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Objective: Primary hyperparathyroidism (PHPT) is a systemic disease which, along with bone and stone disease, also causes several subjective symptoms which impairs the quality of life (QoL). However, NIH guidelines do not include non-specific physical and neuropsychological symptoms as an indication of parathyroidectomy. SF-36 is one of the most commonly used tools for assessing QoL; it measures both physical health (PH) and mental health (MH). Material and Methods: This is a prospective observational study including 50 patients of symptomatic PHPT. Patients were categorized into normocalcemia (8.5-10.4 mg/dL), mild hypercalcemia (10.5-11.9 mg/dL), moderate hypercalcemia (12-13.9 mg/dL), and severe hypercalcemia (>14 mg/dL). QoL was assessed by using SF36 survey both pre-operative and three months after parathyroidectomy. Results: There was an overall improvement in QoL of individual groups both in PH and MH components (p< 0.001). The improvement was more substantial for bodily pain, role physical, vitality and mental health. Although QoL was affected in patients with mild hypercalcemia, it was more affected in patients with severe hypercalcemia. The improvement in MH scores was dependent on the level of pre-operative calcium; however, the improvement in PH scores was independent of pre-operative calcium (p= 0.698). Conclusion: This study showed improvement in all aspects of PH and MH of SF-36 after parathyroidectomy, even in normocalcemics. Despite the fact that current guidelines for the management of PHPT do not include QoL as an indication for parathyroidectomy, we propose that parathyroidectomy should be considered, if patient is fit for surgery.

BACKGROUND Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

Introduction: Focused parathyroidectomy is the gold standard treatment for primary hyperparathyroidism (PHPT) due to single gland disease with a comparable success rate as that of conventional four gland exploration. It is also associated with fewer surgical complications. Despite these benefits, there is still controversy about the high recurrence following the focused approach. Aim: The aim was to analyse our experience regarding the success rate of focused parathyroidectomy for PHPT. Methods: This was a retrospective analysis of 192 patients of PHPT between January 2017 and August 2020 who underwent focused parathyroidectomy without intraoperative parathormone analysis, and had a minimum follow up of six months. Demographic profile, biochemical (pre and postoperative), radiological, operative and histological detail of all patients were recorded. Parathyroidectomy was considered curative if the patient maintained normal serum calcium and parathormone (PTH) levels six months after surgery. Persistent hyperparathyroidism was considered if hypercalcemia or high PTH levels persisted, or recurrent disease when a patient had rising serum calcium and / or PTH levels six months after curative parathyroidectomy. Results: No patient had pain and wound-related complications after parathyroidectomy. Two patients had voice change in the immediate postoperative period which recovered subsequently; no patient had documented vocal cord paralysis. The persistent disease was present in two patients; both required neck exploration. Five patients had recurrence of PHPT within six months of parathyroidectomy; all of them had hyperplasia on the final biopsy. The overall cure rate was 97.92%. Conclusion: Therefore, we propose focused surgery for sporadic PHPT should be considered as a preferred treatment with acceptable recurrence rate and surgical complications. KEYWORDS:focused parathyroidectomy, parathyroidectomy, primary hyperparathyroidism

Extrahepatic portal venous obstruction (EHPVO) and temporomandibular joint (TMJ) ankylosisis are significant problems in Asian countries. Both EHPVO and bilateral TMJ ankylosis may have rare association due to protein C and S deficiency which may cause hypercoagulability as well as reduced fibrinolytic activity. Ankylosis arising in early childhood is associated with facial asymmetry, feeding difficulty and speech development alterations. It is also associated with great challenges of endoscopic management in extra hepatic portal vein obstruction (EHPVO) with variceal bleed as well as air way management during surgical management and post-operative recovery. Recently a case series had shown association of TMJ ankylosis with EHPVO due to protein C deficiency which might be an etiological factor for both EHPVO as well as TMJ ankylosis. This case report documents a case of 14 year young girl who had TMJ ankylosis due to ear infection and EHPVO with esophageal varices had multiple episodes of upper GI bleed with mild deficiency of protein C and S, successfully managed with proximal splenorenal shunt to prevent further episodes of upper GI bleed, as endoscopic management is not feasible due to TMJ ankylosis.

