The study of frequency of malignancy and its types in surgical jaundice; a tertiary care experience.

OBJECTIVE: To determine the frequency of malignancy and its types in patients presenting with surgical jaundice in a tertiary care setting. METHODS: The cross-sectional study was conducted at the North Surgical Ward, Mayo Hospital, Lahore, Pakistan, from May 8 to November 8, 2020, and comprised patients of either gender with a diagnosis of surgical jaundice made on the basis of history, clinical examination, haematological and biochemical reports and radiological investigations. All patients were managed as per the guidelines for surgical jaundice with injection vitamin K intramuscular, hydration with intravenous fluids, avoidance of constipation by lactulose or neomycin, vitals and urine output monitoring and prophylactic antibiotics. Demographic data as well frequency of malignancy were noted using a predesigned proforma. Data was analysed using SPSS 21. RESULTS: Of the 95 patients, 51(53.7%) were male and 44(46.3%) were female. The overall mean age was 49.96±16.54 years (range: 18-80 years). A total of 19(20%) cases had body mass index <30. Malignancy was identified in 50(52.6%) cases; 14(28%) gallbladder, 4(8%) head of pancreas, 9(18%) peri-ampullary carcinoma, 7(14%) cholangiocarcinoma, 6(12%) Klastkin tumour, 5(10%) hepatocellular carcinoma, and 5(10%) metastatic tumour. CONCLUSIONS: More than half of the surgical jaundice cases had malignancy, gallbladder being the most affected site.

Efficacy of Remdesivir on Clinical Outcomes in COVID-19 Patients: A Study in a Tertiary Care Hospital in Pakistan.

Background: As of October 3, 2023, the global COVID-19 case tally exceeded 696 million, with almost 7 million fatalities. Remdesivir, approved for treatment of COVID-19 by regulatory bodies, has seen varying recommendations by the World Health Organization over time. Despite certain studies questioning its efficacy, others highlight potential benefits. The objective of this study was to gauge the impact of remdesivir on clinical outcomes in a Pakistani tertiary care hospital. Methods: An analytical cross-sectional study was conducted on 108 COVID-19 patients at Mayo Hospital Lahore between September 2020 and August 2021. Of these, 52 received remdesivir. The study employed a structured proforma for data collection, with analyses conducted using SPSS version 26, considering a p-value of less than 0.05 as statistically significant. Results: Demographic distribution between remdesivir-treated and untreated groups was similar. Significant improvement was observed in the remdesivir cohort in terms of oxygen saturation (58%), ferritin levels (58.2%), chest X-ray results (67.8%), and discharge rates (66.7%) when compared to the untreated group. Stratification based on disease severity showed that remdesivir was particularly beneficial for moderate illness cases in several parameters. Conclusion: This study suggests that remdesivir can be associated with improved outcomes, especially in patients with moderate COVID-19 severity. The data emphasizes the importance of the disease stage when considering therapeutic interventions and calls for more region-specific research to guide health responses amid diverse epidemiological landscapes.

The Effect of COVID-19 Pandemic on Performance of Postgraduate Medical Trainee Doctors: A Nationwide Epidemiological Study in Pakistan.

OBJECTIVE: To find out various organizational, personal, and systemic factors influencing the performance of the postgraduate trainee doctors in managing COVID-19 pandemic. STUDY DESIGN: Analytical cross-sectional study. PLACE AND DURATION OF STUDY: Conducted in various medical institutions of Pakistan from 15th  April to 30th  June, 2020. METHODOLOGY: An analytical cross-sectional study was conducted on 11,656 postgraduate doctors. They were contacted through the e-log system of College of Physicians and Surgeons Pakistan. Semi-structured questionnaire was used consisting of demographic details, presenting symptoms, systemic involvements, clinical features, diagnostic tests, management of cases, authenticity of the  information used, telemedicine services, practice of preventive measures, training and interactive educational activities, performance-based tasks and details about workplace environment. Mean and standard deviation was reported for continuous variables. Bivariate and multivariate analyses were used to report p values. RESULTS: Among 11,656 postgraduate doctors, 3,193 (27.4%) were directly involved in the management of COVID-19 patients in designated special corona facilities. Multivariate analysis was performed to control confounders. The risk factors, found statistically significant with performance, were presence of comorbidity (OR 1.261; 95% C.I.1.06-1.50), allergic and autoimmune disorders (OR 1.18; 95% C.I.1.03-1.35), confirmed COVID-19 status due to exposure (OR 0.570; 95% C.I.0.41-0.81), and care provision to old parents (OR 1.299; 95% C.I.1.19-1.42). CONCLUSION: The effect of COVID-19 on performance of postgraduate doctors was multi-factorial. Significant risk factors were presence of a comorbidity, allergic and autoimmune disorders, and confirmed COVID-19 due to exposure. Key Words: COVID 19, Postgraduate trainee, Pandemic, Comorbidity, PCR.

Surgical Outcome of Peripheral Vascular Injuries in Adults.

