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   Table of Contents - Current issue
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July-December 2020
Volume 26 | Issue 2
Page Nos. 121-235

Online since Saturday, November 7, 2020

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CHAIRMANíS MESSAGE  

Chairman's message Highly accessed article p. 121
R Padmakumar
DOI:10.4103/ksj.ksj_35_20  
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EDITORIAL Top

Editorial Highly accessed article p. 122
YM Fazil Marickar
DOI:10.4103/WKMP-0210.300249  
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OBITUARY Top

Remembering Dr. Iqbal Ahmed; A skilled cancer surgeon, great teacher and perfect gentleman Highly accessed article p. 123
K Chandramohan
DOI:10.4103/ksj.ksj_31_20  
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BOOK REVIEW Top

From Spanish flu to COVID: The Pandemic Century p. 125
Ekbal Bappukunju
DOI:10.4103/ksj.ksj_26_20  
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REVIEW ARTICLES Top

Comparison of outcomes between non-operative and operative management of blunt splenic trauma in adults p. 127
Danielle Loh, Joseph McAleer
DOI:10.4103/ksj.ksj_29_20  
Treatment for hemodynamically stable patients is mostly nonoperative observation, with increasing use of splenic angioembolization (SAE). There is a lack of consensus on management plan and use of SAE. In this review, relevant recent literature is analyzed to evaluate the failure rates, complications, mortality, and hospital length of stay for each management method. The analysis of 6299 patients from 9 studies showed that SAE decreased failure rates (1.3%) against nonoperative management (NOM) with 9.8%. There was no significant difference in mortality and hospital length of stay between SAE and NOM. There was increased complications with SAE but it is not enough evidence to draw comparisons between NOM and operative management (OM) due to heterogeneity of studies. SAE decreased need for splenectomies, reduced hospital stay, and complications. OM should be used if the patient is hemodynamically unstable or re-bleeds after NOM. It is imperative that clinicians assess each patient individually and follow a center-based protocol, while keeping in mind, the possible complications from NOM and subsequent interventions. Interventional radiologists will also need to approach SAE with care to prevent technical failures and re-intervention.
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The phenomenon of dedifferentiation: Understanding its effect on the post-operative management of papillary thyroid carcinomas p. 131
Sandeep Babu Bhaskaran Pillai
DOI:10.4103/ksj.ksj_21_20  
Well-differentiated thyroid cancers are usually managed by total thyroidectomy with or without neck dissection. High-risk patients are followed up using serial thyroglobulin estimation and radioiodine scans. The phenomenon of dedifferentiation is essential to understand the events during post-operative follow-up of these tumours. This article describes the cascade of sequential dedifferentiation, its genetic undercurrents and its impact on the detection and treatment of post-surgical recurrences. New targeted agents aimed at redifferentiation are also discussed.
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Strategies to mitigate psychosocial stress among health-care workers during COVID-19 Pandemic p. 135
Toney Jose, Joseph Mani, Jose John
DOI:10.4103/ksj.ksj_9_20  
The COVID-19 pandemic has resulted in increased workplace demands from the health-care workers. This along with other psychosocial factors has resulted in increased stress, anxiety and depression. Measures have to be adopted to prevent burnout in the long run. There are various strategies that can be taken at the individual, administrative and community levels to mitigate stress. Everyone involved in healthcare from frontline workers to administrators and policymakers should be aware of the reasons for stress and strategies to mitigate it. A combined effort would decrease the inevitable toll on the health system. Strategies at individual, administrative and community levels can decrease the stress on health-care workers.
