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Morbid obesity in infancy or early childhood is a challenging disease to manage. Here, we present the case report of the successful management of a 2-year-old girl child with morbidly obesity who was bedridden and had sleep apnoea and underwent laparoscopic sleeve gastrectomy. Bariatric surgery in this age group comes with a lot of decision-making challenges and technical and ethical considerations, and literature is scant on paediatric bariatric surgery. We describe the case and associated challenges in detail in this report.

Background: Virtual reality (VR) refers to a computer-generated simulation or environment that can be experienced and interacted with by a person through special electronic equipment, such as a headset with a screen and motion-tracking sensors. VR has been used as a distraction technique to alleviate pain and discomfort during medical procedures or as an alternative to traditional pain medication. This article explores VR’s effectiveness in reducing pain in pediatric patients undergoing painful clinical procedures. Methodology: This systematic review and meta-analysis was performed as per the preferred reporting item for systematic review and meta-analysis guidelines. A systematic literature search was conducted for all articles published till December 2022 in four different databases: PubMed, Scopus, Embase, and LILACS, which yielded 6886 studies. Studies showing the effect of VR on pediatric patients undergoing clinical procedures were included in the study. Risk of bias (ROB) 2.0 was used to assess the ROB. Outcome data were pooled using a random-effects model and reported as standardized mean difference (SMD) with a 95% confidence interval (CI). The meta-analysis was performed on RevMan5.4. Subgroup analysis was done for the different clinical procedures. Results: A total of 2477 participants from 34 studies were included in the meta-analysis. Children in whom VR was used had a significantly lower pain score as compared to the control group with an SMD of 0.87 (CI 95% −1.20, −0.53; (P < 0.00001). Subgroup analysis based on the type of intervention did not reveal any significant difference (P = 0.19). Heterogeneity for overall pain using a random effect model with I2 was significant (P < 0.00001). Conclusion: This systematic review suggests that the use of VR distraction in children undergoing painful procedures is associated with significantly lower pain scores. Hence, VR can be a promising intervention for reducing pain experienced by pediatric patients during medical procedures.

Background: The occupational hazards of glutaraldehyde are well known; the possibility of harm to the patients has been highlighted in the form of isolated reports only. OBJECTIVE: To synthesize evidence for contact mucosal injury or injury due to intraperitoneal instillation of glutaraldehyde following its use during laparoendoscopy. MATERIALS AND METHODS: The current review is Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant. PubMed, PubMed Central, and Google Scholar were interrogated for animal and human studies upon the harmful effects of glutaraldehyde during laparoscopy and proctosigmoido-colonoscopy. Results: Thirty-five studies substratified into animal experiments (n = 2), glutaraldehyde-induced colitis (G-iC) postendoscopy (n = 30), and laparoscopy (n = 3) were included. Rats suffered mucosal injury following colonic injection of glutaraldehyde which was time- and concentration-dependent quantum and developed bloody diarrhoea. Omental and renal injury was observed due to glutaraldehyde instillation during simulation of intra-peritoneal insufflation in rats; the serum leucocytes, CRP and creatinine were also elevated. G-iC following colonoscopy was related to contact mucosal injury due to failure (human or machinery) to rinse the chemical off the instrument surface or as a case of mistaken identity (glutaraldehyde was mistaken for saline or another reagent). The incubation period was

Diffuse esophageal leiomyomatosis (DEL) is a rare condition characterized by the growth of multiple benign smooth muscle tumors (leiomyomas) in the esophagus. These tumors can cause obstruction and functional impairment of the esophagus, leading to symptoms such as difficulty swallowing, chest pain, and weight loss. The disease can present with leiomyomas or glomerular nephropathy in other body parts, hearing defects, astigmatism, or myopia (Alport’s syndrome). However, isolated cases are also reported in the literature. Surgical management of DEL presents several challenges due to the location and extent of the tumors. Herein, we describe a girl afflicted with DEL and required multiple surgeries for management, highlighting the unique challenges faced by the surgical team in restoring esophageal function and improving the patient’s quality of life.

Purpose: The purpose of this study was to synthesize evidence and propose a technique for estimation of stretched penile length (SPL) applicable to children. MATERIALS AND METHODS: This review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Embase, and Scopus databases were queried on penile length (PL) measurement techniques in humans published from 1990 onward. The devices and the techniques used for PL measurement, state of the penis, the habitus of the participants, proximal and distal landmarks for measurement, handling the foreskin and pubic pad of fat, optimal stretching of the penis, and other factors (including the environment) which should be accounted for in the technique were identified from the study cohort (90895 participants across 145 included studies). Results: PL has been represented through flaccid (33.79%), stretched (81.3%), and erect (12.41%) PLs as well as the greatest corporeal length (1.4%). Following devices have been used to measure the PL in the study cohort: rulers [54.68%], calipers [9.7%], measuring tapes [14.5%], coloured measuring strips [2.06%], spatulas/tongue depressors [11.03%], FitKit, syringe [1.4%], cotton swab (and ruler), titan cylinders, slide gauge and ultrasonography [1.37%]. The factors relevant to SPL measurement have been incorporated into the proposed SPL INdicator Technique (SPLINT) which is essentially a holistic extension of the “Conventional PL Measurement” technique. Conclusions: There is a wide range of heterogeneity in the technique for estimation of PL across the study cohort; the underlying factors have been identified along with the respective variables, and the SPLINT for SPL has been described.

