Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Comparative Study Of Combined Co-Enzyme Q10 And Clomiphene Citrate Vs Clomiphene Citrate Alone For Ovulation Induction In Patients With Polycystic Ovarian Syndrome

A total of 136 patients with PCOS were followed through the Department of the Obstetrics and Gynaecology, Unit-IV, Lady Aitchison Hospital, Lahore. Patients were randomly divided by lottery method into two groups i.e., Group-A (CoQ10 plus Clomiphene citrate) and Group-B (Clomiphene citrate alone). The selected patients in the study group (group-A) were given Clomiphene citrate 100mg/day from cycle days 2-6 for 45 days (2 cycles) and CoQ10 in a dose of 50mg soft gel capsules thrice per day starting at cycle day-2, until HCG administration. Patients in controlled group (group 21 B) received Clomiphene citrate 100mg/day twice a day cycle for 45 days. Data were analysed in SPSS v25.0. In group-A (CoQ10 plus Clomiphene citrate), successful ovulation induction was noted in 16 (23.5%) patients, showing that with the addition of CoQ10, the chances of ovulation induction increased.

Computational Modeling, High-Level Soluble Expression and In Vitro Cytotoxicity Assessment of Recombinant Pseudomonas aeruginosa Azurin: A Promising Anti-Cancer Therapeutic Candidate

Azurin is a natural protein produced by Pseudomonas aeruginosa that exhibits potential anti-tumor, anti-HIV, and anti-parasitic properties. The current study aimed to investigate the potential of azurin protein against breast cancer using both in silico and in vitro analyses. The amino acid sequence of Azurin was used to predict its secondary and tertiary structures, along with its physicochemical properties, using online software. The resulting structure was validated and confirmed using Ramachandran plots and ERRAT2. The mature azurin protein comprises 128 amino acids, and the top-ranked structure obtained from I-TASSER was shown to have a molecular weight of 14 kDa and a quality factor of 100% by ERRAT2, with 87.4% of residues in the favored region of the Ramachandran plot. Docking and simulation studies of azurin protein were conducted using HDOCK and Desmond servers, respectively. The resulting analysis revealed that Azurin docked against p53 and EphB2 receptors demonstrated maximum binding affinity, indicating its potential to cause apoptosis. The recombinant azurin gene was successfully cloned and expressed in a BL21 (DE3) strain using a pET20b expression vector under the control of the pelB ladder, followed by IPTG induction. The azurin protein was purified to high levels using affinity chromatography, yielding 70 mg/L. In vitro cytotoxicity assay was performed using MCF-7 cells, revealing the significant cytotoxicity of the azurin protein to be 105 µg/mL. These findings highlight the potential of azurin protein as an anticancer drug candidate.

Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study

Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.

A case report of sacrococcygeal foreign body presenting as pilonidal sinus

Pilonidal disease occurs most commonly in those males who have to sit long hours at their work place e.g. online office workers or drivers. It is caused by piercing of broken hairs into the sacrococcygeal region which causes localised inflammation. Inflammation in this area due to any other foreign body is very rare. Among many treatment options for pilonidal sinus, instillation of crystalloid phenol showed promising results in terms of low recurrence rates, low post-operative complications and less healing time. Here, we present the case of a 13-year-old female student who had pilonidal sinus in sacrococcygeal region for six months and was unresponsive to multiple treatments. Later, on exploration it was revealed to contain a small foreign body of 3cm of hard straw of grass. The patient was treated with crystalloid phenol and on regular follow-up she was completely fine by the end of the third week.

A Rare Co-Existence of Multiple Cerebral Cavernous Malformations and Pleomorphic Adenoma of the Parotid Gland in Myotonic Dystrophy

Myotonic dystrophy is an autosomal dominant inherited disorder primarily affecting muscle function. Myotonia, progressive muscle weakness and wasting, and associated systemic involvement, i.e., cataracts, cardiac conduction defects and endocrine abnormalities especially insulin resistance, are the characteristic features. Recent evidence has shown an increased risk of developing benign as well as malignant tumours in such patients. We report a 39-year male of myotonic dystrophy who presented with multiple cerebral cavernous malformations in addition to pleomorphic adenoma of the parotid gland. Though the association of myotonic dystrophy with salivary gland neoplasms has been sparsely documented in the literature, but the co-existence with multiple cerebral cavernous malformations has not been reported so far. Our case is the first of its kind. Key Words: Cerebral cavernous malformations, Myotonic dystrophy, Parotid gland, Pleomorphic adenoma.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Ruptured splenic abscess: A rare case entity

Ruptured splenic abscess has been reported as a rare clinical entity in literature. We present the case of a middle aged female with peritonitis due to a ruptured splenic abscess. Emergency splenectomy was done and broad spectrum antibiotic was given postoperatively. However, the patient could not survive and died on the 4th postoperative day. We propose that a ruptured splenic abscess should always be considered in the differential diagnosis of peritonitis, especially in an immuno-compromised individual.

