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1JASA, Vol. 23, No. 1, January - April, 2016

Journal of the Association of Surgeons of Assam

JASA, Vol. 23, No. 1, January-April, 2016

Editor :Dr H. K. Dutta, MS,M.Ch.

Editorial Board MembersProf. K.C. Saikia, Guwahati Dr. N.N. Das, GuwahatiDr. K. Bhuyan, Guwahati Dr. D.K. Sarma, GuwahatiDr. AP Lal, Dibrugarh Dr. M. Saha,Guwahati

Editorial ConsultantsProf. Rama Kant, Lucknow Prof. Andre Nicolus, FranceProf. N.C.Bhattacharyya, Tezpur Dr. S. Singhvi, New DelhiProf. Arjun Rao, USA Prof. M. Srinivas, New DelhiProf. K. Das, Bengaluru Dr. R.N. Majumdar, GuwahatiProf. J. Ahmed, Dibrugarh Dr. D. Hazarika, BongaigaonProf. A.C. Baro, Jorhat Dr. N. Das, Silchar

ISSN 2347-811X

Index in : / IndiaCitation Index

2 JASA, Vol. 23, No. 1, January - April, 2016

CONTENTS

Journal of the Association ofSurgeons of Assam

• Editorial : Dr. H.K. Dutta 3

Original Article :

• "Diagnostic and Prognostic Value of Urinary survivin Reverse Transcriptase Polymerase

Chain Reaction Assay in Urothelial Carcinoma of Bladder"

Prof. Rajeev T.P.1, Dr. Shajidul Mazumdar2, Dr. Debanga Sarma3, Dr. Sasanka Kt.

Barua4, Dr. Somor Jyoti Bora5 6

• VP shunt malfunction in children : an analysis of risk factors

Dr. Tamajyoti Ghosh1, Dr. H.K. Dutta2, Dr. R.K. Bhuyan3 15

• Fistula in ano : A Clinical Study

Dr. M. Talukdar*, Dr. Rajesh Paul**, Dr. Sankamithra G** 20

• A study on student perspective on bedside teaching

Dr. Dipak Kumar Sarma 24

Case Reports :

• High-Grade Renal Injury : Non-operative management of urinary extravasation -

A Report of two cases with review of literature

Prof. S.J. Baruah1, Prof. Rajeev T.P.2, Debajit Baishya3, Debanga Sarma4,

Sasankar Kr. Barua5 30

• Cutis Laxa Syndrome : A Case Report

Dr. R. Payeng1, Dr. H.K. Dutta2, Dr. D. Saikia3 33

• Dural Arteriovenous fistula presenting with acute subdural hematoma :

A Rare Case Report

B.K. Baishya1, Deep Dutta2, Shamim Ahmed3, Z.Hussain1 35

• Lumbar Hernia-A Rare Case Report and Review of Literature

Rajeev T.P.1, Sasanka Kumar Barua2, Jyoti Prasad Morang3, Debanga Sarma4 39

• Renal Cell Carcinoma with TFE3 Rearrangement at Xp11.2 - A Case Report

Jayanta Kumar Goswami1, Muktanjalee Deka2, Chandan Jyoti Saikia3 39

• Journal Review: 43

JASA, Vol. 20, No. 2, May-August 13

Vol. 23, Issue No. 1Jan-April, 2016

3JASA, Vol. 23, No. 1, January - April, 2016

Editorial

Journal indexation: What next?

Publication has become an important criteria for any academicinstitutions. MCI guidelines recommend indexed publications forteaching faculties in medical institutions. Therefore, publishingresearch articles in indexed journals has become a priority for medicalprofessionals engaged in teaching job [1]. Hence, finding anappropriate journal for articles has also become important. Thereare now many indexation services available. First published in 1879,Index Medicus has been the most comprehensive index of medicalscientific journals for a long time. Over the years, many newindexation services have developed, such as MedLine, PubMed,SCOPUS, EMBASE, Index Copernicus etc. Indexation of a journalis a reflection of it's quality [2]. Journals indexed in the ThomsonReuters Journal Citation Reports and SCImago Journal Ranking(SJR)are awarded an Impact Factor (IF) based on the quality of thearticles published and this IF is reviewed periodically. However, notall journals indexed in Index Medicus/PubMed/MedLine are indexedin Thomson Reuters Journal Citation Reports or SJR and hence,these jourmals donot have an IF, or other way round, a journalhaving an IF may not be indexed in Index Medicus, Pubmed orMedLine. In recent times, there has been considerable debate on theprocedure of awarding IF to journals. IF has been criticized formanipulation and incorrect application [3]. Garfield has warnedagainst using IF to evaluate individual articles and scientists[4-6].

Journals registered in the database of an indexing service undergorigorous, multidimensional parameterization, proving high quality.The Index Copernicus Journals Master List- a journal indexingdatabase, contains currently over 22,000 journals from all over theworld. Journals which have passed a multidimensionalparametrization receive the Index Copernicus Value (ICV) calculatedfor a given year. ICV is a sum of the points from the evaluation oftwo components:

quality of scientif ic journal - the quality of a journal ismeasured based on the level of fulfilment of the criteria in specificfunctional areas of a scientific journal based on the IC Publishing

4 JASA, Vol. 23, No. 1, January - April, 2016

Stars model,

impact of scientific journal - determined on the basis of thecitation rate of a journal and reflecting the extent to which the journalhas been recognized in the scientific world and the dynamics of itsimpact.

Thomson Reuters recently launched Emerging Sources Citation Index(ESCI), which is similar to the already existing platform ScienceCitation Index Expanded (SCIe), with the difference that journalsindexed with ESCI won't carry an impact factor. However, journalsselected in ESCI will have their content available in Web of Science,thus receiving genuine citation metrics with their citation progressregularly getting monitored. Good journals are automaticallyupgraded to SCIe.

It is a proud moment for the surgical fraternity of Assam, that JASAhas been included in the IC Journals Master List 2014 and has beenaccorded a normalized ICV of 5.45. The onus is on us now to takethe journal to newer heights. The journal should not be used as avehicle just to secure a promotion in professional hierachy formembers, but to maintain the highest standard of medical ethics andscientific quality.

References:1. Balhara YP. Publication: An essential step in research. Lung India. 2011;28:324-5.

[PubMed]2. Balhara YP. Indexed Journal: what does it mean? Lung India 2012;29(2):193.3. Not-so-deep impact. Nature. 2005;435:1003-4. [PubMed]4. Garfield E. The history and meaning of the journal impact factor. JAMA. 2006;295:90-

3. [PubMed]5. Garfield E. How can impact factors be improved? BMJ. 1996;313:411-3. [PubMed]6. Garfield E. Journal impact factor: A brief review. CMAJ. 1999;161:979-80. [PubMed]

5JASA, Vol. 23, No. 1, January - April, 2016

Introduction :Bladder cancer is one of the most common malignant tumour worldwide.

It is the fourth most-common type of cancer in men and the eighth most-common tumour in women [1]. The incidence of bladder cancer increaseswith age, where people older than 70 years develop the disease 2 to 3 timesmore often than do those aged 55 to 69 years, and 15 to 20 times more oftenthan those aged 30 to 54 years1. Despite the fact that there is no comprehensivestatistical report on the incidence rate of bladder cancer in India, accordingto clinical reports it has a very high incidence rate, and most cases aretransitional cell carcinoma (TCC), similar to that in Europe and North America.Tumour growth depends on 2 main factors: cell proliferation and cell death

Original Article

"DIAGNOSTIC AND PROGNOSTIC VALUE OF URI-NARY SURVIVIN REVERSE TRANSCRIPTASE -

POLYMERASE CHAIN REACTION ASSAY INUROTHELIAL CARCINOMA OF BLADDER"

ABSTRACTOBJECTIVES :Bladder cancer is one of the most common malignant tumour worldwide.Considering the potential application of survivin as a specific tumourmarker for cancers, we decided to evaluate the expression of survivin inurine of urothelial cancer patients.MATERIALS AND METHODS :This is a prospective study conducted from January, 2012 to January,2014. A total of 68 cases of urothelial cancer of bladder and equal numberof patients with benign genito-urinary diseases were taken as control.The expression of survivin in urine of urothelial cancer patients wereevaluated using reverse transcriptase-polymerase chain reaction (RT-PCR) to determine its potential diagnostic and prognostic value.RESULTS :Mean age was 57.7 years with M:F ratio of 4.6:1 in the study group. Allhigh grade superficial(22 cases of T1G3) and muscle invasive tumours(18 cases) were positive for survivin RT-PCR assay while urine cytologywas positive in 14 and 12 cases respectively. In low grade tumours,survivin and cytology positivity were both low with survivin havingsignificantly higher positivity. Overall, there were 44.1% and 82.3%cytology and survivin positivity respectively which was statisticallysignificant.CONCLUSION :Urine survivin provides a higher sensitivity and higher or equal specificitycompared to urine cytology in all grades of urothelial tumors of bladder.Higher positivity rate in high grade tumour has prognostic significance.

Prof. Rajeev T.P.1Dr. Shajidul Mazumdar2Dr. Debanga Sarma3Dr. Sasanka Kt. Barua4Dr. Somor Jyoti Bora5

1Professor and Head, Department ofUrology, Gauhati Medical CollegeHospital, Guwahati, Assam, India2 Registrar, Department of Urology,Gauhati Medical College Hospital,Guwahati, Assam, India3 Assistant Professor, Department ofUrology, Gauhati Medical CollegeHospital, Guwahati, Assam, India4 Associate Professor, Department ofUrology, Gauhati Medical CollegeHospital, Guwahati, Assam, India5 Senior Resident, Department of Urol-ogy, Gauhati Medical College Hospi-tal, Guwahati, Assam, India

Corresponding Author :*Prof. Rajeev T.P.Professor and HeadDepartment Of UrologyGauhati Medical College & HospitalGuwahati-781032Email: [email protected] no.: 9864064374

Key Words : Survivin; RT-PCR; Cytology; urothelial carcinoma.

6 JASA, Vol. 23, No. 1, January - April, 2016

by apoptosis [2]. Apoptosis is a form of programmedcell death characterized by morphologic, biologic, andgenetic features. Abnormalities of apoptosis may leadto uncontrolled cellular proliferation and ultimatelycarcinogenesis. Several studies have reportedsignificant correlations between apoptosis andprognosis in malignant tumours such as lung, breast,and esophageal cancer. Two protein families areresponsible for controlling apoptosis: BcL-2 and theinhibitors of apoptosis proteins (IAP). Inhibitors ofapoptosis proteins are a group of evolutionaryconserved proteins characterized by the presence of 1to 3 domains known as baculoviral IAP repeat(BIR)domains, which is necessary for the anti-apoptoticproperty of IAPs [3,4].

Survivin, a new member of IAPs, is structurallyunique, because it has only a single BIR domain andlacks the COOH-terminal RING finger domain [5].Survivin also plays critical roles in regulating the cellcycle and mitosis. Its primary expression in mosthuman malignancies and its low or absence ofexpression in normal tissues suggest that it would be agood diagnostic and prognostic marker as well as anideal target for cancer-directed therapy [5,6]. Extensivestudies have been carried out to elucidate themechanism of its function; however, its role inregulating cell survival and cell cycle is poorlyunderstood [7]. Using molecular markers for diagnosingand determining the prognosis of bladder tumors canbe of great value.

Considering the potential application of survivinas a specific tumor marker for cancers, we decided toevaluate the expression of survivin in urine of urothelialcancer patients .

The objective of the study is to evaluate theexpression of survivin in urine of urothelial cancerpatients using reverse transcriptase-polymerase chainreaction (RT-PCR) to determine its potential diagnosticand prognostic value.MATERIALS AND METHODS:

This is a prospective,study conducted betweenJanuary 2012 and January2014. The study wasapproved by the institutional ethics committee and allpatients gave us written informed consent. The studyincluded a total of 68 urothelial tumour cases(48 newand 20 recurrent) admitted to our department duringthat period where definitive curative intervention likeTUR-BT(50 cases) or radical cystectomy(18 cases) weredone. Pre-operative urine sample were collected fromthose patients. An age-matched control group of 68

individuals comprising healthy individuals and patientwith benign genito-urinary diseases like prostatichypertrophy, urinary infection and urolithiasis werealso taken and urine samples were collected from them.All the samples were subjected to urine cytologicalexamination and survivin RT-PCR assay. 50 ml mid-stream voided urine was collected in two differentsterile containers for cytology and survivn RT-PCRassay with a special precaution of avoiding the firstvoided morning sample. The samples were immediatelysent to pathology laboratory where it was centrifugedat 2000 rpm by Cytospin machine and one portion wasstained with Papanicolaou stain for cytologicalexamination and another portion was stored at -800Cfor RT-PCR assay in the department of Bio-technology. Tumor grading and staging were performed accordingto the principles outlined by the WHO and the TNM"UICC.RT-PCR Assay:

RNA extraction kit : RNeasy Micro Kit cot no:74004.

cDNA synthesis kit: RevertAid™ First StrandcDNA Synthesis Kit, for 100 reaction. Invitrogen,USA.

Survivin gene was amplified using a nested PCRusing the following primers and cycling conditions-

Survivin Primers:FORWARD-15/ CTGCCTGGCAGCCCTTTCTCAA 3/REVERSE-1 5/ AATAAACCCTGGAAGTGGTGCA 3/FORWARD-2 5/CCGCATCTCTACATTCAAGAAC-3/REVERSE-2 5/ CTTGGCTCTTTCTCTGTCC -3/This is a semi-quantitative method for PCR

analysis.The PCR amplification was performed for 25to 35 cycles.The cycling conditions were as follows:94°C for 30 seconds, 55°C for 30 seconds, 72°C for 1minutes, and a final extension at 72°C for 10 minutes.PCR products were then separated on a 1.5% agarosegel and visualized by ethidium bromide staining.

Correlation between survivin and cytologypositivity of the samples were done by Z-test. Thesignificance level was established at 0.05 for allstatistical tests.RESULTS AND OBSERVATIONS :

Total of 68 patients and 68 controls were includedin this study. In the study group, there were 56 maleand 12 female patients with a male: female ratio of4.6:1.The mean age was 57.7 years (range- 31 to 76years). The control group had a mean age of 55.2 yearswhich was statistically similar. Histopathology grades

Prof. Rajeev T.P. at el: Diagnostic and Prognostic Value

7JASA, Vol. 23, No. 1, January - April, 2016

and corresponding cytology and survivin positivity rateobtained by RT-PCR assay are shown in table-1 andfigure-1 .

Table-1: Stage-wise survivin positivity by RT-PCRassay compared with cytology.

Non-muscle invasive(NMIBC) Muscle-invasive(MIBC)

Stage TaG1 T1G1/G2 T1G3 T2G3N0 T3G3N0 T3G3N1

Number 6 22 22 10 4 4

Cytology 0 9 14 6 2 3

Survivin 3 17 21 10 4 4

Out of total 68 cases, 56 were positive for surviving(82.3%) and 30 cases were cytology positive (44.1%)which was significant (p=0.0018).When we furtheranalysed the results in different subgroup of patientswe found that, in out of total 22 high grade superficialtumours (T1G3), all were positive for survivin (100%)and 14 were cytology positive (63.6%) with a p-value of0.027 which was statistically significant. In low gradesuperficial tumours, out of total 28 cases,16 weresurvivin positive (57.1%) and 4 were cytology positive(14.2%) with a significant p-value of 0.017. As a wholewhen we considered all superficial tumours, out of total50 samples, 18 were cytology positive (36%) and 38were survivin positive (76%) with a significant p-valueof 0.0043. Likewise,in 18 cases of muscle invasivetumours, all the samples were positive for survivin(100%) and 12 were positive for cytology (66.6%) withsignificant p-value of 0.057.

All samples in the control group were negative forboth cytology and survivin assay.

Fig 1: PCR products on 1.5% agarose gel.Lane1- negative controlLane 2-positive controlLane3-sampleLane4-ladder.

DISCUSSION :Survivin is one of the family members of inhibitor

of apoptosis protein (IAP) and is the most effective IAP.It has been mapped to chromosome 17q25 and codedfor mRNA with molecular-weight of 119 kb [8]. Highexpression has been found in most commonmalignancies in mankind, including liver cancer, lungcancer, breast cancer, colon carcinoma, gastric cancer,pancreatic cancer, prostates carcinoma; it also has adose-dependent relationship with the occurrence,development and prognosis of these tumors [9-13].Smith et al discovered that survivin was over expressedin urothelial cancer, and its amount has positivecorrelation with the malignant degree of bladder cancer[14]. Thus, the expression level of survivin in urine canprovide simple and non-invasive method to diagnosebladder cancer. At present, exfoliative cytologicalexamination and cystoscopy are widely used todiagnose TCC in addition to imaging study. Cystoscopyis an invasive examination and patients suffer painduring the examination. In addition, the positive rateof exfoliative cytological examination is only (21?40)%;while using bladder tumor antigen (BTA) to diagnoseTCC is contentious [15]. It has been documented thatsurvivin has a high expression in the exfoliate cell inurine of the patients with TCC and only expressesslightly or even does not express in healthy people. Thesensitivity of the test in our patients with TCC is 82,3%.This is in agreement with the result of Shamp et al [16]who found the survivin in urine by using antibodyresponse for bladder cancer, original or recrudescentand its sensitivity was 100% and specificity was 95%.Futhermore, Yale University Research Group used One-Step antibody response to test the survivin in urine andfound sensitivity was 100% and specificity was 95%[14]. The expression of survivin has a dose-dependentrelationship with the pathologic grades of TCC, but itis not correlated with multicentricity and recurrencerisk [17]. It has been shown before that survivinexpression is higher and more frequent in high-gradetumors or later stages of cancer development [18-21]. Inaccordance with this observation, survivin did notdetect cases with papilloma or low-grade bladder cancerin UroScreen study [22], whereas the sensitivity wasbetter for high grade tumors. If this could be confirmed,

Prof. Rajeev T.P. at el: Diagnostic and Prognostic Value

8 JASA, Vol. 23, No. 1, January - April, 2016

BIBLIOGRAPHY :1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics,.CA Cancer J Clin. 1998;48:6-29.2. Guo M, Hay BA. Cell proliferation and apoptosis. Curr Opin Cell Biol.1999;11:745-52.3. LaCasse EC, Baird S, Korneluk RG, MacKenzie AE. The inhibitors of apoptosis (IAPs) and their emerging role

in cancer. Oncogene 1998;17:3247-59.4. Adams JM, Cory S. The Bcl-2 protein family: arbiters of cell survival. Science Review 1998;281:1322-6.5. O'Driscoll L, Linehan R, Clynes M. (2003) Survivin: role in normal cells and in pathological conditions. Curr

Cancer Drug Targets 2003;3:131-52.6. Velculescu VE, Madden SL, Zhang L, et al. Analysis of human transcriptomes. Nat Genet 1999;23:387-8.7. Altieri DC, Marchisio PC. Survivin apoptosis: an interloper between cell death and cell proliferation in cancer.

