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   Table of Contents - Current issue
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July-December 2022
Volume 28 | Issue 2
Page Nos. 111-210

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CHAIRMANíS MESSAGE  

Chairman's message p. 111
Binni John
DOI:10.4103/0973-3051.368587  
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EDITORIAL Top

Editorial p. 112
YM Fazil Marickar
DOI:10.4103/0973-3051.368607  
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ORIGINAL ARTICLES Top

Laparoscopic common bile duct exploration: A single-centre experience p. 113
Arjun Balram, Mano Harsha, Viswanath Tadikamalla, Sriya Prakash Nair, CJ Varghese
DOI:10.4103/ksj.ksj_34_22  
Background: Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endolaparoscopic treatment but with a shorter hospital stay, lower cost and lower recurrent stone rate. Aim: The aim of this article was to report the authors' experience with LCBDE with a rigid telescope during LC. Methods: A retrospective analysis of patients who underwent LCBDE for ductal stones in a single surgical unit were studied from 2017 to 2021. Results: A total of 55 LCBDEs were performed during this period. Ninety percentage of patients presented with biliary colic. Of these 18% were following endoscopic retrograde cholangiopancreatography failure. About 50.4% of patients had multiple stones. About 16.8% of patients had undilated CBD. The mean operative time was 178 ± 71.62 (80–300). The conversion rate was 1.8%. All patients underwent CBD exploration through a supraduodenal choledochotomy. In 9% of cases, pneumatic lithotripsy was used because of impacted large stones. The closure was done over T-tube in 58.18% of cases and over antegrade endobiliary stent in 41% of cases. Post-operative complication was minor CD 1 and 2. The overall success rate of LCBDE was 98%. Conclusion: LCBDE should be considered for treatment for patients with gallstones with CBD stones, especially for patients with large and multiple stones.
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Therapeutic outcome of lateral internal sphincterotomy in the treatment of chronic anal fissures p. 119
Melvin Varghese, S Shaju, N Saran, MH Firoz Khan, S L. Shafy Ali Khan
DOI:10.4103/ksj.ksj_41_22  
Introduction: Chronic anal fissure (CAF) is one of the most common proctologic conditions seen in surgery and is the most common cause of perianal pain. The surgical procedure of choice is lateral internal sphincterotomy (LIS) which usually provides a permanent cure for CAF. The fear of causing incontinence restricts many surgeons from performing LIS for managing CAF. The objective of our study is to evaluate the outcome of LIS in treating CAF in terms of fissure healing and reduction in resting anal pressure (RAP), as well as the incidence of anal incontinence following the procedure. Materials and Methods: A prospective study was conducted among 43 patients with CAF who underwent LIS. Anal manometry of the patients was done and results were noted preoperatively as well as at 6 weeks postoperatively. Patients were followed up and symptom relief, healing of fissure and incontinence to flatus or stool if present were noted on post-operative day, 1 week after surgery and 6 weeks after surgery. Results: Fissure healed in all 43 patients who underwent LIS in our institute. Hence, we observed a 100% healing rate following the procedure. RAP was found to be raised in all patients with CAF who required surgical treatment with a mean pre-operative RAP of 86.6 mmHg (normal 40–60 mmHg.). There was a significant reduction in RAP after the LIS surgery with a P < 0.001. The mean post-operative RAP was 53.16 mmHg which is in the normal range. Only one patient (2.3%) developed post-operative anal incontinence in our study. He was also managed conservatively with no permanent incontinence. Conclusions: We conclude that LIS is the surgical treatment of choice for CAFs, as it gave a 100% healing rate with a very low incidence of post-operative anal incontinence and other complications.