AIMS: Antenatal androgen exposure has been suggested as a contributing factor in hypospadias etiology. This study aimed to investigate the correlation between anogenital distance (AGD), index finger-to-ring finger ratio (2D:4D ratio), and hypospadias severity in prepubertal boys, with the goal of exploring these parameters as potential markers of genital anomalies in utero. MATERIALS AND METHODS: A cross-sectional observational study was conducted on boys under 8 years old presenting to our outpatient department (April 2020–December 2022). Those with hypospadias were included in the study group, whereas those without hypospadias formed the comparator group. Confounding factors (age, weight, and height) were accounted for using multivariate linear regression analysis. AGD, 2D:4D ratio, and hypospadias severity were measured during clinical visits, with still images taken for precise measurements. Statistical analysis was performed using the Mann–Whitney U and student’s t-tests (software: STATA Version 14). Results: Data were collected for 100 cases of hypospadias (26 proximal and 74 distal) and 50 controls. There was no significant difference in mean age between groups (P = 0.90). AGD was slightly lower in cases (3.44 ± 1.13 cm) compared to controls (3.70 ± 1.43) (P = 0.88). 2D:4D ratios were marginally higher in cases compared to controls (P = 0.12 for both hands). Conclusions: Although our study did not find significant associations between AGD and 2D:4D ratios with hypospadias severity, it offers insights into the role of prenatal androgen in genital development. The lack of significance underscores the need for region-specific research, suggesting AGD and 2D:4D ratio may not universally apply as hypospadias markers.

OBJECTIVE: To identify the genetic markers of spina bifida through a systematic survey of the exome in an Indian cohort. MATERIALS AND METHODS: Three consecutive patients (P1: 1 year, male; P2: 2.8 years, male; and P3: 10 years, female) with spina bifida (lumbosacral meningomyelocele) underwent whole-exome sequencing (libraries: SureSelect Human All Exon V8; sequencing: 2 * 150 bp paired-end run, 100×) with NovaSeq 6000. Data analysis was performed using SMART-One™ (secondary analysis) and SMARTer™ (tertiary analysis) for automated quality check, alignment (GRCh38/hg38), variant calling, annotation (ClinVar, OMIM, avsnp150, 1000 Genomes v5b, ExAC v0.3, gnomAD v4.0, and esp6500vi2all v0.0.25), v0.0.25), interpretation. The pathogenic and likely pathogenic (ClinVar/ InterVar), non-synonymous, exonic markers (read depth ≥ 5) were matched with the Familial Neural Tube Defects (Version 1.10) panel (FNTD panel). Results: Pathogenic variants overlapping with the FNTD panel were MTRR, CC2D2A, and ZIC2 in P1 and P2, TGIF1 in P1 only, and none in P3. Novel pathogenic/likely pathogenic variants common to all three patients were PRUNE1, PKD1, PDZD2, and DAB2 in the homozygous state as well as in the heterozygous state, PLK1 and NLGN2. The possible role of such markers in etiopathogenesis was explored through a literatur search. Conclusions: The genetic landscape of the spina bifida in an Indian cohort is diverse compared to that reported from other parts of the world. A comprehensive catalog of single-nucleotide variants in the etiopathogenesis of the spina bifida on a background of the Familial Neural Tube Defects Panel has been generated.

During face mask ventilation, invariably, some air enters the esophagus rather than the airways; this results in gastric insufflation while the esophagus is intact or loss of tidal volume in patients with a cervical esophagostomy (Cx-esophagostomy). OBJECTIVE: The objective of the study was to report the indigenous use of an electrocardiography (ECG) electrode in successfully occluding the Cx-esophagostomy to prevent inadvertent loss of tidal volume. MATERIALS AND METHODS: Twenty-nine observations were recorded on 27 patients (mean age: 10.9 months; male:female = 2.6:1). The oral cavity, pharynx, and Cx-esophagostomy were cleared of saliva. Peristomal area was cleaned with dry gauze and dried with alcohol. Latex-free, 50 mm, ECG electrode was pasted symmetrically over the Cx-esophagostomy. The efficacy of the electrode was assessed using a five-point algorithm: (i) collapse of reservoir bag, (ii) chest expansion, (iii) ballooning of electrode, (iv) cotton-wisp test, and (v) change in compliance with manual compression of the electrode. Subgroup analysis was conducted for laterality and health of Cx-esophagostomy. Results: Study cohort: Cx-esophagostomy was located on the left in 58.26% (n = 17/29) patients. The health of Cx-esophagostomies was graded from I to IV (n = 9, 16, 3, and 1, respectively). The collapse of the reservoir bag and chest rise indicated successful ventilation. Ballooning of the electrode with each breath was observed in 79% (23/29) patients. Partial separation of the electrode from the skin (exaggerated with each breath) was observed in 10.3% (3/29) patients (Group I: n = 1, Group III: n = 1, and Group IV: n = 1). This was related to poor local preparation or pooling of saliva (n = 1; Group I: resolved with procedural re-application of a fresh electrode) and underlying skin condition (n = 2; Groups III and IV: resolved only temporarily with re-application). The cotton-wisp test was positive in two additional patients (1 each in Groups II and III) and was related to the pooling of saliva. No change in compliance was observed with manual compression of the electrode. No difference in success was observed between left and right Cx-esophagostomies. Overall success with this technique was 82.8% with a potential for 100% in those with peristomal health graded I–III. Conclusions: The ECG electrode is a technically simple, cost-effective, and widely available device, instrumental in addressing the problem of air leak through Cx-esophagostomy during face mask ventilation before intubation.