Lab Invest.1999;79:1327-33.8. Ambrosini G, Adida C, Sirugo G, Altieri DC. Induction of apoptosis and inhibition of cell proliferation by

sruvivin gene targeting. J Biol Chem 1998;273:11177-82.9. Tanaka K, Iwamoto S, Gon G, Nohara T, Iwamoto M, Tanigawa N. Expression of survivin and its relationship to

loss of apoptosis in breast careinomas. Clin Cancer Res 2000;6:127-34.10. Ku JH, Kwark C, Lee HS, Park HK, Lee E, Lee SE. Expression of survivin, a novel in inhibitor of apoptosis, in

superficial transitional cell carcinoma of the bladder. J Urol 2004;171 (2Pt1):631-5.11. Monzo M, Rosell R, Felip E, Astudillo J, Sanchez JJ, Maestre J, et al. A novel Anti-apoptosis gene: re-expression

of survivin messenger RNA as apoptosis marker in non-small-cell lung cancers. J Clin Oncol 1999;17:2100-4.12. Lu CD , Atieri DC, Kawasaki H. Expression of a novel antiapoptosis gene, survivin, correlated with tumor cell

apoptosis and p53 accumulation in gastric carcinomas. Cancer Res 1998;58:1808-12.13. Saitoh Y, Yaginuma Y, Ishikawa M. Analysis of bcl-2, bax and survivin genes in uterine cancer. Int J Oncol

1999;15:137-41.14. Smith SD, Wheeler MA, Plescia J, Colberg JW, Weiss RM, Altieri DC. Urine detection of survivin and diagnosis

of bladder cancer. JAMA 2001;285:324-8.15. 8. Fuessel S, Kueppers B, Ning S, Kotzsch M, Kraemer K, Schmidt U, et al. Systematic in vitro evaluation of

surviving directed antisense oligodeoxynucleotides in bladder cancer cells. J Urol 2004;171(6Pt1): 2471-6.16. Shamp JD, Hausladen DA, Maher MG, Wheeler MA, Altieri DC, Weiss RM. Bladder cancer detection with

urinary survivin, an inhibitor of apoptosis. Front Biosci 2002;7:E36-E41.17. Gazzaniga P, Gradilone A, Giuliani L, Gandini O, Silvestri I, Nofroni I, et al. Expression and prognostic

significance of LIVIN, SURVIVIN and other apoptosis-related genes in the progression of superficial bladdercancer. Ann Oncol 2003;14: 85-90.

18. Shariat SF, Karakiewicz PI, Godoy G, Karam JA, Ashfaq R, et al. Survivin as a prognostic marker for urothelialcarcinoma of the bladder: a multicenter external validation study. Clin Cancer Res 2009;15:7012-9.

survivin might be a useful adjunct for the follow-up ofpatients with faster growing tumors where detectionshould be as early as possible. Here, a non-invasivemarker panel would be a promising approach to detectrecurrence sooner and reduce the number ofcystoscopies [23]. Nevertheless, individual molecularmarkers are currently lacking sufficient sensitivity toreplace cystoscopy. In this experiment, the expressionlevel of survivin varied with the pathologic grades ofTCC, which suggested an association between them.The higher the expression levels of survivin, higher thegrade and the more differentiate and malignant degreethe TCC is. In different clinical stages, the expressionlevels vary similarly. This experiment has theadvantage of high sensitivity, availability of materialswithout traumatic procedures. It is significant for the

assessment of the malignant degree and to predict theprognosis and treatment option and the duration oftreatment.CONCLUSION :

The preliminary results of the studies on theexpression of survivin have shown that it can be avaluable marker for bladder cancer. We found that urinesurvivin provides a higher sensitivity and higher orequal specificity compared to urine cytology in allgrades of urothelial tumors of bladder. Higher positivityrate in high grade tumour has prognostic significance.More studies are required for better clarifying thediagnostic and prognostic values of urine survivin inbladder cancer.

Prof. Rajeev T.P. at el: Diagnostic and Prognostic Value

9JASA, Vol. 23, No. 1, January - April, 2016

19. Adida C, Haioun C, Gaulard P, Lepage E, Morel P, et al. Prognostic significance of survivin expression in diffuselarge B-cell lymphomas Blood 2000;96:1921-5.

20. Kren L, Brazdil J, Hermanova M, Goncharuk VN, Kallakury BV, et al. Prognostic significance of anti-apoptosisproteins survivin and bcl-2 in non-small cell lung carcinomas: a clinicopathologic study of 102 cases. ApplImmunohistochem Mol Morphol 2004;12:44-9.

21. Takai N, Miyazaki T, Nishida M, Nasu K, Miyakawa I. Survivin expression correlates with clinical stage,histological grade, invasive behavior and survival rate in endometrial carcinoma. Cancer letters 2002;184:105-16.

22. Johnen G, Gawrych K, Bontrup H, Pesch B, Taeger D, et al. Performance of Survivin mRNA as a Biomarker forBladder Cancer in the Prospective Study UroScreen. PLoS ONE 2012;7(4):e35363.

23. Sanchez-Carbayo M, Urrutia M, Gonzalez de Buitrago JM, Navajo JA. Utility of serial urinary tumor markers toindividualize intervals between cystoscopies in the monitoring of patients with bladder carcinoma. Cancer2001;92: 2820-8.

Prof. Rajeev T.P. at el: Diagnostic and Prognostic Value

eSPIRITUALHow to Be Happy and HealthySomebody once asked Lord Buddha, "After meditatingfor years, I have not been able to gain anything." ThenLord Buddha asked, "Did you lose anything?" Thedisciple said, "Yes, I lost my anger, desires, expectationsand ego." Buddha smiled and said, "That is what yourgain is by meditating."To be happy, one must learn to let go the following:

o One should let go the desires. In Amarnath KiYatra, Lord Shiva firstly let go of the Bull, whichrepresents the sexual desires. In Hanuman kiLanka yatra, desires are represented bySamhiki, a creature who used to catch birds bytheir shadow. Hanuman killed the desires. So,it is possible to kill your desires.

o Again in Ramayana, desires are linked to Rajsikmind and in mythology, Meghnath represents theRajsik mind. Meghnath was killed by Lakshman,the determined mind. Therefore, one should let go ofthe desires by killing them by focused concentrationof the mind on the desires.

o Let go of your expectations. In Amarnath KiYatra, the second thing which Lord Shivadiscarded was the moon, which in mythologyis symbolized by letting go of expectations.

o Let go of your ego. In mythology, ego representsKansa in Krishna era and Ravana in Rama era.Both were killed by Krishna and Ramarespectively, who symbolize the consciousness.Ego can never be killed by the mind and can bekilled only by the consciousness (conscious-based decisions).

o Ego is also represented by Sheshnaag and we haveLord Shiva and Lord Vishnu both having aSheshnaag each with a mouth downwardsindicating the importance of controlling one's ego.

o One should let go his or her ego but alsoremember never to hurt somebody's ego.Hurting somebody's ego in terms of allegationsof sexual misconduct, financial corruption or

abusing one's caste is never forgotten andcarries serious implications.

o In Hanuman Ki Lanka Yatra, ego is representedby Sursa and Hanuman managed her byhumility and not by counter ego. In NaagPanchami also, we worship Naag, the ego, byfolded hands and by offering milk.

o Let go of your inaction. One should learn to livein the present. In Hanuman Ki Lanka Yatra,Hanuman first meets Menak Mountain, whichindicates destination to rest. One should neverdo that and willfully divert his or her mindtowards action.

o Let go of your attachments. Let go of yourattachments to your close relatives and theworldly desires. In Amarnath Ki Yatra, LordShiva first leaves Bull (desires), moon(expectations), sheshnaag (ego) and then hegives up Ganesha and worldly desires (fiveelements). In mythology, this is practiced asdetached attachment and in Bhagavad Gita isequated to Lotus. In Islam, detached attachmentis practiced in the form of Bakra Eid.

o Let go of your habit of criticizing, complainingand condemning people. One should alwayspractice non-violent communication and speakwhich is truth, necessary and kind. One shouldnot criticize, condemn or complain aboutpeople, situation and events. Wayne Dyer said,"The highest form of ignorance is when youreject something you do not know anythingabout."

o Most of us often condemn people withoutknowing their capabilities and label them asunmatchable to us. One should also let go habitof gossiping as it is a form of violentcommunication.

o Let go of your habit of blaming others: Oneshould learn to take the responsibilities andpeople believe in team work. Good leader is theone who learns to be responsible in life.

10 JASA, Vol. 23, No. 1, January - April, 2016

Introduction :

Hydrocephalus is one of the most common congenital neurosurgicalproblems which can lead to significant mortality and morbidity, if leftuntreated. Incidence of congenital hydrocephalus in India is 0.2-2.5 per 1000live birth [1]. Despite significant advances in the treatment of Hydrocephalusduring last 5 decades, it is still regarded as a challenge. Treatment ofhydrocephalus consists of placement of a shunt system within the brain,

Original Article

VP shunt malfunction in children :an analysis of risk factors.

ABSTRACTPurpose : Ventriculoperitoneal shunt (VPS) is the gold standard treatmentfor hydrocephalus. Shunt malfunction is the most common complicationfollowing VP shunt surgery. These may be more common in developingcountries due to poor socioeconomic conditions and lack of adequateresources. This study analyses the causes and risk factors of VPSmalfunction in a tertiary care hospital.Methods : This is a prospective study spanning one year and includedchildren below 15 years who had undergone VPS surgery forhydrocephalus. The various factors responsible for shunt complicationswere analyzed by Fisher Exact T-test and Chi square tests.Results : Among 34 cases of hydrocephalus operated during the studyperiod 12 cases had shunt malfunction. Causes of hydrocephalus wereobstructive in 67.5%, communicating type in 22.5% and spinaldysraphism in 10%. Shunt malfunction was more common during infancy.Median period following shunt insertion to shunt malfunction was 30days. Fever and convulsions were the most common presenting features.Most common cause of shunt malfunction was shunt infection. Risk factorsfor shunt infection were preterm delivery, CSF pleocytosis and CSFneutrophillia. Children with obstructive type of hydrocephalus hadhigher risk of developing shunt infection. Increased frequency of Shuntmalfunction were also found among children from lower socioeconomicstatus and children with delayed developmental milestones.Staphlococcous aureus was the most common infecting organism in theseries. Mortality rate following VP shunt surgery was 7.5%.Conclusion : Prevalence of shunt malfunction and shunt infection werewithin acceptable limits at our institute. Younger age of shunt insertion,preterm baby, raised CSF cell counts and CSF neutrophilia, developmentaldelay, obstructive type of hydrocephalus were independently associatedwith shunt complications.

Dr. Tamajyoti Ghosh1

Dr. H.K.Dutta2

Dr. R.K.Bhuyan3

1 PG student,Dept. of Surgery,2 Associate Prof.,Dept. of Pediatric Surgery,3 Professor,Dept. of Surgery,Assam Medical College & Hospital,Dibrugarh, Assam.

Corresponding Author :Dr. H. K. Dutta,E mail: [email protected]

Key Words : Ventriculoperitoneal shunt; Shunt malfunction; Shuntinfection;hydrocephalus.

11JASA, Vol. 23, No. 1, January - April, 2016

which diverts the flow of CSF from within the CNS to asite outside the CNS where it can be absorbed by thecirculatory system.

Shunt Malfunction depends upon the age ofsurgery as well as the procedure of shunt insertion[2,3].As it constitutes a significant cause of morbidity andmortality among children undergoing VP shunt surgery,early detection of malfunction becomes necessary. Thevarious risk factors of shunt malfunction are gender,age, sex, etiology of hydrocephalus and other associatedinfections in other parts of the body [3,4]. VPSmalfunction leads to either over or under drainage ofCSF which has its detrimental effects on the CNS. Thesigns and symptoms of VPS malfunction are headache,blurred vision, seizure, drowsiness, delayed cognitivefunction, loss of previous acquired skill, memory lossand poor motor co-ordination. Approximately 56% to80 % of patients will experience at least one episode ofVPS malfunction in 10 years following shunt insertionand the annual rate of shunt malfunction is estimatedto be 5% [5,6]. The signs and symptoms of VPSmalfunction are very subtle and overlap with commonchildhood illness in approximately 30% of cases. Thusearly detection is necessary to prevent neurologicaldeficit and improved quality of life of the patients.Recent studies show that shunt infection constitutesapproximately 15-30% of shunt malfunctions andamong different infectious agents, coagulase negativeStaphylococcus aureus reported in majority of the cases[7]. Early detection and prevention of shuntmalfunction will help in reducing unnecessary cost ofhealth expenditure and radiation exposure to children.In this study evaluation of the causes and risk factorsas well as microbiological profile of shunt malfunctioncases in our institute was carried out with an objectiveto find out if any of the risk factors and CSF parametershave any predictive values in the diagnosis of earlyshunt malfunction.

Mathrials and Methods :

All cases of Hydrocephalus <15 years of ageadmitted during one calendar year were included inthe study. Previously operated cases of VP shunt whopresented with shunt malfunction during the periodwere also included in the study. Data collectedregarding patient's age, sex, gestation period, birthweight, developmental history, age of initial shuntinsertion, time since initial shunt insertion to shuntmalfunction, socioeconomic status, type ofhydrocephalus, clinical manifestation, blood andradiological investigations and CSF analysis during

initial shunt placement. Patients on non operativemanagement and patients with shunt malfunctionfollowing shunt surgery done outside our institute wereexcluded from the study. Data from the entire studywas collected and analyzed by SPSS 16 software. Chisquare test with Yates correction were used to find outthe association of different variables studied.

Confounding factors regarding the type of shuntand method of shunt placement were removed byplacing same type of Chhabra type (slit and spring) ofVP shunt and insertion of the shunt through anteriorhorn of dilated lateral ventricles.

Definitions and criterias:

Hydrocephalus was defined as headcircumference >98th percentile or 2SD for gestationalage during infancy. In older children triad of headache,vomiting and lethargy is present in hydrocephaluspatients along with other signs of raised intracranialpressure and radiological signs were used fordiagnosis of hydrocephalus [8].

Shunt Malfunction was defined as partial orcomplete blockage of the VP shunt that causes it tofunction intermittently or not at all. Shunt malfunctionwas diagnosed in a previously operated VP shuntpatient who presented with signs of raised intracranialpressure and after confirmation of the diagnosis by

Table 1: Overtuff's criteria for shunt infection [11]

DEFINITE SHUNTINFECTION

PROBABLE SHUNTINFECTION

Compatible signs andsymptoms

Compatible signs andsymptoms

PLUS CSF consistent with bacterialinfection.

Isolation of bacteria fromdevice puncture,

Negative blood, CSF anddevice culture for bacteria.

Lumbar puncture or othersignificant site (overlyingshunt wound, cellulitis orshunt or shunt tubing)

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12 JASA, Vol. 23, No. 1, January - April, 2016

radiological investigations. Overtuff's criterias wereused to diagnose shunt infection (Table 1).

BG Prasad index of socioeconomic scale was takenas standard for stratification of cases on socioeconomicbasis [13]. WHO cutoff for motor development wasused for assessing child's mental development [14].

Results :

A total of 34 cases (M=17, F=17) of hydrocephaluswas operated during the study period out of which 12cases (M=7, F=5) malfunctioned constituting 35.29%. 6previously operated cases (M=3, F=3) of VP shunt camewith malfunction during the period. The age of thepatients ranged from 2 days to 11 year old. Majority ofthe patients were born full term (n=33) , only 7 cases(M=4,F=3) were born prematurely (17.5%). 36 patients(90%) were born by normal vaginal delivery whereas 4patients were delivered by Caesarian section (10%). 22patients (M=15, F=7) belonged to Class IV SES while 9patients (M=5, F=4) was classified to SES class II. Rest7(17.57%) female hydrocephalus patients were fromSES Class III while Class V had only 2 female (5%)patients. 7 cases (M=4,F=3) were registered with birthweight <2.5kg while rest 33 hydrocephalus patients(M=16, F=17, 82.5%) had normal birth weight of >2.5kg.19 patients (M=8, F=11, 47.5%) had developmentaldelay at the time of presentation while 21hydrocephalus cases (M=12, F=9, 52.5%) achieved theirdevelopmental milestone on time. The mortalityfollowing VPS at our institute was 7.5%. (Table 2)

The most common type of hydrocephalus was ofObstructive variety (n=17, 67.5%) followed bycommunicating type (n=9, 22.5%) and SpinalDysraphism was present in 4 cases (n=10%)

Shunt malfunction :

Out of 34 cases 12 patients (M=7, F=5, 35.29%)developed shunt malfunction during the study period.Age of the patients developing shunt malfunctionranged from 9 day to 7 years with a median age ofpresentation at 1.8 years (Fig. 1). Majority of shuntmalfunction occurred during infancy (77.7%). No shuntmalfunction cases were noted in patients >10 year old.61.66% of VP shunt malfunction cases (n=11, M: F=6:5) occurred within 3 months of initial shunt insertion.Median period since shunt insertion to malfunction was30 days (Fig. 2). Most common cause of hydrocephalusresulting in shunt malfunction was due to Aqueductalstenosis, an obstructive type of hydrocephalus (n=15,M=7, F=8, 83.33%). 3 cases of Post Tubercular

Table 2: Demography of the patients:

Number (%)Male 20 (50)

Female 20 (50)Mean age 1.4 years

Infants 30 (75)Older children

(> 1yr)10 (25)

NVD 36 (90)LSCS 4 (10)

Full term 33 (82.5)Preterm 7 (17.5)< 2.5 kg 7 (17.5)> 2.5 kg 33 (82.5)Class I 0Class II 9 (22.5)Class III 7 (17.6)Class IV 22 (55)Class V 2 (5)Present 19 (47.5)

Absent 21 (52.5)3 (7.5%)

Socioeconomic

status

Developmental delay

Mortality

CharacteristicsSex

Age

Mode ofdelivery

Maturity

Birth weight

meningitis hydrocephalus developed shuntmalfunction (M:F= 2:1, 7.5%). No shunt malfunctionwas noted in 4 cases of spinal dysraphism.

Convulsion and Fever were the most commonpresentation in patients with shunt malfunction in22.22% cases, followed by Drowsiness in 16.66%,enlargement of head was presenting feature of shuntmalfunction in 3 cases (16.66%) and 2 female patientsof shunt malfunction presented with septic wound(11.11%).

Infection was the most common cause of shuntmalfunction in 38.9%, followed by distal shuntmigration which occurred in 27.8%, Shunt malfunctionin 22.2% was due to proximal shunt migration. 1 malepatient each developed shunt malfunction due toDistal and proximal shunt block.

Dr. Tamajyoti Ghosh at el: VP shunt malfunction in children

13JASA, Vol. 23, No. 1, January - April, 2016

Shunt infection :A total of 5 (14.7%) out of 34 cases operated during

the study period had shunt infection. Most commonmicroorganism causing shunt infection was Grampositive cocci Staphylococous aureus in 42.85% (n=3)cases followed by Gram negative bacilli Pseudomonasaeruginosa in 28.57% (n=2) cases and Gram negativecocci Klebsiella pneumoniea in 28.57% (n=2) cases.Antibiotic sensitivity of the infected CSF showed theorganisms were sensitive to Imipenem and Meropenemin 5 out of 7 cases.

