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PARIPEX INDIAN JOURNAL OF RESEARCH, May 15, 2024
Renal cell carcinoma is the most common solid neoplasm of kidney. It accounts for around 90% of a... more Renal cell carcinoma is the most common solid neoplasm of kidney. It accounts for around 90% of all primary renal neoplasm. It arises in the proximal convoluted tubule of renal cortex. The exact cause is unknown but there are several risk factors. Mostly patients are asymptomatic, diagnosed incidentally on imaging, but some patients may present with hematuria , weight loss and palpable flank mass. Diagnosis of this disease require imaging techniques such as abdominal USG and CT scan. Treatment and prognosis of RCC depends on its pathological staging. Important factors are size of tumor and its extension to either Gerota's fascia and IVC. Treatment for this disease consist of partial or total nephrectomy and systemic therapy. This is a case of 64 year old male who diagnosed with Renal call carcinoma extending into IVC below diaphragm and managed with Radical nephrectomy with IVC exploration.
Journal of Clinical and Experimental Hepatology, Dec 31, 2022
Journal of Clinical and Experimental Hepatology, Dec 31, 2022
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Postgraduate Medicine, 2017
Context: Unfortunately, there is confusion among the medical community regarding the management o... more Context: Unfortunately, there is confusion among the medical community regarding the management of amoebic liver abscess (ALA). Therapeutic options range from simple pharmacotherapy to use of interventions like a needle or catheter aspiration under ultrasound guidance to surgical intervention. There is a plethora of thresholds for parameters such as the maximum diameter of the abscess and volume on ultrasound examination suggested by various authors to serve as a criterion to help to decide when to use which modality in these cases. Aims: To assess the outcome of patients with uncomplicated ALA treated using a conservative approach. Moreover, to identify factors associated with its failure. Settings and Design: A prospective, observational study was carried out at a large municipal urban health care center over a period of 3-year (2011-2014) in India. Materials and Methods: Patients with uncomplicated ALA were recruited. All patients were managed with pharmacotherapy initially for a period of 72 h. Response to treatment was assessed by resolution of symptoms within the given time frame. Failure to respond was considered an indication for intervention. Needle aspiration was offered to these patients and response assessed within 72 h. Failure to respond to aspiration was considered an indication for catheter drainage. Statistical Analysis Used: Data recorded were entered in a Microsoft Office Excel Sheet and analyzed using the SPSS version 16.0 (IBM). Results: Sixty patients with ALA were included in the study over its duration. Forty-nine (81.67%) patients were managed conservatively, while 11 (18.33%) patients needed an intervention for relief. Patients who required intervention had deranged liver function at presentation, a larger abscess diameter (10.09 ± 2.23 vs. 6.33 ± 1.69 cm P < 0.001) and volume (399.73 ± 244.46 vs. 138.34 ± 117.85 ml, P < 0.001) compared to those who did not need it. Patients that required intervention had a longer length of hospital stay (7.1 ± 2.4 vs. 4.8 ± 0.9 days, P < 0.001). On post hoc analysis, a maximum diameter of >7.7 cm was found to be the optimal criterion to predict the need of intervention in cases of ALA. Conclusions: A conservative approach is effective in the management of ALA for a majority of patients. Failure of conservative management was predicted by the size of the abscess (maximum diameter >7.7 cm). Even in the cases of failure, a gradual step-up with interventions was found to be safe and effective.
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Transplantation Proceedings
Background. Living donor liver transplantation in small infants is a significant challenge. Liver... more Background. Living donor liver transplantation in small infants is a significant challenge. Liver allografts from adults may be large in size. This is accompanied by problems of graft perfusion, dysfunction, and the inability to achieve primary closure of the abdomen. Monosegment grafts are a way to address these issues. Methods. Two recipients in our cohort weighed less then 6 kg. The prospective left lateral segments from their donors were large for size. Therefore, monosegment 2 liver grafts were harvested. Data regarding the preoperative, intraoperative, and postoperative events in the donor and the recipient were recorded. Results. We were able to achieve significant reduction in the sizes of the grafts harvested. The donors underwent surgery and hospital stay uneventfully. The recipients had normal graft perfusion and no graft dysfunction, and we could achieve primary abdominal closure. One recipient had self-limiting bile leak postoperatively. Conclusions. Monosegment 2 liver allografts are safe and effective for use in living donor liver transplantation in small infants weighing less than 6 kg.