Horner syndrome-A rare complication after thyroidectomy for benign thyroid swelling

Horner syndrome occurring after thyroidectomy is a rare entity and most of the reported cases have happened after surgeries on malignant thyroid swellings. In the present report, we describe a 27-year-old female who developed ptosis, miosis, enophthalmos, and anhidrosis on the second post-operative day after thyroidectomy for benign goiter. Post-operative ultrasound, computed tomography of neck, nerve conduction study, and electromyography of brachial plexus were unremarkable. Patient was kept on conservative management. She was given short course of Prednisolone orally for 2 weeks and was discharged on 150 mcg thyroxine. She had significant improvement in ptosis, miosis, and enophthalmos after six months. Horner syndrome is a rare but an important complication after thyroidectomy which may lead to cosmetic disfigurement. Surgeons should be well aware of this possibility and its presentation for timely recognition and management postoperatively. Early intervention should be done for any reversible cause, i.e., hematoma and oral steroids should be initiated as early as possible.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

A cross-sectional study of body mass index and sleep quality as risk factors to severity of acne

OBJECTIVE

To analyse the association of body mass index and sleep quality with severity of acne.

METHODS

The cross-sectional study was conducted at the Dermatology Department of Mayo Hospital, Lahore, Pakistan, from January to March 2019, and comprised acne patients of either gender aged 12-45 years. Data was collected using a pre-designed questionnaire. Acne grades 1, 2, 3 and 4 were determined by a consultant dermatologist. Pittsburgh sleep quality index was used to assess sleep quality, while body mass index was calculated as per the standard procedure. Data was analyzed using SPSS 22.

RESULTS

Of the 98 patients, 27(27.6%) were male and 71(72.4%) were female. The overall mean age of the sample was 22.3±4.9 years. There were 36(36.7%) patients with acne grade 3, followed by 25(25.5%) each with grades 1 and 2, and 12(12.2%) with grade 4. The relationship between body mass index and acne severity was not significant (p=0.07), and the same was the case with sleep quality (p=0.09).

CONCLUSIONS

Body mass index and sleep quality were not found to be associated with acne severity.

Adrenal Schwannoma: A Case Report

Schwannoma of the adrenal gland is very rare, comprising 0.2% of adrenal tumors, presenting usually as non-specific abdominal pain. We report such a rare case in a 50-year-old female. Her only complaint was right lumbar pain. Ultrasonography (USG) and computed tomography (CT) both showed a supra renal cystic mass most likely of adrenal origin. Excision of mass was performed. Post-operative course was uneventful. Histopathology showed a benign tumor of Schwann cell origin. Usually, pre-operative imaging including CT and magnetic resonance imaging (MRI) are inconclusive and diagnosis has to be confirmed on histopathology.

Quality of Sleep and Academic Performance among Medical University Students

OBJECTIVE

To assess the effect of sleep quality on academic performance of medical university students.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

King Edward Medical University, Lahore, from December 2017 to April 2018.

METHODOLOGY

Second to final year Medical and Allied Health Sciences students filled out questionnaires that comprised of three major components. With the help of questionnaire, demographic data about the subjects along with academic scores were collected. Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleeping Scale (ESS) were used to collect the data. Qualitative variables are represented as frequencies and percentages; while, quantitative variables are reported as mean along with standard deviation ± S.D. Chi-square and was applied for statistical significance, and p-value <0.05 was considered.

RESULTS

A total of 810 students, including both MBBS and Allied Health Sciences (AHS), filled out the questionnaire. Among those, 564 (69.6%) were females and 246 (30.4%) were males. Overall, mean age was 21.35 ±1.51 years. Of the total, 418 (51.6%) were from MBBS programme and 392 (48.4%) were from AHS. No significant relationship was found between PSQI and academic scores. However, academic scores had a strong association with ESS scores.

CONCLUSION

Although the majority of the studied students had poor sleep; but its effect on academic scores was not significant. Key Words: Sleep quality, Medical students, Academic performance.

Left sided appendicitis - a surgical dilemma: Case report

Left-sided abdominal pain is an uncommon presentation of acute appendicitis. When a patient presents with this complaint, appendicitis can be difficult to diagnose, thus resulting in delayed definitive therapy and increased morbidity and mortality. In this report we discuss the case of a middle-aged man, who presented with left-sided abdominal pain, and was diagnosed to be suffering from acute appendicitis along with asymptomatic midgut malrotation.

