A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals.

BACKGROUND: The preferred perineal repair method for full-thickness rectal prolapse is the Altemeier procedure, a perineal proctosigmoidectomy with handsewn anastomosis. A recently described variant of this procedure combines the resection and anastomosis into 1 step by means of linear and transverse stapling. There are few published data comparing the characteristics and outcomes of these 2 approaches. METHODS: This retrospective review, performed at 2 Canadian academic hospitals, compares surgical and cost outcomes between the perineal stapled prolapse resection (PSPR) and the Altemeier procedure. All patients who underwent these procedures between 2015 and 2019 were included. RESULTS: There were 25 patients in the PSPR group and 19 in the Altemeier group. Patients in the PSPR group were significantly older than those in the Altemeier group (81 [95% confidence interval (CI) 70-92] yr v. 74 [95% CI 63-85] yr; p = 0.047), had a lower body mass index (21.4 [95% CI 17.7-25.1] v. 24.4 [95% CI 18.5-30.3]; p = 0.042) and had equivalent American Society of Anesthesiologists scores (2.84 [95% CI 2.09-3.59] v. 2.68 [95% CI 1.93-3.43]; p = 0.49). The operative time for PSPR was significantly less (30.3 [95% CI 16.3-44.3] min v. 67 [95% CI 43-91] min; p < 0.001), as were the operative costs. Recurrence (28.0% v. 36.8%; p = 0.53) and complication rates were equivalent. CONCLUSION: PSPR is a safe, efficient and effective approach to perineal proctosigmoidectomy. It is associated with surgical outcomes comparable to those of the Altemeier procedure, but with a significant reduction in operative time and cost.

Violence against health care workers in rural areas of Sindh, Pakistan.

OBJECTIVE: To determine the magnitude of violence against healthcare workers in a rural setting, and the consequences of this violence on their personal and professional lives. METHODS: The descriptive, quantitative, cross-sectional study was conducted in 4 rural districts of the Sindh province of Pakistan from February to December 2019, and comprised healthcare workers, including doctors, nurses, support staff and field workers. Data was collected using a structured questionnaire. Data was analysed using SPSS 22. RESULTS: Of the 1622 subjects, 929(57.3%) were males and 693(42.7%) were females. The overall mean age was 35.55+/-10.05 years. The largest cluster was that of doctors 396(24.4%), followed by technicians 202(12.5%). Overall, 522(32.2%) subjects had a professional experience of 1-5 years. Violence at workplace in any form was experienced by 693(42.7%) subjects. Verbal violence had been experienced by 396(24.4%) subjects, while 228(14.1%) had witnessed it. The corresponding numbers for physical violence were 122(7.5%) and 22(1.4%). Verbal violence was more prevalent compared to physical violence (p<0.01). The major effect was that the healthcare workers remained alert 537(33.1%), felt frustrated 524(32.3%) and disturbed 503(31%). Also, 272(16.8%) subjects were planning to migrate or quit the profession. CONCLUSIONS: Violence was found to be a significant issue in rural Sindh.

Army Public School Terrorist Attack - Perceptions and Experiences of school children of Karachi.

Objectives: To explore the experiences and perceptions of school children of Karachi after the Army Public School (APS) attack. Methods: It was a qualitative transcendental phenomenological study. Data collection started nine months after the attack, in September 2015, and continued till November 2019. Study participants were school children from Army, Government, and Private schools. The sampling strategy was convenience. Data collection of 53 students was done by focus group discussions and in depth interviews. Data analysis was performed using the phenomenological analytical techniques of Colaizzi. Results: Inductive analysis of the qualitative data gave rise to three themes - The journey beyond fear, Response of parents and schools and Role of media. Conclusion: The study concluded that the APS attack was the source of emotional distress and fear for the school children of Karachi as they personalized the event due to the nature of the attack. Immediately after the incident, they were in anger, grief, and fear, which altered their daily life activities and caused apprehensions in socializing and attending school. However, later they became highly motivated to study and gained courage. This motivation is revenge from terrorists as they wanted to keep children away from schools.

