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Intestinal ischemia commonly occurs after arterial thrombosis or embolism. Thrombosis of the mesenteric vein accounts for less than 10% of cases of intestinal ischemia. Superior mesenteric vein thrombosis (SMVT) in its chronic form is less culpable to produce intestinal ischemia as it forms sufficient collateral drainage. Intestinal obstruction due to mesenteric venous thrombosis is rare, and so far, only 12 cases have been reported. The majority of them had a distinct episode of acute abdominal pain due to ischemia and later developed bowel stricture and intestinal obstruction. Here we report a case of a 44-year-old male who presented with intestinal obstruction as an initial presentation of SMVT. The patient required surgical resection and anastomosis, and he was started on anticoagulation therapy. This case report reiterates the fact that persistent low-grade mesenteric venous ischemia may lead to bowel stricture formation at a later stage. Therefore, etiological workup and early anticoagulant therapy can be useful to improve recurrence., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Vekariya et al.)

Background B-mode ultrasound (BMUS) and color doppler ultrasound (CDUS) could be valuable in evaluating cervical lymphadenopathy compared to palpation. This study aimed at evaluating the efficacy of BMUS and CDUS in differentiating cervical lymph nodes into benign and malignant nature.  Methodology In this cross-sectional analytical study, a total of 166 patients, who were referred for US-guided fine-needle aspiration cytology (FNAC) of cervical nodes, were included. Patients with cystic/ necrotic cervical nodes or without FNAC/biopsy report were excluded. All study patients underwent BMUS and CDUS, followed by the reference investigation of FNAC/biopsy for analysis. In BMUS, short-axis diameter (SAD), short-axis/long-axis diameter ratio (S/L), presence or absence of echogenic hilum and well defined or ill-defined borders were analyzed. In CDUS, the vascular pattern of a cervical node was categorized as hilar, peripheral or mixed. In cases with multiple cervical lymph nodes, the node having the most suspicious features on the greyscale US was chosen. The results were compared with the final FNAC/biopsy reports. Results A total of 166 patients were analyzed in this study. The cut-off point of SAD and S/L ratio for the cervical lymph nodes was 1.28cm and 0.595. The S/L ratio was the best BMUS parameter with a sensitivity of 75%, the specificity of 81%, and an accuracy of 79%. Loss of echogenic hilum was the most sensitive parameter in this study with a sensitivity of 95.4% and an accuracy of 79.5%. The presence of ill-defined margins was significantly higher in the malignant nodes than the benign nodes with a p-value <0.001. The presence of peripheral/mixed vascularity was higher in the malignant nodes than the benign nodes with a p-value <0.001. Conclusions Malignant nodes had significantly higher SAD, higher S/L ratio, loss of echogenic hilum, presence of ill-defined margins and peripheral/mixed vascularity compared to benign nodes. The loss of echogenic hilum was the most accurate and sensitive parameter, while the S/L ratio was found to be the most specific BMUS parameter in the detection of malignant nodes. BMUS and CDUS identify malignant nodes and also helps in guiding FNAC/biopsy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Rohan et al.)

Introduction This study was done to estimate the level of knowledge and attitude about the multimodality treatment (MMT) of breast cancer among the newly diagnosed breast cancer patients and accompanying attendants. Apart from the lack of knowledge, it is equally important to consider their accompanying attendant's knowledge, which changes the patient's attitude. Methodology This was a cross-sectional analytic study, including all newly diagnosed breast cancer patients of age above 18 years. The initial questionnaire one (Q1) was about their overall knowledge of carcinoma breast treatment options. Subsequent questionnaire two (Q2) were asked about MMT for breast cancer at eliciting their attitudes about MMT. After explaining about MMT for breast cancer, they were asked to indicate if they had a positive/negative attitude about MMT by questionnaire three (Q3). Results A total of 84 patients was included in the study. The results indicate a significant association between the relation of the attendant to the patient and their level of knowledge of MMT (p<0.001). Approximately 62% of study patients preferred a passive role in making their treatment decisions of MMT, with nearly 26.2% preferring their treating doctor to make all decisions while 36.7% preferred decisions by accompanying attendants. None of the patients had a negative attitude about MMT. Conclusion The treating surgeon should analyse the patient's knowledge of MMT and their attitude toward involving their accompanying attendants in making MMT decisions. It is necessary to administer adequate knowledge regarding MMT and discuss the various treatment options for breast cancer with the ailing patient, along with the accompanying attendants., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Ruby et al.)

