The effect of pre-endoscopy maltodextrin beverage on gastric residual volume and patient's well-being: a randomised controlled trial.

Prolonged fasting prior to oesophagogastroduodenoscopy (OGDS) could be noxious to patients' well-being. Strict fasting protocol has been used prior to OGDS with the concern of reduced visibility or suboptimal endoscopic assessment. Maltodextrin beverages were also commonly used as the pre-operative carbohydrate loading in enhanced recovery after surgery (ERAS) protocol. Our study aimed to look for the effects of maltodextrin beverage 2 h before OGDS on gastric residual volume and patient's well-being scores. This was a single-blinded, stratified randomised controlled trial, comparing control group (A, received 400 ml of plain water) and carbohydrate loading group (B, received 400 ml of Carborie). The primary objectives were to measure the gastric residual volume (GRV) and patient's well-being scores using visual analogue scale (VAS) scores for hunger, thirst, anxiety, tiredness and general discomfort. Of 80 randomised patients, 78 completed the study (38 received plain water and 40 Carborie). The median (IQR) GRV was not significantly different between group A and B (5.0 ml (20) vs 4.0 ml (19), p = 0.777). Both groups showed significant reduction in VAS scores in all five parameters (p ≤ 0.001). There were no complications attributed to endoscopy in either group. Pre-endoscopy maltodextrin beverage is as safe as clear water with improved patient's well-being in both groups.Clinical Trial Registration: NCT05106933.

Risk factors associated with low anterior resection syndrome: a cross-sectional study.

PURPOSE: Oncological outcomes following rectal cancer surgery have improved significantly over recent decades with lower recurrences and longer overall survival. However, many of the patients experienced low anterior resection syndrome (LARS). This study identified the prevalence and risk factors associated with the development of LARS. METHODS: This cross-sectional study involved patients who were diagnosed with rectal cancer and had undergone sphincter-preserving low anterior resection from January 2011 to December 2020. Upon clinic follow-up, patients were asked to complete an interviewed based questionnaire (LARS score) designed to assess bowel dysfunction after rectal cancer surgery. RESULTS: Out of 76 patients, 25 patients (32.9%) had major LARS, 10 patients (13.2%) had minor LARS, and 41 patients (53.9%) had no LARS. The height of tumor from anal verge showed an association with the development of major LARS (P=0.039). Those patients with less than 8 cm tumor from anal verge had an increased risk of LARS by 3 times compared to those with 8 cm and above (adjusted odds ratio, 3.11; 95% confidence interval, 1.06-9.13). CONCLUSION: Results from our study show that low tumor height was a significant risk factor that has a negative impact on bowel function after surgery. The high prevalence of LARS emphasizes the need for study regarding risk factors and the importance of understanding the pathophysiology of LARS, in order for us to improve patient bowel function and quality of life after rectal cancer surgery.

Factors associated with delay in seeking care for breast symptoms.

BACKGROUND: Breast cancer is the most common cancer in women worldwide. Early detection and intervention are associated with better prognosis and survival. The study aim was to investigate the factors associated with delayed presentation among women with breast symptoms. METHODS: After ethics approval, a cross-sectional study was conducted from January to October 2020 in women with new breast cancer symptoms at their first visit to our clinic. The "Delayed Presentation" questionnaires in the Malay language were used and distributed among the participants. Demographic data and presentation time were recorded. Presentation time was defined as the duration of symptoms prior to visiting any health care facilities. Respondents with presentation times > 90 days comprised the delayed group. The potential factors associated with the delayed presentation were analyzed using cross-tabulation and multiple logistic regression. RESULTS: There were 106 respondents to the questionnaire, with a mean age of 34.0 (SD: 11.2) years, and 73.6% (n = 78) were < 39 years old. A total of 35.8% (n = 38) visited the local government clinic first and only 28.3% (n = 30) came to the BestARi clinic directly. The reasons for presentation were a palpable breast lump on breast self-examination (75.5%, n = 80), mastalgia (15.1%, n = 16), nipple discharge (5.7%, n = 6), skin changes (0.9%, n = 1), and others (2.8%, n = 3). Among the respondents, 10.4% (n = 11) had alternative treatments prior to presentation to a hospital. The mean presentation time was 98.9 (SD: 323.7) days. Most of the participants (61.3%, n = 65) presented to us within 1 month. The delayed presentation group accounted for 19.8% (n = 21) of the respondents. The factor that was significantly associated with delayed presentation was the participants' perception of symptoms as not dangerous (adjusted OR 3.05, 95% CI 1.11, 8.38). CONCLUSIONS: The percentage of delayed presentations among our patients was lower than the percentage reported in a previous study. Interpretation of a symptom as harmless by the respondent was the only factor significantly associated with delayed presentation.

