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OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Objective To examine the safety and complications associated with percutaneous tracheostomy (PT) in critically ill coagulopathic patients under real-time ultrasound guidance. Materials and methods Coagulopathy was defined as international normalized ratio (INR) ≥1.5 or thrombocytopenia (platelet count ≤50,000/mm3). Neck anatomy was assessed for all patients before the procedure and was characterized as excellent, good, satisfactory, and unsatisfactory based on the number of vessels in the path of needle. Percutaneous tracheostomy was performed under real-time ultrasound (USG) guidance, with certain modifications to the technique, and patients in both groups were assessed for immediate complications including bleeding. Results Six hundred and fifty-two patients underwent USG-guided PT. Three hundred and forty-five (52.9%) were coagulopathic before the procedure. Ninety-nine patients (15.2%) had an excellent neck anatomy on USG scan, and 112 patients (62 in coagulopathy group vs 50 in noncoagulopathy group, p value 0.386) had an unsatisfactory neck anatomy for tracheostomy. A total of 42 events of immediate complications were noted in 37 patients (5.7%). No difference was seen in the rate of immediate complications in both groups (5.8% in coagulopathy group vs 5.5% in noncoagulopathy group, p value 0.886). The incidence of minor bleeding in coagulopathic patients was 14 patients (4.1%) and 7 (2.3%) in those without coagulopathy, and this difference was not statistically different (p value-0.199). In the subgroup analysis of patients with significant coagulopathy and unsatisfactory anatomy, no difference was observed in the incidence of immediate complications. Conclusion This study shows the efficacy and safety of real-time ultrasound-guided PT, even in patients with coagulopathy. How to cite this article Kumar P, Govil D, Patel SJ, Jagadeesh KN, Gupta S, Srinivasan S, et al. Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience. Indian J Crit Care Med 2020;24(2):122-127.

A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio 200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio

Gastrointestinal (GI) motility disorders are a common problem in the intensive care unit (ICU) and are associated with increased morbidity, complications like feeding intolerance, malnutrition, bacterial translocation, sepsis, multiple organ failure, prolonged hospital stay and increased risk of mortality. Several risk factors in intensive care setting that contribute to GI dysmotility include mechanical ventilation, vasopressor support, use of opioids, etc. Degree of GI motility dysfunction correlates with severity of critical illness. So, it is important to identify the dysfunction early so that targeted therapy could be prescribed to prevent worsening of clinical outcomes. How to cite this article: Govil D, Pal D. Gastrointestinal Motility Disorders in Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S179–S182.

How to cite this article: Govil D, Kumar GP. Extracorporeal Therapy in Sepsis. Indian J Crit Care Med 2020;24(Suppl 3):S117-S121.

Background and purpose Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. Methods This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. Results This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. Conclusion In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. Abbreviations list ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization. How to cite this article Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6-S30.

How to cite this article: Govil D, Pal D. Can We Predict Outcome in Critically Ill Elderly Patients? Indian J Crit Care Med 2021;25(6):615–616.

The development of a cholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis and it is usually seen to develop in patients with long-standing disease. An incidence of 3–5% has been reported in patients with cholelithiasis and 0.15–4.8% of patients undergoing biliary surgeries may have a CEF (Chowbey et al. J Laparoendosc Adv Surg Tech 16:467–472, 2006). The most common cholecystoenteric fistulae are of the cholecystoduodenal variety (70%), followed by cholecystocolic (8 to 26.5%) and cholecystogastric fistulae (Safaie-Shirazi et al. Surg Gynecol Obstet 137:769–772, 1973; Balent et al. Hawaii J Med Public Health 71:155–157, 2012). In this report, we share our experience of cholecystoenteric fistulae to highlight the presentation, intraoperative findings, and management. Retrospective review of patients with CEF encountered in our experience between 2003 and 2016. Patients admitted for laparoscopic cholecystectomy during this period were involved in the series and patients having cholecystoenteric fistulae were analyzed in detail and their picture is discussed. Among 2450 cholecystectomies encountered, a total of 35 patients had cholecystoenteric fistulae. There were 15 males and 20 females in the age range of 33–76 and with a mean of 55 years. Twenty-eight of the 32 (80%) patients were over 50 years of age. The most common type of fistula was cholecystoduodenal fistula (CDF) and was detected in 32 (91.4%) patients. Other types encountered were cholecystocolic fistula in two patients (5.71%) and cholecystogastric fistula in one (2.857%) patient. Ultrasound was the basic investigation. All cases were diagnosed intraoperatively. Overall 23 patients (65.71%) required a laparotomy. The remaining 12 (34.28%) cases were managed completely by the laparoscopic approach. Earlier in the cases, feeding jejunostomy was regularly used which became occasional in the later part of series. Cholecystoenteric fistulae are rare complication of long-standing gall stone disease. In the era of laparoscopy, many of these cases can be dealt laparoscopically. Low tolerance should be kept for conversion so that patient gets the best possibility of dealing with the condition in the same sitting without added complications.

