Impact of cadaver training for learning abdominal wall reconstruction: our early experience

PURPOSE

Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique.

METHODS

Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees.

RESULTS

Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10 years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course.

CONCLUSION

The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

Modified optical port entry site for laparoscopic cholecystectomy: Our experience

<b><br>Introduction:</b> The four-port laparoscopic cholecystectomy is a recognized entity in the surgical management of gallstone disease. We report our experience and feasibility of optical port entry site modification.</br> <b><br>Material and Methods:</b> To assess the feasibility and safety of laparoscopic cholecystectomy with a different port placement, we undertook a prospective study with 60 patients at Seth GSMC and KEM Hospital, India between Jan 2022 and July 2022. Our study offered the benefit of a flexible optical port entry site, using a 5 mm optical trocar instead of the conventional 10 mm trocar. A single surgeon did all the cases and definite criteria of simple cases of gallstone disease patterned on clinical and radiological grounds.</br> <b><br>Results:</b> 60 cases of gallstone disease were subjected to the new technique of laparoscopic cholecystectomy over seven months. 39 cases were females and 21 were males. The age range of our patients was between 20 and 55 years with a median age of 39 years. Mean Body mass index 30 (range 25 - 37). The mean operative time was 30 min (range 15 - 45 min) and a follow-up period ranged from 10 to 14 months. No cases were converted to open. We did not encounter any untoward mishaps during surgery.</br> <b><br>Discussion:</b> Our modification of the optical port placement and size received good results and patient satisfaction. Moreover, the placement of the port at a site further from the midline and umbilicus decreases the risk of development of trocar site incisional hernia.</br>.

Postoperative Distal Enteral Tube Refeeding in Stoma Patients: A Comparative Analysis of Clinical Outcomes

<b><br>Introduction:</b> Stoma surgery, which involves creating a diversion of the small intestine through an abdominal wall opening, poses challenges in managing fluid and electrolyte imbalances. Patients with high proximal stoma often rely on costly and risky parenteral nutrition (PN). Distal enteral tube feeding, a method of delivering nutrition to the small intestine, is intended to improve clinical outcomes and reduce complications. This study presents a comparative analysis of clinical outcomes between postoperative distal enteral tube refeeding and traditional enteral and PN approaches in stoma patients with distal mucous fistula.</br> <b><br>Aim:</b> To evaluate the effectiveness of distal enteral tube refeeding in improving postoperative outcomes after stoma surgery and to examine the impact of distal enteral tube refeeding on total hospitalization stay, ICU length of stay, TPN duration, and time to closure of the stoma.</br> <b><br>Material and methods:</b> The study is a retrospective, single-center trial involving 84 patients who had undergone stoma surgery. The patients were divided into two groups: those receiving postoperative distal enteral tube refeeding (n = 42) and the control group (n = 42), with standard mucous fistula creation. The data was collected retrospectively from January 2012 to January 2022 and the statistical analysis was performed using descriptive statistics, the chi-square test, and the t-test.</br> <b><br>Results:</b> The results of our study show that the patients who had undergone postoperative distal enteral tube refeeding had a significantly shorter total hospitalization stay (p = 0.0002), a significantly shorter ICU length of stay (p = 0.0006), a significantly shorter TPN duration (p= 0.0004), and a significantly faster time to closure (p = 0.0002).</br>.

A prospective study of head injury patterns in motorcycle riders wearing/not wearing helmets

INTRODUCTION

Road traffic accidents (RTA) are a major public health problem and one of the five leading causes of morbidity and mortality around the world. Use of two wheelers are growing rapidly especially inlow to middle income countries leading to an increase in RTA. 27% deaths related to accidents in India are among users of motorized two wheelers.

AIMS

To study the pattern of head injuries in motorcycle riders wearing/not wearinghelmets.

MATERIALS AND METHODS

The study is designed as a prospective observational study. Study groups shall be initially categorized based on use of helmets and will be studied in terms of clinical presentation on admission. Basic epidemiological information will be collected in every patient. Case record shall be done in two parts.1) clinical survey 2) radiological survey . Survey is designed as per ATLS guidelines of assessment of trauma patients.

RESULTS

Helmet wearers suffered significantly less head and traumatic brain injuries than the non-helmeted counterparts.

CONCLUSION

Helmets provide significant protection against the morbidity and mortality of Traumatic brain injury (TBI) as a result of road traffic accidents (RTA).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients

OBJECTIVE

The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19.

METHOD

A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management.

RESULT

A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%). Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one.

