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   Table of Contents - Current issue
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January-June 2022
Volume 28 | Issue 1
Page Nos. 1-110

Online since Thursday, July 14, 2022

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CHAIRMANíS MESSAGE  

Chairman's Message p. 1
EV Gopi
DOI:10.4103/ksj.ksj_27_22  
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EDITORIAL Top

Editorial p. 2
YM Fazil Marickar
DOI:10.4103/ksj.ksj_24_22  
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REVIEW ARTICLE Top

Safe urethral catheterisation in males: Pearls and pitfalls p. 3
S Lal Darsan, Biju S Pillai, H Krishnamoorthy
DOI:10.4103/ksj.ksj_23_22  
Urethral catheterisation is a bedside clinical skill which is usually acquired by clinicians during their internship or initial medical career. However, many clinicians lack confidence for male catheterisation afterward. This review article revisits the steps of safe urethral catheterisation with a review on male urethral applied anatomy, catheter design, common difficult catheterisation scenarios with pearls and pitfalls to tackle them and steps to remove a stuck urethral catheter from a urologist's perspective.
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ORIGINAL ARTICLES Top

The effect of suction wound drain on laparotomy wound healing in emergency colorectal surgeries p. 9
SG Githu, Binni John, Jiya Mulayamkuzhiyil Saju, MN Sasikumar
DOI:10.4103/ksj.ksj_10_22  
Background: This prospective observational study attempts to compare the healing in the laparotomy midline wounds closed primarily with negative suction wound drain to those wounds where only linea alba was closed with skin and subcutaneous tissue left open for secondary suturing, in emergency colorectal surgeries. Materials and Methods: This study was conducted on 160 patients in the general surgery department of a tertiary care teaching hospital for 12 months in those who underwent emergency colorectal surgery through midline laparotomy and randomly allotted for either laparotomy midline wound closure with suction drain or closure with linea alba suturing alone with skin and subcutaneous tissue left open for secondary suturing. These two groups were compared for wound healing. Statistical analysis was performed using the SPSS software. Results: The wound contamination in those with closed wound with negative suction wound drain (Group A) had 40% in Grade II and 37.5% in Grade III, whereas those in which skin and subcutaneous tissue was left open after closing linea alba (Group B) had 53.8% in Grade II and 38.8% in Grade I and this might have contributed to the better healing as was seen in Group B than in Group A. This showed that wound healing was better in those wounds where only linea alba was closed with skin and subcutaneous tissue left open for secondary suturing after 1 week. Conclusion: In emergency colorectal surgeries, wound healing is better with reduced chance of surgical site infection in those wounds where only linea alba was closed with skin and subcutaneous tissue left open and secondary suturing was done after a week.
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Structural and functional changes after standard percutaneous nephrolithotomy p. 13
Kalpesh Saswade, Lal Darsan, Biju S Pillai, H Krishna Moorthy
DOI:10.4103/ksj.ksj_11_22  
Introduction: The surgical treatment of kidney stones more than 2 cm in size has been vastly simplified with the popularisation of percutaneous nephrolithotomy (PCNL) since the 1980s. However, technological revolution has witnessed miniaturisation of endoscopic instruments claiming more advantages over the usage of conventional instruments. However, the cost of smaller instruments and the higher expertise needed while using these miniature instruments have forced many surgeons to persist with the conventional procedures. Aims and Objectives: This study was intended to evaluate the structural and functional changes occurring in the kidneys after performing standard PCNL. Materials and Methods: Standard PCNL was done in 92 patients with renal stones of more than 2 cm using 25 Fr adult nephroscope. Pre-operative estimated glomerular filtration rate (eGFR) was calculated a day before the procedure and compared with post-operative eGFR estimated at 3 months. Structural changes occurring after PCNL were studied using USG renal morphometry and scarring at 3 months and compared these observations with pre-operative findings. Results: It was observed that the mean eGFR post-operative was 84.48 ± 32.18 ml/min (at 3 months) versus 77.61 ± 30.15 ml/min preoperatively (P < 0.05). The mean change of renal parenchymal thickness on post-operative USG versus pre-operative USG was insignificant (2.19 ± 0.32 cm vs. 2.22 ± 0.34 cm). There was no correlation between age and gender for change in eGFR. A mild positive correlation (correlation coefficient [r] = 0.065) was found between eGFR change and stone burden. Sixteen patients out of 92 were found to have renal scarring (>10% decrease in parenchymal thickness). Conclusions: We conclude that standard PCNL could be performed in indicated patients without apprehensions about functional loss or structural damage due to the procedure.