OBJECTIVE: To describe the management and outcome of adult patients after peripheral vascular injuries. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Accident & Emergency Department, Mayo Hospital Lahore, Pakistan, from January 2014 to December 2018. METHODOLOGY: All adult trauma patients (aged ≥13 years), who were admitted following injury to peripheral blood vessels regardless injuries, were included. Variables including patient data, mechanism of injury, vessel involved, injury severity score (ISS), surgical procedure etc. were retrospectively extracted from patient charts. Binary logistic and multinomial regression analyses were performed. The p-value <0.05 was considered significant for mortality and limb outcome. RESULTS: There were 117 patients, with mean age of 28.9±11.6 years. The commonest cause was blunt trauma (55.6%). The popliteal artery was most commonly involved (44.4%). Complete transection of artery was the most common type of injury (58.1%). The mean ISS was 17.2 ± 10. Reverse saphenous vein graft (RSVG) was the most common surgical repair (49.6%) procedure. Wound infection (17.1%) was the main complication. Limb salvage rate was 73.5% and mortality rate was 5.1%. Variables significantly influencing the limb outcome (amputated vs. salvaged) were duration of injury (p <0.001), concomitant body injury (p=0.009), ISS (p <0.001), surgical procedure (p <0.001), hemoglobin on presentation (p<0.001), number of blood transfusion (p=0.05) complications after surgery (p <0.001) and referral or not (p=0.001). Factors significantly associated with mortality were duration of injury (p=0.008), ISS (p = 0.002) and complications after surgery (p=0.011). CONCLUSION: Low hemoglobin on presentation, postoperative increased requirement of blood transfusions and having reverse saphenous graft as procedure were independent risk factors for amputation. ISS score and postoperative complications led to higher amputation and mortality rates after surgery. Key Words: Injury severity score (ISS), Glasgow coma scale (GCS), Reverse saphenous graft (RSVG), Fasciotomy, Popliteal artery, Mortality.

Comparative study of ultrasound guided fine needle aspiration cytology with open/laparoscopic biopsy for diagnosis of carcinoma gallbladder.

OBJECTIVE: To determine the accuracy of Fine Needle Aspiration Cytology (FNAC) in cases of gallbladder mass. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Surgical Units of Mayo Hospital, Lahore and Lahore General Hospital, Lahore in collaboration with the Department of Radiology, Sir Ganga Ram Hospital, Lahore and Department of Pathology of PGMI, Lahore, from September 2006 to September 2007. METHODOLOGY: Ultrasound guided fine needle aspiration cytology was done in all cases and histopathological findings were confirmed with open/laparoscopic biopsies. The results of these two modalities were compared. RESULTS: Fifty cases with mean age 60.71+11.073 years presented with mass gallbladder underwent FNAC. Smears showed adenocarcinoma 23, undifferentiated carcinoma in 7, dysplasia and suspicion of malignancy in 5, hemorrhagic background without malignant cells in 12 and inflammatory cells with no malignancy in 3 cases. Results compared with open/ laparoscopic biopsy showed a sensitivity, specificity and Positive Predictive Value (PPV) of 72.91%, 100% and 100% respectively. CONCLUSION: Ultrasound guided FNAC is a safe and less invasive diagnostic modality for diagnosing carcinoma gall bladder preventing the patient to undergo major surgery and helps in better quality of life.

Transhiatal esophageal surgery for malignancy--a 7-year experience at a tertiary care hospital.

OBJECTIVE: The aim of this study was to determine the outcomes of transhiatal esophagectomy for dysphagia for esophageal malignancy in terms of short and long-term morbidity and mortality and to determine the survival series. STUDY DESIGN: Case series study. PLACE AND DURATION OF STUDY: South and West Surgical Ward, Mayo Hospital, Lahore, from January 2001 to December 2007. METHODOLOGY: All patients referred electively or admitted through OPD presenting with features of progressive dysphagia due to malignancy were included in the study. The patients were investigated for site of stricture and extent of growth into the surrounding structures. All underwent transhiatal esophagectomy and gastric tube or colon was used as the conduit to restore continuity. Patients with squamous cell variety were referred to oncology department for chemoradiotherapy postoperatively. Morbidity and in-hospital mortality were recorded. RESULTS: A total of 42 patients were operated electively for malignant stricture esophagus through transhiatal approach. Site of lesion were 5 (11.9%) upper, 13 (31%) middle and 24 (58%) at lower end of esophagus. The TNM staging were stage I, IIa, IIb, III and IV in zero (0), 5 (11%), 10 (22%), 24 (57.8%) and 3 (7.1%) respectively. Mean operating time was 154 minutes and average blood loss of 371 ml. Postoperative complications included pneumothorax 16.7%, pulmonary complication (16.7%), anastomotic leakage (9.5%), wound infection (3.4%), recurrent laryngeal nerve injury (4.8%) and stricture formation (4.8%). Only 3 (7.1%) 30-day in-hospital mortality was recorded. CONCLUSION: Transhiatal esophagectomy is the surgical treatment of choice for resection of carcinoma esophagus specifically at the lower and mid-esophageal levels. The frequency of complications is lower as compared to transthoracic approach and the early stage of presentation can lead to high 5-year survival ratios.

Duodenal perforation in a 14-year-old boy with abdominal tuberculosis despite being on antituberculous treatment.

We are presenting a case of a 14-year-old male patient with known history of abdominal tuberculosis on medication for 4 months with frank peritonitis and air under the diaphragm found to have primary perforation of the duodenum due to tuberculosis. Tuberculosis is common in the third world but affects iliocaecal junction commonly. Cases with tuberculous duodenal are rarely reported in the literature.