Surgery

The duration of intra-abdominal hypertension and increased serum lactate level are important prognostic markers in critically ill surgical patient's outcome: A prospective, observational study Hnuman Prasad Gupta, Pema Ram Khichar, Rekha Porwal, Amit Singh, Anil Kumar Sharma, Mukesh Beniwal, Satyaveer Singh Nigerian Journal of Surgery 2019 25(1):1-8 Aim: The present study analyzed the clinical significance of duration of intra-abdominal hypertension (IAH) associated with increased serum lactate in critically ill patients with severe sepsis. Materials and Methods: Our study was an observational, prospective study carried out in the Surgical Intensive Care Unit (ICU) at J.L.N Medical College, Ajmer, Rajasthan, India. In our study, we included a total of 100 patients and intra-abdominal pressure (IAP) was measured through intravesical route at the time of admission and after 6, 12, 24, 48, and 72 h via a urinary catheter filled with 25 ml of saline. Duration of ICU and hospital stay, need for ventilator support, initiation of enteral feeding, serum lactate level at time of admission and after 48 h, and 30-day mortality were noted as outcomes. Results: In our study, an overall incidence of IAH was 60%. Patients with cardiovascular surgery and renal and pulmonary dysfunction were 93.3%, 55%, and 60%, respectively, at the time of admission and 65%, 10%, and 10%, respectively, after 72 h of admission in the surgical ICU. Nonsurvivors had statistically significant higher IAP and serum lactate levels than survivors. Patients with longer duration of IAH had longer ICU and hospital stay, longer duration of vasopressors and ventilator support, and delayed enteral feeding. Conclusion: There is a strong relationship “risk accumulation” between duration of IAH associated with increased serum lactate and organ dysfunction. The duration of IAH was an independent predictor of 30-day mortality. Early recognition and prompt intervention for IAH and severe sepsis are essential to improve the patient outcomes.

Bone level measurements around platform switched and platform matched implants: A comparative study Vivek Rana, Varsharani Madhukar Dhakne, Shrikant Jadhawar, Ishan Kadam, Koyena Mishra, Parisha Patil Nigerian Journal of Surgery 2019 25(1):9-13 Background: The overall success of dental implants depends on the crestal bone support around the implants. During the initial years, the bone loss around the implants determines the success rate of treatment. Platform switching (PLS) preserves the crestal bone loss, and this approach must be applied clinically. Aim: The purpose of this study was to determine the changes in vertical and horizontal marginal bone levels in platform-switched and platform-matched dental implants. Materials and Methods: One fifty patients received one fifty dental implants in the present study over a 1-year period. Measurement was performed between the implant shoulder and the most apical and horizontal marginal defect by periapical radiographs to examine the changes of peri-implant alveolar bone before and 12 months after prosthodontic restoration delivery. Results: These marginal bone measurements showed a bone gain of 1.56 ± 2.4 mm in the vertical gap and 1.49 ± 2.24 mm in the horizontal gap of the platform matching, while in the PLS, a bone gain of 2.67 ± 2.0 mm in the vertical gap (P < 0.05) and 2.89 ± 1.67 mm in the horizontal gap was found. Only a statistically significant difference was found comparing bone gains in the vertical gap between the two groups (P < 0.05). Conclusion: PLS helps preserve crestal bone around the implants, and this concept should be followed when clinical situations in implant placement permit.