Attitudes and practice of surgeons in reporting medical errors at a tertiary care hospital

Medical error reporting is essential in creating a culture of accountability in our healthcare system. The aim of this study was to evaluate the frequency of reporting errors by surgeons in our setup and to analyse the factors resulting in under-reporting of medical errors. A total of 96 practicing surgeons at Mayo Hospital, Lahore were surveyed between the months of February, 2018 to June 2018 on their beliefs regarding the reporting of medical errors by means of a specifically designed questionnaire. This study revealed that 71 (74%) respondents had committed a medical error but only 16 (16.6%) of them reported those errors. Major factors in under-reporting of errors included work stress and fear of medico-legal consequences due to disclosure of error. Eighty-four (87.5%) believed that increase in reporting medical errors would contribute to a better system. Most surgeons had a positive view towards the process but believed that the reporting system was ineffective.

Frequency of gall bladder carcinoma in cholecystectomies performed for symptomatic cholelithiasis

It was a Letter to the Editor to find out the frequency of carcinoma gall bladder in patients which were presented with symptomatic cholelithiasis. Carcinoma of the gallbladder is a rear malignancy with 5 year survival rate of 5%. Carcinoma gall bladder is the most common billiary tract malignancy, it is also 5th most common in gastrointestinal malignancies 1. In Pakistan the incidence of carcinoma gallbladder among patients having symptomatic cholelithiasis is 6 to 28%2. Patients with symptomatic gall stones had more risk for developing carcinoma gallbladder as compared to asymptomatic gall stones. Large stones in cholelithiasis are more dangerous than small stones as stone size reaches >3cm risk increases upto 10 fold. Gallbladder polyps >10mm, calcified(porcelain) gallbladder, choledochal cyst, seclerosing cholangitis, anomalous pancreaticobillary junctions and exposure to carcinogens are other risk factors3. Continuous...

Intravenous drug abusers presenting with pseudoaneurysm and other surgical complications in Pakistan

People who inject drugs (PWIDs) reuse injection equipment and other paraphernalia, which is a major source of transmission of human immunodeficiency (HIV) and hepatitis C virus (HCV) infections. PWIDs who use infected injections develop many surgical complications which are life- threatening. The most common complication is infected pseudoaneurysm. To assess complications requiring surgery in drug abusers, a study was conducted in the East Surgical Ward of Mayo Hospital Lahore, Pakistan from Jan 2017 to Jan 2019. A total of 48 PWIDs presented to the surgical department, out of which 39 (81%) were HIV positive, and 31 (64%) were HCV positive. Of the 52% who had pseudoaneurysm, 92% had femoral and popliteal aneurysm and 8% had brachial aneurysm. After ligation and excision of pseudoaneurysm only 8% required major amputation. Mortality rate was 0%. Ligation and excision is a safe option in pseudoaneurysm. Most common site for pseudoaneurysm was left femoral artery.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Root cause analysis of pre-microscopic errors in anatomical pathology using Eindhoven classification

OBJECTIVE

To evaluate pre-microscopic errors in anatomical pathology.

METHODS

The cross-sectional descriptive study was conducted at the Department of Pathology of a tertiary care hospital in Lahore, Pakistan, from September, 2016, to January, 2017, and comprised surgical pathology specimens. Errors were noted across the pre-microscopic process. Defects per million opportunities were calculated to determine sigma metric value in every step, from requisition to slide preparation. Root cause analysis was applied to the process of histology preparation to identify the root cause of each previously identified problem using Eindhoven classification. All errors were recorded on a pre-designed proforma.

RESULTS

There were 2420 specimens. While errors were encountered in all phases of the pre-microscopic process, but the (G6: n=1085, 44.83%), followed by requisition (R3: n=893, 36.9%) and cover slipping (C1: n=776, 32.06%).

CONCLUSIONS

Development of standard procedures and protocols with staff training is likely to help in controlling the errors.

Acute Presentation and Management of Abdominal Tuberculosis

OBJECTIVE

To study the clinicopatholgical profile and outcomes of surgical management of abdominal tuberculosis (ATB) Study Design: Cross-sectional observational study.

PLACE AND DURATION OF STUDY

Department of Surgery, Services Hospital, Lahore, Pakistan, from May 2008 to April 2018.