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ORIGINAL ARTICLES Top

'Key-hole surgery' – A study on patient perceptions about laparoscopic surgery in Kerala p. 139
Sandhra George, Sanoop K Zachariah
DOI:10.4103/ksj.ksj_5_20  
Background: Patients often demand laparoscopic procedures irrespective of the indications. There seems to be an increased awareness of laparoscopic procedures among the people of Kerala. To date, there is no published study about the patient's awareness, perceptions and understanding of laparoscopic surgery in India. Aims: The aim is to assess the knowledge and identify various factors associated with the patient's perception of laparoscopic surgery. Methodology: This is a prospective cross-sectional study, including 200 participants. Kuppuswamy's Scale was used to assess the educational and occupational status of the participants. Knowledge scoring was obtained utilising a structured questionnaire. An initial survey divided patients into two groups, namely, those who were aware of laparoscopy and those who were not. Patients who were aware completed the remaining questionnaire. Others were briefly educated about laparoscopy, using print and visual aids. They were then assessed for their preference for the surgical procedure. Results: Awareness about laparoscopic surgery was high (96.5%). Friends and family (62%) contributed a major source of information and the least by the media (11.5%). 30.5% did not know that laparoscopy required special equipment. Interestingly, 56.5% were unaware of the requisite of gas insufflation. Educated participants had significantly better awareness. 55% had a good knowledge score. About 81.5% claimed their preference for laparoscopic surgery even if it were to cost more. Conclusion: The local population are well informed about laparoscopic surgery. The disadvantages are less known. Awareness through mass media is less. Health-care providers should focus their attention on deficient areas of awareness.
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Surgical complications in post-live-donor renal transplantation recipients – Our experience and lessons learnt p. 144
Rohan Kumar, Biju S Pillai, H Krishna Moorthy
DOI:10.4103/ksj.ksj_30_20  
Introduction: Renal transplantation has become a common treatment for end-stage renal disease. The surgical techniques for renal transplantation are well established and associated with high success rates. Complications of the procedure are low (15%–17%) when compared to other solid organ transplants such as liver and pancreas. Surgical complications of renal transplantation are mostly related to either surgical site infection or problems in one of the three anastomoses (renal artery, renal vein or ureter). Most of the complications require prompt surgical or radiologic intervention for appropriate management. Materials and Methods: This is a retrospective observational study of surgical complications in patients undergoing live-donor renal transplantation for a period of 10 years before 2020 in the urology department of a tertiary care hospital. The incidence and potential reasons for the complications were analysed and reviewed. Results: Of the 250 cases reviewed, surgical complications were observed in 20 (8%). Among these, ureteric necrosis, arterial thrombosis and significant symptomatic lymphocele were the main surgical complications. Through this study, a causal relationship was established in all these patients with complications and preventive measures have been suggested. Conclusions: Surgical complications of live-donor renal transplantations could be reduced by adopting appropriate precautionary measures. Early identification and treatment of surgical complications are critical for graft survival after kidney transplantation.
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Mechanical complications of central venous catheter insertions p. 147
MK Nikhil, O T. Muhammed Basheer, Preetha Prasad
DOI:10.4103/ksj.ksj_28_20  
Introduction: Central venous pressure (CVP) catheterisation is an important procedure in emergencies. The complications associated with it are common. This article aimed to study the rate of mechanical complications of CVP catheter insertion in 201 patients. Materials and Methods: This was a prospective longitudinal study. Patients were aged above 13 years of both sexes who had CVP catheter introduced. Patients with complications before the procedure and those who had structural malformation of chest wall, bleeding disorders, etc., were excluded from the study. Consecutive sampling was performed. Data were analysed using Chi-square test for testing the strength of association in SPSS version 19.0. Results: The common indication for CVP line was lack of peripheral access (57.2%). Majority had right-sided (81.6%) catheter insertion and 56.7% had multiple percutaneous punctures. A statistically significant association was found in patients with body mass index >25 kg/m2, in the occurrence of multiple percutaneous punctures (P = 0.04). Multiple punctures were associated with complications (P < 0.05). We observed 12.9% of mechanical complications – failure to place the catheter (8.5%), arterial puncture (6%), pneumothorax (2%) and haematoma (1%). Multiple complications were observed in 3.9% of patients. Conclusions: Factors contributing to various complications were number of punctures, presence of comorbidities and female gender.
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Patency and complication rates of arteriovenous fistula created for renal replacement therapy p. 151
Yalini Palaniswamy, EV Gopi, Chandrasekaran Sukumaran
DOI:10.4103/ksj.ksj_16_20  
Introduction: There are many choices for an areteriovenous (AV) access such as central venous catheters used in emergency basis, arteriovenous fistula (AVF), prosthetic AV grafts and vein interposition. Of these, AVF are used the most. It is very essential for surgeon to know about the merits and demerits of the same. Hence, this study was undertaken as a humble attempt to study the patency and complication rates of AVF. Materials and Methods: Eighty patients with chronic kidney disease who had an AV access created for dialysis in the given time period were included. They were assessed for fistula patency following the surgery at 1st month and 6 months clinically and correlated with pre-operative parameters and demographic profile. Results: Patency of AVF at 1 month was 88% and at 6 months was 85%. There was a negative correlation between diabetics and patency which is statistically significant. There was a positive correlation between gender and patency. Males (90%) had patency, whereas 30% of females did not have patency. There was a strong association between diabetics and infection which was statistically significant. Conclusions: Autogenous AVFs are a safe durable option for renal replacement therapy and with due care, complication rates and patency can be maintained with international standards.
