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   Table of Contents - Current issue
July-December 2021
Volume 27 | Issue 2
Page Nos. 109-206

Online since Monday, November 15, 2021

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Chairman's Message p. 109
EV Gopi
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Editorial p. 110
YM Fazil Marickar
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Alterations in liver function test following laparoscopic cholecystectomy p. 111
M Anjin Anand, Joji I Maliekal
Introduction: CO2 pneumoperitoneum induced increased intra-abdominal pressure during laparoscopic procedures produces transient reduction in hepatic blood flow liver enzyme elevation. Aims and Objectives: The aim of this study is to study the alteration of liver function test (LFT) parameters such as aspartate aminotransferase/serum glutamic-oxaloacetic transaminase (SGOT), alanine-aminotransferase/serum glutamic-pyruvic transaminase (SGPT), alkaline phosphatase (ALP) and serum bilirubin (total and direct) in patients undergoing laparoscopic cholecystectomy. Materials and Methods: A prospective, cross-sectional study was conducted. The sample size was 50. Data collected were analysed using the SSPS software version 17. Results: Three quarters were females. The mean age of the study population was 48.5 ± 13.1 years, males having higher mean age of 57.0 ± 8.5 years compared to 45.5 ± 13.2 years for females. The SGOT, SGPT, ALP and bilirubin levels were significantly increased on the next day of surgery. There was a significant positive correlation between SGOT and SGPT levels on day 1 to the increased duration of pneumoperitoneum with correlation coefficient of 0.859 and 0.449, respectively. SGOT and SGPT levels were increased significantly in 61–80 years age group. Conclusion: The duration of pneumoperitoneum had a great effect on the LFT changes after surgery. Age influenced changes in SGOT and SGPT levels.
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Diagnostic validity of x-rays in detection of hollow viscus perforation p. 116
Ajay M Jose, MP Saanida, EV Gopi
Introduction: Identification of a small amount of free intra-abdominal gas remains one of the most significant signs in a perforated viscus. This paper tried to evaluate the sensitivity of chest radiographs in the detection of hollow viscus perforation and to compare the sensitivity of left lateral decubitus view and chest radiograph posteroanterior (PA) view in the detection of pneumoperitoneum. Methodology: Diagnostic validation study was conducted in sixty patients with clinical signs of peritonitis and strongly suspected to have perforation were evaluated with chest radiograph PA view and left lateral decubitus view in search of pneumoperitoneum and confirmed during laparotomy. Results: Out of sixty patients, 54 had gastrointestinal (GI) perforation and 42 out of those 54 were diagnosed in plain chest radiograph. Rest 12 required contrast enhancement computerised tomogam for diagnosis. There was only one case reported with chest radiograph showing pneumoperitoneum and the patient without any breach in the GI tract. Thirty patients with perforation took a left lateral decubitus view which showed free air only in 23 cases. Conclusion: Sensitivity of left lateral decubitus was around 76.6%. Overall, the sensitivity of plain chest radiograph in diagnosing perforation was 77% with specificity 83%, positive predicative value 97.6%, negative predicative value 29.4% and an accuracy of 79.6%.
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Comparative study on outcome of thyroidectomy with and without placement of drain p. 122
D Thahzina Rahim, J Muhammed Salim
Background: Many surgeons routinely use drains after thyroidectomy. The present study aimed to analyse and compare the immediate post-operative outcome in patients undergoing total thyroidectomy with and without placement of drain. Materials and Methods: A comparative observational study was conducted in 30 patients who underwent total thyroidectomy. They were randomly allocated to drain and no drain group post-operatively, with 15 subjects in each group, and the immediate post-operative outcome was assessed on day 0, day 1 and day 3 post-operatively, based on five parameters – post-operative pain, duration of hospital stay, haematoma formation, seroma formation and wound infection. The results were analysed statistically with Chi-square test and Mann–Whitney U test. Results and Discussion: Mean age of the participants was 36.07. All were females. There was association between post-operative pain and placement of drain, pain being less in participants without drain. Post-operative drain had no added advantage in preventing haematoma. None of the study subjects developed wound infection following thyroidectomy in any of the categories. There was a significant statistical association between the two groups based on hospital stay, and patients without drain were discharged earlier when compared to the patients with drain. Conclusion: Routine drain placement after thyroid surgery is not necessary, as thyroid surgery without the drain decreased the length of hospital stay without increasing patient morbidity. Placing of drain increased post-operative pain significantly.
