Publications by authors named "Asuri Krishna"

40 Publications

Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis.

World J Surg 2022 Jun 19;46(6):1359-1375. Epub 2022 Mar 19.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Background: Recommendations regarding the timing of cholecystectomy for acute biliary pancreatitis (ABP) require a systematic summary of current evidence to guide clinical practice. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing early cholecystectomy (EC) versus delayed cholecystectomy (DC) in patients with ABP.

Methods: We searched databases Medline, Embase, SCOPUS, Web of Science and Cochrane CENTRAL for randomized controlled trials addressing this question. Pairs of reviewers abstracted data and assessed the risk of bias in included studies. A random-effects meta-analysis was done to study the effect of the timing of cholecystectomy on outcomes of interest in patients with ABP. GRADE methodology was used to rate the quality in the body of evidence for each outcome as high, moderate, low, or very low.

Results: 11 randomized trials (1176 participants) were included. High-quality evidence from seven RCTs (867 participants) showed a statistically significant reduction in the risk for recurrent biliary events in favour of early cholecystectomy (RR 0.10, 95% CI 0.05 to 0.19, I = 0%). High-quality evidence from five trials was in favour of early cholecystectomy with a significant reduction in the risk 7of recurrent pancreatitis (RAP) in comparison to delayed cholecystectomy (RR 0.21, 95% CI 0.09 to 0.51, I = 0%).

Conclusion: This review showed that EC has definite advantages over DC in terms of reducing recurrent pancreaticobiliary events and LOS following mild ABP. However, more RCTs are required to study the role of EC in patients with moderately-severe and severe ABP. Trial Registration Protocol registered on Prospero (CRD42020192823).
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http://dx.doi.org/10.1007/s00268-022-06501-4DOI Listing
June 2022

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial.

Surg Endosc 2022 Mar 11. Epub 2022 Mar 11.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5026A, 5th Floor, Teaching Block, Ansari Nagar, New Delhi, 110029, India.

Background: There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life.

Method: This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes.

Results: Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective.

Conclusion: eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.
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http://dx.doi.org/10.1007/s00464-022-09180-3DOI Listing
March 2022

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study.

Indian J Urol 2022 Jan-Mar;38(1):53-61. Epub 2022 Jan 1.

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation.

Materials And Methods: The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days.

Results: The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, < 0.001), had early diuresis, better graft turgidity and urine output than Group S.

Conclusion: Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.
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http://dx.doi.org/10.4103/iju.iju_239_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8796753PMC
January 2022

Peritoneal Loose Body in a Patient With Ampullary Adenocarcinoma.

ACG Case Rep J 2021 Nov 18;8(11):e00680. Epub 2021 Nov 18.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.14309/crj.0000000000000680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604031PMC
November 2021

Effect of Short-term-focused Training on a Phantom Model in Improving Operative Room Performance Among Surgical Residents: A Randomized Trial.

Surg Laparosc Endosc Percutan Tech 2021 Oct 22;32(2):159-165. Epub 2021 Oct 22.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Background: Meta-analysis has shown the effectiveness of various training methods for the acquisition of laparoscopic skills in surgical training. However, there is very limited literature focusing on the translation of skill acquisition on training models into improved operating room (OR) performance. This study was conducted to evaluate the effectiveness of the Tuebingen trainer with integrated Porcine tissue in improving OR the performance of surgical trainees using standard assessment tools.

Materials And Methods: The study was a single-blinded double-armed randomized control study conducted between July 2016 and March 2018. Eighteen, fourth, and fifth semesters of surgery residents were included in the study. The baseline performance was assessed in OR by performing laparoscopic cholecystectomy using validated scores, that is, Global Operative Assessment of Laparoscopic Skills (GOALS), Additional Five Criteria, Task-specific Checklist, Error Checklist, Visual Analogue Scale. The residents were then randomized into trainee and nontrainee groups. The training group received 5 days of short-term-focused training on the Tuebingen trainer, and the improvement was reassessed in OR.

