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Papers by Rajan Vaithianathan
International Journal of Case Reports and Images, 2017
Introduction: Clear cell variant of follicular thyroid carcinoma with synchronous bony metastasis... more Introduction: Clear cell variant of follicular thyroid carcinoma with synchronous bony metastasis and a normal thyroid stimulating hormone level, is an extremely rare condition. Case Report: A 55-year-old male was presented to us with a painful swelling in the right arm. The biopsy showed clear cell adenocarcinoma, raising concerns for a metastatic renal cell carcinoma. Computed tomography scan of abdomen failed to show any renal lesions. A detailed physical examination revealed a small nodule of the right thyroid lobe. Fine needle aspiration cytology (FNAC) of the nodule was reported as follicular neoplasm. A right hemithyroidectomy and the subsequent completion thyroidectomy showed clear cell type of follicular thyroid carcinoma. Immunohistochemistry for thyroglobulin (Tg) further confirmed the diagnosis. Conclusion: Clear cell variant of follicular thyroid carcinoma is a very rare condition, hence a high index of suspicion is essential for diagnosis. The importance of performing ...
International Surgery Journal, 2017
Background: The advent of Single incision laparoscopic appendicectomy (SILA) has encouraged surge... more Background: The advent of Single incision laparoscopic appendicectomy (SILA) has encouraged surgeons to compare its benefits over conventional laparoscopic appendicectomy (CLA). We conducted a prospective study comparing SILA with CLA, evaluating parameters like operative time and complications, post-operative pain, duration of stay and the cosmetic outcome. Methods: A prospective, comparative study of 94 consecutive patients was conducted at our institution between December 2014 and May 2016. The data regarding the various parameters were documented in both groups of patients. Results: Among the 94 patients, 30 underwent SILA and 64 underwent CLA. We found statistically significant outcomes for SILA over CLA in variables such as operative time (p=0.0018), duration of hospital stay (p≤0.0001) and cosmetic outcome (p≤0.0001). Almost all patients in the SILA category showed no evidence of a scar after a three month follow up. Conclusions: SILA was found to have a better outcome than C...
Highlights • Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.• Only one... more Highlights • Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.• Only one previous case has been reported till date from the United States.• Surgery is preferred to sclerotherapy, with higher success rates.• Combined supraclavicular and transaxillary approach provides excellent exposure.
The next advancement in the field of minimally invasive surgery, in the recent times, has been th... more The next advancement in the field of minimally invasive surgery, in the recent times, has been the use of single-incision for accessing the abdominal cavity. Potential benefits of single-incision laparoscopic surgery (SILS) are decreased postoperative pain, reduced port site complications and early recovery. We report a novel technique of SILS for performing appendicectomy by employing two ports and conventional laparoscopic instruments without the need for any expensive specialized equipment.
Median arcuate ligament syndrome is an uncommon cause for abdominal pain and weight loss, caused ... more Median arcuate ligament syndrome is an uncommon cause for abdominal pain and weight loss, caused by median arcuate ligament compressing the celiac plexus or artery. Median arcuate ligament is the continuation of the posterior diaphragm which passes superior to celiac artery and surrounds the aorta. In this case report, A 67 year old male presented with complaints of sudden onset chest pain and loss of weight for the past 6 months. CECT thorax and abdomen it showed features of focal stenosis of coeliac axis and post stenotic dilation of the coeliac trunk suggesting median arcuate ligament syndrome. Laparoscopic median arcuate ligament release was done to relieve the patient from symptoms. Diagnosis of median arcuate ligament syndrome should be considered in a patient presenting with chest pain and weight loss with normal cardiac status and unexplained etiology.
Highlights • Jejunogastric intussusception is an extremely rare complication of gastric surgery.•... more Highlights • Jejunogastric intussusception is an extremely rare complication of gastric surgery.• Longest interval from the initial gastric surgery for gastric cancer to be reported.• Fewer than 200 cases have been reported so far.• It could be afferent, efferent or mixed type.• High index of suspicion needed to diagnose this potentially fatal condition.