A 50 year old male, known case of COPD presented to the Emergency with complaints of shortness of breath and cold clammy extremities. On examination he was found to be tachypnec, tachycardiac and hypotensive. A decrease in urine output was also noted. How would ultrasound help in evaluation and management of this patient?

COVID pandemic has taken the whole world off guard, and it has lasting serious implications on every aspect of human life. Surgical services for our elective cases are suffering. There are a lot of issues related to gastrointestinal (GI) cancer patients in these COVID times. It is difficult to decide whether to operate on these patients taking the risk or delay the surgery with attendant risk of cancer progression or use some alternative protocols. Here, we aim to offer guidance for the prioritization of surgical services to further minimize the effect of the COVID-19 pandemic across various overburdened surgical units and to preserve the surgical workforce with special emphasis on GI malignancy patients.

Pancreaticoduodenectemy(PD) is the treatment of choice for malignant and some benign diseases of the pancreas and periampullary region. Common complications after PD include delayed gastric emptying, pancreatic fistula, anastomotic leak and intra abdominal collection. Postoperative medical complications include arrhythmia, renal failure, pulmonary complications, UTI and Deep vein thrombosis. Superior mesenteric artery (SMA) thrombosis is rarely been reported after PD. There is theoretical possibility of arterial thrombosis in patient with history of vascular disease, which may precipitate after postoperative hypovolemia. SMA thrombosis is difficult to diagnose in postoperative period due to nonspecific symptoms and associated with high mortality rate up to 80-90%. Our patient was a 68 years old female with lower end cholangiocarcinoma without any other co-morbidity. She underwent PD without any intraoperative complications. Post operatively she developed SMA thrombosis. Unfortunately patient could not be salvaged and she succumbs to death.

How to cite this article: Govil D, Shafi M. Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist? Indian J of Crit Care Med 2019;23(2):59-60.

Background and Aims: The true incidence of penetration of the posterior wall (through-and-through puncture) of the internal jugular vein (IJV) during cannulation is unknown. This may have implications if there is hematoma formation, penetration and/or inadvertent cannulation of an underlying carotid artery. This study compared the incidence of posterior wall puncture during IJV cannulation using ultrasound guidance versus traditional landmarks-guided technique. Methods: One hundred and seventy adult patients admitted to a gastro-liver Intensive Care Unit who required central venous lines were randomly divided into Group A: IJV cannulation using anatomical landmark-guided technique and Group B: IJV cannulation using real-time ultrasound guidance. In both groups, a second investigator followed the needle path using real-time ultrasound. The incidence of posterior wall puncture, number of attempts for successful cannulation, incidence of inadvertent arterial punctures and occurrence of complications such as hematoma formation and pneumothorax were recorded. Results: Significantly more (37/80, 46%) patients in Group A had posterior wall puncture compared to 19/90 (21%) in Group B. Incidence of arterial puncture was 8/80 (10%) in Group A, 5/90 (5.5%) in Group B. The number of attempts for venous cannulation and hematoma formation was significantly less in Group B. Conclusion : Real-time ultrasound-guided IJV cannulation significantly reduces but does not wholly eliminate the incidence of posterior venous wall penetrations. It also significantly reduces the incidence of inadvertent arterial punctures and number of attempts for successful cannulation.

Parahiatal hernias are rare and distinct subtype of diaphragmatic hernia, which is very difficult to diagnose clinically. Laparoscopic repair has been reported in the literature. We report a case of parahiatal hernia with gastric volvulus, which was repaired successfully by robotic surgery along with gastropexy. We present the case of a 50-year-old male who presented with vomiting and epigastric pain. His CT scan showed a giant parahiatal hernia with intrathoracic gastric volvulus. Intraoperatively, a diaphragmatic muscular defect was found lateral to an attenuated left crus of the diaphragm, distinct from the normal esophageal hiatus. The defect ring was fibrotic and large, making a tension-free primary repair difficult. A prolene mesh repair was done and two point gastropexy to the anterior abdominal wall was performed robotically. Recovery was uneventful and the patient was discharged on the 5th postoperative day. He remained asymptomatic at subsequent follow-up. Robotic repair of parahiatal hernia can be safely performed with advantage of robotic surgery in this difficult access area. In circumstances where a large defect prevents a tension-free primary repair, the use of a mesh can provide effective repair of the hernia defect.