License, which permits unrestricted use, distribution, and reproduction in any medium, provided t... more License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. AnMRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findingswere confirmed. A segmental ileocaecal resectionwas done.Thepatientmade an uneventful recovery.The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolvin...
Principles and Practice of Geriatric Surgery, 2020
The National medical journal of India, 2017
BACKGROUND Acute abdomen is a common surgical emergency. Prompt investigation and treatment, incl... more BACKGROUND Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality. METHODS We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period. RESULTS Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased...
The National medical journal of India, 2014
American Journal of Transplantation, 2021
Coronavirus disease‐19 (COVID‐19) infection causing severe gastrointestinal complications is rare... more Coronavirus disease‐19 (COVID‐19) infection causing severe gastrointestinal complications is rare. A 9‐year‐old child after recovering from mild COVID‐19 infection developed small bowel gangrene due to superior mesenteric artery thrombosis. He required resection of entire necrotic small bowel along with caecum causing ultra‐short bowel syndrome. Reverse transcriptase‐polymerase chain reaction (RT‐PCR) done on the resected specimen was positive for COVID‐19. He was maintained on individualized parenteral nutrition for 3 months. A living donor intestinal transplant was performed using 200 cm of ileum donated by the patient's father. The graft function was satisfactory and was not complicated with thrombosis, infection, reactivation of latent COVID‐19 or rejection. He could be weaned off completely from parenteral nutrition by postoperative day 21. The donor had an uneventful recovery. Six month follow‐up was satisfactory with the child achieving complete enteral autonomy as well as target goal nutrition. Thrombotic phenomena associated with COVID‐19 infection can affect larger vessel‐like superior mesenteric artery leading to small bowel gangrene. Intestine transplant could be done safely after 3 months of recovery from COVID‐19 without any adverse outcomes. Further studies are required to establish optimal timing and safety of small bowel transplant in this situation.
Indian Journal of Surgery, 2020
To report first deceased donor isolated small intestine transplant (DDIT) from western India and ... more To report first deceased donor isolated small intestine transplant (DDIT) from western India and discuss feasibility, procedure and outcome of this complex surgery. A 27-year-old male required massive small bowel resection for gangrene following small bowel volvulus. Patient developed ultrashort bowel syndrome with high output stoma. He was started on total parenteral nutrition. Inability to maintain nutrition along with deranged liver functions necessitated early listing for deceased donor small intestinal transplant. DDIT was performed using small intestine from size matched for a 42-year-old female. Inflow was taken from the infrarenal abdominal aorta. The superior mesenteric vein of the graft was drained into the inferior vena cava. Standard immunosuppression and antibiotic prophylaxis were followed. The graft functioned well, and patient was completely weaned off parenteral nutrition and discharged on day 14. However, he had sudden deterioration of health at home 1 month later and succumbed to death before reaching the hospital. Small intestine transplant is a viable option in patients with intestinal failure with complications of parenteral nutrition. Post-operative care and management remains a bigger challenge. There is a need to increase the awareness and develop expertise in successful execution of this complex procedure.
Surgery in Practice and Science, 2020
Pre-anesthesia checkup (PAC) has been defined as the process of clinical assessment that precedes... more Pre-anesthesia checkup (PAC) has been defined as the process of clinical assessment that precedes the delivery of anesthesia for surgical and nonsurgical procedures. The primary purpose of this endeavor is to assess, known and diagnose unknown co-morbidities which directly or indirectly affect the perioperative management of the patients. In India, there are no national guidelines available for this like those commonly seen in the west. The lack of guidelines and the 'open to interpretation' approach, in our view, lead to the overuse of unnecessary investigations. Most of the western guidelines focus primarily on a comprehensive patient interview and a thorough physical examination in the PAC. There is a dearth of data delineating the practice of ordering preoperative tests for patients undergoing routine elective surgery in India. If routine laboratory testing would detect a sufficiently high number of patients with comorbid conditions that alter perioperative management, then its use may be justified. In such a case it may also hold as a valid defense in the court of law in case of litigation. However, studies from across the globe including India show that detection rates from routine testing are extremely low. In studies from the Indian subcontinent, a clear evidence of abnormal findings on routine testing that may impact management has not been found. In this article, we try to explore the current practices regarding PAC in India and attempt to make recommendations for the establishment of national guidelines.