Background: The most common and significant cause for morbidity following emergency appendicectom... more Background: The most common and significant cause for morbidity following emergency appendicectomy is surgical wound infection. There are conflicting reports regarding the optimal duration of antibiotic prophylaxis in nonperforated appendicitis. The efficacy of prolonged prophylactic antibiotic treatment in preventing wound infection for nonperforated appendicitis is poorly defined. Objective: A prospective randomized study was carried out to compare the efficacy of single dose cefazolin with three doses of cefazolin in reducing the incidence of postoperative wound infection for patients with nonperforated acute appendicitis. Methods: One hundred patients with a clinical diagnosis of appendicitis were randomized into two groups. Group 1 received single intravenous dose of 1gm cefazolin at induction of anaesthesia and group 2 received two further doses of cefazolin following surgery. Postoperative wound infection was the primary endpoint. Results: The two groups were similar with reg...
Background: Thyroid nodules are a common problem which requires an accurate cytological diagnosis... more Background: Thyroid nodules are a common problem which requires an accurate cytological diagnosis for proper management. An essential investigation modality is fine needle aspiration cytology (FNAC) with a sensitivity ranging between 80-90%. Recommendations vary regarding the use of ultrasound in improving the accuracy of free hand fine needle aspiration biopsy. Objective: The aim of our study was to investigate the role and accuracy of ultrasound guided fine needle aspiration cytology in the evaluation of patients with thyroid nodules. Methods: Forty four patients with nodular thyroid disease who were assessed by ultrasound guided fine needle aspiration cytology (US-FNAC) followed by thyroidectomy were identified. Retrospective analysis of data on the cytology specimens and histological results was carried out. Results: The sensitivity and specificity of US-FNAC for diagnosing thyroid neoplasms were 91.7% and 93.3% respectively. The diagnostic accuracy was 92.8%, with the rate of i...
Indian Journal of Surgery
Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of ... more Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of patients. Most scoring systems are complex or involve multiple parameters, which makes it difficult to ascertain the severity of acute pancreatitis at an early stage. Our study aims to evaluate the bedside index for severity in acute pancreatitis (BISAP) in predicting the severity of pancreatitis and mortality in a rural population, where financial constraints pose a major problem during treatment. We studied 55 patients of acute pancreatitis who presented to our institution between October 2014 and August 2016. The BISAP score was calculated within 24 h of admission. During the hospital stay, the CT severity index (CTSI) was calculated, and patients closely monitored to detect presence of organ failure or mortality. The accuracy of the BISAP and CTSI scores in predicting severity and mortality was determined by plotting receiver operating characteristic (ROC) curves, and calculating the area under curve (AUC). Sixteen (29%) patients developed persistent organ failure and were classified as severe acute pancreatitis (SAP), and four (7%) died. No patient with a BISAP score of 0 or 1 developed severe pancreatitis. The area under curve (AUC) for BISAP score in predicting severity and mortality was 0.902 and 0.958, respectively, better than that of CTSI. BISAP scores of 0 or 1 have a very high negative predictive value, and hence accurate for predicting mild disease. These patients can safely avoid a CT scan and the costs associated with it.
International Journal of Current Research and Review, 2013
Background and objectives: Breast lumps in women are a common clinical problem that requires rapi... more Background and objectives: Breast lumps in women are a common clinical problem that requires rapid and accurate evaluation with an important aim of excluding any malignancy. The classical triple test includes physical examination, mammogram and fine needle aspiration cytology. We have modified this approach by substituting mammogram with ultrasound for the assessment of breast lesions. The objective of the study was to evaluate the accuracy of this modified triple test (MTT) in the management of palpable breast lumps. Patients and methods: A prospective cross sectional study was conducted at Mahatma Gandhi Medical College and Research Institute. Eighty patients with palpable breast lumps were assessed by all the components of MTT. The results of individual components as well as the overall MTT were compared with the final histopathological examination. Results: Physical examination showed 96.67% sensitivity, 84% specificity and 78.4% positive predictive value for diagnosing malignant breast lumps. Ultrasonography showed 93.10% sensitivity, 95.9% specificity and 93.1% positive predictive value. Fine needle aspiration cytology (FNAC) showed 96.6% sensitivity, 100% specificity and 100% positive predictive value and the modified triple test showed 100% sensitivity, 82% specificity and an accuracy rate of 88.7%. Conclusions: The triple test is 100% accurate in the diagnosis of palpable breast lesions when all three elements were concordant (benign or malignant). Among the three components, FNAC had the highest specificity. MTT is reliable in guiding the clinician in the efficient management of patients with breast lumps. MTT is beneficial in reducing the number of unnecessary open biopsies to confirm the diagnosis. The output of MTT is easily reproducible, making it a valid and reliable diagnostic test in the management of palpable breast lumps.