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A study on association of iron deficiency and gall stones in cholelithiasis patients p. 17
Stephen K Punnoose, Sakaran Nair Kailasanadhan
DOI:10.4103/ksj.ksj_13_22  
Background: Iron has been shown to have a significant association with gall stones as iron deficiency causes stasis of gall bladder due to the low production of nitric oxide. Reduction of risk factors can prove to go a long way including reducing surgeries for gall stones and associated disorders including pancreatitis, which is associated with morbidity for the patient. Aim: The aim of the study was to find the association between iron deficiency and gall stone disease. Materials and Methods: This was a case–control study in which the patients who underwent ultrasound abdomen in the general surgery department were divided into two groups, one with gallbladder stones (103) and second without gallbladder stones (52) subjects. They were subjected to serum ferritin and serum iron level estimation. The biochemical parameter used as principle maker was iron, and then ferritin was also analysed. Data were compiled into MS excel and was analysed with SPSS. Results: 36.9% of cases had Iron less than the normal value compared to 7.7% of controls with significant P value. Among the subjects with low iron, 90.5% of the subjects had gall stone disease compared to subjects with normal serum iron value with significant P value. Conclusion: We found a significant association between iron deficiency and development of gallbladder stones. Accordingly, correction of iron may help in the curbing of gall stone disease as it is found to be a factor associated with gall stone disease.
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Arterial pH, bicarbonate levels and base deficit as predictors of morbidity and mortality in acute pancreatitis p. 20
Joicy Els Jojo, Satish G Prabhu, Vergis Paul, MG Jayan
DOI:10.4103/ksj.ksj_14_22  
Background: Although multiple criteria are available for prognosis and determination of severity of acute pancreatitis (AP), there is a need to identify better predictors of developing complications. Arterial pH is a component of the APACHE-II scoring system, commonly used in AP. Aim: The aim of this article is to study the diagnostic accuracy of arterial pH, bicarbonate levels and base deficit in predicting morbidity and mortality in AP. Materials and Methods: A cross-sectional study (agreement analysis) was performed on inpatients with AP in a tertiary hospital. One hundred and forty patients based on clinical, biochemical and radiological findings were included in this study. Patients with AP following trauma/surgical intervention, tumours of pancreas and patients with age ≤18 years were excluded all categorical variables were summarised using frequency and percentage. All quantitative variables were summarised using mean and standard deviation sensitivity, specificity, positive predictive value and negative predictive value were estimated. Statistical analysis was performed using EZ R software. Results: All participants who required ventilatory support, haemodialysis or blood product transfusion had a pH of <7.35. 12/13 (92.3%) of patients who were on haemodynamic supports had bicarbonate levels <22mmol/L. Those who required respiratory support had bicarbonate level <22 mmol/L and base deficit <–4 mmol/L. 11/13 (84.6%) who required haemodynamic supports had base deficit <–4 mmol/L. All 5 of the 140 (3.57%) participants who expired had an arterial pH <7.35, bicarbonate level <22 mmol/L and base deficit <–4 mmol/L. Conclusion: In patients with AP, low arterial pH, low bicarbonate levels and high base deficit at presentation predict an adverse outcome with a higher frequency of organ failure and mortality.
