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.

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.

Nutritional Status of Patients Admitted in a General Surgical Ward at a Tertiary Hospital of Punjab.

Nutritional assessment, as a method to identify malnourishment, has long been documented as an essential component of patient management which predicts adverse outcomes. The objective of the study was to find out the frequency of malnutrition and its association with the frequency of complications and deaths postoperatively. This study included all patients who were operated upon in a general surgical unit of Mayo Hospital, Lahore from June to August, 2013. Evaluation of 280 patients showed that 112 (40%) of the patients were malnourished, 90 (32%) were at risk of being malnourished and remaining 78 (28%) of the patients had normal nutritional status, according to the Subjective Global Assessment. Thirteen percent (13%) malnourished and 2 (3%) of the normally nourished patients died within 30 days of operation (p=0.001). Incidence of complications in malnourished patients was 23 (20.53%) as compared to normally nourished patients (5.12%, p=0.006). Malnutrition is very common in patients admitted to surgery wards of our hospitals. It adversely effects the outcome of surgical operations by increasing complications and mortality.

Cigarette smoking and medical students at King Edward Medical University, Lahore (Pakistan).

OBJECTIVES: To observe the frequency of cigarette smoking in medical students of King Edward Medical University and to determine associated variables. METHOD: A cross-sectional survey was conducted and data was collected through a self administered questionnaire from students at King Edward Medical University. Information about demographic characteristics, smoking status in family, number of cigarettes smoked/day, influence for starting it and use of nicotine replacement therapy was obtained. Duration of study was from April 1 to May 30, 2009. Smoker was defined as a person who, at the time of survey smoked cigarettes either daily or occasionally. RESULTS: Response rate was 65.4%, of these 396 (60.55%) were male and 88 (13.45%) were smokers. Smoking was more among the male students than females (p-value < 0.001). The greatest percentage of smokers was in 3rd Year (n = 29, 26.85%), majority were of 21-30 years age (n = 59, 19.53%), started smoking between 11-20 years (n = 48, 54.54%), smoked < 10 cigarettes/day (n = 37, 42.04%) and started smoking due to influence of friends (n = 53, 60.23%). Majority (n = 69, 78.4%) had no intention to quit in the next 6 months. Lack of Incentive (n = 32, 36.36%) and Addiction (n = 24, 27.27%) were the main reasons for not quitting. CONCLUSION: Our results showed a substantial trend of cigarette smoking in medical students in Pakistan. Prevalence is more in higher classes. Majority have a smoker in their family and had started smoking under influence of peers and media. They find it relaxing and addictive, hence difficult to quit. Nicotine use was found to be uncommon.

Cigarette smoking and health care professionals at Mayo Hospital, Lahore, Pakistan.

OBJECTIVES: To observe the frequency of cigarette smoking in doctors and paramedics and study various variables associated with it. METHODS: An anonymous questionnaire was given to randomly selected 250 Doctors and 250 Paramedics at Mayo Hospital in 2009. Information about demographic characteristics, smoking status in family, number of cigarettes smoked per day, influence for starting smoking, reason for continuation of smoking and use of nicotine replacement therapy was obtained. RESULTS: A total of 234 questionnaires from doctors and 207 from paramedics were received back (88.2% response rate). There were 280 males (163 Doctors; 117 Paramedics) and 161 females (71 Doctors; 90 Paramedics). Eightyseven (37.18%) Doctors and 74 (35.74%) Paramedics were smokers with 82 (50.31%) male doctors and 5 (7.04%) females. Similar results were obtained in Paramedics 72 (61.53%) males and 2 (2.22%) females. Of the smokers, majority started smoking between 11-20 years age with 39 (44.83%) Doctors and 48 (64.86%) Paramedics. Twenty three (26.44%) Doctors and 31 (41.89%) Paramedics smoked 11-20 cigarettes per day. Smoking was initiated due to the influence of friends by 48 (55.17%) Doctors and 56 (75.68%) Paramedics. Most smokers, 29 (33.33%) Doctors and 33 (44.59%) Paramedics found use of cigarette smoking as "Relaxing". Addiction was the main reason for difficulty in quitting cigarette smoking as reported by 33 (37.93%) Doctors and 31 (41.89%) Paramedics. Of the smokers, 61 (70.11%) doctors and 50 (32.43%) paramedics had no intention to quit smoking in the next 6 months. CONCLUSION: A significant number of doctors and paramedics, especially males, in Pakistan smoke cigarettes, which requires proper attention.

Presentation and management of pseudoaneurysms of femoral artery.

OBJECTIVE: This study reports our experience of presentation, diagnosis and management of femoral pseudoaneurysms (PSAs). DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: This study was carried out at South Surgical Unit, Mayo Hospital, Lahore over a 3-year period from January 2001 to December 2003. PATIENTS AND METHODS: Data was collected noting patient's demographic characteristics, etiology of aneurysms, modes of presentation, management and outcome. RESULTS: Thirteen patients presented with femoral artery PSAs. All except 2 were young males. Nine patients had aneurysms following IV drug abuse. Three occurred following accidental trauma and one followed angiography access. Ten presented with overt external bleeding (leaking) while 3 had closed rupture. Two PSAs were initially mistaken as an abscess and incised resulting in sudden hemorrhage. All IV drug abusers (n=9) had initial proximal / distal ligation to stop bleeding. Five had no further symptoms of ischemia, one had mild claudication, one developed rest pain and had had extra-anatomical ileo-popliteal bypass through the obturator foramen. One further patient had crossover femoral grafting because of critical ischemia. Four non-infected cases were reconstructed using direct repair, 2 reversed vein grafts and one polytetrafluoroethylene (PTFE) graft respectively. One patient (11%) each had a major and a minor limb amputation respectively. One patient left against medical advice after proximal /distal ligation. There was no mortality. There was one documented instance of recurrent drug abuse of PTFE graft. CONCLUSION: Femoral PSAs in our study was mostly due to IV drug abuse. All PSAs were either leaking or had frankly ruptured on presentation. If significant ischemia develops on ligation, bypass through the obturator foramen, placing the graft in depth away from recurrent abuse, is a useful option. These patients also need dedicated psychiatric rehabilitation to prevent further IV drug abuse.