Introduction: Surgeries involving bowel resection and anastomosis are quite common. Fluid overload, leading to tissue edema and impaired tissue perfusion, may contribute to anastomotic leak, which is one of the most dreaded complication. Methods: In our current study, CT scan, done on postoperative day-4, was used to assess visceral edema, and its effect on development of complications post bowel anastomosis and increase in value of cross section of body trunk area ≥20% was taken as an independent risk factor of severe complication. Results: Twenty three patients were enrolled in the study, 7 of them developed complications. The most common complication observed was wound infection (Clavein Dindo grade II). Only 2 patients (28.57%) had an increase in CT area >20%. Among patients who developed complications, 33.3% had an increase in CT area and 28.6% did not. Various other factors – preoperative albumin level, timing of surgery, duration of surgery – also lead to development of complications. Statistically, no significant association could be derived between the increase in CT area and development of complications. Conclusion: As per the findings of the current study, higher fluid balance was not reflected by an increase in body surface area on CT Scan. Hence, use of CT scan as a tool to assess visceral edema needs further evaluation.

Gastrojejunostomy without gastric resection is performed to bypass the distal stomach or the duodenum. Gastrojejunal stoma (GJ) obstruction is an unusual complication. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities or intraoperatively, as the classic features are absent during the first 24 h and even for several days. Symptoms of injury to other intra-abdominal organs or structures commonly mask or supersede that of pancreatic injury, both early and late in the course of trauma. Hence, these injuries are often overlooked. We present a case of gastrojejunal stoma obstruction after a primary repair of traumatic American Association for the Surgery of Trauma" (AAST) grade IV duodenal injury. The surgery included repair of the duodenum over a T-tube, a pyloric occlusion, a retrocolic loop gastrojejunostomy, and feeding jejunostomy. And thereafter, successful management of postoperative complication with adhesiolysis, necrosectomy, and revised antecolic isoperistaltic Roux-en-Y gastrojejunostomy for retrocolic GJ stoma obstruction due to post-traumatic pancreatitis.

Background and Aim: Conventional surgery for caustic/thermal strictures (CS/TS) entails considerable trauma, which may be mitigated by minimal access surgery (MAS). Experience with its use in CS/TS is both heterogeneous and limited, hence, warrants a comprehensive review. Methods: Medical literature/indexing databases were systematically searched for pertinent articles published in English, from 1990 to 2021, and analysed. Results: Fifty relevant articles, pertaining to over 200 patients, were found. They showed that MAS is feasible in CS/TS management. It reduces the access damage in chest and abdomen whilst facilitating resection or bypass of the affected gut segment through different combination of operations, sequence of steps, conduits and routes. The procedures range from completely minimal access to hybrid ones, with reduced complications and faster recovery. Hybrid procedures prove as expeditious as open ones. Conclusions: MAS proves efficacious in restoring alimentary continuity in corrosive/thermal strictures of the foregut.

Background and purpose Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. Methods Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. Results The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. Conclusions Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

A Correction to this paper has been published: https://doi.org/10.1007/s00423-021-02134-8

INTRODUCTION: Multiple Biliary Hamartomas are rare and asymptomatic and so are diagnosed less in vivo. They are benign malformation of ductal plate of intrahepatic biliary radicals. Patients are usually asymptomatic and the lesions are an incidental radiological finding. They maybe mistaken with liver metastasis, microabscess and other cystic lesions of liver. We report a 45 year old female who had vague right upper quadrant pain on and off for a year. She was diagnosed as extensive multiple biliary hamartomas on CT and MRI of the abdomen. Tumors markers were negative suggesting absence of malignancy. She was managed with symptomatic treatment and is on regular follow up.

Background: Intra-abdominal collections and abscesses are commonly encountered in surgical practice. They contribute to significant morbidity and mortality, hence, need to be addressed expeditiously. Percutaneous catheter drainage (PCD) is an important treatment modality that is now in vogue. Aim: This study was carried out to assess the outcomes of image guided PCD of intra-abdominal collections/ abscesses. Materials and Methods: This prospective study was carried out at a tertiary centre on patients who underwent image guided drainage of intra-abdominal collections/ abscesses from Jul 2014 to Dec 2016. Data was collected by following up the patients both clinically and radiologically. Results: 31 patients underwent PCD. Procedure was successful in 77.4%. Complete resolution was observed in all post-operative collections. Collections resolved after a single drainage procedure in 71% while the remaining 29% required multiple drainage procedures. Liver abscesses were the commonest, with multiple foci. Organisms were isolated in 13%, Escherichia coli being the commonest isolate. Higher leucocyte counts, lower levels of drain amylase and shorter duration of antibiotics were significantly associated with the success of the procedure. There were no complications other than an isolated case of biliary fistula following drainage of liver abscess. Ultrasonography was found to be at par with CT scan for PCD. Conclusion: Image guided PCD is a safe and efficacious procedure for the treatment of intra-abdominal collections and abscesses. It has a high success rate, especially in postoperative collections. The procedure has low morbidity and low complication rates. High leucocyte count, short duration of antibiotic exposure and low levels of drain fluid amylase are independent predictors of favourable outcome after percutaneous drainage.