Results: The demographic profile of residents was similar. The baseline scores were comparable. The training group showed statistically significant improvement in GOALS (9.88±1.76 to 12±0.66, P=0.05 vs. 10.33±1.5 to 11.4±2.24, P=0.28), task-specific checklist (42.22±10.92 to 53.33±14.14, P=0.027 vs. 45.55±10.13 to 50±17.32, P=0.51), and error checklist. The operating time significantly reduced (36.0±4.03 vs. 50.44±11.39, P=0.0025) following training.

Conclusions: Our study concludes that the training on the Tuebingen trainer with integrated porcine organs results in a statistically significant improvement in the OR performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to OR.
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http://dx.doi.org/10.1097/SLE.0000000000001016DOI Listing
October 2021

"Misra's appendicular hitch" stich - Innovative technique for simplifying endo-suturing during laparoscopic appendectomy.

J Minim Access Surg 2021 Oct-Dec;17(4):573-575

Department of Surgery, All India Institute of Medical Sciences, New Delhi, India.

Laparoscopic suture transfixation and free tie ligation are the most commonly used cost-effective technique of managing the base of the appendix during laparoscopic appendectomy in low resource settings such as India. This becomes technically cumbersome especially in the presence of the long friable appendix and for novice surgeons. We hereby describe an innovative technique of suspending the appendix using a transfacial suture to ease the placement of suture at the base of the appendix during laparoscopic appendectomy.
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http://dx.doi.org/10.4103/jmas.JMAS_248_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486057PMC
September 2021

Incidentally Detected High SSTR Expression in Uterine Leiomyoma on DOTANOC PET/CT.

Clin Nucl Med 2022 Jan;47(1):e68-e70

From the Departments of Nuclear Medicine.

Abstract: A 38-year-old woman with a 2-month history of per vaginal bleeding and episodes of palpitations, headache, and vomiting underwent 68Ga-DOTANOC PET/CT for evaluation, which revealed a left suprarenal mass and a large uterine mass, both of which were intensely tracer avid. Histopathology of the masses after surgery revealed a left pheochromocytoma and uterine leiomyoma. SSTR-expressing leiomyoma is an uncommon finding and must be kept in mind as a differential diagnosis of DOTANOC-avid uterine mass.
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http://dx.doi.org/10.1097/RLU.0000000000003850DOI Listing
January 2022

Endoscopic transmural drainage tailored to quantity of necrotic debris versus laparoscopic transmural internal drainage for walled-off necrosis in acute pancreatitis: A randomized controlled trial.

Pancreatology 2021 Oct 21;21(7):1291-1298. Epub 2021 Jun 21.

Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background And Aims: Both endoscopic and laparoscopic transmural internal drainage are practiced for drainage of walled-off necrosis (WON) following acute pancreatitis (AP) but the superiority of either is not established. Our aim was to compare transperitoneal laparoscopic drainage with endoscopic drainage using either lumen apposing metal stents (LAMS) or plastic stents tailored to the amount of necrotic debris in WON.

Methods: In a randomized controlled trial, adequately powered to exclude the null hypothesis, patients with symptomatic WON were randomized to either endoscopic or laparoscopic drainage. In the endoscopy group, two plastic stents were placed if the WON contained <1/3rd necrotic debris and a LAMS was placed if it was >1/3rd. Primary outcome was resolution of WON within 4 weeks without re-intervention for secondary infection. Secondary outcome was overall success (resolution of WON at 6 months) and adverse events.

Results: Forty patients were randomized: 20 to each group. Baseline characteristics were comparable between the groups. Primary outcome was similar between the groups [16 (80%) in laparoscopy and 15 (75%) in endoscopy group; p = 0.89]. The overall success was similar [18 (90%) in laparoscopy vs. 17 (85%) in endoscopy; p = 0.9]. Median duration of hospital stay was shorter in endoscopy group [4 (4-8) vs. 6 days (5-9); p = 0.03]. Adverse events were comparable between the groups.

Conclusion: Laparoscopic drainage was not superior to endoscopic transmural drainage with placement of multiple plastic stent or LAMS depending on the amount of necrotic debris for symptomatic WON in AP. The hospital stay was shorter with the endoscopic approach.
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http://dx.doi.org/10.1016/j.pan.2021.06.006DOI Listing
October 2021

Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients.

