Obstructed inguinal hernia containing ovary with an ovarian cyst: a case report.

A 27-year-old married woman came to the emergency room (ER) with the chief complaint of severe pain in the abdomen for 3 days, which was more pronounced in the right iliac fossa, along with the complaint of multiple episodes of vomiting for the last 6 hours. She also gave a history of swelling in the right inguinal region for last 9 months with the complaint of mild on and off pain in the swelling. On physical examination, diagnosis of obstructed inguinal hernia was made. Ultrasonography (USG) of abdomen was of no use, as it only commented on hernial defect and not on the contents of the hernial sac. An emergency surgery was planned; marsupialisation of ovarian cyst, repositioning of fallopian tube along with ovary and herniorrhaphy was performed without any difficulty.

Role of interventional radiology in surgical diseases of breast.

Since the publication of the first imaging-guided wire localisation technique, the art of breast treatments has made great strides. Radiologists like Hall, Frank, Kopans, DeLuca, and Homer were all the pioneers in innovative breast interventional radiology field. Their approaches and gadgets for enhancing surgical outcomes in cases with breast diseases aided progress in the discipline and have withstood the ravages of time. Many of their methods are still in use. We are all standing together at the beginning of a new chapter in medicine. Cost effectiveness, comparative effectiveness studies, and an older population are all causing clinicians to reconsider what they perform. Similarly, we are now united on a global scale. The studies described in the current narrative review relate to multiple nations around the world. Breast cancer is a worldwide health problem. With the expansion of technological advances, as well as the apparent ease of worldwide travel, we must all collaborate to improve the outcome in the battle against breast cancer.

Post pancreatic surgery complications; surgeon vs interventional interventional radiologists.

Even at high-volume centres, pancreatic resections are linked with a high rate of complications, as well as significant morbidity and mortality. In the management of these occurrences, a multidisciplinary approach is required, and interventional radiology plays an important role in the treatment of patients who develop post-surgical problems. The current review was planned to provide an overview of interventional radiological techniques that can be used to treat various types of problems following pancreatic resection. Percutaneous fluid collection drainage, percutaneous transhepatic biliary operations, artery embolisation, venous interventions, and fistula embolisation are feasible therapeutic alternatives with fewer problems than a re-look surgery. They also have a shorter hospital stay and faster recovery.

Spontaneous splenic rupture during dengue fever.

Dengue fever is one of the most frequent arboviral diseases in the world. Dengue is known to cause myocarditis, hepatitis, and neurological illustrations but one of the established presentations is leakage of plasma resulting in circulatory failure. Spontaneous rupture of the spleen is one of the most infrequent but known outcome of dengue fever which has been reported from time to time in literature. We present, here, the case of a 50-year-old patient who developed this condition during dengue fever and was managed in our department successfully. This complication must be kept in mind while treating any case of dengue fever so that it can be avoided or if not then treated timely.

The study of frequency of malignancy and its types in surgical jaundice; a tertiary care experience.

OBJECTIVE: To determine the frequency of malignancy and its types in patients presenting with surgical jaundice in a tertiary care setting. METHODS: The cross-sectional study was conducted at the North Surgical Ward, Mayo Hospital, Lahore, Pakistan, from May 8 to November 8, 2020, and comprised patients of either gender with a diagnosis of surgical jaundice made on the basis of history, clinical examination, haematological and biochemical reports and radiological investigations. All patients were managed as per the guidelines for surgical jaundice with injection vitamin K intramuscular, hydration with intravenous fluids, avoidance of constipation by lactulose or neomycin, vitals and urine output monitoring and prophylactic antibiotics. Demographic data as well frequency of malignancy were noted using a predesigned proforma. Data was analysed using SPSS 21. RESULTS: Of the 95 patients, 51(53.7%) were male and 44(46.3%) were female. The overall mean age was 49.96±16.54 years (range: 18-80 years). A total of 19(20%) cases had body mass index <30. Malignancy was identified in 50(52.6%) cases; 14(28%) gallbladder, 4(8%) head of pancreas, 9(18%) peri-ampullary carcinoma, 7(14%) cholangiocarcinoma, 6(12%) Klastkin tumour, 5(10%) hepatocellular carcinoma, and 5(10%) metastatic tumour. CONCLUSIONS: More than half of the surgical jaundice cases had malignancy, gallbladder being the most affected site.

