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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
Effect of Carbon Dioxide Pneumo-peritoneum in Coagulation Profile of Patients undergoing Laparoscopic Cholecystectomy: A Prospective Cohort Study
Correspondence Address :
Arup Mandal,
PG Hostel No. 5, RIMS, Lamphelpat, Imphal-795004, Manipur, India.
E-mail: arupmondal.am@gmail.com
Introduction: Laparoscopic Cholecystectomy (LC) is done under general anaesthesia with the patient in a reverse Trendelenburg position and with pressurised carbon dioxide in the peritoneum. This can induce venous stasis in the lower extremities and may affect the balance in the coagulation and fibrinolysis system, thereby thrombo-embolic complications.
Aim: To investigate the effects of carbon dioxide pneumo-peritoneum on the coagulation system of patients undergoing LC.
Materials and Methods: A prospective longitudinal study was carried out from January 2021 to June 2021 among patients aged 18 to 60 years who attended the Surgery Department at Regional Institute of Medical Sciences, Imphal, Manipur, India and were diagnosed with gallstone disease and subsequently underwent LC. Independent variables like age, sex, religion, pre-operative prothrombin time, platelet count, activated Partial Thromboplastin Time (aPTT), and International Normalised Ratio (INR). Outcome variables comprised complications, post-operative prothrombin time, platelet count, aPTT, and INR. Data collected were analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Paired t-tests were employed to test the association between mean values of post-operative and pre-operative PT, aPTT, INR, etc. A p-value of less than 0.05 was considered statistically significant.
Results: The study enrolled 71 patients who encountered LC with carbon dioxide pneumo-peritoneum, including 18 male and 54 female patients. Maximum number of patients (28, 38.9%) fell into the 41 to 50 years age group. There was no significant difference in the mean value of prothrombin time (p=0.150) and INR (p=0.437) measured between the pre-operative and post-operative periods.
Conclusion: LC is a safe procedure without clinically significant changes in the coagulation profile.
Capno-peritoneum, Fibrinolysis, Prothrombin time, Virchow’s triad
Laparoscopy has become one of the most common procedures used for diagnostic and therapeutic purposes. It offers the benefit of better cosmesis, milder post-operative pain, early discharge from the hospital, resume to normal life and work faster than traditional open methods (1). The experience gained from approximately over 500,000 procedures annually has laid a strong foundation of knowledge for advanced laparoscopy, but the effect of carbon dioxide pneumo-peritoneum on the coagulation system needs further exploration (2).
The procedure of LC is done under general anaesthesia with the patient in a reverse Trendelenburg position and pressurised carbon dioxide in the peritoneum. Maintaining this position till the procedure can induce venous stasis in the lower extremities, leading to endothelial changes that affect the balance in the coagulation and fibrinolysis system (2),(3). Thus, all the components of Virchow’s triad can be seen above which could ultimately lead to thrombo-embolic complications. Studies have described the effect of pneumo-peritoneum during LC in relation to coagulation and platelet activation, creating a state of hypercoagulability during the post-operative period (4),(5),(6). The incidence of post-operative deep vein thrombosis among LC patients ranges from 0 to 55% (5). Such variations in incidence and differences of opinion underscore the need for further studies.
The increasing use of laparoscopic techniques in modern surgery demands research on changes in blood coagulation following these operations. Thus far, the data was limited and marked by differences of opinion between those who argue against (7),(8) and those who support (4),(9) the effects of LC on patients’ coagulation profiles.
The consequences of carbon dioxide pneumo-peritoneum need to be further studied with respect to individual systems. Thus, this study was initiated to study the effects of carbon dioxide pneumo-peritoneum on the coagulation system of patients undergoing LC and to make surgeons aware of any potential harmful effects.
A prospective cohort study was conducted in Manipur at the Department of Surgery, RIMS, Imphal, Manipur, from January 2021 to June 2022 after obtaining ethical approval from the institutional Research Ethics Board (reference no. A/206/REB-Comm(SP)/RIMS/2015/752/94/2020).
Inclusion criteria: This study was conducted among patients aged 18 to 60 years who attended the Department of Surgery, were diagnosed with gallstone disease, and underwent LC.
Exclusion criteria: Those who refused to participate, were on anti-coagulation therapy, had a known case of Deep Vein Thrombosis (DVT), had co-existing malignancy, were pregnant, or had their procedure converted to open surgery were excluded from the study.
