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The Surgical bulletin· Issue VII·

February 05, 2021 Pg. 1

THE TRIVIA THEATRE

FIRST BARIATRIC SURGERY

Historical reports claim that the first bariatric surgery was performed in Spain, in the 10th century. D. Sancho, king of Leon was reported to be such an obese man that he could not walk, ride a horse or pick up a sword. This led him to lose his throne. He was then escorted by his grandmother to Cordoba to be treated by the famous Jewish doctor Hasdai Ibn Shaprut. He sutured the kings’ lips who could only be fed on a liquid diet through a straw, consisting of teriaca: a mixture of several herbs, including opium, whose side effects stimulated weight loss. King Sancho lost half his weight, returned to Leon in his horse and regained his throne!

Q-RIOSITY

1. Which of the following is not an indication for bariatric surgery in an Asian patient?

a) BMI > 32.5kg/m2 with CAD b) BMI > 37.5kg/m2 c) BMI > 35kg/m2 with severe

depression d) BMI > 32.5kg/m2 with Pickwickian

syndrome

2. Which of the following is not a component of Obesity Surgery – Mortality risk Score ( OS- MRS)?

a) Age > 45 years b) Type II DM c) Hypertension d) Male gender

CONTOURA VISION With evolving times, LASIK surgeries in India has seen umpteen advancements & progress. They have proved to enhance the vision of millions by reducing the need for corrective eyewear to see clearly. Contoura Vision Eye Surgery is another leap in LASIK Surgery aiding the

eye surgeons in creating a customized LASIK procedure to improve the quality of eyesight. Contoura vision surgery is also known as Topography-guided LASIK surgery. Contoura Vision is the latest FDA approved LASIK procedure which optimally reduces the corneal irregularities of your eyes. As per the clinical studies, Contoura Vision Eye Surgery has helped 30% of the patients achieve better than 6/6 vision. Thus, helping them see better

without glasses than they did with the glasses. The technology used in Contoura surgery is more advanced as compared to conventional LASIK surgery. While the conventional LASIK surgery maps only 200 points on the cornea, the Contoura vision surgery maps 22000 points on cornea.

Instead of just treating the eyeglass prescription, it utilizes unparalleled diagnostic capabilities, i.e., a three-step correction technique using a Femto-Laser, Excimer Laser and a Topolyser, to identify & record the minutest imperfections in the curvature of cornea thereby providing an aspheric correction of spectacle power while also correcting your corneal irregularities and working on visual axis. Post which the measurements are combined with eyeglass prescriptions to give your eyes a better focusing surface, thereby deriving a much superior visual outcome. Not just that, even a lot of the side effects of various

other LASIK procedures such as light sensitivity, difficulty in night driving, difficulty in reading, glare, starbursts, halos tend to diminish with Contoura Vision. Patients who are less than 18 years of age or suffering from immunodeficiency or vascular diseases and patients with myopia higher than 9.00 D are not eligible for Contoura Vision LASIK surgery.

Dept of Ophthalmology, AFMC Pune

SOFT TISSUE OSTEOMA OF HAND: A RARE FINDING Osteoma is a benign, slow-growing tumor composed of well-differentiated, densely sclerotic, compact bone, occurring particularly in the skull and facial bones. Osteomas have no potential for malignant transformation. Osteoma development in soft tissues with no bony attachments is a very rare event. Hand involvement is even rarer with only three such cases reported in the literature thus far. A 68-year-old woman with comorbidities (DM-II, HTN, Pacemaker in situ) presented with a painless solid mass in the thenar region of her right palm, which appeared almost 1 and half years ago and showed a progressive enlargement in the last months. Based on clinical and radiological

05 February, 2021 Pg. 2

3. Which of the following is/ are considered

to be a reversible bariatric surgery? a) Laparoscopic adjustable gastric

banding b) Laparoscopic Roux- en – Y bypass c) Laparoscopic sleeve gastrectomy d) Both A and C

4. In recent years, the most commonly performed bariatric surgery is

a) Roux- en –Y gastric bypass b) Biliopancreatic diversion c) Laparoscopic gastric banding d) Sleeve gastrectomy

5. The most common cause of death in patients of bariatric surgery is

a) Pulmonary embolism b) Anastomotic leak c) Sepsis d) Intra- abdominal bleed

Answers can be emailed to knotsandknives@yahoo.com. Names of the top 3 people who answer correctly will be published in the next issue along with the answer key.