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Effectiveness of acute physiology and chronic health Evaluation-II scoring in predicting outcomes of perforation peritonitis p. 123
Goutham P Sathyapal, Alex Oommen
DOI:10.4103/ksj.ksj_43_22  
Introduction: Several scoring systems have been developed for predicting the severity and outcomes of peritonitis, such as the Acute Physiology and Chronic Health Evaluation (APACHE-II) score, Ranson's score and Mannheim's peritonitis index. The aim of the study was to evaluate the performance of the APACHE-II scoring system in predicting mortality and morbidity in patients with perforation peritonitis. Methods: Diagnostic test evaluation was done from June 2020 to December 2021, including 168 patients with hollow viscous perforation, excluding appendicular abscess perforation, who attended the casualty and underwent surgery. Data were collected by meticulous history, clinical examination, radiological, histopathological and serological investigation, operative findings and follow-up till discharge or death. The outcome of the study is based on an analysis of mortality and morbidity due to perforation peritonitis and its correlation with the scores obtained based on APACHE-2 scoring system. Results: The commonest age group of perforation peritonitis was 41–50 years of age (21.4%), with male preponderance. The most common site of perforation was gastric in all age groups, and the most common aetiology was peptic ulcer, followed by malignancy. The mortality rate was 10.7%, and the rates are higher for females, older age groups, and malignancies. There was a statistically significant association for APACHE-II score in predicting the mortality, complications and morbidity associated with perforation peritonitis. The average APACHE-II score in this study was 6.17 and the average score among survivors was 4.33 and non-survivors 21.44. Morbidity and mortality increased as the score increased; a score above 15 had a sensitivity of 99% and specificity of 94.4% in predicting mortality, the complication rates were more in scores above 10. The low-risk categories (0–5 and 6–10) had a favourable outcome in terms of morbidity and mortality. Conclusions: The mean age was 46.6 years with male preponderance. The most common aetiology was peptic ulcer perforation, followed by perforation due to malignancies and site of perforation being the stomach, followed by colon. There was a statistically significant association for APACHE-II score in predicting the mortality, complications and morbidity associated with perforation peritonitis and score above 15 has a sensitivity of 99% and a specificity of 94.4% in predicting mortality associated with secondary peritonitis.
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Comparison of radiofrequency ablation and conventional surgery in the treatment of varicose veins p. 129
Jibin Leons, Jomine Jose, Binni John
DOI:10.4103/ksj.ksj_33_22  
Background: This retrospective study was aimed to compare the outcomes between radiofrequency ablation (RFA) and conventional surgery which included the Trendelenburg procedure, multiple perforator ligation, hook phlebectomy and stripping for the treatment of varicose veins using Clinical, Etiological, Anatomical, and Pathophysiological classification (CEAP) and Venous Clinical Severity Score (VCSS) in a tertiary care centre. Materials and Methods: The pre-operative and post-operative CEAP classification and VCSS were calculated. The satisfaction from the surgery was assessed using a structured questionnaire and data analysed using IBM SPSS software. Results: The majority of the patients in the study belonged to the age group of 41–50 years. Females comprised 58% and housewives comprised 35% of the total patients. Patients with a body mass index of 18.5–24.9 constituted almost 44%. Twenty-four individuals had a family history of varicose veins. Doppler studies showed that at 83%, the most common pathology was sapheno-femoral junction (SFJ) and perforator incompetence. Five per cent of individuals had perforator incompetence alone. Thirty-four per cent of the individuals underwent RFA. The improvement in CEAP was 3.03 ± 1.513 in RFA group and 2.91 ± 1.279 in conventional surgery group; statistical analysis did not show any significant difference between the groups. The post-operative VCSS improved from 7.94 ± 1.718 in conventional surgery group and 7.38 ± 1.706 in RFA group to 1.52 ± 1.070 and 1.03 ± 0.577, respectively. The most common problem after surgery was saphenous neuralgia (8%). The severity of pain in the 1st week after the intervention was 'very mild' for most of the patients who underwent RFA (47.1%), and moderate for those in conventional surgery group (37.9%). The average days to return to normal activity were 10.26 ± 3.96 and 3.44 ± 1.637 in conventional surgery and RFA groups, respectively, whereas the average days to return to work were 17.41 ± 5.418 and 9.50 ± 1.846 days, respectively. Conclusion: The results indicate that both RFA and conventional surgeries in the form of the Trendelenburg procedure, stripping, phlebectomy and perforator ligation provide comparable relief of symptoms and clinical improvement when applied for the treatment of varicose veins. However, RFA may offer a significant advantage over conventional surgery in terms of faster recovery and early return to normal life and work.