The most common extra CNS site of infectionleading to development of shunt complication was

Fig 1 : Distribution of shunt malfunction casesaccording to age of initial shunt insertion

Fig 2 : Showing the age of presentation of shuntmalfunction cases.

Table 3 : Risk factors of shunt malfunction:

Number (%) P value< 1 year 6 (85.7)> 1 year 1 (14.3)

Male 4 (57.1)Female 3 (42.9)

Obstructive 7 (100)Communicating 0

< 2.5 kg 2 (28.6)> 2.5 kg 5 (71.4)

Term 5 (71.4)Preterm 2 (28.6)

NVD 7 (100)LSCS 0Low 6 (85.7)

Middle 1 (14.3)Glucose <40

mg/dl4 (57.1) 0.7487

Protein > 45mg/dl

4 (57.1) 0.8416

Pleocytosis >10/cc

6 (85.7) 0.009

Neutrophillia >10%

7 (100) 0.006

Socioeconomic

status

CSF analysis

Birth weight 0.7633

Pregnancy 0.0014

Mode ofdelivery

1

FactorsAge 1

Sex 1

Etiology 0.0104

respiratory tract infection in 3 cases, followed by skininfection in 2 cases and neonatal hyperbillirubinemiain 1 patient.

While evaluating risk factors for shuntmalfunction, it was found that age (p=1), sex (p=1),

mode of delivery(p=1), socioeconomic status(p=0.2099), birth weight(p=0.7633) and CSF glucose(p=0.7487) and protein levels (p=0.8416) during initialshunt placement had no significant association inpredicting shunt infection while prematurity(p=0.0014), type of hydrocephalus (p=0.0104) and CSFpleocytosis (p=0.009) especially CSF neutrophillia(p=0.006) were independently associated withdevelopment of shunt infection. (Table 3)Discussion :

The causes of VP shunt malfunction aremultifactorial. The yearly occurrence of VP shuntmalfunction at our institute is 35.5% which was foundto be well within the range published in various Asianand Sub Saharan reports [12,13]. However a lot of effortis required in bringing the rate of malfunction furtherto the level of Western countries. Similarly the frequencyof shunt infection was found to be 14.7% which wasalthough comparable to rates of shunt infection invarious developing countries, but significantly higherthan in western countries [14,15]. There was slight malepreponderance in our study which was consistent to

Dr. Tamajyoti Ghosh at el: VP shunt malfunction in children

14 JASA, Vol. 23, No. 1, January - April, 2016

other published literatures, but it did not have a bearingon shunt malfunction [16]. 72% of shunt relatedcomplications at our institute occurred during shuntinsertion at infancy. The median period of shuntmalfunction in this study was 9.5 months and that ofshunt infection was 3.14 months which were consistentwith the results of other series [17,18]. One possiblereason for younger age of VPS being more susceptiblefor shunt related complications and early shuntmalfunction may be due to immaturity of the bloodbrain barrier and immunity of infants making them moreexposed to infection. Our study showed majority of theshunt malfunction occurred within 1-3 months of initialshunt insertion with a median period of 1 month.

The most common type of hydrocephalus toundergo malfunction at our institute was obstructivevariety. Although no significant correlation was foundbetween the etiology of hydrocephalus and shuntmalfunction unlike other studies [20]. Majority of shuntmalfunction cases at our institute presented with feverand convulsions which was similar to earlier studies[15,18]. Respiratory tract infection is the most commonfoci for dissemination of infection to intracranial shuntfollowing shunt surgery, as reported by few orther series[20]. Although Streptococcus epididermis is thecommonest organism isolated in shunt infection cases,our series noted Staphylococcous aureus as the mostfrequent organism [12,18]. Majority of shuntmalfunction and shunt infection cases occurred in poorsocio economic group of children. However nostatistically significant association could be foundbetween socioeconomic status of the family and shuntmalfunction.

An interesting finding in our study was theassociation between developmental delay and shuntmalfunction. Although it is difficult to attribute

developmental delay as a risk factor for shuntmalfunction as degree of venticulomegaly confers tothe outcome of mental development. Also it is difficultto to discern the difference between the effect caused byhydrocephalus itself and underlying damage to neuralfunction by the cause of hydrocephalus from that ofshunt malfunction.

Earlier studies have shown prematurity as a riskfactor for shunt malfunction, which was also observedin the present series [21]. It is believed that immatureimmune system of LBW and preterm babies expose thebabies to the risk of shunt infection. We found babiesborn following normal vaginal delivery to be moresusceptible for shunt infection , however, there is nostudies supporting our observation. Low glucose andraised protein level in CSF commonly observed in casesof meningitis, however was not seen in patients whodeveloped shunt infection [22,23]. We have observedan association between shunt infection and CSFpleocytosis at the time of shunt insertion as reported byfew earlier studies [24]. But the impact of CSF cellcounts on shunt infection is difficult to interpret becauseCSF cell counts may rise during initial shunt insertiondue to aseptic inflammation of meninges and also thereis no definite cut off value regarding raised CSF countdepicting shunt infection.Conclusion :

Shunt malfunction was more common amongneonates and infants and usually seen during the firstthree months of shunt surgery. Infants and patientsbelonging to lower socioeconomic group, pretermbabies, and babies having developmental delay shouldbe evaluated more frequently during post-shunt period.CSF analysis during shunt insertion should helpidentify high risk group.

References :1. Venkatramana NK. Hydrocephlus, Indian Senario- A review,. Journal of Pediatric Neuroscience 2011; 6

(Suppl1):S11-S22.2. Gasco J, Mohanty A, Hanbali F, Patterso JT, Cerebrospinal fluid shunts, Neurosurgery, Sabiston's Textbook Of

Surgery, 19th Ed., Elsevier Saunders, Philadelphia, 2013; Pp. 1907-8.3. Pena AA, sandia ZR, Riveros PR, Salazar ZC, Herrera OR, Verqara FR. Risk factors for Ventriculoperitoneal

Shunt Infection in pediatric patients from the Hospital of Carlos Van Buren, Rev Chilena Infectol 2012;29(1):38-43.

4. Reddy GK, Bollam P, Caldito G. Long term outcomes of Ventriculoperitoneal shunt surgery in patients withhydrocephalus. World Neurosurg 2013;81(2);404-10.

5. Sainte-Rose C, Piatt JH. Pierre-Kahn A. Mechanical Complications of shunts. Pediatric Neurosurgery, 1992;17:2-9.

6. Madikians A, Conway E. Cerebrospinal shunt problems in Pediatric patients, Pediatric Ann 1997; 26:613-20.7. Gray W, Bulstrode H. Hydrocephalus management, Electective Neurosurgery. Bailey's and Love's Short Practice

Of Surgery, CRC Press New York, 2007;613-4.

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15JASA, Vol. 23, No. 1, January - April, 2016

8. Dincer A, Ozek MM. Radiologic Evaluation of Pediatric Hydrocephalus,Child Nervous System, 2001; 27(10):1543-62.

9. Overturf GD. Defining bacterial meningitis and other infections of the central nervous system. Pediatr CritCare Med . 2005;6(suppl):S14-18 .

10. Dudala SR, Reddy KA K, Prabhu GR. [source Internet] Prasad's socioeconomic status classification. An updatefor 2014. Int j Res health science, 2014;2(3): 875-8.

11. WHO Multicentric Growth Reference Study Group, WHO Motor Development Study; Acta Pediatrics 2006;450:86-95.

12. Mwang'ombe NJM and Omulo T. Ventriculoperitonael shunt surgery and shunt infections in children with nontumour Hydrocephalus at the Kenyatta National Hospital , Nairobi. East African Medical Journal 2000;77(7):386-90.

13. Piatt JH jr and Garton HJ. Clinical Diagnosis of Ventriculoperitoneal shunt failure among children withHydrocephalus, Pediatric Emergency Care 2008; 24(4):201-10.

14. Kinasha AD A, Kahamba JF, Semali IT. Complications of Ventriculoperitoneal Shunts in Children in Dar esSalaam. East and Central African Journal of Surgery. 2005;10(2):55-9.

15. Bokhary MM Aly , Kamal HM. Ventriculo-Peritoneal Shunt Infections in Infants and Children. Libyan J Med .2008;3(1):20-2.

16. Ghritlaharey RK, Budhwani KS, Shrivastava DK, Srivastava J. After Ventriculoperitoneal shunt complicationsneeding shunt revision in children: A review of 5 years of experience with 48 revisions. J Paed Surg 2012;9(1):32-9.

17. Maruyama H, Nakata Y, Kanazawa A, Watanabe H, Shigemitsu Y, Iwasaki Y et al. Ventriculoperitone- al shuntoutcomes among infants. Acta Med. Okayama. 2015;69(2):87-93.

18. Lee JK, Seok JY, Lee JH, Choi EH, Phi JH, Kim S, Wang K et al. Incidence and Risk Factors of VentriculoperitonealShunt Infections in Children: A Study of 333 Consecutive Shunts in 6 Years. J Kor Med Sc 2012;27:1563-8.

19. Brydon HL, Hayward R, Harkness W, Bayston R . Does the cerebrospinal fluid protein concentration increasethe risk of shunt complications?. Brit J Neurosurg 1996;10(3):267-73.

20. Renier D, Lacombe J, Pierre-Kahnn A, Sainte-Rose C, Hirsch J. Factors causing acute shunt infections: A computeranalysis of 1174 operations. J Neurosurg 1984;61:1072-8.

21. Kebriaei MA, Shoja MM, Salinas SM, Falkenstrom KL, Sribnick EA, Tubbs RS et al. Shunt infection in the firstyear of life. J Neurosurg Pediatrics. 2013;12(1):44-8.

22. Stamos JK, Kaufman BA, Yogev R. Ventriculoperitoneal shunt infections with gram-negative bacteria.Neurosurgery. 1993;33(5):858-62.

23. Connen A, Walti L N, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and Treatment Outcome ofCerebrospinal Fluid Shunt-Associated Infections in Adults: A Retrospective Analysis over an 11-Year Period.Clinical Infectious Diseases. 2008;47:73-82.

24. Lan CC, Wong TT, Chen SJ, Liang ML, Tang RB. Early diagnosis of ventriculoperitoneal shunt infections andmalfunctions in children with hydrocephalus. J Microbiol Immunol Infect. 2003;36(1):47-50.

Martin F. D'Souza vs Mohd. Ishfaq, 3541 of 2002, dated 17.02.2009

"… simple negligence may result only in civil liability, but gross negligence or recklessness may result incriminal liability as well. For civil liability only damages can be imposed by the court but for criminalliability the doctor can also be sent to jail (apart from damages which may be imposed on him in a civil suitor by the consumer fora). However, what is simple negligence and what is gross negligence may be a matterof dispute even among experts."

Legal Quote

Dr. Tamajyoti Ghosh at el: VP shunt malfunction in children

16 JASA, Vol. 23, No. 1, January - April, 2016

Introduction : Fistula in ano is one of the commonest diseases treated by the general

surgeons. The surgeon who has the opportunity to treat patient initially isthe one most likely to limit the morbidity and to minimise the disabilities likefaecal or flatus incontinence and recurrence. However, the improved surgicaltechnique and antimicrobial agents have contributed to towards improvedpatient outcome and so also decreased morbidity. Recent advances in theinvestigations of fistula in ano like endoanal or endorectal ultrasonography(USG), Magnetic Resonance (MR) fistulogram, CT scan have replacedconventional fistulography and have become more useful to both surgeonsand the patient due to accurate delineation of the anatomy of the fistuloustract. Our study was designed to evaluate the various types of presentationand different modalities of management of fistula in ano with theircomplications.Materials and Method :

This was a prospective study of 50 patients of fistula in ano over aperiod of one year. The study was approved by the institutional ethicscommittee. All the cases were admitted in the hospital and managed as per

Original Article

Fistula in ano : a clinical study

ABSTRACTBackground : Although there are various methods of surgery for fistulain ano, there are still some controversies regarding its management. Thisstudy aimed to evaluate the surgical anatomy of Fistula in ano, theirmode of presentations, treatment modalities and complications at a tertiarycare centre in Assam.Methods : The study was conducted over a period of twelve months fromJuly, 2014 to July, 2015. Fifty patients diagnosed to have fistula in anowere subjected to various surgical procedures. The patients were assessedduring post-operative period to find out recovery and any residualsymptoms or complications.Results : The most common age group was 30 to 39 years with male tofemale ratio being 11.5: 1. Forty two patients (84%) had history of anorectalabscess. Fissure in ano was present in 20% and diabetes mellitus in 10%of the cases. Low anal variety was the predominant type (76%) and MRfistulogram was found to be a better investigation for complex type offistula. Excellent results were obtained in 88% case, good in 4% cases,fair in another 4% cases and recurrence was noted in 4% cases.Conclusion : MR fistulogram was a better investigation for complexfisula in ano. Fistulotomy, rather than fistulectomy was a better choice ofsurgery for low anal fistula.

Dr. M. Talukdar*Dr. Rajesh Paul**Dr. Sankamithra G**

Corresponding author*Assistant Professor,Department of Surgery,Silchar Medical College and HospitalSilchar, Ghungoor , Pin : 788014Contact no: (M) 9435172184Email id: [email protected]**Post Graduate Trainee,Department of Surgery,Silchar Medical College and HospitalSilchar.

Key Words : Fistula in ano; MR fistulogram; fistulotomy; fistulectomy.

17JASA, Vol. 23, No. 1, January - April, 2016

standard recommendation [1-3]. Follow up of the caseswere done from a minimum period of 3 weeks to amaximum period of one year. The patients wereevaluated in terms of relief of symptoms, healing of thewound, recurrence rate and postoperativecomplications, especially functional defects like analcontinence.

Detailed history including the past history ofanorectal abscess and of previous surgery was taken.The mode of presentation, other co-morbid conditionslike diabetes, the findings on clinical examination(digital examination and proctoscopy) were recorded.If the internal opening could not be identified, thepatient was subjected to an appropriate imagingmodality like conventional fistulogram, MR fistulogrametc. Any associated haemorrhoid or anal fissure wasnoted. Diabetic patients were referred to the physicianfor optimal management of blood sugar level.

Enema was used for preoperative bowelpreparation. Spinal anesthesia was preferred as itprovides adequate muscle relaxation. The patient wasplaced in lithotomy position. A digital examinationand proctoscopy was performed. The tract wasidentified by gentle probing from the external opening.Methylene blue or hydrogen peroxide was injected fromthe external opening to delineate the tract and todetermine the internal opening. In fistulotomy, theentire tract from the internal opening to the externalopening was laid open and material was sent forhistopathological examination. The entire tract wasexcised in fistulectomy and sent for histopathologyexamination. Primary closure was an option dependingon the wound size and external sphincture defect. Thepatients were allowed semisolid diet from the secondday onwards, solid from 3rd day with laxative orallyand all the patients were subjected to sitz bath twice aday starting from the second day evening. All thepatients received injectable antibiotics (cefotaxim-sulbactum combination and metronidazole). Diabeticpatients were kept under strict glycemic control. Thepatients were followed up at weekly and than atmonthly interval for 6 months and then called afterevery 6 months. A thorough examination of anorectumwas done and were graded as: excellent - no symptomsat all, good - no symptoms but having occasional /slight discomfort, fair - an acceptable result, butcomplaining of regular discomfort and recurrence -recurrence of the signs and symptoms.

The statistical software SAS 9.2; SPSS version 20.0was used for calculations.Results and observation :

Fistula in ano was commonly found between 30and 39 years of age and male were more commonlyaffected than female with a ratio of 11.5:1. Dischargefrom fistula and pain were the common symptoms,followed by pruritus and swelling. Duration ofsymptoms ranged from 4 months to 5 years. 42 patientshad past history of anorectal abscess. The mostcommon associated disease was fissure in ano ( Table1).

Among various types of fistula, the low anal varietywas predominant (76%), followed by high anal (10%),subcutaneous (8%), ischiorectal (4%) and submucous(2%). In 4 patients, MR fistulogram was performed andit clearly demonstrated the fistulous tract. The type ofsurgery performed and the hospital stay are shown inTable 2. Fistulotomy was done in maximum number ofpatients. The least mean duration of stay was noted inpatients who underwent fistulectomy with primaryclosure. Immediate complications were severe pain,retention of urine, haemorrhage and soiling (Table 3).

Histopathology reports of fistulous tracts showedtuberculous pathology in 2 patients and others hadchronic nongranulomatous inflammation.Excellent results of treatment were obtained in 44 cases(88%); good results in 2 case (4%); fair results in another2 cases (4%); whereas failure like recurrence of fistulawas seen in 2 cases (4%).Discussion :

The observations made in the present study wasconsistent with other studies in the literature [3-10].Regarding age at presentation, Despande et al andMarks and Ritchie had similar observation [4,9]. Severalstudies also reported that males are predominantlyaffected in fistula in ano [8-11]. Discharge from thetract was the most common symptom is the presentseries, which was similar reported by few other studies[3,5,12]. Fissure in ano is a common association withfistula in ano, especially with the fistula in posteriorlocation [3] (Table 4).

Beckingham et al7 compared digital rectalexamination in a prospective study with dynamiccontrast enhanced MRI (DCEMRI) followed by surgicalexploration [7]. The authors concluded that DCEMRIhad a sensitivity of 97% and a specificity of 100% in thedetection of anal fistula. A fistulogram in our experiencehas only provided information regarding the presenceor absence of an internal opening. Table 5 shows theadvantages and disadvantages of conventionalfistulogram, MR fistulogram with the operativefindings.

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18 JASA, Vol. 23, No. 1, January - April, 2016

Lelius reviewed several large series onmanagement of fistula in ano and cited recurrence rateranging from 0 to 9% and anal incontinence from 0 to31% [13]( Table 6). In the present study, we haverecorded recurrence in only 4% of the patients. In anotherstudy on 458 patients over a period of 10 years, Saino etal found nonspecific cause on histology in 90.4% of thecases, while tuberculous infection was noted in only0.2% of the cases [14]. In the present series, we foundtuberculous infection on histology in 2 cases (4.4%) andboth these patients had past tuberculous infection.

Although excellent results were found in most ofthe cases in the present study, the limitation of the studyis that the number of cases is small and follow up isalso short. The follow up of patients is also not uniform.However recently developed procedures like LIFT(ligation of intersphincteric fistula tract), VAAFT (Videoassisted anal fistula treatment), Fibrin glue, fistula plug,LASER therapy, autologous adipocyte derived stem celltreatment etc. are not performed because of lack offacilities [15].Conclusion :

Fistula in ano is a common surgical conditionusually encountered in young and middle aged malesmostly during 3rd and 4th decade of life but also foundin the extremes of ages. The most common presentationis discharge from the external opening and the mostcommon cause is anorectal abscess. There may beassociated fissure in ano or haemorrhoids. MRfistulogram helps in better understanding of complexityand anatomy of a complex fistulous tract. A long termstudy with large number of patients will surely be morerewarding and informative.