Abstract Purpose To assess the potential benefit of impregnating Merocel (a non‐absorbable nasal dressing) with a topical steroid solution, for use as a direct and slow local delivery system of steroids after sinus surgery to improve postoperative wound healing. Methods In this randomized controlled trial, 40 patients with bilateral chronic rhinosinusitis with nasal polyposis were subjected to functional endoscopic sinus surgery. Following the completion of the surgery, Merocel packs were inserted in the bilateral nasal cavities and infiltrated with 4 mL triamcinolone (40 mg/mL) in one nasal cavity (treatment group) and 4 mL normal saline in the other (control group). Nasal packs were removed on the third postoperative day and postoperative healing assessment was done on postoperative Weeks 1, 2, 4, and 12. The findings were noted as per Lund Kennedy (LKES) and perioperative sinus endoscopy (POSE) scores and compared on both sides. Results Significant (P

Congenital diaphragmatic malformations include congenital diaphragmatic hernia (CDH) and eventration of the diaphragm. The clinical presentation is variable, and the prognosis depends on multiple factors. The coexistence of CDH and diaphragmatic eventration in the same patient is extremely unusual and has not been reported previously in the literature. We report this rare association in a 3-month-old male infant who was managed successfully by minimally invasive approach.

The aim of this study was to propose Management, Outcome, Risk, and Expectation (MORE) as a risk based stratification to aid in antenatal parental counseling and decision making through a systematic review of published literature. A Preferred Reporting Items for Systematic Reviews and Meta Analyses compliant systematic review was conducted to include articles that covered antenatal counseling of pediatric surgical conditions. The following information was solicited for each anomaly: primary organ syste*-m of involvement, single or multi system anomaly, natural history of the disease, standard management of the anomaly, need for antenatal intervention, and whether the anomaly requires any alteration in the obstetric management. Twenty two studies were identified fulfilling the inclusion criteria, between 1993 and 2023. Only two studies were found to have GRADE A recommendation and Level I evidence. Most of the studies were review articles/ survey, and 6 studies were found to be retrospective observational studies. Based on the analysis of the solicited information, the anomalies were stratified into a group subsequently maturing them into a simplified MORE classification scheme which stressed the importance of Management (10, 45.45%), Outcome (9, 40.90%), Risk (9, 40.90%), and Expectation (10, 45.45%) categories during antenatal counseling. MORE classification of fetal structural anomalies is a simple but comprehensive framework to assist the physicians and other medical personnel antenatal parental counseling and decision making.

Abstract Background Low false negative rates can be achieved with sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients with clinical N1 (cN1) disease. We examined changes in axillary management and oncologic outcomes in BC patients with cN1 disease receiving NAC. Methods BC patients with biopsy proven cN1 disease treated with NAC were selected from our institutional cancer registry (2014–2017). Patients were grouped by axillary management, axillary lymph node dissection (ALND), SLNB followed by ALND, or SLNB alone. Univariable and multivariable survival analysis for recurrence-free survival (RFS) and overall survival (OS) were performed. Results 81 patients met inclusion criteria: 31 (38%) underwent ALND, 25 (31%) SLNB + ALND, and 25 (31%) SLNB alone. A SLN was identified in 45/50 (90%) patients who had SLNB. ALND was performed in 25/50 (50%) patients who had SLNB: 18 for a + SLNB, 5 failed SLNB, and 2 insufficient SLNs. 25 patients had SLNB alone, 17 were SLN- and 8 SLN+. In the SLNB alone group, 23/25 (92%) patients received adjuvant radiation (RT). 20 (25%) patients developed BC recurrence: 14 distant (70%), 3 local (15%), 2 regional + distant (10%), and 1 contralateral (5%). In the SLNB alone group, there was 1 axillary recurrence in a patient with a negative SLNB who did not receive RT. Univariable survival analysis showed significant differences in RFS and OS between axillary management groups, ALND/SLNB + ALND vs. SLNB alone (RFS: p = 0.006, OS: p = 0.021). On multivariable survival analysis, worse RFS and OS were observed in patients with TNBC (RFS: HR 3.77, 95% CI 1.70–11.90, p = 0.023; OS: HR 8.10, 95% CI 1.84–35.60, p = 0.006). Conclusions SLNB alone and RT after NAC in BC patients with cN1 disease who have negative SLNs at surgery provides long-term regional disease control. This analysis provides support for the practice of axillary downstaging with NAC and SLNB alone.

Introduction: Surgeries involving bowel resection and anastomosis are quite common. Fluid overload, leading to tissue edema and impaired tissue perfusion, may contribute to anastomotic leak, which is one of the most dreaded complication. Methods: In our current study, CT scan, done on postoperative day-4, was used to assess visceral edema, and its effect on development of complications post bowel anastomosis and increase in value of cross section of body trunk area ≥20% was taken as an independent risk factor of severe complication. Results: Twenty three patients were enrolled in the study, 7 of them developed complications. The most common complication observed was wound infection (Clavein Dindo grade II). Only 2 patients (28.57%) had an increase in CT area >20%. Among patients who developed complications, 33.3% had an increase in CT area and 28.6% did not. Various other factors – preoperative albumin level, timing of surgery, duration of surgery – also lead to development of complications. Statistically, no significant association could be derived between the increase in CT area and development of complications. Conclusion: As per the findings of the current study, higher fluid balance was not reflected by an increase in body surface area on CT Scan. Hence, use of CT scan as a tool to assess visceral edema needs further evaluation.

Aim: The genetic polymorphism of CYP2C19 influences clopidogrel metabolism and resistance. Aim was to assess the association between CYP2C19 loss of function variation, clopidogrel resistance based on platelet reactivity units and clinical outcomes. Methods: A total of 668 patients of Acute Coronary Sundrome (ACS) who underwent Percutaneous Coronary Intervention (PCI) were subjected to genetic screening and 143 patients undrewent platelet function test to study the association between drug metabolization and its effects based on platelet reactivity unit values. Results: Clopidogrel resistance with CYP2C 19 loss of function variation was noted in 54.64% of patients. Clinical outcomes, such as target vessel revascularization, target lesion revascularization, in-stent restenosis, and stent thrombosis, were also studied. Conclusion: CYP2C19 loss of function variation is strongly associated with clopidogrel resistance and adverse clinical outcomes.