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Diagnostic thoracoscopy using a laparoscope p. 154
Rexeena Bhargavan, Chandramohan Krishnan Nair, Arun Peter Mathew, Madhu Muralee, Mira Wagh, Preethi Sarah George
DOI:10.4103/ksj.ksj_33_20  
Introduction: Minimally invasive surgery has revolutionized thoracic oncology. Although there are various nonsurgical methods of biopsy, some patient's require a surgical biopsy. We present an innovative use of laparoscope for thoracoscopic biopsy. Materials and Methods: This is a retrospective analysis of 33 patients who underwent thoracoscopic biopsies for undiagnosed thoracic lesions in our hospital. Diagnostic thoracoscopy was performed with the laparoscopy unit used for abdominal surgeries. Results: Thoracoscopic biopsy yielded a histopathological diagnosis in 32 patients (96.67%). Median surgery duration was 40 min. Conversion rate was 6%. Morbidity rate was 10.7% with no mortality. The sensitivity and specificity of thoracoscopic biopsy was 95.83% and 100% respectively. The positive predictive value was100% and negative predictive value was 90%. Conclusion: Thoracoscopic biopsy using the laparoscopy unit can be done with minimal morbidity and without any additional financial burden in a low resource setting.
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Comparative study of laparoscopic mesh repair and lichtenstein's open mesh repair for inguinal hernia p. 158
Sooraj Sankar, Vimal Iype, Santhosh John Abraham
DOI:10.4103/ksj.ksj_4_20  
Background: Hernias are among the oldest known afflictions of humankind, and surgical repair of the inguinal hernia is one of the most common general surgery procedure performed today. Despite the high incidence, the technical aspects of hernia repair continue to evolve. We conducted a unicentric prospective study to compare the outcome of laparoscopic mesh repair and open Litchtenstein's mesh repair. Methods: We included a total of 80 cases who were diagnosed to have uncomplicated inguinal hernia and underwent surgical management electively for the same. They were randomized into both open or laparoscopic repair groups and results compared. Results: Among the 2 groups, the laparoscopic repair group had significantly low early post operative pain, low complication rate, early return to work and better cosmetic outcome. However, late post operative pain and duration of hospital stay did not show any significant difference between the two groups. Conclusion: Laparoscopic hernia repair offer significant advantages in terms of early post operative pain, early return to work and better cosmetics. But, in 2020, it still accounts for the minority of hernia repairs performed in India because of increased operative times, increased costs, and a longer learning curve. In addition are concerns about the need to use general anesthesia for laparoscopic operations. To summarize, there is no universal repair for groin hernia and no two surgeons will disagree to agree on that point.
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Ultrasound-guided aspiration compared to incision and drainage in the management of breast abscess p. 163
Roben Sebastian, KV Ragesh, Anna Mani, Gomathy Subramaniam
DOI:10.4103/ksj.ksj_20_20  
Introduction: Breast abscess is a common cause of morbidity in women. Ultrasound-guided needle aspiration, as opposed to formal I&D, is becoming the standard of care for most breast abscesses. This study aimed to establish whether ultrasound-guided aspiration is a comparable option to incision and drainage for breast abscess and to study the microbiological profile and antibiotic sensitivity pattern observed in breast abscess. Materials and Methods: Fifty females aged 20–40 years with breast abscess were analysed, of these 25 patients had ultrasound-guided needle aspiration (Group A) and 25 patients had incision and drainage (Group B). Group A patients were followed up on days 3, 7 and 14 by both clinically and radiologically (US), with repeated aspirations done on day 3 and 7. The presence of breast abscess on day 14 was considered as treatment failure, for whom incision and drainage was performed. Group B had incision and drainage done, followed up at 2 weeks. Scar length was assessed at 12 weeks for Group A and B. The results were statistically analysed. Results: The mean age of Group A was 31 and Group B was 30. Out of the 25 in Group A, 88% underwent resolution with no scar and 12% had failure. 100% of the patients in Group B had resolution, but had a definitive scar. Conclusions: US-guided aspiration of breast abscess is a comparable treatment option in the management of breast abscess as opposed to incision and drainage with the added advantage of minimal or no scar.
