictors of major lower extremity amputation in type 2 diabetic patients with DFUs. Methodology A cross-sectional analytical study was conducted at the Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, involving 101 patients with DFUs. The study assessed the association between various clinical and laboratory predictors and the necessity for major lower extremity amputation. Results Significant predictors for amputation included Wagner's grade ≥ 5, absent peripheral pulsation, clinical evidence of infection, and elevated levels of erythrocyte sedimentation rate and C-reactive protein. Conclusion This study highlights the importance of early identification of high-risk patients through detailed clinical assessment and laboratory investigations and underscores the need for aggressive management strategies targeting identified predictors to reduce the risk of major amputation among patients with DFUs.

Renal revascularization in patients with a solitary functioning kidney and a suprarenal abdominal aortic aneurysm (AAA) is a surgical challenge due to the risk of renal ischemia and postoperative renal dysfunction. We present a unique case in which a 69-year-old male with a solitary left kidney and suprarenal AAA was managed successfully with a preemptive splenic artery-to-left renal artery transposition (splenorenal bypass) followed by aneurysmorrhaphy. This approach preserved renal function and avoided ischemic insult during aortic reconstruction. At 2 years of follow-up, the patient maintains stable renal parameters and the reconstruction is patent, underscoring the utility of splenorenal bypass as a viable alternative in anatomically constrained and high-risk scenarios.

Background: Tubercular aortic aneurysms (TBAAs) occur by extension of infection from contagious lesions like lymph nodes, empyema, paraspinal abscess, or hematolymphogenous dissemination and can involve any part of the aortic segment. A high index of suspicion is required to attribute a tubercular nature to an infected aortic aneurysm if there is no underlying history of tuberculosis. Histopathology, culture of aneurysm wall with thrombus, and real-time fluorescent polymerase chain reaction (RT-PCR) should be performed to confirm the diagnosis. Patient status at presentation, the complexity of surgical reconstruction, and the possibility of performing efficient surgical debridement influence the selection of various therapeutic strategies. In the present study, the authors present the management results of TBAAs and their follow-up. Methods: This was a retrospective study of patients who received intervention for TBAA at two institutions from June 2016 to June 2024. Data were collected from medical records. Results: Nine patients were studied; five were male and four female. All patients had abdominal pain and three (33%) had a fever of 2 to 3 months duration at the time of presentation. One patient presented with an aortoenteric fistula (AEF) owing to TBAA. Three patients were diagnosed with pulmonary tuberculosis before aneurysm detection and mycobacterial culture of the aortic wall was positive in two of these. Granulomas and RT-PCR were positive in the aortic tissue of four patients. In situ reconstruction was done in two patients, one patient had a suprarenal aneurysm and another patient infrarenal aneurysm. Extra-anatomical bypass was done in three patients: one with AEF and two others with infrarenal aneurysms with significant periaortic involvement with infected tissue. Endovascular aneurysm repair was performed in two patients with a high risk for open aneurysm repair. Neo-aortoiliac system was done for two patients. Perioperative mortality occurred in one patient (11%) with chronic kidney disease who underwent axillobifemoral bypass. Surgical site infection occurred in AEF patient requiring secondary suturing of laparotomy wound. Conclusions: A high suspicion for the tubercular nature of an infected aneurysms is required for timely diagnosis and treatment. Real-time fluorescent polymerase chain reaction for mycobacterial complex should be considered in mycotic aneurysms because some patients may show an unexpected tubercular etiology. Surgical techniques should be tailored to the presentation, and functional status of the patient weighing the risk-benefit ratio of infection-related complications, patency of revascularization, and ability to tolerate the procedure.