Background: Postoperative pancreatic fistula (POPF) is associated with high morbidity and mortality rates. Studies have reported internal stenting of the pancreaticojejunostomy (PJ) to reduce POPF, but it is still controversial. Aim: In this study, we compared the outcome of internal stenting across the PJ to reduce POPF following pancreaticoduodenectomy (PD) and described our technique of putting the internal stent across the PJ and in to the main pancreatic duct. Materials and methods: Fifty patients undergoing elective PD were included. Patients were divided into two groups in a randomized fashion; Group A (n = 25) without internal stenting across the PJ and Group B (n = 25) with internal stenting of the PJ. The primary endpoint was the occurrence of POPF. Results: Both groups were comparable in demographics, comorbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, a total of 23 (46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p = 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery after conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p = 0.366]. Six patients developed a superficial surgical site infection (2 in group A and 4 in group B; p = 0.445). The length of hospital stay was comparable between the two groups. There was no mortality. Conclusion: Internal stenting of PJ does not decrease the rate of POPF after PD.

lt;bgt; Introduction:lt;/bgt; The COVID-19 pandemic is an exceptional situation which has rigorously affected surgical education and training worldwide. This current situation has carved innovative ways like online teaching to counter the challenges of the pandemic faced by a surgical resident. However, online teaching is not complimentary to bedside teaching which is a traditional practice. Therefore, we designed this study to assess the residents' perceptive towards online learning as a mode of education which is extensively implemented during the COVID-19 pandemic at our centre.lt;/brgt;lt;/brgt;lt;bgt; Methods:lt;/bgt; This study was a cross-sectional survey. An online Google survey was circulated among junior residents in the department of General Surgery. This survey included residents' demographic profile, effect on working hours, their perception with online teaching, and effect on their surgical training during the COVID 19 pandemic.lt;/brgt;lt;/brgt;lt;bgt;Results:lt;/bgt; A total of 95 junior residents participated in this study. Surgical training and teaching was rigorously affected according to most of them and they also believe they have lost crucial training time in their tenure as a surgical resident. A majority found the communication with the faculty during online teaching adequate; however, the main drawback of online classes was the lack of clinical exposure and practical experience. Only 4.2% preferred 100% online teaching in future.lt;/brgt;lt;/brgt;lt;bgt; Conclusion:lt;/bgt; COVID-19 pandemic has affected surgical training much more as compared to other medical fields. However, we believe online education is still a potential instrument during the COVID-19 pandemic. Online learning platforms can be used in future as a supplement to time-honoured classroom teaching and didactic lectures.

Necrotizing fasciitis (NF) is a rapidly progressing infection of the soft tissues associated with high morbidity and mortality and hence it is a surgical emergency. Early diagnosis and treatment are of paramount importance. LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) and SIARI (Site other than lower limb, Immunosuppression, Age, Renal impairment, and Inflammatory markers) scoring systems have been established for early and accurate diagnosis of necrotizing fasciitis. This study compared the two scoring systems for diagnosing NF, predicting management, and elucidating the prognostic performance for re-operation and mortality.This prospective study was conducted in PGIMER Chandigarh, India, between February 2020 and June 2021. The study was approved by the Institutional Review Board (No. INT/IEC/2020-90). The clinical presentation, laboratory parameters, and imaging were used to classify patients into NF or severe cellulitis groups. We also calculated the LRINEC and SIARI scores. Demographic variables and mortality were recorded. The area under the receiver operating characteristic was used to express the accuracy of both scores at a cut-off LRINEC and SIARI scores of ≥6 and ≥ 4, respectively.The study comprised 41 patients with NF and 11 with severe cellulitis. Informed written consent was taken from all the participants. At LRINEC score ≥6, the C-statistic for NF diagnosis was 0.839 (95% confidence interval [CI] 0.682-0.995, P 0.001), which was better than SIARI score at ≥ 4, C-statistic of 0.608 (95% CI 0.43-0.787, P 0.297). Both scores accurately predicted 30-day mortality. The LRINEC score showed a C-statistic of 0.912 (95% CI 0.798-1, P 0.001). Simultaneously, the SIARI score showed 70% sensitivity and 77% specificity, with a C-statistic of 0.805 (0.62-0.99, P = 0.017).LRINEC score is an effective diagnostic tool for distinguishing necrotizing fasciitis from severe cellulitis. Additional research is required to establish the SIARI score's external validity.