Abstract Background Chest wall chondrosarcomas, although common, pose unique challenges due to their aggressive nature, rarity of abdominal wall involvement, and propensity for recurrence. We highlight the critical role of meticulous surgical planning, multidisciplinary collaboration, and innovative reconstruction techniques in achieving optimal outcomes for patients with composite giant chest and abdominal wall chondrosarcoma. Case Presentation A 38-year-old female patient presented with progressive left chest and abdominal wall swelling for two years; on evaluation had a large lobulated lytic lesion arising from the left ninth rib, scalloping eighth and tenth ribs measuring 13.34 × 8.92 × 10.71 cm (anteroposterior/transverse/craniocaudal diameter) diagnosed with chondrosarcoma grade 2. A three-dimensional (3D) composite mesh was designed based on computed tomography using virtual surgical planning and computer-assisted design and manufacturing technology. She underwent wide local excision and reconstruction of the chest and abdominal wall with 3D-composite mesh under general anesthesia. The postoperative condition was uneventful, with no recurrence at 12 months follow-up. Conclusion A 3D-composite mesh facilitates patient-specific, durable, and cost-effective chest and abdominal wall reconstruction.

The therapy for complicated appendicitis presents a clinical challenge, as it is characterised by inflammation with a contained or localised perforation that results in the formation of an abscess. This case report describes the presentation, diagnosis, and effective non operative management of a 14-year-old girl with acute complex appendicitis. Investigations and clinical examination confirmed the presence of an appendicular abscess in the patient, who exhibited characteristic symptoms. The treatment course adhered to the Ochsner-Sherren protocol, which included fluid resuscitation, broad-spectrum intravenous antibiotics, and a Nil Per Oral (NPO) status. An ultrasound-guided aspiration of periappendicular pus indicated that an empirical upgrade to Piperacillin + Tazobactam was necessary. The patient showed improvement in all symptoms, including fever and abscess resolution, after the switch in antibiotics. This case adds to the increasing body of research that supports non operative therapy for complex appendicitis, particularly when assisted by diagnostic tools such as ultrasonography. The decision to forego emergency surgery aligns with current evidence advocating for conservative strategies, which demonstrate higher success rates and lower risks of postoperative complications. Although appendectomy remains the preferred treatment for perforated appendicitis without an abscess, this case highlights the viability and effectiveness of non operative interventions in certain situations. This report emphasises the significance of customised treatment strategies based on patient presentation and clinical response, contributing to the ongoing discussion regarding the best therapy for complex appendicitis.

Intra-peritoneal migration of abdominal drain is a rare complication. Cutting of abdominal drain and putting a colostomy bag over it is done to reduce the pain and infection and to increase the mobility of a patient, but it is also a risk factor for drain intra-peritoneal migration. This case report depicts a case of intra-peritoneal migration of abdominal drain after laparoscopic cholecystectomy and its retrieval.

Stomal prolapse is one of the most common complications of enterostoma. Stoma if persistent and significant often requires revision of stoma. The techniques described often require laparotomy with resection or internal fixation of the bowel. Such procedures may make further laparotomy more difficult. We herein describe the use of a relatively simple procedure for the correction of stomal prolapse.

BackgroundHispanic patients have a higher incidence of gastric cancer when compared to non-Hispanics. Outlining clinicodemographic characteristics and assessing the impact of ethnicity on stage-specific survival may identify opportunities to improve gastric cancer care for this population.MethodsPatients with gastric cancer in the US Safety Net Collaborative (2012-2014) were retrospectively reviewed. Demographics, clinicopathologic characteristics, operative details, and outcomes were compared between Hispanic and non-Hispanic patients. Early onset gastric cancer was defined as age

Background:. Immediate lymphatic reconstruction (ILR) has traditionally required a fluorescent-capable microscope to identify lymphatic channels used to create a lymphaticovenous bypass (LVB). Herein, a new alternative method is described, identifying lymphatic channels using a commercially available handheld fluorescence imaging device. Methods:. This was a single-center study of consecutive patients who underwent ILR over a 1-year period at a tertiary medical center. Intradermal injection of fluorescent indocyanine green dye was performed intraoperatively after axillary or inguinal lymphadenectomy. A handheld fluorescent imaging device (SPY-PHI, Stryker) rather than a fluorescent-capable microscope was used to identify transected lymphatic channels. Data regarding preoperative, intraoperative, and outcome variables were collected and analyzed. Results:. The handheld fluorescent imaging device was successfully able to identify transected lymphatic channels in all cases (n = 15). A nonfluorescent-capable microscope was used to construct the LVB in 14 cases. Loupes were used in one case. In 13 cases, ILR was unilateral. In two cases, bilateral ILR was performed in the lower extremities. All upper extremity cases were secondary to breast cancer (n = 7). Lower extremity cases (n = 8) included extramammary Paget disease of the penis, ovarian cancer, vulvar squamous cell carcinoma, squamous cell carcinoma of unknown origin, soft tissue sarcomas, cutaneous melanoma, and porocarcinoma. Conclusions:. ILR, using indocyanine green injection with a handheld fluorescent imaging device, is both safe and effective. This method for intraoperative identification of lymphatic channels was successful, and LVB creation was completed in all cases. This approach makes ILR feasible when a fluorescent-capable microscope is unavailable, broadening access to more patients.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post-TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined "post-TIPS renal dysfunction" as a change in estimated glomerular filtration rate (ΔeGFR) ≤-15 and eGFR ≤ 60 mL/min/1.73 m2 or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post-TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD-Na was 17. After 30 days post-TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post-TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00-4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01-1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16-3.61; P = 0.01) were associated with post-TIPS renal dysfunction. Competing risk regressions showed that those with post-TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18-2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post-TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.

