Patient and Physician Perceptions of Changes in Surgical Care in Mongolia 9 Years After Roll-out of a National Training Program for Laparoscopy.

INTRODUCTION: In 2005, the general population of Mongolia was not aware of laparoscopic surgery and was skeptical about the safety of surgical care. A 9-year initiative to expand laparoscopic surgery was initiated by Mongolian surgeons. This study examines the current barriers to and perceptions of surgical care following laparoscopic surgical expansion countrywide. MATERIALS AND METHODS: In September 2013, interviews were conducted with 71 patients, and 39 physicians in Mongolia. Patients and physicians were interviewed using separate sets of interview questions. Questions were designed to gauge perceptions of surgical care in Mongolia evaluating for access, affordability, sustainability, barriers to care, quality, and knowledge of laparoscopy. Responses were fine coded for statistical analysis. RESULTS: 79 % of patients felt surgical care was improving in Mongolia, and 76 % would choose laparoscopy if available. Physicians (100 %) felt laparoscopic surgery had improved surgical care in Mongolia. Barriers to care for patients were time to work up and diagnosis (37 %), and funding an operation (39 %). None of the 36 % of patients who stated funding an operation would be difficult identified government sources of funding (p < 0.001). Physicians identified insufficient equipment supply (69 %), insufficient training (41 %), and cost (38 %) as barriers for laparoscopy. 74 % of physicians felt that Mongolian physicians return or stay in Mongolia after training, defying the trend of migration in low-resource settings. DISCUSSION: Improved local patient and physician perception of laparoscopy is propelling the expansion of laparoscopy in Mongolia.

Efficacy of radiofrequency ablation for cystic thyroid nodules / Монголын Анагаах Ухаан

Background@#Thyroid nodules (TNs) are a common clinical issue, and their prevalence has been increasing over the last 2 decades [1] due to the widespread use of ultrasound (US) imaging. More than 50% of TNs are detected with US examination In the general population, while only 3–7% are detected with palpation [2]. Nodular goiter is the most common cause of thyroid disease in Mongolia, as in other countries. Recent guidelines suggest that a nodule without clinical symptoms should be treated with watchful waiting; however, some patients require treatment because of cosmetic problems or symptoms. There are several treatment options, but neither is perfect. The main treatment of the disease is still the traditional surgical resection. it still carries a 2–10% prevalence of complications, such as neck scarring, hypothyroidism, transient or definitive postoperative hypoparathyroidism, recurrent laryngeal nerve injury, and the recognized risks associated with general anesthesia [3,4]. Minimally invasive alternatives have been explored. Laser ablation, microwave ablation, HIFU, and radiofrequency ablation (RFA) are safe and effective techniques for the treatment of nodular goiter. it is possible to treat small nodules early and enlarge them before surgical intervention is indicated. We have introduced a new method of RFA treatment (2019) in our country. @*Purpose@#To assess the effectiveness of radiofrequency ablation (RFA) for cystic thyroid nodules. @*Material and Method@#This retrospective study was approved by the Research Ethics Committee of the Mongolian National University of Medical Sciences and informed consent was obtained from all patients before RFA. The study was conducted from 9th Jan 2019 to 15th Oct 2021, 485 nodules from 183 patients (M:F=9:174; mean age±SD=46.3±11.4 years) who met the eligibility criteria and provided written informed consent were enrolled at the First Central Hospital of Mongolia. Nodules were assessed pre-treatment and at 1, 3, 6, 12, and 24 months post-treatment. Nodule volume were recorded at each time point. </br>The primary endpoint was the volume reduction ratio (percentage) at 1, 3, 6, 12, and 24 months follow-up. @*Results@#For the primary outcome of nodule volume reduction, the absolute volume reduction at the 24-month follow-up was 45 (77.6%). Completely destroyed 10 (17.2%), volume increased by 3 (5.2%) (table. 3). The median volume reductions at the 1, 3, 6, 12, and 24-months follow-ups were 34.9%, 61.0%, 74.9%, 83.3% and 74.0% respectively. Median volume statistically decreased by a significant p=0.0001. At 3 months follow up after RFA, the nodules decreased most. All study subjects recovered without sequelae. Therefore, no patient experienced a life-threatening or delayed complication during the follow-up.@*Conclusion@#Our study demonstrates that RFA is a safe and effective treatment for cystic thyroid nodules. Advantages of RFA include no surgical scars or general anesthesia, low complication rates, and avoiding lifelong thyroid hormone replacement.