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Comparative study between conventional dressing and collagen-based dressing in burn patients p. 127
Thomas Kurien, OT Muhammed Basheer
Introduction: Burn is a devastating emergency with many physical and psychological disabilities, mortality and morbidity. The conventional treatment of burns is by daily washing of wound, removal of dead tissue and saline and silver sulfadiazine dressing till formation of granulation tissue. The current trend has shifted to more holistic approach of improvement in the long-term form and function of the healed wounds and quality of life. This has demanded the emergence of various skin substitutes. The biological skin substitutes may allow the construction of a more natural new dermis and allow excellent re-epithelialisation characteristics due to the presence of a basement membrane. This study aims to compare the efficacy of collagen dressing (a biological dressing) in treating burn wounds with that of conventional dressing materials. Objectives: The objective was to study the efficiency of collagen dressing in reducing pain, scar formation and infection in burn patients as compared to conventional dressing. Methodology: A comparative study was conducted for a period of 1 year which included 42 cases in burn intensive care unit in a tertiary care hospital on patients admitted with first-degree and second-degree burns covering 10%–50% of total body surface area (BSA). Half of the patients were dressed with collagen dressing and other half received conventional silver sulfadiazine dressing. They were interviewed with series of questions and laboratory parameters were compared. The data obtained were statistically analysed. Results: About 43% were male and the rest were female. Majority were in category 3 (31–40 years). Almost 86% were not having any co-morbidities. Majority had category 3 BSA burns (21%–30%). Haemoglobin (Hb) on the 5th day of dressing showed that in patients with collagen dressing, only 9.5% have anaemia, as against 38% anaemic in conventional dressing, which was found statistically significant. About 62% of patients with collagen dressing and 71% of patients with conventional dressing had low albumin value. On comparing both the dressings 52.4% of patients had no pain in collagen dressing and 28.6% of patients had no pain in conventional dressing which is nearly half of collagen dressing. Only 29% of patients developed infection with collagen dressing and 57% of patients developed infection with conventional dressing. Nearly 71% of patients with collagen dressing produced less scar when compared to conventional dressing where 52% developed bad scars. Conclusion: Collagen-based dressing is a safe and effective alternative for treating burns. Use of collagen for dressing causes rapid epithelialisation and decreased pain though statistically not significant over conventional dressing. Other advantages of using collagen-based dressing for burn wounds include ready availability commercially; simple storage and application; prevents protein/blood loss through wound and it combats infection.
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Intraperitoneal saline instillation in reducing shoulder tip pain after laparoscopic surgeries p. 132
R Anjali, J Muhammed Salim
Introduction: The incidence of shoulder pain after laparoscopic surgery ranges from 35 to 80%. Objectives: The objective of the study was to find the proportion of shoulder tip pain after laparoscopic surgeries with and without intraperitoneal subdiaphragmatic saline instillation and to compare the frequency of post-operative analgesics usage in both groups. Methods: A longitudinal comparative study was conducted on 56 patients undergoing laparoscopic surgeries. Twenty-eight subjects in the study group received intraperitoneal subdiaphragmatic saline wash at the end of the procedure and the control group received no wash. Post-operative shoulder pain was assessed by a visual analogue scale at fixed time intervals. Post-operative use of analgesics, length of stay in the hospital and early mobilisation and discharge from the hospital were also considered. Results and Discussion: Among the 56 patients, there was a statistically significant reduction in the shoulder tip pain postoperatively at 6, 12, 24 and 48 h. Additional analgesic requirement was less in the Wash group, statistically significant at 6, 12, 24 and 48 h post surgery. This significance in outcome was also reflected in the length of the hospital stay, smooth recovery, early discharge, better quality of life and early return to work. Conclusion: Intraperitoneal subdiaphragmatic normal saline wash significantly improved the surgical outcome after laparoscopic surgery by diminishing the shoulder tip pain, minimising analgesic requirements in the post-operative period, thus enhancing early mobilisation and discharge.