Introduction Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India. Methods The study was conducted as a prospective analytical study. Indications for endoscopy were classified as "ASGE appropriate" and "ASGE inappropriate". The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed. Results ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively. Conclusion According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases., Competing Interests: The authors have declared that no competing interests exist.

Sarcomatoid carcinomas are unusual high-grade tumors, predominantly composed of spindle cells. There appears to be no predilection for any specific site. A few cases of sarcomatoid tumors arising in the penis have been reported. We report a 60-year-old man with a pathological diagnosis of sarcomatoid carcinoma of the penis. This case reiterates the importance of including sarcomatoid carcinoma in the differential diagnosis, especially at uncommon sites., Competing Interests: The authors have declared that no competing interests exist.

Introduction This study was done to analyze the morphometric features of the inguinal canal with different types of inguinal hernias to determine the appropriate size of mesh required to cover potential sites of recurrence. A morphometric assessment in the particular population is essential to recommend the appropriate mesh size in inguinal hernias to cover all the potential sites of recurrence. Materials and methods This was a prospective observational study, including all consecutive patients undergoing open inguinal hernia repair under local/regional/general anesthesia over a period of three years. Surgeries that were done in emergencies for complicated hernias, laparoscopic repair, and recurrent inguinal hernias were excluded. Intra-operative parameters were studied to predict the appropriate mesh size, which included the position of the superficial and deep inguinal ring (SIR and DIR) with the diameter, the distance of SIR and DIR from the anterior superior iliac spine (ASIS), and the distance from the summit of the muscular arch to the inguinal ligament. The differences in morphometric details between the types of hernias and categorical variables were assessed using the chi-square test. Results The study included a total of 170 patients with a mean age of 50.67 + 17.59 years. An indirect hernia was the most common type in patients less than 60 years. The mean distance from ASIS to SIR was 10.2+ 1.9 cm, and in indirect hernia patients, it was found to be significantly increased (p=0.042). The mean distance from ASIS to DIR was 4.14+1.57 cm, where the indirect hernia patients had a significantly less distance (p=0.029). The mean length of the inguinal canal in a direct hernia was 5.66 + 0.5 cm, whereas, in an indirect inguinal hernia, it was 6.46 + 0.8 cm, which was significant (p=0.029). The mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch was 4.03 cm, and there was no significant difference between the indirect and direct hernia patients. Conclusion After considering the morphometric assessments of the length of the inguinal canal, the mean distance from the midpoint of the inguinal ligament to the summit of the muscular arch, the mean distance from ASIS to DIR, the ideal mesh size for the population would be 9 X 15 cm to cover all the potential sites of recurrence., Competing Interests: The authors have declared that no competing interests exist.