CONCLUSION

A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

Hepaticocystic Duct in an Era of Laparoscopic Cholecystectomy

The biliary tract is notorious for its variable anatomy. A persistent hepaticocystic duct with agenesis of common bile duct is a rare biliary anomaly that creates a diagnostic dilemma and can add to the operative difficulties. It is important to diagnose this anomaly preoperatively since the gallbladder forms an integral part of bilioenteric continuity and an inadvertent cholecystectomy can lead to a surgical catastrophe. If diagnosed, surgeons can plan definitive treatment in the form of biliary diversion. We present a case of a 22-year-old man, who presented to us with obstructive jaundice and cholangitis. The biliary system was decompressed initially with a percutaneous transhepatic biliary drainage and an endoscopic retrograde cholangiogram established the diagnosis of a type IV hepaticocystic duct preoperatively in our case. Since diagnosis was made prior to operative intervention, we were able to perform a cholecystojejunostomy to maintain biliary continuity. The patient was discharged with an uneventful postoperative course. To our knowledge, this is the first report of such a variation being diagnosed preoperatively. We are also presenting a brief review of literature about persistent hepaticocystic ducts and the embryological basis of their origin.

A Never Described Variant of the Cervical Rib Causing Arterial Thoracic Outlet Syndrome: World's First Case

Cervical ribs, also known as Eve's ribs, are rare and found in 1% of population. They are more common in females and more common on right side. They are asymptomatic in 90% of cases. Cervical rib fused with transverse process of sixth vertebra is rarer. We present a case of dry gangrene of lateral three fingers with right radial and subclavian artery thrombosis with rest pain, due to right cervical rib fused with transverse process of sixth vertebra. After development of line of demarcation of the dry gangrene, patient was operated for excision of cervical rib and sixth cervical vertebral transverse process followed by Ray's amputation of right second finger. Postoperative course was uneventful. Patient was discharged with oral anticoagulation and a healthy wound in right hand.

Role of Indocyanine Green to Mitigate Wound Complications in Component Separation Technique for Ventral Hernia Repair-Our Early Experience

BACKGROUND

The ease of the anterior component separation technique (ACST) makes it an attractive surgical option for ventral hernia repairs (VHR). Incorporation of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion during open ACST is an effective way to minimize the wound complications. This study aims to evaluate the impact of adoption of ICG-FA on wound-related complications following open ACST in VHR.

METHODS

We performed a retrospective review of patients who underwent VHR with the open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of open ACST with onlay meshplasty done before (March 2018-April 2019) and after (May 2019 to July 2020) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin.

RESULTS

The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of surgical site occurrence's was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less patients of the post-ICG cohort (29% vs. 5%; p value 0.045).

CONCLUSION

This study demonstrates the effectiveness of perfusion mapping by the use of ICG angiography to determine potential areas of decreased perfusion and thereby minimize wound complications. Using ICG-FA to guide removal of at-risk tissue to minimize wound complications may substantially improve the patients outcome.

Complicated Ventral Hernia: A Perquisite for Perforated Peptic Ulcer-Unusual Clinical Scenario

Introduction  Peptic ulcer usually presents to the emergency in the form of an acute abdomen, which is usually diagnosed easily either clinically or radiologically. Although its incidence has decreased with the introduction on proton pump inhibitors it is still one of the most common emergencies encountered by a surgeon.

Case Presentation  A 60-year-old woman complained of epigastric swelling for 6 months which gradually increased and became irreducible over the last 2 months. The patient also complained of pain associated with vomiting. Radiological investigations revealed a epigastric hernia with omentum and stomach as content along with fluid collection in the right perihepatic region, with tiny air foci. The patient was explored for the same.

Discussion  Perforated peptic ulcer is a serious complication and carries high risk of morbidity and mortality. Early diagnosis with immediate resuscitation and surgical intervention is essential to improve outcomes. This is a rare case of perforated gastric ulcer which was masked under the complicated ventral hernia.