Ilioinguinal and iliohypogastric nerve block / Монголын Анагаах Ухаан

Ilioinguinal (II) and iliohypogastric (IH) nerve blocks are often performed to provide intra- andpostoperative analgesia for hernia repair in children and adults. Several techniques are describedin the literature. Recently an ultrasound guided technique for II and IH nerve blocks were describedin the international journals. The block success rates are variable specially for using anatomicallandmark blind techniques. In the present study, the anatomical variations in course of the II andIH nerves are described. Knowledge of the course of these nerves in the inguinal region, and anunderstanding of variations seen in their topography, can decrease the incidence of postoperativecomplications and adverse effects. Ultrasound guidance of block performance will shorten the time,reduce the number of needle passes and shorten the block onset time. Blocks may be performedusing lower local anesthetic doses.

TRANSFORAMINAL PERCUTANEOUS ENDOSCOPIC DISCECTOMY FOR LUMBAR DISC HERNIATION AND NERVE ROOT DECOMPRESSION FIRST TIME IN MONGOLIA / Мэс засал

Introduction: Various modalities oftechniques from standard discectomy,microdiscectomy, percutaneous discectomy,and transforaminal endoscopic discectomyhave been in use for lumbar intervertebraldisc prolapse1. The access to spine is keptto a minimum without stripping paraspinalmuscles minimizing muscle damage bytransforaminal endoscopic approach2.Currently in the population of the Mongoliabeen increased of the spinal nerve rootcompression, which are resulting in lumbardisc pathological changes. In other developedcountries has been successfully introducingthe spine endoscopic surgery use for thatpathological changes. In regard to our countryhad not yet implemented for until now asthese high technological surgeries3. Spinesurgery department team of the GrandMedhospital had successfully introduced that thespine endoscopic surgery.Materials and Methods: We performedtransforaminal endoscopic lumbardiscectomy surgeries on patients age of 24,38, 78 on July/23/2016 All patients withsingle nerve root compression due to Lumbardisc herniations, including sequestrated ormigrated and selected central disc at L4-5. All patients had preoperative MRI andpostoperative MRI to check the adequacy ofdecompression. All patients were operatedby 18-mm ports of the S-Gun endoscopicequipments. Procedure had done under localanesthesia. Postoperatively, all patients weremobilized as soon as the pain subsided anddischarged within 24-48 h post-surgery.Patients were followed up at 2, 6 weeks.Results: The mean follow up was 2-6weeks. The average surgical time was 70min (range 25-210 min). Average blood losswas 20-30 ml. Postoperative MRI showedcomplete decompression. All of patients hadgood-to-excellent results and straight raisingleg test (Lasegue) were 90/90 respectively.All patient is preoperatively visual analogyscale was 8±1 and then became to 1±1.Conclusion: Microendoscopic discectomyis minimally invasive procedure fordiscectomy with results of this procedure areacceptable safe and effective. However, forthis technique has required to do accuracyand experienced surgeon.

