Global 30-day morbidity and mortality of surgery for perforated peptic ulcer: GRACE study.

BACKGROUND: There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. METHOD: We performed an international study of adults (≥ 18 years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50 years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24 h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. RESULTS:  1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49 years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50 years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality. CONCLUSIONS: This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality.

Insight on the structural, electronic and optical properties of Zn, Ga-doped/dual-doped graphitic carbon nitride for visible-light applications.

The density functional theory (DFT) was applied for the first time to study the doping and co-doping of Ga and Zn metals on graphitic carbon nitride (g-C3N4). The doping of these metal impurities into g-C3N4 leads to a significant decrease in the bandgap energy. Moreover, the co-doping leads to even lower bandgap energy than either individual Zn or Ga-doped g-C3N4. The theoretical electronic and optical properties including the density of state (DOS), energy levels of the frontier orbital, excited state lifetime, and molecular electrostatic potential of the doped and co-doped g-C3N4 support their application in UV-visible light-based technologies. The quantum mechanical parameters (energy band gap, binding energy, exciton energy, softness, hardness) and dipole moment exhibit higher values (ranging from 1.36 to 4.94 D) compared to the bare g-C3N4 (0.29 D), indicating better solubility in the water solvent. The time-dependent DFT (TD-DFT) calculations showed absorption maxima in between the UV-Vis region (309-878 nm). Additionally, charge transfer characteristics, transition density matrix (TDM), excited state lifetime and light harvesting efficiency (LHE) were investigated. Overall, these theoretical studies suggest that doped and co-doped g-C3N4 are excellent candidates for electronic semiconductor devices, light-emitting diodes (LEDs), solar cells, and photodetectors.

The mystery of post-cholecystectomy persistent bile leak: a case report.

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. She remained stable. This is a rare complication of one of the most common surgical procedures performed in the world.

A case report of sacrococcygeal foreign body presenting as pilonidal sinus.

Pilonidal disease occurs most commonly in those males who have to sit long hours at their work place e.g. online office workers or drivers. It is caused by piercing of broken hairs into the sacrococcygeal region which causes localised inflammation. Inflammation in this area due to any other foreign body is very rare. Among many treatment options for pilonidal sinus, instillation of crystalloid phenol showed promising results in terms of low recurrence rates, low post-operative complications and less healing time. Here, we present the case of a 13-year-old female student who had pilonidal sinus in sacrococcygeal region for six months and was unresponsive to multiple treatments. Later, on exploration it was revealed to contain a small foreign body of 3cm of hard straw of grass. The patient was treated with crystalloid phenol and on regular follow-up she was completely fine by the end of the third week.

Primary squamous cell carcinoma of liver. First case report from Pakistan and South Asia.

INTRODUCTION AND IMPORTANCE: Primary squamous cell carcinoma (PSCC) of liver is quite rare and very few cases reported in literature. It has high metastatic rate with poor prognosis. The pathogenesis is unclear, but is generally considered to be correlated with the long-term inflammation or metaplasia of biliary epithelial cells or congenital cyst of the liver. We report here a case of PSCC of liver which mimicked a complex hydatid cyst. CASE PRESENTATION: A 25 years male admitted with right hypochondrium pain associated with fever and yellowish discoloration of eyes for 20 days. He was jaundiced with epigastric tenderness and deranged liver function tests. When thoroughly investigated with ultrasound, CT abdomen and MRI liver, he was found to have a large cystic lesion in right lobe of the liver. He underwent right hepatectomy, peri-cystectomy of the cyst and T-tube placement in common bile duct. Histopathology of the resected sample showed primary squamous cell carcinoma of liver. Patient was discharged after 7 days and died after 6 months due to acute liver failure. CLINICAL DISCUSSION: Because of a very low incidence of hepatic SCC, there is not a single definite therapeutic regime and various different methods of management include surgical resection, generalized chemotherapy, radiotherapy, Hepatic Arterial ChemoEmbolization (HACE) and the combinations of these therapies. CONCLUSION: PSCC is a rare condition of the liver and is associated with other benign liver conditions such as non-parasitic and epidermoid cysts. Histopathology with radiological investigations are needed to diagnose and treat this aggressive tumor before it metastasizes.