Comparison of vacuum-assisted closure therapy and conventional dressing on wound healing in patients with diabetic foot ulcer: A randomized controlled trial Sangma M D James, Sathasivam Sureshkumar, Thirthar P Elamurugan, Naik Debasis, Chellappa Vijayakumar, Chinnakali Palanivel Nigerian Journal of Surgery 2019 25(1):14-20 Background: Vacuum-assisted closure (VAC) therapy has been shown to be beneficial in a variety of wounds. However, evidence of its benefit in diabetic foot ulcers (DFUs), especially with respect to Indian population, is sparse. Methodology: This randomized controlled trial included DFUs of Wagner's Grades 1 and 2. Patients were further stratified with respect to DFU size <10 cm and ≥10 cm. Patients with vascular disease, osteomyelitis, and bilateral DFUs were excluded from the study. The enrolled patients were randomized to receive VAC therapy or conventional dressing. The time to wound healing, granulation tissue formation, and complications such as pain, infection, and bleeding were compared between the two groups. Results: A total of sixty patients were randomized, of which 27 in each group were analyzed. The mean time to healing in days was significantly less in VAC group (22.52 vs. 3.85; P < 0.0001). Mean time to achieve 75%–100% granulation tissue cover was significantly less in VAC group (23.33 vs. 32.15; P < 0.0001). Rate of granulation tissue formation was also found to be significantly better in VAC group (2.91 cm2/day vs. 2.16 cm2/day; P = 0.0306). There was no difference between the two groups with respect to wound infection and bleeding which are commonly attributed to VAC therapy. VAC therapy group had significantly lesser pain at week 3 (Visual Analog Scale score 3 vs. 4; P = 0.004). Conclusion: VAC therapy significantly decreases the time to complete wound healing, hastens granulation tissue formation, and reduces the ulcer area compared to conventional dressing. The study did not find any significant increase in the bleeding and infection in the VAC therapy group.

Histopathological changes in gallbladder mucosa associated with cholelithiasis: A prospective study Amandeep Singh, Guramritpal Singh, Kanwardeep Kaur, Gagandeep Goyal, Girish Saini, Deepika Sharma Nigerian Journal of Surgery 2019 25(1):21-25 Background and Aims: Cholelithiasis is known to produce diverse histopathological changes in the gallbladder mucosa. In the present study, we aimed to find the correlation between various gallstone characteristics (i.e., number, size, and morphological type) with the type of mucosal response in gallbladder mucosa (i.e., inflammation, hyperplasia, metaplasia, and carcinoma). Methods: The present study was conducted prospectively on 100 patients undergoing cholecystectomy for symptomatic cholecystitis. Gallstones were assessed for various parameters, i.e., number, size, and morphological type. Gallbladder mucosa was subjected to histopathological examination. Sections were taken from body, fundus, and neck of gallbladder. Results: Of 100 cases, maximum type was of mixed stones (54%) and was multiple in number (46%). However, gallstone type and number are nonsignificant variables to produce precancerous lesions (i.e., hyperplasia and metaplasia). Statistically significant results were obtained while comparing the mucosal response with gallstone size (P = 0.012). Conclusion: As the gallstone size increases, the response in gallbladder mucosa changes from cholecystitis, hyperplasia, and metaplasia to carcinoma. Gallstone type and number are nonsignificant variables to produce precancerous lesions.

Endoscopic management of ureteric stones: Our initial experience Taiwo Opeyemi Alabi, Emmanuel Ajibola Jeje, Moses Adebisi Ogunjimi, Rufus Wale Ojewola Nigerian Journal of Surgery 2019 25(1):26-29 Aims: The aim of this study is to present our initial experience with intracorporeal pneumatic ureterolithotripsy highlighting the pattern of patients' clinical presentation, techniques, and limitation of the procedure. Materials and Methods: This is a retrospective study of cases of ureteric stones managed over a period of 18 months in a private hospital. Data obtained include patients' sociodemography, clinical presentation, stone burden, procedural technique, complication, and need for a secondary procedure. Data were analyzed using the Statistical Package for the Social Sciences version 21. Results: The total number of patients managed was 20 with an age range of 28–75 years and a mean of 48.2 ± 12.4 years. Majority of them, i.e., 11 (55%) were middle aged. Female gender was more predominant, 11 (55%). Flank pain was the most common mode of presentation. Right-sided stone occurred in 9 (45%), left sided in 7 (35%), and bilateral in 4 (20%). Stone location was in the upper ureter in 4 (16.7%), mid-ureter in 7 (29.2%), and lower ureter in 13 (54.2%). The stone size ranged from 6 to 18 mm with a mean of 9.7 ± 2.5 mm. Four patients (20%) required initial bilateral ureteric stenting before definitive procedure to allow for recovery from sepsis and/or nephropathy. All patients had double-J stenting and were discharged 2 days after the procedure. The procedure was successful in 19 (95%) with 100% stone clearance rate and complete resolution of symptom without any complication. One patient (5%) had a very hard upper ureteric stone which retropulsed into the renal pelvis requiring open nephrolithotomy. Conclusion: Endoscopic treatment of ureteric stone with intracorporeal pneumatic lithotripsy is a safe and effective treatment modality. It is, however, limited in the management of hard upper ureteric stone, especially those that are close to the pelviureteric junction due to the risk of retropulsion of the stone into the kidney.