Winners of the previous quiz Col Ravikant Narayan Answer key:

1. D 2. B 3. B 4. A 5. C

appearance, a formative diagnosis of benign bony tumour involving 1st metacarpal head was made, with differentials being osteochondroma and osteoma. However, both age of the patient and location of mass were contradicting the existing thought. A MRI was definitely indicated to confirm the diagnosis and rule out possibility of malignancy. However, to complicate things, patient had a pacemaker in situ, which was not MRI safe. Under regional anaesthesia an excisional biopsy was performed and the histopathological evaluation of the lesion confirmed the diagnosis of soft tissue osteoma. The postoperative follow-up period was uneventful without any

complication. Mostly idiopathic, it is proposed that soft-tissue chondroma, myositis ossificans, soft-tissue osteochondroma, and soft-tissue osteoma lie on a spectrum related to soft tissue injury. In most of the patients the soft-tissue osteoma arises spontaneously without any trauma. Soft tissue osteomas consist of bone in the centre with hyaline cartilage at its periphery. This feature can be utilised in differentiating it from Myositis Ossificans where calcification occurs at periphery and proceeds in centripetal manner. Conventional radiological examination reveals a homogenous, well-

demarcated and calcified mass embedded in soft tissues. It is estimated that of all the soft tissue osteomas, 15% are localised in hand. Soft tissue osteoma should always be kept in differential diagnosis for all hand tumours; Since Osteoma is a benign condition, simple surgical excision is the treatment of choice. Early diagnosis and initiation of treatment will reduce the symptoms and early restoration of activities of daily living. Dept of Orthopaedics, AFMC, Pune

MUCORMYCOSIS IN COVID-19 Mucormycosis is a fulminant fungal infection occurring in debilitated patients with an underlying pathologic condition. Mucormycosis is an infection caused by fungi of the class Phycomycetes, which are characterized by nonseptate mycelia. Specific organisms involved in man are species of the genera Mucor, Rhizopus, and Absidia, which are members of the order Mucorales. These fungi are ubiquitous in nature, being found in soil, vegetable debris, and manure. They are recognized generally as bread molds or contaminants on culture plates that grow rapidly by aerobic metabolism. Once the fungus enters tissue, it invades local arteries, causing thrombosis. Post COVID-19 sepsis and use of steroids in its management facilitates secondary bacterial and fungal infections. Indian epidemiology of invasive mould infections has recently emerged as a life-threatening complication of COVID-19 especially with other predisposing factor like diabetes. Coupled with the potential implications of steroid-induced hyperglycaemia, the COVID 19 patient receiving corticosteroids or other immunosuppressants is exceptionally vulnerable to the development of mucormycosis. Two most important manifestations of Mucormycosis in this setting are rhino-orbital-cerebral and pulmonary. Intranasal inspection most often shows dry, black crusting of the turbinates, septum, or palate, unless the patient is immunosuppressed. In this instance, minimal ischemic changes may be the only manifestation of the disease. There is often facial swelling, with tenderness over affected sinuses. If the disease has progressed, orbital signs will be present. These include progressive loss of function of the second, third, fourth, and sixth cranial nerves with proptosis, ptosis, dilated pupil, and loss of vision. The fifth and