J Vasc Access 2021 Mar 14:11297298211001158. Epub 2021 Mar 14.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients.

Material And Methods: This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent -test, chi-square test, logistic regression analysis and multivariate analysis were used. The -value of <0.05 was considered significant.

Results: A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome ( < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure ( = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001).

Conclusion: In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.
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http://dx.doi.org/10.1177/11297298211001158DOI Listing
March 2021

Quality of Life Outcomes Following Single-stage Laparoscopic Common Bile Duct Exploration Versus 2-stage Endoscopic Sphincterotomy Followed by Laparoscopic Cholecystectomy in Management of Cholelithiasis With Choledocholithiasis.

Surg Laparosc Endosc Percutan Tech 2021 02 3;31(3):285-290. Epub 2021 Feb 3.

Departments of Surgical Disciplines.

Introduction: With various studies in the literature showing laparoscopic common bile duct (CBD) exploration to have equal or similar results when compared with endoscopic sphincterotomy (EST) clearance, decision-making in regard to the treatment modality to be used may become debatable. Thus, quality of life (QoL) data may assist both the patient and the clinician in deciding the management of the disease. The present prospective randomized trial was undertaken to compare QoL of patients undergoing treatment with these 2 approaches.

Methodology: The study was conducted March 1, 2013, to September 31, 2016. Consecutive patients with CBD stones were randomized to either laparoscopic CBD exploration with cholecystectomy (group I) and EST followed by laparoscopic cholecystectomy (group II). Diagnosis was confirmed preoperatively using magnetic resonance cholangiopancreatography and/or endoscopic ultrasound. QoL scores were assessed by World Health Organization Quality of Life-Brief Version (WHOQOL-BREF), European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires.

Results: A total of 77 patients with concomitant gallstones and CBD stones were finally recruited (38 patients in group I and 39 patients in group II). The demographic and clinical profiles were similar in both the groups. On EORTC QLQ-C30 questionnaire, there was significant improvement in physical, emotional, and role functioning in both the groups (P<0.01) with no intergroup variation preprocedure or postprocedure. Patients in both the groups reported similar WHOQOL scores with significant improvement postprocedure and minimal intergroup variation. Both the depression and anxiety scores on HADS were comparable between the 2 groups preoperatively and at 3 months postoperatively.

Conclusion: Single-stage management of patients with gallbladder and CBD stones and EST followed by laparoscopic cholecystectomy were similar in terms of improvement in QoL.
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http://dx.doi.org/10.1097/SLE.0000000000000902DOI Listing
February 2021

Effect of structured training in improving the ergonomic stress in laparoscopic surgery among general surgery residents.

Surg Endosc 2021 08 1;35(8):4825-4833. Epub 2020 Sep 1.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.

Background: Minimal access surgery has fast become the standard of care for many operative procedures, but is associated with lot of ergonomic stress to the surgeons performing these procedures, which may result in reduction in surgeon's performance and work capacity. In this study, we evaluated the impact of structured training program in improving the ergonomic stress in trainee laparoscopic surgeons.

Methods: Laparoscopic surgeons were divided in 2 groups: trainee surgeons (ten) and expert surgeons (three). Baseline surface electromyography (sEMG) data were collected from bilateral deltoid, biceps brachii, forearm extensors, and pronator teres during a predefined suturing task on Tuebingen trainer with integrated porcine organs in both the groups. Trainee surgeons underwent 20 h of laparoscopic intra-corporeal suturing training and surface electromyography data were recorded at the end of training again and compared with baseline.

Results: Experts were found to have lower muscle activation (p < 0.05) and muscle work (p < 0.05) and better bimanual dexterity than the trainee surgeons at baseline. After training, the trainee surgeons showed significant improvement (p = 0.01), but still did not reach the values of the expert surgeons (p = 0.01). Right deltoid and pronator teres muscles were found to have maximal activity while performing intra-corporeal suturing.

