Vishnu Prasad Nelamangala Ramakrishnaiah

Background: Short bowel syndrome (SBS) is a condition where a significant portion of the small intestine is lost/ absent, either congenitally or secondary to surgical resection. Complications arising due to the short length of the remnant bowel account for the high morbidity and mortality. In this case series, we describe our experience with 23 patients who underwent major intestinal resection. Methods: Retrospective data were retrieved from departmental records from January 2017 to June 2024 of patients who underwent major small bowel resection at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry with a remnant small bowel length of <200cm. Results: After excluding patients with incomplete records, data from 23 patients were analyzed. Mesenteric ischemia due to thrombosis of the superior mesenteric artery or vein was the most common etiology behind massive bowel resection. Most of the patients required intensive care in the immediate postoperative period, with ventilator support. The wound related complications included superficial and deep surgical site infection (52.2%), wound dehiscence (21.7%), and stomal necrosis (26.1%). Dyselectrolytemia, in the form of hyponatremia, was common in Type I (90%) and Type II SBS (80%), whereas it had a lower incidence in Type III SBS (28.6%), p value = 0.023. Early postoperative mortality occurred in 5 patients. Conclusions: The present case series shows the high morbidity and mortality associated with massive small bowel resection. Early initiation of enteral feeds, with or without parenteral supplementation, may help prevent dependence on parenteral nutrition and is associated with lower morbidity and mortality.

Acute corrosive injury most commonly affects the upper aerodigestive tract and may necessitate emergency surgery in a minority of cases when transmural necrosis develops. The present case manifested with multiorgan dysfunction and subsequently deteriorated, developing acute peritoneal signs that required emergency surgical intervention. Intraoperatively, the distal thoracic esophagus and proximal stomach appeared unexpectedly viable; however, there was extensive transmural circumferential gangrene involving the distal stomach, duodenal C-loop, and proximal jejunum. A surgical decision between pancreatoduodenectomy and pancreas-sparing duodenectomy was required. Given the patient’s poor general condition and hemodynamic instability, pancreas-sparing duodenectomy with ampullo-jejunal anastomosis was performed. Although the postoperative course was complicated, the patient gradually recovered and was discharged on an oral liquid diet. This report outlines the complexities associated with such atypical presentations and emphasizes the importance of individualized surgical decision-making and multidisciplinary postoperative care in the comprehensive management of acute corrosive injuries.

Colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-related mortality worldwide. A significant proportion of patients present as emergencies with obstruction, perforation, or bleeding, necessitating emergency colorectal surgery (EMCRS). This study aimed to compare the outcomes of patients undergoing EMCRS with those undergoing elective colorectal surgery (ELCRS). This retrospective-prospective cohort study included patients undergoing curative CRC resections at a tertiary center in Southern India between January 2010 and June 2022. Patients with metastatic disease or palliative procedures were excluded. Propensity score matching (PSM) was performed (1:1) based on age, sex, tumor location, and stage. Outcomes assessed included postoperative complications, inpatient mortality, disease-free survival (DFS), and overall survival (OS). Among 558 patients (106 EMCRS, 305 ELCRS), 106 matched pairs were analysed. Before PSM, EMCRS had significantly higher morbidity (71.4% vs. 40.7%, p < 0.001) and mortality (17.9% vs. 2.3%, p < 0.001). After PSM, EMCRS continued to show increased severe complications (Clavien-Dindo IV/V), sepsis, pulmonary and cardiac complications, and higher inpatient mortality (17.9% vs. 0.9%, p < 0.001). However, long-term outcomes were not significantly different (DFS: 58 ± 3 vs. 55.5 ± 4.7 months, p = 0.19; OS: 67.5 ± 2.9 vs. 69.7 ± 4.9 months, p = 0.391). EMCRS is linked to significantly worse short-term outcomes. The difference in long-term survival appears to stem from advanced disease at presentation rather than the emergency nature of surgery. Enhanced screening and preoperative optimization strategies may help improve patient outcomes.

Background Closure of the peritoneum has been a standard practice in appendectomy. However, it has been proposed that closure of the peritoneum following any abdominal surgery is more likely to give rise to adhesions and increased postoperative pain. This study was based on the hypothesis that peritoneal non-closure would result in decreased postoperative pain without causing any significant increase in complications like surgical site infection or wound dehiscence. Objective The primary objective of this study was to compare the pain scores in patients undergoing open appendectomy and peritoneal closure, with non-closure using the visual analogue scale (VAS) on postoperative day 1. Results Median VAS score on postoperative day 1 was found to be 4 (3,4) in the patients where the peritoneum was left open as compared to 5 (4,5) in patients where the peritoneum was closed (p < 0.001). Similarly, on postoperative day 2, the median VAS score in the peritoneum closure group was 4 (3,4) as compared to 3 (3,5) in the non-closure group. 29 out of 69 patients (42%) in the peritoneal closure group required rescue analgesia as compared to 11 out of 71 patients (15.5%) in the group with non-closure of the peritoneum (p < 0.001). The median duration of analgesia received, across both study groups was found to be 5 days. Conclusion This study showed that peritoneal non-closure during open appendectomy is associated with less post-operative pain. It also significantly reduces the need for rescue analgesia and decreases the total number of days of analgesia used. There is no significant increase in surgical site infection and wound dehiscence after 30 days through the above intervention, implying no difference in morbidity with the intervention.

