Indian Surgeons Research Articles

Editorial: 14th pediatric endoscopic surgeons of India 2019 annual conference

Editorial: 14th pediatric endoscopic surgeons of India 2019 annual conference

Benefit of Tympanoplasty with or without Cortical Mastoidectomy in Active Mucosal Otitis Media – A Comparative Study

Introduction: 
 Chronic otitis media (COM) is amongst the most common diseases treated by ENT surgeons in India. It has been advocated in lot of research articles that there is no significant difference in tympanoplasty done in active and inactive COM. The objective was to see if cortical mastoidectomy in cases of active mucosal COM, improves the success rate of tympanoplasty measured as per the following parameters: improvement in the hearing threshold by 15 dB, increased graft uptake and reduction in retraction of tympanic membrane in post operative period.
 Materials and Methods: 
 This study comprises of 120 patients coming to the ENT OPD from October 2016 to October 2017 with active mucosal COM with central perforation requiring tympanoplasty. These patients were randomly assigned to two groups: Group 1 of 60 subjects in which tympanoplasty without mastoidectomy was done, Group 2 of 60 subjects in which tympanoplasty with mastoidectomy was done. Patients were evaluated after a post operative period of 3 months.
 Results: 
 The Results were the hearing improvement was 73.33% in group 1 while 83.33% in group 2, graft uptake was 63.33% in group 1 and 80% in group 2, graft retraction was 33.33% and 23.33% in group 1 and group 2 respectively.
 Conclusion:
 There was statistically significant difference in results in group with and without mastoidectomy in active mucosal chronic otitis media with respect to graft uptake and improved hearing.

A comparative study between rubber band ligation and local application of herbal caustic compound (pratisaraneeya kshara) in management of internal haemorrhoids

Image 1071765.

The Current Status of Peritoneal Surface Oncology in India.

With the increasing acceptance of cytoreductive surgery and HIPEC as a potentially curative treatment for primary and secondary peritoneal surface malignancies, peritoneal surface oncology has emerged as a distinct sub-specialty of surgical oncology. In the last 10years, the acceptance of a conceptually different approach towards the management of peritoneal metastases has increased in India. During this period, over 1000 combined procedures have been performed in the country and most of the major cities have centers performing offering this treatment. Indian surgeons have formed collaborative groups to promote research and development of this specialty across the country. This article provides a detailed account of current practices pertaining to peritoneal surface oncology in the country and a future perspective.

Analysis of Clinical Outcomes of Pseudomyxoma Peritonei from Appendicular Origin Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy-A Retrospective Study from INDEPSO.

To evaluate the clinical outcomes of patients of pseudomyxoma peritonei of appendiceal origin undergoing cytoreductive surgery and HIPEC. Data collected from members, an independent collaborative group of Indian surgeons specializing in the management of peritoneal surface malignancy (INDEPSO), was analyzed retrospectively. Clinicopathological and perioperative outcomes of patients treated for pseudomyxoma peritonei (PMP) of appendicular origin were evaluated. Ninety-one patients were diagnosed with pseudomyxoma peritonei of appendicular origin between March 2013 and December 2017. The median age was 53years and 60% were females. The median PCI was 27 [range 3-39] and a CC-0/1 resection was achieved in 83.5% patients. The most common histological grade was low-grade PMP, seen in 71.4% cases. The overall rate of grades 3-4 morbidity was 33% (30/91) and the 90-day mortality rate reported was 6.5%. Pulmonary complications and systemic sepsis emerged as the most significant factors affecting morbidity, mortality, and failure to rescue. At a median follow-up of 24months, the median OS was not reached and the median PFS was 53months. On univariate and multivariate analysis, high-grade histology, prior chemotherapy, debulking surgery alone without HIPEC, and high PCI > 10 were predictors of poor progression-free survival. The survival and morbidity results of pseudomyxoma peritonei from appendicular origin following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are encouraging. With further awareness and understanding of the disease, and improvement in surgical expertise and learning curve, there is scope for further reduction in morbidity and better improvement in survival.