A Monster in the Chest: A Tale of a Goiter.

Substernal goiter is usually presented in elderly patients and is mostly asymptomatic. A large substernal goiter is surgically challenging and can be managed through a transcervical incision and sternotomy. This case report is about a large substernal goiter extending into the anterior mediastinum and causing superior vena cava syndrome that was resected via a transcervical and full sternotomy approach. The patient was a 47-year-old male, who visited our hospital for surgical treatment of substernal goiter. The computed tomography (CT) of the neck and thorax revealed a large substernal goiter extending into the mediastinum causing tracheal compression, vessel compression, and development of collateral vessels. Total thyroidectomy was performed via a full sternotomy and transcervical approaches. Postoperatively, the patient recovered well with no nerve palsy. Histopathological examination revealed the lesion as an adenomatous goiter. Substernal goiters are usually managed by transcervical approach, but a full sternotomy is required in cases of large substernal goiter with extension up to the pericardium and the presence of superior vena cava syndrome. A multidisciplinary team approach is necessary and can help reduce the risk of complications, such as nerve injury, major vessel injury, tracheal injury, and morbidity of the surgery.

Conversion rate and risk factors of conversion to open in laparoscopic appendicectomy.

PURPOSE: Laparoscopic appendicectomy (LA) has several advantages over conventional open appendicectomy (OA). However, about 5% to 10% of LA patients still need to be converted to open surgery. Identifying risk factors that contribute to conversion to OA allows for early identification of patients who may benefit from primary OA. This study aimed to determine the conversion rate of LA to OA and to identify its associated risk factors among patients with acute or perforated appendicitis. METHODS: A retrospective review of medical records was performed among patients with acute or perforated appendicitis who underwent LA between December 2015 and January 2017. With the use of multivariable logistic regression analyses, the predictors of conversion from laparoscopic to OA were investigated. RESULTS: Out of 120 patients, 33 cases were converted to OA which gives a conversion rate of 27.5%. Among 33 patients who were converted to OA, 27 patients (81.8%) had perforated appendix, while in the LA group, perforated appendix cases consisted of 34.5% (P<0.001). Histopathology of the appendix was the predictor of conversion from LA to OA (adjusted odds ratio, 8.82; 95% confidence interval, 3.13-24.91; P<0.001). CONCLUSION: The result from our study shows that the overall conversion rate for the study period was high. Patients with perforated appendicitis had a higher risk of conversion to OA. Therefore, preoperative diagnosis of perforated appendicitis may be paramount in predicting conversion to OA.

Isolated Renal and Ureter Metastasis as the First Manifestation of Rectal Adenocarcinoma.

Colorectal carcinoma (CRC) rarely metastasizes to the urinary system in isolated form. It usually spreads through direct invasion with intra-ureteric growth or local ureter mucosal metastasis without involving the muscular layer. We present a case of a 63-year-old man who came with uraemic symptoms and a ballotable right kidney. Laboratory and imaging showed acute renal failure with right renal mass suspicious of malignancy and left ureteric stricture causing hydronephrosis. He underwent right radical nephrectomy and left open ureteric stenting plus biopsy sampling. Adenocarcinoma was detected through the evaluation of the specimen. In view that adenocarcinoma rarely occurs in the urinary system, an investigation was carried out to search for the primary source. Colonoscopy was performed, which later showed adenocarcinoma of the rectum. Adenocarcinoma in the renal system should always raise the suspicion of another primary source of malignancy, especially colorectal origin. The advanced stage of this cancer should be managed with the best palliative treatment rather than aggressive surgical intervention.

Predictors of early postoperative hypocalcemia after total parathyroidectomy in renal hyperparathyroidism.