PARIPEX INDIAN JOURNAL OF RESEARCH, May 15, 2024
Renal cell carcinoma is the most common solid neoplasm of kidney. It accounts for around 90% of a... more Renal cell carcinoma is the most common solid neoplasm of kidney. It accounts for around 90% of all primary renal neoplasm. It arises in the proximal convoluted tubule of renal cortex. The exact cause is unknown but there are several risk factors. Mostly patients are asymptomatic, diagnosed incidentally on imaging, but some patients may present with hematuria , weight loss and palpable flank mass. Diagnosis of this disease require imaging techniques such as abdominal USG and CT scan. Treatment and prognosis of RCC depends on its pathological staging. Important factors are size of tumor and its extension to either Gerota's fascia and IVC. Treatment for this disease consist of partial or total nephrectomy and systemic therapy. This is a case of 64 year old male who diagnosed with Renal call carcinoma extending into IVC below diaphragm and managed with Radical nephrectomy with IVC exploration.
Journal of Clinical and Experimental Hepatology, Dec 31, 2022
Journal of Clinical and Experimental Hepatology, Dec 31, 2022
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Postgraduate Medicine, 2017
Context: Unfortunately, there is confusion among the medical community regarding the management o... more Context: Unfortunately, there is confusion among the medical community regarding the management of amoebic liver abscess (ALA). Therapeutic options range from simple pharmacotherapy to use of interventions like a needle or catheter aspiration under ultrasound guidance to surgical intervention. There is a plethora of thresholds for parameters such as the maximum diameter of the abscess and volume on ultrasound examination suggested by various authors to serve as a criterion to help to decide when to use which modality in these cases. Aims: To assess the outcome of patients with uncomplicated ALA treated using a conservative approach. Moreover, to identify factors associated with its failure. Settings and Design: A prospective, observational study was carried out at a large municipal urban health care center over a period of 3-year (2011-2014) in India. Materials and Methods: Patients with uncomplicated ALA were recruited. All patients were managed with pharmacotherapy initially for a period of 72 h. Response to treatment was assessed by resolution of symptoms within the given time frame. Failure to respond was considered an indication for intervention. Needle aspiration was offered to these patients and response assessed within 72 h. Failure to respond to aspiration was considered an indication for catheter drainage. Statistical Analysis Used: Data recorded were entered in a Microsoft Office Excel Sheet and analyzed using the SPSS version 16.0 (IBM). Results: Sixty patients with ALA were included in the study over its duration. Forty-nine (81.67%) patients were managed conservatively, while 11 (18.33%) patients needed an intervention for relief. Patients who required intervention had deranged liver function at presentation, a larger abscess diameter (10.09 ± 2.23 vs. 6.33 ± 1.69 cm P < 0.001) and volume (399.73 ± 244.46 vs. 138.34 ± 117.85 ml, P < 0.001) compared to those who did not need it. Patients that required intervention had a longer length of hospital stay (7.1 ± 2.4 vs. 4.8 ± 0.9 days, P < 0.001). On post hoc analysis, a maximum diameter of >7.7 cm was found to be the optimal criterion to predict the need of intervention in cases of ALA. Conclusions: A conservative approach is effective in the management of ALA for a majority of patients. Failure of conservative management was predicted by the size of the abscess (maximum diameter >7.7 cm). Even in the cases of failure, a gradual step-up with interventions was found to be safe and effective.
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Journal of Clinical and Experimental Hepatology
Transplantation Proceedings
Background. Living donor liver transplantation in small infants is a significant challenge. Liver... more Background. Living donor liver transplantation in small infants is a significant challenge. Liver allografts from adults may be large in size. This is accompanied by problems of graft perfusion, dysfunction, and the inability to achieve primary closure of the abdomen. Monosegment grafts are a way to address these issues. Methods. Two recipients in our cohort weighed less then 6 kg. The prospective left lateral segments from their donors were large for size. Therefore, monosegment 2 liver grafts were harvested. Data regarding the preoperative, intraoperative, and postoperative events in the donor and the recipient were recorded. Results. We were able to achieve significant reduction in the sizes of the grafts harvested. The donors underwent surgery and hospital stay uneventfully. The recipients had normal graft perfusion and no graft dysfunction, and we could achieve primary abdominal closure. One recipient had self-limiting bile leak postoperatively. Conclusions. Monosegment 2 liver allografts are safe and effective for use in living donor liver transplantation in small infants weighing less than 6 kg.