Necrotizing enterocolitis is one of the most common and worrying diseases in neonates, commonly shown in premature neonates, and is associated with significant mortality and morbidity. Necrotizing enterocolitis is characterized by intestinal mucosal injury that can progress to transmural bowel necrosis, and radiologically it can present with either pneumatosis intestinalis or portal venous gas. It is postulated to develop in an immunocompromised host in the setting of bacterial colonization, usually after administration of non-breast milk feed. Cow's milk allergy association with necrotizing enterocolitis has not been well determined, and the pathophysiology is still not clear. Necrotizing enterocolitis is very rare following living donor liver transplant. In our case, a 6-year-old boy who was doing well in the postoperative period had sudden worsening of general condition after he was started on milk feed. On evaluation and reexploration, he was diagnosed with necrotizing enterocolitis and later succumbed to death.

Hepatic arterial vasospasm can be a potential vascular complication after liver transplantation and can manifest as hepatic artery thrombosis. Due to the scarcity of literature on this pathology, its incidence, mechanism, relevance, diagnosis, and prognosis remain to be investigated. Our index case, a 64-year-old man with decompensated alcohol-related cirrhosis, underwent a cadaveric orthotopic liver transplant and was having a normal postoperative course. On postoperative day 12, liver enzymes were elevated, and Doppler ultrasound performed showed hepatic arterial occlusion. In view of hepatic artery thrombosis digital subtraction angiography (DSA) was done, which showed a string bead appearance of graft hepatic artery, with no thrombosis or stenosis of hepatic artery anastomosis. It was managed by oral administration of vasodilator, as well as intra-arterial administration of vasodilators through DSA catheter tip placed in the hepatic artery. He responded well to the management and was discharged on postoperative day 24 with normal liver enzymes.

Introduction Abdominal aortic aneurysms (AAA) are uncommon in young adults ≤55 years of age. There is a lack of literature on clinical characteristics, risk factors, and therapeutic outcomes so we present a case series of 11 patients of AAA aged ≤55 years. Methods We included single-center retrospective case series between 2013 to 2020. We reviewed 44 patients who were operated for AAA in a tertiary care center in India. We identified 13 patients who were ≤55 years; two patients with incomplete records were excluded. A patient information sheet was used to retrieve demographic data, clinical presentation, outcomes, and follow-up. Results Out of 11 patients, 10 were men. Nine patients (81.8%) had symptomatic AAA. The majority (45.4%) exhibited an infrarenal aneurysm and the median size of the aneurysm was 5.8 cm (IQR: 5.5-6.4 cm). Eight patients (72.7%) had a history of smoking. Hypertension was observed in six patients and one patient had associated coronary artery disease. Clamping time was > 45 minutes among three patients; all smokers. Blood loss was > 500 ml in five patients. The median length of hospital stay was 10 days (7-40); more among patients with metabolic equivalents (METS) score < 4, 14.5 (8-19) days. No grade III-IV complications and mortality were noted with a median follow-up of 15 months, with all patients living. Conclusion The aneurysm was symptomatic in the majority of participants. An association of smoking in increasing both the median clamping time and length of hospital stay was seen. No mortality and good disease-free follow-up suggested good outcomes.

Postoperative pancreatic fistula is associated with high morbidity and mortality. Studies have reported internal stenting of the pancreaticojejunostomy anastomosis to reduce postoperative pancreatic fistula, but it is still controversial.Fifty patients undergoing elective pancreaticoduodenectomy, were included. Patients were divided into 2 groups in randomized fashion; Group A (n-25) without internal stenting across the pancreaticojejunostomy anastomosis and Group B (n-25) with internal stenting of the pancreaticojejunostomy anastomosis. Primary endpoint was the occurrence of postoperative pancreatic fistula.Both the groups were comparable in demographics, co morbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, total 23(46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery on conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p-0.366]. Six patients developed superficial surgical site infection (2 in group A and 4 in group B; p-0.445). The length of hospital stay was comparable in two groups. There was no mortality.Internal stenting of pancreaticojejunostomy anastomosis does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.