Sample size calculation: A sample size of 72 was calculated using the formula N=(u+v)2 (s12+s22)/(m1-m2)2, where u=0.84 (at 80% power), v=1.96 (at 5% significance level), and the following values were taken from a study by Milic DJ et al., (6):
m1=mean of APTT value at the pre-operative level=26.8276
m2=mean of APTT value at the post-operative level (24 h)=25.8704
s1=standard deviation of APTT value at the pre-operative level=2.2876
s2=standard deviation of APTT value at the post-operative level (24 h)=1.7809
Procedure
Patients were enrolled by convenient sampling in this study. Independent variables included age, sex, pre-operative prothrombin time, platelet count, aPTT, INR, etc. Outcome variables were complications, post-operative prothrombin time, platelet count, aPTT, and INR.
Data collection: A detailed structured proforma was used. Those with gallstones who underwent LC at 12 mmHg pressured pneumo-peritoneum were included in the study as per the inclusion and exclusion criteria. Written informed consents were taken from all the participants. After collecting the socio-demographic profile of the patients, a detailed clinical history was obtained, followed by a thorough physical examination. Basic routine examinations were done for all patients. A blue top tube with 3.2% sodium citrate was used to collect 1.8 ml of the patient’s blood for studying the coagulation profile. Similarly, a lavender top tube containing Ethylene Diamine Tetra-Acetic Acid (EDTA) was used to collect 1 mL of the patient’s blood to determine platelet counts.
For each patient, one blood sample was collected prior to surgery, and another sample was collected after 24 hours from the onset of pneumo-peritoneum. All the blood samples were examined for Prothrombin Time (PT), aPTT, INR, and platelet count values. The participants were assured of their anonymity at the time of data collection, and the importance of providing honest answers was stressed. Collected data were checked for completeness and consistency before the patient was discharged, and necessary rectifications were made.
Statistical Analysis
The collected data were collated and analysed in SPSS (IBM) version 21.0. Summaries of the data were carried out and presented as mean, standard deviation, and percentages. The paired t-test was employed to test the association between the mean values of post-operative and pre-operative PT, aPTT, INR, etc.
During the study period, 72 patients who underwent LC using carbon dioxide pneumo-peritoneum were enrolled in the study, of which 18 were male and 54 were female patients, as shown in (Table/Fig 1). The maximum number of patients, 28 (38.9%), were in the age group of 41 to 50 years. The mean age of the study participants was 42.5±10.3 years. A total of 46 (63.9%) of the patients were exposed to pneumo-peritoneum for 1-2 hours during surgery. Similarly, 60 (83.33%) patients had no complications, and 13.89% of the patients had post-operative port site infection. Only 2 (2.78%) of the patients had bile leakage (Table/Fig 1).
No significant difference in the mean value of prothrombin time (p=0.150) and INR (p=0.437) measured between the pre-operative period and the post-operative period was seen in the study population (Table/Fig 2).
The mean value of aPTT before surgery was higher than the mean value of aPTT after surgery, and it was found to be statistically significant (p=0.004). Similarly, the mean value of platelet count before surgery was higher than the mean value of platelet count after surgery, and it was found to be statistically significant (p<0.001) (Table/Fig 3).
In this study, out of 72 patients who underwent LC, 54 (75%) were females, and the remaining 18 (25%) were males. Similarly, in a study by Amin B et al., female patients (56%) were more than male patients (44%) (4). In a study by Garg PK et al., most of the patients were females, with 88%, and males were only 12% (5). In a similar study by Natkaniec M et al., they also found that 80% of the patients were females, and only 20% were males (7). Thus, females predominated the study population in most of the studies; it may be due to the fact that females are more commonly affected with cholelithiasis than males (10).
The mean age of the population was 42.5±10.3 years in this study, with a comparable mean age between males and females. In a similar study by Natkaniec M et al., the mean age of their study population was 48.3±14.6 years, which is slightly higher than in this study (7). Another study by Amin B et al., reported the mean age to be 56.7±11.5 years, which is also higher than in this study (4). But in a study by Garg PK et al., the mean age of their study population was 36.0±10.7 years, which is slightly lower than in this study (5). Thus, the commonest age group for LC was during the period of midlife, which was similar to the findings of this study, with the maximum cases reported in the age group of 41 to 50 years.
The duration of the operation, which correlates with the exposure to pneumo-peritoneum, was observed to be between 1 to 2 hours for 69.3% of the patients in this study, and 27.8% of the patients were exposed for more than three hours. In a study by Amin B et al., the average time of exposure to pneumo-peritoneum was 64.6±24.4 minutes, which falls within the range of 1 to 2 hours, similar to this study (4). Another study by Garg PK et al., found that the mean duration of pneumo-peritoneum exposure was 74.20±19.57 minutes (5).