Is someone listening? The first IJTC National Survey of CTVS trainees.

Cardiothoracic surgery will soon have a shortage of qualified surgeons in India, because the profession is losing appeal among surgical residents. Do we really understand why the profession is not their first choice, or what the current cardiothoracic residents think about their training? This article is the first nationwide survey meant only for cardiothoracic residents in training, conducted through online survey tool to report on the issues concerning our residents.

Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry

Background: The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry. • Identify operational problems.Methods: A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons’ attitudes and existing practices pertaining to the registry and identify operational problems.Results: During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres.Conclusions: These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

First nationwide survey on the experience of Indian cardiac surgeons about international fellowship programmes.

The correct path after finishing residency in cardiac surgery (CS) has been unclear to most of the young cardiac surgeons. Pursuing a fellowship abroad is by far the most preferred option for many residents after residency. We report the results of the first nationwide survey on the experience of Indian cardiac surgeons who have pursued a fellowship abroad. A 10-question Web-based survey was distributed in March, 2018, to all cardiac surgeons in India who have done at least 1year of fellowship or registrarship in CS abroad. A reminder was sent after 1month. All responses were verified for genuineness and entirety. A significant 55 responses qualified for survey analysis. Fifty-five surgeons with a mean experience of 8.1years after residency and at least 1year of international training responded to the survey. Australia and New Zealand were the most common countries opted for post-residency training and a majority did a 2-year international fellowship. Most of them were fairly satisfied with protocol learning (4.1/5), research work (3.3/5) and financial support (3.7/5) but not with the surgical hands-on experience (2.9/5). The greatest challenge after the fellowship was to establish an independent practice and get patient referrals. Forty per cent of the surgeons felt that Indian post-residency training could be comparable to international fellowships if the centre is chosen wisely. A few (16%) of them even believed that Indian post-residency training is better than international fellowships. International fellowships have their own merits and demerits and are to be chosen wisely. In the present situation, Indian post-residency training for basic surgical work is comparable to that of overseas. However, international exposure is recommended for learning advances in cardiac surgical subspecialities like minimally invasive cardiac surgery (MICS), robotic CS, aortic and endovascular techniques and heart failure surgeries.

Making heart-lung machines work in India: Imports, indigenous innovation and the challenge of replicating cardiac surgery in Bombay, 1952-1962.

In 1962, surgeons at two hospitals in Bombay used heart-lung machines to perform open-heart surgery. The devices that made this work possible had been developed in Minneapolis in 1955 and commercialized by 1957. However, restrictions on currency exchange and foreign imports made it difficult for surgeons in India to acquire this new technology. The two surgeons, Kersi Dastur and PK Sen, pursued different strategies to acquire the ideas, equipment, and tacit knowledge needed to make open-heart surgery work. While Dastur tapped Parsi networks that linked him to local manufacturing expertise, Sen took advantage of opportunities offered by the Rockefeller Foundation to access international training and medical device companies. Each experienced steep learning curves as they pursued the know-how needed to use the machines successfully in dogs and then patients. The establishment of open-heart surgery in India required the investment of substantial labor and resources. Specific local, national, and transnational interests motivated the efforts. Heart-lung machines, for instance, took on new meanings amid the nationalist politics of independent India: Even as surgeons sought imported machines, they and their allies assigned considerable value to 'indigenous' innovation. The confluence of the many interests that made Sen and Dastur's work possible facilitated the uneasy co-existence of conflicting judgments about the success or failure of this medical innovation.

