Evaluating the Safety and Quality of Diagnostic Colonoscopies Performed by General Surgeons: A Retrospective Study.

Introduction Colonoscopy, which is a challenging procedure and requires adequate time to master the skill, is the procedure of choice to visualize colonic mucosa to rule out many colonic pathologies. There is a dearth of published information from real clinical experiences regarding successful procedures and limitations. The end point of colonoscopy is the visualization of the cecal pole by intubating the cecum. Many Europeans and English health organizations recommend that the procedure should have a completion rate of around or above 90%. Gut preparation is an important determinant for a successful procedure and obviates the need for further invasive and/or expensive procedures such as imaging. The majority of colonoscopies are being performed by gastroenterologists (GI) throughout the world, and the role of a surgeon as an endoscopist is in debate. Before this study, neither a retrospective nor a prospective evaluation of the general surgeon's (GS) endoscopy's quality and safety had been evaluated in our institution. Material and method This retrospective observational study was carried out from 1 January 2022 to 31 August 2022 in the Department of Surgery at Mayo Hospital, Lahore, to evaluate colonoscopy completion rates, reason for failure, and complications in terms of bleeding and perforation. All patients undergoing lower gastrointestinal endoscopy (LGiE), both elective and emergency, were included. Patients under 15 years of age and patients known to be hepatitis B-positive or hepatitis C-positive were excluded from the study. All relevant data were entered into a data sheet. Qualitative variables such as gender, cecal intubation, adjusted cecal intubation, gut preparation, reasons for failed colonoscopy, analgesia use, and complications (bleeding and perforation) were calculated as frequency and percentage. Quantitative data such as age and pain score were reported as mean and standard deviation (SD). Details obtained were tabulated and analyzed via the Statistical Package for Social Sciences (SPSS) version 29.0 (IBM SPSS Statistics, Armonk, NY). Results A total of 57 patient data were collected; 35.1% (n=20) were female, and 64.9% (n=37) were males. The cecal intubation rate (CIR) was 49.1% (n=28), and the adjusted rate was 71.9%, excluding incompleteness due to mass obstructing lumen, 8.8% (n=5); planned left colonoscopy, 7% (n=4); sigmoidoscopy, 3.5% (n=2); distal stoma scope, 1.8% (n=1); and colonic stricture, 1.8% (n=1). The prevalent reason for failed colonoscopy was inadequate gut preparation (15.8% {n=9}). Other reasons include patient discomfort, 3.5% (n=2); looping of scope, 7% (n=4); and acute colonic angulation, 1.8% (n=1). No complications were recorded. Conclusion This study shows that colonoscopy can be done by general surgeons safely and effectively with adequate training. High rates of cecal intubation emerge during colonoscopies performed under deep sedation and by skilled colonoscopists. Adequate bowel preparatory regimen is compulsory for quality procedure.

Accuracy of RIPASA and Lintula Scores in Diagnosing Acute Appendicitis Using Surgical Findings as the Gold Standard.

BACKGROUND: Appendicitis is an inflammation of the vermiform appendix's inner lining that spreads to its other sections. Appendectomy is still the standard way to cure appendicitis. The diagnosis of acute appendicitis is still clinical and supported by a raised neutrophilic count and imaging studies; moreover, scoring systems, such as the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Lintula scores, help the clinicians in the diagnosis. The main objective of this study was to establish the diagnostic accuracy of RIPASA and Lintula scores for acute appendicitis using surgical findings as the gold standard, in an Asian population. METHODS: This was a retrospective cohort study conducted at the Department of Surgery, Mayo Hospital, Lahore, and Department of Surgery, Services Hospital, Lahore. This study was conducted from January 2020 to January 2022, for the duration of two years. A total of 120 patients were enrolled after meeting the inclusion criteria, and demographic data were obtained. Lintula and RIPASA scores were recorded, and patients were classified as positive or negative based on histopathological findings. IBM SPSS Statistics, version 26 (IBM Corp., Armonk, NY) was used to evaluate all of the gathered data. RESULTS: The average age of the patients in this study was 37.39±14.36 years, with a male-to-female ratio of 1.14:1. Taking surgical finding as the gold standard, RIPASA scoring had a diagnosis accuracy of 91.67% while the Lintula score had a diagnostic accuracy of 79.17%. CONCLUSION: While both the RIPASA and the Lintula scoring systems were accurate, the RIPASA scoring system outperformed the Lintula scoring system when surgical findings were used as the gold standard.

Performance of Pediatrics' residents as clinical teachers: A student-based assessment.