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Comparison of surgical outcomes in laser haemorrhoidectomy and stapler haemorrhoidopexy for grade II and III haemorrhoids – A prospective cohort study p. 24
UV Akshay Viswanath, Rojan Kuruvilla, P Sajan, Amal George, Jinto Augustine Thomas
DOI:10.4103/ksj.ksj_15_22  
Background: Haemorrhoids often necessitate surgical intervention. Laser haemorrhoidectomy and stapler haemorrhoidopexy are two alternative techniques that may be employed for the resolution of symptoms. Aim: The current study aims to compare the two modalities of treatment in terms of post-operative pain, post-operative complications and recurrence at 6 months. Methodology: It was a hospital-based prospective cohort study done in the department of general surgery at a tertiary care centre. Patients were included if they were symptomatic with Grade II or III haemorrhoids in ano and underwent surgery in the same institute. Patients were excluded if they were <18 years of age, had co-existing anorectal diseases (perianal fistula, anal fissure or abscess), had a previous history of anorectal surgery or open haemorrhoidectomy, had a history of recurrent haemorrhoids, had regular use of medications such as analgesics or immunosuppressants, had a history of neurologic deficit or chronic pain syndrome, was unfit for surgery or anaesthesia, or if they were pregnant. Post-operative pain was evaluated using visual analogue scale. Results: Seventy-two patients were included in the study, and no one was lost to follow-up. The mean age was 51.8 (13.9) years and ranged from 22 to 77 years. Majority were males (80.6%). Post-operative pain was lower in the laser group at all time points. Surgical complications were slightly lower in the stapler group. Recurrence at 6 months of follow-up was noted in only one patient belonging to the stapler group. Conclusion: Laser haemorrhoidectomy has significantly lower post-operative pain, but stapler haemorrhoidopexy had lesser post-operative complications, though not statistically significant. Both surgical techniques have low recurrent rates.
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Laparoscopic submucosal appendectomy for complicated appendicitis: A salvage technique to minimise complications p. 29
Jimmy C John, IC Srinivas, PK Arjunith
DOI:10.4103/ksj.ksj_16_22  
Background: Complicated appendicitis with delayed presentations is difficult to manage surgically due to dense adhesions and distorted anatomy. Submucosal appendectomy could be an option in these cases. Materials and Methods: Out of 789 laparoscopic appendectomies, 239 were complicated cases. In 79 of these cases, no plane could be established between the appendix and adjacent bowel. Hence, the mucosa was identified by blunt dissection through the wall of intact appendix or through the perforation site and the mucosal tube was pulled out, and then dissected out fully from the tip and up to the base by blunt dissection, leaving behind the muscular wall. The base was then ligated and divided distally. Post-operatively, the patients were managed with ERAS protocol. Results: Out of 79 cases, 56 were male. Age ranged from 14 to 55 years. Forty-six cases were perforated, and 33 had mass formation. Submucosal appendectomy was done in all. There were no intra-operative complications. The average operating time was 56 min. In 68 cases, oral feeds were tolerated early, 11 cases suffered from prolonged ileus and one case had post-operative faecal leak, which settled on conservative management for 10 days. The average post-operative hospital stay was 3–5 days. Follow-up ranged from 2 months to 2 years. Three cases required re-admission, reported occasional abdominal pain, which on clinical evaluation and imaging showed no residual collection or stump appendicitis. Two cases presented with residual abscesses, which were managed with image-guided tube drainage. Conclusions: Submucosal appendectomy minimises bowel injury, avoids the need for conversion, and is a safe option for difficult cases during laparoscopy and also an alternative for the Ochsner–Sherren regimen.
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Neutrophil–Leucocyte ratio as a predictor of bowel viability in incarcerated hernia: A cross-sectional study p. 32
TK Deepak
DOI:10.4103/ksj.ksj_17_22  
Introduction: Incarcerated hernias can lead to bowel obstruction or strangulation, leading to loss of bowel viability. One of the changes occurring in our body during incarceration or strangulation of hernia is neutrophil leucocyte ratio (NLR) change. This relationship can be made use of for recognising hernia as, early or late leading to bowel ischaemia. It helps to decide safe non-operative management or early surgical intervention to prevent life-threatening complications. Primary objective of the study was to assess the predictive accuracy of preoperative neutrophil–leucocyte ratio and bowel viability amongst patients with incarcerated hernia. The secondary objective was to identify the relationship between preoperative neutrophil–lymphocyte ratio and bowel viability in incarcerated hernia. Methodology: This cross-sectional study which used diagnostic test evaluation was done with a sample size of 100 patients, after obtaining informed consent. Detailed history, physical examination and laboratory investigations were collected, and the need for bowel resection was assessed, surgery was carried out under aseptic precautions and checked for bowel viability and then comparison done with neutrophil–leucocyte ratio and data analysed using SPSS software (IBM-SPSS, New Delhi, India 2021) using Chi-square test. Results: The majority belonged to 51–60 years of age, 66 belonged to male gender and 31 patients underwent bowel resection. The mean neutrophil–leucocyte ratio was obtained as 0.84, and using the Chi-square test was found to be statistically significant in comparing relation between the ratio and bowel non-viability. The mean neutrophil–lymphocyte ratio was obtained as 11.1, and using the Chi-square test, there is a statistically significant relation between the ratio and bowel non-viability. Conclusion: Neutrophil–leucocyte ratio can be used as a predictive marker for early detection of non-viability of bowel. There is a statistically significant relation between the ratio and bowel non-viability.