Fig: Mass attached to underlying

soft tissues

Fig: Excised mass

05 February, 2021 Pg. 3

Emil Theodor Kocher

Emil Theodor Kocher was a Swiss physician and medical researcher who received the 1909 Nobel prize for his work in the physiology, pathology and surgery of the thyroid. Among his accomplishments are the introduction and promotion of aseptic surgery and scientific methods in surgery, specifically reducing the mortality of thyroidectomies below 1% in his operations. He was the first Swiss citizen and first surgeon to ever receive a Noble prize. Named in his honor:

1. Kochers forceps 2. Kochers point 3. Kocher manoeuvre 4. Kocher – Debre – Semelaigne

syndrome 5. Kocher incision 6. Kocher sign

Interestingly, The Kocher Lunar crater is named in his memory along with an asteroid (2087) Kocher which also commemorates his name.

Dept of General Surgery, AFMC Pune

seventh cranial nerves are compromised as the fungus proceeds relentlessly toward the brain. India bears the dubious distinction of being both the diabetes, as well as the mucormycosis, ‘capital’ of the world. COVID-19 and its treatment, against this backdrop,

amounts to a recipe for disaster. Mucormycosis remains one of the most devastating complication in uncontrolled diabetics with mortality rates ranging between 40-80%. Almost half of Indians are unaware of their diabetic status and only a quarter of all patients achieved adequate glycaemic control on treatment. Rapid diagnostic methods include biopsy, KOH mount and Calcofluor stain. While treating, the first goal is control of the underlying disease process. Rehydration and correction of diabetic acidosis will slow the aggressive spread of this disease. Once the patient's metabolic status has been

stabilized, immediate debridement of all devitalized tissue is performed, including orbital exenteration if vision is gone. In the postoperative period, amphotericin is given intravenously. Treatment is prolonged because of the nephrotoxicity of this drug, as well as its fungistatic, rather than fungicidal, mode of action. Patients are followed up closely for azotemia, rise in serum creatinine level, decreasing creatinine clearance, renal acidosis, and nephrocalcinosis, all of which are dose related. If renal function is not closely monitored, with adjustment of dosage, irreversible renal damage will occur. Non-nephrotoxic alternatives- Posaconazole or Isavuconazole . Benefit of using steroids in COVID-19 was specifically shown with low dose, short duration dexamethasone in moderate to severe illness. Mucormycosis needs to be actively managed by a team which includes members from almost all departments in the hospital. Dept of Otorhinolaryngology, AFMC, Pune

RETURNING TO THE ICE AGe Fibroadenoma is one of the most common benign tumors of the breast in women under 30 years of age. In the adolescent population, the overall incidence of fibroadenoma is 2.2%. They account for 68% of all breast masses and 44%–94% of biopsied breast lesions. Being so common, they still cause panic in the patient and the idea of surgery can seem daunting to them. Science has yet again attempted to cater that need of the patient with the advent of minimally invasive procedures such as radiofrequency and laser ablation, sequential piecemeal excision using automated vacuum-assisted biopsy devices, and cryoablation. Cryoablation, is a relatively simple technique, which can be done in tumors <4 cm in size and <3 in number, with no malignant component proved by histology and no evidence of

bleeding tendency and local skin infection. Under ultrasound guidance, a cryoprobe is introduced into the breast and guided into the center of the lesion, probe is placed through the long axis of the fibroadenoma. A double freeze-thaw cycle is used for an ice ball formation. The efficacy of cryoablation is based on the cytotoxic effects of cold that produce both instant and delayed destruction of cellular ultrastructure. Additionally, ice crystals in the intracellular milieu damage organelles and plasma

membranes. Cryoablation also damages tumor cells by causing endothelial cell dysfunction, microthrombus formation, ischemia, and platelet aggregation.

1. The cold temperature kills two birds with one stone, providing analgesia during

the procedure. A low dose local analgesic will suffice if required.

2. It comes with few rare side effects of fat necrosis, skin swelling, ecchymosis, and

skin burns.

Dept of General Surgery, AFMC Pune