Angiofibroma is a benign soft tissue tumour presenting as a gradually progressive swelling in the vulvovaginal area in women and in the inguinoscrotal region in men. Being a rare tumour, there are only a few case reports in the literature, and among them, presentation as perineal herniation is very rare. En bloc resection of angiofibroma either via laparoscopic or open approach is the choice of treatment to avoid recurrence. Detailed pathological examination and immunohistochemistry workup are imperative to distinguish it from various mesenchymal tumours. Perineal hernia is itself rare and may occur spontaneously or following abdominoperineal resection, sacrectomy or pelvic exenteration. Surgical repair via open transabdominal and transperineal approaches has been described. Here, we report a case of a young woman who presented with spontaneous reducible perineal hernia with a soft tissue tumour as its content, which on histopathological investigation was found to be an angiofibroma.

Mucormycosis is a rare, life-threatening, angioinvasive opportunistic fungal infection. Most common sites involved are rhino cerebral, pulmonary, cutaneous followed by gastrointestinal. We report a successful management of rare gastrointestinal ileal mucormycosis with perforation peritonitis managed surgically. Later histopathology revealed the ileal mucormycosis with transmural necrotizing inflammation. Histopathological demonstration of the fungus in surgical specimens remains cornerstone of the diagnosis of mucormycosis in view of its non-specific symptoms, low isolation rates of mycological culture and lack of other rapid tests.

Background: The pandemic has imposed a prodigious limitation on surgical training and has disrupted hospital procedures, hindering continuing medical training. We have established an online classroom platform at our institute to pursue medical education, which has been a new experience for our residents and consultants.Method: Across-sectional survey was conducted in the department of general surgery to know the perception of surgical consultants/registrars and junior residents regarding online classes and conventional teaching methods. Survey was conducted online, wherein questionnaires related to online teaching were circulated to resident surgeons and consultants/registrars.Results: A total of 91 surgery residents and 26 surgical supervisors consisting of faculty members and registrars completed the survey. Junior residents provided encouraging feedback and supported online education in the COVID-19 period; they felt that courses were well discussed, except clinical case presentation. A total of 84.6% of surgery residents and all the surgical supervisors felt that lack of a functional operating theatre impeded their training. Majority of surgical supervisors (66%) were moderately satisfied by the quality of online training, whereas junior residents (79%) were very to extremely satisfied and most (83%) approved online classes in future. Majority of junior residents (90%) found the virtual platform very easy to use, opposite to surgery supervisors.Conclusions: Our study demonstrated that online education is a feasible way to train surgical residents. However, since surgical specialties depend heavily on practical experience, it is very important to implement new ways of acquiring practical skills.

Micro-gallbladder is a rare clinical entity and mostly linked with cystic fibrosis (CF), which is an autosomal recessive disease involving a protein Cystic fibrosis transmembrane conductance regulator (CFTR) which regulates secretion and absorption in the pulmonary, reproductive and gastrointestinal systems including the liver. Biliary secretion becomes hyperviscous, leading to cholestasis and partial obstruction of the cystic duct. This causes recurrent cholecystitis and gallstone formation. Ultimately, atrophy of the gallbladder results, thus a ‘micro-gallbladder’ defined as being

Primary abdominal wall mucormycosis rarely occur in immunocompetent, non-diabetic patients but may affectin patients with traumatic injury with contaminated wounds and patients underlying malignancies usually infiltrating into skin. Herein we are reporting a case of primary cutaneous mucormycosis in a 17-year-old male without immunodeficiency or any comorbidity. He was managed with multiple debridement of the wound and intravenous amphotericin B therapy with cumulative dose of 2000 mg of liposomal amphotericin B followed by split skin grafting. We would like to emphasize the importance of high index of suspicionof fungal sepsis and early start of antifungal therapy in this condition can reduce high rate of mortality and management of large wound with split skin grafting in same setting to avoid morbidity.

COVID-19 was declared as a public health emergency of international interest on 30 January 2020; and as a pandemic on 11 March 2020.1 In order to minimise the spread and to optimize the health care resources Indian government announced national lock down with suspension of all routine hospital activities (outpatient clinics, routine surgeries) on March 24, 2020. Only emergency services were allowed along with diversion of all available resources to COVID centre.