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ORIGINAL PAPER Top

Use of serial monitoring of serum albumin and total leucocyte in predicting septicaemia in burns patients p. 167
Shabin Majeed, EV Gopi, PT Abdul Basith
DOI:10.4103/ksj.ksj_22_20  
Introduction: The most common complication of burns is infection-producing sepsis. Therefore, it is necessary that septicaemia be diagnosed early. Many biomarkers help to diagnose septicaemia early. Serum albumin levels and total leucocyte counts were commonly measured blood parameters in burn patients. This study was undertaken due to the dearth of information on the role of serum albumin levels and total leucocyte count in the diagnosis of septicaemia. Materials and Methods: This retrospective, correlational study used existing medical record data of 60 patients including the laboratory values admitted in the burns intensive care unit of the department of general surgery during the period January 2017–May 2019 and during the follow-up period. Results: Statistically significant association was observed between low serum albumin values and positive blood culture (P < 0.0001). Mean serum albumin had an excellent predictive validity in predicting blood culture indicated by area under the curve of 0.907. Similarly, septicaemia was correlated with a high total number of leucocytes and a statistically significant correlation (P < 0.0001). In predicting blood culture, mean total leucocyte counts demonstrated excellent predictive validity indicated by area under the curve of 0.985. Conclusion: Serial monitoring of serum albumin and total leucocyte count could be used in burn patients to predict septicaemia.
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ORIGINAL ARTICLES Top

A comparison of laparoscopic appendicectomy versus open appendicectomy p. 171
Rayeez P Abdul Nazir, Santhosh John Abraham
DOI:10.4103/ksj.ksj_10_20  
Introduction: Laparoscopic appendicectomy is being adopted by majority of general surgeons, but its advantages over open appendicectomy, considering the cost difference, have not been established. This study aims to describe the difference in outcome between the two procedures and compare the costs involved. Materials and Methods: Seventy patients were studied with 35 in both laparoscopic and open appendicectomy groups. The two groups were compared for operation time, post-operative complications, pain, duration of hospital stay, days to return to work, quality of scar and costs involved. Results: Laparoscopic appendicectomy group had shorter operation times, lower post-operative pain, shorter hospital stays and better scars, whereas the open appendicectomy group had lower costs. No significant difference was observed in days to return to work or post-operative complications. Conclusion: Laparoscopic appendicectomy offers considerable advantages compared to open appendicectomy despite the higher costs.
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Variation of serum carcinoembryonic antigen with grading and radiological staging in colorectal malignancy p. 175
Akshaya Mohan, MR Rajesh, MP Sreejayan
DOI:10.4103/ksj.ksj_6_20  
Introduction: Serum carcinoembryonic antigen (CEA) is used universally as a tumour marker for colorectal malignancies. The study aims to compare the serum CEA levels in different histopathological grades and radiological stages and to see if there is a relation between them so that advanced stage can be predicted early with serum CEA level. Methodology: An observational study was done on 101 patients with colorectal malignancies. Pre-operative serum CEA value, radiological staging and pathological grading were compared. Results: Fifty-eight patients were male and 43 female. The mean age was 62.6 years. The mean serum CEA value was 14.99 ng/ml. There was a significant relation between CEA and T staging. There was no significant relation with nodal status or metastases or grading. Conclusion: The study revealed a relationship of higher T staging with CEA. No relationship was found with nodal/metastasis status/grading. We can suspect tumours with advanced T stage clinically, if CEA is elevated in patients with colorectal malignancies.