Pheochromocytoma, is a rare neuroendocrine tumor, which usually presents as hypertension. We report a young male patient, who presented with intracerebral hemorrhage and intractable hypertension. On further evaluation, for uncontrolled secondary hypertension, he was diagnosed to have right adrenal pheochromocytoma. After hemodynamic stabilization, laparoscopic adrenelectomy was performed. Pheochromocytoma crisis presenting as intracerebral hemorrhage and cardiomyopathy is an uncommon phenomena. Even though it is a crisis, it is not a surgical emergency. Proper preoperative hemodynamic stabilization is essential before surgery is performed. An experienced anesthetist, to manage intraoperative fallacies, is warranted. Postoperatively, they must be on lifelong follow-up to watch for recurrence.

Gastro-oesophageal reflux disease (GERD) is, now, common in Indians. Anti-reflux surgery is gaining popularity as its definitive treatment option. However, studies from India on anti-reflux surgery are scarce. This study audits a low volume centre’s experience with laparoscopic Nissen’s fundoplication (LNF) in the management of GERD. Patients undergoing LNF between June 2014 and September 2019 were studied. Subjective and objective assessments of GERD were made using validated symptom indices and endoscopy, respectively, during both pre-operative evaluation and post-operative follow-up, to assess outcomes. Twenty-four-hour pH monitoring was selectively used in equivocal cases. Short and floppy LNF was constructed without using oesophageal bougie. Fifty-nine patients (39 males:20 females) with a mean age of 52.5 ± 16.2 years underwent LNF. The severity of typical symptoms improved significantly (p < 0.05) within 15 days following surgery. Clinical improvement, in the severity of atypical symptoms too, was observed but was not found statistically significant. There were no major perioperative complications or mortality. Three patients needed endoscopic dilatation at 3 months for persistent dysphagia. No failures or recurrences were observed during the follow-up. Structured subjective and objective assessment by the operating team has revealed that LNF proves efficacious in the management of GERD even in a low volume centre.

Background: Repair of large, upper thoracic, cuff-induced, tracheo-esophageal fistula (TEF) is technically demanding and is conventionally performed by open surgery. Minimal access approach is, hitherto, unreported. Technique & Case: Minimally invasive repair of TEF involving fistula isolation - by thoracoscopic oesophageal exclusion, and simultaneous establishment of alimentary continuity - by laparoscopy-assisted sub-sternal colonic transposition, is described. The technique was successfully employed in repairing a large (4.5 centimetres), cuff-induced, upper thoracic TEF, in a25-year-old woman. The rationale behind the technique, its pros and cons are analysed and contrasted against conventional techniques of TEF repair. Conclusion: Large upper thoracic, cuff-induced TEF can be successfully repaired employing minimal access.

BACKGROUND:Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure.METHODS:Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire.RESULTS:Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group.CONCLUSION:Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

Background: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. Material & methods: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014- Dec 2018, was audited. Results: 144 patients [76 Males: 68 Females] with an average age of 48.25 years underwent surgery using modified Makuuchi incision. ’J’ and ‘L’ incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients [13.2%]. Incisional hernias was observed in 6 patients [4.2%], on an average follow up of 27.78 months. Conclusions: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Corrosive upper aerodigestive tract strictures are conventionally treated by open surgery. Surgical advancements permit these strictures to be addressed with minimal invasion. Corrosive strictures treated minimally invasively over a 2-year period (2014-2015) were audited. Colonic mobilization and retrosternal tunneling were performed laparoscopically. The left colic vessel-based isoperistaltic colonic/ileocolonic segment was transposed substernally into the neck, aided by miniceliotomy. Proximal anastomosis was side-to-side esophagocolic in all patients except those who underwent pharyngolaryngectomy or partial laryngectomy, where pharyngocolic/pyriform fossa-ileal anastomosis was employed. Distal anastomoses were colo-jejunal and colocolic/ileocolic in all the patients. Enteral nutrition and ambulation were commenced on the first postoperative day. Oral nutrition was commenced following a normal contrast swallow on the seventh postoperative day. Patients were followed up on an outpatient basis. Ten adults, aged between 19 and 40 years, were treated for acid-induced strictures. Esophagus and stomach were multiply strictured in all patients. Additionally, duodenum was involved in two patients while pharynx and larynx were strictured in three patients. Two patients underwent pharyngolaryngectomy. One patient underwent partial laryngectomy. The average operative time was 240 minutes (range: 210-300 minutes). The mean blood loss was 150 mL (range: 100-200 mL). One patient (10%) had cervical anastomotic leak on the ninth postoperative day, which was resolved spontaneously. One patient (10%) had proximal anastomotic stricture, requiring dilatation thrice. One patient (10%) had the transient left recurrent laryngeal nerve paresis, which was resolved spontaneously. All the patients are on oral solid diet. The followup ranged from 5 months to 2 years. Minimal access substernal colonic transposition is feasible and efficacious in restoring alimentary continuity in corrosive strictures.