Prepuce development in Mongolian boys / Монголын Анагаах Ухаан

BackgroundThe prepuce (foreskin) is a simple fold of skin formed from an outer keratinized layer and inner mucosallayer, lining a preputial sac and provides functions such as protective, erogenous, and immunologic. Theprepuce is normally non-retractile during neonatal development, as the inner epithelial lining of prepuceand glans adhere each other. Non retractile prepuces are common among young boys and normalpart of preputial development. However, unnecessary circumcision is widely practiced among youngadolescents due to poor understanding of foreskin and lack of medical indication.GoalTo assess preputial retractibility in Mongolian boys at various ages to determine natural process ofpreputial separation.Material and MethodsWe evaluated 1697 Mongolian boys aged 2 to 12. Preputial condition was classifi ed into 5 types basedon preputial retractability: type I-phimosis, type II–partial phimosis, type III–adhesion of prepuce, IV–normal, V–circumcised. We also prospectively evaluated 30 histological materials of patients (2-12 yearsold), who were treated by complete circumcision. The materials were fi xed 10% solution of formalin,embedded in paraffi n, stained with hematoxylin-eosin and examined by 3 pathologists.ResultsThe incidences of type I was 67.9% in 2 years old, 12% in 6years, and 4.1% in 10 years and1.1% in12 years old, respectively. On the contrary, the incidences of type IV were 15.4% in 2 years old, 29.8%in 6 years, 74.7% in 10 years and 91.6% in 12 years. Thecircumcisionswere0% in 2 years old, 5.7%in 6 years old, 2.9% in 10 years old and 5% in 12 years old. Most patients (76.7%) did not have anyhistological alterations of the skin and infl ammatory alteration, not lichen sclerosis, were observed in23.3% in histological examination followed by circumcision.Conclusion: Preputual separation increases with ages in boys and surgical treatment of the phimosisshould be performed with cautions.

Assessment of biliary complication after liver transplantation in Mongolia / Мэс засал

Introduction: A considerable proportionof adult living donor liver transplantation(LDLT) recipients experience biliarycomplication (BC), but there are few reportsregarding BC based on long-term studies ofa large LDLT population.Methods: The present study examinedBC incidence, from 16 adult and pediatricpatients (14 right liver and 2 left liver graft )between 2011 and 2016 First Central Hospitalof Mongolia.Results: The mean follow-up period was36±1 months. First Central Hospital has DDanastmosis (n=22) double DD (n=2) singlehepaticojejunostomy (n=3). There 3 caseshave biliary stricture after operation. One ofthe 3 cases has biliary laek 2 months laterafter the operation.Conclusion: Close surveillance for BCappears necessary for at least the first 3 yrafter LDLT. In terms of anastomotic stenosisrisk, HJ appears a better choice than DD forright liver grafts involving ducts less than 4mm in diameter.

RESULT OF KASAI OPERATION, CHILDREN LIVER TRANSPLANTATION IN MONGOLIA / Мэс засал

Introduction: Biliary Atresia is a fibroobliterativedisorder of the intra andextrahepatic bile ducts in infancy, which isgoing progressively cholestatic liver disease.The failed Kasaiportoenterostomy requiresliver transplantation. The goal of this studyis to show the outcome of Kasai operation,recent improvement and correlation the datato overseas.Methods and Materials: This study wasconducted in the department of generalsurgery of National Center for Maternal andChild Health of Mongolia between 2010 and2016 on a total of 66 infancies with biliaryatresia.Results: Patient diagnosed with biliaryatresia, which performed Kasai operationwithin first 2 months the outcome is verygood early and late post-operation period.There were 3 patients with 10 year survival, 4patients with 5-10 year and 28 patients with5 year survival after Kasai operation. The mostcomport age for liver transplantation is 1 yearlater after Kasai operation in Mongolia. Livertransplantation programme is necessary forMongolian pediatric surgery, and we thoughtour team was assembled.Conclusion: The children with biliary atresiaperform the Kasai operation within 2 monthsthe outcome is very good. Children with biliaryatresia often experience long wait times fortransplant unless exception points are grantedto reflect severity of disease.In Mongolia livertransplantation done in 2 child.