Medical education online, 2013
In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general... more In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general surgery residency with certification (MS/DNB) is required for entering 3 years of thoracic surgery residency (MCh/DNB). There are two certifying boards at the national level. One being the Medical Council of India (MCI), which oversees the major accreditation process involving the undergraduate and postgraduate medical education in India, and the other being the National Board of Examinations (NBE), which was formed for the purpose of establishing a uniform standard of postgraduate medical education. Recently, the latter body has come up with an alternative model for thoracic surgery residency in India. This model includes an integrated 6-year residency, with lesser emphasis on general surgical skills and greater exposure to CT surgery. Changes to the current model of training for CT surgery is the need of the hour and should be initiated very soon by the MCI to meet the future demand f...
The Indian Journal of Surgery, May 11, 2014
Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia w... more Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2 % diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71 % had complete healing of fissure at 6 weeks, with fair amount of pain relief (mean VAS—3.38), and in group B, 96 % showed healing of fissure, with excellent pain relief (mean VAS—1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.
International Journal of Case Reports and Images, 2017
Introduction: Clear cell variant of follicular thyroid carcinoma with synchronous bony metastasis... more Introduction: Clear cell variant of follicular thyroid carcinoma with synchronous bony metastasis and a normal thyroid stimulating hormone level, is an extremely rare condition. Case Report: A 55-year-old male was presented to us with a painful swelling in the right arm. The biopsy showed clear cell adenocarcinoma, raising concerns for a metastatic renal cell carcinoma. Computed tomography scan of abdomen failed to show any renal lesions. A detailed physical examination revealed a small nodule of the right thyroid lobe. Fine needle aspiration cytology (FNAC) of the nodule was reported as follicular neoplasm. A right hemithyroidectomy and the subsequent completion thyroidectomy showed clear cell type of follicular thyroid carcinoma. Immunohistochemistry for thyroglobulin (Tg) further confirmed the diagnosis. Conclusion: Clear cell variant of follicular thyroid carcinoma is a very rare condition, hence a high index of suspicion is essential for diagnosis. The importance of performing ...
International Surgery Journal, 2017
Background: The advent of Single incision laparoscopic appendicectomy (SILA) has encouraged surge... more Background: The advent of Single incision laparoscopic appendicectomy (SILA) has encouraged surgeons to compare its benefits over conventional laparoscopic appendicectomy (CLA). We conducted a prospective study comparing SILA with CLA, evaluating parameters like operative time and complications, post-operative pain, duration of stay and the cosmetic outcome. Methods: A prospective, comparative study of 94 consecutive patients was conducted at our institution between December 2014 and May 2016. The data regarding the various parameters were documented in both groups of patients. Results: Among the 94 patients, 30 underwent SILA and 64 underwent CLA. We found statistically significant outcomes for SILA over CLA in variables such as operative time (p=0.0018), duration of hospital stay (p≤0.0001) and cosmetic outcome (p≤0.0001). Almost all patients in the SILA category showed no evidence of a scar after a three month follow up. Conclusions: SILA was found to have a better outcome than C...
Highlights • Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.• Only one... more Highlights • Lymphatic cyst is an unusual cause of neurogenic thoracic outlet syndrome.• Only one previous case has been reported till date from the United States.• Surgery is preferred to sclerotherapy, with higher success rates.• Combined supraclavicular and transaxillary approach provides excellent exposure.