The liver transplantation (LT) population is aging, with the need for transplant being driven by the growing prevalence of nonalcoholic steatohepatitis (NASH). Older LT recipients with NASH may be at an increased risk for adverse outcomes after LT. Our objective is to characterize outcomes in these recipients in a large multicenter cohort. All primary LT recipients ≥65 years from 2010 to 2016 at 13 centers in the Re-Evaluating Age Limits in Transplantation (REALT) consortium were included. Of 1023 LT recipients, 226 (22.1%) were over 70 years old, and 207 (20.2%) had NASH. Compared with other LT recipients, NASH recipients were older (68.0 versus 67.3 years), more likely to be female (47.3% versus 32.8%), White (78.3% versus 68.0%), Hispanic (12.1% versus 9.2%), and had higher Model for End-Stage Liver Disease-sodium (21 versus 18) at LT (P

Introduction: A scientometric analysis was conducted to characterize the global research publications in extrahepatic portal venous obstruction (EHPVO), and state-of-the-art visualization graphics were generated to provide insight into specific bibliometric variables. Materials and Methods: The Web of Science database was accessed for research productivity and bibliometric variables of countries, institutions, authors, journals, and content analysis of top-20 cited documents were performed. Collaborative networks and co-occurrence of keywords map were generated using VOSviewer software. Results: Two hundred and sixteen records were retrieved with an annual growth rate of 2.53%. India is the leading country in productivity (n = 4339), followed by the USA and China. Post Graduate Institute of Medical Education and Research, Chandigarh, was the top productive institute. Sarin SK was the most prolific author, having the highest citations received and h-index. The hotspot topics were “portal hypertension,” “cirrhosis,” “children,” “biliopathy/cholangiopathy,” “liver fibrosis,” and “liver transplantation” as per keyword co-occurrence networking. J Gastroenterol Hepatol had the most publications of EHPVO research as well the h-index. Regarding collaborative network mapping, the USA and Primignani M were the significant nodes among country and author, respectively. Conclusion: EHPVO research publication volume is low but is gradually progressing with dominant contributions from Indian institutes and authors. Most highly cited articles are of low level of evidence, and multi-institutional collaborative research can be the way forward.

Aim: In addition to the well-known toxicities of treatment, survivors of pediatric solid tumors can also develop other health-related conditions. They may either be an indirect consequence of therapy or could be unrelated to their prior history of malignancy. We aim to evaluate the nontoxicity related health conditions in survivors of pediatric solid tumors. Materials and Methods: The study included a cohort of hepatoblastoma (HB), Wilm's tumor (WT), and malignant germ cell tumors (MGCT) survivors registered at pediatric surgical-oncology clinic from 1994 to 2016. Follow-up was done according to standard protocols and children were evaluated at each visit for any health-related conditions. Results: Of the survivors, 318 survivors, comprising of 48, 81, and 189 survivors of HB, MGCT, and WT, respectively, were included in the analysis. We found 20.8% of patients with HB, 11.1% of patients with MGCT, and 16.4% of patients with WT to report nontoxicity-related health issues. A high prevalence of surgical conditions (3.4%), secondary malignancies (1.2%), gynecological conditions in girls (16.9%), tuberculosis (1.2%), gallstone disease (0.9%), pelvi-ureteral junction obstruction (0.9%), and neurological issues (0.9%) was noted. Two presumed survivors had died, one due to a late recurrence and the other due to a secondary malignancy. Conclusions: A high prevalence of medically or surgically manageable conditions makes it imperative to keep these children under follow-up to address any health-related conditions they may subsequently develop.

De novo or persistent gastro-oesophageal reflux disease which may or may not be associated with injury of the oesophageal mucosa is now a known complication in post-sleeve gastrectomy patients. Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax, which is now a well-known complication. We report four cases of post-sleeve gastrectomy patients who presented with reflux symptoms, with their contrast-enhanced computed tomography abdomen showing intrathoracic sleeve migration and had hypotensive lower oesophageal sphincter with normal body motility on their oesophageal manometry. A laparoscopic revision Roux-en-Y gastric bypass surgery with hiatal hernia repair was performed for all four of them. No post-operative complications were seen at 1-year follow-up. Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass surgery can be safely performed for patients presenting with reflux symptoms in cases of intra-thoracic sleeve migration with good short-term outcomes.

Background: Right living donor nephrectomy is technically more demanding because of the anatomical differences. Patient safety is the utmost priority because it is performed on healthy donors. We hereby describe our experiences with surgical modifications to minimize donor morbidity and overcome surgical challenges in the cases of right living donor nephrectomy. Materials and Methods: In this retrospective comparative study, we analyzed the prospectively maintained perioperative and follow-up data of standard and modified right living donor nephrectomies performed in the recent past 10 years at our institute. We also compared the significant events in corresponding recipients. Student's t-tests were used to define statistical significance. Results: A total of 1530 laparoscopic living donor nephrectomies were performed between 2012 and 2021, of which 117 were on the right side. Of them, 62 donors underwent modified right laparoscopic donor nephrectomy (MRLDN) and 55 underwent standard right laparoscopic donor nephrectomy. The mean duration of surgery (103.44 ± 14.59 vs. 139.45 ± 25.99 min), warm ischemia time (4.30 ± 0.59 vs. 5.89 ± 0.91 min), and blood loss (90.24 ± 24.75 vs. 103.72 ± 33.37 mL) were significantly lower in modified as compared to standard donor nephrectomy (P < 0.05). There was no significant difference in postoperative diuresis, acute tubular necrosis, and serum creatinine at 3 months in the corresponding recipient group. Conclusion: MRLDN is a safe, reliable, and reproducible technique of right laparoscopic donor nephrectomy.

