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Summary Background Elective splenectomy has various indications and can be performed open or minimally invasively. Laparoscopic splenectomy (LS) is popular but has limitations. Some studies suggest potential superiority of robotic splenectomy (RS) over LS. As such, we conducted a systematic review to determine whether RS has greater positive perioperative outcomes in comparison to LS in the adult population. Methods We searched for studies that reported perioperative outcomes and compared RS to LS in the adult population. Outcome measures were operative time, conversion to open surgery, postoperative complications, mortality, length of stay, blood loss and cost analysis. A simple, unpaired two-tailed student’s t‑test was used to compare outcomes between the RS and LS patient groups. Results After full-text analysis of 47 papers, three studies met the inclusion criteria. The studies involved 72 patients (28 in the RS group, 44 in the LS group). RS demonstrated no significantly reduced blood loss in comparison to LS (p = 0.13). RS had no cases converting to open surgery and no postoperative complications in comparison to LS. No significant difference was found between RS and LS with regards to LOS (p = 0.89) and cost benefit (p = 0.74). RS had a higher operative time in comparison to LS which was not statistically significant (p = 0.45). Conclusion The RS approach may be associated with lower blood loss and a lower risk of conversions. There was no statistical difference between RS and LS with regards to length of stay (LOS) and cost. RS takes longer to perform in comparison to LS.

ObjectiveLarge data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma.DesignSecondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease.Setting39 public and private hospitals across India during the study period from 22 April to 14 July 2020.ParticipantsOf the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed.Primary outcome measureFactors associated with all-cause mortality at 28 days after enrolment.ResultsThe mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3–7) and non-survivors (4 days; IQR 3–6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p2/FiO2 ratio 10 (9.97, 3.65–27.13, p1.0 mg/L (2.50, 1.14–5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44–4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60–5.45, p=0.001) were significantly associated with death.ConclusionIn this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death.Trial registration numberCTRI/2020/04/024775.

ObjectivesConvalescent plasma (CP) as a passive source of neutralizing antibodies and immunomodulators is a century-old therapeutic option used for the management of viral diseases. We investigated its effectiveness for the treatment of COVID-19.DesignOpen-label, parallel-arm, phase II, multicentre, randomized controlled trial.SettingThirty-nine public and private hospitals across India.ParticipantsHospitalized, moderately ill confirmed COVID-19 patients (PaO2/FiO2: 200-300 or respiratory rate > 24/min and SpO2 ≤ 93% on room air).InterventionParticipants were randomized to either control (best standard of care (BSC)) or intervention (CP + BSC) arm. Two doses of 200 mL CP was transfused 24 hours apart in the intervention arm.Main Outcome MeasureComposite of progression to severe disease (PaO2/FiO2< 100) or all-cause mortality at 28 days post-enrolment.ResultsBetween 22ndApril to 14thJuly 2020, 464 participants were enrolled; 235 and 229 in intervention and control arm, respectively. Composite primary outcome was achieved in 44 (18.7%) participants in the intervention arm and 41 (17.9%) in the control arm [aOR: 1.09; 95% CI: 0.67, 1.77]. Mortality was documented in 34 (13.6%) and 31 (14.6%) participants in intervention and control arm, respectively [aOR) 1.06 95% CI: −0.61 to 1.83].InterpretationCP was not associated with reduction in mortality or progression to severe COVID-19. This trial has high generalizability and approximates real-life setting of CP therapy in settings with limited laboratory capacity. A priori measurement of neutralizing antibody titres in donors and participants may further clarify the role of CP in management of COVID-19.Trial registrationThe trial was registered with Clinical Trial Registry of India (CTRI); CTRI/2020/04/024775.

This study was conducted to observe the effect of vitamin B12 supplementation on glycemic control in poorly controlled hyperhomocysteinemic type 2 diabetic patients by measuring HbA1c levels at baseline and 4 weeks. Patient having serum homocysteine more than 15 µmol/L or vitamin B12 less than 223 pg/mL were enrolled in this study. One group received methylcobalamin 500 µg daily with their usual anti-diabetic therapy and the other group received only suitable anti-diabetic drug therapy. Methylcobalamin 500 µg was given daily for period of 4 weeks. Glycemic control was measured by levels of HbA1c, blood sugar at baseline and at 4 weeks. Serum homocysteine levels was reduced from 21.5 ± 2.6 to 15.4 ± 6.4 (p=0.04) with vitamin B12 supplementation at 4 weeks. At 4 weeks, HbA1c decreased from 9.9 ± 0.9 to 8.7 ± 0.5 (p12 deficient patients after vitamin B12 supplementation. There is role of vitamin B12 in glycemic control in poorly controlled type 2 diabetic patients.

A 62-year-old man was referred to the Hepato-Pancreato-Biliary (HPB) surgeons with left upper quadrant discomfort. The initial investigations and CT scans revealed a tumour in the pancreatic tail with liver metastases, confirmed on MRI. It was initially thought to be an adenocarcinoma; however, further investigations found that it was a grade 1 neuroendocrine tumour with Ki 67 at 1% and it was agreed that he would undergo a total robotic surgery involving resection of the locally advanced tumour of the tail of pancreas, with the involvement of the stomach, and splenic flexure of the colon with liver metastases. The resulting procedure was a total robotic distal pancreatectomy, splenectomy, sleeve resection of stomach, cholecystectomy, atypical resection of two liver lesions and microwave ablation of multiple liver lesions. Four days post-operatively, he was discharged from hospital and commenced adjuvant chemotherapy. He currently enjoys a good quality of life.

Primary pigmented adrenocortical disease is a rare disorder usually affecting both adrenals. It causes Cushing’s syndrome that is adrenocorticotropic hormone independent. It is treated by bilateral adrenalectomy. We present an unusual case where this condition was unilateral and was diagnosed as adenoma on imaging. The patient was subsequently treated by unilateral adrenalectomy, and had no signs of recurrence in 5-year postoperative follow-up. This case emphasizes the importance of histopathology and immunohistochemistry in diagnosis of this condition.

Takayasu's arteritis also known as aortoarteritis is an inflammatory disease of the large elastic arteries occur - ring in the young resulting in occlusive or ectatic changes mainly in the aorta and its immediate branches as well as the pulmonary artery and its branches. Vessel inflammation leads to wall thickening, fibrosis, stenosis, and thrombus formation. Symptoms reflect end organ ischemia. More acute inflammation can destroy the arterial media and lead to aneu - rysm formation. The exact cause is not known, though it is suggested to be due to an autoimmune response to an unknown antigen. We report a case of 47 years old female presenting with severe pulmonary hypertension, congestive cardiac failure that turned out to be a case of Takayasu's Arteritis.

Purple urine bag syndrome (PUBS) is an infrequent condition, seen mostly in elderly female patients, char- acterized by an intense purple discoloration of contents of urine bag following long-term indwelling urinary catheterization. The purple discoloration is most often due to the presence of indigo and indirubin pigments which are metabolites of tryptophan. Urinary bacteria with indoxyl sulphatase activity metabolize indoxyl sulphate to produce indigo and indirubin, particularly in alkaline urine. We report an elderly woman with a urinary tract infection and constipation who presented with PUBS. The purple urine disappeared after antibiotic therapy and change of the urine bag. To the best of our knowledge, this is the first case of PUBS reported from this region.