Table 1: Associated diseases with fistula in ano

Associated diseases Number ofcases Percentage

Fissure in ano 10 20Internal haemorrhoids 1 2Tuberculosis 2 4Diabetes mellitus 5 10

Table 2: Duration of hospital stay according to thetype of surgery

Type of Surgery Number of

patients (N)

mean duration of

hospital stay

Variance (V) Standard

deviation(SD)

Fistulotomy 24 5.54 days 8.17 2.85

Fistulectomy 19 5.68 days 5.34 2.31

Fistulectomy with

primary closure

5 4.8 days 3.2 1.78

Seton 2 15 days 50 7.07

Table 3: Results of post operative follow up

Type of Surgery Number of

patients (N)

mean duration of

hospital stay

Variance (V) Standard

deviation(SD)

Fistulotomy 24 5.54 days 8.17 2.85

Fistulectomy 19 5.68 days 5.34 2.31

Fistulectomy with

primary closure

5 4.8 days 3.2 1.78

Seton 2 15 days 50 7.07

Table 3: Results of post operative follow up

1st

week3rd

week3rd

month6th-12th

month22 1 Nil Nil1 Nil Nil Nil1 1 Nil Nil1 Nil Nil Nil

Flatus 5 4 2 2Faecal 2 2 1 1soiling 2 2 1 2

Follow up

PainBleedingDelayed healingAbscess formation

Incontinence

Table 4: Comparison of types of fistula in ano indifferent studies

Types offistula`

Despande et al9

(1975) (%)Kumar et al8

(1987) (%)Present study(2014-2015) (%)

Low anal 60 97 76High anal 23.5 0 10Submucous 13 0 2Subcutaneous 2 0 6Ischiorectal 1.5 0 4Pelvirectal 0.5 3 0

Dr. M. Talukdar at el: Fistula in ano : a clinical study

19JASA, Vol. 23, No. 1, January - April, 2016

Table 5: Table showing comparison of fistulogram,MR fistulogram and operative findings.

Cases Fistulogram MRfistulogram

Operativefinding

Intersphincteric Twobranchedfistulous tract

Intersphincteric with 3tracts oneending intoabscess

Same as MRfistulogram

High fistula inano

Perianalsinus

High fistulain ano 2tracts

Same as MRfistulogram

High fistula inano

Single tract Two tractsendingabove thesphinctercomplex

Transphincteric fistulain ano with2 tract andmultipleblind tractsending atvariouslength

High fistula inano

Fistula in ano Suprasphincteric fistula

Same as MRfistulogram

Table 6: Comparison of our study with somerelevant studies in terms of recurrence and

incontinence.

Faeces Flatus Soiling

Hill17 626 1 4 0 0

Lellius13 150 5.5 13.5 0 0

Mazier5 1000 3.6 0.1 0 0

Mc Elwain et al16 1000 3.9 7 0 0

Park and Stitz18

(1976) 156 9 2.2 0 0

Mark and Ritchi4 793 0 17 25 31Our series(2014-

15) 50 4 2 4 4

Authors Number ofpatients

Recurrence(%)

Disturbance in continence (%)

References:1. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery - The biological basis of

modern Surgical practice 19th edition: Saunders: 2012.2. Willims NS, Bulstrode CJK, O'connell PR. Bailey and Love's -Short practice of Surgery. 26th edition: CRC press, 2013.3. Goligher JC. Surgery of the anus rectum and colon by, 5th edition: Bailliere Tindal London, Baillere Tindall, 2002.4. Marks CG, Ritchie JK. Anal fistulas at St Mark's Hospital. Br J Surg 1977; 64(2): 84-91.5. Mazier WP. The treatment and care of anal fistulas: a study of 1,000 patients. Dis Colon Rectum 1971;14(2):134-44.6. Parks AG. The management of fissure in ano. Br J Hosp Med 1969;1:737.7. Beckingham IJ, Spencer JA, Ward J et al. Prospective evaluation of dynamic contrast enhanced magnetic resonance

imaging in the evaluation of fistula in ano. Br J Surg 1996;83:1396-8.8. Kumar R, Gupta AK, Mathur D. Anal Fistula: A Non-operative method of treatment. A report of 100 cases. Ind

J. Sugery 1987;49:239-43.9. Deshpande PJ, Sharma KR, Sharma SK, Singh LM. Ambulatory treatment of fistula-in-ano: results in 400 cases.

Ind J Surgery 1975;37:85-9.10. Khanna RC and Singh W. A Statistical review of 1000 cases of diseases of rectum and anus. Ind J. Surgery

1955;17:143.11. Sohn N, Korelitz BI, Weinstein MA. Anorectal Crohn's disease: definitive surgery for fistulas and recurrent

abscesses. Am J Surg 1980;139(3): 394-7.12. Eisenhammer S. The final evaluation and classification of the surgical treatment of the primary anorectal

cryptoglandular intermuscular (intersphincteric) fistulous abscess and fistula. Diseases of the Colon and Rectum1978;21(4):237-44.

13. Lelius, H.G. quoted by Mazier, W.P., Dis. Col and Rectum 1979;14:2.14. Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol

1984;73(4):219-24.15. Gupta RL. Recent advances in Surgery, Ed. Jaypee Brothers 2016;14: 247- 65.16. McElwain JW, MacLean MD, Alexander RM, Hoexter B, Guthrie JF. Anorectal problems: experience with primary

fistulectomy for anorectal abscess, a report of 1,000 cases. Diseases of the Colon and Rectum 1975;18(8):646-9.17. Hill JR. Fistulas and fistulous abscesses in the anorectal region: personal experience in management. Dis. Colon

Rectum 1967;10:421-34.18. Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Colon Rectum 1976;19:487-99.

Dr. M. Talukdar at el: Fistula in ano : a clinical study

20 JASA, Vol. 23, No. 1, January - April, 2016

Introduction :Bedside clinical teaching is an essential part of teaching. Bedside

teaching includes any kind of training in the presence of the patient, regardlessof the environment in which the training is presented.[1,2] It has beenobserved that bedside teaching is declining.[2-5] Improvement of diagnostictools following advancement of science and technology is cited as one ofreason. One cannot deny that clinical skill is a must for choice of theinvestigations required for a particular patient. Use of clinical skill alsoreduces cost and time necessary for patient care. Moreover interpersonalskills, behavior, ethics and professionalism are learnt at bedside. Bedsideteaching also teaches the learner to be empathic in his dealing with thepatients. From the early days of medical teaching bedside teaching has beenconsidered as an effective method. But, scientific studies about bedsideteaching in surgery are much less than other subjects of surgery. There are

Original Article

A study on student perspective on bedsideteaching

ABSTRACTAims & Objectives : Bedside teaching is declining since 1960s though itis a reliable and effective method of teaching. This study is aimed to findout the view points of the learner on learning through bed side teaching.Methodology : The study was conducted in surgical wards of a teachinghospital. A questionnaire was prepared to collect data from theundergraduate final year students. The questions were on effectivenessof bedside teaching in history taking, physical examination,communication, application of scientific knowledge, self directedlearning, evidence based learning, record keeping, time management andquality of bed side teaching. A five point Likert Scale was used to recordtheir responses.Results : Sixty subjects responded to the questionnaire out of which 76.7%were male and 23.3% were female. 86.67% agreed on effectiveness ofbedside teaching in history taking. All (100%) agreed its effectiveness inlearning physical examination. 93.3% agreed that they had effectivecommunication as a result of bed side teaching, 93.3% agreed that theycould apply basic science knowledge and 83.3% agreed that they acquiredself directed learning, 90% felt that bedside teaching was helpful forevidence based learning. 70% agreed that they learned record keepingand 60% agreed that they learned time management. 90% of respondentsagreed that the quality of bedside teaching was good and 63.3% thoughtthat their bedside learning was inadequate.Conclusion : From learners' point of view bed side teaching is an effectivemethod of learning. More time should be spent in bedside teaching toprovide adequate knowledge to the learner. Measures should be taken tomake bedside teaching more interesting and effective.

Dr. Dipak Kumar SarmaAssociate Professor of Surgery,Gauhati Medical College, Guwahati,Assam, Pin -781032

Corresponding Author:Dr. Dipak Kumar Sarma,Associate Professor of Surgery,Gauhati Medical College, [email protected] Ph. +919864064974(m)

Key Words : Bedside teaching; students; perspective, surgery; Likert scale

21JASA, Vol. 23, No. 1, January - April, 2016

some studies on bedside teaching in literature from theperspective of the teachers and the patients. [6-11] Onlyfew studies are available in literature on bedsideteaching from the perspective of the learners. Suchstudies are unavailable in the region where the studyhas been taken up. This study is aimed at focusing theviews of the learners on different aspects of bedsideteaching.Materials and methods :

The study was conducted in the surgical wards ofa teaching hospital between January, 2014 to June, 2014.A questionnaire was prepared on different aspects ofbedside teaching to collect data from the undergraduatefinal year students. The questions were on theirperceptions about history taking, physical examination,communication, basic sciences, self directed learning,record keeping and time management after bedsideteaching. A five point 'Likert Scale' was used to recordtheir responses as strongly disagree-1, Disagree-2,neither agree nor disagree-3, agree-4 and strongly agree-5. [12] Conventional skills were measured in terms ofimprovement of history taking after bedside teaching,improvement of physical examination after bedsideteaching and improvement of communication capacitywith the patient after bed side teaching. Problem basedlearning was measured by observing the response interms of improvement in application of basic scienceknowledge and self directed learning and evidencebased learning as a result of bed side teaching. Theresponse of the students on usefulness of bedsideteaching in keeping records and managing time, aspart of their development in administrative skills werealso noted in 'Likert scale'. Students' opinion regardingquality of bedside teaching was noted in the said scale.

Learner's preference for location of bedsideteaching (Bedside, Tutorial room or in combination)noted as a direct answer from the student. Opinions onquantity of bedside teaching were also taken as eitheradequate or inadequate.

The questionnaires were distributed after theclinics and ward rounds and responses were collectedwithout having the responder's name or anyidentification sign in it.

Results and Observations: A total of 80 studentswere approached, out of which 60 (75%) responded.Out of these sixty students 76.6% were male and 23.3%were females.

Forty six respondents strongly agreed and 6respondents agreed that their history taking wasimproved after bedside teaching. Overall effectivenessof bedside teaching was 86.67% among the respondents,Fifty two respondents strongly agreed and 8

respondents agreed that their physical examinationimproved following bedside teaching. Overalleffectiveness of bedside teaching was 100%. Forty fourrespondents agreed strongly and 12 respondents agreedthat their communication skill improved followingbedside teaching. The overall effectiveness of bedsideteaching in this area is 93.3%. Thirty eight studentsstrongly agreed and 18 students agreed that their abilityto apply basic science in clinical set up improved afterbedside teaching. The overall effectiveness was 93.3%.Thirty six students strongly agreed and 14 studentsagreed that they developed self directed learningfollowing bedside teaching. Overall effectiveness was83.3% Thirty nine students strongly agreed and 15students agreed that they developed evidence basedlearning. The overall effectiveness was 90%. Twentyeight students strongly agreed and 14 students agreedthat they learned record keeping from bedside teaching.The overall effective response in learning recordkeeping was70%. Nine students strongly agreed and27 students agreed that they learned time managementfrom bedside teaching. The overall effectiveness ofbedside teaching was 60% in this regard. Forty fourstudents strongly agreed and 10 students agreed thatthat they received good quality bedside teaching. Theoverall effective response was 90%.Preferred location for bedside teaching :

Thirty eight students (63.33%) preferred bedsideteaching in combination with a tutorial room. Sixteenstudents (26.67%) preferred bedside teaching near thebed of the patient and six students (10%) preferred it intutorial room.Quantity of teaching :

Majority of students (38 students, 63.33%) feelsthat their teaching at bedside is inadequate. Twentytwo students (36.67%) feel that the quantity of bedsideteaching is adequate for them.Discussion :

Bedside teaching is interdependent between theteacher, student and the patient. So the issues relatedto it can be viewed from the viewpoint of the teacher,student or the patient. There are some studies in theliterature where bedside teaching is analyzed from theperspective of either the teacher or the patient or both.Relatively there is less number of studies where bedsideteaching is observed from the perspective of the student.William K. et al showed in his study that learnersbelieved that bedside teaching is effective in developingof clinical skills. [1] Nair et al observed studentperspective in terms of professional skills like historytaking, physical examination, communication, basicscience, evidence based medicine, self directed learning,

Dr. Dipak Kumar Sarma at el: A study on student perspective

22 JASA, Vol. 23, No. 1, January - April, 2016

History taking :The conventional skills that are gained at bed side

teaching depend on many factors. History taking is animportant skill that is to be learnt at bedside. Historytaking is playing an important role in diagnosis andmanagement of diseases in medicine from its inception.Even now 56% of the diagnosis is derived only from apatient's history.[14] In the study of Nair et al 93% ofthe respondents considered their history taking skillbecame effective as a result of bedside teaching.[9] Inthe study done by Kianmehr N et al more than 90% ofthe medical students expressed their belief that bedsideteaching is the most effective way for learning principlesof history taking, physical examination and practicalskills.[15] In our study 86.67% of the respondent feltthat their history taking became effective followingbedside teaching.Physical Examination :

A good physical examination is considered as aneffective tool for diagnosis in bedside teaching. Acomprehensive physical examination can providediagnosis in 70% of the patients. [14] In the prospectivestudy done by Celenza and Rogers in the emergencydepartment, the learners opined that they learned theskills of history taking, physical examination andclinical reasoning from the bedside teaching.[16] In across sectional study on 70 teachers (clinical andnursing) and 70 students (medical and nursing) it wasfound that a high percentage of students expressed thatthey found bedside teaching effective in acquiringprofessional skills (83%).[17] In our study we havefound that no student have doubt about effectivenessof bedside teaching in acquiring skill in physicalexamination and the effective response rate was 100%..It is worth mentioning that in the study done by AhmedK and Mel B almost all students (99%) felt that theirskill in performing physical examination was becomingeffective following bedside teaching. [14]Communication skills :

There is enough evidence to show thatinterpersonal skills and communication skills havesignificant role in providing patient care. [18-21] In thestudy done by Mosalanejad L et al 72.3% of studentrespondents considered bedside teaching as a suitabletool for learning communication. [17] The humanisticapproach to a patient is learnt at bedside duringcommunication and it is a great tool for building trustbetween the patient and the clinician. The humanisticaspects of medicine cannot be taught in a classroom.[2, 22] The bedside teaching provides an opportunityto the learners to observe an experienced clinician andlearn the humanistic approach in patient care. [23-25]

time management and record keeping. [9] Their moduleis followed more or less in this study to know aboutstudents' perspective in terms of bedside teaching. It isa study based on survey and the study design is corelational research design. Likert type of scale used hereis useful with researchers attempting to measure lessconcrete concepts such as trainee motivation; patientor student's satisfaction etc. [12] Survey researchillustrates the principles of co relational research. It isconsidered as an effective method for describingpeople's opinion, thoughts and feelings.[13] This studyshows that bed side teaching is immensely helpful fora learner in terms of conventional skills and problembased learning although it is not that much helpful interms of administrative skills.

Table: 1 Number and percentage of patients whoresponded to the questions asked in relation to

bedside teachingStronglydisagree,

(number ofrespondents/ Total no)

Disagree,(number of

respondents/ Total no)

Neither agreenor disagree,(number of

respondents/ Total no)

agree,(number of

respondents/ Total no)

stronglyagree,

(number ofrespondents/

Total no)

History takingimprovesfollowing BST

0/60 0/60 Aug-60 Jun-60 46/60

Physicalexaminationskill developsfollowing BST

0/60 0/60 0/60 Aug-60 52/60

Communicationskill improvesfollowing BST

0/60 Feb-60 Feb-60 Dec-60 44/60

Application ofbasic science iseffectivefollowing BST

0/60 0/60 Apr-60 18/60 38/60

Self directedlearningimproves afterBST

O/60 0/60 Oct-60 14/60 36/60

Evidence basedlearningimproves afterBST

Feb-60 Feb-60 Feb-60 15/60 39/60

BST is effectivefor recordkeeping is

O/60 Feb-60 16/60 14/60 28/60

BST is helpfulfor timemanagement

Feb-60 0/60 22/60 27/60 Sep-60

Quality ofbedsideteaching isgood

Feb-60 0/60 Apr-60 Oct-60 44/60

Dr. Dipak Kumar Sarma at el: A study on student perspective

23JASA, Vol. 23, No. 1, January - April, 2016

In our study 93.3% respondents feel that they learnedan effective communication method from bedsidelearning. This is an important observation from theirperspective. This skill will be helpful for them inproviding care to the patient.Application of Basic Science :

Bedside teaching helps the learner to apply his orher knowledge of basic science in a patient in a logicalway. A very high percentage of our respondents (93%)feel that bedside teaching is an effective tool in thisregard. In a study conducted for evaluation of theeducational methods the students expressed that theylearned more about diagnosing in bedside teaching.But their knowledge about the mechanism of diseaseswas lower in bedside teaching than what they gainedfrom the presentation out of the clinical wards. [26] It isnecessary that teacher should stress on both theknowledge and its application at the time of bedsideteaching.Self directed learning :

Learning at bedside is a form of active learning inreal context. It does not only provide the conventionalprofessional skill to the patient. It instills motivation inthe learner and increases his ability to think in aprofessional way by integrating his conventionalclinical skills with communication. It increases hisability to solve clinical problems, understand thepatients' need and to take an ethical decision regardingpatient care. [4, 27-29] This pushes the learner to aprocess of self directed learning. In our study we havefound that 83.9% of the respondents found self directedlearning effective as a result of bedside teaching.Evidence based learning :

Bedside teaching provides a student to get directfeedback from the patient. It helps the learner to thinkcritically about the investigations that are in hand withhim in terms of the patient's ailments and it strengthenslearning from the patient. In one study 82.3% ofrespondents said that bedside teaching enhanced theirknowledge. [17]Record keeping :

Nair and his colleagues found that 55% of therespondents agreed about the effectiveness of bedsideteaching in record keeping and 27% of the respondentsconsidered learning from bedside as enough for recordkeeping practice. [9] In our study seventy percent ofrespondents felt that bedside teaching was effective forthem in record keeping practice.Time management :

In the study of Nair et al 60% of the respondentsagreed and 28% responded as yes enough about

Table 2: Numbers and students who stronglyagreed and agreed to different parameters of

effective bedside teaching

(A)Coventional Skills

(ii)PhysicalExamination

52/60 Aug-60 60/60(100%)

(iii)Communication

44/60 Dec-60 56/60(93.3%)

(B) ProblemBasedLearning(i)Applicationof basicsciences

38/60 18/60 56/60(93.3%)

(ii)Self directedlearning

36/60 14/60 50/60(83.3%)

(iii)Evidencebased learning

39/60 15/60 54/60(90%)

(C)Organisational/Administrative skills(i)Recordkeeping

28/60 14/60 42/60(70%)

(ii)Timemanagement

Sep-60 27/60 36/60(60%)

(D) Quality ofBedsideteaching

44/60 Oct-60 54/60(90%)

Strongly Effectiven/Total

AgreedEffectiven/Total

Total (InPercentage)

(i)HistoryTaking

46/60 Jun-60 52/60(86.67%)

effectiveness of bedside teaching in timemanagement.[9] In our study 60% of respondents feltthat bedside teaching effective for them in managingtime. Commenting on lower percentage of this responseNair et al said that perhaps it was because that theseskills (record keeping and time management) were nottargeted as key learning goals in the clinical teachingof the Newcastle Medical School, where their study wasperformed. [9] It is also doubtful whether bedsideteaching is an appropriate way to teach these skills. Itappears that these skills can be effectively instilled inthe initial postgraduate years. [9]Quality of bedside teaching :