Decalogue of Transversus Abdominis Release Repair- Technical Details and Lessons Learnt

Background Posterior component separation (PCS) via transversus abdominis release (TAR) technique overcomes the pitfalls of traditionally described repairs. We evaluate the safety and efficacy of this approach and present the lessons we have learnt in our experience with a large series of complex ventral hernias. We also evaluate the importance of pre-operative optimisation and the value of a dedicated abdominal wall reconstruction (AWR) team in improving the surgical outcomes. Study Design A retrospective review of all patients undergoing TAR at a specialised hernia centre in the 2016-2019 period was performed. Pertinent data collected included patient demographics, peri-operative details and post-operative complications. Primary outcome variables were surgical site occurrences (SSO) and hernia recurrence. A multivariate regression model was developed to determine significant predictors of SSO. Results In 92 consecutive patients, the mean age was 52 years with a mean body mass index of 27.9%. Major comorbidities included diabetes (41%), hypertension (23%), and chronic obstructive pulmonary disease (15%). The mean hernia defect was 13.2 cm and the average operative time was 232 minutes. Complete posterior sheath closure was achieved in 95.6% cases. There were 18 (19.5%) cases of SSO which were managed conservatively and no cases required mesh explanation. There were 2 (2.1%) recurrences which required a redo surgery. On multivariate analysis operative time (p value 0.047) was a significant predictor of SSO. Conclusions AWR using the TAR approach offers a robust repair with low overall morbidity. A holistic pre-operative optimisation strategy and a dedicated AWR team can further improve surgical outcomes.

Marine natural products as source of new drugs: a patent review (2015-2018)

INTRODUCTION

Natural products from plants, animals, microbes, and minerals have long been a traditional source for the treatment of human diseases. In the past decades, research on natural products for the pharmaceutical industry had declined due to numerous challenges. However, the recent developments in analytical technology, spectroscopy, and high-throughput screening have tremendously revived natural product drug discovery, including contribution from marine-based drugs. The marine environment is a unique resource enclosing a massive biological diversity, which if genuinely explored might potentially lead to breakthrough therapies. A growing number of compounds from marine sources are entering clinical trials and thus, the impact of this field on the pharmaceutical industry is increasing.

AREAS COVERED

This review summarizes the progress in the field of marine natural products as therapeutic agents based on an analysis of the patents published in the period January 2015 through June 2018.

EXPERT OPINION

Marine organisms are excellent producers of natural chemicals with diverse structures and pharmacological activities. Cumulative increase in the number of patents published in the last few years clearly justifies the importance of these chemicals as sources of new therapeutic agents and this study. Despite the critical supply challenges, marine-derived actives are being explored as sources for anticancer, antimicrobial, antiviral and anti-inflammatory drugs and treatments for several other conditions.

Development and application of HPLC-RI and HPLC-MS/MS based methods for quantification of residual deoxycholate levels in pneumococcal polysaccharides

The analysis of residual sodium deoxycholate (DOC); a detergent of biological origin used in manufacturing of polysaccharide vaccines is challenging due to complex sample matrices and the lack of suitable methods. Here we report, rapid and sensitive high-performance liquid chromatography-refractive index (HPLC-RI) and tandem mass spectrometry (HPLC-MS/MS) methods for estimation of residual DOC in pneumococcal polysaccharides. For HPLC-RI method, separation was achieved using Luna C18 column and mobile phase compositions of acetonitrile: methanol: 20 mM sodium acetate (60:05:35% v/v). For HPLC-MS/MS method, separation was achieved using a Hypersil BDS C18 column with gradient elution of methanol and water (0.1% formic acid). MS/MS method showed linearity (r² = 0.997) over the range of 10-320 ng/mL with limits of detection (LOD) and lower limit of quantitation (LOQ) of 3 and 10 ng/mL respectively. Precision (% RSD) and accuracy (% recovery) for both methods were in the range of 0.74-8.29% and 82.33-117.86% respectively. Sample matrices interferences were addressed following novel sample clean-up method based on liquid-liquid extraction. Both methods enabled traceable quantitation of DOC in intermediate and purified pneumococcal polysaccharides of serotypes: 1, 5, 6A, 6B, 7F, 9V, 14, 19A, 19F and 23F.

Natural Products based P-glycoprotein Activators for Improved β-amyloid Clearance in Alzheimer's Disease: An in silico Approach

Alzheimer's disease is an age related disorder and is defined to be progressive, irreversible neurodegenerative disease. The potential targets which are associated with the Alzheimer's disease are cholinesterases, N-methyl-D-aspartate receptor, Beta secretase 1, Pregnane X receptor (PXR) and P-glycoprotein (Pgp). P-glycoprotein is a member of the ATP binding cassette (ABC) transporter family, which is an important integral of the blood-brain, blood-cerebrospinal fluid and the blood-testis barrier. Reports from the literature provide evidences that the up-regulation of the efflux pump is liable for a decrease in β -amyloid intracellular accumulation and is an important hallmark in Alzheimer's disease (AD). Thus, targeting β-amyloid clearance by stimulating Pgp could be a useful strategy to prevent Alzheimer's advancement. Currently available drugs provide limited effectiveness and do not assure to cure Alzheimer's disease completely. On the other hand, the current research is now directed towards the development of synthetic or natural based therapeutics which can delay the onset or progression of Alzheimer's disease. Since ancient time medicinal plants such as Withania somnifera, Bacopa monieri, Nerium indicum have been used to prevent neurological disorders including Alzheimer's disease. Till today around 125 Indian medicinal plants have been screened on the basis of ethnopharmacology for their activity against neurological disorders. In this paper, we report bioactives from natural sources which show binding affinity towards the Pgp receptor using ligand based pharmacophore development, virtual screening, molecular docking and molecular dynamics simulation studies for the bioactives possessing acceptable ADME properties. These bioactives can thus be useful to treat Alzheimer's disease.