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Variations in course of laryngeal nerves during thyroid surgery p. 138
Hafiz Mohammed, Ranjith Sukumar, KP Abid Ali
Introduction: Recurrent laryngeal nerve (RLN) is routinely exposed and traced during all thyroid surgeries. The refinement in surgical techniques has made recognition of the RLN and the external branch of superior laryngeal nerve (EBSLN) possible during surgery resulting in lesser morbidity. Aims and Objectives: The aim of this study is to describe the variations in surgical anatomy of both RLN EBSLN in patients undergoing thyroidectomy and to look for proportion of cases with injury to RLN. Methodology: It was a prospective, observational study. The demographic details of the patient, the diagnosis and the surgical findings (variants of EBSLN, branches of RLN and relation of RLN to inferior thyroid artery [ITA]) were recorded. Postoperatively, after 48 h, the vocal cords were assessed by indirect laryngoscopy. The data were analysed using the SPSS software. Results: Cernea type 1 is the most common position of external laryngeal nerve (67.8%). The RLN passes posterior to the ITA in 46.5% on the right side and 44.3% on the left side. RLN gives one branch in 69.3% cases. There was no injury to the laryngeal nerves noted during this study. Conclusion: Very meticulous dissection helps in identifying the RLN and preserving it. The best way to preserve the RLN nerves is to identify the nerve and preserve them rather than staying away.
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Association of low-lying pubic tubercle with inguinal hernia p. 141
Manu Jose Chirayath, Meer M Chisthi
Background: Low-lying pubic tubercle can lead to narrow origin of internal oblique muscle and alteration in structural anatomy making the shutter mechanism of internal oblique ineffective and predispose to inguinal hernia. Methods: A case–control study was done to find the prevalence of inguinal hernia in patients with low pubic tubercle. Twenty-two cases and 22 control male patients with symptomatic uncomplicated inguinal hernia were studied. Distance between two anterior superior iliac spines and vertical distance from pubic tubercle to the inter-spinous spine were measured. The relation of these lines to patients' height and weight and to each other was calculated. Results: The mean value of spine to spine distance was 26.32 cm in cases and 25.86 cm in controls. The mean distance of this line from pubic tubercle was 7.82 cm in cases and 6.77 cm in controls. Vertical distance from the pubic tubercle to inter-spinous line and its ratio with height and weight were found to be significantly associated with inguinal hernia by multivariate analysis. Conclusions: People with low-lying pubic tubercle have a less efficient protective mechanism of inguinal canal and thus greater predisposition for inguinal hernia. Pelvimetric assessment can be used to pick up susceptible adults to plan early surgery and to decide about prophylactic repair of uninvolved contra-lateral side.
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Recurrent varicose veins - Radiological and operative profile from a tertiary care centre p. 146
Anil Sundaram, RC Sreekumar
Background: Recurrent varicose vein (RVV) still remains a complex, debilitating, common clinical condition despite the advances in imaging technology and operative techniques. The prevalence of developing recurrence ranges from 5% to 65% over a time period of 5–15 years. Aim: The aim of the study is to identify the radiological patterns and operative profile leading to RVV. Materials and Methods: Twenty-eight patients were included in our study who presented with RVV from 1 January 2019 to 1 January 2021. Results: Recurrence was identified in 19 patients post-Trendelenburg (TBG) procedure and perforator ligation, 5 patients post-TBG and stripping above knee, 3 patients post-TBG and sclerotherapy for perforators and 1 case post-endovenous LASER therapy. RVV developed in a time span from 1 to 15 years. Conclusion: TBG along with just perforator ligation has high chance of recurrence, and thorough knowledge regarding the tributaries and anomalous connections at saphenofemoral junction is of utmost importance in primary surgical management of varicose veins.