In a study done in United States it was found thatless than five percent time of bedside teaching was spent

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24 JASA, Vol. 23, No. 1, January - April, 2016

for observing learners' clinical skill and correcting theirfaulty examination techniques. [30] In our study,though a very high percentage (90%) of students feltthat the quality of bedside teaching was good, the feelingwas subjective. No parameter was used to judge sucheffectiveness. It is recommended that further studyshould be undertaken to investigate the issues relatedto quality of bedside teaching. Nair et al commentedthat quality of bedside cannot be overemphasizedbecause of its subjective quality. [9] Bedside teaching ismore interactive and challenging for both the learnersand the teachers. It needs experience of a teacher. WangChang et al found in their study that doctors who hadbeen qualified for more than 10 yrs prefer bedsideteaching as a mode of teaching. [7]

Inadequate BST :Many studies show that bedside teaching is not

adequate for a learner in the present context. As ateaching modality it is underutilized. [1] La Combeidentified that actual teaching at the bedside withemphasis on history taking and physical diagnosis hasdeclined from 75% in the 1960s to 16% in 1978 andeven lesser today. [5] Review of literature shows that inthe present era bedside teaching comprises 8% to 19%of the total teaching time. [1] In a study done in UnitedKingdom 35% of the respondents either stronglydisagreed or disagreed that they had a good amount ofsupervised bedside teaching.[31] Nair et al in their studyreported that only 48% of the learners reported theyhad been given adequate bedside teaching during theirundergraduate training. [9] In a study done in 210internal medicine graduates who were trained 10 yearspreviously felt that their bedside teaching wasinadequate for history taking, physical examination,selection of investigations, problem solving skills andinterpersonal skills. [31] A great percentage (63.3%) ofthe respondents in our study believed that their learning

Chart 1:Responses shown according to 'Likert Scale'

from bedside teaching was not adequate enough.Feeling of inadequate learning of bedside teaching bydoctors was also seen in some other studies. [15, 19, 32-35]

Despite the belief that bedside teaching is the mosteffective method to teach clinical and communicationskills, the frequency of bedside rounds is decreasing.In a study done in United States it was found that lessthan 25% of the clinical teaching was done at bedside.[30] It is believed that this is a major factor causing asharp decline in trainees' clinical skills. [2]

The decline in overall clinical skill among traineesand junior faculty was observed in a study done byMangione et al. [36] Time constraints have been shownto be an important factor for insufficient bedsideteaching. The constraint arises from pressure to seemore and more patients, shortened hospital stays,increased present day demands for documentation ofpatient care and preceptors' worry about patientcomfort. [7-9, 37]

B R Nair et al pointed out in their study that it isvery difficult to ascertain whether too little good qualitybedside teaching took place or adequate quality butpoor quantity bedside teaching took place. [9] In ourstudy the parameter of judging quality and quantitywas subjective. There is scope of judging this arena withsome predesigned parameters to minimize the biasnessof the view of the students. Study shows that evaluationof bedside teaching can be done in a formal mannerand it contributes to the quality of medical education.[38]

At present, in many centers clinical skills areincreasingly taught in preclinical courses by integratingclinical scenarios. The effects of this educational reformneed further research to term it as effective.[39] In astudy done in U K, 78% of the respondents opined thatclinical simulation is a good learner's tool for clinicalexamination.[31]Preferred location of BST :

In our study 63.33% of the respondents preferredbedside teaching in combination with teaching in atutorial room. In some studies it has been found thatlearners prefer conference room over bedside teaching.[7, 40] It has been seen in a study that majority of therespondents (87%) preferred bedside rounds overconference room rounds. [41] This has been a subjectfor debate in literature. Wang-Cheng et al observed thatyounger learners prefer the conference room setting. Inthis study 53% learner preferred the conference roomand 41% a combination of conference room and bedside.[7] In some other studies it is seen that the patientspredominantly prefer bedside rounds, but, the learners

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25JASA, Vol. 23, No. 1, January - April, 2016

have generally been shown to prefer rounds,particularly case presentations, away from thepatients.[3,8,10] Tarique M et al observed that eightyseven percent of their study population wanted roundsto be conducted at bedsides rather than in conferencerooms. However, 91.8% of them felt the need for post-round group discussions/tutorials. [41]

The co relational research guidelines publishedby Capilano University says that there should be atleast 3o or more participants in such type of studies.[42] In our study there are 60 participants. The availableliterature also shows that many studies have lownumber of participants. In the study of Ramani S et althere were 22 participants. [6] A study done by Khan IA, where bedside teaching was evaluated as an effectivetool there were 18 participants.[11] There was 70students participants (medical and nursing) in thestudy of Mosalanejad L et al.[17] In the study of GreenThompson et al there were 30 students in each of twoblocks.[38]

Summary and Conclusion :Our study has clearly points out the importance

of bedside teaching from the learners' point of view.The study has also pointed out certain areas of bedsideteaching which need attention for efficacy of bedsideteaching. Learners felt that bedside teaching is valuablefor the learner for gaining professional skills, acquiringproblem based learning and to some extent obtainingsome organizational skills. Learners felt that more timeis to be dedicated for bedside teaching and quality ofbedside teaching is to be improved so that maximumbenefit can be passed to the learner.Disclaimer :

The results of this research were presented in ane-poster presentation at the 74th Annual Conference ofAssociation of Surgeons of India held in December, 2014in Hyderabad, India.

References:-1. Williams K, Ramani S, Fraser B., Orlander JD. Improving Bedside Teaching: Findings from a Focus Group

Study of Learners. Academic Medicine, 2008:83(3): 257-64.2. Ramani S. Twelve tips to improve bedside teaching. Medical Teacher, 2003;25(2):112-5.3. Landry MA, Lafrenaye S, Roy MC, Cry C. A randomized, controlled trial of bedside versus conference-room

case presentation in a pediatric intensive care unit. Pediatrics. 2007:120:275-80.4. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach. 2003; 25:127-30.5. LaCombe MA. On bedside teaching. Ann Intern Med. 1997:126:217-20.6. Ramani S, Jay DO, Lee S, Thomas W. Barber Whither Bedside Teaching? A Focus-group Study of Clinical

Teachers Academic Medicine 2003:78(4):384-90.7. Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Bedside case presentations: Why patients like

them but learners don't. J Gen Intern Med. 1989: 4(4):284-7.8. Kroenke K, Omori DM, Landry FJ, Lucey CR. Bedside teaching South Med J 1997:90 (11):1069-74.9. Nair BR, Coughlan JL, Hensley MJ. Student and patient perspectives on bedside teaching. Med Educ. 1997:31:341-

6.10. Nair BR, Coughlan JL, Hensley MJ. Impediments to bed-side teaching. Med Educ. 1998: 32(2):159-62.11. Khan IA. Bedside teaching- Making it an effective instrumental tool. J.Ayub Med. Coll Abbottabad 2014:26(3):286-

9.12. Gail MS, Anthony RA, Jr. Analysing and interpreting data from Likert type scales. J.Grad Med Educ. 2013:5(4):541-

2.13. Shaughnessy, Zechmeister. Correlational Research: Surveys, Chapter 4, Research Methods in Psychology, 5th

edition, McGraw-Hill, 200014. Ahmed K, Mel B. What is happening to bedside clinical teaching. Med Educ. 2002:36:1185-8.15. Kianmehr N, Mofidi M, Yazdanpanah R, Ahmadi MA. Medical student and patient perspective on bedside

teaching Saudi Med J 2010:31(5):565-8.16. Celenza A, Rogers IR. Qualitative evaluation of a formal bedside clinical teaching programme in an emergency

department. Emerg Med J 2006:23:769-73.17. Mosalanejad L, Hojjat M, Gholami M, A holistic approach to bedside teaching from the views of main users.

Middle east Journal of nursing 2014:8(1):24-30

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18. Langlois JP, Thach S. Teaching at the bedside. Fam Med. 2000:32:528-30.19. Salam A, Faizal A, Pardaus M, Isa SHM, Zainuddin Z, Lattiff AA al. UKM medical graduates perception of their

communication skills during housemanship. Medicine and Health. 2008:3(1):54-8.20. Rider EA, Keefer CH. Communication skills competencies: definitions and a teaching toolbox. Medical Education.

2006:40:624-29.21. Nobile C, Drotar D. Research on the quality of parent-provider communication in pediatric care: implications

and recommendations. J Dev Behav Pediatr. 2003:24:279-90.22. Hartley S, Gill D, Carter F, Walters K, Bryant P. Teaching Medical Students in Primary and Secondary Care: a

resource book. Oxford University Press. 200323. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J.

1995:152:123-33.24. Dent JA. A Practical Guide for Medical Teachers. Churchill Livingstone:2001. Hospital wards.25. Doshi M, Brown N. Why and how of patient-based teaching. Advances in Psychiatric treatment. 2005:11:223-31.26. Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: patients'

and students' perceptions. Acad Med. 2003:78(9):945-9.27. Chipp E, Stoneley S, Cooper K. Clinical placements for medical student: factors affecting patients´ involvement

in medical education. Med Teach. 2004:26:114-9.28. Jenkins C, Page C, Hewamana S, Brigiey S. Techniques for effective bedside teaching. Br J Hosp Med (Lond)

2007:68:150-3.29. Aldeen AZ, Gisondi MA. Bedside Teaching in the Emergency Department. Acad Emerg Med. 2006:13:860-6.30. Shankel SW, Mazzaferi EL. Teaching the resident in Internal Medicine: present practice, suggestions for the

future. Journal of the American Medical Association, 1986:256:725-9.31. Jones P, Rai BP. The status of bedside teaching in the United Kingdom : the student perspective , Advances in

Medical Education and Practice 2015:6:421-9.32. Mandel JH, Rich EC, Luxenburg MG, Spilane MT, Kern DC. Perrino TA. Preparation for practice in internal

medicine: a study of ten years of residency graduates. Archives of Internal Medicine 1988:148:853-6.33. Hyppola H, Kumpussalo E, Neittaanmaki K, Mattila I, Virjo S, Kujala P et al. Where should special attention be paid in

undergraduate medical education ? Two surveys among Finnish doctors. Medical Education 1996:30(1):31-7.34. Lai NM, Sivalingam N, Ramesh JC. Medical students in their final six months of training: progress of self-

perceived clinical competence, and relationship between experience and confidence in practical skills. Med J.2007:48:1018-27.

35. Taylor DM. Undergraduate procedural skills training in Victoria: is it adequate? Med J Aust. 1997:166(5):251-4.36. Mangoine S, Peitzman SJ, Gracely E, Nieman IZ. The teaching and practice of cardiac auscultation during

internal medicine and cardiology training: a nationwide survey, Annals of Internal Medicine 1993:119:47-54.37. Simons RJ, Bailey RG, Zelis R, Zwillich CW. The physiological and psychological effects of the bedside

presentation. NEJM. 1989:321:1273-5.38. Green-Thompson L, Mcinerney P, Veller M. The evaluation of bedside teaching -an instrument for staff evaluation

and student experience: A pilot study at a South African university. SAJS 2010:48(2):50-5.39. Franklyn-Miller AD, Falvey EC, McCrory PR. Patient-based not problem-based learning: An Oslerian approach

to clinical skills, looking back to move forward. J Postgrad Med. 2009:55:198-203.40. Chauke HL, Pattinson RC. Ward rounds -- bedside or conference room? S Afr Med J 2006:96 (5):398-400.41. Tariq M, Motiwala A, Ali S A, Riaz M, Awan S, Akhter J. The learners' perspective on internal medicine ward

rounds: a cross-sectional study , BMC Medical Education2010:10:53.42. Correlational Research Guidelines- Capilano University, www.capilanou.ca

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Introduction :Renal injury occurs in approximately 10% of all trauma cases. It occurs

more often in cases involving blunt trauma [1]. Renal injury can be isolatedor associated with other intra-abdominal injuries. Conservative, nonoperativeapproach has become widely accepted over the last 2 decades especially incases of low grade (I-III) renal injuries. The management of high-grade bluntrenal trauma (IV-V) is controversial and has developed over time towardsmore conservative approach [2]. In case of complications, the patient is firstmanaged as conservatively as possible using minimally invasive techniques[3]. Management of urinary extravasation with urinoma is essentiallymanaged by DJ stenting or percutaneous nephrostomy placement and closemonitoring [4]. We describe our experience of here non operative managementof high grade renal injury in two patients with urinoma formation and reviewof literature.Case history:Case I:

A 29-years-old unmarried male presented to the emergency departmentof our hospital after road traffic accident. He complained of left flank painand hematuria. Initially the patient was normotensive (130/80?mm/Hg),tachycardia (112?bpm), tachypneic (30?/min) and afebrile. A focusedassessment with sonogram for trauma (FAST) was performed which showeda large left perinephric hematoma. After stabilisation of the vitals a contrastCT of the chest, abdomen and pelvis was done which revealed a grade IV left

Case Report

High-grade renal injury: non-operativemanagement of urinary extravasation - a

report of two cases with review of literature

ABSTRACTRenal injuries are common occurrence in many trauma cases. Themanagement of these cases varies, but, currently, a conservative, nonoperative approach is the norm. Urinary extravasation or urinomaformation is seen most commonly in high grade renal injury. They aremost commonly treated with conservative nonsurgical approach.Persistent urinary leakage and infected urinoma or perinephric abscesscan be managed with percutaneous catheter drainage with or withoutureteric stenting. In refractory cases of persistent urinary leakage, anoperative intervention may be necessary, emergency total nephrectomybeing the most common procedure reported in the literature. Here, wereport two cases of high grade renal injury with urinary extravasationmanaged conservatively.

Prof. S.J. Baruah1

Prof. Rajeev T.P.2

Debajit Baishya3

Debanga Sarma4

Sasanka Kr. Barua5

Corresponding Author:Prof. Rajeev T.P.Professor and HeadDepartment Of UrologyGauhati Medical College & HospitalGuwahati-781032Email: [email protected] no.: 9864064374

Key Words : Renal injury; non operative management;urinary extravasation.

28 JASA, Vol. 23, No. 1, January - April, 2016

renal injury with perinephric collection. Initialhemoglobin was 12.3gm/dl and creatinine was 1.5 mg/dl. The only significant finding on physicalexamination was mild left flank tenderness. He wasmanaged conservatively with parenteral antibiotics andIV fluid. After 2 weeks he developed gradual increaseof left flank pain with fever. A repeat contrast CTrevealed a left sided perinephric collection with contrastextravasation from the mid pole (Fig 1). Apercutaneouse nephrostomy (PCN) was placed on theleft side and the symptoms improved. PCN tube drained600 ml urine per day initially which reduced to 200 mlper day in next 2 weeks. Due to persistent drainage ofurine a retrograde pyelography was done whichshowed contrast extravasation from the left kidney (Fig2). A DJ stent was placed on the left side. Thenephrostomy drain reduced to 20 ml per day in next 5days and PCN was then removed. Patient wasdischarged with a DJ stent in situ on the left side. DJstent was removed after 6 weeks and patient is onfollow up for the last 14 months and is doing well.Case II :

A 10-years-old boy presented in the emergencydepartment of our hospital after road traffic accident.He complained of left flank pain and gross hematuria.On examination, patient's vitals were stable and he wasafebrile. A focused assessment with sonogram fortrauma (FAST) showed a left perinephric hematoma. Acontrast CT abdomen revealed a grade IV left renal injurywith contrast extravasation from the mid pole. Initialhemoglobin was 11.5 gm/dl and creatinine was 0.7mg/dl. On per abdominal examination, abdomen wassoft but left flank tenderness was present. He wasmanaged conservatively with parenteral antibiotic andIV fluids. After 7 days he developed gradual increaseof pain in the left flank. On examination, a lump wasfelt in the left flank associated with tenderness. Anultrasonography abdomen was done which revealed a10x 8 cm left perinephric collection (Fig 3). A PCN tubewas placed following which symptoms relieveddramatically. Initially the PCN tube drained 800-1200ml urine per day which was reduced to 20 ml per dayover the next 2 weeks. The nephrostomy tube was thenremoved and the patient was discharged. Patient is onfollow up for the last 9 months and is doing fine.

Prof. S.J. Baruah at el: High-grade renal injury

Fig 1 Left perinephric collection and contrastextravasation from the mid pole

Fig 3 USG left kidney showing large perinephriccollection

Fig 2 Retrograde pyelography showed contrastextravasation from left kidney

Discussion :Kidney injury accounts for approximately 10% of

all trauma cases. The causes of renal trauma may beclassified as: (1) blunt trauma: direct blow to the kidney;

29JASA, Vol. 23, No. 1, January - April, 2016

(2) penetrating trauma: stab or gunshot injury, and (3)high-velocity deceleration: pedicle injury. A distinctionis usually made between blunt and penetrating injurybecause of the increased occurrence of significant renalinjury with a penetrating object and its effect onmanagement [5-7]. Overall, 80-90% of renal injuries aredue to blunt trauma, most often incurred in falls, motorvehicle accidents, and assault [8]. The vast majority ofrenal injuries result from motor vehicles accidents [9].

Major renal injury has been reported in upto 25%of blunt renal trauma and in upto 70% of penetratingrenal trauma cases. However, in less than 10% of thecases, the injuries are serious enough to require surgery[10]. Penetrating mechanisms are much more likely tocause severe renal injuries requiring operativeintervention and nephrectomy [11]. High-velocitydeceleration may cause avulsion of the major renalvessels or stretching of the renal artery, leading to arterialocclusion. Rapid-deceleration kidney injuries areexplored more often because of the increased incidenceof renal pedicle and ureteropelvic junction avulsion[12].

A contrast enhanced abdominal CT withintravenous injection of contrast medium is the bestmodality for evaluation of renal trauma, accuratestaging of the injury, recognition of pre-existingpathologies of the injured kidney, documentation offunction of the contralateral kidney and identificationof associated injuries to the other organs [13]. Becausehelical CT can obtain images before intravenouscontrast medium is excreted in the urine, injury of thecollecting system may be missed. Therefore it isimportant to obtain delayed scans 5-20 min afterinjection of contrast medium.

The general approach to patients with blunt renaltrauma is non surgical, as ?90% of them have minorrenal injuries. Conservative management impliesregular monitoring of vital signs, abdominal symptomsand signs, haemoglobin and haematocrit values. Bedrest is maintained until clinical signs have beenstabilised for a few days and macroscopic haematuriahas cleared. Strenuous physical exertion should beavoided for 6 weeks. Although renal laceration causedby blunt trauma is an uncontaminated injury,antibiotics may be indicated in cases with urinaryextravasation occurring in the presence of multipleintravascular lines and urinary catheters which maycause bacteraemic colonization. Coverage for aerobicGram-negative bacilli and enterococci requirescombinations of ampicillin and cephalosporins orquinolones [1]. Managing high-grade blunt renaltrauma remains a controversial issue. The absolute and

Table I. Indications for renal exploration in traumapatients

Absolute RelativePersistent life-threateninghemorrhage

A large laceration ofthe renal pelvis

Renal pedicle avulsion Coexisting bowel orpancreatic injuries

Abnormalintraoperative one-shot IVU

Devitalizedparenchymal segmentwith associated urineleakComplete renal arterythrombosis of bothkidneys, or of asolitary kidney, orwhen renal perfusionappears to bepreservedRenal vascularinjuries after failedangiographicmanagement

Renovascularhypertension

Expanding, pulsatile oruncontained retroperitonealhematoma (thought to indicaterenal pedicle avulsion)

Persistent urinaryleakage with failedpercutaneous orendoscopicmanagement

relative indications for surgical exploration of thekidney in trauma patients are shown in table I

Renal injury is graded based on CT findings, andclassified according to the Committee on Organ InjuryScaling of the American Association for Surgery ofTrauma.