A rare case report of short bowel anastomosis after acute mesenteric ischaemia in Covid-19 postive patient.

Acute mesenteric ischaemia is one of the serious abdominal surgical emergency, which has got very high morbidity and mortality. During the pandemic of COVID-19, besides respiratory complications, the virus was causing venous and arterial thromboembolism that can lead to acute mesenteric ischaemia in otherwise healthy individuals. Early diagnosis and suitable surgical procedures are the key to the better outcome of this disease. Surgical resection of gangrenous gut, leaving healthy gut is an important step of this operation. Leaving less than 200 cm of small intestine leads to short bowel syndrome which has got its own complication. This case report is on a healthy COVID-19 positive patient who presented with acute mesenteric ischaemia. After surgical resection only 1.5 feet small bowel (60 cm) was left behind and anastomosis was done with healthy transverse colon. He was later managed for complications of small bowel syndrome and was discharged successfully with dietary modifications.

A rare case of acute mesenteric ischaemia and duodenal ulcer perforation together in a single patient in a tertiary care hospital.

A 57 years old male presented in the emergency department of EAST Surgical Ward, MAYO Hospital Lahore in February 2021 with complaints of abdominal distension, pain and vomiting. He was a chronic smoker and diagnosed hypertensive for the last 14 years but was non-compliant with oral antihypertensive medications. He was a factory worker and took NSAIDs off and on for pain in the knee joint for the last five years. On examination, his abdomen was tense and tender with resonant percussion notes in the right hypogastrium and epigastrium. His chest x-ray showed free gas under the right diaphragm. Diagnosis of a perforated duodenal ulcer was made and exploratory laparotomy was done. Examination revealed a perforated ulcer in the first part of the duodenum with greenish gangrenous patches on the next 3 feet of the small gut. Graham's patch repair and resection of the diseased small gut was done and a jejuno ileostomy was performed. Unfortunately, the patient expired on 2nd postoperative day due to sudden cardiopulmonary arrest.

Spectrum of hollow visceral injury due to isolated blunt trauma abdomen presented to a tertiary care trauma hospital of Pakistan.

OBJECTIVE: To evaluate the spectrum of isolated hollow visceral perforations in patients presenting with abdominal blunt trauma. METHODS: The observational, analytical, cross-sectional study was conducted at the surgical ward of Mayo Hospital, Lahore, Pakistan from July 1, 2020, to June 31, 2021, and comprised patients who presented in the emergency department after blunt trauma to abdomen without any open wound. Findings of hollow visceral injury were confirmed on exploration laparotomy. Data was analysed using SPSS 26. RESULTS: Of the 216 patients, 173(80.9%) were male and 43(19.9%) were female. The overall mean age was 42±9.7 years. Most of the blunt trauma abdomen cases were caused by motor vehicle accidents 59(27.3%). The most common hollow viscus affected was jejunum 42(19.4%), followed by transverse colon 29(13.4%). The most common type of injury observed was single complete disruption of hollow viscus 74(34.2%). CONCLUSIONS: The most common hollow organ affected by blunt trauma to the abdomen was jejunum, followed by transverse colon, and motor vehicle accidents were the major cause of these injuries.

Predictors of lower limb amputations in patients with diabetic foot ulcers presenting to a tertiary care hospital of Pakistan.