Determination of visual portfolio for surgeons overseas assessment of surgical needs Nigeria study: Consensus generation through an e-Delphi process Felix Makinde Alakaloko, Etienne St-Louis, Adesoji O Ademuyiwa, Dan Poenaru, Christopher Bode Nigerian Journal of Surgery 2019 25(1):30-35 Background: Surgery as a public health priority has received little attention until recently. There is a significant unmeasured and unmet burden of surgical illness in low- and middle-income countries (LMICs). Our aim was to generate a consensus among expert pediatric surgeons practicing in LMICs regarding the spectrum of pediatric surgical conditions that we should look out for in a community-based survey for Surgeons OverSeas Assessment of Surgical Needs Nigeria study. Materials and Methods: The Delphi methodology was utilized to identify sets of variables from among a panel of experts. Each variable was scored on a 5-point Likert scale. The experts were provided with an anonymous summary of the results after the first round. A consensus was achieved after two rounds, defined by an improvement in the standard deviation (SD) of scores for a particular variable over that of the previous round. We invited 76 pediatric surgeons through e-mail across Africa but predominantly from Nigeria. Results: Twenty-one pediatric surgeons gave consent to participate through return of mail. Thirteen (62%) answered the first round statements and 8 (38%) the second round. In general, the strength of agreement to all statements of the questionnaire improved between the first and second rounds. Overall consensus, as expressed by the decrease in the mean SD from 0.84 in the first round to 0.68 in the second round, also improved over time. The strength of consensus improved for 23 (74%) of the statements. The strength of consensus decreased for the remaining 8 (26%) of statements. Out of the 31 consensus-generating statements, 16 (51%) scored high agreement, 13 (42%) scored low agreement, and 2 (15%) scored perfect disagreement. Conclusion: We have successfully identified the pediatric surgical conditions to be included in any community survey of pediatric surgical need in an LMIC setting.

Fast-track protocol versus conventional protocol on patient outcome: A randomized clinical trial Sandhya P Iyer, Zeeshan Kareem Nigerian Journal of Surgery 2019 25(1):36-41 Background: The aim of this study is to compare fast-track methodology with traditional methods of surgical care in achieving better patient outcome, and ensuring a timely discharge from the hospital, and also note the factors that are responsible for a delayed discharge from the hospital. Materials and Methods: One hundred patients undergoing elective surgeries were randomly allocated into fast-track and traditional protocol of perioperative care. Patients who underwent fast-track protocol (FTP) were started on early oral feeding and were encouraged for early discharge, while the others were made to follow the traditional method of recovery. The gastrointestinal functions, postoperative complications and hospital stay time were recorded. The results were tabulated and analyzed. Results: Early feeding was well tolerated by all the patients in the “fast track” group, while the patients in the control group had increased number of “nil by mouth” days, and this result was statistically significant. Ambulation was started earlier in the case group as compared to the controls, and the mean period of starting of ambulation was statistically significant, in the cases as compared to the controls. The patients in the case group had an earlier discharge from the hospital, as compared to the control group. The most common reason for a delay in discharge from the hospital, in either group, was seen to be inadequate pain relief postoperatively. Conclusion: The FTP can significantly shorten the postoperative hospital stay after elective surgery, as compared to the traditional protocol.

Ocular fireworks injuries in Eastern Nigeria: A 3-year review Akunne Ijeoma Apakama, Cosmas C Anajekwu Nigerian Journal of Surgery 2019 25(1):42-44 Aim: The aim of this study is to determine the incidence and types of ocular injuries caused by fireworks in patients seen at Guinness Eye Centre Onitsha and their effects on vision. Methods: This was a 3-year retrospective study evaluating case files of patients with ocular fireworks injuries seen at Guinness Eye Centre Onitsha during the Christmas and New Year festivities (2010–2012). Information was extracted into a pro forma and analyzed using Excel, AutoSum, and calculators. Results: Subconjunctival hemorrhage, corneal lacerations, and hyphema were the most common injuries seen. Patients had multiple ocular pathologies, and the left eye was affected in 62.5% of cases. Bystanders accounted for 75% of those with ocular fireworks injuries. All were males. Half of the affected eyes went blind. Conclusion: Fireworks injuries constituted only 5.1%, 0%, and 10% of ocular injuries in 2010, 2011, and 2012, respectively, with devastating consequence of blindness in 50% of affected eyes.