Conclusion: Structured and focused training outside operation theater can significantly reduce unnecessary muscle activation of trainee laparoscopic surgeons and better dexterity leading on to lesser ergonomic stress and thus possibly may reduce the risk of development of future musculo-skeletal disorders.
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http://dx.doi.org/10.1007/s00464-020-07945-2DOI Listing
August 2021

Long-term Outcomes Following Primary Closure of Common Bile Duct Following Laparoscopic Common Bile Duct (CBD) Exploration: Experience of 355 Cases at a Tertiary Care Center.

Surg Laparosc Endosc Percutan Tech 2020 Dec;30(6):504-507

Departments of Surgical Disciplines.

Introduction: Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital.

Materials And Methods: All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded.

Results: Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted.

Conclusions: Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.
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http://dx.doi.org/10.1097/SLE.0000000000000830DOI Listing
December 2020

Laparoscopic sigmoid vaginoplasty: a salvage option for genitourinary fistula after failed McIndoe's repair.

BMJ Case Rep 2020 Jun 30;13(6). Epub 2020 Jun 30.

Department of Urology, All India Institute of Medical Sciences, New Delhi, Delhi, India.

A 30-year-old woman presented with vesicovaginal fistula after a forceful intercourse. She was diagnosed as a case of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome 14 years ago and had underwent McIndoe's vaginoplasty using amniotic membrane. Similarly, another 14-year-old girl presented with an iatrogenic urethral and bladder neck injury during an attempt at McIndoe's vaginoplasty 4 months ago at another centre leading to urinary fistula with absent vagina. A laparoscopic salvage was done for both the cases along with repair of genitourinary fistula using sigmoid colon. There was no further requirement of vaginal dilation. Both patients remain fully continent at 1 year follow-up. Laparoscopic sigmoid vaginoplasty is a worthy minimally invasive salvage method for the patients of MRKH who develop fistulous complication after a previous attempt at neovagina creation. The bowel wall provides a structurally strong layer to withstand the repeated sexual trauma of the vagina.
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http://dx.doi.org/10.1136/bcr-2020-235297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328744PMC
June 2020

A three-arm randomized study to compare sexual functions and fertility indices following open mesh hernioplasty (OMH), laparoscopic totally extra peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair of groin hernia.

Surg Endosc 2021 06 15;35(6):3077-3084. Epub 2020 Jun 15.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: With evolving technology, the focus of groin hernia repair has shifted to sexual function and fertility outcomes.

Methods: This three-arm randomized study was conducted in tertiary care hospital from 1st July 2017 to 30th March 2019. Consecutive patients of groin hernia were randomized into 3 groups, TAPP (Group 1), TEP (Group 2), and OMH (Group 3). Demographic profile and hernia characteristics were assessed preoperatively. Sexual functions (using BMSFI) and fertility (using surrogate fertility indices, viz., semen analysis and anti-sperm antibodies (ASA)) were assessed preoperatively at 3 months after the surgery.

Results: A total of 121 patients were included in the study with 41 patients in TAPP (Group 1) and 40 each in TEP (Group 2) and OMH (Group3) group. All the 3 groups were comparable in terms of demographic profile, hernia characteristics, intra-operative and early post-operative outcomes. Significant improvement was found in most of the domains of BMSFI score in the study population (p value < 0.001) with no intergroup difference. There was significant increase of anti-sperm antibody level in OMH group as compared to TAPP and TEP (p = 0.001), however, the levels were within normal limit.

Conclusions: In conclusion, this study has shown that inguinal hernia repair whether open or laparoscopic (TEP or TAPP) leads on to improvement in sexual functions and fertility indices and can have a significant impact on pre-op counseling of the patient in terms of choice of repair, depending on the available expertise in a given center.
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http://dx.doi.org/10.1007/s00464-020-07697-zDOI Listing
June 2021

A prospective randomized comparison of sexual function and semen analysis following laparoscopic totally extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) inguinal hernia repair.

Surg Endosc 2021 06 15;35(6):2936-2941. Epub 2020 Jun 15.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: With standardization of laparoscopic technique of groin hernia repair, the focus of surgical outcome has shifted to lesser studied parameters like sexual function and fertility.