License, which permits unrestricted use, distribution, and reproduction in any medium, provided t... more License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. AnMRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findingswere confirmed. A segmental ileocaecal resectionwas done.Thepatientmade an uneventful recovery.The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolvin...
Principles and Practice of Geriatric Surgery, 2020
The National medical journal of India, 2017
BACKGROUND Acute abdomen is a common surgical emergency. Prompt investigation and treatment, incl... more BACKGROUND Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality. METHODS We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period. RESULTS Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased...
The National medical journal of India, 2014
American Journal of Transplantation, 2021
Coronavirus disease‐19 (COVID‐19) infection causing severe gastrointestinal complications is rare... more Coronavirus disease‐19 (COVID‐19) infection causing severe gastrointestinal complications is rare. A 9‐year‐old child after recovering from mild COVID‐19 infection developed small bowel gangrene due to superior mesenteric artery thrombosis. He required resection of entire necrotic small bowel along with caecum causing ultra‐short bowel syndrome. Reverse transcriptase‐polymerase chain reaction (RT‐PCR) done on the resected specimen was positive for COVID‐19. He was maintained on individualized parenteral nutrition for 3 months. A living donor intestinal transplant was performed using 200 cm of ileum donated by the patient's father. The graft function was satisfactory and was not complicated with thrombosis, infection, reactivation of latent COVID‐19 or rejection. He could be weaned off completely from parenteral nutrition by postoperative day 21. The donor had an uneventful recovery. Six month follow‐up was satisfactory with the child achieving complete enteral autonomy as well as target goal nutrition. Thrombotic phenomena associated with COVID‐19 infection can affect larger vessel‐like superior mesenteric artery leading to small bowel gangrene. Intestine transplant could be done safely after 3 months of recovery from COVID‐19 without any adverse outcomes. Further studies are required to establish optimal timing and safety of small bowel transplant in this situation.
Indian Journal of Surgery, 2020
To report first deceased donor isolated small intestine transplant (DDIT) from western India and ... more To report first deceased donor isolated small intestine transplant (DDIT) from western India and discuss feasibility, procedure and outcome of this complex surgery. A 27-year-old male required massive small bowel resection for gangrene following small bowel volvulus. Patient developed ultrashort bowel syndrome with high output stoma. He was started on total parenteral nutrition. Inability to maintain nutrition along with deranged liver functions necessitated early listing for deceased donor small intestinal transplant. DDIT was performed using small intestine from size matched for a 42-year-old female. Inflow was taken from the infrarenal abdominal aorta. The superior mesenteric vein of the graft was drained into the inferior vena cava. Standard immunosuppression and antibiotic prophylaxis were followed. The graft functioned well, and patient was completely weaned off parenteral nutrition and discharged on day 14. However, he had sudden deterioration of health at home 1 month later and succumbed to death before reaching the hospital. Small intestine transplant is a viable option in patients with intestinal failure with complications of parenteral nutrition. Post-operative care and management remains a bigger challenge. There is a need to increase the awareness and develop expertise in successful execution of this complex procedure.
Surgery in Practice and Science, 2020
Pre-anesthesia checkup (PAC) has been defined as the process of clinical assessment that precedes... more Pre-anesthesia checkup (PAC) has been defined as the process of clinical assessment that precedes the delivery of anesthesia for surgical and nonsurgical procedures. The primary purpose of this endeavor is to assess, known and diagnose unknown co-morbidities which directly or indirectly affect the perioperative management of the patients. In India, there are no national guidelines available for this like those commonly seen in the west. The lack of guidelines and the 'open to interpretation' approach, in our view, lead to the overuse of unnecessary investigations. Most of the western guidelines focus primarily on a comprehensive patient interview and a thorough physical examination in the PAC. There is a dearth of data delineating the practice of ordering preoperative tests for patients undergoing routine elective surgery in India. If routine laboratory testing would detect a sufficiently high number of patients with comorbid conditions that alter perioperative management, then its use may be justified. In such a case it may also hold as a valid defense in the court of law in case of litigation. However, studies from across the globe including India show that detection rates from routine testing are extremely low. In studies from the Indian subcontinent, a clear evidence of abnormal findings on routine testing that may impact management has not been found. In this article, we try to explore the current practices regarding PAC in India and attempt to make recommendations for the establishment of national guidelines.