Effect Of Age, Gender And Type Of Varicosity On The Post-Operative Pain Score After Seven-Day Compression Dressing After Varicose Vein Surgery.

Great saphenous vein insufficiency is linked to 80% of all remarkable lower limb varicosities. A total of 30 patients were enrolled from OPD fulfilling the inclusion criteria after the approval of the hospital's ethical committee. Patients had compression dressing for seven days after surgery. The patients were divided into two groups-Group-A (Compression dressing for two days) and Group-B (Compression dressing for seven days). Stratification of pain score was done against age, gender, and grades of varicose veins, and after dividing into groups t- test was put into use. A p 20 value ≤0.05 was contemplated to be remarkable. Thirty patients with primary varicose vein were enrolled in this study. The mean age of patients was 35.4±9.9 years. Mean pain score in these patients was 2.9±0.8 years. Pain score after seven days of compression dressing after the surgery for varicose veins depend upon the gender, age, and grades of the varicosity of the veins. It is lesser in the females, younger age groups, and in those who had initially lesser severity of the varicose veins.

Experience of surgical management of rare cases of choledochal cyst in last five years-tertiary care reflection.

Choledochal Cyst (CC), also known as the biliary cyst, is one of the rare inherited anomalies of intrahepatic and/or extrahepatic biliary system characterised by varying degrees of cystic dilatation of the biliary tract without acute obstruction. The prevalence ranges from 1 in 13,000 people to 1 in 2 million people with preponderance in Asia1, particularly in Japan. Moreover, the presentation also varies in children and adults, and is usually vaguer and non-specific in adults. The prevalence is even lower in males, with female to male ratio being 3:1-4:12. We present here three cases of adult choledochal cysts excised in our surgical unit in the last five years. We discuss the aetiopathogenesis, presentation, diagnosis, surgical treatment, and complications of choledochal cysts based on the available literature. It is crucial to establish a multidisciplinary group of professionals, that comprises paediatric surgeons, pathologists, paediatric gastroenterologists, physiotherapists, nutritionists, oncologists, and radiologists, to get acceptable outcomes in diagnosing and treating children with choledochal cysts.

Intravenous fosphenytoin as treatment for acute exacerbation of trigeminal neuralgia: A prospective systematic study of 15 patients.

INTRODUCTION: Intravenous fosphenytoin is widely used for acute exacerbation of trigeminal neuralgia, however, few studies have investigated this treatment. We aimed to examine the efficacy and side effects of initial intravenous fosphenytoin plus oral tapering of phenytoin for exacerbation of trigeminal neuralgia. METHODS: Consecutive patients with primary trigeminal neuralgia were included in this prospective observational 90-days follow-up study. Data were collected using standardized interviews before, at 24 hours, day 7, 30 and 90 post loading dose. The primary outcome was the proportion of responders defined as a 50% reduction in pain intensity 24 hours post loading dose. RESULTS: We included 15 patients. Nine patients (60%) were responders. Pain intensity 24 hours post loading dose was reduced by 5.00 points on the numerical rating scale (p < 0.001), and at day 7 by 5.5 points (p < 0.001). The most common side effects were hypotension and dizziness. CONCLUSION: Intravenous fosphenytoin relieves trigeminal neuralgia pain in most patients and provides a window for titrating prophylactic trigeminal neuralgia medications or planning neurosurgery. The decision to administer intravenous fosphenytoin should be taken with support from trigeminal neuralgia experts and involves considerations of co-morbidities and other treatment options for acute exacerbation of trigeminal neuralgia.Clinical Trial: Preregistered (ClinicalTrials.gov Identifier: NCT03712254.

An outcome of emergency vascular surgery performed by general surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

OBJECTIVE: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality. METHODS: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20. RESULTS: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8±11.5 years (range: 14-63 years). Mean duration of hospital stay was 11±3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003). CONCLUSIONS: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Inflammatory mediators as surrogates of malignancy.