Introduction Only a few studies compare the efficacy of the harmonic scalpel and electrocautery in performing mastectomies, and these have mainly compared their intraoperative parameters. But the main concern with electrocautery is the incidence of flap necrosis and seroma formation. Therefore, this study was done to determine if the harmonic scalpel has any advantages over electrocautery in reducing postoperative flap necrosis and seroma formation in patients undergoing a modified radical mastectomy (MRM). Methodology This randomized control trial was carried out over a one-year period in a tertiary care centre in South India. The study patients were randomized into an electrocautery group and a harmonic scalpel group. In the first group, mastectomy including flap and axillary dissection was done using electrocautery. In the second group, a harmonic scalpel was used for dissection. This study compared the efficacy of the harmonic scalpel with electrocautery in terms of postoperative seroma formation and flap necrosis. Various other perioperative parameters like the number of drain days, total drainage volume (in mL), operating time (in minutes), intraoperative blood loss (in mL), and postoperative wound site pain were also studied. During each postoperative visit, the presence of seroma was assessed clinically, and the number of aspirations required for the seroma was also analysed. Results A total of 240 patients were randomized into two groups of 120 patients each. Baseline parameters were comparable across both groups. There were significant differences in the duration of surgery [151.38 mins vs. 112.33 mins; p = 0.001] and intraoperative blood loss [276.25 mL vs.200.13 mL; p = 0.001]. On Postoperative Day (POD) 1, the difference in the mean pain scores [6 vs. 4; p = 0.001] was statistically significant. In addition, the differences in the mean total drainage volume [937.5 mL vs. 470 mL; p = 0.002] and the incidence of seroma during the first follow-up [34.2% vs. 21.7 %; p = 0.030] were statistically significant. The difference in the incidence of flap necrosis on POD 4 [7.5% vs. 4.2%; p = 0.2706] was not statistically significant. None of the patients developed flap necrosis after four days. Conclusion The harmonic scalpel reduces the total drainage volume of seromas, the number of drain days, intraoperative blood loss, duration of surgery, postoperative pain (especially on POD 1 and 5), and incidence of flap necrosis., Competing Interests: The authors have declared that no competing interests exist.

Background To appraise the spectrum of small bowel complications following pelvic irradiation and to assess the clinical outcome and factors associated with adverse clinical outcome in these patients. Methods This descriptive clinical study was done for three years in a tertiary care center in South India. Patients managed for post-irradiation small bowel complications, irrespective of the indication for radiotherapy, were studied. Patients with associated non-gastrointestinal radiation toxicity, radiation proctitis, and radiation colitis were excluded. The parameters assessed were the range of small bowel complications, a comparison of operative and non-operative management, morbidity and mortality, the severity of complications in relation to the dose of radiotherapy, and various factors influencing the clinical outcome. Results A total of 50 patients were studied. Stricture and perforation peritonitis were the most common presentation (n=25; 50%). A majority of the patients (n=37; 74%) presented after six months following radiotherapy. Post-operative mortality was 16% (n=5). Age, body mass index (BMI), previous surgery, operative intervention, primary or adjuvant radiotherapy, concurrent chemoradiotherapy (CCRT), and various radiation protocols were not associated with adverse clinical outcomes with respect to overall mortality, the requirement of surgery, and operative mortality. However patients who were operated and those who received CCRT had a significantly longer mean intensive care unit (ICU) stay (3.51 days vs. 0.68 days; p = 0.0001) as well as overall mean hospital stay (14.87 days vs. 5.58 days; p = 0.001) and an insignificant mortality rate (16% vs. 15%; p = 0.4085). Conclusion The present study observed that the patients who were operated and those who received CCRT had significantly longer hospitalization and relatively higher mortality. Considering the fact that many of the patients who develop post-irradiation complications may not report back to the same center, the incidence of small bowel complications could be higher in reality, which ascertains the necessity for more precision in the radiation technique and operative care in developing countries., Competing Interests: The authors have declared that no competing interests exist.

Introduction Stoma closure is one of the most frequently performed surgeries. The common complications are surgical site infection (SSI) and poor scar cosmesis. Purse-string sutures are expected to have less incidence of SSI due to the free drainage of secretions from the wound and possibly the early detection of a wound infection. Compared to the conventional linear closure, the purse-string closure technique is expected to have less wound infection, improved scar cosmesis, and good patient satisfaction because of a smaller size scar. Hence, a well-structured study is required to substantiate the advantage of this technique. Methodology This randomized control trial was carried out for two years in a tertiary care centre in Southern India. Patients with various stoma reversals, including colostomy, as well as ileostomy reversal, were included in the study. Patients were divided into Group I - conventional linear skin suturing (n = 40) and Group II - purse-string closure (n = 40). After the closure of rectus muscle, the skin is closed using the purse-string method (subcuticular) in the experimental group. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), the presence of co-morbidities, and indication for surgery. Stomal procedures were done (26.3%) for malignant cases. The difference in mean hospital days for both groups were statistically insignificant (11.95 vs. 9.9; p = 0.927). The incidence of SSI between the groups were statistically significant (17 vs. 3; p = 0.003). The mean Patient and Observer Scar Assessment Scoring (POSAS) scores between the groups (65.30 vs. 83.40; p = 0.012) were statistically significant. This proved significant improvement in scar cosmesis in purse-string skin closure. At one month postoperative, the purse-string group had better patient satisfaction (3.08 vs. 4.48; p = 0.001), which was evidenced by a mean Likert 3 scale score. The mean visual analogue scale (VAS) score did not show any significant difference in pain between the groups. Conclusion Purse-string skin closure for stoma reversal had significantly less incidence of SSI. The duration of antibiotic therapy was also less in purse-string skin closure patients as compared to linear skin closure patients. Purse-string skin closures significantly improved the scar outcome and patient satisfaction., Competing Interests: The authors have declared that no competing interests exist.