METHODOLOGY

All patients who underwent emergency laparotomy during the study period due to abdominal tuberculosis, and consented to participate in the study were included. Demographic variables and type of surgical procedure performed were recorded. Patients were followed-up for histopathology, recurrence, or any anti-tuberculous therapy related complications at 1, 4, 6, and 12 months. Data were analysed using SPSS version 21.

RESULTS

Out of the 80 patients, 36 were males and 44 were females. The median age was 23.5 years (range = 11-90 years). Mean weight of the patients was 48.7 ±12.2 kg. Commonest presenting symptom was abdominal pain 72 (90%). On exploration, ileocecal region was most commonly involved segment 68 (85%). Stoma formation was the most common surgical procedure performed in 59 (73.8%) patients. Complications and mortality rate were 48 (60%) and 7 (8.7%), respectively. A significant relationship of complications was found with prolonged hospital stay (p <0.001).

CONCLUSION

Abdominal tuberculosis is a major public health concern. Vague symptoms lead to diagnostic delay so patients present late with intestinal obstruction. Ileocecal tuberculosis is the most common site of involvement.

Transverse testicular ectopia with persistent Mullerian duct syndrome: an operative eureka

•

This case report accounts two remarkable cases of transverse testicular ectopia associated with persistent Mullerian duct syndrome.

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It gives a helpful discussion of the various treatment options for these two conditions when present alongside an inguinal hernia.

•

It emphasizes the importance of resection of Mullerian duct derivatives and orchiectomy to eliminate the possibility of carcinoma.

•

It highlights the importance of acute suspicion on part of the surgeon to diagnose the condition before taking to the operation theatre.

Introduction

Transverse Testicular Ectopia (TTE) is a rare entity in which both testes descend on the same side, and can be found in ectopic locations. When present with Persistent Mullerian Duct Syndrome (PMDS), a yet rarer entity, the persistence of Mullerian duct derivatives i.e. fallopian tubes, uterus, cervix and upper two-thirds of vagina occurs alongside testicular ectopia. There have only been about a hundred and fifty reported cases of TTE; a fifth of these accompanied by PMDS.

Presentation of Case

Two middle-aged male patients presented with two separate complaints of inguinoscrotal swellings. In both patients, ultrasonography showed a hernial defect protruding into the scrotum on one side and the testis absent on the contralateral side. During hernia surgery, Mullerian duct remnants were found. Diagnosis of TTE with PMDS was established. Bilateral orchidectomy was done and Mullerian derivatives were excised.

Discussion

There is controversy over the treatment of TTE with PMDS. Some authors,in addition to hernia repair, advocate the preservation of Mullerian structures because of risk to injury to vas deferens while others advocate resection of these structures due to risk of carcinoma. In pediatric patients, orchidopexy should be done to preserve fertility.However, in the older age group, orchidectomy should be done due to an increased risk of testicular carcinoma.

Conclusion

TTE should be suspected in cases of unilateral inguinal hernia with contralateral undescended testes. Orchidectomy is recommended in patients older than 12 years old, otherwise, orchidopexy should be done. No Mullerian duct remnants should be left in situ.

A review of access to cancer facilities in Punjab, Pakistan

BACKGROUND

Punjab is the most populous province of Pakistan, with only 12 countries in the world succeeding it in terms of population.

AIMS

This review article has the objective of providing novel statistics regarding available cancer therapeutics in Punjab across four different sectors-including government, semi-private, trust and private sectors.

METHODS AND RESULTS

Keywords such as "cancer treatment," "facilities," "Pakistan," were used to search Pubmed Database. 36 results were generated: after sifting based on a personal reference list as well as for relevance, 16 articles were finally reviewed. Novel statistics regarding current state of access to cancer facilities were drawn from personal references as well as from studies conducted in other LMICs. There is a gross deficit of oncological services in Punjab, with the ratio of medical oncologists to population being 0.027 per 100, 000, and every oncologist checking 1300-1500 patients annually. Only 21.4% of the population has access to radiotherapy facilities. Major problems include lack of healthcare professional awareness; poor infrastructure including drug access, radiotherapy, and cancer pain management facilities; lack of planning; and lack of educational and research programs.

CONCLUSIONS

Improving education & training, developing infrastructure based on public-private-partnership models, building cancer registries and organizing national cancer screening programs, as well as encouraging basic health education and research in oncology, are measures that can ensure Punjab's healthcare delivery system becomes capable of handling increasing incident burden of cancer.

Benign idiopathic retroperitoneal cyst: A case series of three patients

IMPORTANCE

Retroperitoneal cysts are a rare entity in the field of surgery and their management remains a clinical dilemma for many surgeons. This study addresses the clinical management of three benign retroperitoneal cysts which were presented in our hospital.

