Introduction: Inflammation is known to be associated with cancer development and progression. Neutrophil to lymphocyte ratio (NLR) is a simple and efficient marker of inflammation in numerous malignancies. Aim and Objective: The study aimed to investigate the usefulness of NLR as an adjunct to fine needle aspiration cytology (FNAC) to suggest malignancy confirmed by histopathological report postoperatively in Bethesda classes III, IV, and V. Materials and Methods: This was a prospective observational study at a tertiary care hospital over 2 years. Preoperative blood samples were collected in the admission ward between 08:00 and 09:00 h and analyzed using Beckman Coulter hematology and immunoassay analyzers for complete blood counts, absolute neutrophil and lymphocyte counts, differential leukocyte count, Thyroid stimulating Hormone (TSH), and free T4. NLR was calculated and compared between the two groups based on postoperative histopathology. Results: NLR in the benign group and malignant group were 1.75 ± 0.23 and 2.19 ± 0.29 (mean ± SD), respectively (P < 0.001). Area under ROC curve plotted was 0.823 (P < 0.001), with recommended cut-off of 1.9. Relatively high sensitivity and specificity at 87.5% and 82.5% imply excellent diagnostic accuracy. Conclusion: NLR with a value of 1.9 or higher is recommended as a predictor of malignancy in thyroid nodules.

Background Flap reconstruction is a critical aspect of plastic surgery, often challenged by complications. Prompt identification of impaired blood flow is essential to salvage compromised flaps. Conventional methods for flap monitoring are expensive and not widely accessible. This study sought to assess the feasibility of using a handheld blood gas analyzer to measure capillary blood values in flaps, with the aim of predicting flap outcomes effectively. Methods Pedicled flaps for reconstruction were utilized for measuring the proximal and distal capillary blood gas values. The outcome was recorded with flap inset, with or without complications, during the initial 15 days postsurgery, and categorized into problematic flap inset (PFI) and normal flap inset (NFI). The obtained values were analyzed for statistical significance. Results A total of 109 patients were evaluated, of which NFI n = 88 (80.73%), and PFI n = 21 (19.26%). There were 61 males (55.9%) and 48 females (44.03%). The measured values for distal flap lactate (PFI: 1.75 ± 0.14 NFI: 1.59 ± 0.16; p = 0.001), partial pressure of oxygen (PO2) (PFI: 54.75 ± 8.58 NFI: 84.25 ± 5.12; p = 0.001) and pH (PFI: 7.27 ± 0.06 NFI: 7.43 ± 0.07; p = 0.001), were statistically significant. The remaining variables measured; partial pressure of carbon dioxide (PCO2), sodium (Na), potassium (K), transcutaneous carbon dioxide (TCO2), oxygen saturation (SO2), and base excess (BE) were not statistically significant. Conclusion Recent research focuses on blood gas analysis for free-flap procedures; however, this study provides insights into pedicled flap survival through blood gas analysis. The data suggest that the levels of lactate, pH, and PO2 measured from the distal flap are associated with outcomes in pedicled flap survival.

Background: The aim of the study was to compare the accuracy and efficacy of automated three-dimensional (3D) software-aided computed tomography (CT) volumetry and manual CT volumetry in calculating the graft weight of living-donor livers for liver transplant (LT) with actual graft obtained during surgery. Materials and Methods: A total of 27 volunteer donors for LT were evaluated and operated at an LT Center from 2014 to 2017. Triple-phase contrast-enhanced computed tomography was done for all the donors and their graft liver volumes were calculated manually and by an automated postprocessing software. The residual liver volume was also calculated automatically with remnant percentage of total volume. Donor hepatectomies were performed as per the standard procedure. Graft volume requirement is assessed preoperatively based on body weight and Graft Recipient Weight Ratio >0.8 of the recipient. The correlation of graft weight calculated by these two methods was done against actual graft weights (AGWs) during surgery to evaluate the exact accuracy and efficacy of these preoperative measurements. Results: The average total liver volume (TLV) by the automated 3D method was 1207.22 cc (range 785–1596 cc), while the average TLV by the manual method was 1286 cc (range 904.7–1590 cc). The mean graft volume calculated by 3D-automated method and manual volumetry was 581.96 cc and 610.70 cc, respectively, while AGW calculated was 562.55 g. The mean difference between graft volume calculated by 3D-automated volumetry method and AGW was 19.40 g, while the mean difference between graft volume calculated by the manual volumetry method and AGW was 48.14 g. Conclusion: Manual volumetry and 3D-automated volumetry methods were both efficient and precise in measuring and predicting the graft volumes (TLV, standard liver volume, and future liver remnant) in living donor LT.