Pancreatic inflammation limited to the area between the wall of the duodenum and common bile duct is referred to as groove pancreatitis. The condition is often associated with cystic dystrophy in the medial wall of the duodenum. These patients can present with features of either pancreatitis or pancreatic malignancy. CA19.9 levels are usually normal and serum amylase and lipase may be slightly elevated. Diagnosis is confirmed with either computerized tomography abdomen or endoscopic ultrasound. Management consists of conservative management and endoscopic shincterotomy. Pancreatico-duodenectomy may be required in some cases. In our case, a pancreatico-duodenectomy was required as the patient was suffering from gastric outlet obstruction and severe episodes of recurrent acute pancreatitis.

Highlights • Sclerosing mesenteritis (SM) is difficult to be diagnosed preoperatively if careful attention is not given at imaging ordered. • Vessel encasement seen on imaging is not definite till you confirm it during surgery. • Debilitating disease even with complete excision. • Long term follow up is required with good palliative care., Mesenteric panniculitis (MP), also known as sclerosing mesenteritis (SM), retractile mesenteritis or mesenteric lipodystrophy, is a rarely diagnosed inflammatory condition of unknown etiology that involves the mesenteric adipose tissue. We are presenting a case of sclerosing mesenteritis which presented us with features suggestive of malignant lesion and turned out to be benign one. An elderly gentleman of 68 years male presented to us with history of nonprogressive pain abdomen since 2 months associated with low grade fever and on and off constipation. On evaluation with CECT he was found to have mesenteric mass probably malignant. PET/CT showed an FDG avid lesion suggestive of malignancy, requiring surgery. He underwent radical excision of mesentery with resection of corresponding bowel. Final histopathology report showed poorly defined lesion comprised of nodular, poorly defined proliferation of bland looking fibroblast like cells, which at places are lying in fascicles, in a background of dense fibrosis and mature fat cells, with prominent focal lymphocytic infiltrate, at place forming reactive follicles, suggestive of sclerosing mesenteritis. Now patient is on follow up for further therapy.

Aims To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). Patients and methods An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. Results On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. Conclusions The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.

Colorectal cancer is a major cause of morbidity and mortality worldwide. The Indian scenario also shows a similar trend, and this has been attributed to the changing dietary patterns. Recurrence in colorectal cancer is associated with many factors, some related to the tumor itself and some to the surgical principles applied. Understanding these factors and application of sound surgical principles can go a long way in decreasing the incidence of colorectal cancer. Here, we highlight the main biological and technical factors implicated in the recurrence of colorectal cancer.

We present a case of 87-year-old overweight male who presented to us with intestinal obstruction. He was found to have the classical sings of gall stone ileus (pneumobilia, intestinal obstruction & gall stones in the distal ileum). He was managed with a single stage procedure. Here we also describe the available literature and the various treatment options available for the same.

Multiple primary tumours in a single individual are reported in the literature with incidence which varies from 1% to 20%. Few common combinations are labelled as the syndrome and showed a common genetic association; however, sporadic cases of multiple primaries are relatively rare. Such a combination of Renal Cell Carcinoma (RCC) with pancreatic carcinoma is sparingly being reported in the literature. Here, we present a case of pancreatic carcinoma in a patient who was treated for renal cell carcinoma, 10-years-back. A few cases, which have been published before also could not establish any specific reason for this combination. We recommend considering a possibility of the second primary in any patient with unusual symptoms different from primary lesion and research for genetic association in these patients.