Some results of using abdominal wall block in children undergoing appendectomy surgery / Шинэ санаа Шинэ нээлт

The aim of this study was to evaluate of analgesic effect of ultrasound guided transversus abdomines plane block in children undergoing open appendectomy surgery and compare to children were used GA alone.Twenty children aged 5-15 years with ASA I-II classification were randomly enrolled in this study.Each group had 10 children and all children were received GA with same techniques. Study group(transversus abdomines plane block group) were assigned to receive ultrasound guided block using 0.3 ml/kg of Bupivacaine 0.25%. Intraoperative hemodynamic changes, postoperative maximum pain score, the time the first analgesic requirement, correllation between inflammatory process, surgical disease complication and pain intensity were studied. Statistic analysis was made in Excel usingdescriptive analysis, correlation and regressive analysis. A p-value<0.05 was considered significant.There was no differencies between the two studied groups regarding demographic and clinicalcharacteristics. Intraoperative systolic blood pressure changes was higher in control group than studygroup (17%), and HR and BP were more stable in the study group. Level of WBC had direct positive relationship with appendix inflammation (r=0.71 (p-утга <0.001) and weak positive correlation (r=0.44 p-утга <0.05) with pain intensity. Postoperative pain score was higher in control group and the first analgesic requirement time was 2h. In the study group had mild to moderate pain and the the firstanalgesic requirement time was 4h.Transversus abdomines plane block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing open appendectomy surgery.

Mongolian and Japanese Joint Conference on "Echinococcosis: diagnosis, treatment and prevention in Mongolia" June 4, 2009.

The first Mongolian-Japanese Joint Conference on "Echinococcosis: diagnosis, treatment and prevention in Mongolia" was held in Ulaanbaatar on June 4th, 2009. It was the first chance for Mongolian experts (clinicians, pathologists, parasitologists, biologists, epidemiologists, veterinarians and others working on echinococcosis) joined together. Increase in the number of cystic echinococcosis (CE) cases year by year was stressed. CE in children may be more than adult cases. Alveolar echinococcosis was suspected chronic malignant hepatic tumors or abscesses. Main discussion was as to how to introduce modern diagnostic tools for pre-surgical diagnosis, how to establish the national system for the data base of echinococcosis with the establishment of a network system by experts from different areas. The importance of molecular identification of the parasites in domestic and wild animals was also stressed.

Study on the association between general surgeon volume, professional skill and surgery outcome / Монголын Анагаах Ухаан

Background: Several researchers had been previously done the health professional workload study,however, because of the lack of studies of the relationship between physicians’ volume and outcome, wedid not have enough evidence of the resource allocation, the surgery outcome and quality improvementin our country.Goal: The study was aimed to study general surgeon volume and surgery outcome.Materials and Methods: We randomly selected 1147 patients diagnosed with gallbladder disease whounderwent laparoscopic cholecystectomy (LC) and acute appendicitis from 2012-2013 at the First andThird Clinical hospital and Khovd province Regional Diagnostic and Treatment Center were included.Patient demographics and clinical information, such as drug cost, duration of surgery, and name ofsurgeons were derived from patient medical records. Surgeons’ information, such as age, gender,professional and academic degree, and work experience were derived from hospital human resourcedepartment and correlation analysis was performed to examine the association between surgeryduration, surgeon experience and drug cost.Results: Hospitals LC was done 51,3±32,8 minutes with 24900,70 tugriks, appendectomy was done52,7±31,4 minutes with 18361,00 tugriks of drug cost. The Third Clinical hospital surgeons operatedhigher costs (28631,34±16985,86tugriks) and shorter time (39,86±39,54 ìèí) of an appendectomy. Butthe First Clinical hospital surgeons incurred lower cost (8460,82±13231,40 tugriks) of appendectomy.However, there were no significant differences in operation time and drug average cost in appendectomyin terms of positive and weak correlation(r0.05). Conclusion: General surgeon volume was notassociated with surgery outcome.