Nd:YAG laser capsulotomy in the prone position under general anesthesia.

Neodymium:YAG (Nd:YAG) capsulotomy is the most common treatment for posterior capsule thickening. Occasionally, patients are unsuitable for receiving this treatment by slit lamp and require alternative surgical options. A technique enabling patients to undergo Nd: YAG laser capsulotomies while under general anesthesia is described. After induction of anesthesia in the supine position, the patient is transferred into the prone position and his or her neck is extended with the chin supported onto the Nd:YAG laser delivery slit lamp before the administration of the laser treatment. The procedure was performed in three individuals, who experienced good outcomes.     

Indications and Outcomes of Re-Exploratory Laparotomy in Adult Living Donor Liver Transplantation—Single-Center Experience of 1352 Consecutive Liver Transplantations from Indian Subcontinent

Liver transplantation (LT) is the gold standard for end-stage liver disease (Prince Postgrad Med J 78:135–141, 2002). LT is a technically demanding operation. It needs experienced surgical team along with good anesthesia and critical care support (David et al. Gastroenterol Clin North Am 17:1–18, 1988). Survival after LT is approximately 90% at 1 year. Unlike other organs, 1 and 10-year survival for liver transplantation are the same (Jain and Reyes Ann Surg 232(4):490–500, 2000). Complications after LT are classified into technical, infective, and immunological (Moon and Lee Gut Liver 3(3):145–165, 2009). Re-exploratory laparotomy (REL) is one of the surgical complications of LT. Our study was aimed at analyzing the indications and impact of REL on the patient outcomes after living donor liver transplantation in our center. Retrospective analysis of all LTs done at our center by the same surgical team from January 1 2011 to June 30 2016 was included in the study. Pediatric transplants, combined liver kidney transplants, cadaveric transplants, planned REL, and re-transplantations were excluded from the study. Re-explored patients (REL) were classified as study group, and non-re-explored (NREL) patients were used as controls for statistical comparison. Twenty-five parameters (preoperative, intraoperative, and postoperative) between the two groups were studied. SPSS 22 statistical software was used for statistical analysis. The total number of LT during the study period was 1352. After exclusion, 1241 patients were in the study group. REL group had 111 patients. Out of 111 patients, 97 had one REL, 13 patients had two RELs, and 1 had three RELs. Hence, there were 126 RELs in 111 patients. NREL group had 1140 patients. REL rate in our series was 10.02%. On univariate analysis of 25 parameters analyzed between the two groups, age, graft weight, multiple bile ducts, and mortality were found to be statistically significant (P < 0.05). Preoperative total leucocyte count, model for end-stage liver disease, and warm ischemia time were statistically significant (P < 0.1). On subgroup analysis of REL, bleeding was the commonest indication followed by intraabdominal sepsis. Delayed non-function and small for size had high mortality rates. Multiple RELs were associated with higher mortality compared to single REL (P < 0.05). REL is associated with poor prognosis after adult living donor liver transplantation.     

Complicated colonic diverticulosis: surgical perspective from an Indian Centre.

INTRODUCTION: Colonic diverticulosis was previously uncommon in India but its incidence seems to have increased recently. Patients with the disease in developing countries are also underdiagnosed and are therefore more likely to present with complications needing operation. However there is a paucity of surgical data on the condition. METHOD: Between August 1996 and February 2005 we operated on 32 patients (28 males, 4 females mean age 60 years) with colonic diverticulosis and analysed their characteristics from a prospective database. We here with describe our experience. RESULTS: Operations for diverticular disease constituted 3% of all the colorectal operations we performed. The diverticula were in the sigmoid colon in 28 (88%) and also in the descending colon in 4 (12%). Twenty-four patients were symptomatic. Twenty-two patients were diagnosed before surgery, 8 at operation and the rest from resected specimens. Emergency operations were performed in 23 and elective procedures in 9 patients. Ten patients were operated on for perforation and abscess, 8 for obstruction, 8 for colovesical fistula, 3 for peritonitis and 3 for haemorrhage. Emergency procedures were performed in 2 stages (resection plus a proximal diversion) in 20; unless done for bleeding in a stable patient where a primary anastomosis was done. One patient who had had an emergency procedure died of sepsis and ketoacidosis in the post-operative period. The 8 patients with colovesical fistulae were all males, had only sigmoid involvement and had had symptoms for a longer duration than the 24 without fistulae. CONCLUSIONS: Although operations for colonic diverticulosis still form a small proportion of the total number of colorectal operations, the diagnosis is often delayed till complications ensue and thus patients usually require emergency procedures. Males with long standing symptoms and sigmoid diverticula may develop colovesical fistulae.     

Surgery for Obscure Lower Gastrointestinal Bleeding in India

Western patients with obscure lower gastrointestinal hemorrhage (OLGIH) are usually 60 years or older, bleed from colonic diverticulosis or angiodysplasia, and need localizing investigations. In India, patients are younger, the causes of bleeding different, and health resources scarce. We followed a policy of early surgical exploration operation and excision of the bleeding source or, if this was not identified, did a right hemicolectomy. The outcome of this strategy was evaluated. Between 1996 and 2003, we managed 62 patients with OLGIH. Localizing investigations such as enteroclysis, radioisotope scanning, angiography, and peroperative enteroscopy were infrequently performed. Fifty patients underwent surgery, emergency (35 pts) or elective (15 pts), and comprised the study group. At operation the lesion was localized in 33 (66%) patients (jejunum in 9 and terminal ileum or cecum in 24) and was resected. In 17 patients no lesion was found and they had a right hemicolectomy. The 30-day mortality was six patients (12%) and included persistent bleeding (three), liver failure (one), and chest infection (one). Five (10%) patients rebled after operation at a mean follow-up of 31 months. Cirrhosis (P=0.003) as a comorbid illness was the only significant factor for rebleed in the right hemicolectomy group. Advanced age (>60 years; P=0.08) might be another risk factor in a larger study. In conclusion, patients with obscure OLGIH in India should have an early operation. If a lesion is not detected, a right hemicolectomy may be done. In this group those with cirrhosis have a higher chance of rebleed, as well as, perhaps, elderly patients.     

Percutaneous Device Closure of a Bifurcated Inferior Vena Cava and Completion of the Kawashima Procedure for the ��Difficult�� Univentricular Heart

Azygos continuation of inferior venacava (IVC) is well known in association with interrupted IVC. We report azygos connection of uninterrupted IVC in a young child with complex univentricular heart. This peculiar anatomy was made suitable for univentricular repair by combining percutaneous device closure of prehepatic right limb of IVC and bidirectional Glenn shunt. The azygos vein acted as a conduit for IVC flow to superior venacava as in Kawashima’s operation. This case highlights a rare IVC morphology. Also this innovative strategy allowed simple solution to a challenging problem and is first time described in the literature.