Objectives Extracranial to intracranial (EC-IC) bypass is an important part of the armamentarium of a neurosurgeon in managing different vascular and neoplastic pathologies. Here, we report our initial experiences of EC-IC bypasses as experiences in the ‘learning curve’, including preparation and training of the surgeon, getting cases, patient selection, imaging, operative skills and microtechniques, complications, follow-up, and outcome. Lessons learned from the ‘learning curve experiences’ can be very useful for young vascular neurosurgeons who are going to start EC-IC bypass or have already started to perform and find themselves in the learning curve. Methods From July 2009 to September 2018, 100 EC-IC bypasses were performed. We looked back to these cases of EC-IC bypass as our initial or ‘learning curve’ experiences. The recorded data of patient management (EC-IC bypass patient) were reviewed retrogradely. Our preparation for EC-IC bypass was described briefly. Case selection, indications, preparation of the patient for operation, techniques and technical experiences, preoperative difficulties and challenges, postoperative follow-up, complications, patency status of the bypass, and ultimate results were reviewed and studied. Result A total of 100 bypasses were performed in 83 patients, of which 43 were male and 40 were female. The age range was from 04 to 72 years old (average 32 years old). Eleven patients were lost to follow-up postoperatively after 3 months and they were not even available for telephone follow-up. The follow-up period ranged from 3 to 120 months (average of18.4 months). Eight bypasses were high flow bypasses, whereas the number of low flow STA-MCA bypasses was 92. Indication of bypass were (in 83 cases):1. Arterial stenosis/occlusion/dissection causing cerebral ischemia (middle cerebral artery [MCA] stenosis/occlusion-05, MCA dissection-04, internal carotid artery [ICA] occlusion-19); 2. Intracranial aneurysm-30; 3. Moya-Moya disease-21; and 4. Direct carotid cavernous fistula [CCF]-04. Common clinical presentation was hemiparesis & dysphasia in ischemic group with history of transient ischemic attack (H/O TIA) (including Moya Moya disease). Features of subarachnoid hemorrhage (SAH) were the presenting symptoms in intracranial aneurysm group. The average ischemic time, due to clamping of recipient artery, was 28 minutes (range: 20–60 minutes). There was no clamp-related infarction. Two anastomoses were found thrombosed intraoperatively. One preoperatively ambulant patient deteriorated neurologically in the postoperative period. She developed hemiplegia but improved later. Here, the cause seemed to be hyperperfusion. Headache resolved in all cases. TIA and seizures were also gone postoperatively. Ophthalmoplegia recovered in all cases in which it was present, except in one CCF, in which abducent nerve palsy persisted. Complete unilateral total blindness developed in one patient postoperatively (due to ophthalmic artery occlusion), where high flow bypass with ICA occlusion were performed. Red eye and proptosis were cured in CCF cases. Motor and sensory dysphasia improved in all cases in which it was present, except for one case in which preoperative global aphasia converted to sensory aphasia in the postoperative period. Three patients died in the postoperative period. The rest of the patients improved postoperatively. All patients were ambulant with static neurostatus and without new stroke/TIA until the last follow-up. All bypasses were patent until the last follow-up. Conclusion The initial experiences of 100 cases of EC-IC bypass revealed even in inexperienced hand mortality and morbidity in properly indicated cases were low and result were impressive according to the pathological group and aim of bypass. Lessons learned from these experiences can be very helpful for new and beginner bypass neurosurgeons

Objective The objective of this study was to describe our early experience with laparoscopic pedicled peritoneal flap in patients undergoing male-to-female gender affirmation vaginoplasty. Methods This is a case series of five patients who underwent laparoscopic pedicled peritoneal flap vaginoplasty for gender reaffirmation from October 2020 to July 2021. The clinical and functional outcomes were recorded. Results Two patients underwent the surgery as a primary procedure, and three patients underwent surgery as a secondary deepening procedure after failed penile skin inversion. There were no complications after surgery, and the median length of hospital stay was 3 days. No patient developed vaginal stenosis in 6-month follow-up period, and the median vaginal depth was 6 inches with a healthy vaginal surface. Conclusion Laparoscopic pedicled peritoneal flap can be considered as a first choice in gender affirmation surgeries for patients with inadequate penoscrotal skin or failed penile skin inversion.

We report our initial experience using the intraoperative positioning system (IOPS), a novel endovascular navigation system that does not require contrast or radiation, in the treatment of chronic mesenteric ischemia (CMI). We used IOPS to help treat three of four consecutive patients with CMI. Technical problems prevented successful use in one patient. For the patients for whom IOPS was used effectively, catheterization of the mesenteric artery was accomplished more quickly than for the patient for whom IOPS was not effective. Our experience has shown that IOPS can be safely and effectively used for CMI and can reduce the contrast load and radiation dose.

Introduction: Standard PCNL, where a nephrostomy tube is placed at the end of the surgery, is the predominant modality in the treatment of renal stones at present. With the advancement of techniques however, a new method has developed where tube placement is omitted. More and more studies are being done to evaluate the benefits of tubeless PCNL over the standard PCNL. Objectives: To compare the perioperative characterstics, analgesics requirement(according to VAS score), duration of hospital stay, post surgical complication, to know the which one is more beneficial to patient Methods: The study was done in Muzaffarnagar Medical College and Hospital, Muzaffarnagar, U.P. on indoor patients of the General Surgery department by following inclusion and exclusion criteria, clinical examinations, and interpretation of laboratory results. Results: Tubeless PCNL is better than the standard pcnl in terms of analgesics requirement, duration of hospital stay and complication. Conclusion: Standard PCNL has a longer operating time, that leads to more bleeding and drop in haemoglobin. Tubeless pcnl has a lesser analgesic requirement, lower rates of complications and shorter duration of hospital stay, as well as more cost effectiveness. [ABSTRACT FROM AUTHOR]