Indian Survey of Surgical Antibiotic Prophylaxis (ISSAP 2017)

Background: Surgical site infections(SSIs) are one of the most common healthcare-associated infections. Patients developing SSIs are 60% more likely to be admitted to an ICU, and are > 5 times likely to be re-admitted to hospital. Using Antibiotic prophylaxis(AP) decreases SSIs, but the usual long courses of AP can lead to increasing antimicrobial-resistance, super-infection with resistant pathogens, and unnecessary costs. WHO has constantly addressed the issues related to surgical antimicrobial prophylaxis(SAP) but there is less of Indian data. This survey helps us understand the current trends in SAP in common surgical practice of Indian-surgeons. Methods & Materials: This was a real-world, questionnaire-based survey involving 126 surgeons from India. Of these, 94(74.6%) surgeons duly filled in the questionnaire. The analysis was based on the data from these 94 surgeons and performed using SPSS version 22.0. Results: In 95.74% of cases, SAP was selected based upon the classification of surgical wounds. The risk of SSIs was higher in case of dirty-surgeries(70.21%) compared to contaminated-(58.5%) and clean-contaminated(12.77%). Out of 94, 36.17% preferred cefazolin as the first-line SAP for prevention of deep wound infections followed by cefuroxime(32%), ceftriaxone(28.72%), and co-amoxiclav(15.96%). For pre-operative prophylaxis, 42.5% of surgeons preferred giving one dose within 1 hour prior to incision and 29% of surgeons gave it 30-minutes prior to incision. Intra-operatively, 38% of surgeons re-dosed the antibiotic every 4 hours due to following reasons: half-life/duration of surgery(59.57%), wound size/procedure/case complexity(21.28%), estimated blood loss/IV fluid dilution-(15.96%), literature reference(4.26%). A few cases continued SAP post-operatively because: operation theatre (OT) doesn’t meet the required standards(23.4%), consultant surgeon's preference(22.34%), prevention of SSIs(20.21%), lack of OT discipline(19.15%), and unreliable sterility of instruments(18.09%). In the high (>10%) extended-spectrum beta-lactamases (ESBL)-prevalent areas, 95.74% of surgeons opined that SAP should be modified to either piperacillin-tazobactam(44.4%) or cefoperazone-sulbactam(26.67%) depending upon susceptibility. However, 16% of surgeons used the combination of amikacin-metronidazole. Conclusion: Surgeon in India are largely following the published SAP guidelines. However well-designed, randomised trials are needed to address concerns like post-operative continuation and choice of the SAP in ESBLs prevalent areas.

Results of single row versus double row arthroscopic repair in massive rotator cuff tear

Introduction: Rotator cuff disease is a painful condition with a multifactorial aetiology in which severe or chronic impingement of the rotator cuff tendons on the under- surface of the coracoacromial arch is often a significant factor. Although not a life-threatening condition, RC tears may cause significant pain, weakness, and limitation of motion. A shoulder disorder can increase functional dependency in the elderly due to difficulties in completing activities of daily living and in young it causes absenteeism from work, decreased productivity and consequential socioeconomic loss. In recent years, arthroscopy is gaining a steady popularity among Indian orthopaedic surgeons. While more complete arthroscopic or arthroscopic-assisted rotator cuff repairs are done day by day, the literature on this subject is relatively sparse. We undertook the present study to evaluate functional outcome of total arthroscopic repair of rotator cuff tear using UCLA and ASES scores at Government Institute. Aim: This study was carried out to assess the results in terms of functional outcome and patient satisfaction of arthroscopic repair of rotator cuff tear. Materials and Methods: “Results of single row versus double row arthroscopic repair in massive rotator cuff tear” is a prospective cohort study conducted for 30 months from July 2015 to December 2017, on 30 patients admitted and operated for rotator cuff tear at Civil Hospital Ahmedabad affiliated to B J Medical College. The functional outcome was assessed by two scoring systems: UCLA (University of California at Los Angeles) [12, 13, 14] and ASES (American Shoulder and Elbow Surgeon) scores [15] and constant Murley score. Results and Discussion: In our study, we have included only arthroscopically operated rotator cuff tears. Comparison with open, miniopen approaches is thus not possible. We have found 100% success rates in terms of improvement in UCLA, ASES and Constant scores. Mean preop UCLA scores (8.53), Ases (9.91) and Constant (9.83) scores were improved upto UCLA (30.63), ASES (76.98) and Constant (86.9) at end of 12 months follow-up. In our study we have compared results of single row and double row techniques using functional outcome, surgical time and expence. We have compred our results with BMC review conducted by Tudisco et al. Conclusion: In current orthopaedics practice, arthroscopic repair of rotator cuff tear offers excellent results in terms of functional outcome with minimal morbidity.

Results of uncemented total hip replacement

Background: Indian surgeons annually perform more than 150,000 total hip replacements (THRs), 90% of which are primary procedures. Improved surgical technique and instrumentation have expanded the clinical indications for Uncemented THR. Aim: To study the results of Uncemented Total Hip Replacement. Materials and Methods: All the patients were evaluated clinically (according to Modified Harris Hip Score) and radiologically at 6 months post operatively and were followed up to 3 years. Results: The patients operated in our study had an average Modified Harris Hip Score 97.25. Discussion: Compare the preoperative and postoperative modified Harris hip score. Conclusion: Results of Uncemented total hip replacement are excellent and good.

Antibiotic prophylaxis in cataract surgery: Understanding the trends of the day.

Postoperative endophthalmitis (POE) remains the most dreaded complication for any cataract surgeon worldwide. Although with more stringent peri-operative prophylactic measures in place, the rates of POE have dropped to <0.1% all over the world, the perfect formula which would provide the maximum protection against ocular infection remains the Holy Grail. It is interesting to see the preferred practice patterns of cataract surgeons all over the world, and these surveys have often formed the recommendations in the absence of a fixed set of guidelines on this topic. The 2006 ESCRS study[12] had first recommended the routine use of intracameral (IC) cefuroxime at the end of the cataract surgery as a safe and effective measure against POE. Eight years down the line, the 2014 ESCRS survey[3] showed that 74% of its members had routinely inculcated IC antibiotic usage into their practice. However, this also means that approximately one-fourth of the respondents had not inculcated this effective measure in their practice in 8 years since the publication. Similarly, the endophthalmitis prophylaxis surveys of ASCRS, 2007 and 2014,[45] showed a growing trend of IC antibiotic use from 30% to 50% among its respondents. This again also indicates that 50% of respondents in 2014 were not using IC antibiotic. In the Indian subcontinent, the practice patterns of cataract surgeons have been seen to vary widely. Some robust studies from larger institutes such as by Haripriya et al. concluded that IC moxifloxacin prophylaxis is effective with a 3.5-fold reduction in the overall rate of POE.[6] This study acknowledges that, while this does not constitute Level 1 evidence and that there is no consensus that IC antibiotic prophylaxis should be the standard of care, IC moxifloxacin prophylaxis should be considered for high-risk eyes experiencing posterior capsule rupture with vitreous loss. Kelkar et al. in their article “Antibiotics prophylaxis practice patterns for cataract surgery in India – Results from an Online Survey”[7] could elicit responses from a small number of participants – 1228 respondents (8.2%), which may not be truly representative of the prevalent practices among cataract surgeons in India; however, it does provide insights into POE prevention. In this study, preoperative povidone-iodine antisepsis was adopted by 94% of the respondents. Unfortunately, this figure needs to be made 100%. Nearly 38% of the respondents reported IC antibiotic usage routinely after cataract surgery, but 68% believed that it is important to have a commercially approved drug for IC use. Nearly 48% of the respondents were not using intraocular antibiotics since they were not convinced of the need. The AIOS member survey by Maharana et al.[8] is a commendable effort in bringing out some glaring shortcomings, and we can hope it will be the step toward formulation of a recommended set of guidelines which every anterior-segment surgeon practicing in the country will be expected to adhere to. In addition, following up with repeated surveys with the same cohort in the future would help to assess the changes which could be brought by these recommendations. However, only 30.2% of participation in the survey is still a small number, and it can be hoped that this participation can be increased in future surveys. The revelation from the study that only 83% use of povidone-iodine is an eye-opener showing that <100% of the respondents perform mandatory preoperative preparations. Use of postoperative subconjunctival antibiotics by 46% of the respondents is another revelation highlighting rigid barriers to the changing protocols of postoperative antibiotic regimen. Thus, we do understand that preferred practice patterns should not only give mandatory protocols on specific disease issues from time to time, but the ophthalmological community must also institute measures to execute the same in the large interest of our patients. There is a strong need to educate our ophthalmologists across the country of the changed protocols of antibiotic prophylaxis in the current scenario. These are the interesting facts which prove that there is a major challenge in convincing the respondents on the use of safety measures.

Knowledge and attitudes of Indian surgeons regarding professional medical writing support.

Aim:The number of scientific papers published from India each year is low. We tried to determine how often Indian surgeons publish in biomedical journals, challenges preventing them from publishing more often, their awareness of the international guidelines that acknowledge professional medical writing as an ethical service, and their willingness to hire medical writers for their publications.Materials and Methods:A convenience sample of 100 of the surgeons attending a national conference were explained about the survey and asked to complete a survey questionnaire. All results were expressed as absolute frequencies and percentages.Results:Of the 81 who responded, 43 (53%) had never published. Only 31/81 (38%) had published in the last 5 years. The challenges preventing more frequent publication were reported to be the lack of support for carrying out statistical analyses (58%), lack of time (41%), lack of sufficient data (38%), and lack of support for literature search (37%). Twenty-two (27%) surgeons were aware that they could hire a professional medical writer (PMW), 26 (32%) knew that the International Committee of Medical Journal Editors allowed PMWs to contribute to articles published in the biomedical journals, 75 (93%) were interested in hiring medical writers or to consider it in the future. Only 6 (7.4%) showed no such interest.Conclusion:There was poor awareness and great interest in hiring PMWs. It might be beneficial to increase the awareness of clinicians about the scientific expertise and communication skills of PMWs and how they can add value to biomedical publications.

Setting up of the Indian HIPEC Registry: A Registry for Indian Patients with Peritoneal Surface Malignancies.

There are various registries for patients with peritoneal metastases (PM) that aid pooling of data and generate evidence that dictates current clinical practice. This manuscript describes the setting up of the Indian HIPEC registry that was set up with a similar goal by a group of Indian surgeons. This is a registry for patients with PM treated with CRS and HIPEC in India. It also acts as a database for storing treatment-related information. Patients with PM from colorectal ovarian, gastric, appendiceal tumors, and other rare peritoneal tumors/metastases from rare tumors are enrolled in the registry. A coordinator updates the disease status of patients on a yearly basis. A private organization maintains the database. A non-disclosure agreement is signed between the company and each surgeon contributing to the registry to maintain confidentiality. For enrolling patients, securing institutional permission depends on the requirement of each institute; patient consent is mandatory. Data entry can be prospective or retrospective. To propose and conduct a study, the approval of a scientific committee linked to the registry is required. The Indian HIPEC registry is a practical database for Indian surgeons. There is no regulatory body that mandates collection and publication of scientific data in India. The onus is on each surgeon to capture valuable information pertaining to these common and rare diseases that could contribute to the existing scientific knowledge and guide the treatment of these patients in the future. The next challenge will be to enter data into the registry.

Report of SSAT-IASG Travelling Fellowship: A new award for Indian gastrointestinal surgeons from the Society for Surgery of the Alimentary Tract, USA.

Report of SSAT-IASG Travelling Fellowship: A new award for Indian gastrointestinal surgeons from the Society for Surgery of the Alimentary Tract, USA.

Indian survey on practice patterns of lacrimal & eyelid disorders (iSUPPLE): Report 3 – Cataract and nasolacrimal duct obstruction