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LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) scoring system as a predictor for early diagnosis of necrotizing fasciitis in soft-tissue infections p. 133
C Rajeev, A Mohamad Safwan, K P C Muhammed Irfan, KN Vijayan, Liju Varghese
DOI:10.4103/ksj.ksj_45_22  
Introduction: Necrotizing soft-tissue infections are often fatal, characterized by extensive necrosis of the fascia and subcutaneous tissues. To aid the early diagnosis of necrotizing fasciitis (NF), there is a Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system for the early diagnosis of NF. Our study was undertaken to evaluate LRINEC score, based on routine laboratory investigations that are readily available, that could help distinguish NF from other soft-tissue infections. Materials and Methods: The study was conducted on all inpatients, admitted with features of soft-tissue infections suspected to have NF and later underwent wound debridement or amputation in a tertiary care hospital. LRINEC score more than or equal to 6 was considered as case and the score <6 considered as control. Both were treated with intravenous (IV) antibiotics, IV fluids and surgical intervention based on their clinical findings and outcome. The confirmatory diagnosis for NF was done through culture of tissue and other body fluids. Results: The cutoff value of LRINEC for predicting NF was 6 with sensitivity of 85.7% and specificity of 70.7%. The negative predictive value of LRINEC-OC was 87.9% and positive predictive value (PPV) 66.7%. The accuracy was 76.8%. Conclusion: LRINEC scoring system has a better PPV in identifying the onset of NF and risk strategizing of the patients with severe soft-tissue infections. We recommend LRINEC score to be used as a predictor in the diagnosis of NF. Multi-disciplinary team may guide immediate operative and supportive management, thereby improving the clinical outcome of the patient.
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The perioperative outcome in geriatric patients undergoing major gastrointestinal surgery p. 138
VR Anantha Krishna, TU Shabeer Ali, A Mohamad Safwan
DOI:10.4103/ksj.ksj_50_22  
Background: The surgical impact on the 30-day mortality and morbidity in geriatric patients is a scarcely studied topic. The aims of this study were to identify the 30-day morbidity and mortality in geriatric patients undergoing major gastrointestinal surgery and to identify the risk factors associated with the same. Materials and Methods: A cross-sectional study was conducted on 93 patients at a tertiary care centre. Thirty-day morbidity was broadly grouped into wound, renal, cardiac, respiratory, psychiatric, neurologic complications and others. The complications were also graded into five based on the Clavien–Dindo classification. Data were analysed using appropriate statistical methods. Results: The 30-day mortality in our study was 3.2%. The 30-day overall morbidity was 58.06%. Grade 2 and above Clavien–Dindo complications were encountered in 25/93 patients – 26.9%. There was an increased risk of Grade 2 and above Clavien–Dindo surgical complications in patients who had prior history of falls, who had timed up and go test more than 14 s, who had significant weight loss, who were operated for malignant causes and those who underwent open surgeries. Majority of complications occurred in the 65–69-year age group. Patients operated for non-malignant causes had no post-operative complications in our study. Conclusion: Elective surgery is generally well tolerated by the elderly. Age should not be used as the only criterion when deciding suitability for surgery in this age group. The results of elective surgery in the elderly are in fact reproducibly good, especially in non-malignant causes.
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Predictive value of Serum C-Reactive protein and serum lactate in intestinal obstruction with suspected strangulation p. 143
A Mohamad Safwan, K P.C Muhammed Irfan, Rajeev Chellapan, MH Firoz Khan, KN Vijayan
DOI:10.4103/ksj.ksj_37_22  
Background: Intestinal obstruction is one of the common clinical problems encountered in surgical practice, and the dreadful complication of intestinal obstruction is strangulation, which requires an emergency surgery for management. The main objective of our study was to evaluate patients with clinical suspicious intestinal obstruction and to find out the significant levels of serum C-reactive protein (CRP) and serum lactate in the early detections of strangulation preoperatively. Materials and Methods: A total of 30 patients who aged between 15 and 80 years were included in the study after excluding the patients of comorbid medical illness and patients with findings other than obstruction or strangulation. The serum values of CRP and lactate were measured pre-operatively and compared between obstruction with strangulation and obstruction without strangulation. Receiver operating characteristic (ROC) curve was drawn, and cut-off values for the diagnosis of strangulation were calculated along the calculation of sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs). Results: Fifteen patients of strangulated bowel obstruction had significantly higher values of serum CRP and lactate when compared with 15 patients of simple bowel obstruction (99 vs. 38.3 mg/L and 35 vs. 9.9 mg/dl, respectively, P < 0.05). Using ROC analysis, the area under the curve of serum CRP and lactate was found to be 0.809 and 0.947, respectively for bowel strangulation. The serum CRP test has the sensitivity of 80.0%, specificity of 66.7%, PPV of 70.6% and NPV of 76.9% to detect the obstruction with strangulation when using a cut-off value of 49 mg/L. The serum lactate test has the sensitivity of 86.7%, specificity of 73.3%, PPV of 76.5% and NPV of 84.6% to detect the obstruction with strangulation when using a cut-off value of 19 mg/dl. Conclusion: The serum CRP and lactate are useful and reasonable diagnostic markers for predicting strangulation in cases of acute intestinal obstruction in an emergency setting.