The next advancement in the field of minimally invasive surgery, in the recent times, has been th... more The next advancement in the field of minimally invasive surgery, in the recent times, has been the use of single-incision for accessing the abdominal cavity. Potential benefits of single-incision laparoscopic surgery (SILS) are decreased postoperative pain, reduced port site complications and early recovery. We report a novel technique of SILS for performing appendicectomy by employing two ports and conventional laparoscopic instruments without the need for any expensive specialized equipment.
Median arcuate ligament syndrome is an uncommon cause for abdominal pain and weight loss, caused ... more Median arcuate ligament syndrome is an uncommon cause for abdominal pain and weight loss, caused by median arcuate ligament compressing the celiac plexus or artery. Median arcuate ligament is the continuation of the posterior diaphragm which passes superior to celiac artery and surrounds the aorta. In this case report, A 67 year old male presented with complaints of sudden onset chest pain and loss of weight for the past 6 months. CECT thorax and abdomen it showed features of focal stenosis of coeliac axis and post stenotic dilation of the coeliac trunk suggesting median arcuate ligament syndrome. Laparoscopic median arcuate ligament release was done to relieve the patient from symptoms. Diagnosis of median arcuate ligament syndrome should be considered in a patient presenting with chest pain and weight loss with normal cardiac status and unexplained etiology.
Highlights • Jejunogastric intussusception is an extremely rare complication of gastric surgery.•... more Highlights • Jejunogastric intussusception is an extremely rare complication of gastric surgery.• Longest interval from the initial gastric surgery for gastric cancer to be reported.• Fewer than 200 cases have been reported so far.• It could be afferent, efferent or mixed type.• High index of suspicion needed to diagnose this potentially fatal condition.
Background: The most common and significant cause for morbidity following emergency appendicectom... more Background: The most common and significant cause for morbidity following emergency appendicectomy is surgical wound infection. There are conflicting reports regarding the optimal duration of antibiotic prophylaxis in nonperforated appendicitis. The efficacy of prolonged prophylactic antibiotic treatment in preventing wound infection for nonperforated appendicitis is poorly defined. Objective: A prospective randomized study was carried out to compare the efficacy of single dose cefazolin with three doses of cefazolin in reducing the incidence of postoperative wound infection for patients with nonperforated acute appendicitis. Methods: One hundred patients with a clinical diagnosis of appendicitis were randomized into two groups. Group 1 received single intravenous dose of 1gm cefazolin at induction of anaesthesia and group 2 received two further doses of cefazolin following surgery. Postoperative wound infection was the primary endpoint. Results: The two groups were similar with reg...
Background: Thyroid nodules are a common problem which requires an accurate cytological diagnosis... more Background: Thyroid nodules are a common problem which requires an accurate cytological diagnosis for proper management. An essential investigation modality is fine needle aspiration cytology (FNAC) with a sensitivity ranging between 80-90%. Recommendations vary regarding the use of ultrasound in improving the accuracy of free hand fine needle aspiration biopsy. Objective: The aim of our study was to investigate the role and accuracy of ultrasound guided fine needle aspiration cytology in the evaluation of patients with thyroid nodules. Methods: Forty four patients with nodular thyroid disease who were assessed by ultrasound guided fine needle aspiration cytology (US-FNAC) followed by thyroidectomy were identified. Retrospective analysis of data on the cytology specimens and histological results was carried out. Results: The sensitivity and specificity of US-FNAC for diagnosing thyroid neoplasms were 91.7% and 93.3% respectively. The diagnostic accuracy was 92.8%, with the rate of i...