Chemical Modifications of Cinchona Alkaloids Lead to Enhanced Inhibition of Human Butyrylcholinesterase

Butyrylcholinesterase (BChE) inhibitors were identified from a collection containing cinchonine, cinchonidine and synthetic derivatives, and further characterized using cytotoxicity and molecular docking studies. The most active ones were: (10≡)-10,11-dibromo-10,11-dihydrocinchonidine (11), a competitive inhibitor with Ki, = 3.45±0.39 μM, and IC50 BChE = 9.83±0.30 μM/human (h)BChE = 34.47±4.63 and O-(trimethylsilyl)cinchonine (15), a mixed inhibitor with Kiuc = 1.73±0.46 μM and Kic = 0.85±0.26 μM, and IC50 BChE = 0.56±0.14 μM / hBChE = 0.24±0.04. In cytotoxicity experiments, ≥80% of the cells remained viable when exposed to concentrations of up to 80 μM of both inhibitors in four different cell lines, including neurons. Due to the bulkier trimethylsilyl side group of 15, it covered the active site of hBChE better than 11 with an OH-group while not being able to fit into the active site gorge of hAChE, thus explaining the selectivity of 15 towards hBChE.

Chemical modifications of cinchona alkaloids lead to enhanced inhibition of human butyrylcholinesterase

Butyrylcholinesterase (BChE) inhibitors were identified from a collection containing cinchonine, cinchonidine and synthetic derivatives, and further characterized using cytotoxicity and molecular docking studies. The most active ones were: (10 triple bond)-10,11-dibromo-10,11-dihydrocinchonidine (11), a competitive inhibitor with Ki = 3.45 +/- 0.39 microM, and IC50 BChE = 9.83 +/- 0.30 microM/human (h)BChE = 34.47 +/- 4.63 and O-(trimethylsilyl)cinchonine (15), a mixed inhibitor with Kiuc = 1.73 +/- 0.46 microM and Kic = 0.85 +/- 0.26 microM, and IC50 BChE = 0.56 +/- 0.14 microM/hBChE = 0.24 +/- 0.04. In cytotoxicity experiments, > or = 80% of the cells remained viable when exposed to concentrations of up to 80 microM of both inhibitors in four different cell lines, including neurons. Due to the bulkier trimethylsilyl side group of 15, it covered the active site of hBChE better than 11 with an OH-group while not being able to fit into the active site gorge of hAChE, thus explaining the selectivity of 15 towards hBChE.

Polymersome surface decoration by an EGFP fusion protein employing Cecropin A as peptide "anchor"

Polymer based nanocompartments have potential applications in synthetic biology, medicine (drug release) and industrial biotechnology (chiral nanoreactors, multistep syntheses, selective product recovery). A step towards the aforementioned goals is the polymer membrane functionalization through covalent bonding of chemical anchors or insertion of proteins/peptides, to obtain specific properties like recognition, catalytic activity and facilitated diffusion, mimicking the complexity of a biological membrane. The use of genetic engineering techniques widens the possible applications of peptides and proteins specifically designed for polymer membrane interactions. A fusion protein (CecEGFP) based on the antibacterial peptide Cecropin A and the EGFP (Enhanced Green Fluorescent Protein) was designed, expressed and biophysically characterized. CecEGFP interaction with the tri-block copolymer PIB-PEG-PIB (PIB=polyisobutylene, PEG=polyethylene glycol) based polymersome membrane was analyzed by circular dichroism as well as EGFP and Trp fluorescence measurements. Results proved that Cecropin A is usable as a "membrane surface anchor" for water soluble proteins, as it inserts into the polymer membrane. The aim and novelty of this study is within the design of fusion proteins specifically developed for polymer membrane interactions. The use of amphiphilic Cecropin A "anchoring" water soluble proteins to the polymersome surface, avoids chemical coupling between polymers and proteins.