Methods: This prospective randomized study was conducted in a single surgical unit at a tertiary care hospital. A sample size of 144 was calculated with 72 in each group (Group 1 TEP and Group 2 TAPP). Primary outcomes measured included comparison of sexual function using BMFSI, qualitative semen analysis and ASA levels between patients undergoing TEP or TAPP repair. Semen analysis and ASA was measured pre-operatively and 3 months post-operatively.

Results: A total of 145 patients were randomized into two groups, TAPP (73) and TEP (72) patients. Both the groups were comparable in terms of demographic profile and hernia characteristics with majority of the patients in both the groups having unilateral inguinal hernia (89.0% in TAPP group and 79.2% in TEP group). Both the groups showed statistically significant improvement in overall sexual function score (BMFSI) at 3 months; however, there was no inter group difference. Both the groups were also comparable in terms of ASA and qualitative semen analysis.

Conclusion: Both TEP and TAPP repair are comparable in terms of sexual function and effect on semen analysis. Laparoscopic repair improves the overall sexual functions in patients with groin hernia.
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http://dx.doi.org/10.1007/s00464-020-07733-yDOI Listing
June 2021

Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

J Minim Access Surg 2020 Jul-Sep;16(3):195-200

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.
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http://dx.doi.org/10.4103/jmas.JMAS_93_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440016PMC
June 2020

Outcomes following laparoscopic internal drainage of walled off necrosis of pancreas: experience of 134 cases from a tertiary care centre.

Surg Endosc 2020 11 6;34(11):5117-5121. Epub 2019 Dec 6.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years.

Materials And Methods: This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution.

Results: Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15-58 years). The mean operative time was 94 min (range 64-144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2-19 days). The mean duration of follow-up was 5.5 years (range 6 months-13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date.

Conclusion: In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate.
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http://dx.doi.org/10.1007/s00464-019-07282-zDOI Listing
November 2020

Unusual pseudocyst in a wandering spleen.

BMJ Case Rep 2019 Sep 5;12(9). Epub 2019 Sep 5.

General Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Pseudocysts of the spleen are rare, generally asymptomatic lesions developing secondary to trauma, infection or infarction. When symptomatic, they typically present as non-specific pain in the left hypochondrium, with or without a palpable lump on clinical examination. However, these conventions fail when they occur in a wandering spleen, making imaging critically important. This report describes an unusual case of a 50-year-old who presented with a large cystic mass in a pelvic spleen; imaging facilitated a successful splenectomy and subsequent histopathology revealed a pseudocyst in a wandering spleen.
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http://dx.doi.org/10.1136/bcr-2019-229948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731936PMC
September 2019

Complete duplicated hindgut anomaly presenting in adolescence: Six Ostia in perineum.

Indian J Urol 2019 Jul-Sep;35(3):234-236

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

A 17-year-girl presenting with features of intestinal obstruction and managed with colostomy was referred for continuing to pass feces per anus despite a functioning colostomy. She was diagnosed with a rare congenital anomaly with duplication of urethra, bladder, vagina, uterus, anus, and distal colon; all openings close together in the perineum. Excision of the obstructed duplicated colon was done. The anomaly and its features are discussed with review of literature.
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http://dx.doi.org/10.4103/iju.IJU_264_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639991PMC
August 2019

Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial.

Surg Endosc 2020 03 28;34(3):1157-1166. Epub 2019 May 28.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP.

Patients And Methods: Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications.

Results: Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention.

Conclusions: Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.
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http://dx.doi.org/10.1007/s00464-019-06866-zDOI Listing
March 2020

Totally Extraperitoneal Repair in Inguinal Hernia: More Than a Decade's Experience at a Tertiary Care Hospital.

Surg Laparosc Endosc Percutan Tech 2019 Aug;29(4):247-251

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Introduction: There are 2 standard techniques of laparoscopic groin hernia repair, totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). TEP has the advantage that the peritoneal cavity is not breached but is, however, considered to be more difficult to master when compared with TAPP. We describe herein our experience of TEP repair of inguinal hernia over the last 14 years.