What Information Are Patients Receiving from the Internet about the Operative and Nonoperative Management of Acute Appendicitis?

INTRODUCTION: Recent studies suggest that nonoperative management of appendicitis (NOMA) may be a reasonable option for managing uncomplicated acute appendicitis. We examined the Internet to see if patients are likely to find the information they need to make an informed decision between the 2 options. METHODS: A list of 29 search terms was established by a focus group and then entered into Google, resulting in 49 unique webpages, each reviewed by 3 reviewers. Consensus was obtained for bias (surgery, NOMA, or balanced), webpage type, JAMA score, reading grade, and DISCERN score, a measure of quality of written information for patients. RESULTS: Thirty of the 49 websites (61%) favored surgery, while 13 (27%) favored NOMA, and 6 sites (12%) provided balanced information. Twelve of 49 sites (24%) did not list NOMA as an option. The majority of patient-directed (11/12 = 92%) and physician-directed (7/9 = 78%) webpages favored surgery, whereas academic webpages presented a more balanced distribution. Academic and physician-directed webpages ranked higher than commercial and news webpages (median ranks 3 and 4 vs. 7.5 and 8). Only 8/49 sites (16%) mentioned that the presence of a fecalith predicts the failure of NOMA. Reading grades were almost all well above the recommended grade 8 level. CONCLUSION: Most of the webpages available on the Internet do not provide enough information, nor are they sufficiently understandable to allow most patients to make an informed decision about the current options for the management of acute appendicitis.

Accuracy of portrayal by standardized patients: results from four OSCE stations conducted for high stakes examinations.

BACKGROUND: The reliability in Objective Structured Clinical Exams (OSCEs) is based on variance introduced due to examiners, stations, items, standardized patients (SP), and the interaction of one or more of these items with the candidates. The impact of SPs on the reliability has not been well studied. Accordingly, the main purpose of the present study was to assess the accuracy of portrayal by standardized patients. METHODS: Four stations from a ten station high-stakes OSCE were selected for video recording. Due to the large number of candidates to be evaluated, the OSCE was administered using four assessment tracks. Four SPs were trained for each case (n = 16). Two physician assessors were trained to assess the accuracy of SP portrayal using a station-specific instrument based on the station guidelines. For the items with disagreement a third physician was asked to review and the mode was used for analysis. Each instrument included case-specific items on verbal and physical portrayal using a 3-point rating scale ("yes", "yes, but" and "not done"). The physician assessors also scored each SP on their overall performance based on a 5-item anchored global rating scale ("very poor", "poor", "ok", "good", and "very good"). SPs at location 1 were trained by one trainer and SPs at location 2 had another trainer. All SPs were employed in a high-stakes OSCE for at least the second time. RESULTS: The reliability of rating scores ranged from Cronbach's alpha of .40 to .74. Verbal portrayal by SPs did not significantly differ for most items; however, the facial expressions of the SPs differed significantly (p < .05). An emergency management station that depended heavily on SPs physical presentation and facial expressions differed between all four SPs trained for that station. CONCLUSIONS: Variation of trained SP portrayal of the same station across different tracks and at different times in OSCE may contribute substantial error to OSCE assessments. The training of SPs should be strengthened and constantly monitored during the exam to ensure that the examinees' scores are a true reflection of their competency and devoid of exam errors.

The role of collaboration and mentorship in the publication of surgical resident research.

Background: Research is an integral part of surgical training and a mandated competency by national accreditation bodies. Most residents engage in research, but the conversion of this research into peer-reviewed publications is unknown. The objectives of this study were to assess the conversion rate of resident research into published manuscripts and determine what variables predict publication. Methods: Through a retrospective design, 99 resident research abstracts were identified from the Surgery Research Day at the University of Saskatchewan 2008-2018. Publication status was verified using Google Scholar and PubMed. Variables associated with resident-specific, mentor-specific, and project-specific variables were assessed for their role in predicting publication. Results: Fifty-two (53%) of the 99 abstracts were published in a peer-reviewed journal, and 43 (43%) were presented at a national conference. Logistic regression analysis revealed multidisciplinary research (OR 4.46, CI 1.8-11.4, p = 0.002), projects involving multiple resident researchers (OR 2.56, CI 1.02-6.43, p = 0.045), and faculty supervisor having > 25 publications (OR 2.46, CI 1.03-5.88, p = 0.042) as significant predictors of publication. Conclusions: Our study identifies three variables related to collaboration and mentorship that can serve as potential starting points to increase research productivity amongst medical trainees.