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Quality of life in patients undergoing endovenous laser ablation and saphenofemoral ligation and stripping p. 149
Deepesh D Madhu, MT Saji, PK Manilal
DOI:10.4103/ksj.ksj_38_22  
Introduction: Surgery for varicose veins was the treatment of choice before the advent of minimally invasive procedures. Aim: This study was done to compare the utility of endovenous laser ablation (EVLA) as an effective alternative to surgery to treat varicose veins. Materials and Methods: The study was conducted in a tertiary care hospital between October 2019 and March 2021. One hundred and six patients with varicose veins of the long saphenous system were included in the study, 53 in the laser surgery group and 53 in the open surgery group. European Quality of life 5 dimensions questionnaire, the WHO VAS score and clinical aetiological, anatomical and pathological classification for varicose veins scores of the affected limb of the patients were recorded preoperatively and postoperatively at day 90. Data were statistically analysed using SPSS. Results: Patients treated by EVLA enjoyed a better quality of life than the ligation and stripping group. They experience significant reduction in the post-operative pain, the absence of wound infection and a significant reduction in the clinical severity scores. Conclusion: EVLA is a safer and effective means for treating varicose veins.
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Incidence and role of large vessel disease in diabetic foot p. 154
Akash Sasidharan, S L. Ali Khan Shafy, MH Khan Firoz, U Namita
DOI:10.4103/ksj.ksj_42_22  
Introduction: Diabetic patients are at risk for considerable morbidity as a result of chronic foot ulceration and infection, including limb loss. Diabetic foot infections are usually a consequence of skin ulceration from ischaemia or trauma to a neuropathic foot. The accurate diagnosis of the underlying cause is very important in planning the treatment. The aim of the study was to study the incidence and role of large vessel disease in patients with diabetic foot. Materials and Methods: Seventy-five patients admitted with features of diabetic foot and its complications were included in the study after excluding patients of comorbid medical illness. The presence of macrovasculopathy was assessed by examination for peripheral pulses, followed by assessment using arterial Doppler amongst patients with macrovasculopathy, those with gangrene or non-healing ulcers and those who underwent amputations or disarticulations were analysed. Results: Clinically, dorsalis pedis artery pulses were absent in 81.3% and posterior tibial artery pulses were absent in 54.7%. In arterial Doppler, involvement is 66.7% for dorsalis pedis and 68% for posterior tibial. Fifty-six percentage of patients ended up having poor outcomes in the form of amputations or disarticulations. There is a significant incidence of large vessel disease, especially in elderly patients who were diabetic for more than 10 years. Large vessel disease seems to have a significant role in the final outcome of diabetic foot complications. Conclusions: Vasculopathy is a strong risk factor in the development of diabetic foot lesions. An arterial Doppler will help detect involvement early in cases presenting with diabetic foot complications. The presence of diabetic microvascular disease imparts an even greater importance on the early detection and treatment of significant macrovascular disease.
