Clinical Practice Guidelines For The Management Of Colorectal Cancer, A Consensus Statement By The Society Of Surgeons® And Surgical Oncology Society Of Pakistan®.

A joint effort by the Society of Surgeons Pakistan and Society of Surgical Oncology Pakistan, these guidelines provide a framework for the practicing surgeons involved in care and management of patients with colorectal cancer. The guidelines take into account the issues related to our local circumstances and provide a minimum standard of care that must be given to these patients. The Guideline Committee had members from all disciplines, including surgery, surgical oncology, medical oncology and radiation oncology. The guidelines have attempted to simplify things to understand and follow for the practicing surgeons. With these guidelines we wish to eliminate disparities in treatment among institutions and prevent any under treatment of patients.

Using Telemedicine to Diagnose Surgical Site Infections in Low- and Middle-Income Countries: Systematic Review.

BACKGROUND: A high burden of preventable morbidity and mortality due to surgical site infections (SSIs) occurs in low- and middle-income countries (LMICs), and most of these SSIs occur following discharge. There is a high loss to follow-up due to a wide geographical spread of patients, and cost of travel can result in delayed and missed diagnoses. OBJECTIVE: This review analyzes the literature surrounding the use of telemedicine and assesses the feasibility of using mobile phone technology to both diagnose SSIs remotely in LMICs and to overcome social barriers. METHODS: A literature search was performed using Medline, Embase, CINAHL, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar. Included were English language papers reporting the use of telemedicine for detecting SSIs in comparison to the current practice of direct clinical diagnosis. Papers were excluded if infections were not due to surgical wounds, or if SSIs were not validated with in-person diagnosis. The primary outcome of this review was to review the feasibility of telemedicine for remote SSI detection. RESULTS: A total of 404 articles were screened and three studies were identified that reported on 2082 patients across three countries. All studies assessed the accuracy of remote diagnosis of SSIs using predetermined telephone questionnaires. In total, 44 SSIs were accurately detected using telemedicine and an additional 14 were picked up on clinical follow-up. CONCLUSIONS: The use of telemedicine has shown to be a feasible method in remote diagnosis of SSIs. Telemedicine is a useful adjunct for clinical practice in LMICs to decrease loss to postsurgical follow-up.

Swirl Sign - A C T Angiogram Alarm Sign or Congenital Trans-Mesenteric Hernias.

Congenital trans-mesenteric hernias (CTMHs) are caused by rent in the mesentry of bowel. The lesions commonly present in pediatric age group. Adult CTMHs usually present with complication of the problem. The diagnosis is often late and is associated with morbidity as well as mortality due to bowel ischemia. There is no specific sign associated with this condition. A case is reported of a patient diagnosed with CTMH on high suspicion by the radiologist based on her finding of abnormal swirling of superior mesenteric artery on CT angiogram. Swirl sign on CT angiogram warrants an early surgical consultation to prevent any morbidity.

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.

Effectiveness of Ultrasound Shear for Clipless Laparoscopic Cholecystectomy Versus Conventional Unipolar Electrocautery in Patients with Cholelithiasis.

OBJECTIVE: To determine the efficacy of ultrasound shear in laparoscopic cholecystectomy in terms of total operative time, postoperative bile leaks, gall bladder perforation rate, and postoperative bleeding from cystic artery and collateral injury to bowel and duodenum. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Mayo Hospital, Lahore, from June 2013 to May 2014. METHODOLOGY: 150 cases (75 in each group) were randomized into two groups, i.e. harmonic scalpel clipless group (HSG) versus conventional laparoscopic cholecystectomy (CLC) with electrocautery group. The above stated variables were documented. The data for age, blood loss, and drain output were positively skewed as calculated using the Shapiro-Wilk test. The histograms, Q-Q plots and box plots were analyzed for all the dependent variables. Skewed qualitative continuous data was analyzed using the Mann-Whitney U-Test. RESULTS: Operative time was significantly lower in HSG as compared to CLC. Median operative times were 30 minutes (IQR 10) versus 35 minutes (IQR 10) (p<0.001). HSG group had perforation rate of 5/75 (6.67%) as compated to 16/75 (21.33%) in CLC (p=0.010). Intraoperative blood loss in group Awas significantly lower than in group B (p=0.001). Postoperative median pain score was 3 (IQR 2) versus 3 (IQR 3) in HSG versus CLC, respectively. CONCLUSION: All the primary outcomes showed improved results in the ultrasound shear group as compared to the group for conventional electrocautery.

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.

The efficiency, accuracy and acceptability of smartphone-delivered data collection in a low-resource setting - A prospective study.