BACKGROUND:There is no standard treatment to accelerate recovery from melphalan-induced thrombocytopenia in multiple myeloma (MM) patients undergoing autologous stem cell transplantation (ASCT). Romiplostim, a thrombopoietin receptor agonist, has been developed to upregulate platelet production. OBJECTIVE:This study aimed to assess the efficacy and safety of romiplostim in reducing platelet transfusions post-ASCT in MM patients. METHODS:This was an investigator-initiated, single-center, open-label, comparative pilot study conducted from January to December 2022. We evaluated 18 melphalan-conditioned MM patients treated with pegylated granulocyte colony-stimulating growth factor (GCSF) (6 mg subcutaneously, SC, on day 2) and romiplostim (250 mcg SC on day 3) post-ASCT (romiplostim cohort). We compared them with 56 MM patients who had undergone ASCT and received GCSF alone (conventional or retrospective cohort, enrolled from 2015 to 2021). Efficacy endpoints included the number of mean single donor platelet (SDP) and packed red blood cell (PRBC) transfusions, time to platelet and neutrophil engraftment, and safety and tolerability assessments. RESULTS:In the romiplostim cohort, the average number of SDP transfusions required was significantly lower than that in the conventional cohort (1.39 vs. 3.40, p = 0.0001). Platelet engraftment occurred significantly faster in the romiplostim cohort versus the conventional cohort (9.72 vs. 12.57 days, p = 0.0018). Neutrophil engraftment days and PRBC transfusion requirements were comparable between the two groups. No deaths or major safety concerns were reported. CONCLUSION:Romiplostim demonstrated an improved efficacy and a favorable safety profile compared to the conventional approach in patients undergoing ASCT.

Background:There is a widening gap between the patients requiring transplants in proportion to the availability of organs donated. After brain stem death (BSD), counselling for consent is mandatory and if successful, and viable organs are recovered. A low consent rate for donation results in failed donation in a number of potential donors. Many potential donors fail to make a donation due to various social and familial reasons resulting in a poor consent rate. The aim of this study was to identify the variables that lead to donation denials. Methods:This retrospective study, carried out from Jan 2009 to Dec 2021 at a tertiary centre with an active transplant and donation programme, analysed BSDs and their counselling outcomes. Results:A total of 10998 patients were admitted to the intensive care unit, with 2401 (21.8%) deaths. BSD was diagnosed in 8.5% of all deaths, with donor suitability seen in 77.1% (n = 158) cases. After counselling, 55.7% families consented for organ donation. Amongst the families declining consent, most had multiple reasons. The commonest reasons were a difference of opinion among the family members (70%) and unclarity of BSD concept (44.3%). Other reasons included fear of mutilation, religious beliefs, and hope of a miracle. Conclusion:As most reasons of denial are social and related to public awareness, a meticulous transplant program with enthusiastic coordinators coupled with augmentation of public awareness, responsible media reporting, and improved doctor-patient-relative communication would result in enhanced rates of consent.

