Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel.

Background & Objective: To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer. Methods: This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system. Results: A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months. Conclusion: For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

Emergency esophagectomy: Experience of a high volume esophageal cancer center.

Objective: The objective of the study was to review the experience of dealing oncological emergency esophagectomies at a dedicated Cancer hospital. Methods: We performed a retrospective review of data of eleven esophagectomies at the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (SKMCH&RC) Pakistan, from 1st January, 2009 to 30th June, 2019. Out of 590 oncological esophagectomies, eleven patients had emergency resection. We collected the data of demographics, primary disease, comorbidities, location of tumor and perforation, cause of perforations, radiological and endoscopic findings, clinical findings and follow-up visits after discharge. Data was analyzed by SPSS version 21 for windows. Result: All 11 patients out of five hunded ninety had esophageal cancer. At the time of initial staging, eight (72%) had locally advanced stage (stage III and IV). Open transhiatal approach was used in six (55%) patients, and the rest had three stage esophagectomies. Primary reconstructions with gastric conduit were performed in all, except in two (18%) patients, Respiratory complications were the most common of the encountered complications, seven (63%) of the patients had palliative resection. Ninety day mortality was observed in 3(27.3%) patients. On long term follow up, six patients had recurrence, with median Disease-Free Survival (DFS) 5.88 months and Median Overall Survival (OS) was 6.37 months. Out of 11, only three patients are alive without disease, while one patient is lost during follow-up. Conclusion: Emergency esophagectomy is a lifesaving procedure; there should be multidisciplinary team approach towards the management. Early diagnosis and management is of paramount importance.

Topical Diltiazem Ointment For Post- Hemorrhoidectomy Pain.

BACKGROUND: Hemorrhoids are one of the most common anal pathology affecting millions of people around the world. Milligan-Morgan open hemorrhoidectomy is the most effective hemorrhoidectomy method used as gold standard procedure. Post-operative pain is recognized as a distressing complication of hemorrhoidectomy leading to increase hospital stay and psychological stress to both patient and surgeon. This study is designed to determine the efficacy of diltiazem gel in relieving pain after hemorrhoidectomy caused by anal muscle spasm. This will lead to decreased hospital stay and save both patient and surgeon from stress in postoperative period. OBJECTIVE: To compare mean post-operative pain in patients undergoing hemorrhoidectomy with vs. without topical application of diltiazem gel. METHODS: Total 80 patients who were diagnosed with third- and fourth-degree hemorrhoids and undergo hemorrhoidectomy were included in the study. Patients were randomly allocated to two groups using opaque sealed envelope method. Group A and B both have 40 patients in each group. Pain score was measured on visual analogue scale (VAS) by asking the patients to fill a questionnaire or by the help of the doctor. RESULTS: The patient's average age was 39.98±7.98 years. At 24 hours, mean pain score was significantly high in group B than group A [7.23±0.95 vs. 5.38±1.06; p=0.0005]. At 3rd post-operative day, mean pain score was significantly high in group B than group A [5±0.78 vs. 3.08±0.99; p=0.0005]. Seventy percent cases were observed in group B which required rescue analgesia. CONCLUSIONS: It is concluded that application of diltiazem ointment at perianal area with standard treatment considerably decreases pain after haemorrhoidectomy.

Effect of Paper- and Computer-based Simulated Instructions on Clinical Reasoning Skills of Undergraduate Medical Students: A Randomized Control Trial.