Indian Journal of Surgery
Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of ... more Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of patients. Most scoring systems are complex or involve multiple parameters, which makes it difficult to ascertain the severity of acute pancreatitis at an early stage. Our study aims to evaluate the bedside index for severity in acute pancreatitis (BISAP) in predicting the severity of pancreatitis and mortality in a rural population, where financial constraints pose a major problem during treatment. We studied 55 patients of acute pancreatitis who presented to our institution between October 2014 and August 2016. The BISAP score was calculated within 24 h of admission. During the hospital stay, the CT severity index (CTSI) was calculated, and patients closely monitored to detect presence of organ failure or mortality. The accuracy of the BISAP and CTSI scores in predicting severity and mortality was determined by plotting receiver operating characteristic (ROC) curves, and calculating the area under curve (AUC). Sixteen (29%) patients developed persistent organ failure and were classified as severe acute pancreatitis (SAP), and four (7%) died. No patient with a BISAP score of 0 or 1 developed severe pancreatitis. The area under curve (AUC) for BISAP score in predicting severity and mortality was 0.902 and 0.958, respectively, better than that of CTSI. BISAP scores of 0 or 1 have a very high negative predictive value, and hence accurate for predicting mild disease. These patients can safely avoid a CT scan and the costs associated with it.
International Journal of Current Research and Review, 2013
Background and objectives: Breast lumps in women are a common clinical problem that requires rapi... more Background and objectives: Breast lumps in women are a common clinical problem that requires rapid and accurate evaluation with an important aim of excluding any malignancy. The classical triple test includes physical examination, mammogram and fine needle aspiration cytology. We have modified this approach by substituting mammogram with ultrasound for the assessment of breast lesions. The objective of the study was to evaluate the accuracy of this modified triple test (MTT) in the management of palpable breast lumps. Patients and methods: A prospective cross sectional study was conducted at Mahatma Gandhi Medical College and Research Institute. Eighty patients with palpable breast lumps were assessed by all the components of MTT. The results of individual components as well as the overall MTT were compared with the final histopathological examination. Results: Physical examination showed 96.67% sensitivity, 84% specificity and 78.4% positive predictive value for diagnosing malignant breast lumps. Ultrasonography showed 93.10% sensitivity, 95.9% specificity and 93.1% positive predictive value. Fine needle aspiration cytology (FNAC) showed 96.6% sensitivity, 100% specificity and 100% positive predictive value and the modified triple test showed 100% sensitivity, 82% specificity and an accuracy rate of 88.7%. Conclusions: The triple test is 100% accurate in the diagnosis of palpable breast lesions when all three elements were concordant (benign or malignant). Among the three components, FNAC had the highest specificity. MTT is reliable in guiding the clinician in the efficient management of patients with breast lumps. MTT is beneficial in reducing the number of unnecessary open biopsies to confirm the diagnosis. The output of MTT is easily reproducible, making it a valid and reliable diagnostic test in the management of palpable breast lumps.
Medical education online, 2013
In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general... more In India, cardiothoracic (CT) surgery training follows a 3+3-year model, where 3 years of general surgery residency with certification (MS/DNB) is required for entering 3 years of thoracic surgery residency (MCh/DNB). There are two certifying boards at the national level. One being the Medical Council of India (MCI), which oversees the major accreditation process involving the undergraduate and postgraduate medical education in India, and the other being the National Board of Examinations (NBE), which was formed for the purpose of establishing a uniform standard of postgraduate medical education. Recently, the latter body has come up with an alternative model for thoracic surgery residency in India. This model includes an integrated 6-year residency, with lesser emphasis on general surgical skills and greater exposure to CT surgery. Changes to the current model of training for CT surgery is the need of the hour and should be initiated very soon by the MCI to meet the future demand f...
The Indian Journal of Surgery, May 11, 2014
Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia w... more Fissure in ano is a very common disorder of the anorectal region. Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure (CAF). Though lateral internal sphincterotomy (LIS) remains the gold standard of treatment for the disease, it is accompanied by the potential complication of incontinence to both flatus and faecal matter. The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure. Ninety patients with CAF were randomly assigned to group A and group B, with 45 patients each. Group A patients received 2 % diltiazem topical application, twice daily, and group B patients underwent LIS. All the patients were reviewed at first, fourth and sixth week after initiation of treatment. Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared. In group A, 71 % had complete healing of fissure at 6 weeks, with fair amount of pain relief (mean VAS—3.38), and in group B, 96 % showed healing of fissure, with excellent pain relief (mean VAS—1.87). Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence. We conclude that LIS is more effective than topical diltiazem in the treatment of CAF. Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative.