We read with interest the multicenter study by Schadde and colleagues in the April issue regarding the novel procedure of Associating Liver Partition and Portal vein Ligation for Staged Liver resection (ALPPS) [1]. Since the initial description 2 years ago [2] ALPPS has gained popularity as a surgical option for treating patients with advanced liver lesions not considered amenable to conventional two-stage or future liver remnant-enhancing procedures propagated by Rene Adam et al.[3] a decade ago. Indeed, the explosion of interest in ALPPS by surgeons and its adoption as a procedure of choice is concerning, given that the procedure appears to come with considerable cost to the patient, as shown in this study. The increased severe morbidity of 27 versus 15 % and the mortality of 15 versus 6 % may not achieve traditional measures of statistical significance in this study, but the effect size is concerning, and the direction of effect is consistent across outcome measures and studies. Is ALPPS in its current form safe enough for the widespread adoption that has occurred given increasingly effective nonsurgical approaches, including ablation, chemotherapy, selective internal radiation therapy [4], and growth factor/receptor inhibition?As the authors rightly point out, the risk of selection bias is significant given the study design. It is unclear whether the logistic regression analysis adequately adjusts for the imbalance in baseline risk in favor of the ALPPS group: why, for instance, was operative risk (ASA grade) not controlled for in the multivariate analysis?One of the potential benefits of a two-stage procedure is that it may disclose biologically unfavorable disease. By its very nature, ALPPS does not lend itself to such selection given the short time interval between the first and second stages. The authors appear to reject this argument, citing a similar overall recurrence rate seen in this study. We were puzzled with this position given that the study highlights an interesting observation: in the PVE/PVL group 11 % of patients had systemic progression prior to the second stage. Presumably this group of patients would not have benefitted from ALPPS.In our practice, patients who may be deemed by others to be ideal candidates for ALPPS are seldom not amenable to either a two-stage liver resection or a single-stage resection with prior volume-enhancing maneuvers. Indeed, it is difficult to understand why an ALPPS approach was used at all in some of the cases presented at recent international conferences. We wonder what proportion and kind of patients with advanced liver lesions would really benefit from the ALPPS approach. The international ALPPS registry will perhaps provide clearer evidence for the role of this challenging approach to liver resection.

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Aim: To evaluate prospectively the effect of pterygium excision on visual acuity and contrast sensitivity before and after surgery. Material & method: A prospective observational study where in 63 eyes of 63 patients with primary pterygia were studied before and after surgery. Examination was done in which contrast sensitivity was measured with pellirobson chart pre-operatively and one month postoperatively following pterygium excision with Conjunctival Limbal Auto Graft. Result: As the grade of pterygium increases, decrement in contrast sensitivity occurs. The visual acuity significantly increased after the surgery. Mean contrast sensitivity following pterygium surgery improved from 1.49±0.21 to 1.70±0.20 (p value <0.001). Conclusion: Visual acuity and contrast sensitivity improved significantly following pterygium excision surgery.

ABSTRACT:The aim of the present study was to identify the prevalence of non-viral etiological agents, their geographic, climatic and occupational risk factors associated with microbial keratitis in patients of Kannauj district of Uttar Pradesh, India. Microbial keratitis is a leading cause of monocular blindness world-wide. This study was conducted to find out the epidemiological factors associated with this disease in our set up. METHOD: A prospective analysis of 250 clinically diagnosed cases coming to OPD of Govt. Medical College, Kannauj were examined over a period of one year, from 1 st January 2013 to 31 st December 2013. Age, Sex, Occupation, Agents leading to the ulcer were some of the parameters included in our study. Corneal scrapes were collected and subjected to microscopy, culture and sensitivity. RESULTS: In 250 patients of clinically diagnosed microbial keratitis, 153(61.2%) were Males and 97(38.8%) Females. Most common Age group was 41-60 yrs. (40.8%) followed by 21-40 yrs. (39.2%). Most common cause of Microbial keratitis was Ocular Trauma. Among the microbial keratitis fungal ulcer were more frequent due to trauma by Organic Vegetative matter and as Kannauj is rural area, so Farmers were mostly affected (54%). CONCLUSION: Microbial keratitis is mostly seen in Farmers in this part of India. Males are affected more than Females. Aspergillus and staphylococcus aureus were the most common causative agents. Increased prevalence of Microbial keratitis was seen during harvest and post-harvest seasons.

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