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Intravesical oxybutynin – A better option to treat catheter-related bladder discomfort? p. 180
Devesh Bansal, Biju S Pillai, Mohan P Sam, H Krishna Moorthy
DOI:10.4103/ksj.ksj_19_20  
Introduction: Catheter-related bladder discomfort (CRBD) is a distressing symptom due to bladder spasm occurring in patients who are on catheter. This study was conducted to evaluate the efficacy of intravesical Oxybutynin as an alternate to the existing treatment for the management of CRBD. Materials and Methods: Two hundred and thirty four patients requiring bladder catheterization for >48 h following various surgeries were randomized into three groups of 78 each, once they developed CRBD. Group OO (Oxybutynin) received oral oxybutynin 5 thrice a day, Group OS (Solifenacin) received oral Solifenacin 10 mg once a day and Group OI (intravesical Oxybutynin) received Oxybutynin 5 mg dissolved in 30 ml normal saline instilled intravesically. The bladder discomfort was assessed according to visual analogue scale at 1, 6 and 24 h after drugs administration. The relief in CRBD and the side effects of the drugs were compared. Results: Out of 234 patients, relief of CRBD observed with intravesical oxybutynin was higher (87%) as compared to oral Oxybutynin and oral Solifenacin (66.3% and 74.3%, respectively; P < 0.05). OO group had maximum side effects and intravesical group had least side effects. Conclusions: Intravesical Oxybutynin therapy is a better option for the management of CRBD with minimal side effects.
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Calcium and Vitamin D supplementation in the prevention of post-operative hypocalcaemia in thyroidectomy p. 184
Vishnu Santhosh Menon, T Rajan Kumar, EP Unnikrishnan, EV Gopi
DOI:10.4103/ksj.ksj_7_20  
Introduction: The incidence of transient hypocalcaemia after thyroidectomy varies in centres. It increases morbidity and delays discharge. This randomised controlled trial aimed to ascertain the usefulness of calcium and Vitamin D supplementation for 1 week pre-operatively in the prevention of hypocalcaemia in patients undergoing total thyroidectomy (TT) for multi-nodular goitre. Methodology: Patients undergoing TT for multi-nodular goitre from January 2019 to August 2019 were included in the study. They were randomly divided into two groups by block randomisation. Group A received oral calcium (500 mg every 6 h) and Vitamin D (calcitriol 0.25 mg every 6 h) 7 days before surgery and Group B did not receive supplementation. Symptoms and signs of hypocalcaemia were monitored. Calcium profile was measured pre-operatively and post-operatively at 6 h, 24 h, 72 h and 14th day. Serum calcium level ≤8.5 mg/dl was considered as hypocalcaemia. Results: 8/62 patients in Group A and 26/62 in Group B had symptoms of hypocalcaemia. 11/62 patients in Group A and 34/62 in Group B developed signs of hypocalcaemia. 15/62 patients in Group A and 36/62 in Group B had biochemical hypocalcaemia. 9/62 patients in Group A and 25/62 in Group B developed post-operative hypocalcaemia, which required post-operative oral supplementation. 3/62 patients in Group A and 16/62 in Group B needed post-operative intravenous calcium supplementation. Conclusions: It is concluded that post-operative hypocalcaemia which manifested as signs and symptoms and correlated with biochemical values was lower after receiving pre-operative oral calcium and Vitamin D3 supplement for 7 days. The need for post-operative supplementation was lower in this group.
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Factors affecting lymph node involvement in non-melanoma skin cancers p. 188
V Revathy, KC Soman, Sreekanth S Kumar
DOI:10.4103/ksj.ksj_11_20  
Introduction: Non-melanoma skin cancers (NMSCs) with lymph node involvement usually have aggressive clinical course with high rate of treatment failure and recurrence. Materials and Methods: The aim of the study was to find out the clinicopathological factors affecting lymph node involvement in NMSC. This study with 48 cases was conducted over a period of 1 year (May 2018–May 2019) in the histologically proven patients of NMSC of the general surgery department. Results: Lymph node-positive patients with and without prior lesions (chronic non-healing ulcers) were 12.5% and 10.4% of the total population, respectively. Conclusions: Of all factors affecting lymph node involvement assessed in this study, the presence of pre-existing lesions was the only one attaining statistical significance.