Grade IV injuries are defined as: laceration throughthe parenchyma into the collecting system, vascularsegmental vein or artery injury as well as any injuryinvolving the collecting system (including renal pelvislaceration and ureteric pelvic disruption). Persistentextravasation of urine or urinoma is the most frequentand occurs in approximately 10%-20% of cases after

Prof. S.J. Baruah at el: High-grade renal injury

30 JASA, Vol. 23, No. 1, January - April, 2016

References:-1. J. C. Buckley and J. W. McAninch, Revision of current american association for the surgery of trauma renal

injury grading system. Journal of Trauma 2011;70(1):35-7.2. McGuire J, Bultitude MF, Davis P, Koukounaras J, Royce PL, Corcoran NM . Predictors of outcome for blunt

high-grade renal injury treated with conservative intent . J Urol 2011;185:187 - 91.3. Hammer CC, Santucci RA. Effect of an institutional policy of nonoperative treatment of grades I to IV renal

injuries. J Urol 2003;169:1751-3.4. Alsikafi NF, McAninch JW, Elliott SP, Garcia M. Nonoperative management outcomes of isolated urinary

extravasation following renal lacerations due to external trauma. J Urol 2006;176:2494-7.5. Nguyen H, Carroll P. Blunt renal trauma: renal preservation through careful staging and selective surgery.

Semin Urol 1995;13:83-9.6. McAndrew J, Corriere J Jr. Radiographic evaluation of renal trauma: evaluation of 1103 consecutive patients. Br

J Urol 199473:352-4.7. Guerriero W. Etiology, classification and management of renal trauma. Surg Clin N Am 1988;68:1071-84.8. Miller K, McAninch J. Radiographic assessment of renal trauma: our 15 year experience. Urol 1995;154:352-5.9. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW et al. Consensus on genitourinary

trauma. Evaluation and management of renal injuries: consensus statement of renal trauma subcommittee. BJUInt 2004;93:937-54.

10. Sagalowsky AL, McConnell JD, Peters PC: Renal trauma requiring surgery: an analysis of 185 cases. J Trauma1983;23:128-31.

11. Moudouni SM, Hadj SM, Manunta A, Patard JJ, Guiraud PH, Guille F et al. Management of major blunt renallacerations: is a nonoperative approach indicated? Eur Urol 2001;40:409-14.

12. Carroll PR. Renovascular trauma: evaluation and management. Probl Urol 1994;8:191-4.13. Vasile M, Bellin MF, Helenon O, Mourey I, Cluzel P. Imaging evaluation of renal trauma. Abdom Imaging

2000:25:424-30.14. Moudouni SM, Patard JJ, Manunta A, Guiraud P, Guille F, Lobel B: A conservative approach to major blunt renal

lacerations with urinary extravasation and devitalized renal segments. BJU Int 2001;87:290-4.15. Knudson MM, Harrison PB, Hoyt DB et al.Outcome after major renovascular injuries: a Western trauma

association multicenter report. J Trauma 2000; 49:1116-22

grade IV renal injury [14]. Urinary extravasation aloneis not an indication for surgical exploration, as itresolves spontaneously in ?80% of cases. On CT scan, aperirenal low-density collection is seen, often withopacification on delayed films. Monitoring of suchpatients by serial CT or US is necessary. Infectedurinomas and perinephric abscesses can occursecondary to local or systemic bacterial seeding of aurinoma, perinephric haematoma or devitalized renalfragments, coexisting enteric or pancreatic injuries,devitalized colon or duodenal injuries, or infectedcentral venous lines. Persistent urinary leakage andinfected urinoma or perinephric abscess can bemanaged with percutaneous catheter drainage with orwithout ureteric stenting [11]. Persistent urinary leakagefrom a fragment of a transected kidney can also bemanaged by selective embolization of leakingfragments. Surgery in the form of renorrhaphy or anephrectomy is required only in 15% of cases ofpersistent urinary leakage after failure of allconservative measures [14]. It has been suggested thatall patients with grade 4-5 renal injuries should be re-evaluated with a quantitative assessment of renalfunction by radionuclide scintigraphy, regardless of the

method of treatment after 4-6 months of the initialtrauma [15].Conclusion :

Accurate staging of trauma is mandatory for thesafe and effective management of renal injury.Generally, minor injuries to the kidney resolve onconservative measures. Close monitoring of vitals, fluidreplacement, prophylactic parenteral antibiotics,adequate rest and avoidance of strenuous exertions willimprove majority of renal trauma cases except thosegrade V injuries with avulsion of pedicle or pelviuretericjunction distraction. Surgical exploration will onlyresults in unnecessary nephrectomy. Urinaryextravasation after high grade blunt renal trauma iscommon and can be successfully managedconservatively. In refractory cases of urinaryextravasation, DJ stenting or PCN is an option as inour cases. Surgery by either renorrhaphy ornephrectomy may be required in cases of persistenturinary leakage despite percutaneous nephrostomy orDJ stenting. Stringent follow up of these patients forrenal function assessment is of equal importance.

Prof. S.J. Baruah at el: High-grade renal injury

31JASA, Vol. 23, No. 1, January - April, 2016

Introduction :Cutis laxa is a rare acquired or inherited disorder of unknown cause

characterized by progressive wrinkling of the skin associated withabnormalities of others organs and structures containing elastic tissue suchas lung, vasculature, or gastrointestinal tract [1]. The most common clinicalfeature is loose and pendulous skin, sagging of cheeks, or prematurely agedappearance. The disease is characterized by a generalized reduction in theamount and size of elastic fibers and fragmentation and disruption of theirnormal arrangement [2, 3]. Inborn errors of elastin synthesis and structuraldefects of extracellular matrix proteins have been described leading to thedecreased elasticity and redundant, sagging skin in patients.Case report :

NS, a 7 months old boy, product of nonconsangenious marriagepresented with excessive wrinkling of skin with inguinal hernia, respiratorydisorders associated with the fever and cough. The child had history ofrecurrent episodes of cough and breathlessness since the age of 3 months,with an increase in the frequency and severity of the episodes in the few pastweeks. There was no family history of similar disease. On examination, thechild was afebrile and had respiratory rate 34/min with subcostal retraction,heart rate 90/min, and blood pressure 90/70 mmhg, SaO2 was 94% inambient air. The weight was 7 kg and height was 68cm, head circumference43cm (normal); weight for height between -1 and -2SD,weight for age betweenmedian and -1SD respectively. The face had old man appearance withpendulous ear lobes and lax skin (Fig. 1). The child had developementaldelay in motor domain. There was a right sided-irreducible, inguinal hernia(Fig. 2). There was no laxity of joints. On chest ausculatation, bilateralvesicular breath sounds were present. Cardiovascular examination revealedcardiomegaly with ejection systolic murmur. Examination of the abdomendid not reveal any organomegaly. Others systems were normal. Hishemoglobin level was 10g/dl, a total WBC count of 13500/mm3 with adifferential count of polymorphs of 22%, lymphocytes of 70%. Routinebiochemical investigations yielded normal results. Thyroid profile was doneand shows T3 -1.5 ng/ml,T4-125ng/ml TSH 6.0UIU/ml ,mildly elevated. A

Case Report

Cutis Laxa syndrome: a case report

ABSTRACTCutis laxa is a rare connective tissue disorder characterized clinically byloosely hanging skin folds. It may be an inherited or acquired disorder.We present a 7 month old male child with Cutis laxa. The child hadsevere associated cardiovascular malformation, mild hypothyroidism andbilateral inguinal hernia. Bilateral herniotomy was done successfully.

Dr. Rita Payeng1

Dr. H.K. Dutta2

Dr. D. Saikia3

1 Assistant Professor,Dept. of Pediatrics2 Associate Professor,Dept. of Pediatric Surgery3 Assistant Professor,Dept. of Anaesthesiology

Address for correspondence:Dr. Hemonta Kr. Dutta,Dept. of Pediatric SurgeryAssam Medical College & HospitalDibrugarh-786002.E mail: [email protected]

Key Words : Cutis laxa; connective tissue disorder; genetic disorder.

32 JASA, Vol. 23, No. 1, January - April, 2016

chest x-ray showed cadiomegaly with a cardiothoracicratio of 0.7. Electrocardiography showed severe rightventricular hypertrophy with mild TR with moderatePS. The child was operated for bilateral inguinal herniarepair. He had uneventful recovery. Biopsy of skin tissueshowed normal squamous lining with subepidermallymphatic infiltration and loose collageneous stroma.Discussion :

Cutis laxa is a rare connective tissue disordercharacterized clinically by loosely hanging skin folds.

Fig. 1: The child with characteristic facial expressionof cutis laxa.

Fig. 2: Cutis laxa with bilateral inguinal hernia

Histologically, there are changes in dermal elasticfibers. It is generally an inherited condition. The modeof transmission can be autosomal recessive (OMIM219100) with the severest clinical manifestations [4, 5].Children with the disease have obviously loose skin atbirth, and most die during infancy fromcardiopulmonary complications. It has been shown tobe caused by a fibulin 4 and 5 mutations in Chromosome11q13 and 14q32.1 respectively [6]. In contrast,autosomal dominant (OMIM123700) inheritance isassociated with mild condition without systemicabnormalities; this form is caused by mutations in theelastin gene [7]. The third type of cutis laxa istransmitted by x-linked inheritance (OMIM 304150). Inour patient, there was no history of any similar problemin any of the family members, thus ruling out anautosomal dominant inheritance. He had milddevelopmental delay and didnot have any joint laxity.The child probably suffered from type I recessive form.He had the characteristic cutaneous abnormalitiesdescribed in all the varieties of cutis laxa. Additionally,he had inguinal hernia, and stenosis of pulmonaryarteries. Cardiopulmonary abnormalities are commonin type I recessive cutis laxa and are the main factors todetermine the prognosis and life expectancy.Pulmonary emphysema, and right-sided heart failurecaused by pulmonary disease have been commonlydescribed. Cardiovascular abnormalities includingaortic aneurysm, pulmonary artery stenosis as was seenin our patient have been reported with this form ofcongenital cutis laxa. Mutation analysis of the patientcould not done because of non availability of procedurein our setting.Conclusion :

Cutis laxa is a rare genetic disorder characterizedby a clinical and genetic polymorphism. Autosomalrecessive type have a high risk of seriouscardiopulmonary complications and die duringinfancy.

References:-1. Andiran N, Sarikayalar F, Saraçlar M, Caglar M. Autosomal recessive form of congenital cutis laxa: More than

the clinical appearance. Pediatr Dermatolo. 2002;19(5):412-4.2. Patricia M, Karen H, Sheldon R. A familial cutis laxa syndrome with ultrastructural abnormalities of collagen

and elastin. Journal of invest dermatol. 1980;75(5):399-403.3. Franziska Ringpfeil. Selected disorders of connective tissue: pseudoxanthoma elasticum, cutis laxa, and lipoid

proteinosis. Clinics in dermatology. 2005;23(1):41-6.4. Turner SL, Turton C, Pope FM, Green M. Emphysema and cutis laxa. Thorax. 1983;38(8):790-2.5. Szabo Z, Crepeau MW, Mitchell AL, Stephan MJ, Puntel RA, Yin Loke K et al. Aortic aneurismal disease and cutis

laxa caused by defects in the elastin gene. J Med Genet. 2006;43(3):255-8.6. Urban Z, Gao J, Pope FM, Davis EC. Autosomal dominant cutis laxa with severe lung disease: synthesis and

matrix deposition of mutant tropoelastin. J Invest Dermatol 2005;124:1193- 9.

Dr. Rita Payeng at el: Cutis Laxa syndrome: a case report

33JASA, Vol. 23, No. 1, January - April, 2016

Introduction :AVFs involving the superior sagittal sinus (SSS) account for 7.4% to 8%

of intracranial DAVFs. Headache occurs in 50% of patients with SSS DAVFs.The risk for intracranial hemorrhage and stroke is dictated by the presenceof cortical venous reflux, galenic drainage and venous congestion. [1]Lasjaunias and associates proposed that the source of intracranialhemorrhage in these cases is not the fistula itself but rather ectatic thin wallarterialized veins.Case report :

Our patient 43 years old, male, presented with headache which wassudden in onset, moderate to severe in intensity and associated withvomiting. Although he was conscious he had altered sensorium. Onexamination his blood pressure was 130/80mm Hg. His vitals were normal.There was no neurological deficit. On plain computed tomography (CT) scanof brain there was left sided acute subdural hematoma in the fronto-temporo-parietal convexity of 9 mm width causing ipsilateral mass effect, midlineshift of 8 mm to the right side and evidence of subfalcine herniation (Figure1). On the same day we did a magnetic resonance imaging (MRI) of brainwith magnetic resonance angiography (MRA) and magnetic resonance

Case Report

Dural arteriovenous fistula presenting withacute subdural hematoma: A rare case report

ABSTRACTDural arteriovenous fistula /malformation (DAVF/AVM), presentingwith spontaneous acute subdural hematoma is relatively rare. We reporton a male patient presenting with headache and on CT scan showedacute subdural hematoma (SDH), who was diagnosed to have duralarteriovenous fistula at the level of posterior parietal region with arterialfeeders from bilateral middle meningeal arteries draining directly intomultiple cortical venous sacs and then into the superior sagittal sinus.Our patient did not give any history of trauma or head injury. He hadheadache which was spontaneous in onset and had a brief history ofloss of consciousness associated with vomiting. And on examination hewas conscious but disoriented without any neurological deficit. DuralAVF/AVM usually causes subarachnoid hemorrhage (SAH) orintracerebral hemorrhage (ICH). Our case presented with a pure SDH.We are reporting this case because of its rarity. We should consider fordural AVF/AVM and do angiography if a patient presents with headacheand spontaneous acute SDH.

B.K.Baishya1

Deep Dutta2

Shamim Ahmed 3

Z.Hussain1

1 Professor, Dept. of Neurosurgery,Gauhati Medical College, Guwahati2 Mch trainee, Dept of Neurosurgery,Gauhati Medical College, Guwahati3 Assist. Professor, Dept. ofNeurosurgery, Gauhati MedicalCollege, Guwahati

Corresponding author:Prof. B. K. Baishya. (MCh)Professor, Dept. of NeurosurgeryGauhati Medical College,Guwahati, AssamSrimanta Shankaradeva Universityof Health and Sciences.Guwahati, 785001,Assam, IndiaCountry : IndiaEmail:[email protected]

Key Words : Dural arteriovenous fistula; acute subdural hematoma;angiography; headache.

34 JASA, Vol. 23, No. 1, January - April, 2016

Fig.1: Acute Subdural Hematoma at left fronto-temporo-parietal convexity.

Fig .2a : Dural arteriovenous fistula at the level ofposterior parietal region with feeders from right

middle meningeal artery draining directly into thesuperior sagittal sinus.

Fig.3 : Chronic Subdural hematoma transformationafter two weeks over left fronto-temporo-parietal

convexity.

Fig. 2b : Dural arteriovenous fistula at the level ofposterior parietal region with feeders from left middlemeningeal artery draining directly into the superior

sagittal sinus.

venography (MRV) which showed dural AVM withvenous hypertension in the left parafalcine occipitallocation, involving superior sagittal sinus with arterialcommunication from meningeal arteries. There was anacute SDH in the entire left cerebral convexity. After 4days we did a 6 vessels cerebral digital subtractionangiography (DSA) which showed a duralarteriovenous fistula (AVF) at the level of posteriorparietal region with arterial feeders from bilateralmiddle meningeal arteries draining directly intomultiple dilated cortical venous sacs and then into thesuperior sagittal sinus (Figure: 2a, 2b). There was noreflux flow noted. No feeders were seen from the internalcerebral artery (ICA). Bilateral anterior cerebral arteries(ACA), middle cerebral arteries (MCA), vertebral arteries(VA) and basilar artery were normal. It was a type 4intracranial dural AVF (Cognard Classification) at theposterior parietal region. All the blood parameters werefound to be normal. His headache subsequentlysubsided and on repeat CT scan of brain after 2 weeksshowed chronic SDH at left fronto-temporo-parietalconvexity (Figure 3). We planned for surgery and after4weeks, we did a biparietal craniotomy. There weredilated cortical veins over both the cerebralhemispheres, more over left side and had multiplefistulas between dural arteries and cortical veins nearthe superior sagittal sinus. These abnormal veins wereectatic and arterialized having feeders from the middlemeningeal artery. Their connections from the feedingvessels were coagulated and separated from the duraunder the microscope. Then the dura was closed watertightly and bone flap was replaced. The patientimproved and he was discharged without anyneurological deficit on the 8th post operative day.

Discussions :Dural arteriovenous fistulas are abnormal

arteriovenous connections within the dura and areusually located within the walls of a dural sinus or an

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35JASA, Vol. 23, No. 1, January - April, 2016

References:-1. Lasjaunias P, Chiu M, terBrugge KT: Neurological manifestations of intracranial dural sinus arteriovenous

malformations. J Neurosurgery 1986;64:724-30.2. Sencer A, Kiris T. Intracranial dural arteriovenous fistulas: A brief review on classification and general features.

Turk Neurosurg. 2006;16(2):57-64.3. Cognard C,Gobin YP,Pierot L,et alCerebral Dural Arteriovenous fistulas: Clinical and angiographic correlation

with a revised classification of venous drainage.Radiology 1995;194:671-80.4. Kohyama S, Ishihara S, Yamane F, Kanazawa R, Ishihara H. Dural arteriovenous fistula presenting as an acute

subdural hemorrhage that subsequently progressed to a chronic subdural hemorrhage: case report. Minim.Invas. Neurosurg. 2009;52:36-8.

5. Ito J., Imamura H., Kobayashi K., Tsuchida T., Sato S. Dural arteriovenous malformations of the base of theanterior cranial fossa. Neuroradiology. 1983;24: 149-54.

6. Halbach VV, Higashida RT, Hieshima GB, Rosenblum M, Cahan L. Treatment of dural arteriovenousmalformations involving the superior sagittal sinus. AJNRAm. J. Neuroradiol. 1988;9:337-43.

7. Kominato Y, Matsui K, Hata Y, Matsui K, Kuwayama N. et al. Acute subdural hematoma due to arterio - venousmalformation primarily in dura mater: a case report. Legal Med. 2004;6:256-60.

8. Katsuhiko OGAWA, Minoru OISHI, Tomohiko MIZUTANI, Sadahiro MAEJIMA, AND Tatsuro MORI . Duralarteriovenous fistula on the convexity presenting with pure acute subdural hematoma Acta Neurol. Belg.2010;110:190-2.