OBJECTIVE: To assess the clinical teaching skills of Pediatrics' residents as rated by final year MBBS students by using augmented Stanford Faculty Development Program questionnaire (SFDPQ) in a teaching hospital, Lahore. METHODS: This cross- sectional survey was conducted in the Department of Pediatrics, King Edward Medical University, Lahore in six months in 2016.Total of 265 students of final year MBBS, attending the teaching sessions organized by residents during their four weeks rotation in Pediatrics were included by non-probability purposive sampling. The augmented SFDPQ was emailed to the study participants after the completion of the clinical rotation, following several encounters with the resident. The data was entered in SPSS 22 for statistical analysis. Scores for each domain (learning climate, control of session, communication of goals, promoting understanding and retention, evaluation, promoting self-directed learning, teacher's knowledge and teacher's attitude) were also presented as mean and standard deviation. One-sample Kolmogorov-Smirnov test was applied to observe the normality of data. Where normality of data was observed, independent sample t-test was applied and where normality of data was not observed, Mann-Whitney U test was applied to compare the score between genders. Score of four was considered as cut off score for satisfactory results. RESULTS: Out of 265 students, 250 responded with response rate of 94.3%. Out of 250 medical students, 105 (42.0%) were male and 145(58.0%) were female. The internal consistency (Cronbach's alpha) of this score was excellent (0.973). The mean score for all SFDPQ domains was also sub-optimal (2.90±0.611). The mean total score was sub-optimal for learning climate (3.39±0.69), control of session (3.25±0.77), communication of goals (3.26±0.86), promoting understanding and retention (3.26±0.77), evaluation (2.25±0.67), promoting self-directed learning (3.17±0.90), teacher's knowledge (3.14±0.93) and teacher's attitude (3.31±0.89), while it was good only for feedback (4.03±0.11). The mean total score for all SFDPQ domains in males and females was 3.05±0.54 and 2.79±0.64 respectively. Although sub-optimal in both the genders, the score was significantly higher in males with p-value 0.001. CONCLUSION: We found suboptimal clinical teaching skills of Pediatrics' residents as rated by final year MBBS medical students.

Duodenal Perforation due to Ingested Partial Denture.

Ingestion of foreign bodies including dentures can be a cause of morbidity and mortality. We report a case of poor-fit denture in an elderly male with pulmonary and musculoskeletal comorbidities, who presented as an acute abdomen. The pin attached to the denture caused perforation of first part of duodenum. The only positive finding prior to surgery was a radiopaque density in the abdominal radiograph of the patient and air under the diaphragm. It is important for all the surgeons dealing with acute care patients to be aware of different designs and constructions of dentures.

Penile Shaft Strangulation with Wrought Iron Metallic Pipe.

Penile strangulation due to any solid encircling ornament or metal is rarely reported. Venous outflow obstruction due to any constricting item around the shaft leads to venous congestion, urinary obstruction, and rarely gangrene of the penile shaft skin. We report a case presenting with penile near-strangulation due to iron-lead metallic junction pipe which was cut using a heavy electric metal cutter.

Use of box simulators for improving intraoperative laparoscopic skills - an essential tool for the surgeon in training.

OBJECTIVE: To compare the improvement of intraoperative laparoscopic skills by measuring GOALS score between residents who have undergone simulator training with those who have not received any simulator training. STUDY DESIGN: A randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, from August 2013 to February 2014. METHODOLOGY: Thirty residents belonging to year 1, 2 and 3 were included in the study. They were randomly divided into 2 groups. Both groups had a baseline evaluation with GOALS score while performing dissection of gallbladder from liver bed during laparoscopic cholecystectomy. Group-A underwent formal training on simulators whereas group-B did not receive any formal training on simulators. After 6 months, a repeat evaluation was done again by measuring GOALS score while performing gallbladder dissection. RESULTS: Baseline GOALS scores of both the groups were similar. Group-A baseline score was 7.66 ± 0.93 and group-B score was 7.46 ± 1.04 (p = 0.585). However repeat scores for group-A showed a significant improvement (an increase of 7.16 ± 1.48 to 14.76 ± 1.67, p < 0.001) from baseline scores. Residents in group-B improved their scores by 2.30 ± 0.99 to 9.76 ± 0.79 (p < 0.001). When inter group comparison was done the second score of group-A was significantly higher than that of group-B (14.76 ± 1.67 vs. 9.76 ± 0.79, p < 0.001). Inter-rater reliability was moderately significant (Kappa 0.540).

Communication skills training of undergraduates.

OBJECTIVE: To assess the adequacy or deficiency of relevant communication skills needed in clinical practice among students of King Edward Medical University and identify the need of developing curriculum for communication skills. STUDY DESIGN: Sequential mixed method design using survey questionnair and in-depth interviews. PLACE AND DURATION OF STUDY: King Edward Medical University, Lahore, from March - September 2010. METHODOLOGY: Final year students consented to participate in the survey questionnaire regarding communication skills needed in clinical practice selected on the basis of random stratified sampling technique. The questioned aspects include communication skills, supervised training, breaking bad news, counselling and written communication skills. In the second qualitative phase, volunteers who had passed final year were selected on the basis of non-probability purposive sampling technique for recording in-depth interviews. Qualitative data was analyzed with content analysis after identifying themes and trends from the data. RESULTS: Only 20% students had clarity of communication skills training, 28% believed that their learning was supervised, 20% believed training was structured, 28% were confident about handling difficult situations, 15% could effectively break bad news, and 22% were confident in written communication skills. In the interviews 70% felt that their peers had average skills in handling difficult situations like breaking bad news and counselling, 60% believed that communication skills program was non-existent and 100% agreed that patient turnover is a strength for the institute and structured training would improve their communication skills performance. CONCLUSION: The communication skills of the studied group were inadequate to address special situations. This presses need for developing a communication skills training program.