OBJECTIVES

The objective of this case series is to explore the different clinical presentation of the retroperitoneal cyst (RPC). This study also aims at different tools of investigations especially role of CT scan in the diagnosis of RPC and finally the different treatment options available for RPC.

METHODS

This is a single centered case series of three retroperitoneal cysts which were presented in surgical department of our hospital in the year 2016 and 2017. Total three patients were presented in this case series, two of them were females and one was male. Females were 13 years and 23 years age-old, male was 45 years old. Two of them admitted through the Outdoor Patient Clinic and one was presented to the surgical emergency. Informed consent from the patients and guardian (case1) has been taken. Research work has been reported in line with the PROCESS criteria.

RESULTS

They were investigated and treated in our hospital. Two of them were diagnosed with retroperitoneal cysts preoperatively and one was diagnosed pre-operatively. In all three cases, surgery had been carried out and they had been observed in their early postoperative period and then followed up for two years. All biopsies had been followed and turned out to be benign idiopathic cysts. These patients have been followed up for 2 years after completion of their treatment.

CONCLUSION

Retroperitoneal cysts in adults are an uncommon manifestation of abdominal pathology. Their presentation is quite vague. The rarity catches the surgeon off guard at times. Radiology plays a crucial role in defining these lesions and complete surgical excision remains the cornerstone of treatment for symptomatic and complicated patients.

Breaking bad news skill of postgraduate residents of tertiary care hospital of Lahore, Pakistan: A cross-sectional survey

OBJECTIVE

To evaluate the skill of postgraduate residents in breaking bad news to the patients in a tertiary care hospital.

METHODS

The cross-sectional study was conducted at King Edward Medical university, Lahore, Pakistan, from January to April 2016, and comprised postgraduate residents of different specialties at Mayo Hospital, Lahore. The subjects were examined in terms of their personal experience in breaking bad news to the patients by means of a specifically-designed questionnaire based on six-step protocol of Setting, Perception, Invitation, Knowledge, Empathy and Summarising model. Data was qualitatively and quantitatively analysed using SPSS 22.

RESULTS

Of the 200 respondents, 141(70.5%) were males and 59(29.5%) were females. Overall mean age of the sample was 23 } 2.55years. Of the total, 94(47%) respondents were only fairly satisfied with their breaking bad news skill, while 130(65%) were eager to get training in this regard. The knowledge regarding breaking bad news protocols was lacking across all comparisons (p>0.05).

CONCLUSIONS

Majority of the residents had little satisfaction regarding their breaking bad news skill. It is necessary to plan special training for the residents in this key area.

An evaluation of management of transferred paediatric burn patients

The aim of study was to evaluate whether adequate initial management and safe transfer of paediatric burn patients was carried out in our setup. Patients transferred from other hospitals/ cities to Paediatric Surgery Department, Mayo Hospital were evaluated in this prospective study. Data was entered in a proforma. Around 90.4% patients on presentation had discrepancy in their burn percentage calculation. No intravenous fluids were administered to 75.4% patients and 71.1% patients did not have any intravenous access. Foley's catheter was inserted in 2 patients only though 72.8% needed it. No fasciotomy was performed in 10.5% patients needing it. Two patients needed endotracheal intubation but it was not passed, 49.1% patients were transferred by ambulance and 28.9% patients presented with sepsis. The mortality rate was 38.2%. Initial fluid resuscitation was compared with survival and found significant (p=0.000). This shows that initial burn management, transfer system and referral system is full of errors.

Knowledge, attitude and practices amongst the Pakistani females towards breast cancer screening programme

OBJECTIVE

To assess the knowledge, attitude and practices amongst Pakistani females towards breast screening programmes.

METHODS

The descriptive cross-sectional study was conducted from June 2013 to July2014 at Mayo Hospital, Lahore, and comprised attendants and patients who visited out-patients department and/or were treated as in-patients. The questionnaire contained 25 open and close-ended questions regarding knowledge and attitude, along with 7 questions regarding practices. Data was analysed using SPSS 17.

RESULTS

There were 1184 women with a mean age of 32.7±8.6 years. The mean score was 12.7±4.9. Positive family history of breast cancer was reported by 156(13.2%) women; 420(35.5%) believed advancing age was a risk factor; 1041(87.9%) never had breast self-examination; 1106(93.4%) never had a clinical breast examination; and 1171(98.9%) never had screening mammogram.

CONCLUSIONS

The knowledge and practices regarding breast cancer screening, breast self-examination and mammogram among women were not good. The knowledge about breast cancer risk factors was very poor and showed an alarming attitude towards practices.