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1. Necrotizing Soft Tissue Infections
  SR Tambwekar, KJ Khadalia, VS Tambwekar, RF Ginwalla
 
The term Necrotizing Soft Tissue Infections (NSTI) covers a spectrum which includes some potentially life-threatening infections characterized by insidious, extensive, rapidly progressive necrosis which can involve the skin, subcutaneous tissues, fascia, muscle, and extend even into bone and many lead to sepsis and also death. When predisposing factors exist such infections may be initiated by trauma or surgery or other causes or appear to arise de novo in the tissues. Essential to successful treatment are early recognition, repeated aggressive surgical excisional debridement, antibiotics, supportive intensive care, Hyperbaric Oxygen Therapy when feasible and subsequent reconstruction.

The main snag in the management, is the initial misdiagnosis of Cellulitis. NSTI must be considered when continued spread of the “cellulitis” occurs despite adequate treatment.

Various infections having similar pathophysiologies resulting in a “vascular disaster of infective origin” come under this diagnostic umbrella of NSTI: Fournier’s gangrene, Necrotizing Fasciitis, Meleney’s gangrene, Hospital gangrene, Synergistic bacterial gangrene, Noma vulvae, Cancrum oris, Gas gangrene and Diabetic gangrene. The thrombosis prevents the host defenses and even the antibiotics from reaching the affected area and therein lies the importance of the surgical intervention.

A similar clinical picture can be seen following snakebite, scorpion bite, other insect bites and also vascular gangrene. Some fungal infections can result in soft tissue necrosis.

The infection could be monomicrobial but is usually caused by a mixture of synergistically acting aerobic and anaerobic bacteria. The clinical course and extent of the condition are influenced by the virulence of the microbe, the size of the inoculum and the host defense.

Any region of the body is susceptible but the commoner sites of involvement are the extremities, the abdomen and the perineum. The various predisposing factors include unrecognized or inadequately treated cutaneous infections, bites, parenteral drug abuse, contaminated operation, soft tissue injury, burns, obesity, diabetes mellitus, smoking, malnutrition, peripheral vascular disease, alcoholism and immunosuppression.

Diagnosis is usually confirmed by surgical exploration following clinical suspicion although X-ray, aspiration, CT scan, MRI and Frozen section biopsy have all been recommended.

We are presenting a series of 50 cases ranging from Diabetic foot infections, Fournier’s gangrene, necrotizing fasciitis following trauma, snakebite, bee sting, cardiac surgery, total knee replacement, and immunosuppression. Other predisposing factors in our series were diabetes and lower limb varicosities. We have been able to avoid major amputations. There were two fatalities.

Even with advances in intensive care and antibiotics, this disease is still plagued with a high mortality, which can be reduced with timely and appropriate management.
 
2. Surgery for the Obese - Changing Concepts
  SR Tambwekar, KJ Khadalia, VS Tambwekar, RF Ginwalla
 

Surgery for the obese has seen many changes in the past few decades and these changes have been brought about by a variety of specialists interested in this field.

In the early days the concept was to reduce size and thus weight. Reduction meant excision of vertical excess and myriad methods of excision were introduced-each having distinct advantages and disadvantages.

A study of these procedures led workers to the concept of horizontal and vertical excess. As times changed society became vain and vertical excision incisions became inverted ‘T’ shaped and later horizontal incisions.

Ongoing research led to the understanding of muscle laxity, diastasis of the muscles, and the presence of intra abdominal fat, which also play an important role in determining the final outcome of, and the design of the procedures designed for helping the obese.

The discovery of liposuction added a further dimension to treatment protocol, decreasing the morbidity in those patients who could then avoid abdominoplasty procedures. Endoscopy is another advance in the field of abdominoplasty with limited indications.

Plastic surgeons then started to combine these procedures of excision and suction in various permutations to incorporate the advantages and minimize the disadvantages and to give the patients the best possible outcome.

Gastroenterologists also began to give thought to the predicament of the obese and developed restrictive and malabsorptive procedures to make patients lose weight. Of late these procedures have become very common as a result of which patients are losing 40-50 Kgs or more over a two to three year period. At the end of this extreme weight loss patients’ skin sags and they require a circumferential body contouring.