Risk-adjusted analysis of patients undergoing emergency laparotomy using POSSUM and P-POSSUM score: A prospective study Mohan Lal Echara, Amit Singh, Gunjan Sharma Nigerian Journal of Surgery 2019 25(1):45-51 Background: Comparison of operative morbidity rates after emergency laparotomy between units may be misleading because it does not take into account the physiological variables of patients' conditions. Surgical risk scores have been created, and the most commonly used is the Physiological and Operative Severity Score for the enumeration of Mortality (POSSUM) or one of its modifications, the Portsmouth-POSSUM (P-POSSUM), usually requires intraoperative information. Objective: The objective of this study is to evaluate the POSSUM and P-POSSUM scores in predicting postoperative morbidity and mortality in patients undergoing emergency laparotomy. Methodology: This is a prospective, cross-sectional, and hospital-based study that was conducted at J.L.N. Medical College and Hospital, Ajmer, Rajasthan, India, from April 2017 to December 2017. Adult patients who presented at the causality and underwent emergency laparotomy were included in the study. Observed and predicted mortality and morbidity were calculated using POSSUM and P-POSSUM equations, and statistical significance was calculated using Chi-square test. Results: A total of 100 patients were included in this study, with a mean age of 42.83 ± 18.21 years. The observed (O) mortality was 12 (12.0%), while POSSUM predicted 40 (40%) and P-POSSUM 27 (27%). The O/E ratio for POSSUM was 0.29 and for P-POSSUM was 0.44, and this means that they both overestimate mortality. When the results were tested by Chi-square test, the P value was found to be 0.55 and 0.85 for POSSUM and P-POSSUM, respectively, which showed no significant correlation for observed and expected mortality. The observed morbidity was 69 (69%), while POSSUM expected morbidity was 79 (79%), O/E ratio is 0.87, and this again overestimates the morbidity. POSSUM is overpredicting the rate of morbidity, and test of correlation showed no significance with P = 0.75. Conclusion: POSSUM and P-POSSUM were found to overestimate mortality and morbidity in our patient's population.

Micronuclei in exfoliated cells: A biomarker of genotoxicity in tobacco users Meenakshi Upadhyay, Parul Verma, Robin Sabharwal, Santosh Kumar Subudhi, Suruchi Jatol-Tekade, Vihang Naphade, Basanta Kumar Choudhury, Pravudeva Devidutta Sahoo Nigerian Journal of Surgery 2019 25(1):52-59 Aims: The aim of this study was to analyze the tobacco-related genotoxic effects in individual with habit of smoking and chewing tobacco. Materials and Methods: The present study sample consisted of 120 individuals attending the outpatient department of D. J. College of Dental Sciences and Research, Modinagar, Uttar Pradesh (UP). The sample was divided into four groups as follows: Group I (individuals with habit of smoking tobacco), Group II (individuals with habit of chewing tobacco), Group III (individuals with habit of smoking and chewing tobacco), and Group IV control group (nontobacco-exposed individuals). Patients were asked to rinse their mouth gently with water. The exfoliated cells were obtained by scraping the buccal mucosa of individuals with a wooden spatula. The scraped cells were placed on the precleaned slides. The smears were then stained with RAPID-PAP™ and analyzed under the microscope. Data were analyzed using SPSS statistical software. Results: In the present study, an arbitrary unit was obtained using frequency/day multiplied by the duration of years (risk multiplication factor [RMF], a positive and significant correlation were observed between the RMF and the mean percentage of micronucleated cell count in smokers, chewers, and in individuals with both smoking and chewing habit, respectively. A weak positive and nonsignificant correlation were observed between age and mean percentage of micronucleated cells in smokers and smokers + chewers, respectively, while it was weak negative and nonsignificant in chewers. In control group, correlation between age and percentage of micronucleated cells was weak positive and nonsignificant at 5% level of significance. Conclusion: The micronuclei in exfoliated mucosal cells from buccal mucosa can be used as a biomarker of genotoxicity in predicting the effects of carcinogens.