PURPOSE: The aim of this study is to evaluate the predisposing risk factors, clinical presentations, laboratory parameters, and treatments taken and outcomes in patients of nocardiosis in the span of 5 years in a tertiary care hospital.MATERIALS AND METHODS: The patients whose specimens showed Nocardia like organism in Gram-staining, Kinyoun staining and characteristic colonies in culture were included in the retrospective analysis study. Retrospective analysis of associated risk factors, clinical presentations, and radiological findings was performed.RESULTS: Of the thirteen patients, 11 (76.9%) had immunosuppressive pathologies including solid organ transplantation, autoimmune disease, use of steroids, and immunosuppressive drugs as important risk factors. Four types of clinical manifestations were observed, pulmonary (46.1%), cutaneous (23.07%), cerebral (15.3%), and bacteremia (15.3%). The most common presentation was pulmonary with steroid therapy as a significant risk factor. Consolidation and pleural effusion were the common radiological findings in these cases. In eight of the nine patients anti-nocrdial drugs were given. Cotrimoxazole as monotherapy was given in four cases (44.44%), cotrimoxazole in combination with meropenem in two cases (22.22%); minocycline and linezolid were given in one case each. The overall mortality was 36.36% and was seen in patients with pulmonary nocardiosis.CONCLUSIONS: The study indicates that Nocardial infections are re-emerging on account of an increase in numbers of immunocompromised patients due to increased organ transplants, autoimmune diseases, malignancies, and use of immunosuppressive drugs and steroids. The diagnosis is often missed/not suspected and delayed because of the clinical resemblance to many other infections. Nocardial infection should be suspected and assessed particularly in immunocompromised patients not responding to treatment/improving clinically.

Introduction Although liver transplantation is a definitive cure for Wilson's disease (WD), there is limited data about results of living donor liver transplantation (LDLT) in adults. Material and methods 18 adults underwent LDLT for WD. The presentations before LDLT were decompensated cirrhosis (n = 16), acute on chronic liver failure (n = 1) and acute liver failure (n = 1). The donors were parents (n = 2), siblings (n = 3), cousin (n = 1), daughter (n = 1), nephew (n = 1), spouse or relatives of spouse (n = 9) and from swap transplantation (n = 1). All genetically related donors were negative for screening of WD. Results The study cohort comprised of 15 males and 3 females, aged 32 ± 10 years. Severity of liver disease (excluding acute liver failure patient) was as follows; Child's score 10 ± 2, model for end-stage liver disease (MELD) score 18 ± 6. The graft to recipient weight ratio was 1 ± 0.2. The ICU and hospital stay were 5.5 ± 0.9 and 15 ± 5 days. Two patients died in first month after liver transplantation, rest of patients are doing well at median 15 (8–38 months). Two patients had acute cellular rejection that responded to steroids, one had hepatic artery thrombosis and 2 had biliary strictures. Three patients had neurological symptoms; 2 of these patients had partial recovery while one had complete recovery. There was no significant difference between LDLT from genetically related or unrelated donors. Conclusion LDLT for WD in adults is associated with good outcomes.

Introduction: Feeding jejunostomy (FJ) is a lifesaving procedure on many occasions in patients requiring long term nutritional assistance. It is associated with many short and long term complications. Small bowel perforations, small bowel volvuli with infarction, intraperitoneal leaks and intussusception are well reported complications of FJ. Here we present a case report of FJ giving rise to small bowel volvulus. Case report: An elderly male patient of 71 years with underlying systemic hypertension, diabetes mellitus, and thoracic aortic aneurysm with aortoesophageal fistula underwent feeding jejunostomy for long term feeding purpose. Feeding went on well for almost a year. He had a second intravascular procedure for type 1 endoleak. Four months following this he developed an episode of severe colicky abdominal pain associated with vomiting. He was evaluated with CECT abdomen which showed the possibility of mesenteric volvulus with small bowel obstruction at distal ileal level. Patient underwent emergency exploratory laparotomy and untwisting of mesentery with redoing of FJ distal to the previous site of FJ. There was no bowel compromise. He developed severe hypokalemia post operatively which required intra venous potassium infusion and ventilator support. With all supportive management patient continued to deteriorate and succumbed.