Background. Nonthyroidal neck swellings are common and cause diagnostic challenges. This study highlights various diagnosis associated with non-thyroidal neck swellings and their management challenges. Objective. This pilot study highlights the various diagnosis associated with nonthyroidal neck swellings and their management challenges. The clinical spectrum of two most common aetiology of nonthyroidal neck swelling: tubercular cervical lymphadenopathy and lymphomas, are also compared. Methods. This prospective study was conducted in a tertiary care teaching hospital from 01 Jun 2018 to 31 Dec 2019. The first 100 nonthyroidal neck swellings presented to the surgical outpatient department were included and assessed clinically, radiologically and histopathologically. Comparison was carried out between the first two common diagnosis of tubercular cervical lymphadenitis and lymphoma. Continuous variables were analysed using Student’s t-test and categorical data were analysed using the Chi square test. A statistical p value <0.05 was taken as significant. Results. There were 73 lymph node swellings and 27 non-lymph node swellings in the study. The most common diagnosis was tubercular cervical lymphadenitis (n=38) and lymphoma (n=17). The mean volume of lymph nodes in the lymphoma group (38.72±22.12 cm3) was significantly bigger than in the tuberculosis group (9.44±5.99 cm3) P=0.00001. The mean age (33.81±11.8 years) of tubercular patients was significantly less than the lymphoma (52.38±25.3 years) with P=0.000167. The clinical diagnosis was nearly accurate in 85% of cases. However, in 15 cases clinical diagnosis was changed after fine needle aspiration cytology. Conclusions. Ultrasonography and fine needle aspiration cytology are very useful adjunct in arriving at a definite diagnosis of a lymph node swelling in neck. Tubercular cervical lymphadenopathy and lymphoma were two major diagnosis. Tubercular cervical lymphadenopathy is significantly different from lymphomas in terms of early age of presentation and smaller size at the time of presentation

Background:Laparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP).Methods:The present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques.Results:The demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%).Conclusions:Low-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

Introduction: Pain is the most frequent complaint following laparoscopic cholecystectomy and the main reason for staying overnight at hospital. The retrieval of gall bladder (GB), an important terminal event of laparoscopic cholecystectomy, has been reported as one of the factors affecting postoperative port-site pain due to tissue trauma at port site. This extraction of GB is usually done either from the epigastric or umbilical port as per the surgeon’s preference. We tried to compare the postoperative pain and ease of retrieval among epigastric and umbilical port retrieval. Materials and Methods: It was a randomized controlled trial at a tertiary care hospital over 2 years. A total of 70 participants were finally analyzed in the study. The participants were divided into 2 groups based on the port of retrieval. The postoperative pain and ease of retrieval were analyzed among the groups. Results: Mean postoperative port-site pain and ease of retrieval were significantly better with retrieval through umbilical port as compared with the epigastric port with P values of. 0013 and. 0023, respectively. However, time taken for retrieval was significantly less when done through epigastric port. Conclusion: This study thus recommends umbilical port to be used for retrieval of GB due to significantly lesser port-site pain and better ease of retrieval.

This study aimed to compare the efficacy of Harmonic Scalpel Haemorrhoidectomy versus Stapled Haemorrhoidopexy in the management of grade 3 and grade 4 haemorrhoids. This comparison factored in post-operative pain, operating time, intra-operative bleeding, post-operative complications, and recurrence rates. The aim was to aid the decision-making process to determine the course of treatment to be offered to patients. Over the course of 18-months, it was a randomised control trial. A total of 42 patients (21 in each arm) were studied to observe the outcomes of procedures in treating grade III / IV haemorrhoids. The only statistically significant difference was in the post-operative pain, as calculated using Visual Analog Scale, with patients undergoing Stapled Haemorrhoidopexy experiencing lesser pain, thus translating to early hospital discharge and return to work. In conclusion, Stapled Haemorrhoidopexy can be regarded as a better modality with reduced post-operative pain as compared to Harmonic Scalpel Haemorrhoidectomy.

