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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Head and Neck Malignancies and Neck Dissection Complications: A Cohort Study from a Tertiary Care Centre in Telangana, India
Correspondence Address :
Shubranshu Jena,
Room No. 404, Department of Surgical Oncology, Speciality Block, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad-500082, Telangana, India.
E-mail: sjena678@gmail.com
Introduction: Complications after major surgery are a significant cause of morbidity and mortality, and they have been shown to harm long-term quality of life. Lymph node status is the chief prognostic indicator. In the head and neck, complications from oncosurgeries can also delay adjuvant treatment, which is known to adversely affect survival. Neck dissection is a standard procedure for head and neck cancer following resections of the primary tumour. The invasive nature of neck dissection predisposes patients to a variety of intraoperative and postoperative complications.
Aim: To analyse the complications in patients with head and neck malignancies following neck dissections.
Materials and Methods: This was a single-centre cohort study conducted at the Department of Surgical Oncology, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India. All patients diagnosed with head and neck malignancies who underwent neck dissections from July 2022 to December 2022 were included in the study. Complications such as bleeding, haematoma, infection, seroma, wound dehiscence, flap necrosis, fistula, chyle leak, shoulder dysfunction, and nerve and vascular injuries following various neck dissections were observed until discharge. The data was entered in Microsoft excel and results were expressed in terms of frequency and percentage.
Results: A total of 67 patients were analysed in this study. Among them, 42 (62.7%) were males and 25 (37.3%) were females, with a mean age of 48 years and an age range of 25-84 years. Three patients underwent bilateral neck dissection, and a total of 70 neck sides were studied. Among the patients who received prior radiotherapy (20, 29.8%), 6 (30.0%) experienced complications, and there were no deaths.
Conclusion: Head and neck surgery carries the potential for many complications due to the presence of major vessels and nerves. Carefully performed surgery is the cornerstone of success. Thorough preoperative assessment, proper surgical technique, and postoperative care are essential in preventing and managing complications. A step-by-step approach to studying details and conducting a complete check-up of the patient after the procedure ensures optimal results with minimal late side-effects and complications.
Chyle leak, Haematoma, Nerve injury, Seroma
Complications after major surgery are a significant cause of morbidity and mortality and have been shown to affect quality of life (1). Lymph node status is the chief prognostic indicator (2). Metastatic dissemination into lymph nodes of the neck frequently occurs in head and neck cancers, downgrading the patient’s curability and survival (3). In head and neck oncosurgeries, complications can also delay adjuvant treatment, which is known to adversely affect survival (3),(4),(5),(6),(7),(8). Following resections of the primary tumour, neck dissection is a standard procedure for head and neck cancer (5),(9). Since the introduction of radical neck dissections in the early 20th century, many factors associated with treating neck dissections have affected the complication rates and morbidity associated with them. Complications encountered following neck dissections include bleeding, haematoma, infection, seroma, wound dehiscence, flap necrosis, fistula, chyle leak, shoulder dysfunction, nerve, and vascular injuries (7),(10). The transition from radical neck dissection to selective neck dissection have decreased morbidity and complications while maintaining surgical efficacy and oncological principles. These modifications still present variable degrees of shoulder dysfunction as a common complication (7),(10). Chemotherapy has been investigated as an alternative approach to primary surgical resection with the aim of preserving organs in patients with advanced head and neck tumours. Neck metastatic disease is one of the most significant prognostic factors (11),(12). Hence, the present study was conducted to evaluate the complications of neck dissections arising in head and neck malignancies following different types of neck dissections.
The present study was a single-centre cohort study. All patients who were diagnosed and operated for head and neck malignancies with neck dissections from July 2022 to December 2022 were included as participants in the study after obtaining ethics approved IEC no. EC/NIMS/3049/2022.
Inclusion criteria: Patients with No/N1 neck status for all head and neck malignancies, those undergoing neck dissection for an unknown primary or primary neck dissection or post neoadjuvant Chemotherapy (CT)/Concurrent Chemo-Radiation (CTRT)/Radiotherapy (RT), those with metastatic neck nodes or with primary tumour excision and neck dissection were included in the study.