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Diagnostic test evaluation of Raja Isteri Pengiran Anak Saleha appendicitis score in patients with acute appendicitis p. 158
S Gowshika, S Santhosh Kumar
DOI:10.4103/ksj.ksj_36_22  
Introduction: The diagnosis of acute appendicitis is still heavy reliant on clinical judgement as the availability and quality of imaging studies are quite variable. The Alvarado score and newer scores have been proposed in recent times, one of which is the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score. It has been developed for a better diagnosis of acute appendicitis; the score includes 14 clinical parameters, which have higher sensitivity, specificity and diagnostic accuracy than Alvarado scoring, especially in the Asian population. Methodology: The objective was to evaluate the diagnostic accuracy of the RIPASA score with respect to histopathologically proven appendicitis. A diagnostic test evaluation was conducted in the surgical wards of a tertiary care centre for 1 year on patients undergoing emergency appendicectomy for acute appendicitis. Consecutive sampling was done on 132 participants. After administering the RIPASA score questionnaire to the patients, the histopathological reports were collected and the scoring system was compared to obtain sensitivity, specificity, predictive values, likelihood ratios and area under curve (AUC). Results: Of the 132 patients, 50.8% were male and 49.2% were female, with the majority of patients <40 years. Among components of the RIPASA score other than age, sex, anorexia, duration of symptoms and Rovsing's sign, all other components had an independent statistically significant association to histologically proven appendicitis. The receiver operating characteristic curve analysis of the RIPASA score showed an AUC of 0.915 (P < 0.0001). The negative appendicectomy rate was about 19.6%. Conclusion: The RIPASA score is a simple scoring system with high sensitivity and specificity for the diagnosis of acute appendicitis. The 14 clinical parameters are easily obtained from a good clinical history and examination and can be easily and quickly applied. Therefore, a decision on the management can be made early and complications can be prevented.
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Validation of a scoring system to predict difficult laparoscopic cholecystectomy p. 163
N Saran, Shafy Ali Khan, AA Najeeb, TG Jithu, A Mohamad Safwan, Melvin Varghese, S Shaju, KN Vijayan
DOI:10.4103/ksj.ksj_49_22  
Background: Acute calculous cholecystitis is one of the common conditions. The initial radiological investigation of choice is ultrasonography of the abdomen. Cholecystectomy is the definitive treatment for acute cholecystitis. Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. Sometimes there is a need for conversion to open cholecystectomy due to intra-abdominal adhesions which make laparoscopic cholecystectomy difficult. Hence, pre-operative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. In our study, we aimed to analyse the various risk factors and to predict the difficulty and degree of difficulty pre-operative lay by the use of a scoring system. Materials and Methods: All 100 patients were evaluated and their clinical and ultrasound parameters were recorded. They received symptomatic treatment with antibiotics and analgesics preoperatively. Following that, they were subjected to laparoscopic cholecystectomy, time taken, bile spillage, stone spillage, injury to duct, artery and conversion to open cholecystectomy were noted. All patients were operated by similarly experienced surgeons. Postoperatively, cases were followed up for any complications and they were discharged on recovery. Results: Receiver operating characteristic curve analysis of pre-operative with an intraoperative score in our study with area = 0.846, P = 0.0005 <0.01 is highly statistically significant at P < 0.01 level. The sensitivity and specificity of the scoring system at score 0–5 for the prediction of easy laparoscopic cholecystectomy are 89.2% and 80.0%, respectively, and the sensitivity and specificity of the scoring system at score 6–10 for the prediction of difficult laparoscopic cholecystectomy are 80.0% and 89.2%, respectively. Conclusion: Our study concludes that the scoring system evaluated is robust, reliable and useful to predict difficult laparoscopic cholecystectomy.