Stent-assisted coiling is an endovascular means of managing wide-necked bifurcation aneurysms. In spite of the wide availability of various newer devices in managing such difficult aneurysms, the Y stenting offers a safe and cost-effective alternative to treat such cases in resource poor settings. This article provides an insight of our initial six cases of Y stent-assisted coiling along with their follow-up over a period of 6 months with no recanalization in any case. It also highlights the various technical aspects involved in such cases. One case had recurrent subdural hematoma probably due to use of antiplatelets and another patient had sudden dip in level of consciousness probably due to hematoma expansion that might also have been due to antiplatelet usage. However, none of the cases had any issues regarding stent migration, malapposition, and dissection. In our experience, Neuroform Atlas stent used for Y stenting offers a safe and technically easy alternative to various newer bifurcation devices.

Introduction: The extraction of smooth spherical objects is challenging as they are difficult to grasp within the jaws of the forceps and tend to slip distally. Objective: The authors herein have shared their experience with the use of a Fogarty catheter (FC) for safe extraction of smooth and spherical “foreign body (FB) with a hole.” Materials and Methods: Report on pediatric cases (n = 4) of airway “FB with a hole” wherein the FC was used for their extraction. Mean age was 27.5 months (range: 17 months–39 months). The male: female ratio was 3:1. The technique of FB extraction with a FC has been described, including the principle of the technique, indications, and contra-indications, technical problems and troubleshooting. Results: The FB spectrum included a necklace bead (n = 2), nonnecklace bead (n = 1) and a fragmented end-piece of the housing of a ball-pen (n = 1). The locations of the FBs were right main bronchus (n = 1), secondary bronchus on the right (n = 1), and in the left main bronchus (n = 2). Successful removal of FB with use of FC during rigid broncoscopy was possible. The bead had to be rotated in n = 2 patients to align the hole with the FC. Problems associated with threading the hole and disimpaction of the FB have been highlighted. No complications were observed. The advantages and limitation of the technique have been discussed. Conclusions: The use of FC with the described technique offers a safe, effective and reproducible method for removal of airway “FB with a hole” in a controlled environment while minimizing the possibility of iatrogenic injury to the wall of the surrounding airways.

Background: There has been a dramatic effect of the coronavirus disease 2019 pandemic on the daily health-care services. The era of physical consultations is slowly being replaced with teleconsultation, and this current pandemic has tipped the scales further. This study highlights the preliminary experience in providing teleconsultation to pediatric surgical patients at a tertiary care hospital in north India. Materials and Methods: A retrospective analysis of the electronic medical record system records of the patients undergoing teleconsultation at the authors' department between the June 26, 2020 and the September 26, 2020 was performed. The data were categorized on the basis of the type of consultation (urgent, semi-urgent, or routine) and the type of intervention. A comparison with the data from the corresponding months of 2019 was also performed. Results: A total of 261 teleconsultations were conducted during the study period, with a success rate of 69% (181/261). Of these, 96% (171/178) were follow-up patients and 56% (99/178) presented with genitourinary complaints. After triaging, only 10% (18/178) of the patients required urgent medical/surgical attention. Conclusion: In the current as well as postpandemic phase, teleconsultation can act as a potent triaging tool and can help in better utilization of resources alongside helping in the maintenance of social distancing by decreasing the number of physical visits to the hospital.

Aim: The aim is to study the impact of nutritional status on outcomes and treatment-related complications in patients of neuroblastoma. Materials and Methods: Anthropometry (height, weight, weight for height [in

Background: Differentiation of neonatal cholestasis into neonatal hepatitis (NH) and extrahepatic biliary atresia (EHBA) is essential to formulate the treatment plan; promptness is indispensable for optimal outcomes. The clinical and nonoperative algorithms lack precision; the gold standard investigations (liver biopsy or per-operative cholangiogram) are invasive. There is a need for a noninvasive test which is both, sensitive and specific and has a high likelihood ratio. Aim: To study the (diagnostic) role of matrix metalloproteinase 7 (MMP-7) as a serum biomarker to differentiate between EHBA and NH and evaluate the prognostic significance in EHBA based on its correlation with liver histopathology and serological predictors of liver fibrosis – Aspartate-to-Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4). Materials and Methods: This was a prospective study conducted upon patients of neonatal cholestasis presenting with acholic stools (n = 46) with equal number of controls (n = 45) with no liver pathology. Observational parametric included disease-specific workup and serum MMP-7 levels (all participants); liver biopsyl and APRI-FIB-4 (EHBA). Results: (Diagnostic) Serum MMP-7 levels were significantly elevated in EHBA (n = 25; 28 ng/mL) as compared to those in NH (n = 21; 1.88 ng/mL) and normal infants (n = 45; 1.2 ng/mL) (P < 0.001 for both). Serum cutoff at 4.99 ng/mL differentiated EHBA-NH with a high sensitivity (96%), specificity (90.5%), and a negative predictive value (95%), with the number needed to misdiagnose being 23. (Prognostic) Inflammatory activity and fibrosis-stage on liver histopathology (METAVIR-and-Ishak scores) correlated with MMP-7 levels. APRI and FIB-4 scores also depicted a strong correlation with each other, age of the patient, and liver fibrosis. Conclusions: MMP-7 has a diagnostic value in differentiating EHBA from NH and may also be used as a prognostic biomarker in the follow-up of these patients. MMP-7 levels in controls may be used as a baseline for future studies.