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A hospital-based prospective short-term study on efficacy of infrapopliteal angioplasty in critical limb ischaemia in terms of limb salvage and quality of life p. 37
Stalin Thomas, Vimal Iype, Santhosh John Abraham
DOI:10.4103/ksj.ksj_18_22  
Introduction: Critical limb ischaemia (CLI) refers to chronic ischaemic pain at rest, ulcers or gangrene due to arterial occlusive disease. It is the end stage of peripheral artery disease (PAD). The commonly available treatment is amputation in a low-income family, which is quite disastrous. Aim: This study aimed to find out the efficacy of infrapopliteal angioplasty in tibial lesions of CLI patients. Materials and Methods: A prospective, observational study was conducted on 50 patients with CLI. The patient was taken up for tibial angioplasty and followed up for 4 months. Results: At the end of 4 months, the limb salvage rate was 92% and major amputation rate was 8%. The role of angioplasty in limb salvage is undoubted and has resulted in high levels of limb salvage. Conclusion: CLI lesion if amenable to revascularisation should have angioplasty with regular follow-up. Control of risk factors forms an integral part of the follow-up. Early detection of CLI is the need of the hour.
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Prevalence of multi-organ dysfunction syndrome amongst patients with acute pancreatitis p. 44
Thulasi Bhai Amma Preethi, A Nizarudeen
DOI:10.4103/ksj.ksj_19_22  
Background: Approximately 20% of patients with acute pancreatitis (AP) develop multi-organ dysfunction syndrome (MODS). Factors which determine the severity of pancreatitis and the development of MODS are multiple and early identification may lower the morbidity and mortality. The Sequential Organ Failure Assessment (SOFA) scoring system has been shown to measure disease severity. The objectives of this study were to estimate the prevalence of MODS amongst patients with AP and to assess the factors associated with it. Methodology: All selected consecutive cases were interviewed for relevant history. Physical examination was done, and blood samples were tested. The prevalence of MODS amongst the patients was assessed using the SOFA scoring system, and the proportion of organ involvement was assessed. Several physical and aetiological factors and laboratory parameters were compared in those with and without MODS. Values were analysed using Chi-square test in SPSS. Results: Out of the 238 patients included, 46 (19.3%) developed MODS. There were 217 males and 21 females. Using SOFA scoring system score MODS, the most commonly involved organs were the liver (26%) and kidney (18%). Majority of MODS patients were elderly (age > 40 years; P = 0.014) and male sex (P = 0.004). Smoking (P = 0.015), hypertriglyceridaemia (P = 0.001), pancreatic cancer (P = 0.019) and body mass index (BMI) (P = 0.006) had a statistically significant relation. Serum amylase and lipase, total leucocyte count, serum C-reactive protein (CRP), lactate dehydrogenase (LDH) and erythrocyte sedimentation rate (ESR) also had statistically significant relation (P < 0.001). The mean serum amylase value in those with MODS was 4027.9U/L, serum lipase was 6168.9 IU/L, mean leucocyte count was 17,449.1 cells/mm3, serum CRP value was 5.7 mg/L, mean ESR was 36 mm/h and serum LDH was 600.7 IU. Conclusions: Pancreatic cancer and BMI had significant relation with MODS in AP. Biochemical markers such as serum amylase, Serum lipase, serum LDH, serum CRP, total leucocyte count and ESR had significant predictive value in detecting MODS in AP.