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Validation of Boey's scoring system in predicting short-term morbidity and mortality in peptic ulcer perforation peritonitis p. 169
Geethu Saiphy, S Sunil
DOI:10.4103/ksj.ksj_48_22  
Aim: This study aims to assess the validation of Boey's scoring system in predicting short-term morbidity and mortality amongst patients with peptic ulcer perforation (PULP) peritonitis. Methodology: 110 patients with PULP peritonitis were included in this study. Boey's score was calculated based on three parameters, pre-operative shock, concomitant medical illness and duration of perforation >24 h. All patients with PULP were treated with exploratory laparotomy with peritoneal lavage and omental patch repair and the patients were then followed up throughout the data collection period to look for clinical outcomes. The main outcomes assessed were mortality and short-term morbidity (1 month). Data were analysed using SPSS (IBM, Delhi, India). Chi-square test was used to check for the association between the outcome variables and the categorised Boey's score. The level of statistical significance was assigned as a P < 0.05. Results: Amongst the 110 patients, half belonged to the age group of 31–50 years, and 90% were male. The most common site of perforation was the first part of duodenum (78%). The rate of mortality was 10%. With respect to the distribution of the Boey's score, the percentage of patients with Boey's score 0, 1, 2 and 3 was found to be 12.75%, 58.2%, 24.5% and 5%, respectively, and their corresponding mortality was found to be 0%, 4.7%, 25.9% and 40%, respectively. Their morbidity at 1 week was found to be 21.4%, 42.6%, 80% and 100%, respectively, and morbidity at 1 month was found to be 0%, 39.3%, 75% and 100%, respectively. Conclusion: There was a significant association between mortality and morbidity at 1 week and at 1 month with the distribution of Boey's score. This highlights the importance of Boey's score in determining the outcome amongst perforated peptic ulcer patients. Boey's score being an easily applicable score for day-to-day clinical practice can aid clinicians in predicting the outcome amongst perforated ulcer patients. Several studies have also shown better accuracy with Boey's scoring system when compared to the other scoring systems.
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Hypocalcaemia following thyroid surgery in a tertiary care centre p. 174
Anusha Vadivelu, KN Vijayan, Liju Varghese
DOI:10.4103/ksj.ksj_47_22  
Introduction: Hypocalcaemia may occur secondarily to surgical trauma, devascularisation, unintentional removal of parathyroid glands and ligation of both inferior thyroid arteries. The objective of the study was to evaluate the calcium level after thyroid surgery and to evaluate the clinical symptoms and signs of hypocalcaemia after thyroid surgery. Materials and Methods: Eighty-one patients were evaluated; post-operatively, the calcium levels were monitored and early hypocalcaemia was detected by looking for the symptoms and signs of hypocalcaemia. The calcium levels were recorded from post-operative day 1, 2, 3 and 7. By this method, low serum calcium levels are corrected by calcium supplements and can prevent the need of parental calcium. Results: The most common age group affected by thyroid disorders was 41–50 years and less common age group affected was above 60 years. Females (71.6%) were commonly affected by thyroid disorders compared to males (28.4%). Majority of the patients were diagnosed with multinodular goitre (42%), followed by papillary carcinoma (39.5%). Most of our study population underwent total thyroidectomy (around 90%). The number of patients who encountered carpodeal spasm was 1.2% Chovstek sign, trousseau sign, electrocardiogram changes were seen in 2.5% population Patients who received treatment for symptomatic hypocalcaemia was 2.5%. Conclusion: Females were more prone to hypocalcaemia compared to males. Hypocalcaemia was found to be more prevalent in those patients who underwent total thyroidectomy compared to other surgeries. This can be prevented by meticulous dissection, identification of parathyroid and serial monitoring of calcium levels. Our study also serves as a cost-effective tool for the general population and immediate intervention can be given to the patients who are at risk to become symptomatic and improve their quality of life.
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Intraoperative parathyroid hormone assay to guide completion of parathyroid surgery p. 178
S Shaju, Melvin Varghese, N Saran, A Mohamad Safwam
DOI:10.4103/ksj.ksj_40_22  
Introduction: Primary hyperparathyroidism (pHPT) is characterised by an autonomous production of parathyroid hormone (PTH), which causes hypercalcemia. It is classified into adenoma, glandular hyperplasia and carcinoma. The standard treatment for the pHPT has been bilateral neck exploration (BNE) and the visualisation of all parathyroid glands. However, the increasing sensitivity of pre-operative localisation methods such as 99Tc-sestamibi scanning and ultrasound in combination with intra-operative PTH monitoring (ioPTH) assay can be utilised to decrease the need of BNE and subsequent complications. The aim of the study was to determine the effectiveness of ioPTH during parathyroidectomy and to assess the effectiveness of ioPTH in surgery for pHPT. Materials and Methods: Thirty-one patients admitted to the general surgery department in our tertiary care centre with hyper-parathyroidism and underwent parathyroidectomy, whose ioPTH evaluation was done were considered for the study. Their pre-operative and post-excision (10 min after excision of suspicious gland) values of PTH were as noted. Reduction in ioPTH value, based on MIAMI criteria was considered as the eradication of hyper-functioning tissues and its effectiveness in confirming the success of pHPT-surgery in terms of post-operative serum calcium level, thereby evaluating MIAMI criteria. Results: Twenty-nine (90.6%) patients showed a reduction of more than 50% in PTH following excision of suspicious glands from pre-operative PTH which is statistically significant, whereas only 21 (65.6%) patient shows normal PTH value following excision of suspicious gland. However, all 31 patients showed decline in PTH value as compared to pre-excision value. Conclusion: When the abnormal parathyroid gland is excised, there will be the reduction of PTH more than 50% from their pre-excisional value. Hence, by utilising ioPTH assay to confirm the excision of pathological gland, we can reduce BNE.