OBJECTIVE: To assess the risk factors for lower limb amputations in diabetic patients presenting with foot ulcers. METHODS: The analytical cross-sectional study was conducted at the Mayo Hospital, Lahore, Pakistan, from December 1, 2019, to May 31, 2020, and comprised patients of either gender having type 1 or type 2 diabetes and foot ulcers. The wounds were assessed according to Wagner wound staging and wound sepsis was evaluated in terms of local infection of the wound, leucocytosis and osteomyelitis of the bone. The glycaemic control of these patients was assessed on presentation by measuring glycated haemoglobin levels. Data was analysed using SPSS 26. RESULTS: Of the 135 patients, 82(60.7%) were males and 53(39.2%) were females. Majority patients 59(43.7%) were aged 50-60 years. All 135(100%) patients underwent some type of amputation. Of all the amputations, 91(67.4%) were done in patients with poor glycaemic control on presentation, and 56(41.5%) in those with stage 4 wound. Local wound infection, increased total leukocyte count and bone showing features of osteomyelitis were significantly associated with increased risk of lower extremity amputations (p<0.05). CONCLUSION: With proper glycaemic control and early presentation and treatment, majority of amputations could be avoided in diabetic patients with foot ulcers.

Outcome of abdominal binder in midline abdominal wound Dehiscence in terms of pain, psychological satisfaction and need for reclosure.

OBJECTIVE: To assess the role of abdominal binder in patients with midline wound dehiscence after elective or emergency laparotomy in terms of pain, psychological satisfaction and need for reclosure. METHODS: It was a comparative study done at EAST Surgical Ward of Mayo Hospital, Lahore from 1st January 2018 to 31st December 2019. One hundred and sixty-two (162) patients were included in this study with post-operative midline abdominal wound dehiscence and after informed consent by consecutive non probability sampling technique. Patients were divided into two groups by lottery method into eighty-one patients each. Group-A included patients where abdominal binder was applied and Group-B included patients without abdominal binder. In both groups pain score, psychological satisfaction and need for reclosure was assessed and compared. RESULTS: Patients with abdominal binder shows significantly less pain (P value =0.000) and more psychological satisfaction (P value = 0.000) as compared to the patients where abdominal binder was not used. However, there was no difference in reducing the need for reclosure in patients who use abdominal binder (P value = 0.063). CONCLUSION: Although abdominal binder helps in reducing the pain and improving the psychological satisfaction in patients with midline abdominal wound dehiscence yet it doesn't help in healing of wound and reclosure of the dehisced abdominal wound is needed.

Neck exploration for a huge synovial sarcoma, case report and literature review.

A 47-year-old woman presented in the outpatient department of EAST Surgical ward of MAYO Hospital Lahore, Pakistan, on February 2019 with complaint of swelling in the front section of the neck since five months which increased gradually in size and had been causing pain since two months. She had no comorbidities and insignificant family history. Examination revealed a 23×20 cm mass on the right side of the posterior triangle of the neck. Fine Needle Aspiration Cytology (FNAC) was inconclusive and CT of the neck showed a huge mass on the right side of the neck with cervical lymph nodes. Exploration was planned, and modified radical neck dissection Type III (Also known as Functional Neck dissection) was performed. The biopsy revealed synovial sarcoma of the neck. The patient's post-operative condition was satisfactory and she was discharged on the fifth post-operative day.

A case report of abdominal sponge in ileum in a patient with intestinal obstruction.

A 36-year-old woman presented in the emergency department of East Surgical Ward of MAYO Hospital Lahore, Pakistan, in August 2019 with complaint of abdominal pain and vomiting for the past five days. The patient had a history of three Caesarean sections, the last one three years back. Off and on, she experienced abdominal pain and distension which was relieved after taking local medicines. She had no comorbid conditions and her baseline investigations were normal. On examination she had tachycardia with pulse 110/min and her whole abdomen was tender with exaggerated bowel sounds. X-ray of the abdomen showed multiple air fluid levels in the small intestine. Exploration plan was made; a distended segment of ileum was later found to have an abdominal sponge inside its lumen. There was a perforation in the ileum through which the sponge was retrieved and resection and end-to-end anastomosis was done. The patient was discharged on third post operation day.