A BSTRACT Background: Neck dissections in carcinoma oral cavity are associated with various postoperative comorbidities. Internal jugular vein (IJV) occlusion and stenosis is a rare serious complication, which leads to serious clinical sequalae. Existing medical literature reports an incidence of this complication varying from 0% to 30%. Lacunae exist regarding any correlation between clinicopathological parameters and treatment options, of such patients, with the incidence of this complication, which might aid in adapting a preventive approach accordingly. Aims and Objectives: a. Primary objective: To study the patency of IJV postoperatively with preoperative status b. Secondary objective: Correlation of postoperative IJV patency with clinicopathological parameters (age, subsite, and pathological nodal status) and treatment options offered (neck dissection, radiotherapy, and reconstruction). Subject and Methods: Patency of IJV was analyzed preoperatively and postoperatively and correlated with various parameters, after neck dissection in 50 carcinoma oral cavity patients. Settings and Design: Prospective observational study at a tertiary care hospital done over 2 years. Statistical Analysis Used: Data were recorded in Excel data sheet and statistically analyzed by using the SPSS Ver 22.0. Results: IJV occlusion was demonstrated in 2 (4%) patients and IJV stenosis in 7 (14%) patients. Postradiotherapy patients had higher incidence of occlusion compared to patients who did not undergo radiotherapy (11.7% vs. 0%; P < 0.05). The incidence of stenosis and occlusion was significantly higher in left side neck dissection (20.6%; P < 0.05). Conclusion: Radiotherapy and left sided neck dissection are statistically significant risk factors for postoperative IJV occlusion in carcinoma oral cavity patients.

Delayed gastric emptying (DGE) is the most common complications after Whipple pancreaticoduodenectomy (WPD). Braun enteroenterostomy (BEE) is a useful technique to divert bile from the stomach. We recently started doing binding pancreaticogastrostomy (BPG) for pancreatic reconstruction after WPD, and the most frequent complication was DGE. The aim was to study the effect of Braun enteroenterostomy on delayed gastric emptying in binding pancreaticogastrostomy following Whipple pancreaticoduodenectomy. The study included all patients who underwent BEE in BPG following WPD from February 2014 till May 2016 at a tertiary care center. Braun enteroenterostomy was constructed approximately 25 cm distal to the gastrojejunostomy by a side-to-side hand-sewn or stapled anastomosis. Delayed gastric emptying was defined as per International Study Group of Pancreatic Surgery (ISGPS) definition. All patient data including patient demographics, type of procedure performed, complications, mortality, hospital stay, postoperative interventions, or re-operations were documented. There were 13 (30.95%) patients with DGE A and 4 (9.52%) patients with DGE B, and no patients had DGE C. Hence, there were only 4 patients (9.52%) with clinically significant DGE. Addition of Braun enteroenterostomy reduces delayed gastric emptying after Whipple pancreaticoduodenectomy with binding pancreaticogastrostomy.

Background: Despite advances in medical sciences, modified radical mastectomy (MRM) remains the mainstay of treatment in breast cancer management in India. However, a wide range (0.8%–26%) of postoperative complications occur following MRM. Lacunae exist in the existing extensive medical literature regarding any correlation between preoperative staging and demographic profile of such patients with the incidence of these complications, which might aid in adapting a preventive approach accordingly. Aim: The aim of this work was to study the association of preoperative tumor size, nodal status, and clinical profile (age, diabetes mellitus, hypertension) of breast cancer patients with the postoperative complications (seroma formation, surgical site infection, wound dehiscence, flap necrosis, paresthesia, and lymphedema). Methods: All patients diagnosed with carcinoma breast and undergoing MRM. a. Settings and Design: This was a prospective observational study at a tertiary care hospital. b. Duration: Two years. c. Statistical Analysis Used: Data were recorded in an Excel datasheet and statistically analyzed by using the SPSS version 22.0. Results: A significant positive association was established between seroma formation, wound dehiscence with increasing age (P = 0.006), tumor staging (P = 0.003), and nodal staging (P = 0.022). However, no significant correlation could be established between the other parameters that were studied. Conclusion: Meticulous surgical techniques and postoperative care should be used to reduce Seroma formation and wound dehiscence in patients with advanced age, higher tumor, and nodal staging.