Contexte: La recherche fait partie intégrante de la formation en chirurgie et elle est définie comme une compétence obligatoire par les organismes d'agrément nationaux. La plupart des résidents font de la recherche, mais la portion de ces travaux qui donne lieu à des publications évaluées par les pairs demeure inconnue. Les objectifs de cette étude étaient d'évaluer le taux de conversion en publications des travaux de recherche des résidents et de déterminer les variables permettant de prédire la publication. Méthodes: Aux fins de cette étude rétrospective, nous avons repéré 99 résumés de recherche présentés par des résidents dans le cadre de la Journée de la recherche en chirurgie à l'Université de Saskatchewan entre 2008 et 2018. Le statut de publication a été vérifié en utilisant Google Scholar et PubMed. Des variables liées au résident, au mentor et au projet ont été évaluées pour déterminer leur rôle dans la prédiction d'une publication. Résultats: Cinquante-deux (53 %) des 99 résumés ont été publiés dans une revue évaluée par les pairs, et 43 (43 %) ont été présentés à une conférence nationale. L'analyse de régression logistique a révélé que la recherche multidisciplinaire (OR 4,46, CI 1,8-11,4, p=0,002), les projets regroupant plusieurs chercheurs résidents (OR 2,56, CI 1,02-6,43, p=0,045) et ceux supervisés par un membre du corps professoral ayant > 25 publications (OR 2,46, CI 1,03-5,88, p=0,042) étaient des prédicteurs significatifs d'une publication. Conclusions: Notre étude fait ressortir trois variables liées à la collaboration et au mentorat qui peuvent servir de points de départ pour accroître la productivité en recherche des médecins résidents.

Hemorrhagic cholecystitis from isolated gallbladder injury following blunt abdominal trauma: An unusual case report.

INTRODUCTION AND IMPORTANCE: Gallbladder contusion after blunt abdominal trauma is a rare event that presents with diagnostic challenges. There is no clear evidence supporting conservative or surgical management of gallbladder contusion injuries, especially when they present in isolation. Here, we report the first case of an isolated gallbladder contusion injury after blunt abdominal trauma resulting in hemorrhagic cholecystitis that was successfully managed non-operatively. CASE PRESENTATION: A 22-year-old male patient presented with a 3-day history of severe right upper quadrant pain, leukocytosis, and elevated bilirubin after suffering blunt abdominal trauma from being kicked in the abdomen during a soccer game. The patient was evaluated using computed tomography (CT), ultrasound (US), and magnetic resonance cholangiopancreatography (MRCP). His imaging findings were consistent with cholecystitis without cholelithiasis. His bloodwork and imaging were initially concerning for choledocholithiasis, but were later determined to be blood products within the common bile duct (CBD). Through conservative management, which included antibiotics, bed rest, and bowel rest, he had complete resolution of symptoms and normalization of bloodwork after four days of admission and remained symptom free at 1-year. CLINICAL DISCUSSION: This case serves to highlight isolated gallbladder contusion as a potential outcome of blunt abdominal trauma. We re-affirm the diagnostic inconsistencies between CT and US in the work-up of cholecystitis and other biliary pathology. Furthermore, we describe the role of non-operative management in the treatment of traumatic cholecystitis, in the absence of gallstones. CONCLUSION: Gallbladder contusion and hemorrhagic cholecystitis after blunt abdominal trauma can be managed with non-operative interventions.

Be Kind to Your Behind: A Systematic Review of the Habitual Use of Bidets in Benign Perianal Disease.