Materials And Methods: This study is a retrospective analysis of a prospectively maintained database of all patients with groin hernia who underwent TEP repair in a single surgical unit between January 2004 and January 2018. Patients' demographic profile and hernia characteristics (duration, side, extent, content, and reducibility) were noted in the prestructured proforma. Clinical outcomes included the operation time, intraoperative and postoperative complications, length of postoperative hospital stay, hernia recurrence, chronic pain, recurrence, seroma, and wound infections. Long-term follow-up was carried out in the outpatient department.

Results: Over the last 14 years, TEP repair was performed in 841 patients and a total of 1249 hernias were repaired. The mean age of patients was 50.7 years. There were 748 primary and 345 unilateral hernias. The majority were direct (61%) inguinal hernias. Telescopic dissection was the commonest method of space creation. The average operating time was 54.8 and 77.9 minutes for unilateral and bilateral hernias, respectively. With 81 conversions, the success rate for TEP was 93.5%. Seroma was the most common postoperative complication seen in 81 patients. The incidence of chronic groin pain was 1.4%. The follow-up ranged from 3 months to 10 years, and there were only 3 recurrences (<1%).

Conclusion: In conclusion, TEP repair is an excellent technique of laparoscopic inguinal hernia repair with acceptable complications after long-term follow-up.
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http://dx.doi.org/10.1097/SLE.0000000000000682DOI Listing
August 2019

The Prevalence of New Onset Diabetes Mellitus after Renal Transplantation in Patients with Immediate Posttransplant Hyperglycemia in a Tertiary Care Centre.

Indian J Endocrinol Metab 2017 Nov-Dec;21(6):871-875

Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India.

Objectives: This study aimed to determine the prevalence of immediate posttransplant hyperglycemia and new onset diabetes after renal transplantation (NODAT). It also aims at answering whether posttransplant hyperglycemia is a risk factor for future development of NODAT.

Methods: A retrospective study was conducted among patients undergoing kidney transplantation under a single surgical unit in a tertiary care hospital in the past 5 years. All known patients with diabetes were excluded from the study. Immediate postoperative hyperglycemia was defined as random blood sugar (RBS) ≥200 mg/dl or requirement of insulin. NODAT was defined as fasting plasma glucose ≥126 mg/dl or RBS ≥200 mg/dl or if the patient is receiving therapy for glycemic control at 6 weeks or 3 months posttransplantation.

Results: The study population included 191 patients. The overall prevalence of posttransplant hyperglycemia and NODAT was 31.4% and 26.7%, respectively. NODAT developed in 28 patients (46.7%) of those who had posttransplant hyperglycemia. Thus, posttransplant hyperglycemia was associated with a fourfold increased risk of NODAT ( = 0.000). Posttransplant hyperglycemia was associated with increased infections ( = 0.04) and prolonged hospital stay ( = 0.0001). Increased age was a significant risk factor for NODAT ( = 0.000), whereas gender, acute rejection episodes, cadaveric transplant, hepatitis C virus status, human leukocyte antigen mismatch, and high calcineurin levels were not significantly associated with the future development of NODAT.

Conclusion: The significant risk of NODAT posed by posttransplant hyperglycemia makes it prudent to follow up these patients more diligently in a resource-limited setting wherein routine monitoring in all patients is cumbersome.
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http://dx.doi.org/10.4103/ijem.IJEM_309_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729676PMC
December 2017

Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study.

Surg Laparosc Endosc Percutan Tech 2016 Dec;26(6):476-483

Departments of *Surgical Disciplines †Anaesthesia ‡Psychiatry, All India Institute of Medical Sciences, New Delhi, India.

Background: Laparoscopic incisional and ventral hernia repair (LIVHR) has been associated with a high incidence acute and chronic pain due to use of nonabsorbable tackers. Several absorbable tackers have been introduced to overcome these complications. This randomized study was done to compare 2 techniques of mesh fixation, that is, nonabsorbable versus absorbable tackers for LIVHR.

Materials And Methods: Ninety patients admitted for LIVHR repair (defect size <15 cm) were randomized into 2 groups: nonabsorbable tacker fixation (NAT group, 45 patients) and absorbable tacker fixation (AT group, 45 patients). Intraoperative variables and postoperative outcomes were recorded and analyzed.