Exclusion criteria: History of previous ipsilateral neck dissections or neck surgery in the past on the side of neck dissection were excluded from the present study.
Procedure
A total of 67 patients were included as subjects in the present study, by random sampling method, and the following data were collected from the patients admitted to the Surgical Oncology department at NIMS for elective neck dissection after obtaining informed consent.
Demographic parameters including age, gender, history of diabetes, hypertension, tuberculosis, history of tobacco, gutkha chewing, Smoking, alcohol, Contrast-Enhanced Computed Tomography (CECT) of the face and neck, ultrasound of the neck, biopsy/Fine-Needle Aspiration Cytology (FNAC) of the primary tumour/neck node/both. The included patients were noted for complications following neck dissections: bleeding, haematoma, infection, seroma, wound dehiscence, flap necrosis, fistula, chyle leak, shoulder dysfunction, nerve and vascular injuries. The surgical procedure followed was selective neck dissection technique. During the closure of the neck wound, proper approximation ensures complete closure of the neck and proper healing with minimum scarring. The platysma elevation of flaps was strictly subplatysmal in all dissections, and closure was done in three layers (platysma, subcutaneous tissue, and skin), which aided in better wound healing (4). Postoperative drain management has necessary considerations in the healing of the surgical wound (4),(8). Placing drainage was considered as a separate step during the procedure, from the incision itself, to lower down the chances of infection and was monitored properly.
Statistical Analysis
Descriptive statistics were used, and the data were tabulated and represented as frequency, percentage, and mean±SD, bar graphs, and pie-charts. The association among various variables was calculated by the Chi-square test. Statistical Package for Social Sciences (SPSS) version 16.0 was used for analysis and p-value <0.05 was considered statistically significant.
A total of 67 patients who met the inclusion and exclusion criteria were included. Among them, 42 (62.7%) were males, and 25 (37.3%) were females, with a mean age of 48 years and an age range of 25-84 years. Three patients underwent bilateral neck dissection, and 70 neck sides were studied. All the study participants and subjects were observed for complications following various neck dissections until discharge. Patients who received prior radiotherapy were 20 (29.8%), and 6 (30.0%) patients out of these had complications, and no deaths occurred in this study.
(Table/Fig 1) provides the differential diagnosis of head and neck malignancies of all participants of the study, who were further planned to undergo the procedure of neck dissection.
Six patients underwent functional neck dissection, four had posterolateral neck dissection, and two had Modified Radical Neck Dissection (MRND) type 1. Radical neck dissection was done in two cases, and extended radical neck dissection in one. The most commonly performed neck dissection was Modified Radical Neck Dissection (MRND) type 2 in 43 cases, followed by supraomohyoid neck dissection in 12 (Table/Fig 2).
The most commonly injured nerve was the spinal accessory in 5 (7.5%) cases, marginal mandibular in 2 (3%) cases (Table/Fig 3), while two patients (6%) suffered vessel injury.
Postoperative complications was observed in 60 patients. The most common postoperative complication observed was the development of a seroma in 25 (37.3%) cases, followed by chyle leak in 9 (13.4%) cases and dehiscence in 7 (10.4%) cases, respectively (Table/Fig 4).
The most common complication among the post-RT patients (n=20) was seroma (10.0%), wound infection, wound dehiscence, and chyle leak, occurring in 0.05% of patients each (Table/Fig 5).
Most study participants, 39 (58.2%), had their drain removed between postoperative days 5 and 7 (Table/Fig 6). A comparison between men and women concerning the development of postoperative complications (n=60), showed that more postoperative complications occurred among men compared to women. However, these differences were not found to be statistically significant in the analysis (Table/Fig 7).
A comparison between the age of the participants concerning the development of postoperative complications (n=60) (Table/Fig 8) revealed that patients aged 55 years or younger suffered more from seroma, abscess, and wound infection than their older counterparts, who, in turn, suffered more from wound dehiscence and chyle leak. However, a statistically significant difference was observed only for wound infection (Table/Fig 8).
