BACKGROUND: Postpancreatectomy hemorrhage (PPH) is one of the most severe complications after pancreaticoduodenectomy. METHODS:This prospective study was done in a tertiary care center to find out the role of gastric pH in postpancreatectomy hemorrhage. The gastric pH study is done by Ryle’s tube aspiration – 1) fasting ph value 1 hour before surgery and second value after 48 hrs of surgery. RESULTS: Of the total 27 patients who underwent Whipple’s procedure, 6 patients develop postpancreatectomy hemorrhage. On applying unpaired T test it was found that the difference was significant (p value <0.05) in the mean pH values among those with PPH when compared to those without PPH. The mean pH levels (mean ± Sd) among bleeders was 3.39 ± 1.80 and among non bleeder was 6.33 ± 1.03. The mean pH values were significantly lower in those where bleeding was present. The area under the curve of the ROC analysed and it was found that that the PH of 4.1 had maximum sensitivity (50%) and specificity (95.2%). Based on this, association between bleeding and PH value of 4.1 as cutoff was analysed using chi square test and it was found that the incidence of bleeding was significantly (p value <0.05) higher among those who had a PH value <4.1 (75%) compared to those with PH >4.1 (13%) CONCLUSION: Persistent low gastric pH is associated with increased risk of post pancreatectomy Hemorrhage.Suppression of the intrinsic gastric acid secretion will be helpful in reducing the risk of bleeding after Pancreaticogastrostomy in Whipple procedure.

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Fournier gangrene (FG) is a rare but rapidly progressing disease with a higher mortality rate in women as compared to men. This study aims to perform a literature review about FG in females and associated mortality and morbidity. We searched databases including MEDLINE (Ovid), the National Library of Medicine (Medical Subject Headings (MeSH)), the Cochrane Database of Systematic Reviews (Wiley), as well as Embase (Ovid), Scopus, and Global Index Medicus (WHO), and reviewed literature from 2002 to 2022 and selected 22 studies that met our study’s inclusion criteria, which included 134 female patients with a mean age of 55±6 years. The perineal abscess was a more common nidus (n=41, 35%; 95%CI 23-39%) than vulvar pathology (n=29, 22%; 95%CI 15-30%). The most common initial presentation was cellulitis (n=62, 46%; 95%CI 38-55%), followed by perineal pain (n=54, 40%; 95%CI 32-50%), fever (n=47, 35%; 95%CI 27-43%), and septic shock (n=38, 28%; 95%CI 21-37%). Escherichia coli was the most frequently identified bacteria (n=48, 36%; 95%CI 28-46%). All patients had treatment with a mean of three (SD 2) debridement and those with negative pressure dressings received fewer debridements than those who received a conventional dressing. However, of those who had surgical intervention, 28 (20%; 95%CI 14-29%) patients underwent diversion colostomy. General surgeons performed 78% (n=104) of cases out of which 20% (n=20) were consulted by obstetrician-gynecologists, 14% (n=18) were treated by urologists, and only 8% (n=10) by plastic surgeons. The mean length of stay in the hospital was 24±11 days, and the gross mortality rate was 27 (20%; 95%CI 14-28%). In conclusion, while females have a low incidence rate of FG, they carry a higher mortality rate. Lack of cardinal signs and delayed presentation to the hospital from the onset of symptoms are some possible causes for the increased mortality rate along with the disease process being under-recognized in women. A high index of clinical suspicion is essential to avoid delay in the definitive management coupled with an early surgical consult and establishing a common general care pathway could minimize mortality and morbidity.

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High degree suspicion is mandatory in dealing with a post-operative patient presenting with a crampy postprandial abdominal pain, as potential for internal hernias remains fairly under diagnosed. Except in setting of small bowel obstruction or gangrene and radiological proven internal hernia, intervening a patient with herald symptoms is still debatable, though certain authors advocate that in lap. Roux-en Y gastric bypass patients with herald symptoms should promptly be offered elective laparoscopic exploration elective repair safely and expeditiously.