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Factors influencing quality of life after lower extremity amputation p. 49
Dantis John Thomas, CV Rajendran
DOI:10.4103/ksj.ksj_20_22  
Background: Despite the fact that patients with critical limb ischaemia, diabetic foot, advanced malignancies and major trauma to extremities undergo lower limb amputation, the personal satisfaction or quality of life (QoL) of such patients remains inadequately portrayed. This study tried to portray which spaces' amputees consider significant in deciding their well-being related QoL. Objective: To study the factors influencing QoL of patients who have undergone lower extremity amputation attending the department of general surgery of a tertiary hospital and to compare the QoL of amputee population with that of general population. Methodology: It was a cross-sectional study. The study population included patients who underwent lower extremity amputation in the department. 110 subjects, aged above 18 years, who have undergone lower extremity amputation and who consented to take part in the study were included. Results: The QoL as calculated from the Physical Component Summary and Mental Component Summary scores, using short-form-36 questionnaire showed that the physical health and the mental health (MH) both were significantly low in the amputee population. It was seen that gender with female sex having a better physical health quality compared to the male sex. Gender, use of prosthetic devise, stump infections and employment status contributed to MH quality. The QoL of an individual was severely altered following amputation. Both physical and MH domains were significantly reduced in an amputee compared to the general population. Gender influenced both the mental and physical QoL, with females performing better. Use of prosthesis was seen to be significant in MH. This underscores the need for proper rehabilitation programmes. Conclusion: The factors recognised should be seriously addressed in order to improve the QoL of lower limb amputees.
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Effectiveness of antibacterial-coated suture material to prevent post-operative superficial surgical site infection among patients undergoing abdominal wall closure p. 56
JP Sabari, M R. Rakesh Praveen Raj
DOI:10.4103/ksj.ksj_21_22  
Background: Despite the use of prophylactic antibiotics, surgical site infection (SSI) is still a real risk of surgery. This study focuses on the method of wound closure with regard to the suture material used since the suture material itself has long been known to be a significant cause or cofactor in SSIs. We compared the rates of superficial SSIs in patients in whom the subcutaneous layer of abdominal incisions was closed with antibacterial-coated polyglactin 910 suture materials with those in whom coated polyglactin 910 alone was used. Materials and Methods: Patients were divided into two groups as per the unit system. The patients selected for the study were those undergoing abdominal wall closures. All patients above 18 years of age, who undergoes abdominal surgery for various ailments at our hospital, were included in the study. All the patients were given antibiotics pre-operatively and post-operatively. The patients were followed up for up to the day of discharge, 1-week post-discharge and 30-day post-operative as routinely followed in our institute. Results: There was a statistically significant relationship between plain polyglactin 910 and triclosan-coated polyglactin 910 (P < 0.05). The infection rate associated with the use of plain polyglactin 910 was 22.6% and with triclosan-coated polyglactin 910 was 12.3 (P = 0.025). The most common organism causing skin and skin-structure infection were Klebsiella (26%) and Staphylococcus (26%). Conclusion: Our study confirms a significant benefit to the patient in reducing superficial SSI in abdominal wall closure with the use of triclosan-coated polyglactin 910 when compared to plain polyglactin 910 usage for the same.
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Factors associated with development of post-operative pancreatic fistula: A record-based observational study p. 62
Amal George, P Sajan, Rojan Kuruvilla, UV Akshay Viswanath, Jinto Thomas Augustine, Abishek Rajan, Rajesh Nambiar, Sajeesh Sahadevan, M Noushif
DOI:10.4103/ksj.ksj_3_22  
Introduction: Post-operative pancreatic fistula (POPF) is one of the major complications of pancreaticoduodenectomy (PD), which is the procedure of choice for many peripancreatic diseases. POPF may lead to or be combined with post-pancreatectomy haemorrhage and delayed gastric emptying or abscesses and sepsis, possibly leading to subsequent shock, multiorgan failure and mortality. The study was conducted with the objective to identify the factors associated with the development of POPF following PD. Methodology: This was a record-based cross-sectional study done in Kerala which recorded the details of 125 patients who underwent surgery between January 2018 and January 2020. Inclusion criteria were patients admitted with pathology in and around the head of the pancreas and requiring PD. Patient characteristics, disease-related details, pre-operative morbidities, details of surgery, and post-operative details were accessed from the patient record. Results: The mean standard deviation age of the participants was 60 (11.2) years. There was a higher proportion of males compared to females. The underlying lesion was malignant for the majority. Nearly 90% of the participants underwent classical PD. Nearly half of the patients developed POPF of which one-third were clinically relevant. Lack of history of chronic pancreatitis and post-operative drain fluid amylase was found to be significantly associated with POPF occurrence. Conclusion: Lack of history of chronic pancreatitis, amount of drainage fluid and amylase level was found to be significantly associated with the presence of post-operative fistula.