Meckel’s diverticulum can manifest with various complications such as obstruction, intussusception, inflammation or diverticulitis, perforation, haemorrhage and fistula, and commonly manifests in children. Adult intussusception due to inverted Meckel’s diverticulum is an uncommon aetiology of intestinal obstruction but should be suspected in individuals. Imaging such as contrast-enhanced computed tomography aids in the diagnosis but it is not confirmatory to diagnose inverted Meckel’s diverticulum as a leading point. Resection of the intussusception segment is the definitive treatment. We present the case of a young man who presented in emergency with complaints of intestinal obstruction and ileo-ileal intussusception was the aetiology of for the same diagnosed on contrast-enhanced computed tomography of the abdomen. On exploration we discovered an inverted Meckel’s diverticulum to be the leading point for intussusception.

Background: COVID-19 disease caused by SARS-COV-2 has become a pandemic. Outcome of surgical patients infected with COVID-19 is not very clear.Methods: Retrospective analysis of the surgical outcome of COVID-19 infected patients admitted in emergency and elective surgical settings in a designated COVID care center.Results: Total 53 patients were included. Surgery was done in 47.16% (n=25) patients and 52.84% (n=28) patients were managed non-operatively. Overall mortality was 37.7 % (n=20). In operated group it was 52% (n=13) and 25% (n=7) in the non-operative group (p=0.043). The total leukocyte (p=0.018), serum CRP (p=0.031), urea and creatinine level (p=0.025) were higher in the mortality group. Patients aged more than 50 years had a significantly higher mortality compared to less than 50 years (p=0.010). Patients having multiple comorbidities had higher mortality (p=0.159).Conclusions: COVID-19 infection has a definite adverse impact on the outcomes of surgical patients.

The incidence of associated common bile duct stones in patients undergoing cholecystectomy is 10%. The present day management of common bile duct stone is pre- or post-operative endoscopic retrograde cholangio-pancreatography and clearance of common bile duct. Complications of ERCP and CBD stone extraction have been reported to occur in 5 to 10% cases which may range from mild to life threatenin Here we report a case of cholelithiasis with choledocholithiasis with obstructive jaundice and patient while undergoing ERCP and stone retrieval had complication of impacted dormia basket which was managed by surgery.

Percutaneous transhepatic biliary drainage (PTBD) catheter site metastasis in cases of cholangiocarcinoma is reported sporadically. But it is unusual to see left-sided tumour metastasising to the right PTBD catheter site. Metastasis, in general, has a poor prognosis, but recurrence along the catheter tract in the absence of other systemic diseases can be a different scenario altogether. To date, there is no consensus on the management of this form of metastasis. But carefully selected patients can benefit from aggressive surgical resection. We report a case of a young patient with isolated chest wall metastasis 1 year after resection of left-sided hilar cholangiocarcinoma. The metastasis was resected and, on pathological analysis, was confirmed to be due to implantation of malignant cells along the tract of the PTBD catheter placed via a transpleural route.

Background and Objectives: Anaerobic infections are usually caused by the host’s endogenous flora due to a breach in the anatomical barriers and Bacteroides spp. are the most notorious organisms associated with anaerobic infections. The identification of anaerobes has been a challenge since times. MALDI-TOF-MS is a boon for aiding the rapid detection of anaerobic organisms and has helped us to enlist the distribution of various anaerobic pathogens. Materials and Methods: This retrospective analysis (January 2018 to December 2019) was carried out in a tertiary care hospital in North India, in which the anaerobic microbiological profile of all patients admitted to surgical wards, ICU, and OPD of various departments (Orthopedics, Surgery, Gynecology, and Obstetrics) was reviewed. Samples received were immediately processed aerobically (5% sheep blood agar and Mac Conkeyagar) as well as anaerobically (RCM and freshly prepared sheep blood agar) as per the laboratory protocols. Results: Bacteroides fragilis (19.12%) was the most common anaerobe whereas among aerobes Escherichia coli (30.2%) followed by Klebsiella pneumoniae (10.34%) were most commonly isolated. The majority of patients were males (56%) and the most common presentation was with abscesses (21.4%). Polymicrobial infections (69.51%) outnumbered monomicrobial ones (30.48%). Conclusion: There is a paucity of literature on anaerobe isolation from surgical infections from our country which motivated us to study anaerobic infections and the high sample size in our institute enabled us to study surgical infections from an anaerobic perspective. This will add to the knowledge of microbiologists and clinicians. MALDI-TOF MS helped in rapid and accurate identification and hence we could report a wider spectrum of organisms in our study