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A randomised controlled trial comparing ultrasonic dissection with electrocautery for axillary dissection in breast cancer p. 148
Siva Ranjith, Arun Peter, Madhu Muralee, Paul Augustine, Jem Prabhakar
Background: Morbidity of axillary dissection includes prolonged lymphatic drainage, surgical site infections, haematoma, flap necrosis and seroma. These complications are likely to delay wound healing and thereby delay administration of adjuvant treatments. Ultrasonic dissection device, the Harmonic Scalpel@, is a recent addition into the breast. Ultrasonic dissection reduces blood loss and reduces post-operative drain and seroma formation, without the use of surgical clips and ties. We hypothesised that axillary lymph node dissection (ALND) performed with ultrasonic dissection will decrease post-operative drain volume and number of days the patient is put on drain. Here, we present our randomised controlled trial study to compare the outcomes of ALND using ultrasonic dissection (harmonic scalpel) with standard electrocautery. Methods: A total of 113 patients were randomised to two arms - the control arm underwent ALND by standard electrocautery dissection and the experimental arm underwent axillary dissection with ultrasonic scalpel. The primary objectives were (1) to measure the total post-operative drainage volume and (2) the total number of days with drain. Results: The total drainage was significantly less in the intervention arm with a P = 0.015. However, the total number of days on drain was not significantly different in both the arms. The drainage on the 1st post-operative day, which indirectly measures haemostatic capacity, was also not different between the two groups. Conclusion: Although ultrasonic dissection of the axilla significantly reduces the total drain output, the total days the patients spent with drain in situ was not significantly different. The operating time was significantly increased with ultrasonic dissection. Hence, with this study, the routine use of ultrasonic dissection could not be recommended.
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Rapid urease test in the diagnosis of pylori infection p. 153
H Thasneem, KA Sidhic
Introduction: Helicobacter pylori is one of the most important causes of the varied spectrum of gastroduodenal diseases. At present, several diagnostic techniques are available to identify infection with H. pylori, including rapid urease test (RUT). Objectives: The aim of this study was to evaluate RUT in the diagnosis of H. pylori infection in patients with upper GI symptoms suspecting peptic ulcer disease. Materials and Methods: It was a prospective study done in department of gastroenterology. Patients of both the sexes in the age group 18–60 years, attending with upper gastrointestinal symptoms suspecting peptic ulcer disease, during a period of 1 year were enrolled in the study. Results: Two ninety-one patients were included, 59% of male, with a mean age of 48.31 ± 15.79 years old. Most common identifiable lesions at endoscopy were antral erosion and gastritis. Significant association was observed between RUT results and biopsy findings. The study proves that positive result of RUT for H. pylori means 5.78 times chance of getting a positive finding in histology. Even though sensitivity of RUT for H. pylori infection was low, specificity was much higher. The sensitivity, specificity and positive and negative predictive values for RUT were, respectively, 41.12%, 88.3%, 71% and 68.47%, which was improved when patients taking proton-pump inhibitors were excluded. Conclusion: RUT positive alone of H. pylori infection is not sufficient as it has a low sensitivity and specificity. A negative RUT result does not fully exclude an active infection hence would need other tests like histology to confirm.
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Hybrid surgery in hernias: Our experience p. 157
Madhukara Pai, R Padmakumar, Premna Subin
Introduction: Hybrid surgery is a procedure in which laparoscopic and open surgical steps are used for a better outcome to the patient. The aim of this study is to identify the factors that necessitated hybrid surgery in cases of hernia. Materials and Methods: It is a retrospective narrative study of 69 patients with hernia, who underwent hybrid surgery. Deciding factors and outcomes were analysed. Results: Of the 69 cases, 32 were open surgery followed by laparoscopy (OL)/open surgery followed by laparoscopy and then by open surgery again (OLO) and 37 were laparoscopy followed by open surgery (LO)/laparoscopy followed by open surgery and then by laparoscopy once more (LOL). Incorporating laparoscopic steps during open surgery helped in combining multiple surgeries, intra-abdominal adhesiolysis, etc., without enlarging the incision. Open surgical steps incorporated during laparoscopy, helped in reduction of irreducible hernia, darning of defects from outside, etc., Ventral hernia with apron and need for combining other surgeries had an association with OLO (P < 0.001). Inguinal hernia or ventral hernia without apron, irreducibility and need for omentectomy had an association with LO/LOL (P < 0.001). Factors having statistically significant association with sandwich repair were large defect size, multiple previous open surgeries, presence of precipitating factors and recurrent hernias. Conclusion: Hybrid surgery offers definite benefits in select cases of hernias. Case-to-case planning is needed preoperatively and should be based on the difficulties anticipated. It will help the surgeon perform a safe procedure.