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Serum bilirubin as a predictor of complications of acute appendicitis in adults p. 182
K P C Muhammed Irfan, C Rajeev, A Mohamad Safwan, Shafy Ali Khan, KN Vijayan, Liju Varghese
DOI:10.4103/ksj.ksj_39_22  
Introduction: Acute appendicitis is a very common cause of acute abdomen and the diagnosis is essentially clinical. A decision to operate based on clinical suspicion alone can result in removal of a normal appendix; whereas, if left untreated, appendicitis can result in necrosis and perforation. Therefore, improving the diagnostic accuracy of appendicitis is a need of the hour. This study was conducted to evaluate hyperbilirubinaemia in acute appendicitis to find out its predictive value in complications like perforation. Materials and Methods: This prospective study for diagnostic test evaluation was conducted amongst the inpatients in the Department of General Surgery, KIMSHEALTH Trivandrum, during the period from August 2019 to August 2020. A total number of 100 patients who were admitted with the clinical diagnosis of acute appendicitis were studied, and serum bilirubin and liver function tests were carried out in all of them. Results: Total bilirubin levels when compared with histopathological diagnosis by unpaired samples t-test, the t-value = 0.763, P = 0.447 > 0.05 which shows no statistically significant difference between total bilirubin levels in uncomplicated and complicated acute appendicitis based on histopathological diagnosis. Sensitivity is 81.8%; specificity is 29.2%; positive predictive value (PPV) is 12.5%; negative predictive value (NPV) is 92.9%. Conclusion: Elevated total serum bilirubin levels have a fairly high sensitivity and NPV in predicting complications of acute appendicitis, but the specificity and PPV are quite low, and hence, hyperbilirubinaemia could be used as an aid in diagnosing complicated acute appendicitis along with the clinical findings and ultrasonography findings, but it is not reliable as a standalone diagnostic test. If the total serum bilirubin levels are low, an alternate diagnosis could be suspected, and the chances of complicated appendicitis are quite low, but elevated serum bilirubin values alone cannot confirm the presence of complications. Therefore, our study could not find any correlation between the absolute levels of elevation of total bilirubin values and the presence or absence of complications in acute appendicitis.
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Utility of surgical apgar score in predicting morbidity and mortality in post-operative patients p. 186
TG Jithu, MH Firoz Khan, Kusuma Halemani, KN Vijayan
DOI:10.4103/ksj.ksj_44_22  
Introduction: Predicting complications forms an essential part of risk management in surgical practice. Recognising patients at high risk of developing a complication will contribute substantially to the quality of surgery and financial burden. This study aimed to assess the utility of surgical Apgar score in assessing morbidity and mortality in post-operative patients. Materials a Methods: The surgical Apgar score was calculated on all patients between 16 and 75 years undergoing surgery that required intensive perioperative monitoring in the general surgery department and correlated the score with the patient's outcomes in the form of complications, including death within 30 days of surgery. Results: Among the 214 patients, more than 70.6% of the patients were in the age group of above 40 years. The relationship with the lower surgical Apgar score is significant in terms of predicting post-operative complications (P < 0.001). The most common comorbidities were hypertension (43.9%) and diabetes mellitus (DM) (16.4%). However, the presence of DM and coronary artery disease influenced the outcome significantly. Emergency surgeries were associated with significantly more risk of complication within 30 days of surgery. Prolonged intensive care unit care and ventilation support, sepsis and pneumonia are the major set of post-operative complications in our study. A low surgical Apgar score is associated with an increased likelihood of complications. Conclusion: The surgical Apgar system is effective in stratifying patients into high-risk and low-risk groups and anticipating post-operative complications.