9. Mauri F,Iaconetta G,Sardo L,Briganti F.Dural arteriovenous malformation associated with recurrent subduralhaematoma and intracranial hypertension. Br J Neurosurg. 2001;15:273-6.

adjacent cortical vein. DAVF comprise 10-15% of allintracranial arteriovenous malformations. [2] They areclassified according to venous drainage pattern whichhas many important implications for prognosis. Theyare also classified according to location. The followingclassification scheme originally forwarded by Djinjianand Merland (later modified by Cognard) is establishedon venous drainage. [2,3]

AVFs involving the superior sagittal sinus accountfor 7.4% to 8% of intracranial DAVFs. Symptoms andsigns of DAVFs are reportedly headache, pulsatile

tinnitus and /or bruit while some cases of aggressiveclinical course may present with signs of raisedintracranial pressure due to intracranial hemorrhageor infarction.[1,2,3] Headache is the most commonpresenting symptom . Non traumatic SDH caused bydural AVF is usually accompanied by ICH and/or SAH.[3] AVF presenting with spontaneous acute SDH is rare.In our patient we had done MRA and MRV on the sameday when the patient presented with headache andaltered sensorium whose plain CT head showed acuteSDH over left fronto-temporo-parietal convexity. In theliterature there are only 6 reported patients with nontraumatic dural AVF/AVM , presenting with onlySDH[4,5,6,7,8,9] and our patient. The initial symptomwas headache in 3 reported cases (Kohyama et al, 2009;Kominato et al, 2004; K.Ogawa et al, 2010) and ourpatient. The AVF located at or near the superior sagittalsinus in all the reported cases.[4-9] In type I DAVFwhich are clinically and angiographically benignlesions, the indication of treatment may be control offunctional symptoms. Other types of DAVF needcombination of transarterial embolisation and surgeryor surgery alone if it is accessible. Complete cure of thefistula should be aimed as inadequate treatment maycause re-bleeding. Our patient was managed surgically.All the fistulas were coagulated and separated. Patientimproved symptomatically and was discharged. He ison regular clinical and radiological follow up.

Table 1: Classification of DAVF according tovenous drainage.

Type Venous DrainageType I Drainage into a dural sinus,

with normal antegrade flowDrainage into a dural sinus,with reflux intoII a: (other) sinusesII b: cortical veinsII a+b: sinuses + cortical veins

Type III Drainage into cortical veinsType IV Drainage into cortical veins

with cortical ectasiaType V Drainage into spinal

perimedullary veins

Type II

B.K.Baishya at el: Dural arteriovenous fistula

36 JASA, Vol. 23, No. 1, January - April, 2016

Introduction :Lumbar hernia is a protrusion of intraperitoneal and extraperitoneal

contents through a posterior-lateral abdominal parietal defect. They occurthrough superior and inferior lumbar triangle in 98% of cases and mostlyoccur in superior lumbar triangle (Grynfelt's triangle) than inferior Petit'striangle. Lumbar hernia can be classified as congenital and acquired andthe later may be spontaneous or secondary. Secondary lumbar hernia mayresult from surgery, infection, trauma. Contents of lumbar hernia may beretroperitoneal fat, bowel or even segments of liver [1]. Unless repairedpromptly lumbar hernia may develop complications like incarceration orstrangulation and sometimes it may lead to urinary obstruction withhydronephrosis [2]. Repair either by open or laparoscopic method may bedone to rectify the defect.Case report :

A 40 year old female presented with painless swelling over the rightflank for 2 years. It was small when first noticed and gradually increased insize. Size of the swelling was noted to increase on straining, coughing anddecrease in lying down position. There was no history of any past surgery,trauma or infection. Her general examination findings were within normallimit. There was a soft , nontender and reducible swelling in the region ofsuperior lumbar triangle. Impulse on cough was present and the swellingwas not translucent. On ultrasonography a 3 cm defect was noted in theposterior abdominal wall with extrusion of retroperitoneal fat (Figure1).Patient was subjected to open surgical repair. A 3.5 cm fascial defect in theposterior abdominal wall was repaired with prolene mesh behind theperitoneal envelop and mesh was secured with surrounding fascial sheathand muscle (Figure2). Postoperative period was uneventful. Patient wasfollowed up for 2 years and there is no evidence of any recurrence.Discussion :

Lumbar hernia is a rare entity and till date only few cases have beenreported after Barbette, who first reported it in 1672 [3]. Superior lumbar

Case Report

Lumbar hernia-A rare case reportand review of literature

ABSTRACTLumbar hernia is a protrusion of intraperitoneal and extraperitonealcontents through a posterior-lateral abdominal parietal defect. Unlessrepaired promptly lumbar hernia may develop complications likeincarceration or strangulation and sometimes it may lead to urinaryobstruction with hydronephrosis. Repair either by open or laparoscopicmethod may be done to rectify the defect.

Rajeev T. P.1

Sasanka Kumar Barua2

Jyoti Prasad Morang 3

Debanga Sarma 4

1 Department of Urology,Gauhati Medical College andHospital, India.2 Department of Urology, GauhatiMedical College and Hospital, India.3 Department of Urology, GauhatiMedical College and Hospital, India.4 Department of Urology, GauhatiMedical College and Hospital, India.

Corresponding author:Jyoti Prasad Morang ,Gauhati Medical College,Guwahati, Assam, India [781032]Tel: 918721811045Email: [email protected]

Key Words : Lumber hernia; hernia; surgical repair.

37JASA, Vol. 23, No. 1, January - April, 2016

References:-1) Salemis NS , Nisotakis k, Gourgiotis S, Tsohataridis E: Segmental liver incarceration through a recurrent

incisional hernia. Hepatobiliary pancreat dis.int.2007;6:442-44.2) Walgamage TB, Ramesh BS, Alsawafi Y. Case report and review of lumbar hernia : Int. J Surg. Case Rep. 2015:

6:230-32.3) Fokou M, Fosto P, Ngowe M, Essomba A, Sosso M. Strangulated or incarcerated spontaneous lumbar hernia as

exceptional cause of intestinal obstruction: case report and review of literature. World J Emergency surgery2014,9;44-6.

4) Loukas M,Tubbs R, El-Sedfy A, Jester A, Polepalli S, Kinsela C. The clinical anatomy of the triangle of petit.Hernia 2007;11:441-4 ( Pubmed).

5) Suarez S, Hernandez JD. Laparoscopic repair of lumbar hernia: report of a case and extensive review of literature.Surg. Endosc 2013;27(9):3421-9.

6) Tavares -de-la Paz LA, Martinez -Ordaz JL. Lumbar hernia, case report and literature review. Cir cir. 2007;75(5):381-4.

7) Stumpf M, Conze J, Prescher A, Junge K, Krones CJ, Klinge U et al. The lateral incisional hernia: anatomicalconsideration for a standardized retromuscular sublay repair. Hernia 2009;13(3):293-7.

8) Shekarriz B, Graziottin TM, Gholami S, Lu HF, Yamada H, Duh QY, Stoller ML. Transperitoneal preperitoneallaparoscopic lumbar incisional herniorrhaphy. J Urol 2001;166(4):1267-9.

9) Meinke AK. Total extraperitoneal laparoendoscopic repair of lumbar hernia. Surg Endosc 2003;17(5):734-7.

Figure 1 : Ultrasonography showing herniated(arrow marked) mass through the right posterior-

lateral wall of abdomen

Figure 2 : Intraoperative photograph showingabdominal wall defect which was repaired with

prolene mess (arrow marked).

triangle is an inverted triangle with its base formed bythe 12 the rib and medial and lateral borders by erectorspinae and internal oblique muscle respectively. Inferiortriangle is smaller with illiac crest forming the base;external oblique and latissimus dorsi muscle the lateraland medial borders respectively. Congenital lumbarhernia is the most rare variant usually associated withother anomalies like bilateral undescended testes,bilateral renal agenesis, lumbocostovertebralsyndrome. Acquired lumbar hernia represent 80% ofcases. Primary or spontaneous cases are nontraumaticand account for over half of the reported acquiredhernia cases [4]. Twenty five percent of lumbar herniasare considered secondary and may be related to trauma,surgery or infection. Lumbar hernia may be associatedwith other types of hernias like inguinal, femoral orobturator hernia in 13% of cases [5]. Spontaneouslumbar hernia is more common in superior lumbartriangle as in our case and secondary traumatic herniasare most often found in inferior lumbar triangle [6]. Theypresent with painless swelling in 91% cases, may alsopresent with pain or back pain mimicking sciatica andsometimes present as an emergency (8%) with intestinalobstruction. The most common differential diagnosisare lipomas, fibromas, hematomas, abscess,intraabdominal and retroperitoneal tumours [2].Ultrasonography, CT scan and sometimes MRI may alsobe helpful in diagnosis. Surgery is always indicatedwith use of prosthetic material and muscular flap [6].Retromuscular sublay repair can be considered asstandard procedure for all types of hernia outside themidline [7]. Minimally invasive laparoscopic procedurereduces the morbidity associated with open repair [8].Total extra peritoneal laparoendoscopic approach torepair lumbar hernia is also a suitable alternative [9].

Rajeev T. P. at el: Lumbar hernia-A rare case report

38 JASA, Vol. 23, No. 1, January - April, 2016

Introduction :Renal cell carcinoma (RCC) is a rare tumor in children [1]. In 2004

World Health Organisation published a renal tumor classification schemeand described conventional papillary, clear cell and chromophobe renal celltypes along with a group of rare tumors. These rare tumors make 10 to 15percent of cases and consist of sporadic and hereditary tumors. Most ofthese tumors have emerged as distinct entities with special manifestationand prognosis. Renal cell carcinoma with protein coding gene TFE3rearrangement at Xp11.2 is considered as one such rare variety [2]. Somestudies have shown that this variety is common in children if comparedwith adults [3]. The epidemiological characteristics of this tumor differ fromadult RCC and Wilms' tumor, suggesting its distinctive biology and potentialneed for alternative treatment strategies [1]. Conventional histopathologymay create some confusion as this subtype is morphologically heterogeneousand can be misclassified as clear cell or papillary renal cell carcinoma. Butimmunohistochemistry (IHC) for TFE3 can show a definite histologicalpicture. Apart from TFE3 renal tumor some other rare tumors like alveolarsoft tissue sarcoma, perivascular epithelioid cell neoplasms, chordoma etc,may show similar picture with this stain. In those cases fluorescence in situhybridization (FISH) probe set specific for TFE3 can help in definitivediagnosis [4]. IHC staining is considered as conclusive for this diagnosis.

Case Report

Renal Cell Carcinoma with TFE3Rearrangement at Xp11.2 - A case report

ABSTRACTIn 2004 World Health Organization classified Renal cell carcinoma (RCC)based on conventional staining. One genetic variant of this tumor is'transcription factor binding to immunoglobulin heavy constant muenhancer 3' (TFE3) rearrangement at Xp11.2. Various studies have shownthat this tumor behaves differently both in adult and children. This varietyof tumor can be diagnosed by Florescence in situ hybridization (FISH)technique or indirectly by immunohistochemical (IHC) study. We reporta case of TFE3 rearrangement at Xp 11.2 tumor here. This case was treatedfirst as classical papillary renal cell carcinoma. The patient had recurrenceof tumor while on chemotherapy. On immunohistochemistry, it wasproved as TFE3 rearrangement at Xp11.2 renal cell carcinoma. Thepatients received chemotherapy accordingly and responded well. ThoughRCC is rare in children, its variant TFE3 rearrangement at Xp11.2 shouldalways be kept in mind.

Jayanta Kumar Goswami1

Muktanjalee Deka2

Chandan Jyoti Saikia3

1 Associate Professor,Department of Paediatric Surgery2 Associate Professor,3 DemonstratorDepartment of Pathology,Gauhati Medical College, Guwahati,Assam, India

Corresponding author:Dr. Jayanta Kumar Goswami,Department of Pediatric Surgery,Gauhati Medical College,Guwahati, Assam, India.E-mail: [email protected]

Key Words : TFE3 renal cell carcinoma; IHC; RCC.

39JASA, Vol. 23, No. 1, January - April, 2016

Case Report :NS, an 11 year female presented with history of

hematuria for four days following blunt injury on theright flank caused by a fall. On examination, the patientwas pale but stable. The lower pole of the kidney waspalpable. A CECT scan revealed a heterogeneouslyenhancing mass in the mid and lower pole of the rightkidney with collection of blood in the pelvi-calycealsystem and in the right ureter. FNAC from the massrevealed inflammatory cellular infiltration with nogranuloma or malignant cells. The patient wasmanaged conservatively and was discharged withadvice to come for follow-up after an MRI scan. Thepatient came back with haematuria after three weeks.After readmitting the patient a contrast enhanced MRarteriography (CEMRA) was done. It revealed a welldefined heterogeneously hypoenhancing mass in themiddle and lower pole of the right kidney with internalhemorrhage, suggesting a neoplastic etiology. No otherstructures were involved. The other kidney was normal.At operation the mass was found in the lower part ofthe right kidney. Surrounding structures, IVC andureter were free from the tumor invasion.Nephroureterectomy was done. Tumor located in thelower pole of the kidney was 3.6 x 3.6 x2 cm in size(Figure 1).

Fig.1: Cut section of the tumour

Pelvicalyceal system contained blood clot. HPE ofthe tumor showed papillary and solid pattern withround to oval nuclei, prominent nucleoli and clear toeosinophilic cytoplasm. Fuhrman nuclear grading was3. Some Psammoma bodies were present. The diagnosis

was conventional papillary renal cell carcinoma(Figure 2).

Fig.2: HPE showing the nested pattern of tumorcellswith occasional papillary architecture separated

by thin fibrovascular septa (40X)

Chemotherapy was started according to NWTSregime for Stage I/II Wilms'tumour. While on last partof the chemotherapy course the patient had localrecurrence of the tumor with multiple prominentmesenteric lymph nodes, largest one measured 11.6 X 7mm. Chemotherapy regimen was revised with additionof adriamycin. External Radiotherapy 30Gy wasadministered to the right renal fossa. The paraffin blocksof the nephrectomy was reexamined with IHC stainingand it showed nuclear positivity for marker TFE3(Figure 3).

Fig.3: Nuclear positivity of IHC marker TFE3 (40×).

After completion of the revised treatment, thepatient was followed-up for eleven months and is doingwell. CT scan done six months after the revisedtreatment showed regression of the disease with centralnecrosis of the previously detected pre, para and retro-caval nodes. There was no evidence of recurrence ofthe tumor.

Jayanta Kumar Goswami at el: Renal Cell Carcinoma with TFE3

40 JASA, Vol. 23, No. 1, January - April, 2016

Discusssion :RCC, also known as hypernephroma or renal

adenocarcinoma is the most common type of kidneycancer in adult, and responsible for approximately 90-95% of cases [5]. But it is rare in children and most ofthe reported series had small number of cases and therewas diverse opinion on the pathogenesis of the disease[1]. Silberstein et al. quoted the results published in theCalifornia Cancer Registry that 53.49% of RCC werelocalized, 20.93% were regionally advanced, and25.58% were metastatic [1]. They observed actuarialsurvival at 5 and 10 years was 61% (+/-15.7%). Theauthors agreed that the tumor was different from adultRCC or Wilms' tumor in children and was aggressivein nature. Suggesting its distinctive biology the authorsadvocated the potential need for alternative treatmentstrategies for this tumor.

Barros LR et al.[3] presented a series of three casesof RCC who presented with hematuria and werediagnosed with U/S and CT scan. All the cases hadlymph node involvement at diagnosis. They were treatedwith radical nephrectomy associated with regionallymphadenectomy. Adjuvant radiotherapy was used in2 cases. All the three cases were disease-free over a periodranging from 9 to 77 months. The authors however,opined that RCC in childhood was a less aggressivedisease and radical nephrectomy with regionallymphadenectomy was the best treatment for it.

Some other observers also agreed that childhoodRCC is a different entity and its treatment needs

standardization [5]. Histopathological examinationwith conventional staining may not give the accuratediagnosis and hence the prognosis and result oftreatment. In the present case, the initial diagnosis wasbased on histology with H & E stain. Only after IHC,the correct diagnosis was possible and the treatmentwas initiated accordingly. Kuroda et al also agreed thatRCC with IHC for TFE3is a distinct entity and resultsof treament of this disease in children and adults differ.In children nephrectomy with local lymph adenectomygives good result. Whereas in adults, the results are notvery encouraging and protease inhibitors may help insuch cases [6].

Meyer et al, in their series of five cases of morethan eighteen years of age found that all the casespresented late with involvement of local lymph nodesand the results were dismal. In older patients the resultswere even gloomier [7]. Similar views also have beenexpressed by Sukov et al. after screening 632 cases ofRCC and identifying 6 cases of TFE3 rearrangement byFISH technique [8].Conclusion :

Though RCC is rare in children, among these casestranslocation involving TEF3 is relatively common. Incomparison to adults the prognosis of this disease isbetter in children. But for this proper diagnosis ofgenetic variant and proper treatment is important.

References:-1. Silberstein J, Grabowski J, Saltzstein SL, Kane CJ. Renal cell carcinoma in the pediatric population: Results from

the California Cancer Registry. Pediatr Blood Cancer 2009;52:237-41.2. Argani P, Ladanyi M. Renal carcinomas associated with Xp11.2 translocations/TFE3 gene fusions, In:Eble J,

Sauter G, Epstein J, Sesterhenn I(eds) World Health Organization Classification of Tumours. Pathology andGenetics of Tumours of the Urinary System and Male Genital Organs. IARC Press: Lyon; 2004, pp 37-8.

3. Barros LR, Glina S, Melo LF. Renal cell carcinoma in childhood. Int Braz J Urol 2004;30:227-9.4. Hodge JC, Pearce KE, Wang X, Wiktor AE, Oliveira AM, Greipp PT. Molecular cytogenetic analysis for

TFE3rearrangement in Xp11.2 renal cell carcinoma and alveolar soft part sarcoma: validation and clinicalexperience with 75 cases. Mod Pathol 2014;27:113-27.

5. Chow WH, Dong LM, Devesa SS. Epidemiology and risk factors for kidney cancer. Nat Rev Urol 2010;7:245-57.6. Kuroda N, Mikami S, Pan CC, Cohen RJ, Hes O, Michal M, et al. Review of renal carcinoma associated with

Xp11.2 translocations/TFE3 gene fusions with focus on pathobiological aspect. Histol Histopathol. 2012;27:133-40.

7. Meyer PN, Clark JI, Flanigan RC, Picken MM. Xp11.2 translocation renal cell carcinoma with very aggressivecourse in five adults. Am J Clin Pathol. 2007;128:70-9.

8. Sukov WR, Hodge JC, Lohse CM, Leibovich BC, Thompson RH, Pearce KE, Wiktor AE, Cheville JC. TFE3rearrangements in adult renal cell carcinoma: clinical and pathologic features with outcome in a large series ofconsecutively treated patients. Am J Surg Pathol. 2012;36:663-70.