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Clinical and microbiological profile of liver abscess p. 193
Afrah Abdurahman, KC Soman, S Sreekanth
DOI:10.4103/ksj.ksj_14_20  
Introduction: Liver abscess may be due to bacterial, parasitic or mixed infection in the parenchyma. Materials and Methods: A cross-sectional study was directed on 51 patients admitted in one of the government medical colleges for liver abscess over 1½ years. Pertinent clinical history, physical examination and investigations were done, and the patients were exposed to ultrasound-guided needle aspiration of liver abscess. Results: The majority of the pyogenic liver abscess (PLA) patients were 40–60 years old. Males accounted for 90.2% compared to females, 9.8%. The most common symptoms were abdominal pain and fever present in 88.2% and 64.7%, respectively. Dyspnoea was present in 9.8% of the patients and pleural effusion in 17.6%. Hepatomegaly was the most common sign, followed by jaundice in 11.8% and ascites in 2% of the patients. All patients had involvement of the right lobe of the liver, with segment 7 being the most commonly involved segment (66.7%). Single abscess cavity was seen in 33% of the patients. Pyogenic abscess was more common than amoebic liver abscess (39.2%). In pyogenic abscess, the most common organism cultured was Klebsiella (39.2%). Conclusion: The majority of the patients were young males suffering from alcoholism and belonged to the lower socioeconomic group with PLAs that presented as multiple right lobe abscesses. The seventh segment was the segment most commonly implicated. In female patients, the liver abscess was rare. The average age of patients was in the forties, and the rate of mortality in patients in the seventh decade was increased. Klebsiella was the most prevalent cultured organism. Perhaps, low overall mortality was because of the use of minimally invasive drainage procedures and appropriate antimicrobials for aetiology in all patients.
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Does timing of cholecystectomy in acute cholecystitis affect morbidity p. 197
Jinto Augustine Thomas, Aniz Akbar Ratani, Sajeesh Sahadevan, Rojan Kuruvilla, Rajesh Nambiar, Amal George, UV Akshay Viswanath
DOI:10.4103/ksj.ksj_8_20  
Background: Laparoscopic cholecystectomy (LC) is the accepted treatment for acute cholecystitis (AC), presenting in the first 72 h. Delayed surgery after 6 weeks is the accepted norm in late presentations. Many studies have been done to find the ideal time for surgery in AC and assess complications of surgery in AC. LC after the initial 72 h of onset of symptoms has been associated with increased incidence of conversion to open surgery and also complications. The main was the technical difficulty of dealing with the inflammatory changes, when it becomes denser and fibrotic, thereby increasing chances of biliary and adjacent bowel injuries. Aims and Objective: To determine the relation between timing of surgery and the postoperative outcomes, and to determine the appropriate timing of surgical intervention in acute cholecystitis. Materials and Methods: We conducted a prospective cohort study of 2-year duration. One hundred patients who were diagnosed to have AC based on the clinical and the radiological features were divided into two groups based on the onset of their symptoms and were offered LC at the index admission. Results: Group A included 61 patients within 3 days of starting of symptoms and 42 days after the initial symptoms, and Group B had 39 presenting between 4th day and 41st day of symptoms. No statistical difference was seen between the groups regarding the duration of operation, need for conversion to open procedure and post operative complications. The length of hospital stay was longer in Group B, thus increasing expenditure (P = 0.015). Long term follow up showed no difference in recovery in both the groups. Conclusion: we conclude that LC at index admission is safe and the morbidity of LC remains the same irrespective of the timing of presentation.
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Proportion of malignancy in solitary thyroid nodule p. 201
Rajan Kumar, J Hitesh
DOI:10.4103/ksj.ksj_25_20  
Introduction: Solitary nodule of thyroid (SNT) is a common diagnostic challenge, as it may be malignancy. Investigations are essential to establish functional status and cytopathological nature. Fine-needle aspiration cytology (FNAC) is very important. The incidence of malignancy in SNT is approximately 40%. Hence, early diagnosis is necessary for adequate treatment. This study focuses on the incidence of malignancy in SNT and study of different histopathological types. Materials and Methods: An observational study was conducted on 200 patients with solitary thyroid nodule and followed up with imaging, FNAC, intraoperative findings and histopathological report. Results: There was a female preponderance (139; 69.5%), and majority were between 4th and 5th decades of life (55.2%). The Mean age of at presentation was 47 years. The proportion of malignancy in SNT revealed by histopathological examination in this study was 36%. Out of which females are having 46 out of 139 that is 33% were malignant. In males 25 out of 61, means 40% were malignant. In females, out of the 46 cases, 16 (34%) had follicular carcinoma and 30 (65%) papillary carcinoma. In males, out of 25 cases follicular carcinoma comprised 9 (36%) and papillary carcinoma comprised 46 (64%) cases. Conclusions: The risk of malignancy in SNT was significant. Malignancy was more predominant in males. Papillary carcinoma represented more number of cases than follicular carcinoma. Malignancy was mostly present as hard nodules. There was no significant association with size of nodule and pattern of malignancy. Lymph node involvement was more with papillary carcinoma. The solitary nodules involved the left side of the thyroid more commonly than the right.