This and the concept that the trunk hips and thighs is a unit, which needs reduction, led to the development of belt lipectomies and to reversal to the vertical incision. This presentation gives an overview of the changing concepts of surgery for the obese and its current form.

 
3. Study of 20 Mcases of Chronic Calcific Pancreatin’s Managed Surgically
  Neeraj, V Shrikhande, MM Begani
 
Chronic calcifying pancreatitis is a special form of pancreatitis that is associated with pancreatic lithiasis. Lithiasis refers to true stones in duct system of pancreas called pancreatic calculi or false stones due to calcification of parenchyma.

It is most frequently the result of chronic alcoholism but has pathology similar to hypercalcaemic pancreatitis and herediatary pancreatitis. In our study also, alcohol was a key aetiological factor with abdominal pain and diabetes mellitus being the major presenting symptom.

Main pancreatic duct dilatation, intra-ductal and parenchymal calcification detected by X-rays, USG and CT scan, determine the course of management.
Though analgesics, pancreatic enzyme supplements and stenting or an ERCP were among the major modalities used for pain relief, these patients had to be treated surgically by Lateral pancreatic jejunostomy. Post operative complications were minimal with excellent pain relief in 95% of cases, weight gain and blood sugar level control was also detected to some extent.

We conclude that surgical approach in a Lateral pancreatic jejunostomy is a good modality of management in patient of chronic calcific pancreatitis with dilated main pancreatic duct.
 
4. Stappler Haemorrhoidectomy - A Newer Technique for Piles and Prolapse
  MM Begani, Niranjan Agarwal, Naresh Row
 
Haemorrhoids (Piles) are a common general surgical disease encountered by us. Surgery is advised in III and IV degree of Piles. In past, open and closed haemorrhoidectomy had been standard practice. For last few years the newer modality for tackling large piles and mucosal prolapse had been available which has low mobility and pain but more expensive as compared to the open surgery, as the cost of PPH Staplers is app. Rs.15,000/-. The operations can be done as Day care under very light general or regional anaesthesia. As the post operative pain is low the patient can resume his job within few days of surgery.

In last 3 years, we had operated 15 patients with this technique under sedation and local analgesia (Pudendal nerve block), 4 cases as hospitalized and 11 cases as day case. Post operative complications, namely pain, bleeding, retentions of urine and lesser pain killer requirement, had been significantly as compared to open haemorrhoidectomy, with the added benefit of early resumption of work. Cost in a significant factor in our country to limit the use of this technique to large number of patients.
 
5. Case Presentation of a High Risk Patient Operated for Gall Bladder Empyema Under Local Anaesthesia
  MM Begani, Niranjan Agarwal, Fatima
 
The operation of cholecystectomy is a major intra abdominal surgery done under general, spinal or epidural anaesthesia as an open or laparoscopic procedure.

However, these forms of anaesthesia carry a high risk in patients with ASA grade IV. We present a case of gall bladder empyema in an elderly lady with cardiac ailments operated under local anaesthesia.

Mrs. XYZ, 50 years old, was admitted with severe right hypochondriac pain, nausea, vomiting and fever since the past 3 days, USG showed a distended gall bladder with a stone impacted at the Hartmanns pouch. The high leucocyte count of 25,000, indicated gallbladder empyema.
The patient had previous history of ischaemic heart disease, transient ischaemic attack and taking medication of HT. With an ejection fraction of 20%, was a very high risk for GA.

Decision to operate the patient under local anaesthesia with sedation was taken and solution of 2% xylocaine with 0.5% sensorcaine was used to give intercostals Nerve block with field block. As the abdomen was opened local anaesthesia was infiltrated in the various layers, fundus first method was used and cholecystectomy done for empyematous Gall bladder, post operatively the patient was shifted for monitoring to intensive care unit. Patient was shifted back to ward after 2 days and discharged on day 4 of surgery with no untoward incident during the hospital stay.

We conclude that open cholecystectomy under local anaesthesia is an option in high risk cases, in cases needing emergency surgery of gall bladder.