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Hepatopulmonary syndrome (HPS) worsens the prognosis of cirrhosis and liver transplantation is only definitive treatment. There is paucity of data about role of living donor liver transplantation (LDLT) in HPS.Fourteen patients with HPS and cirrhosis who underwent LDLT were prospectively included. HPS was defined as PaO280 mmHg in presence of demonstrable macro-aggregated albumin (MAA) scan shunt fraction6%.The study group composed of 11 male and three female patients, mean age 50.3 ± 8.6 yr. Most common presentations were dyspnea (92.8%), cyanosis (78.5%) and clubbing (64.2%). Mean model for end-stage liver disease (MELD) score was 18.2 ± 4.7, mean MAA shunt fraction was 23.0 ± 13.2%, mean PaO2 was 58.7 ± 8.4 mmHg. Two patients had very severe HPS (PaO250 mmHg), five had severe HPS (PaO25060 mmHg) and seven had moderate HPS (PaO26080 mmHg). All patients underwent right lobe LDLT. The overall time to extubation was 2 (1-32 days) and for hospital stay was 20 (17-46 days). The main complications in post-LT course were infection in 57% (cytomegalovirus or bacterial). All the patients are alive and off oxygen at a mean follow up of 29 ± 25 months.We report one of the largest series of LDLT in HPS which has shown excellent results.

An epiphrenic oesophageal diverticulum is most commonly a pulsion diverticulum which develops consequent to protrusion of mucosa through the muscular wall of the distal oesophagus. Most of them are associated with underlying oesophageal motility disorders. The predominant symptoms are dysphagia with regurgitation, and sometimes retrosternal pain, if accompanied by spasm of the oesophagus. Surgical management is recommended for symptomatic patients. Traditional procedures include thoracotomy or laparotomy with excision of the diverticula, but these are associated with high morbidity. Laparoscopic approach is a safe treatment option associated with lesser morbidity. Here, we present a case of epiphrenic diverticulum which was treated by the robotic approach without any complication. There was also no associated motility abnormality in our case so fundoplication was not done. Robotic surgery is a useful tool while operating near the hiatus and gastro-oesophageal junction. We consider transhiatal robotic approach as a safe and easy approach for surgery of epiphrenic diverticulum.

Aim To assess the accuracy of CT scan in preoperative staging, to correlate preoperative findings with operative findings and with post-operative histopathological findings of colorectal carcinoma. Methods Twenty-six diagnosed cases of colorectal carcinoma were included in the study. They were evaluated preoperatively by 64 slice multidetector CT (MDCT) scan. Intra-operative evaluation was done at the time of surgery. Post-operative evaluation was based on detailed histological examination by experienced pathologist. Data was statistically assessed by SPSS software (version 14.0) and the correlation was deduced from "kappa" value and " P ". Results The correlation of CT scan staging is significant ( P ≤ 0.0001) when compared to intra-operative staging. MDCT findings correlated with intra-operative findings in terms of site of lesion ( P P P P P = 0.004). In estimating size of lesion, it also correlated with the intra-operative findings (44 %). MDCT findings correlated with histopathological findings in terms of site of lesion ( P P P = 0.018) and size of lesion. The CT findings did not correlated significantly in terms of pericolic/ perirectal fat involvement ( P = 0.127) and assessment of lymph nodes ( P = 0.68). Conclusion Multidetector CT scan can be useful in the preoperative assessment of patients with colorectal carcinoma as a means for assisting surgical planning.