Background: Camp approach has been advocated as an effective means of motivating the target population to adopt vasectomy as a method of permanent sterilization. There is a high degree of acceptance of Non-scalpel Vasectomy (NSV) among physicians and laypersons. With this knowledge, we organized camps and found good results which we share in this article. Methods: Four NSV camps were organized in four different villages across India on a vehicle-mounted mobile operation theater. The meticulous and detailed planning, dissemination of information, careful execution, and post-procedure follow-up is enumerated. Results: A total of 76 individuals underwent the operation in these camps. The mean age of the participants was 35 ± 5.2 years (range, 27–44 years). The complication rate was negligible and there was no failure of vasectomy. There was a high level of satisfaction among those who underwent this procedure as seen by the increased number wanting to undergo the procedure from places where camps were located. Conclusion: NSV as a procedure is perceived as being simple and pain-free. Re-enforcing this fact and removing doubts, and conducting operations at the camp in an environment the client is familiar with achieved rewarding results.

Background. Gastrointestinal stromal tumours (GIST) are non-epithelial mesenchymal solid neoplasm with varied presentation. The study reports the case of a retroperitoneal GIST in a 21‑year‑old male presented with an abdominal lump for six months. The lesion was initially thought to be a retroperitoneal sarcoma. Exploratory laparotomy revealed an abdominopelvic mass covering the entire right side of abdomen and pelvis. The tumour was adherent to the terminal ileum and ascending colon. There were dense adhesions between the retroperitoneum with involvement of the middle third of the right ureter. The tumour was resected with right hemicolectomy with ileotransverse anastomosis. Post-operative histopathology revealed it as high-grade spindle cell type GIST. The patient is presently on post-operative chemotherapy with Imatinib mesylate. Objective. Atypical presentations of GIST are seldom discussed but frequently encountered in clinical practice. This article depicts different challenges the surgeon has to face while diagnosing such atypical entity. Methods. Case report of atypical GIST presenting as retroperitoneal lump. Results. The patient underwent surgical resection and is presently on post-operative chemotherapy with good overall outcome for a one year follow up. Conclusions. GISTs presenting as retroperitoneal lumps are very rare, they should be considered in their differential diagnosis of an atypical retroperitoneal mass.

Background: Inflammation is known to be associated with cancer development and progression. NLR is a simple and efficient marker of inflammation in numerous malignancies. Aim: The study aimed to investigate usefulness of neutrophil to lymphocyte ratio (NLR) as an adjunct to Fine needle aspiration cytology (FNAC) to suggest thyroid malignancy confirmed by histopathological report post operatively in Bethesda class III, IV & V. Methods: Prospective observational study at a tertiary care hospital over 2 years. Results: NLR in the benign group and malignant group were 1.75 + 0.23 and 2.19 + 0.29 (mean + SD) respectively (p-value <0.001). Area under ROC curve plotted was 0.823 (p-value <0.001), with recommended cut-off of 1.9. Relatively high sensitivity and specificity at 87.5 % and 82.5% implies excellent diagnostic accuracy. Conclusion: NLR with a value of 1.9 or higher is recommended as predictor of malignancy in thyroid nodule.

Background: Most diabetic wounds are infected and eradication of the infected source is paramount to the success of healing. Antibiotic culture and sensitivity of samples aid in the assessment of the severity of the infection and the state of sensitivity or resistance of organisms in an infected ulcer to antibiotic treatment, thereby preventing or minimizing the necessity of amputation. Aims: To compare two methods of evaluating bacterial infection, wound swab culture (SC) against tissue sample cultures (TC), and determine sensitivity patterns and compare them for establishing the diagnosis of infected diabetic foot ulcers. Methods and Material: New-onset diabetic foot ulcers were subjected to tissue sampling and wound swabbing; specimens were cultured for aerobic and anaerobic organisms. a. Settings and Design: Prospective observational study at a tertiary care hospital done over two years. b. Statistical analysis used: Data was recorded in excel data sheet and statistically analysed by using the SPSS Ver 22.0. Results: Three hundred and eight micro-organisms were isolated from a cumulative total of 127 infected wounds (2.75 and 2.08 per wound for SC and TC, respectively). Sensitivity and specificity were 82.27% vs 78.48% and 71.43% vs 52.38% for the SC and TC groups, respectively. The maximum concordance was noted in the Grade 2 ulcer group (73.84%). Conclusion: Wound SCs were comparable to TCs for Grade 2 ulcers. For higher grades of ulcers, tissue sampling method is recommended.