ObjectiveChronic venous insufficiency (CVI) is a progressive disease, leading to calf muscle pump dysfunction and reduced range of ankle motion (ROAM). A full ROAM increases venous return decreasing venous hypertension. The dysfunction of foot pump in static foot disorder (SFD) further contributes to chronic venous insufficiency. In present study we studied the effect of ROAM and SFD on CVI.MethodsA prospective observational study was conducted from July 2022 to June 2023, with Institute Ethical clearance (INT/2022/MS-533). A total of 402 legs were included, of which 368 legs of the study group had CVI and 34 legs were in control C0 group. Patients were divided into control C0, mild C1-C3 and advanced C4-C6 disease group based on the severity of CVI. SFD and ROAM were evaluated from X-rays by Djian-Annonier angle and goniometry respectively. The primary objective was to study, impairment of ROAM in patients from C1-C6 and its comparison with control C0 group and impact of static foot disorders on ROAM.ResultsROAM was highest in controls and decreased towards the lowest value in progression to advanced stages of CEAP classification (87° in C0, 71° in mild CVI and 45° in advanced CVI, p < .001). Controls had just nine % legs afflicted with SFD whereas 62.3% and 68.6% with mild and advanced disease had SFD, p < .001. ROAM was highest in those without SFD (68.9°) and least in hollow feet (58.3°), p < .001. ROAM was lower in the symptomatic C2 disease (80°) than asymptomatic type (69°) (p < .001).ConclusionThis study showed that poor ROAM is associated with higher rate of advance CVI. In addition patients with SFD had advance CVI and poor ROAM. So, it is important to consider treatment of SFD and physical rehabilitation to improve ROAM and break vicious cycle of progression to severe CVI.

Myoepithelial carcinoma (MC) arises from the myoepithelial cells. It is a rare tumor with a predilection for salivary glands. MC in soft tissue is uncommon. Soft tissue MC exhibits dual epithelial and smooth muscle phenotype. The extremities and limb girdles are commonly affected. We present cytological findings of retroperitoneal MC with an accurate diagnosis being rendered with the aid of immunocytochemistry on the cell block and demonstration of EWSR1 rearrangements by fluorescence in situ hybridization on cytology smear. The smears were cellular, showing loose clusters and sheets of tumor cells embedded in dense eosinophilic to myxoid matrix material. The cells were oval to polygonal, with focal areas showing moderate nuclear pleomorphism, vesicular to coarse chromatin, and vacuolated cytoplasm with clearing. On immunocytochemistry, tumor cells were positive for epithelial membrane antigen, pan-cytokeratin, calponin, smooth muscle actin, and S-100. A literature review shows only a handful of cases of soft tissue MC. The current report emphasizes the need for cytomorphological awareness with the employment of ancillary testing for accurately diagnosing this rare tumor at an uncommon location. We also discuss the diagnostic challenges and troubleshooting.

Background: Enhanced recovery after surgery(ERAS) is a set of multiple perioperative care component not a rigid protocol with improved outcomes for elective surgeries. This study aimed to assess the feasibility and outcomes in trauma patients undergoing laparotomy. Study design:Prospective single-centre randomized controlled trial(RCT). Patients undergoing emergency laparotomy following trauma were randomized into ERAS(early removal of catheters, early mobilization and initiation of diet, use of opioid-sparing multimodal analgesia) and conventional care groups 24 h post-surgery. Outcome measures included length of hospitalization(LOH), recovery of bowel function, duration of removal of catheters and 30-day complications(Clavien-Dindo). Results: Fifty patients were randomized into ERAS(n = 25) and conventional care(n = 25) groups. Ninety-two percent of patients were young males, 58 % had blunt trauma to the abdomen and the most common indication of surgery was hollow viscus injury(88 %). ERAS group had a reduced median LOH(days) (6 versus 8, p = 0.007), early recovery of bowel function(p = 0.010) and shorter times for nasogastric tube(p = 0.001), urinary catheter(p = 0.007) and drain(p = 0.006) removal. The complications were comparable in both groups except for deep surgical site infection[significantly lower in ERAS group(p = 0.009)]. Conclusion: ERAS is safe and significantly reduces LOH in select trauma patients undergoing laparotomy.

Surgical decompression of the thoracic outlet along with treatment of the involved nerve or vessel is the accepted treatment modality when indicated. While neurogenic thoracic outlet syndrome (nTOS) is often operated via the axillary approach and venous TOS (vTOS) via the paraclavicular approach, arterial thoracic syndrome is almost always operated via the supraclavicular approach. The supraclavicular approach provides excellent access to the artery, brachial plexus, phrenic nerve and the cervical and/or first ribs along with any bony or fibrous or muscular abnormality that may be causing compression on the neurovascular structures. Even for nTOS, where the axillary approach offers good cosmesis, the supraclavicular approach helps adequate decompression while preserving the first rib. This approach may also be sufficient for thin patients with vTOS. For aTOS, a supraclavicular incision usually suffices for excision of bony abnormality and repair of subclavian artery.