Raised intracranial pressure (ICP) is a complication not just of traumatic brain injury and other acute cerebral insults, but also of a number of general medical conditions. Monitoring of ICP is of paramount importance in Neurointensive Care Unit. Increased ICP causes brain insult which may be associated with increased mortality and poor neurological outcomes.[1,2,3] Bedside clinical diagnosis can be difficult as early clinical signs may be misinterpreted, and heavy reliance on cross-sectional imaging studies may further delay diagnosis. Ultrasound is a bedside imaging modality that is increasingly available in most critical care units. The diameter of the optic nerve sheath has been found to be a strong predictor of raised ICP, with a high sensitivity and specificity in multiple studies and in a systematic review.[4] The optic nerve sheath is bound more loosely to the optic nerve closer to the globe. This loose binding creates a much larger, and potentially more distensible, subarachnoid space in this region, which can appear bulbous on ultrasound.[5] Consistent with this, the optic nerve sheath is at its most distensible anteriorly, where it is potentially most reflective of raised ICP. As per a 1996 study, using modern ultrasonography (USG) techniques showed that optic nerve sheath diameter (ONSD) increased by up to 60% at a distance of 3mm behind the globe in comparison to only 35% at 10 mm.[6] This has been confirmed in subsequent studies, indicating that a position 3 mm behind the globe is preferred for measurement.[7] Measurements made at this point are more reproducible since ultrasound contrast is greater at this depth with a linear probe. While papilloedema viewed by funduscopy may take the time to develop, dilatation of the optic nerve sheath occurs much earlier and may be a near instantaneous manifestation of raised ICP.[6,8] Studies of sonographic ONSD have mainly correlated findings with clinical and radiological signs and symptoms of elevated ICP. Intraventricular measurement is the gold standard for measuring ICP. These measurement devices carry many risks, including hemorrhage and infection. These complications partly account for increasing interest in noninvasive methods such as neuroimaging, transcranial Doppler sonography, ONSD USG and computed tomography/magnetic resonance imaging (CT/MRI). In addition, invasive methods may not be available to individual patients due to contraindications, such as coagulopathy, thrombocytopenia, or the lack of local facilities. The optic nerve and its surrounding sheath can be accurately imaged and measured on MRI using a fat-suppressed T2-weighted sequence. MRI is often spoken of as a reference test for ONSD, as it has a higher spatial resolution, and the images offer a more representative calculation of the mean diameter than CT. While Lagreze et al. contend the accuracy of MRI exceeds sonographic methods for determining ONSD,[9] Bauerle showed good scan-rescan reproducibility and good observer agreement in 15 healthy volunteers.[10] Two questions that need to be answered when we talk about bedside measurement of ONSD by ultrasound for diagnosis of raised ICP: First, does the bedside ultrasound measurement of ONSD correlate strongly with a neuroimaging technique such as an orbital MRI; and secondly what should be the cut-off of ONSD values to determine raised ICP. The authors of the current study[11] have attempted to resolve the first question regarding the correlation of ONSD measured by bedside ultrasound and MRI. They have studied 100 adult patients of either sex, diagnosed with meningoencephalitis who were to undergo MRI of the brain and measured the ONSD 3 mm behind the globe using a bedside ultrasound and correlated its measurement with that measured by MRI at the same point. They found a high level of correlation between the ultrasound measurement and MRI measurement of ONSD. A Bland-Altman analysis was done to show agreement between both methods of measurement of ONSD, the analysis showed a significant correlation between ocular sonography and MRI. Previous Studies performed between both modalities to measure ONSD were done in subjects with normal ICP or in cadavers. This is the first study done with a relatively large group subjects with meningoencephalitis and it adds further proof that bedside ultrasound readings of ONSD may be as accurate as MRI, given the proper technique and training. With regards to the second question, there is wide variation in the literature regarding in the optimal cut-off values, when ONSD was compared with invasive ICP monitoring, ranging from 4.8 to 5.9 mm.[12,13] The reasons cited for these varied cut-off include: Heterogeneous patient populations, varied methods for confirming raised ICP, and ethnic difference among the patient population. The current authors have selected cut-off values of 4.6 mm for females, and 4.8 mm for males in accordance to a study by Shirodkar et al.[14] on 101 Indian patients who demonstrated a high level of sensitivity and specificity with these cut-off values for the diagnosis of intracranial hypertension as evident on CT or MRI imaging. However, the current authors have limited themselves to comparing the numerical accuracy of ONSD values obtained with USG and MRI. They have not commented on the presence or absence of MRI findings of raised ICP and hence have not corroborated the cut-off values of ONSD for raised ICP in Indian patients which as per Shirodkar et al.[14] was found to be somewhat less than those from previous studies. Nevertheless, the high level of correlation between MRI and a bedside ultrasound found in this study suggests that ultrasound can be used to detect acute rise in ICP with a high level of accuracy and despite its limitations, USG ONSD measurement is likely to be more reliable than clinical assessment in the diagnosis of intracranial hypertension and has the potential to become one of the first line modalities in detecting increased ICP especially in situations when altered sensorium or administration of sedative medication precludes such assessment.[15] Further, larger studies need to be performed on Indian population to decide an optimal cut-off value for raised ICP and that needs to be correlated with a standard which could be either direct measurement of ICP or by means of characteristic findings on neuroimaging.

Chronic ulcerative colitis (UC) is a risk factor for malignancy in long-term disease process. Obstruction, perforation, and hemorrhage are the possible emergency situations in colorectal malignancy. A 68-year-old male with chronic UC for 18 years with steroid-dependent disease (on 10 mg prednisolone daily) presented with acute pain abdomen with distention not passing stool or flatus for 2 days. The patient was diagnosed to have perforation of colon secondary to rectosigmoid malignancy. Following the adjuvant therapy, the patient denied any definitive surgery and opted to stay on a colorectal cancer surveillance program. At present, the patient's positron emission tomography/computed tomography shows pelvic, liver surface, and small bowel deposits, suggestive of recurrence or metastasis. This case report is discussed to emphasize the importance of aggressive surgical treatment in long-term steroid-dependent disease and poor prognosis of perforated malignancy irrespective of pathological staging.