Background and objectives Skilled clinical reasoning is a critical tool for physicians. Educators agree that this skill should be formally taught and assessed. Objectives related to the mastery of clinical reasoning skills appear in the documentation of most medical schools and licensing bodies. We conducted this study to assess the differences in clinical reasoning skills in medical students following paper- and computer-based simulated instructions. Materials and methods  A total of 52 sixth semester medical students of the Dow University of Health Sciences were included in this study. A tutorial was delivered to all students on clinical reasoning and its importance in clinical practice. Students were divided randomly into two groups: group A received paper-based instructions while group B received computer-based instructions (as Flash-based scenarios developed with Articulate Storyline software [https://articulate.com/p/storyline-3]) focused on clinical reasoning skills in history-taking of acute and chronic upper abdominal pain. After one week, both groups were tested at two objective structured clinical examination (OSCE) stations to assess acute and chronic pain history-taking skills in relation to clinical reasoning. Results There were 27 students in group A and 25 students in group B. The mean OSCE score for group A (paper-based) was 28.6 ± 9.4 and that for group B (computer-based) was 38.5 ± 6.0. Group B's mean score was statistically significantly greater (p < 0.001) than group A's mean score for clinical reasoning skills.  Conclusion A computer simulation program can enhance clinical reasoning skills. This technology could be used to acquaint students with real-life experiences and identify potential areas for more training before facing real patients.

Comparison of hemorrhoidectomy by LigaSure with conventional Milligan Morgan's hemorrhoidectomy.

OBJECTIVE: To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy. METHODS: This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A (Haemorrhoidectomy by Ligasure) and group B (Milligan Morgan Haemorrhoiectomy). Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7(th) post operative day. RESULTS: Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 - 60 years. Third degree Heamorrhoids were present in 37 (67.3%) of patients while remaining 18 (32.7%) had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6± 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34±25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method. CONCLUSION: The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups.

Sentinel lymph node identification by blue dye in patients with breast carcinoma.

OBJECTIVE: To determine the diagnostic accuracy of methylene blue dye to detect axillary lymph node metastases in patients with breast carcinoma by taking histopathology as gold standard. METHODS: This quasi experimental study was done at Department of Surgery of Dow University Hospital Karachi during January 2013 to September 2015 after the approval of Hospital Ethical Committee. A total number of 85 patients with biopsy proven carcinoma were included in the study.1% methylene blue dye was infiltrated in the peri tumoural area of the diseased breast. The blue stained node called sentinel lymph node (SLN) was recognized and carefully dissected out. SLN and mastectomy with axillary clearance specimen was sent for histopathology in two separate bottles and the report of the histopathology was compared. RESULTS: The axillary lymph nodes were positive for carcinoma in 61 cases out of 85(71.7%). Two of the patients had negative sentinel lymph node but positive non sentinel lymph node (false negative), and in three cases sentinel lymph node were involved only but not the rest of the axilla (False positive). The sensitivity, specificity and accuracy were 96.8%,86.36% and 94.1% respectively. CONCLUSION: Methylene blue dye technique is a reliable and safe diagnostic modality for detection of Sentinel lymph node in breast cancer patient because of its high accuracy.

Quality of Surgical Case Notes at Dow University Hospital according to modified ANKLe score.

OBJECTIVE: To find out quality of surgical case notes according to modified Adjusted Note keeping and Legibility (ANKLe) score in Dow University Hospital. METHODS: For this audit, medical records of all the patients admitted in Dow University Hospital surgery department were reviewed from February 2012 to April 2012. The modified ANKLe score (total 24) is formed by the combination of, the content (out of 20) and legibility (out of 4) to give an overall score out of 24. A score of at least 20 (content score 17/20; legibility score 3/4) is considered as acceptable. It means that a surgical record is legible and the majority of the essential content is recorded. RESULTS: A total of 236 records were evaluated. Overall mean ± standard deviation (SD) of ANKLe score was 18.4± 2.1 out of maximum score of 24. Content and legibility has overall mean scores of 14.4 out of 20 and 3.9 out of 4 respectively. Only two variables, patient's name and consultant on call were documented in 100% of records while the least documented variable were social history 2 (0.2%). Legibility scoring system provides that 218notes out of total set of 236 notes (that is 92.4% of overall notes) have achieved a score of 4. The benchmark of 80% was achieved in 26.1% for total ANKLe score, 6.8% for contents and 99.1% for legibility. CONCLUSION: Overall, quality of records is not good but legibility part scores exceptionally high.