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CASE REPORTS Top

Primary hyperparathyroidism and metastatic papillary carcinoma of the thyroid complicating a twin pregnancy p. 190
A Mohamad Safwan, KN Vijayan, Rakesh Chandru, S Aakash
DOI:10.4103/ksj.ksj_35_22  
Primary hyperparathyroidism (PHPT) is the unregulated overproduction of parathyroid hormone due to abnormal parathyroid gland which results in abnormal calcium homeostasis. PHPT in pregnancy is a rare and often unrecognised condition which possesses a threat to both the mother and the foetus. Papillary carcinoma of the thyroid is the most common thyroid malignancy and its management is quite challenging when it is diagnosed during pregnancy. Herewith, we report the case of a 28-year-old pregnant woman who presented with severe hyperemesis and hypercalcaemia due to PHPT along with incidentally detected metastatic papillary carcinoma thyroid complicating the pregnancy.
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Heterotopic mesenteric ossification p. 194
Roshan Rajan, VK Prathapan
DOI:10.4103/ksj.ksj_46_22  
Heterotopic calcification has been previously noted in healed laparotomy scars, within the peritoneum and is extremely rare. Heterotopic mesenteric ossification (HMO) is a rare disease that refers to intra-abdominal calcification of unknown aetiology, involving the mesentery. They can lead to serious complications such as enterocutaneous fistulations, intestinal obstruction, perforation and recurrent sepsis. We report a case of 26-year-old who presented with recurrent intra-abdominal collection, following an operation for blunt trauma abdomen, and was found to have HMO. He underwent exploratory laparotomy, and multiple intrabdominal new bone formations were observed, especially over the small bowel mesentery.
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Feasibility of pectoralis major myocutaneous flap for primary reconstruction of near-total glossectomy defects: A report of 2 cases p. 198
Jency Mathews, Shali Subash, PM Prathiba, Prince Seviar
DOI:10.4103/ksj.ksj_32_22  
The aim of tongue cancer surgery is to restore speech and swallowing. Smaller defects have a plethora of options, including local and distant flaps to restore volume and function may not be compromised. Large tumours of the tongue require extensive resection - near total or total glossectomy, which creates large volume defects. Free flaps using microvascular reconstruction techniques are the ideal method of reconstruction in such defects. Regional flaps like pectoralis major myocutaneous (PMMC) flaps are used only as salvage flaps when the free flaps fail and they are not used as the primary method of reconstruction. The disadvantage with free flaps is that it requires a team of surgeons with microvascular expertise, which may not be feasible in low-resource settings. Hence, the workhorse flap of head–neck reconstruction, the PMMC flap, has a lot to offer in the primary reconstruction of large tongue defects. There is always a risk of lifelong dependence on feeding tubes and tracheostomy tubes following these surgeries despite free flap reconstruction. The outcomes of the reconstruction methods are validated by the absence of dependence on these tubes. We report 2 cases of near glossectomy defects reconstructed primarily by PMMC flap and the functional outcomes of speech and swallowing and the absence of dependence on tubes for feeding and breathing.
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Macroprolactinoma presenting as galactorrhoea in a male p. 202
Abdul Basith Ambalamcheri, Rojan Kuruvilla, MV Vimal, Ashbina
DOI:10.4103/ksj.ksj_31_22  
Macroprolactinomas account for more than 50% of all functional pituitary tumours. These are equally prevalent in males and females, although they are diagnosed earlier in females. In females, the usual presentations include oligomenorrhoea, amenorrhoea, galactorrhoea and infertility, whereas males usually present with headache, sexual dysfunction and visual field defects. The following is a case of a 30-year-old male who presented with unilateral nipple discharge, sexual hypoactivity and grossly elevated serum prolactin levels. His magnetic resonance imaging revealed a macroprolactinoma. He responded well to cabergoline.
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PICTORIAL CME Top

Pictorial CME p. 204
A Mohamad Safwan
DOI:10.4103/ksj.ksj_51_22  
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ANNUAL REPORT Top

Report of ASI Kerala Chapter 2022-2023 p. 210
Jayan Stephen
DOI:10.4103/0973-3051.368610  
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