BACKGROUND Bile leaks and anastomotic strictures are important complications of hepaticojejunostomy (HJ). Evidence suggests that the use of hepatic round ligament (HRL) to buttress HJ may be beneficial. This study evaluates the feasibility of this approach. METHODS HJs performed over 2 years (Jun 2014- May 2016), with HRL reinforcement, were analyzed. Operative outcomes measured included technical difficulty, blood loss, time necessary for flap harvest, and reinforcement of HJ. The postoperative outcomes measured were the presence of bile leak and anastomotic stricture. RESULTS Forty-one patients (27 M: 14 F), aged 2-79 years, median age of61 years, underwent HJ with HRL buttress; 27 for periampullary/ head of the pancreas carcinoma; 4 for choledochal cysts; 4 for chronic pancreatitis; 3 for gallbladder carcinoma; 3 for benign biliary stricture. The time for harvesting HRL flaps and buttressing HJ was <10 minutes. No blood was lost during harvesting the flaps. One patient (2.5 %) had grade A leak following radical cholecystectomy, and structures were not observed during a median follow-up of 18 months (6 months to 2years). CONCLUSION HRL-based buttressing of HJ can reduce the bile leak and/or stricture rate.

Marchiafava- Bignami disease is a rare condition characterized by demyelination of corpus callosum due to alcohol or malnutrition. Here we report a young lady who, due to her religious beliefs had stopped taking food and presented with neuropsychiatric manifestations. Neuroimaging was suggestive of Marchiafava Bignami disease and with adequate nutritional and thiamine therapy she had dramatic improvement clinically and had near complete resolution of lesions in neuroimaging.

Acute abdominal pain is a frequently encountered symptom, often indicating a life-threatening, underlying medical condition. Abdominal pain may be caused by peritonitis, usually due to perforate appendicitis, may cause sepsis that can progress to septic shock. A 5-year 8-month-old boy presented to the emergency ward diagnosed with septic shock. He had felt low-grade fever and abdominal discomfort for 5 days in duration. At admission he looked severely ill, hypotensive and tachycardia with narrow pulse pressure. Abdomen was tender on palpation and peritoneal sign was found on the patient. Skin mottling was found with cold extremities. An initial management of septic shock was done. Leukocytosis and high serum C-reactive protein was found. Dengue and typhoid serology were negative. Abdominal radiography, ultrasonography, and CT-Scan with contrast identified several loculated ascites. Surgical exploration found intracystic hemorrhage and multicystic mass rupture within the greater omentum adjacent to the jejunum and ileum. The appendix was dilated and perforated. Cyst resection and appendectomy were performed. Histopathologic examination confirmed acute transmural appendicitis with concurrent cystic lymphangioma of the omentum. Enterococcus faecalis was identified from blood and intra-abdominal culture. Intraabdominal cystic lymphangioma is a rare and possible differential diagnosis in a child presenting with acute abdominal pain.

Neuroendocrine tumors (NET) are rare, albeit, well known in gastrointestinal tract (GIT).1 However, in GIT, biliary tree (BT) is an unusual site for NET.2 Further, in BT, distal common bile duct (CBD) is a very rare site indeed, as we report the 8th case in literature.2 Ours is the first case where tangential portal vein excision was employed for its radical resection.

The use of extracorporeal membrane oxygenation (ECMO) has been described to facilitate removal a laryngeal and/or tracheal and foreign body that resulted from aspiration. Most of these descriptions have been acute cases in the pediatric population. We present the case of a foreign body, cervical screw, in an adult female that resulted from dislodgment and migration into the sub-glottic space through the membraneous trachea. Atraumatic intubation was not possible, therefore a supra-glottic airway (SGA) was placed after induction, venous - venous (v-v) ECMO was used to oxygenate the patient and the foreign body was removed through the trachea.