Abstract Background Urinary incontinence is a major problem in operated exstrophy patients. Most of the repairs described in literature stress on the importance of dividing the intersymphyseal band (ISB) to place the bladder in the pelvis. But the origin of this band and its importance has hardly been discussed in literature. The purpose of this study is to establish the nature of tissue the ISB is composed of. This can be used to determine its role in the surgical management of exstrophy epispadias complex (EEC) patients. Results Thirty out of 33 operated patients demonstrated smooth muscle with/without fibrous tissue in the sections taken through the ISB. A significant percentage of patients (χ 2 = 38.319, p < 0.0001) in whom this band was reconstructed around the bladder neck gradually became continent/partly continent with an increase in the dry interval with time. Conclusion It can be a considerable factor to pay attention to the step of wrapping the ISB around the bladder neck during EEC repair. This serves to function as the smooth muscle of the bladder neck as proven histologically in our operated patients. It may have a role to support future continence in these patients.

Objective: To serially evaluate the effect of trans-radial coronary angioplasty (TRA) on the vascular function of radial artery (RA) and upstream brachial artery (BA) and to find out the relative contribution of endothelial dependent flow-mediated vasodilatation (FMD) and endothelial independent nitrate mediated dilatation (NMD). Methods: Forty patients of chronic stable angina with successful TRA were studied. FMD and NMD of bilateral RA and BA were measured with high-resolution ultrasound, before and at 24 h and at 3 months, after catheterization. Results: FMD as well as NMD were significantly decreased in right RA (16.3 ± 3.6% to 5.7 ± 1.8%; p = 0.001, and 24.1 ± 5.3% to 9.7 ± 2.8%; p = 0.001, respectively) as well as in upstream BA (17.0 ± 1.6% to 9.4 ± 0.5%; p = 0.001,and 26.5 ± 6.8% to 20.5 ± 3.7%; p = 0.001, respectively) at 24 h. FMD/NMD ratio was also decreased in RA (70 ± 10% to 60 ± 10%; p = 0.04) and as well as in BA (70 ± 20% to 50 ± 10%; p = 0.03). The endothelial dysfunctions returned to normal at 3 months. Control arm did not show any change in vascular function at any point of time. Radial artery diameter/sheath ratio 2 were the independent predictors for >50% decrease in FMD. Conclusions: TRA results in reversible depression in FMD as well as NMD in the radial artery as well as upstream brachial artery. These vascular dysfunctions are limited to the catheterized arm only and return to normal after 3 months.

Coronary angiography mostly underestimates coronary artery size. Indian data is scarce on correlating quantitative angiographic coronary diameter (DQCA) to intravascular ultrasound derived coronary diameter (DIVUS). We retrospectively analyzed 10-year data (2008–2017) of patients undergoing IVUS guided left main percutaneous coronary intervention (LM-PCI). LM, ostio-proximal LAD (op-LAD), and ostio-proximal LCX (op-LCX) were analyzed in 186, 177 and 44 patients, respectively. A linear correlation was noted between D IVUS and D QCA with derived equations for LM DIVUS = 1.68 + 0.69 × DQCA, op-LAD DIVUS = 1.91 + 0.53 × DQCA, op- LCX DIVUS = 1.93 + 0.49 × DQCA. We conclude that our equations could be used for an approximate estimation of true vessel size in the absence of IVUS assessment.

Background: In the past decade, there has been an increase in the number and types of bariatric procedures in India. It is, thus, important to monitor prevalent bariatric practices. Aim: To identify prevalent pre- and post-operative dietary practices by bariatric professionals across India. Materials and Methods: Data regarding various pre- and post-surgery dietary practices were collected using an Internet-based survey. Thirty-three bariatric professionals including dietitians (n = 25) and surgeons (n = 8) across the country participated in the survey. The data were analysed, and prevalent dietary practices were identified. Results: Five (20%) dietitians were not involved in the pre-surgery consultation. Nineteen (70%) professionals put all patients on a low-calorie pre-surgery diet regardless of their body mass index, with a preference (n = 21; 77.7%) for liquid diet. Twenty-three (70%) professionals put patients on post-surgery liquid diet for 1–2 weeks. Thereafter, 28 (84.8%) professionals recommended soft diet for 2–4 weeks. Twenty-seven (81%) professionals used protein shakes (as opposed to dietary sources) as their primary source of protein for the first 3 months post-surgery. Fourteen (36%) professionals stopped protein shake supplements within 6 months post-surgery. Ten (30%) professionals reported whey protein aversions in >25% of the patients. Twenty-three (71%) professionals advocated a meal with

Acromegaly is associated with increased cardiovascular morbidity and mortality. 49 acromegaly patients were evaluated for presence of cardiovascular risk factors and manifestations using 2D-Echocardiography, strain, strain-rate, carotid intima media thickness (CIMT) and flow mediated dilatation (FMD) and correlated with disease activity. 32 patients with growth hormone (GH) level >1 ng/ml were considered active. Patients with active disease have more LV dysfunction as assessed by strain(p-0.031) and strain rate(p-0.001); trend towards lower ejection fraction(p-0.11) with significant correlation to GH(cc −0.252,p-0.05). Patient with active disease have reduced FMD(p- 0.042); with no difference in prevalence of cardiovascular risk factors and CIMT inrelation to disease activity.

Gastrointestinal (GI) angioectasias/angiodysplasias are the most frequent vascular lesions of GI tract, responsible for ∼5 to 6% of GI bleedings. It commonly involves the small bowel, making it difficult to diagnose and manage endoscopically. Though medical management has been used to prevent bleeding, it has only a limited role in acute severe hemorrhage. In such cases, surgical resection remains the only practical option. However, multiple lesions pose a unique challenge, as resection may not be advisable for long length of bowel involvement. Here, we report a case of recurrent GI bleeding due to multifocal small bowel angioectasias who was managed by a novel technique of full-thickness transmural sutures under intraoperative enteroscopic guidance. At 6 months follow-up, no new bleeding episodes were observed.