Out of the 67 cases, 25 (37.3%) patients developed seroma, which were drained by aspiration followed by applying compression dressings. A total of 6 (9%) patients developed a haematoma, and 4 (6%) needed re-exploration.
The authors of this study observed four patients (6%) with thoracic duct injury, while a similar injury was reported by Kumari S in 4% of patients (13). The specific procedure to be followed in neck dissection surgery was planned according to wound complications, as details are also mentioned in previous literature (4). Wound complications were higher in MRND technique and surgery, as described in previous studies (11) or RND than in the case of SND, due to a larger area involved in the surgical field in RND procedure and its modifications. Furthermore, these procedures also involve triflapped incision technique (11), while SND technique involves biflapped incision technique, supporting the same reason. The use of three flaps results in reduced vascularisation at the periphery of the skin, leading to ischaemia (14), which explains the observed higher incidence of skin-flap necrosis or dehiscence. However, these did not occur in the present study as the authors practiced keeping a small tissue of Sternocleidomastoid (SCM) muscle intact with the posterior flap. In any case, all the RND/MRND procedures in the present study were associated with a 3-flap incision.
Most study participants 39 (58.2%) had their drain removed between postoperative days 5 and 7. The mean postoperative day of drain removal (15) for the participants was 6.5±1.6 days, which was 4 days in Urquhart AC and Berg RL (16). A total of eight male patients and one female patient presented with chylous leak, who were managed accordingly. Many previous studies, although an uncommon complication, also depicted the surgical management of chylous leak (17). The reported incidence of wound complications after CRT varies from 3-61%. Some authors have reported that they did not find any significant differences (3) in complications between groups of patients who were or were not submitted to preoperative RT [8,18], while others assumed that CRT (12) should be considered a risk factor (8) for wound complications. The present study reported an incidence of haematoma in 9% of patients after neck dissections, while a previous study mentioned an incidence of 4.2% of cases presenting with haematoma after head and neck surgeries (19). Preoperative optimisation is followed in order to lower the chances of complications (4). Co-morbidities such as diabetes, hypertension, cardiac, respiratory, and relative malnutrition were controlled and managed before the patient was prepared for surgery (4). Enhancement of nutritional status with either a nasogastric tube or percutaneous gastrostomy, depending on the condition of the patient, was done preoperatively. Postoperatively, general systemic co-morbidities were managed effectively with high-quality healthcare, including a team of physicians, anaesthesiologists, and surgeons. Advanced respiratory support may be necessary for patients in order to clear secretions and improve pulmonary function.
If oral and oro-pharyngeal lesion resection is carried out concurrently, the resultant through-and-through defect increases (1),(2),(20) the wound infection rate in the neck. However, simultaneous application of antiseptics or antibiotics reduces the chances of this complication to a great extent. Meticulous suturing of the resultant defect minimises the neck infection rate. Suturing of oral mucosa in two layers helps add strength. Reducing the length of perioperative treatment with intravenous antibiotics limits the development of drug-resistant bacterial infections. All complications were successfully treated with medication and surgical revision (20).
Limitation(s)
In the present study, the small sample size presented difficulty in generalising the results. Moreover, the three-flap incision technique was used, which reduces vascularisation to the skin, increasing the chances of ischaemia.
Head and neck surgery has the potential for many complications due to the presence of major vessels and nerves. Carefully performed surgery is the cornerstone of success. A step-by-step approach with attention to detail and a thorough check after the completion of the procedure will ensure optimal results without complications. The possible integrity of the cranial nerves should be maintained unless it compromises tumour resection. Modified procedures should be used to reduce the adverse effects of the classical operation and preserve its effectiveness in oncological terms. A protocol-driven approach and a vigilant and proactive emphasis in the entire perioperative period can minimise complications. Further studies are recommended in the future with the two-flap incision technique to compare the resultant complications.
DOI: 10.7860/JCDR/2023/64263.18866
Date of Submission: Mar 24, 2023
Date of Peer Review: May 24, 2023
Date of Acceptance: Oct 27, 2023
Date of Publishing: Dec 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
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• iThenticate Software: Oct 25, 2023 (7%)
ETYMOLOGY: Author Origin
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