Jayanta Kumar Goswami at el: Renal Cell Carcinoma with TFE3

41JASA, Vol. 23, No. 1, January - April, 2016

Journal Review

Compiled by:Dr. H.K.Dutta, MS, M.Ch.

Researchers reviewed outcomes in children with congenital heart disease(CHD) undergoing noncardiac surgery requiring general anesthesia (GA) ina tertiary pediatric center between January 2010 and December 2012.Procedures that require GA, they concluded, can be safely conducted onchildren from any of the three risk groups in a nonspecialist cardiac centerprovided that there is close liaison and careful planning between the differentspecialties.Methods

Researchers conducted a retrospective case note review of children<16?years of age with confirmed CHD undergoing a surgical orinterventional procedure requiring GA was performed.

They categorized patients into three risk groups according to Whiteand Peyton's anesthetic risk classification of children with CHDundergoing noncardiac surgery (Critical Care and Pain 2012;12:17-22).

Results Researchers identified 117 children with CHD, who underwent a

total of 240 procedures. These procedures were classified as follows: 36 procedures in the

high-risk group, 135 in the intermediate-risk group, and 69 in thelow-risk group.

In all, 40% of procedures were major operations such as small boweland colonic procedures.

The overall mortality rate at 7 days was 0%, and at 30 days, 0.4%,with a 1% mortality rate in minor procedures and 0% mortality ratein major procedures.

No unexpected deaths occurred, and 17% of procedures resulted incomplications.

Emergency procedures carried a higher rate of complications, with17% requiring admission to the intensive care unit, and the highestadmissions rate found in the high-risk group.

The median duration of hospital stay for the whole cohort was 1 day(range of 0-71 days).

2. Comparison of transumbilical laparoscopic-assisted appendectomyversus single incision laparoscopic appendectomy in children: Which isthe better surgical option?

Journal of Pediatric Surgery, 02/09/2016 Boo YJ, et al.The aim of this study was to compare the surgical outcomes of

1.Outcome of noncardiac surgery in chil-dren with congenital heart disease per-formed outside a cardiac centerJournal of Pediatric Surgery, 02/08/2016 Ng SM, et al.

42 JASA, Vol. 23, No. 1, January - April, 2016

Transumbilical laparoscopic-assisted appendectomy(TULA) with SILA in pediatric appendicitis. In thisstudy TULA is preferable to SILA for treating pediatricacute appendicitis because it is technically easier, resultsin better surgical outcomes, and provides the sameexcellent cosmetic results.Methods

A retrospective review of medical recordsbetween April 2011 and April 2015 identified250 pediatric patients who underwent singleincision laparoscopic appendectomy.

Of these, 137 patients underwent TULA and113 patients underwent SILA.

Measured outcomes included patients'demographics, clinical characteristics,operative time, length of stay, pain, andpostoperative complications.

Results TULA group had a shorter operative time than

SILA group (28.93 vs. 49.19 min, p < 0.001). The use of rescue analgesics was more frequent

in the SILA group (six cases (6.5%) vs. 19 cases(23.4%), p < 0.001).

There was no significant difference in cosmeticoutcome between the two groups.

However, TULA was associated with a lowercomplication rate (2/137, 1.5%) than SILA (11/113, 9.8%) (p = 0.0035).

In multiple logistic regression analysis, TULAwas significantly associated with a lowercomplication rate (p = 0.049).

3. Duodenal electric stimulationObesity Surgery, 02/01/2016 Aberle J, et al.The aim of this study was to demonstrate feasibility

and safety of a new electric duodenal stimulation system(EDS, BALANCE) in humans. Secondary objectives wereto evaluate the effect on glycemic control and weightloss in patients with obesity and type 2 diabetes mellitus(T2DM). This study suggests that EDS is a feasible andsafe procedure. Positive effects on T2DM and somecardiovascular parameters (HDL, weight) were seen.However, further prospective randomized blindedstudies are needed in order to evaluate the potential ofthis new minimally invasive method.Methods

In an open-labeled, prospective, single-arm,non-randomized multicenter study, 12 obeseT2DM patients with a mean HbA1c of 8.0 %received laparoscopic implantation of theBALANCE duodenal stimulating device.

Adverse events, changes in glycemic control,

cardiovascular parameters, and weight werecollected.

The follow-up period after implantation was12 months.

Results Device related severe adverse events did not

occur. Mean HbA1c decreased by 0.8 % (p = 0.02) and

mean fasting blood glucose level (FBG) wasreduced by 19 % (p = 0.038) after the 12 months.

Mean HDL level increased from 44 to 48 mg/dl(p = 0.033).

4. A novel device for cleaning the camera portduring laparoscopic surgery

Surgical Endoscopy, 01/29/2016 Kobayashi E,et al.

Poor visualization of the operative field due to anobscured camera lens is a problem frequentlyencountered while performing laparoscopic surgery. Theaim of this study is to develop a new device, theEndowiper, for cleaning the laparoscopic port. Resultsof this study suggest that this Endowiper will be aninexpensive device with a benefit to laparoscopicsurgeons.Methods

The new cleaner for the port's valve is madefrom rolled gauze.

To simulate a surgical environment in thelaboratory, the authors have used pseudo-bloodto smudge the port's valve.

In order to demonstrate the efficacy and safetyof the Endowiper, the authors compared theirmethod using this device with three previouslyreported port cleaning methods.

These methods included use of gauze tightlywrapped around an endoscopic dissectingcramp, a small piece of gauze grasped by anendoscopic dissecting cramp, and a swab.

The authors repeated the performance tests 280times, 240 using a 12-mm trocar port and 40with a 5-mm port.

Results With the 12-mm port, the complete port

clearance rate achieved was 83.3 % byEndowiper, 56.7 % by wrapped gauze, 36.7 %by small gauze, and 40.0 % by swab.

Trouble rate encountered during the procedurewas 0 % by Endowiper, 1.7 % by wrappedgauze, 15 % by small gauze, and 90 % by swab.

For the 5-mm port, the complete port clearance

43JASA, Vol. 23, No. 1, January - April, 2016

rate was 85 % by Endowiper and 20 % by sterileswab.

The trouble rate was 0 % by Endowiper and 30% by swab.

Endowiper had a significantly superior resultrelated to clearance rate than the other threemethods in both the 12- (p < 0.001) and 5-mm(p < 0.001) ports.

For trouble rate, Endowiper had a significantlysuperior result in both the 12- (p < 0.001) and 5-mm (p < 0.01) ports.

5. Endoscopy vs surgery in the treatment of earlygastric cancer: Systematic review

World Journal of Gastroenterology, 12/17/2015 Kondo A, et al.

The authors aim to report a systematic review,establishing the available data to an unpublished 2astrength of evidence, better handling clinical practice.Three-, 5-year survival, recurrence and mortality aresimilar for both groups. Considering complication,endoscopy is better and, analyzing complete resectiondata, it is worse than surgery.Methods

A systematic review was performed usingMEDLINE, EMBASE, Cochrane, LILACS,Scopus and CINAHL databases.

Information of the selected studies wasextracted on characteristics of trial participants,inclusion and exclusion criteria, interventions(mainly, mucosal resection and submucosaldissection vs surgical approach) and outcomes(adverse events, different survival rates,mortality, recurrence and complete resectionrates).

To ascertain the validity of eligible studies, therisk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale.

The analysis of the absolute risk of the outcomeswas performed using the software RevMan, bycomputing risk differences (RD) of dichotomousvariables.

Data on RD and 95%CIs for each outcome werecalculated using the Mantel-Haenszel test andinconsistency was qualified and reported in ?2and the Higgins method (?2).

Sensitivity analysis was performed whenheterogeneity was higher than 50%, asubsequent assay was done and other findingswere compiled.

Results Eleven retrospective cohort studies were

selected. The included records involved 2654 patients

with early gastric cancer that filled the absoluteor expanded indications for endoscopicresection.

Three-year survival data were available for sixstudies (n = 1197).

There were no risk differences (RD) afterendoscopic and surgical treatment (RD = 0.01,95%CI: -0.02-0.05, P = 0.51).

Five-year survival data (n = 2310) showed nodifference between the two groups (RD = 0.01,95%CI: -0.01-0.03, P = 0.46).

Recurrence data were analized in five studies(1331 patients) and there was no differencebetween the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09).

Adverse event data were identified in eightstudies (n = 2439).

A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05),demonstrating better results with endoscopy.

Mortality data were obtained in four studies (n= 1107).

There was no difference between the groups(RD = -0.01, 95%CI: -0.02-0.00, P = 0.22).

6. WHO recommends withdrawal of OPV as acrucial strategy to end polio

The Strategic Advisory Group of Experts onImmunization (SAGE) of the WHO has recommendedwithdrawal of type 2 component of oral polio vaccine(OPV). The globally synchronized switch from trivalentoral polio vaccine (tOPV) to bivalent OPV (bOPV) shouldoccur between 17 April and 1 May 2016

The type 2 component of OPV accounts for 40% ofVAPP cases, and upwards of 90% of cVDPV cases. Bycontrast, wild poliovirus type 2 has not been detectedanywhere since 1999 and the Global Commission forthe Certification of Poliomyelitis Eradication (GCC)declared this strain globally eradicated at its meeting inSeptember 2015. Countries have therefore beenpreparing to remove the type 2 component from OPV,by switching from trivalent OPV (containing all threeserotypes) to bivalent OPV (containing only type 1 and3 serotypes). All oral polio vaccines will be removedafter global eradication of wild poliovirus types 1 and 3has been certified.

SAGE also concluded that significant progress hadbeen made since its last meeting, in April 2015, with nocases of wild poliovirus in Africa since August and morethan a year having passed since the last case was seenin the Middle East, strengthened surveillance and more

44 JASA, Vol. 23, No. 1, January - April, 2016

children being reached with vaccines in key areas ofPakistan and Afghanistan. As a result of these steps, allcountries and the partners of the Global PolioEradication Initiative (GPEI) should intensify theirpreparations for the global withdrawal of OPV type 2(OPV2) in April 2016.

SAGE cautioned, however, that more work needsto be done ahead of the switch date. It is critical thatcountries meet deadlines to protect populations bymoving towards destruction of wild poliovirus type 2stocks or their containment in 'poliovirus essential'facilities. Ongoing vaccine-derived type 2 poliooutbreaks in Guinea and South Sudan need to bestopped. A global shortage of inactivated polio vaccineneeds to be managed ahead of the switch, with availablesupplies prioritized for the highest-risk areas. (WHO)7. Small Bowel Limb Lengths and Roux-en-YGastric Bypass: a Systematic ReviewObesity Surgery, First online: 09 January 2016

Mahawar KK, Kumar P, Parmar C, Graham Y,Carr WRJ, Jennings N et al.

AbstractThere is currently no consensus on the combined

length of small bowel that should be bypassed asbiliopancreatic or alimentary limb for optimum resultswith Roux-en-Y gastric bypass. A number of differentlimb lengths exist, and there is significant variation inpractice amongst surgeons. Inevitably, this means thatsome patients have too much small bowel bypassed andend up with malnutrition and others end up with a lesseffective operation. Lack of standardisation poses furtherproblems with interpretation and comparison ofscientific literature. This systematic review concludesthat a range of 100-200 cm for combined length ofbiliopancreatic or alimentary limb gives optimumresults with Roux-en-Y gastric bypass in most patients.T his systematic review concludes that a range of 100-200 cm for combined length of biliopancreatic oralimentary limb gives optimum results with Roux-en-Ygastric bypass in most patients.Symptoms of Zika virus infection

About 1 in 5 people infected with Zika virus becomeill (i.e., develop Zika). The most common symptoms ofZika are

low-grade fever (between 37.8°C and 38.5°C) arthralgia, notably of small joints of hands and

feet, with possible swollen joints. myalgia. headache, retro-ocular headaches. conjunctivitis. cutaneous maculopapular rash.

post-infection asthenia which seems to befrequent

The incubation period (the time from exposureto symptoms) for Zika virus disease is notknown, but is likely to be a few days to a week.

The illness is usually mild with symptomslasting for several days to a week.

Zika virus usually remains in the blood of aninfected person for a few days but it can be foundlonger in some people.

Severe disease requiring hospitalization isuncommon.

Deaths are rare.Diagnosis

The symptoms of Zika are similar to those ofdengue and chikungunya, diseases spreadthrough the same mosquitoes that transmitZika.

See your healthcare provider if you develop thesymptoms described above and have visited anarea where Zika is found.

If you have recently travelled, tell yourhealthcare provider when and where youtravelled.

Your healthcare provider may order blood teststo look for Zika or other similar viruses likedengue or chikungunya.

Treatment No vaccine or medications are available to

prevent or treat Zika infections. Treat the symptoms:

o Get plenty of rest.o Drink fluids to prevent dehydration.o Take medicine such as acetaminophen to

relieve fever and pain.o Do not take aspirin and other non-steroidal

anti-inflammatory drugs (NSAIDs), likeibuprofen and naproxen. Aspirin andNSAIDs should be avoided until denguecan be ruled out to reduce the risk ofhemorrhage (bleeding). If you are takingmedicine for another medical condition,talk to your healthcare provider beforetaking additional medication.

If you have Zika, prevent mosquito bites for thefirst week of your illness.o During the first week of infection, Zika virus

can be found in the blood and passed froman infected person to another mosquitothrough mosquito bites.

o An infected mosquito can then spread thevirus to other people.

45JASA, Vol. 23, No. 1, January - April, 2016

HON. SECRETARY`S REPORT fromASSAM STATE CHAPTER of ASI

Respected esteemed members of Association of Surgeons of Assam (Assam State Chapter of ASI),

Rongali Bihu Greetings to you all. It gives me immense pleasure in presenting before you the brief report of ourchapter till March, 2015.

2nd January 2016 : Guwahati: Charge handover ceremony of newly elected Chairman held at Guwahati.Immediate past Chairman Dr. R. N. Mazumder handed over his charge to newly elected Chairman Dr. ManojKumar Choudhury. Many past chairman and general members of association attended the ceremony. A Clinicalmeeting followed the ceremony. Dr.N N Das delivered a lecture on Anatomic consideration in Liver resection. Dr.SAhmed presented a case report on portal vein resection in whipple's Procedure

18th January 2016: Dibrugarh : The Sept to Dec 2015 issue (Vol- 22, No 3) of JASA , the Journal of Associationof Surgeons of Assam was released on 18th January 2015 at Dibrugarh.

5th February, 2016 : Guwahati: Burn Care Day 2016 : Association of Surgeons of Assam, in association withthe Burn Care Foundation, organized Burn Care Day with a day long program at Guwahati on 5th February 2016.The day included : Public awareness program with a Rally, an exhibition, one interactive session and a seminaron "Present and Future of Burns Management"

13th February, 2016: Dubri :

1. A public awareness meeting to popularize NSV( Non Scalpel Vasectomy), a process of male sterilization,was organized at Dhubri, resource person Dr. Kanakeswar Bhuyan, Chairman of Guwahati Branch alsoperformed NSV cases.

2. A Free Surgical Camp was also organized on the same day at Dhubri Civil Hospital, Dhubri. Five Lapchole, one open chole, one large ventral hernia and three inguinal hernioplasty operation were performedat the camp. The surgical team was lead by Dr.M K Choudhury,Chairman Assam state Chapter of ASI.Dr.K Bhuyan, Dr.Elbert Khiangte, Dr.P P Das,Dr.S Phukan, Dr.R Sarma, Dr.N M Ahmed and Dr,B Deka(Anaesthesia) were other members of the team.

3. A CME was also organized in the evening by IMA Dhubri branch. Dr.K Bhuyan delivered a lecture on"Engagement of Men in family planning" and Dr.M K Choudhuiry delivered lecture on "Lap managementof CBD stone

20th February, 2016 : Jorhat: Jorhat Branch of ssociation of Surgeons of Assam along with Doctors Club, Jorhatorganized a CME on 20th Februry, 2016 with following topics:

1. Endocrine Surgery: An Emerging Speciality- by Dr. Sunil Malla Bujar Barua.

2. Intervention Radiology: Current prospesct- by Dr. Firdus Ahmed.

3. Neurosurgery: When and Where? - by Dr. Nabajyoti Bora.

28th February, 2016 : Tezpur : Tezpur Branch of Association of Surgeons of Assam organized a CME Programmeat Tezpur in association with IMA Tezpur Branch at IMA Hall , Tezpur at 7.30 pm on 28th February 2016 on thefollowing topics:

Association News

46 JASA, Vol. 23, No. 1, January - April, 2016

1. An Overview of Bariatic Surgery by Prof. Subhash Khanna.

2. Whipple's Procedure for Pancreatic Tumour, by Dr. Jadunath Buragohain.

3. Current Trends in Aesthetic Surgery by Prof. Swagata Khanna.

12th March 2016 : Dibrugarh Branch oF Assam Chapter of ASI, organised a "Hands-on Training on BasicLaparoscopic Skills" in Department of Surgery, Assam Medical College, Dibrugarh. Dr. Sanjoy Mandal, Director,Department of GI Surgery (GI Cancer & Advanced Laparoscopy), Medica Superciality Hospital, Kolkata was thevisiting faculty for the Skill Course. The Skill Course was largely attended by the members of Dibrugarh Branchand Post Graduate Trainees of Surgery, Obstetrics & Gynaecology, ENT as well as Junior Residents of AssamMedical College, Dibrugarh.

On the same day, that is, on 12th March 2016, Dibrugarh Branch also organised a Branch Meet in HotelGarden Treat, Dibrugarh with following scientific presentations -

1. “Science of Tissue Management" - Dr. S. Mandal, MS, Mch (GI Surgery), Director, Department of GI Surgery,Medica Superciality Hospital, Kolkata

2. "Spectrum of Whipples'- My Series" - Dr. S. A. Fazal, Associate Professor, Department of Surgery, AMCH.

3. "SAGES Safe Cholecystectomy Program" - Dr. A. Dutta, Consultant Surgeon, TATA Tea Referral Hospital,Chabuwa.

17th. March 2016 : Bongaigaon Branch of the Association organised a scientific presentation on IBS at LowerAssam Hospital, Bongaigaon. The topic was presented by dr. A Tham.

22nd March 2016: A CME was held at Cachar cancer hospital under the banner of ASA, Borak Valley Branchon "Overview of breast cancer". It was moderated by Dr.Ravi Kannan, Director Cachar cancer hospital and pre-sented by Dr.Toral Gathani, Clinical Epidemiologist, Cancer Epidemiology Unit, University of Oxford ConsultantOncoplastic Breast Surgeon, Oxford University Hospitals NHS Trust,Oxford, United Kingdom

OBITUARY:

Senior Uro Surgeon and an active member of our Association and life member of ASI Dr Rnendra KumarMahanta was expired on 09th February, 2016. Members of ASA condoled on his death and prayed for eternal peaceof the departed soul.

We are regularly publishing our quarterly Journal "JASA" and the news letter "Surgery Papyrus" as before. Irequest all members to contribute their experiences and achievements in the both.

Before I conclude, let me offer my sincere thanks to you all for your co operation and active participation indifferent activities of the association during the year 2015. We seek your co operation, guidance and suggestions toserve our dear Organisation better.

Thanking you all

Dr. Pulakananda Bharali

Hon. Secretary.

Assam Chapter of ASI

E-Mail: [email protected]