Is fistulotomy with marsipulization more effective than fistulectomy alone for low fistula in ano?

Background: Fistula in ano is a very common perianal condition seen in outpatient departments. Fistulotomy and fistulectomy are two conventional options of surgery. The present study is designed to observe wound healing time and mean postoperative pain score in the comparison of outcome of the fistulectomy to fistulotomy with marsupialization. Methods: This prospective randomized trial was conducted in the surgical department of the Civil Hospital Karachi for a period of 12 months, in which 60 patients with low anal fistula were divided into 2 groups. Thirty patients in group A were treated with fistulectomy, and 30 in group B were treated with fistulotomy with marsupialization. The postoperative pain severity was assessed after 24 hrs through a visual analogue scale and on weekly and fortnightly follow-ups for 6 weeks. Wound healing was assessed by clinical examination on weekly and fortnightly follow-ups for 6 weeks to estimate the mean healing time. Results: The mean pain score was significantly lower in group B in comparison to group A (3.6±1.99 versus 2.40±1.52; p=0.01). The mean wound healing time was shorter in group B in comparison to group A (4.23±0.77 versus 5.80±0.41 weeks; p=0.0005). Conclusion: Fistulotomy with marsupialization is a simple, easy, and more effective method than fistulectomy for the treatment of simple perianal fistula. (AU)

What Does the Future Hold for a Surgical Trainee? This Lockdown Is Not a Letdown Yet: A Survey on Moodle Learning Management System as a Part of Blended Learning During COVID-19 Pandemic.

Background The COVID-19 pandemic brought about a major shift in the educational training of surgical trainees. As the Lockdown was implemented and the daily workforce reduced, an alternate method was employed to provide uninterrupted learning. Blended learning that includes virtual learning with face-to-face learning/teaching was utilized for the surgical trainees. MOODLE (Modular object-oriented dynamic learning environment), an open-source learning management system, was integrated as an Online Component of our Blended Learning Program. We aimed to evaluate the perception of postgraduate trainees of General Surgery regarding the benefits and limitations of Blended Learning, particularly its online component, i.e., Moodle LMS, for the betterment of surgical -education during the COVID-19 pandemic. Material and Methods Thirty-three postgraduate general surgery trainees were enrolled in a blended learning program, in which its online component, Moodle LMS, comprised four major topics on General Surgery. A questionnaire was provided to the trainees to obtain feedback on blended learning in general, and Moodle LMS was mainly themed on the Likert scale. Results The approach of blended learning was positively received by the participants, the majority of whom were females (75%) and comprising of Year 1 residents (33.3%). Nearly half of the participants found Moodle LMS user-friendly, practical and a good platform for learning. However, nearly two thirds (60.6%) were uncertain if it ever helped in applying knowledge to interpret laboratory and radiological results for patient management. Even then, most of them found that the face-to-face component of blended learning helped them develop specific clinical and surgical skills (42.4%). Emphatically, 78.7% would recommend it for surgical training. Conclusion Blended learning was found to be beneficial in the training process of surgical postgraduates in the current COVID-19 pandemic situation. We recommend it for the training of doctors for optimized learning.

Combined Diagnostic Accuracy of Total Leukocyte Count, Neutrophil Count, and Ultrasonography for the Diagnosis of Acute Appendicitis.

Acute appendicitis is a common surgical emergency that classically presents with right lower abdominal pain and tenderness on palpation. The diagnosis is often based on clinical examination in order to avoid the complications of surgery delay, yielding a high rate of negative appendectomies. Ultrasonography is a regularly used modality for establishing the diagnosis, whereas abdominal computed tomography (CT) is often used in sonologically equivocal cases. Other parameters include total leukocyte count, granulocytes, C-reactive protein (CRP), leukocyte elastase activity, D-lactate, phospholipase A2, and interleukin-6 (IL-6). We conducted a prospective study to assess the combined accuracy of total leukocyte count, neutrophil count, and ultrasound as an integrated diagnostic tool. The results of these investigations were tabulated and compared to histopathological evidence of acute appendicitis on biopsy (taken as the gold standard) to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Combined sensitivity and specificity were calculated using cross-tabulation, whereas diagnostic accuracy was estimated from the receiver operating curve (ROC) at the optimal cut-off point. The results showed that the absence of inflammatory findings on ultrasound and normal blood parameters (total leukocyte count and neutrophil count) have a high combined diagnostic accuracy and appendicitis may be ruled out.

Association between Vitamin D deficiency and Breast Cancer.

OBJECTIVE: To determine the association between vitamin D deficiency and breast cancer. METHODS: This case control study included 94 female patients aged 20-75 years of any marital status and parity. Newly diagnosed 42 breast cancer patients who presented to surgical OPD of Dow University Hospital from Jan 2016 to June 2016 were included into the study as "cases" after informed consent. Age-matched 52 females who presented to OPD for complain other than breast pathology were included as the "control group". The sociodemographic of both cases and controls and histopathological characteristics of cases were recorded. Serum 25-(OH)2D levels were studied by the ELISA technique and recorded in ng/ml. Vitamin D deficiency was considered at serum level less than 20 ng/ml. RESULTS: Mean age was 40.1 Years for controls and 47.6 Years for cases. Mean height, weight and BMI did not differ between cases and controls. Serum Vitamin D levels were significantly lower in cases (85.7%) than controls (55.8%). The unadjusted and adjusted ORs for breast cancer in cases and controls showed a statistically significantly increased risk of breast cancer with low vitamin D concentration (p value0.003). After adjustment for age, parity, BMI, sun exposure, economic status and education status the ORs (95% CIs) for breast cancer risk was7.8 (1.99 - 30.58) for women with vitamin D concentrations <20 ng/mL. CONCLUSION: Findings of our study conclude that vitamin D deficiency is associated with risk of breast cancer.