Background: Percutaneous transhepatic biliary drainage (PTBD) effectively alleviates obstructive jaundice in benign and malignant pancreaticobiliary diseases but is associated with significant morbidity and mortality. Methods: This retrospective study analysed patients who underwent PTBD for obstructive jaundice at a tertiary care centre in southern India between January 2019 and December 2022. Data on demographics, clinical history, diagnoses, procedural details, and outcomes were collected from medical records (MRD), laboratory reports (HIS), and imaging archives (PACS). Result: Out of 148 patients who underwent PTBD from 2019 to 2022, data from 128 patients could be obtained and analysed. Most patients were male (60%) with an average age of 56, and the majority had malignant biliary obstructions, predominantly hilar cholangiocarcinoma (35%) and gall bladder carcinoma (28%). PTBD was considered successful in 80%, marked by a minimum 25% reduction in bilirubin within 2 weeks. Left-sided duct cannulation was the most common; a minority required bilateral drainage. Morbidities included peri-tubal pain (35.84%) and catheter blockage (20.75%). Kaplan–Meier curve revealed higher mortality in the initial days following PTBD. Mortality was significantly higher in patients presenting with cholangitis. Conclusions: This study emphasises the utility of PTBD as a viable intervention for patients with obstructive jaundice, especially when ERCP is not an option. The procedure effectively reduces bilirubin and allows for surgical or chemotherapy preparation in most patients. However, complications such as cholangitis and catheter-related issues remain concerns that warrant meticulous procedural technique and careful patient follow-up.

Diagnostic value of vascular endothelial growth factor (VEGF) levels in gastrointestinal cancers with ascites - A cross sectional study - Turkish Journal of Surgery

Objectives: This study aimed to evaluate the outcomes of laparoscopic inguinal hernia repair (LIHR) regarding postoperative pain, recurrence rates, duration of hospital stay and other postoperative outcomes within the context of a tertiary care teaching hospital in South India, and the initial experience of laparoscopic repairs. The current consensus in the literature often suggests LIHR as superior to open inguinal hernia repair (OIHR). Methods: This single-centre, retrospective, observational study was conducted at the Jawaharlal Institute of Postgraduate Education and Research, Puducherry, India, from January 2011 to September 2020. All patients who underwent elective OIHR and LIHR were included. Data on the patients demographics, comorbidities, hernia type, mesh characteristics, surgery duration, hospital stay and immediate postoperative complications were collected and analysed. Results: A total of 2,690 OIHR and 158 LIHR cases were identified. The demographic profiles, hospital stay and complication rates were similar in both groups. However, surgical site infection was present exclusively in the OIHR group (3.55% versus 0.0%; P <0.05). The timeline for returning to normal activities was statistically shorter for the LIHR group (6 versus 8 days; P <0.05). The most frequent immediate complication in the LIHR group was subcutaneous emphysema (6.54% versus 0.0%; P <0.05). Recurrence (9.23% versus 3.61%; P = 0.09) and chronic pain (41.53% versus 13.55%; P <0.05) were higher in the LIHR group. Conclusion: Lower recurrence and chronic pain rates were observed with OIHR in the initial experience with LIHR in the hospital. However, LIHR had significant advantages concerning faster patient recovery and lower rates of surgical site infections. While the results contribute an interesting deviation from the standard narrative, they should be interpreted within the context of a learning curve associated with the early experience of the research team with LIHR.

Liver haemangiomas are the most common benign hepatic tumours, but secondary portal hypertension resulting from haemangiomas is exceedingly uncommon. We present a case of a man in his 50s who presented with a progressively enlarging mass in the right upper abdomen. CT of the liver revealed a large hypodense lesion involving the right lobe, with two smaller lesions in the left lobe. The portal vein was compressed by the tumour, causing portal hypertension. The patient underwent right hepatectomy. Postoperatively, the patient had an uneventful course, and a 3-month follow-up demonstrated resolution of the oesophageal varices, portal gastropathy, with hypertrophy of the left lobe. This case report highlights the successful surgical management of a rare massive hepatic haemangioma causing portal hypertension with surgical resection, emphasising the potential benefits of surgical intervention with minimal complications.