Prothrombin time assesses the extrinsic pathway (factor VII) and common pathway protein factors (fibrinogen, prothrombin, Factor V and X) of the coagulation mechanism (11). In this study, it was observed that there were variations in prothrombin times among the study patients. The reason for some patients being hyper-coagulable or hypo-coagulable may be due to other underlying conditions which were not considered in this study. This study showed no significant perioperative reduction in PT (p-value >0.05), which could indicate hypercoagulability. However, in a study by Natkaniec M et al., the mean PT value of the post-operative sample was higher than the pre-operative, and it was statistically significant (p=0.0009) (7). In contrast, in a study by Amin B et al., the mean PT value of the post-operative sample was lesser than the pre-operative sample, and it was statistically significant (p<0.05) (4). Similarly, in a study by Garg PK et al., the mean prothrombin time in the post-operative sample was lesser than the pre-operative sample, but it was not significant (p=0.07) (5). Thus, PT could not be concluded to have an association with pneumo-peritoneum. Similarly, in this study, there were similar mean values of INR between the pre-operative and post-operative samples. This means that there was no major coagulation cascade abnormality during LC.
The aPTT assesses the intrinsic pathway (factor XII, XI, IX, VIII) and common pathway factors (fibrinogen, prothrombin, Factor V, and X) of the coagulation mechanism (11). In this study, there was a significant difference in the mean value of aPPT between the pre-operative and post-operative samples. The mean value of aPPT before surgery was higher than the mean value of aPPT after surgery, and it was found to be statistically significant. Garg PK et al., also found in their study that the mean aPTT pre-operatively was significantly (p-value <0.001) higher than the post-operative sample (5). Similarly, in a study by Amin B et al., the mean aPPT pre-operatively was higher than the post-operative sample, and this was found to be statistically significant (p-value <0.05) (4).
The observed decrease in aPTT indicates an active coagulation. Coagulation activity is commonly enhanced after surgery as a normal response to surgical insult (12). For that reason, it is not easy to differentiate the cause as it can be either by pneumo-peritoneum or surgical trauma. In a contrast study by Larsen JF et al., between LC using CO2 pneumo-peritoneum and gasless LC using lifting devices, no differences were seen between the two groups, suggesting CO2 pneumo-peritoneum has no role in triggering the coagulation and fibrinolysis mechanism (13). Another study by Ntourakis D et al., revealed that PT, aPTT, INR, D-dimer, fibrinogen, and Fibrinogen-Degradation Product (FDP) levels were elevated during the post-operative period in a statistically significant way (14). This study also observed an insignificant elevation of INR during the post-operative 24th hour. This elevation in INR levels is believed to reduce the DVT risk associated with LCs (1).
In this study, there was a significant decrease in the mean value of platelet count between the pre-operative value and the post-operative value. Dabrowiecki S et al., also found that there was a significant difference in platelet value between the pre-operative and post-operative (first post-operative day) LC, where the platelet values of post-operative cholecystectomy were lower than the pre-operative values, which was similar to the findings in this study (15). This may be due to intra-operative haemodilution and increased peri-operative platelet consumption (16). A comparison of the coagulation profile among different studies can be found in (Table/Fig 4) (1),(2),(4),(5),(7).
Limitation(s)
In this study, only two coagulation markers were measured. If the levels of coagulation markers D-dimers and fibrinogen were considered, a more thorough and in-depth outcome could have been derived in terms of the post-operative risks of thrombosis. Secondly, a larger sample size may reveal the occurrence of thrombotic events.
The blood serum levels of aPPT and platelet count in the post-operative sample, when compared with the pre-operative sample, were found to be significantly reduced after LC using carbon dioxide pneumo-peritoneum, but there was no clinical evidence of hypercoagulability. There were no significant differences in prothrombin time and INR values between the pre-operative and post-operative samples. Since there were few post-operative complications and no significant changes in the coagulation profile, it can be assured that LC using carbon dioxide pneumo-peritoneum is a safe procedure. A multi-center study with a larger sample size and randomised controlled clinical studies are needed to shed light on and explore the risks of post-operative venous thrombosis after LC.
DOI: 10.7860/JCDR/2024/68494.19203
Date of Submission: Nov 06, 2023
Date of Peer Review: Dec 18, 2023
Date of Acceptance: Feb 01, 2024
Date of Publishing: Mar 01, 2024
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
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