Comparison of hemorrhoidectomy by LigaSure with conventional Milligan Morgan's hemorrhoidectomy.

OBJECTIVE: To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy. METHODS: This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A (Haemorrhoidectomy by Ligasure) and group B (Milligan Morgan Haemorrhoiectomy). Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7(th) post operative day. RESULTS: Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 - 60 years. Third degree Heamorrhoids were present in 37 (67.3%) of patients while remaining 18 (32.7%) had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6± 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34±25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method. CONCLUSION: The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups.

Sentinel lymph node identification by blue dye in patients with breast carcinoma.

OBJECTIVE: To determine the diagnostic accuracy of methylene blue dye to detect axillary lymph node metastases in patients with breast carcinoma by taking histopathology as gold standard. METHODS: This quasi experimental study was done at Department of Surgery of Dow University Hospital Karachi during January 2013 to September 2015 after the approval of Hospital Ethical Committee. A total number of 85 patients with biopsy proven carcinoma were included in the study.1% methylene blue dye was infiltrated in the peri tumoural area of the diseased breast. The blue stained node called sentinel lymph node (SLN) was recognized and carefully dissected out. SLN and mastectomy with axillary clearance specimen was sent for histopathology in two separate bottles and the report of the histopathology was compared. RESULTS: The axillary lymph nodes were positive for carcinoma in 61 cases out of 85(71.7%). Two of the patients had negative sentinel lymph node but positive non sentinel lymph node (false negative), and in three cases sentinel lymph node were involved only but not the rest of the axilla (False positive). The sensitivity, specificity and accuracy were 96.8%,86.36% and 94.1% respectively. CONCLUSION: Methylene blue dye technique is a reliable and safe diagnostic modality for detection of Sentinel lymph node in breast cancer patient because of its high accuracy.

Computer Based Assessment (CBA): Perception of residents at Dow University of Health Sciences.

UNLABELLED: Background and objective : During the past few years, Computer-based assessment (CBA) has gained popularkity as a testing modality. This assessment offers several advantages over paper based assessment (PBA) testing. The objective of this study was to find out residents' perception of this method of assessment. Methods : The post graduate residents of Dow University of Health Sciences in the field of Surgery, Medicine, Gynecology and Obstetrics experienced their first formative Computer-based assessment (CBA) in year 2013.Immediately after formative CBA, an anonymous paper based questionnaire was distributed amongst the residents and response was sought for their self-perceived computer usage competence before starting residency, perceptions regarding CBA method and to determine their preference for PBA or CBA in future assessment preferences. RESULTS: Total 173 residents completed the questionnaire. More than half of residents, 56.1% had no prior experience of CBA. Three fourth, 76.4% of the residents were less than confident before sitting in CBA, while after completing CBA, 64.8% were either confident or extremely confident for CBA. Most common problem encountered by students was logging in 28.9%. More students (53.2%) believed that paper assessment took longer to complete than CBA. Majority of the students (61.8%) rated CBA as better than PBA despite experiencing it for the first time. CONCLUSION: Resident's perception for CBA is good and they recommend its use in future assessment as well. However, to take maximal advantage of this technology, faculty should be trained to develop questions not only with text and pictures but with audio and video support.

Comparison of complications of circumcision by 'Plastibell device technique' in male neonates and infants.

OBJECTIVES: To determine the effectiveness of the circumcision by Plastibell technique with comparison of complications among neonate and infant age groups. METHODS: A retrospective, descriptive study was conducted in all the plastibell circumcisions performed by the first author, during the period October 2006 to December 2008 at a private hospital Karachi. The record of all the cases fulfilling the inclusion criteria were obtained and analyzed for determining the outcome and complications if any in neonates and infants and to compare it with in these two groups. RESULTS: Overall 245 cases of neonates and infants were selected. Mean age of neonates and infants was 14 +/- 2 days and 3 +/- 0.5 months respectively. The plastibell circumcision was done in all the cases i.e. 90 neonates and 155 infants. Out of these, the successful rate of plastibell circumcision without any complication was recorded as 196 cases (80.00%) whereas, 49 cases (20.00%) developed complications. In neonates it was recorded as 04.44% cases, whereas this ratio was 29.03% in infants. Most common complications were delayed separation of the ring in 17 cases (6.93%), bleeding in 12 cases (4.89%), localized superficial infection in 12 cases (4.89%), and proximal migration of ring in 07 cases (2.85%). CONCLUSION: The ratio of complications of circumcision by plastibell is significantly higher in infants as compared to neonates. However it is an easy, quick and safe technique. Outcome of this procedure is encouraging while infants are more prone to develop post operative complications than neonates.