Introduction Laparoscopic cholecystectomy (LC) is the most commonly done, minimally invasive surgical procedure. Routinely used electrocautery produces more smoke, which masks the operating field, thereby prolongs the surgery and posing an increased risk of gallbladder (GB) perforation. The titanium clips used for clipping the cystic artery and cystic duct have a risk of slippage, which may lead to bleeding, and an increased risk for bile leakage. In addition, it may act as a nidus for stone formation. Advanced energy sources, such as the harmonic scalpel, though expensive, may provide the advantage of shorter operating time by reducing smoke, bloodless dissection in the GB bed, lower risk of bleeding from the cystic artery due to secure vessel sealing, and avoiding the use of a larger number of titanium clips. However, evidence to substantiate this advantage is limited. Aim To compare the operating time and perioperative complications between conventional laparoscopic cholecystectomy (CLC) and harmonic scalpel assisted laparoscopic cholecystectomy (HLC). Methodology All consecutive patients who underwent elective LC were included. Patients with acute infection, impaired liver function tests, concomitant common bile duct calculi, chronic liver disease/cirrhosis, suspected GB carcinoma, and pregnant women were excluded from the study. Patients were allocated into two groups. In the CLC group, both the cystic duct and the cystic artery were divided after conventional titanium clip application and electrocautery was used for thermal energy. In the HLC group, the cystic duct was clipped with a titanium clip and the rest of the procedure was carried out using Harmonic Ace (Ethicon, New Jersey, United States) and Harmonic Hook (Ethicon, New Jersey, United States). Outcome parameters analyzed were operating time in minutes, post-operative pain using visual analogue scale (VAS) scoring, frequency and route of analgesic requirement after 24 hours, and intraoperative complications, including bleeding, bile duct injury, GB perforation, and surgical site infection (SSI) in the postoperative period, per the Centers for Disease Control (CDC) criteria. Results Both the groups were comparable with respect to age, gender, body mass index (BMI), and the presence of comorbidity and an indication of cholecystectomy. The duration of surgery did not significantly differ between the groups (67.3 vs. 64.3 mins; p = 0.30). Other parameters, such as analgesic required on postoperative Day 1 (3.2 vs. 3; p = 0.67), VAS scores on Day 0 (4.55 vs. 4.65; p = 0.59), VAS scores on Day 1 (2.3 vs. 2.2; p = 0.84), superficial SSI (15% vs. 10%; p = 0.63), intraoperative GB perforation (30% vs. 20%; p = 0.71), and intraperitoneal drain (30% vs. 20%; p = 0.71) did not significantly differ between the groups. Conclusion HLC has no significant advantage over CLC with respect to operating time, postoperative pain, and perioperative complications., Competing Interests: The authors have declared that no competing interests exist.

Background The color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement. Objective To compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb. Methods This was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg's test, multiple tourniquet tests and, the Fegan's tests were performed and incompetent perforators were marked on a template as 'C' to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as 'D'. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler 'D' marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as 'D' positive or 'C' and 'D' positive and were recorded in the specified proforma. Results It was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients. Conclusion A combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients., Competing Interests: The authors have declared that no competing interests exist.