Results: Patients in both the groups were comparable in terms of demographic profile and hernia characteristics. Mesh fixation time and operation time were also comparable. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 8.8 months. However, cost of the procedure was significantly higher in AT group (P<0.01) and NAT fixation was more cost effective as compared with AT. Postoperative quality of life outcomes and patient satisfaction scores were also comparable.

Conclusions: NAT is a cost-effective method of mesh fixation in patients undergoing LIVHR with comparable early and late postoperative outcomes in terms of pain, quality of life, and patient satisfaction scores.
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http://dx.doi.org/10.1097/SLE.0000000000000347DOI Listing
December 2016

Outcomes of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography in Patients with Concomitant Gall Stones and Common Bile Duct Stones: A Prospective Study.

J Laparoendosc Adv Surg Tech A 2016 Dec 9;26(12):985-991. Epub 2016 Nov 9.

1 Department of Surgical Disciplines, All India Institute of Medical Sciences , New Delhi, India .

Introduction: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration.

Materials And Methods: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment.

Results: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05).

Conclusion: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.
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http://dx.doi.org/10.1089/lap.2016.0272DOI Listing
December 2016

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs.

Surg Endosc 2017 03 5;31(3):1478-1486. Epub 2016 Aug 5.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

Methods: This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

Results: The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

Conclusions: Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.
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http://dx.doi.org/10.1007/s00464-016-5142-0DOI Listing
March 2017

Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial.

Surg Endosc 2017 03 21;31(3):1287-1295. Epub 2016 Jul 21.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: The incidence of shoulder pain (SP) following laparoscopic cholecystectomy (LC) varies between 21 and 80 %. A few randomised controlled trials and meta-analysis have shown lesser SP in LC performed under low-pressure carbon dioxide pneumoperitoneum (LPCP) than under standard-pressure carbon dioxide pneumoperitoneum (SPCP). However, the possible compromise in adequate exposure and effective working space during LPCP has negatively influenced its uniform adoption for LC.

Materials And Methods: All consecutive patients undergoing elective LC for gallstone disease who met the inclusion and exclusion criteria were enroled. Fourty patients were randomised to SPCP group (pressure of 14 mmHg) and 40 to LPCP group (pressure of 9-10 mmHg). Primary outcome measured was incidence of SP and its severity on visual analogue scale (VAS) at 4, 8, 24 h and 7 days after LC. Secondary outcomes measured were procedural time, technical difficulty, surgeons' satisfaction score on exposure and working space, intra-operative changes in heart rate and blood pressure, abdominal pain and analgesic requirement. Analyses were performed using Stata software.

Results: There was no conversion to open surgery, bile duct injury or need to increase intra-abdominal pressure on either group. Twenty-three patients (57.5 %) in SPCP group and nine patients (22.5 %) in LPCP group had SP (p = 0.001). The severity of SP was significantly more in SPCP group at 8 and 24 h (p = 0.009 and 0.005, respectively). Both the groups had similar procedural time, surgeons' satisfaction score, intra-operative changes in heart rate and blood pressure.

Conclusion: The incidence and severity of SP following LC performed at LPCP are significantly less compared to that in SPCP. The safety, efficacy and surgeons' satisfaction appear to be comparable in both the groups. Hence, a routine practice of low-pressure carbon dioxide pneumoperitoneum may be recommended in selected group of patients undergoing laparoscopic cholecystectomy.

Clinical Trial Registration Number: CTRI/2016/02/006590.
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http://dx.doi.org/10.1007/s00464-016-5108-2DOI Listing
March 2017

Learning Curve in Laparoscopic Inguinal Hernia Repair: Experience at a Tertiary Care Centre.