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A prospective randomised study comparing transabdominal pre-peritoneal versus totally extra-peritoneal laparoscopic approaches for inguinal hernia repair p. 67
Satish Reddy Manda, Sujith Philip, CN Rajesh, Sruthy Merry Sam, Deepak Varma
DOI:10.4103/ksj.ksj_4_22  
Background: Inguinal hernia repair is one of the most common surgical procedures undertaken in routine surgical practice worldwide. Laparoscopic inguinal hernia repair has now become accepted as a standard method of treatment There are two widely accepted methods of laparoscopic inguinal hernia repair, transabdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP). Materials and Methods: Our study was a prospective randomised study to compare the outcome of both TAPP and TEP for inguinal hernia repair and included a total of 120 patients who were diagnosed to have inguinal hernia and underwent surgical management electively for the same. They were randomised into both TAPP and TEP groups and the results were compared. Results: Amongst the two groups, laparoscopic TAPP repair required more time compared to laparoscopic TEP repair. However, post-operative pain, duration of hospital stays, complication rate and return to normal work did not show any significant difference between the two groups. Conclusion: Both laparoscopic TAPP and laparoscopic TEP repair are acceptable and equally efficacious treatment choices for inguinal hernia repair.
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Prognostic factors related to delayed healing in venous leg ulcers treated with four-layer compression bandaging: A prospective observational study on a cohort of patients p. 71
Sasidharan Vineeth, Sanju Samuel, Anoop Vasudevan Pillai, Riju Ramachandran, Renjitha Bhaskaran
DOI:10.4103/ksj.ksj_5_22  
Background: Four-layer compression bandage is found to be very effective in healing most venous ulcers. Various causes have been suggested in the literature for delay in healing despite compression. However, Indian literature on venous ulcers, compression bandage and prognostic factors for healing of venous leg ulcers (VLUs) are lacking. This study was a prospective observational study on a cohort of patients with VLU treated with four-layer compression bandage, to assess prognostic factors causing delay in the healing process. Subjects and Methods: After obtaining approval from the institutional review board, all patients with VLUs treated using four-layer compression bandage in the department of general surgery from October 2018 to October 2020 were included in the study. Age, gender, body mass index (BMI), waist–hip ratio, duplex/Doppler findings, culture and sensitivity report of swab taken at the time of first visit and ulcer healing time were recorded. To test the significant association of categorical variables between groups, Chi-square test with continuity correction was applied. Results: There were 150 patients included in the study. Ulcer healed completely in 101 patients, and there was delay/non-healing in 49 (32.7%) patients. Ulcer was more common in male patients and those above 45 years of age (mean age: 57.0200 ± 8.86 years). Female gender had a better prognosis. BMI > 25 (P = 0.04); infection with Pseudomonas (P = 0.001), staphylococci (P = 0.001) and Klebsiella and saphenopopliteal junction (SPJ) incompetence (P = 0.001) adversely affected healing of VLUs. Conclusion: Compression bandage significantly improves wound healing in VLUs. Female gender, obesity, SPJ incompetence and secondary infections are independent risk factors for delayed healing in VLUs.
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Open abdominal aortic aneurysm repair – Case experience in a tertiary care centre p. 76
Manu Jose Chirayath, MK Soumya Soman, Sreekumar Ramachandran
DOI:10.4103/ksj.ksj_7_22  
Background: Abdominal aortic aneurysm (AAA) mostly affects men than women. Materials and Methods: This paper attempts to study the clinical and demographic profile of patients undergoing open surgical AAA repair. This case series is based on five successfully surgically repaired open AAA at the department of general surgery of a tertiary hospital. Results: All cases were male patients. All cases became well after the surgery. The mean hospital stay was 8.2 days. Conclusion: The study identifies the importance of vascular surgery in the successful outcome of these patients.