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Revised atlanta classification for acute pancreatitis – A pictorial depiction p. 164
Ashwin Raghavendra Athikayula, Ajith Vettuparambil, Ravindran Chirukandath
Introduction: There are various classifications for clinical presentation of acute pancreatitis. However, most of them are not standardised. Aims and Objectives: The revised Atlanta classification is designed to precisely describe patients with acute pancreatitis, standardise terminology across specialties and help in treatment planning. Materials and Methods: The revised Atlanta classification was analysed to describe the features of acute pancreatitis. Results: Acute pancreatitis is now divided into two distinct subtypes: necrotising pancreatitis and interstitial oedematous pancreatitis (IEP). Use of the terms such as acute pseudocyst and pancreatic abscess is currently being discouraged. Four distinct collection subtypes are identified based on the presence of pancreatic necrosis and the time elapsed since the onset of pancreatitis which include acute peripancreatic fluid collections, pseudocysts, acute necrotic collections (ANCs) and walled-off necrosis (WON). Conclusions: The updates in classification and terminology of local complications have clarified confusing terms from the original Atlanta classification. In this article, we report an image-rich guide to the revised Atlanta classification system to improve stratification of the patients both for clinical care and research.
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Neoadjuvant chemotherapy in cancer breast p. 169
Jiya Mulayamkuzhiyi Saju, KG Krishnakumar
Introduction: This observational study attempts to assess the proportion of carcinoma breast patients showing complete pathological response to neoadjuvant chemotherapy post-surgery and to study the factors contributing to complete pathological response. Subjects and Methods: This was conducted on 290 female patients with locally advanced breast cancer who underwent neoadjuvant chemotherapy (NACT) followed by surgery in the Department of General Surgery from April 2018 to April 2020. The post-operative histopathological specimen was checked for evidence of pathological complete response (pCR). Statistical analysis was done using SPSS software. Results: The proportion of breast cancer patients with pCR following NACT was 18.6% (54 out of 290 patients). Factors found to have a significant association with pCR were the clinical size of tumour, size of lump in mammogram, histological grade of tumour and duration of swelling. Clinical stage, molecular subtype of cancer and age had no significant association with pCR. Conclusion: Less advanced tumours i.e., those with clinical and mammogram size ≤5 cm achieved higher pCR than more advanced tumours. Higher histological grade achieved less pCR than histological Grade I tumours. Association could not be elicited between pCR and triple-negative molecular subtype.
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Risk factors of port-site infections in laparoscopic surgeries p. 173
VK Sheeba Mariyam, J Muhammed Salim, Rakesh Praveen Raj, Riyaz Sheriff
Introduction: Laparoscopic surgery has brought in a paradigm shift in surgery. The ever-expanding applications of laparoscopic surgery have made the study of its complications crucial. Objectives: Our aim was to study the incidence of port-site infection (PSI) in laparoscopic procedures and the associated risk factors. Materials and Methods: A longitudinal observational study was conducted on 96 patients who underwent laparoscopic surgeries for various ailments and were observed for the development of PSIs and the association with the studied risk factors using the Chi-square test. Results: Prolonged duration of surgery (>120 min) was found to have a statistically significant association with increased risk of development of PSI. Obesity, presence of comorbidities and increase in the number of ports also were risk factors that had a statistically significant association with the incidence of PSI. The most common procedure associated with PSI was laparoscopic cholecystectomy and the most common organisms found to be Staphylococcus aureus and Escherichia coli. Conclusion: Proper sterilisation techniques and operation theatre aseptic protocol have brought down the incidence of PSI a great deal. Identification of the other hidden risk factors is vital for the elimination of PSI in laparoscopic surgery.
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Sodium abnormalities in patients with acute retention of urine due to bladder outlet obstruction p. 179
Riju Joseph Paul, VP Muhammed Farooq, NM Mujeeb Rahman
Introduction: Bladder outlet obstruction is the most common cause of urinary retention. Electrolyte disturbances are among one of the most overlooked counterparts of urinary retention. Reports suggest that acute urinary retention can lead to derangements in sodium levels. Objective: The objective of the study was to find out the incidence of sodium abnormalities in patients admitted with urinary retention due to bladder outlet obstruction. To compare serum sodium levels before and after relief of bladder outlet obstruction in these patients. Materials and Methods: This is a prospective, observational study design. All patients above 18 years who presented with complaints of acute retention of urine due to bladder outlet obstruction and fulfilled the inclusion and exclusion criteria were included in the study. After history and physical examination, a urinary catheter was placed to empty the bladder. Serum sodium levels were checked before catheterisation, at 24 h and 48 h after catheterisation to note if there is a change in values of serum sodium. Results: There were 92 cases of acute urinary retention, of which 88 were male and 4 were female. The mean serum sodium value at the time of catheterisation was 131.64, at 24 h after catheterisation was 133.48 and 48 h later was 134.95. Conclusion: An increase in serum sodium levels was noted in the majority of the patients who were catheterised. We infer that hyponatraemia is seen in acute urinary retention and that it gets corrected on catheterisation.