Ulnar artery thrombosis (UAT) is an uncommon cause of digital ischemia which occurs in less than 3% of population presenting with hand ischemia. The superficial palmar arch of which the ulnar artery is the main contributor can develop intimal damage following repetitive trauma. We present a uncommon case of a 60-year-old male farmer who presented with features of digital ischemia of right hand and found to have long segment UAT on color Doppler imaging and was managed in a step wise manner with a trial of conservative management initially followed by embolectomy, thrombectomy, and interposition vein graft as the last option. This case report brings out the rarity of UAT manifesting as digital ischemia in patient with complete SPA and the challenges faced by a surgeon in retrieving thrombi from distal segmental arteries of SPA. It also highlights the predisposing factors like occupation, presentation, and length of thrombosed segment that are crucial in determining the primary modality of treatment which was resection of thrombosed segment and RIVG in our case.

BACKGROUND:Thrombosis of hepatic artery anastomosis (HAT) after liver transplantation is a catastrophic and dreaded complication. Early identification of HAT can salvage the situation. To monitor the anastomosis, conventional daily transcutaneous Doppler is performed. However, it has disadvantages of being noncontinuous, operator-dependent and technically difficult. Implantable Doppler probes wrapped around the anastomosed vessel giving continuous signal may be an important tool; however, very few studies are performed to study its efficacy after intra-abdominal vascular anastomosis, and its role is not clearly established.METHODS:Patients who underwent deceased donor liver transplant surgery were part of the study. On hepatic arterial anastomosis, implantable Doppler probe was fixed for monitoring. Conventional daily transcutaneous Doppler was also performed and the results were compared.RESULTS:A total of 40 hepatic arterial anastomoses were studied. The incidence of HAT was 10.53%. For the implantable Doppler probe monitoring, sensitivity and negative predictive value was 100%, whereas specificity was 94.44% and positive predictive value was 66.66% with an overall accuracy of 95%. A mean of 10 h of lead time was gained by implantable Doppler probe monitoring.CONCLUSION:Our study showed that there was high sensitivity and negative predictive value of implantable Doppler probe monitoring system, which makes it ideal for post-operative vascular anastomoses surveillance monitoring; however, abnormal positive finding on implantable Doppler probe monitoring needs to be confirmed by conventional transcutaneous Doppler. The implantable Doppler probe monitoring, because of its round the clock and continuous nature gives us a good lead time in identifying vascular complication, which translates into graft salvage and reduction in morbidity and mortality.

Background: COVID-19 patients are at increased risk of coagulopathy. This coagulopathy may be due to a severe pro-inflammatory state (cytokine storm) and/or by viral sepsis. This can sometimes lead to consumption coagulopathy and decreased platelet count, leading to increased risk of bleeding and may manifest like hematomas in atypical locations. These bleeding manifestations may be spontaneous or can be induced by even minor trauma. Cases: It is a single-center retrospective analysis. Four patients with a confirmed diagnosis of COVID-19 depicting increased risk of bleeding manifestations were included. Patients in our study were managed as per guidelines recommended by the Ministry of Health and Family Welfare Directorate General of Health Services, Government of India. Results: All patients were male. The mean age was 56 ± 18.64 years. One patient was managed conservatively with discontinuation of anticoagulants, volume resuscitation, and transfusion of blood products. Drainage with incision was done for 2 patients. One was managed with pigtail drainage. Conclusion: The effect of anticoagulants given in therapy and their varied presentations are discussed in this article. The article concludes that we need vigilant observation to identify this complication in the early period, resulting in successful management.