Smartphones are increasingly used in healthcare, yet little is known about their utility in medical research as a means of data collection in low- and middle-income countries (LMIC). In this letter, we discuss results from our experiences with data collection on smartphones in an LMIC setting. Our experience found smartphones a secure and reliable data collection tool for medical research that can empower researchers in countries to participate in surgical studies.

Surface Microbiology of Smartphone Screen Protectors Among Healthcare Professionals.

BACKGROUND: The use of smartphones with touch screens has become a norm for healthcare professionals (HCP). The risk of smart screen contamination has been proven, and guidelines are available to deal with possible contamination. A large number of smartphone users apply plastic or glass screen protectors onto their mobile phone screens to prevent scratches. However, these materials are not scratch proof, and their antipathogenic properties have not been studied. METHODS: We have conducted a study to determine the frequency of smartphone screen protector contamination and compared the data with contamination on the bare area on the same mobile screens. The sample size included only HCPs working in acute care settings and having at least eight hours of exposure time every day. RESULTS: A total of 64 samples were collected, which reported 62.5% (n = 40/64) positive culture swabs from the protected areas of the screen and 45.3% (n = 29/64) from the unprotected area of the screen. Micrococcus and Gram-negative rods grew only on samples taken from the protected area whereas the bare area showed no such growth. There was no statistically significant difference in the frequency based on smart screen size, duration of use during duty hours, or the setting where it was used. CONCLUSIONS: Smartphone screen protectors from healthcare providers may harbor pathogenic bacteria, especially in acute care settings. Coagulase-negative Staphylococci followed by Bacillus species were the most commonly yielded bacteria among house officers and postgraduate trainees in the present study.

E-Log System in Monitoring of Residency Program: Trainees' Perspective.

OBJECTIVE: To record residents' perspective about the utility of newly introduced E-Log system at the College of Physicians and Surgeons Pakistan (CPSP). STUDY DESIGN: Sequential mixed method design using survey questionnaire and in-depth interviews. PLACE AND DURATION OF STUDY: CPSP, Regional Center, Lahore, from March to June 2014. METHODOLOGY: Data was collected from registered trainees through a web-based survey questionnaire on a scale of 1 to 7 about the utility of E-log system. In-depth interviews were conducted with 7 students using non-probability purposive sampling. The interviews were tape recorded and subsequently transcribed. Quantitative data was analyzed using SPSS version 20 and qualitative data was analyzed using content analysis by identifying themes and patterns. RESULTS: Atotal of 4399 responses were received. Motivation was 4.61 ± 1.98; 4.33 ± 2.00 remained acknowledgment of control of one's training by the new system. Ease of use got a mean score of 4.56 ± 2.15. CONCLUSION: The overall acceptance of the students regarding E-Log system was high. Scheduling IT workshop at the start of training will add to the student satisfaction regarding utility of E-Log system.

Postgraduate trainee performance with structured assessment techniques in competency-based model of training.

OBJECTIVE: To determine the effect of changes in curriculum and structured assessment on the performance of candidates at the end of the first phase of residency program by comparing pass percentages of candidates with older residency program. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: From 2007 to 2009 at the College of Physicians and Surgeons Pakistan. METHODOLOGY: Results of midterm assessment (intermediate module, IMM) for the years 2006-2007 (Historical group) in 9 specialties were compared with those of years 2008-2009 (Interventional group) after implementation of curricular changes. The changes were evaluated with structured assessment technique. Results for the IMM exams for years 2006 to 2009 were included in the study. Percentage changes in results of both groups were subjected to statistical analysis. RESULTS: The average pass percentage for theory examination in the Historical group was 52.6% + 13.87, and 59.96 + 14.88 in Intervention group. The pass percentage in old-residency program for the clinical examination was 61.6% (ranging from 48.0% to 78.4%) which was less when compared with the new residency system that was 73.9% (ranging rom 61.5% to 82.45%). CONCLUSION: The curricular changes and structured assessment at set competency standard resulted in better performance and higher pass percentages of candidates at midterm assessment.

Stray bullet in inferior vena cava.

A young boy presented in emergency with history of being hit by a stray bullet injuring the right hypochondrium. Ultrasound of abdomen showed hemoperitoneum and the radiograph showed bullet in the pelvis. Exploratory laparotomy showed injuries to liver and cystic duct with tract leading retroperitoneally into the inferior vena cava. The bullet was found wandering inside the vena caval lumen. Stray bullets are presumed to remain limited to the soft tissues. However, the trajectory, impact velocity and the involved region ultimately determine the outcome and influence management.

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.

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.

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.