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Post-operative adhesive intestinal obstruction p. 205
TK Ravidas, KC Soman, Sreekanth S Kumar
DOI:10.4103/ksj.ksj_13_20  
Introduction: Post-operative adhesions are the most important cause of small-bowel obstruction. This article aims to analyse the clinical manifestations, causes and management of patients diagnosed with post-operative adhesive intestinal obstruction. Methodology: The study was conducted in 91 patients aged >12 with characteristics of intestinal obstruction who were having a previous history of abdominal surgery. Scores were given for each clinical parameter. From the data collected various clinical manifestations, previous surgeries and intraoperative findings and their management were analysed. Pearson Chi-Square test and Fisher's exact test were used to examine the data in SPSS software. Results: Open appendicectomy was the most common previous surgery. The average interval between the onset of symptoms after surgery was 36 months. More number of recurrent adhesive small-bowel obstruction were associated with colorectal surgeries. Majority of the surgical intervention was made after 48 h of presentation and conservative treatment. Majority of the operated patients underwent adhesiolysis. There was a significant relationship between clinical features such as vomiting constipation, tachycardia, hypotension and operative management. Conclusion: Early surgery is advised for patients with clinical features of strangulation and conservative management for uncomplicated cases and surgical intervention if the progression of symptoms occurs. No effective prophylaxis could be found.
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Pre-operative scoring method for assessing the easiness of laparoscopic cholecystectomy p. 208
Thejas Lal, Alex Oommen, E Manjush
DOI:10.4103/ksj.ksj_24_20  
Introduction: Laparoscopic cholecystectomy is now the gold standard treatment modality for cholelithiasis. Many pre-operative factors affect the proceeding of laparoscopic cholecystectomy. The overall mortality and morbidity associated with the procedure can be measured through such pre-operative parameters. This study was done to propose a pre-operative scoring method for assessing the easiness of laparoscopic cholecystectomy. Materials and Methods: A cohort study was conducted for patients admitted to a government hospital to undergo laparoscopic cholecystectomy. They were interviewed with a series of question and data were collected from the operation noted of the same patients. These were compared to the per-operative findings and easiness of surgery. Results: Body mass index, number of previous attacks more than 2, thickened gall bladder and total white blood cell count > 10,000 were noted as significant predictors for assessing the easiness in doing laparoscopic cholecystectomy. Conclusions: It is possible to predict the easiness of surgery in laparoscopic cholecystectomy using a pre-operative scoring system.
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CASE REPORTS Top

Left adrenalectomy and proximal splenorenal shunt p. 212
B Dasanayake, WG P Kanchana, AD Darmapala, T Jayasinghaarachchi, V Pinto, Kuda B Galketiya
DOI:10.4103/ksj.ksj_27_20  
Portal hypertension is managed using pharmacological, endoscopic and interventional radiology. Shunt surgery is used in selected patients with good long-term prognosis. We present a patient who underwent a left adrenalectomy and splenorenal shunt.
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Large perinephric urinoma acting as a pop-off in a patient with asymptomatic upper ureteric stone p. 215
Kalpesh Saswade, Ganesh Sonawane, Biju S Pillai, Mohan P Sam, H Krishna Moorthy
DOI:10.4103/ksj.ksj_18_20  
Perinephric extravasation of urine with subsequent urinoma formation is a rare complication of neglected, obstructing ureteric calculi. It is associated with symptoms such as fever, lumbar pain and vomiting. We present the case of a minimally symptomatic patient who had an obstructed left upper ureteric calculus causing left hydronephrosis and a large perinephric urinoma, which probably was acting as a pop-off mechanism. Our patient was successfully managed by ureteroscopic lithotripsy with double J stenting.