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A study to determine the incidence of coexisting carcinoma In situ in mastectomy specimens with invasive breast carcinoma p. 79
Bineesh Prakash, PK Mohanan
DOI:10.4103/ksj.ksj_8_22  
Background: In situ breast carcinoma is a pre-invasive cancer that has not breached the epithelial basement membrane. This was previously a rare but is becoming increasingly common. It may be ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). DCIS is a precursor of invasive carcinoma, whereas LCIS is not a precursor but only a predictor of invasive carcinoma. In those with LCIS, 50% of the carcinomas occur in the contralateral breast. Aim: This paper aims to study the incidence of DCIS and LCIS in mastectomy specimens of invasive carcinoma breast. Materials and Methods: This is a subjective study of 226 patients in a tertiary care hospital over a period of 18 months. Patients with invasive breast carcinoma undergoing mastectomy were included. Patients with invasive breast carcinoma and those who have undergone any breast surgeries in the past were excluded. The histopathology reports were analysed for finding out DCIS and LCIS coexisting with invasive carcinoma of the breast. Results: The patients had a mean age of 56–11.025 years. 59.7% were in the 41–60-year age group. DCIS coexisted with invasive carcinoma in 28.3% (64). LCIS was absent in all cases of invasive carcinoma. Amongst those with DCIS, high-grade DCIS was found in 65.6% (42) and low-grade DCIS in 34.4% (22). Amongst the DCIS group, comedo type was present in 46.9% (30), followed by cribriform type 31.2% (20), solid type 18.8% (12) and papillary type 3.1% (2). Conclusion: DCIS was found to coexist with invasive carcinoma in 28.3% of cases, whereas LCIS was absent in all cases of invasive carcinoma.
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An observational study to evaluate the efficacy of micronised purified flavonoid fraction in improving venous clinical severity score p. 83
G Adhip, EV Gopi
DOI:10.4103/ksj.ksj_9_22  
Background: Medical care of chronic venous disease (CVD) entails different strategies that can be used either alone or in combination. Micronised purified flavonoid fractions (MPFFs) are venomodulator drugs used for CVD. Aim: In the present study, the efficacy of MPFF in lowering Venous Clinical Severity Scoring (VCSS) for CVD [Clinical, Etiological, Anatomical and Pathological (CEAP) C3 disease] is assessed and identified a subgroup who will benefit from the therapy. Materials and Methods: This was an observational study based on 35 cases of CVD CEAP Class C3 attending a tertiary hospital. Their initial VCSS was assessed and the same was reassessed after 6 months of MPFF therapy. The data were statistically analysed. Results: The mean age among the study participants was 45.9 ± 9.4 years. Almost half of the study participants, 16 (45.7%), belonged to 41–50 years. More than half of the study participants were female. The median pain score was statistically significantly lower after flavonoid administration compared to baseline (P < 0.001). Similarly, statistically significant lower median oedema and VCSS scores were obtained after flavonoid administration (P < 0.001). However, no significant decrease was observed in the VCSS after flavonoid administration. The median VCSS was statistically significantly lower in females aged 41–50 years after flavonoid administration compared to baseline (P < 0.001). Conclusion: MPFFs are efficient in lowering VCSS in CEAP Class C3 cases of CVD in all age groups. The best efficiency was noted in 41–50 years' age group females. Patients with venous pain and venous oedema had the best response. The least response was noted in clinically demonstrable varices.
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CASE REPORTS Top

Enterocutaneous fistula in thigh p. 88
MK Dinu, E Sugeeth
DOI:10.4103/ksj.ksj_1_22  
Enterocutaneous fistula is a condition with a mortality rate as high as 10% in recent reports. Hence, early detection is important. This is a case report of a 53-year-old male with a rare presentation of an enterocutaneous fistula as a thigh abscess.
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A rare case of right thyroid hemiagenesis associated with papillary carcinoma in remnant lobe p. 91
Amal George, P Rajan, UV Akshay Viswanath,, Jinto Thomas Augustine, Tony George
DOI:10.4103/ksj.ksj_2_22  
Thyroid hemiagenesis is a rare congenital abnormality, in which one thyroid lobe fails to develop. The associated diseases in the remaining thyroid lobe include benign multinodular goiter, adenoma, hyperthyroidism, chronic thyroiditis and rarely carcinoma. The most common pathology involved in thyroid hemiagenesis is hyperthyroidism. The presence of carcinoma in a patient with hemiagenesis is quite rare and very few cases are reported in the world literature.