AimTo assess the practice patterns pertaining to pre-cataract screening for nasolacrimal duct obstruction (NLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the current screening and treatment strategies for NLDO and the interval between lacrimal surgery and subsequent cataract surgery. MethodsAn online survey was sent to all members of Oculoplastic Association of India. All valid responses were tabulated and analyzed. ResultsMajority of the respondents (92%) felt that nasolacrimal duct patency should be checked prior to performing cataract surgery: 59.6% felt that checking for regurgitation on pressure over the lacrimal sac (ROPLAS) was sufficient and 32.6% preferred to perform lacrimal irrigation to check for NLD patency. Dacryocystorhinostomy (DCR) was the preferred surgery for NLDO thus detected. The preferred interval between a DCR and subsequent cataract surgery was 4weeks (48.9%). A small minority (7.9%) of the respondents felt that pre-cataract screening for NLDO was not required. Also, a small but significant number (12.6%) felt that no treatment was required for NLDO in such patients and that to could go ahead with cataract surgery even in the presence of coexisting NLDO. ConclusionsThere is a general agreement on the need for pre-cataract screening for NLDO and a majority indicated that checking for ROPLAS was sufficient. Most surgeons prefer to perform a DCR in cases of NLDO and wait for 4weeks before intraocular surgery. There is however, a lacuna in the literature on guidelines regarding the optimal interval between lacrimal surgery and subsequent intraocular surgery.

Trends in scientific publications of Indian arthroplasty surgeons over 15 years (2001–2015)

BackgroundThe quality and number of scientific publications reflect the developmental status of research in a country. However, the contribution of Indian arthroplasty surgeons toward global research publications is unknown yet increasing. This study aims at determining the active role of Indian arthroplasty surgeons for scientific publications between 2000 and 2015. Materials and methodsA literature search of the publications by Indian arthroplasty surgeons was performed using PUBMED. The search terms used were India and several joint related terminologies. The main information of the selected papers including the scientific journal, publication year, type of pathology, or Orthopedic study center, type of study, and the type of article was analyzed. ResultsA total of 20,485 Total Hip Arthroplasty articles; 17,151 Total Knee Arthroplasty articles; 400 Total shoulder arthroplasty articles; and 250 Total Elbow Arthroplasty articles were identified using PUBMED and after exclusion, 68 Total Hip Arthroplasty articles; 125 Total Knee Arthroplasty articles; 2 Total shoulder arthroplasty articles; and 3 Total Elbow Arthroplasty articles were analyzed. A growth of 250% in the number of publications in THR & 530% in the number of publications in TKR was observed in the period between 2011 and 2015, during which 35 of the articles in THR, 82 in TKR were published. The three most common pathologies studied for knee were (osteoarthritis, post-traumatic arthritis and complex fracture of a knee); for hip were (osteoarthritis, avascular necrosis, developmental dysplasia of the hip and post tubercular hip arthritis). ConclusionThe current study concept reveals that publications in arthroplasty have been on growing rate in the last decade, although seems to be less. Further efforts such as research training of arthroplasty surgeons, international collaborations, and allocation of adequate funds, proper English tutorials are key factors to improve the scientific publications from India.

Bilateral internal thoracic artery grafting in India—Time to raise the bar

ObjectivesBilateral internal thoracic artery (BITA) grafting strategy is the current trend in coronary artery bypass grafting for multivessel coronary artery disease. Although better long-term outcomes have been shown, BITA grafting is underutilized as a main strategy for revascularization by most of the surgeons. The survey was conducted to ascertain the current usage and concerns of BITA grafting in India. MethodsDatabase of 856 Indian cardiac surgeons currently with predominantly adult practice was prepared and a questionnaire was sent about use of single and bilateral ITA grafts and BITA grafting strategy in different clinical scenarios. ResultsA total of 112 surgeons (13.08%) from 75 institutions responded and 92 surgeons (10.7%) completed the survey. Single ITA is used by 79% of surgeons in more than 90% of their patients. 31% and 29% of surgeons use BITA grafting in 5–10% and 11–98% of their patients respectively. 53% of surgeons avoided the usage of BITA grafting in patients with smoking, 35% of surgeons in chronic obstructive pulmonary disease, 58% of surgeons in obesity and 62% of surgeons in acute coronary syndrome, 36% of surgeons in patients with left ventricular dysfunction and 61% of surgeons in patients with poor coronary anatomy. The concerns for BITA usage are risk of deep sternal wound infection (DSWI) (40%), increased operative time (27%), unknown superiority (12%) and limited length of right ITA (5%). ConclusionsThe usage of BITA grafting is restricted to 10% in India and main concerns are DSWI and increased operative time.

Executive Summary - TheAssociation of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016.

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.