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Fetal immature sacrococcygeal teratoma p. 217
Amal George, UV Akshay Viswanath, Abraham Mammen, A Binesh
DOI:10.4103/ksj.ksj_1_20  
Sacrococcygeal teratoma (SCT) is an unusual congenital tumour that arises from embryologically multipotent cells in the Hensen's node, which is located in the coccyx. Neonatal SCT is rare, with an incidence of one in 35,000 live births with a female predominance (3:1–4:1 ratio). It generally presents in two distinct fashions: (a) Newborns with large predominantly external masses, which are noted in utero or at the time of delivery and are rarely malignant, and (b) older infants and young children presenting with tumours predominately confined to the pelvis with a much higher rate of malignancy. Most SCTs are diagnosed prenatally because of the routine obstetric ultrasonography. Here, we are reporting the case of newborn with SCT presenting as external mass.
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Leiomyosarcoma of inferior vena cava p. 219
Mohamad Safwan, Sandeep Babu, Shaji Palangadan, Annes Thivya
DOI:10.4103/ksj.ksj_15_20  
A 57-year-old female presented with intermittent abdominal pain and bilateral pedal oedema. She was diagnosed as leiomyosarcoma from inferior vena cava (IVC). Imaging suggested encasement and occlusion of infra-renal IVC. She had received palliative chemotherapy from elsewhere, with no regression. We excised the tumour. At 14 months after the surgery, she is disease-free. Surgery is the mainstay in the treatment of retroperitoneal sarcomas. Even locally advanced retroperitoneal sarcomas may be successfully managed with complete surgical resection. Reconstruction of resected IVC segment may be avoided in selected cases.
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Huge extrarenal retroperitoneal angiomyolipoma complicating pregnancy p. 222
Amal George, Salahudheen Thottiyen, UV Akshay Viswanath, VP Salim, Jinto Augustine Thomas, O Rasheeda Beegaum, Shahid Shameem, Shehla Basheer
DOI:10.4103/ksj.ksj_2_20  
Retroperitoneal extrarenal angiomyolipoma (AML) presents a diagnostic challenge, because it can mimic other malignant and benign retroperitoneal tumours. Oestrogen and progesterone receptor expression is frequent in AML, so hormonal changes during pregnancy act as fertile soil for attaining huge size. During pregnancy, AMLs have high inclination to enhance in size and break. This increased risk is due to presence of progesterone and oestrogen receptors in AMLs, an enhanced maternal circulation and potentially greater intra-abdominal pressure related with pregnancy. We are presenting a 38-year-old pregnant patient with retroperitoneal extra renal AML, which presented as incidentally detected huge retroperitoneal mass.
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Urachal adenocarcinoma – A rare case report in a young female p. 225
Anil Sundaram, Manoj Kumar, Satish Kurup
DOI:10.4103/ksj.ksj_3_20  
Urachal adenocarcinoma has come to the limelight of surgical practice during the last three decades. Due to the rarity of this tumour, the complete biological behaviour and treatment protocols have not been developed. This is a case report of a 22-year-old female who was diagnosed with urachal adenocarcinoma and underwent radical surgery with adjuvant chemotherapy based on a multidisciplinary team meeting. This is the youngest case reported from India.
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Bilateral gluteal fasciocutaneous flap for perineal reconstruction following abdominoperineal resection p. 227
M Venkata Naga Srinivas, Arun Peter Mathew, Amrita V Rao, Madhu Muralee, Mira S Wagh, S Vijayasarathy, K Chandramohan
DOI:10.4103/ksj.ksj_32_20  
Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects. Benefits of V-Y flaps compared with other methods such as vertical rectus abdominis myocutaneous include reduced donor-site morbidity and increased ease of harvest and inset. This is a case report of bilateral gluteal V-Y fasciocutaneous reconstruction of perineal defect, in a post-irradiated anorectal carcinoma patient, with excellent outcome.
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LETTER TO EDITOR Top

Morbidity and mortality associated with perioperative SARS-CoV-2 p. 230
Toney Jose, Joseph Mani
DOI:10.4103/ksj.ksj_12_20  
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PICTORIAL CME Top

Pictorial CME p. 232
YM Fazil Marickar
DOI:10.4103/ksj.ksj_34_20  
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ASSOCIATION NEWS Top

Annual report of association of surgeons of India Kerala Chapter 2019–2020 p. 234
Jimmy C John
DOI:10.4103/ksj.ksj_36_20  
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