Fluoroquinolones (FQs) in the environment: A review on their abundance, sorption and toxicity in soil.

The use of fluoroquinolones (FQs) antibiotics as therapeutic agents and growth promoters is increasing worldwide; however their extensive uses are also resulting in antibiotic resistance among world communities. FQs have also become one of the major contaminants in the waste water bodies, which are not even completely removed during the treatment processes. Furthermore, their abundance in agricultural resources, such as the irrigation water, the bio-solids and the livestock manure can also affect the soil micro-environment. These antibiotics in soil tend to interact in several different ways to affect soil flora and fauna. The current review endeavors to highlight the some critical aspects of FQs prevalence in the environment. The review presents a detailed discussion on the pathways and abundance of FQs in soil. The discussion further spans the issue of sorption and FQs transformation into the soil better understand of their behavior and their toxicity to soil flora and fauna.

Colposcopy in oral epithelial dysplasia: seeing the unseen, a pilot study.

CONTEXT: The diagnosis of malignant and potentially malignant epithelial lesions of oral mucosa cannot be based solely on clinical findings. The histologic evaluation of a representative biopsy specimen thus becomes necessary. The site for biopsy, however, is always a subjective choice that sometimes raises doubts about its representativeness. So far, no simple and reliable method is available for the selection of the most appropriate area for biopsy. Colposcopy is helpful in the selection of these sites of epithelial dysplasia depending upon the vascular patterns. AIMS: The study was planned to assess the role of colposcopic examination in the selection of biopsy site in patients with varying grades of oral epithelial dysplasia at various sites. SETTINGS AND DESIGN: Fifty patients between the ages of 30-60 years clinically diagnosed with leukoplakia and carcinoma buccal mucosa were included in the study. MATERIALS AND METHODS: For each of the subject, a thorough clinical examination followed by colposcopic assessment was carried out for the selection of biopsy site from the involved mucosa. The histopathological findings were then compared in the two cases and results analyzed. STATISTICAL ANALYSIS USED: The statistical analysis was done using paired t-test. RESULTS: In our study, sensitivity and specificity for the selection of biopsy site by colposcopic examination came out to be higher for leukoplakia than carcinoma buccal mucosa patients. CONCLUSIONS: It was concluded that colposcopic examination was found more significant in the selection of biopsy site for leukoplakia patients while clinical criterion was found to be more appropriate for carcinoma buccal mucosa cases.

Complicated jejunal diverticula as surgical emergency: experience at a tertiary care hospital in Peshawar, Pakistan.

BACKGROUND: Diverticula of small intestine are rare. Jejunal diverticula can be single or multiple. Diverticula in the jejunum tend to be large and multiple. Clinically they may be asymptomatic or may give rise to symptoms like pain, flatulence and borborygmi, may produce malabsorption syndrome or may present in emergency with different acute pathologies like perforation, haemorrhage, obstruction, enterolith formation and inflammation. The Objective was to see the pattern of complications in jejunal diverticula presenting as a surgical emergency. METHODS: This descriptive study was conducted at Surgical Units of the 3 tertiary care Hospitals of Peshawar, for 7 years from January 1, 2002 to December 31, 2008. Study included all patients presenting to and admitted in Surgical Unit, Hayatabad Medical Complex, Peshawar with complicated jejunal diverticula during the above mentioned period. Name, age, sex, other relevant data, history and examination findings and results of investigation were recorded. Uncomplicated jejuna diverticula were excluded from study. The operative findings and the type of complication were recorded. RESULTS: Ten patients were admitted during 7 years of study. Out of all patients 9 were male and 1 was female. Eight out of 10 patients presented with perforation of diverticula while 1 patient had severe inflammation of diverticulum causing pain, ileus and acute abdomen. One patient had acute pain due to adhesion formation. CONCLUSION: It is seen that complicated jejunal diverticulae are quite rare and the most common complication is perforation. Inflammation and adhesion are other complications with which jejunal diverticula presented during this study.