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Filarial dance in epididymis: A pathognomonic sign of scrotal filariasis p. 182
Rohan Kumar, Biju S Pillai
Lymphatic filariasis is caused by the worms Wuchereria bancrofti, Brugia malayi, and Brugia timori. The most common clinical presentation is hydrocele, with lymphedema and elephantiasis occurring less commonly. Among various imaging modalities, sonography is most commonly used for diagnosis and assessing treatment response. We report a case of a boy with painless swelling and low-grade fever in whom real-time ultrasonography depicted the presence of filarial dance sign in right epididymis.
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A rare complication following partial nephrectomy for renal cell carcinoma p. 184
H Krishna Moorthy, Biju S Pillai
Partial nephrectomy (PN) is currently the treatment of choice for T1a renal cell carcinoma (RCC). However, the procedure is technically demanding and is associated with some notable complications. Recurrence of tumour and vascular complications are major complications of the procedure. Foreign-body granulomas have been not been reported following PN in literature. In this paper, we present the case report of suture granuloma (foreign-body granuloma) at the resected margin of the kidney in a patient who underwent PN for RCC, which caused a diagnostic dilemma. With the increasing use of a variety of suture materials for closing the resected margin of renal tissue after PN, the possibility of occurrence of foreign-body granulomas (suture granulomas) should also be thought of in the differential diagnosis of locally recurrent masses at the resection site.
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Familial adenomatous polyposis presenting as synchronous adenocarcinoma colon p. 186
R Sathish Kumar, B Ajay Kumar
Familial adenomatous polyposis is a genetic condition. It is diagnosed when a person develops more than 100 adenomatous colon polyps. Synchronous colon neoplasia is defined as two or more primary tumors identified in the same patient and at the same time. We report a case of a 43 year old female presenting with synchronous colon cancer and multiple adenomatous polyps.
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Giant gastrocolic omental lipoma p. 190
G Adhip, MP Sreejayan
A lipoma is a benign noninvasive encapsulated mesenchymal tumor that resembles normal fat. It is ubiquitous and the most common tumor to affect soft tissues. Although lipoma may arise from any tissue containing fat, omental lipoma is extremely rare. We report a case of a 38-year-old female with no known comorbidities presenting with early onset of satiety, abdominal distension and nausea for the past 6 months. Contrast-enhanced computed tomography showed a lipomatous lesion in the region of the greater omentum, which was treated by surgical resection.
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Surgical management of retrosternal (intrathoracic) goitre p. 193
KN Vijayan, Mohamad Safwan, S Akash
The neck is 'a space with no bottom' as described by Lahey and Swinton. Large multinodular goitre in the neck enlarges and descends to the chest for variable extent. Such goitre is called plunging or secondary retrosternal goitre. Rarely, these can be primary intrathoracic goitre from ectopic thyroid tissue. Large retrosternal goitre produces pressure symptoms and may become toxic or malignant. Thyroidectomy is the treatment of choice for retro-sternal goitre which carries great challenge for the surgeons. Here, our objectives to present (1) characteristic features of primary and secondary intrathoracic goitre. (2) Basic evaluation and concise pre-operative assessment for thyroidectomy and (3) surgical steps of the procedure emphasising on safety for a large intrathoracic goitre. Most of the cases of retrosternal goitre can be removed safely via a cervical approach.
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Documentation in surgical practice p. 199
Sanjay Kumar Jain
Documentation and record keeping are the important aspects of health-care practice, and peri-operative practice is no exception to this rule. Recording every activity or intervention that a patient receives is a legal. The clarity of information is essential. Hence, the surgeon has to record appropriate information in the appropriate and meaningful language in a timely manner maintaining confidentiality. Thus, record keeping is a 'part of the professional duty'. In this article, the essential parts of surgical case recording are highlighted.
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Pictorial CME p. 202
YM Fazil Marickar
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Annual report of ASI kerala chapter 2020–2021 p. 205
Jayan Stephan
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