Background: Benign perianal disease carries significant morbidity and financial burden on the healthcare system. Given that sitz baths are recommended as a treatment modality, we considered whether using a continuous stream of water, in the form of a bidet, offers a convenient and effective alternative. Bidet use is the predominant form of perianal hygiene in Asia, but its role in perianal disease is unknown. Purpose: To critically analyze and systematically review the current evidence regarding the effect of habitual bidet use on symptoms of benign perianal disease. Data Sources. A database search was conducted on MEDLINE and Epub Ahead of Print, Embase, ClinicalTrials.gov, the Cochrane Library, and ProQuest Dissertations. All studies on bidet use in pruritus ani, hemorrhoids, or anal fissures were included. Data Extraction. The studies were screened and critically analyzed by two independent reviewers in line with PRISMA guidelines. Results: Two prospective trials and 1 cross-sectional study found that habitual use of bidets had no impact on the odds of developing hemorrhoids or hemorrhoidal symptoms. One RCT concluded that using bidets was non-inferior to sitz bath for post-hemorrhoidectomy pain. Two prospective trials and 1 cross-sectional study determined that habitual bidet use may increase the odds of developing pruritus ani. Two case series found that habitual bidet use may cause perianal burns or anterior anal fissures. A meta-analysis was not performed because only a limited number of studies were available, and they were of variable quality. Conclusion: The current evidence does not identify using bidets as a treatment modality for perianal disease, and further research is warranted to study this increasingly utilized technology.

Surgical treatment of a canal of Nuck cyst presenting as a femoral hernia: An unusual case report.

INTRODUCTION AND IMPORTANCE: A canal of Nuck cyst forms because of a patent peritoneal fold evaginating through the inguinal canal in a female patient. It is a rare diagnosis because the canal often obliterates within the first year of a female patient's life. A persistent canal of Nuck may cause indirect inguinal hernias, or form hydroceles, termed canal of Nuck cysts. Here we report the first case of a canal of Nuck cyst discovered to be evaginating through the femoral canal. CASE PRESENTATION: A 70-year-old female patient initially presented with a symptomatic groin mass, and a suspected inguinal hernia on pre-operative ultrasound. Intraoperatively, she was found to have a canal of Nuck cyst terminating within the femoral canal. This was successfully repaired using a modified McVay approach, and approximation of the internal inguinal ring. She performed well post-operatively with no signs of recurrence at her six-month follow-up. CLINICAL DISCUSSION: This case report serves to highlight the canal of Nuck cyst, a rare embryologic remnant, and the first literature-reported femoral canal of Nuck cyst. We re-affirm the diagnostic unreliability of ultrasound imaging in the workup of groin hernias. Furthermore, we describe surgical techniques to repair a canal of Nuck cyst found within the femoral canal. CONCLUSION: To the best of our knowledge, no prior literature reports a canal of Nuck cyst presenting as a femoral hernia. This rare diagnosis may be encountered in common operations and is amenable to definitive repair using traditional hernia repair techniques.

The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature.

INTRODUCTION AND IMPORTANCE: A gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus. CASE PRESENTATION: In this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery. CLINICAL DISCUSSION: We review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus. CONCLUSION: Through this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management.

Prognosticating Outcome in Pancreatic Head Cancer With the use of a Machine Learning Algorithm.

Background: The purpose of this project is to identify prognostic features in resectable pancreatic head adenocarcinoma and use these features to develop a machine learning algorithm that prognosticates survival for patients pursuing pancreaticoduodenectomy. Methods: A retrospective cohort study of 93 patients who underwent a pancreaticoduodenectomy was performed. The patients were analyzed in 2 groups: Group 1 (n = 38) comprised of patients who survived < 2 years, and Group 2 (n = 55) comprised of patients who survived > 2 years. After comparing the two groups, 9 categorical features and 2 continuous features (11 total) were selected to be statistically significant (p < .05) in predicting outcome after surgery. These 11 features were used to train a machine learning algorithm that prognosticates survival. Results: The algorithm obtained 75% accuracy, 41.9% sensitivity, and 97.5% specificity in predicting whether survival is less than 2 years after surgery. Conclusion: A supervised machine learning algorithm that prognosticates survival can be a useful tool to personalize treatment plans for patients with pancreatic cancer.