Indian J Surg 2016 Jun 12;78(3):197-202. Epub 2015 Sep 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

One of the major reasons for laparoscopy not having gained popularity for repair of groin hernia is the perceived steep learning curve. This study was conducted to assess the learning curve and to predict the number of cases required for a surgeon to become proficient in laparoscopic groin hernia repair, by comparing two laparoscopic surgeons. The learning curve evaluation parameters included operative time, conversions, intraoperative complications and postoperative complications, and these were compared between the senior and the junior surgeon. One hundred thirty-eight cases were performed by the senior surgeon, and 63 cases by the junior surgeon. Both were comparable in terms of intraoperative and postoperative complications. Using the moving average method, minimum of 13 laparoscopic hernia repairs are required to reach at par the operating time of an experienced surgeon. For total extraperitoneal (TEP) repair, the number of cases was 14; and for transabdominal preperitoneal (TAPP) repair, this number was 13.
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http://dx.doi.org/10.1007/s12262-015-1341-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907907PMC
June 2016

A prospective randomised controlled trial comparing chronic groin pain and quality of life in lightweight versus heavyweight polypropylene mesh in laparoscopic inguinal hernia repair.

J Minim Access Surg 2016 Apr-Jun;12(2):154-61

Department of Anaesthesiology, All India Institute of Medical Sciences, Delhi, India.

Background: The aim of our study was to compare chronic groin pain and quality of life (QOL) after laparoscopic lightweight (LW) and heavyweight (HW) mesh repair for groin hernia.

Materials And Methods: One hundred and forty adult patients with uncomplicated inguinal hernia were randomised into HW mesh group or LW mesh group. Return to activity, chronic groin pain and recurrence rates were assessed. Short form-36 v2 health survey was used for QOL analysis.

Results: One hundred and thirty-one completed follow-up of 3 months, 66 in HW mesh group and 65 in LW mesh group. Early post-operative convalescence was better in LW mesh group in terms of early return to walking (P = 0.01) and driving (P = 0.05). The incidence of early post-operative pain, chronic groin pain and QOL and recurrences were comparable.

Conclusion: Outcomes following laparoscopic inguinal hernia repair using HW and LW mesh are comparable in the short-term as well as long-term.
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http://dx.doi.org/10.4103/0972-9941.170018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810950PMC
April 2016

Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy.

Indian J Surg 2015 Dec 12;77(Suppl 2):703-7. Epub 2013 Nov 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.
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http://dx.doi.org/10.1007/s12262-013-0992-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692950PMC
December 2015

Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post-cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre.

Indian J Surg 2015 Dec 13;77(Suppl 2):472-9. Epub 2013 Feb 13.

Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India.

Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity, reduced long-term survival and quality of life. There has been little literature on the long-term outcomes after surgical reconstruction and factors affecting it. The aim of this study was to study factors affecting long-term outcomes following surgical repair of iatrogenic bile duct injury being referred to a tertiary care centre. Between January 2005 to December 2011, 138 patients with bile duct injury were treated in a single surgical unit in a tertiary care referral hospital. Preoperative details were recorded. After initial resuscitation, any intra-abdominal collection was drained and an imaging of biliary anatomy was done. Once the general condition of the patient improved, patients were taken up for a side-to-side extended left duct hepaticojejunostomy. The post-operative outcomes were recorded and a hepatobiliary iminodiacetic acid scan and liver function tests were done, and then the patients were followed up at regular intervals. Clinical outcome was evaluated according to clinical grades described by Terblanche and Worthley (Surgery 108:828-834, 1990). The variables were compared using chi-square, unpaired Student's t test and Fisher's exact test. A two-tailed p value of <0.05 was considered significant. One hundred thirty-eight patients, 106 (76.8 %) females and 32 (23.2 %) males with an age range of 20-63 years (median 40.8 ± SD) with bile duct injury following open or laparoscopic cholecystectomy, were operated during this period. Majority of the patients [83 (60.1 %)] had a delayed presentation of more than 3 months. Based on imaging, Strasburg type E1 was seen in 17 (12.5 %), type E2 in 30 (21.7 %), type E3 in 85 (61.5 %) and type E4 in 6 (4.3 %). On multivariate analysis, only level of injury, longer duration of referral and associated vascular injury were independently associated with an overall poor long-term outcome. This study demonstrates level of injury at or above the confluence; associated vascular injury and delay in referral were associated with poorer outcomes in long-term follow-up; however, almost all patients had excellent outcome in long-term follow-up.
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http://dx.doi.org/10.1007/s12262-013-0880-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692855PMC
December 2015
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