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Recurrent submandibular pleomorphic adenoma with metastasis: Carcinoma ex pleomorphic adenoma p. 93
Ajil Antony, R Santhoshkumar
DOI:10.4103/ksj.ksj_52_21  
Carcinoma ex pleomorphic adenoma (CXPA) is a carcinoma arising from a primary or recurrent benign PA. The entity is difficult to diagnose preoperatively. PA is a common neoplasm that arises from the major salivary glands and infrequently undergoes a malignant transformation. PA can metastasise without histological malignant transformation. Malignant changes in PA are associated with a long duration, tumour recurrence, radiation therapy, advancing age and tumour size. Since the incidence of malignancy is correlated with the duration of PA, the risk of developing malignancy is only about 1.5% for a duration of <5 years, but increases to 9.5% for a duration of >15 years. We describe a case of CXPA of submandibular salivary gland in a 70-year-old female who had a history of right submandibular sialoadenectomy in 2017 and then redo excisions at the same site in 2018 and 2021.
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Primary jejunal melanoma presenting as gastrointestinal bleeding p. 98
Agil Babu, TV Haridas, AK Abdul Siyad, Bevin Roys Daniel, KN Radhakrishnan
DOI:10.4103/ksj.ksj_53_21  
Intestinal melanomas are very rare causes of upper gastrointestinal bleeding and abdominal lump. The occurrence of both primary and secondary in the intestine is an uncommon presentation. Jejunal melanoma is extremely rare, and only <20 cases have been reported in the literature so far. We are presenting a 52-year-old male patient who presented with fatigue, melaena and an abdominal lump of 1-month duration. He was operated on for biopsy as none of the investigations helped in reaching a definitive diagnosis. Peroperative findings were indicative of jejunal melanoma with infiltration to the right colon. Right hemicolectomy with jejunal resection was done. Histopathological examination revealed malignant melanoma with primary from jejunum. This case is discussed because of the rarity of the disease, and better management can be planned if preoperatively diagnosed.
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Submandibular pleomorphic adenoma in a male: An unusual case report Highly accessed article p. 101
Mohan Nayak Guguloth, Sai Kiran Kuchana, Tarun Kumar Suvvari, Anthony Reddy Gopu, Shanteja Reddy Mamidi, Rahul Jagdishchandra Mittal
DOI:10.4103/ksj.ksj_6_22  
Pleomorphic adenoma (PA) of the submandibular gland is a very unusual neoplasm and comprises only 8%–10% of all benign tumours, most commonly affecting females between 30 and 50 years of age. In this case report, we described a case of a 36-year-old male patient who presented with swelling in the left neck region for 5 years, associated with dull aching pain and increased salivation. The ultrasonography and plain computed tomography (CT) of the neck revealed iso-hypointense lesions arising from the left submandibular gland. Fine needle aspiration cytology of the swelling revealed sheets and clusters of cells with an eccentric nucleus in the chondromyxoid and haemorrhagic background, and a probable diagnosis of PA was made based on Milan's scoring system. The patient underwent an excision of the gland. Post-operative biopsy showed islands of mesenchymal and epithelial components with intervening fibrous tissue and areas of haemorrhage, confirming the diagnosis of submandibular PA.
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Catamenial haemothorax: A rare case of thoracic endometriosis syndrome p. 105
KJ Lukumanul Hakeem, Atul Abraham, PK Najeeb
DOI:10.4103/ksj.ksj_12_22  
Catamenial haemothorax (CH) is a rare manifestation of thoracic endometriosis (TE) syndrome. It is commonly seen associated with pelvic endometriosis in nulliparous reproductive-age women. Most cases are minor and self-limiting. We present an uncommon case of a 22-year-old woman with TE causing massive CH.
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PICTORIAL CME Top

Pictorial CME p. 108
YM Fazil Marickar
DOI:10.4103/ksj.ksj_25_22  
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ANNUAL REPORT Top

ASI Kerala chapter annual report p. 110
Jayan Stephen
DOI:10.4103/ksj.ksj_26_22  
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