PURPOSE: Patients with secondary hyperparathyroidism are at high risk for developing postoperative hypocalcemia. However, there are limited data regarding predictors of postoperative hypocalcemia in renal failure patient with secondary hyperparathyroidism. This study aimed to determine the clinical presentations of renal hyperparathyroidism and the predictors of early postoperative hypocalcemia after total parathyroidectomy. METHODS: Data of patients with renal hyperparathyroidism who underwent total parathyroidectomy between January 2007 to December 2014 were reviewed retrospectively. Patients were divided into 2 cohort groups according to their serum calcium levels within 24 hours of parathyroidectomy: the hypocalcemia group (calcium levels of 2 mmol/L or less), and the normocalcemia group (calcium levels more than 2 mmol/L). With the use of multivariable logistic regression analyses, the predictors of early postoperative hypocalcemia after total parathyroidectomy in patients with renal hyperparathyroidism were investigated. RESULTS: Among 68 patients, 56 patients (82.4%) were symptomatic preoperatively. Fifty patients (73.5%) presented with bone pain and 14 patients (20.6%) had muscle weakness. Early postoperative hypocalcemia occurred in 25 patients (36.8%). Preoperative alkaline phosphatase level was the predictor of early postoperative hypocalcemia (adjusted odds ratio, 1.004; 95% confidence interval, 1.001-1.006; P = 0.002). CONCLUSION: Results from our study show that most of the patients with renal hyperparathyroidism were symptomatic preoperatively and the most common clinical presentations were bone pain and muscle weakness. The significant predictor of early postoperative hypocalcemia after total parathyroidectomy was the preoperative alkaline phosphatase levels.

Snakehead Consumption Enhances Wound Healing? From Tradition to Modern Clinical Practice: A Prospective Randomized Controlled Trial.

BACKGROUND: Snakehead fish (Channa striatus) is a fresh water fish indigenous to many Asia countries and believed to have medical value. Studies showed that it contains all the essential amino acids and fatty acids able to accelerate wound healing and it has antinociceptive effect. However, little human study has been done to assess the effectiveness of Channa striatus in wound healing. A prospective RCT has been conducted on the effect of Channa striatus spray versus placebo on clean wound to assess its pain control effect and cosmetic outcome. METHODOLOGY: One hundred and two patients (102) underwent clean elective surgery; postoperatively they were randomized into two group. One group received Channa striatus extract spray (n=51) another group received placebo (n=51) on daily basis for 2 weeks. They were followed up on 2nd, 4th, and 6th weeks. Pain control effect was assessed based on Visual Analog Pain Score (VAPS) and cosmetic outcome based on Visual Analog Cosmetic Scale (VACS), Wound Evaluation Scale (WES), and Vancouver Scar Scale (VSS). RESULT: The patient treated with Channa striatus spray displayed a better outcome in terms of pain control compared to placebo. During analysis using repeated measure ANOVA, there was significant difference of patient's pain score based on VAPS between Channa striatus spray and placebo (F-stat (df) = 4.80 (2), p-value = 0.010). For cosmetic outcome it showed a better result in Channa striatus spray group for all the 3-scoring system, VACS, (F-stat (df) = 2.68 (2) , p-value <0.001), WES (F-stat (df) = 3.09 (2), p-value = 0.048), and VSS (F-stat (df) = 1.72 (2) , p-value = 0.011). CONCLUSION: Our study suggest that application of Channa striatus extract spray on clean wound has shown a significant better pain score result and cosmetic outcome on week 2, week 4, and week 6 comparatively with placebo.

Postoperative major surgery patients developing silent deep vein thrombosis: A prospective observational study.

Surgical patients are at high risk for developing deep vein thrombosis (DVT). There are many reports concerning DVT, but little is known about silent deep vein thrombosis (sDVT). This study aimed to determine the incidence of sDVT. Secondary objective is to identify the associated factors for the use of DVT prophylaxis and Caprini risk scores among major surgery patients. This prospective observational study involved postoperative surgical patients who are at risk of developing sDVT. The Caprini risk-assessment scores were calculated, and each subject had a preoperative and postoperative compression ultrasound complemented by duplex venous ultrasonography of deep venous system. No patient from the study experienced sDVT. There were significant associations between Caprini risk score group (odds ratio, 8.16; 95% confidence interval [CI], 1.01-68.74; P = .016) and the use of central venous catheter (odds ratio, 6.34; 95% CI, 1.62-24.80; P = .008) with DVT prophylaxis. Interestingly, the use of central venous catheter resulted in more than four-point increment of Caprini risk scores (mean increment, 4.19; 95% CI, 3.16-5.21; P < .001). Besides that, age was also significantly associated with Caprini risk scores (ß coefficient, 0.06; 95% CI, 0.02-0.11). Result from our study shows that the sDVT was nonexistent in this study setting. High-Caprini risk score group and the presence of central venous catheter were the significant predictor factors for the use of DVT prophylaxis. Significant predictor factors for Caprini risk scores were age and the presence of central venous catheter.