Cancer pancreas is an aggressive cancer with dismal prognosis. Smoking, chronic pancreatitis increase the risk of pancreatic cancer. It usually presents late. Accurate staging is important as curative resection is the only curative treatment. Contrast enhanced multi slice CT scan and Endoscopic ultrasonography are important for diagnosis. Resection is possible in only approximately 10-20% patients. Whipples operation or pylorus preserving pancreato-duodenectomy is the preferred treatment. Post operative chemotherapy with gemcitabine may be helpful. After resection the median survival is 11-20% and 5 year survival is 7-25%

PURPOSE: Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients. METHODS: The Acute Kidney Injury-Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge. RESULTS: A total of 1032 ICU patients out of 1802 [57.3%; 95% confidence interval (CI) 55.0-59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage 1 = 1.679 (95% CI 0.890-3.169; p = 0.109), stage 2 = 2.945 (95% CI 1.382-6.276; p = 0.005), and stage 3 = 6.884 (95% CI 3.876-12.228; p < 0.001). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) in 47.7% (95% CI 43.6-51.7) versus 14.8% (95% CI 11.9-18.2) in those without AKI, p < 0.001. CONCLUSIONS: This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.

The medical therapy of ulcerative colitis (UC) has improved significantly allowing many patients to defer or avoid surgery. Despite this about 25% of patients with inflammatory bowel disease (IBD) complicated by acute colitis undergo emergency colectomy. Emergency colectomy is needed in acute severe colitis unresponsive to medical management and for life threatening complications like toxic megacolon, perforation and severe hemmorhage. Most important predictive factor for postoperative morbidity and mortality after colectomy is the timing of surgery. Prolonged unsuccessful medical treatment will delay surgery and increase the risk of postoperative complications in these seriously ill, immunocompromised, malnourished, and deteriorating patients.

Carcinoma pancreas is a common malignant disorder of the digestive system. Unfortunately, most cases of pancreatic cancer often present late and are not amenable to surgical cure. Approximately 40% of patients have metastatic disease at the time of presentation. Common metastatic sites include liver, peritoneum, and lung. However, central nervous system metastases are rarely seen in carcinoma pancreas, and most reported cases show lesions in the brain parenchyma. Carcinoma pancreas with meningeal metastasis is an extremely rare presentation, and fewer than 10 cases have been reported in literature. Meningeal infiltration by solid tumors has been reported in 3%–8% of cases. Clinical presentation is similar to meningitis or brain tumors and includes dizziness, nausea, vomiting, neck rigidity, and sensory and motor deficits. Treatment of meningeal metastasis consists of palliative chemotherapy and radiation. The meningeal carcinomatosis has a poor prognosis with median survival of 8–10 weeks. Here, we present a case of carcinoma pancreas with meningeal metastasis, presenting as meningitis. In view of poor general condition of the patient, the Eastern Cooperative Oncology Group score of 4, and after multidisciplinary discussion, only palliative treatment was given. She rapidly deteriorated and succumbed to her illness, 5 days after admission to our hospital.

Celiac axis (CA) stenosis is a commonly detected condition in candidates planned for upper abdominal surgery. In major abdominal surgeries, CA stenosis has its own importance. In our case, a 57-year-old female was admitted with obstructive jaundice and diagnosed to have distal cholangiocarcinoma and was planned for surgery. Computed tomography scan (done from outside centre) was discussed with our radiologist; a moderate-to-severe CA stenosis was noted with collaterals being developed between superior mesenteric and gastroduodenal arteries. Based on this, she was planned for preoperative biliary and vascular stenting before definitive surgery. Whipple procedure was done after stenting of the CA stenosis. Intraoperatively, we found a wide and good caliber hepatic artery being fed by the CA itself. Postoperatively, there was no complication related to ischemia or anastomotic leak. This case is being reported to emphasize the importance of thorough radiological evaluation before taking up any major abdominal surgery.

The incidence of cardiac complications in the post live donor liver transplantation (LDLT) period has been reported to be nearly 70% [1]. Stress cardiomyopathy (SC) is a severe complication which has varied presentation and has grave prognosis if not diagnosed and managed aggressively.