INTRODUCTION:Extracranial carotid artery (CA) pseudoaneurysms are uncommon and can cause embolic stroke, compressive symptoms, or (rarely) can rupture. It is of paramount importance to treat this entity to avoid life-threatening complications. In this study, the authors described a cohort of patients that required open surgical repair. METHODS:This article reported the authors' experience with open surgical repair of extracranial CA pseudoaneurysms by presenting a retrospective review of data at their institution from 2016 to 2022. RESULTS:Of 8 patients that underwent open repair, 6 were male and 8 were female. The most common etiology was traumatic (penetrating trauma in 4 patients, iatrogenic injury in 2, and blunt trauma in 1) and 1 was infective. All patients presented with a neck mass, and 5 had compressive symptoms. Primary repair was performed in 4 patients, interposition graft using an autologous vein in 2, and patch repair in 2. None of the patients experienced perioperative mortality or stroke; nor did they develop any complications over a median follow-up period of 30 months. CONCLUSION:This report demonstrated that large-size extracranial pseudoaneurysms, whether traumatic or infective etiology, can be safely repaired using an open surgical approach.

Introduction: Static foot disorders (SFDs) are prevalent among adults and have been linked to chronic venous disease (CVD). This study aimed to investigate the prevalence of SFDs in patients with CVD and their association with disease severity. Methodology: This study was performed at the Department of General Surgery, Postgraduate Institute of Medical Education and Research to study the relationship between the SFDs and clinical, etiological, anatomical, and pathological elements (CEAP) clinical severity in the Indian population. A complete CEAP classification and venous symptoms were noted. Djian's angle was used to quantify SFD. Results: Among the 224 feet examined, 50.4% had SFD (14.73% had hollow feet and 35.7% had flat feet), and 56.7% had advanced CVD (C3-6 group). There was no difference in SFD and CEAP class based on the laterality of the foot. Patients with advanced CVD (C3-C6) had a significantly higher incidence of SFDs compared to those with less severe disease (C0-C2), particularly among individuals aged <30 years (P < 0.05). Conclusion: This study underscores the high prevalence of SFDs in patients with CVD, especially among younger individuals with advanced disease. Search for SFD should be made during the examination of CVD. Further research is warranted to explore whether correction of SFD improves CVD symptoms.

Background: Laparoscopic cholecystectomy (LC) is the gold standard management for benign gallbladder diseases. It has been observed that there is alteration in vitamin D levels and bone mineral density after cholecystectomy due to altered enterohepatic circulation. With increase in average age expectancy of the population, low levels of vitamin D levels and osteoporosis after cholecystectomies might cause increased health care burden. Methods: A prospective observational study was planned between 1 January 2022 and 30 June 2023 in the Department of General Surgery at PGIMER Chandigarh, a tertiary care hospital in north India. One hundred and three post-menopausal women who underwent LC and met the inclusion and exclusion criteria were included in the study. All participants underwent estimation of vitamin D and bone mineral density preoperatively and third-post operative month (POM). Results: The mean age of the patients was 58.46 +/- 7.44. Pain abdomen was present in 68(66%) patients, 18 had epigastric discomfort and 17 had dyspepsia. The mean levels of vitamin D decreased from 21.92 at the baseline to 20.12 at third POM (p < .001). There was a significant change in t score Femoral Neck (-1.12 vs -1.15, p < .001) and Lumbar spine L1-L4 - 1.98 vs -1.98 (p = .033). z-scores of the femoral neck were -0.34 vs -0.54 (p < .001) and of lumbar spine L1-L4 were -0.95 vs 1.02 (p < .001). The decrease in fracture risk for the femoral neck (p = .344) and the lumbar spine (p = .223) was not statistically significant. Conclusion: There is a significant decrease in vitamin D and BMD levels after LC in post-menopausal females.