Inflammation related to cancer occurs in the cellular vicinity of the tumour and is involved with predictions related to the course of disease and survival prognosis in varioua malignancies. These inflammatory markers affect different phases of tumourigenesis, i.e. carcinogenesis, tumour expansion, lymphovascular invasion, and distant metastasis, and, as a result, tumour cells can activate immune mediators and cells directly and/or chemokines as well as prostaglandins. Numbers of circulating different blood cells, i.e. lymphocytes, platelets, neutrophils and levels of plasma proteins, like C-reactive protein and interleukins that are components of inflammatory responses, are hallmarks of pathways leading to tumourigenesis. Thus, they can provide vital information in stratifying patients according to the risk and precisely targeted clinical care and outcome in malignancies. The current narrartive review was planned to discuss the role of platelet-to-lymphocyte ratio alongside the use of systemic immune inflammation index as the inflammatory mediators of malignancies along with overview of their role in different studies. It was also planned to recommend what the future studies should should aim at, including multiple risk factors, exposures and inflammatory profiles and as well as their combined interactions, for a better understanding of the role of the inflammatory mediators in malignancy.

Comparison of outcome of compression dressing for two days Vs seven days after varicose surgery.

Incompetence of the great saphenous vein (GSV) is a global issue and the most prevalent cause of chronic venous disease of the leg. Clinical manifestations range from moderate to severe, including tiredness, heaviness, and irritation, as well as hyperpigmentation and leg ulcers. A study was conducted to address this controversy,1 i.e. to determine the outcome of compression dressing after varicose vein surgery in terms of postoperative pain, on the Surgical floor, of Mayo Hospital, Lahore, from October 1, 2020, to April 1, 2021. A total of 60 patients with Primary varicose veins were enrolled in this study, fulfilling the inclusion criteria after obtaining approval from the ethical committee of the hospital. The patients were divided in two groups. Group A wore compression dressing for two days after surgery and Group B wore compression dressing for seven days after surgery. All the patients received 1gm Paracetamol I/V eight hourly followed by tablet Paracetamol 500mg P/O eight hourly. Then the outcome of compression dressing was analysed in the form of mean postoperative pain. The mean pain score was assessed on one week. Data were entered in SSPS v23.0. Stratification of pain score was done against age, gender, and grades of varicose veins. A comparison of the two groups was done by applying a t-test. A p-value of ≤ 0.05 was considered significant. Prescribing compression stockings for longer than two days after Trendelenburg's procedure leads to reduced pain and improved physical function during the first week after treatment.

Past, present, and future of surgical simulation and perspective of a developing country: A narrative review.

Healthcare systems around the globe have been revolutionised in the last few decades, resulting in a greater need and demand for surgical education outside the operation theatres. Surgical education through simulations started around 2,500 years ago when they were first used in the planning of unique and innovative surgeries while ensuring the safety of the subjects. Currently, simulations include animal models, cadaveric models, benchtop models and complex robotic models. In a programme involving surgical simulators, four requirements are followed to optimise their effectiveness, including mandatory involvement, skill-based instruction, standardised training plan, and overtraining. We can make a reasonable estimation that the future is technology-based. The speed with which we anticipate the fusion of these virtual reality and robotics-based simulation technology with medical educations and practices largely depends on the affordability and economics of these tools. The current narrative review was planned to highlight the historical aspects of simulations, their role in surgical education, and their importance in the future as an essential adjunct to surgical education.

Thyroid-like follicular carcinoma of kidney: Case presentation and literature review.

Thyroid follicular carcinoma like renal tumour (TFCLRT) is a rare variant of primary renal epithelial tumour and was first reported in 2006. Up till now, 40 cases have been identified worldwide and alarmingly, 17 cases have been identified from China only. The condition has been included in the WHO Renal Tumours Classification 2016. We present here the first case of thyroid follicular carcinoma like renal tumour from Pakistan that was managed in our surgical unit and a literature review. Left-sided radical nephrectomy was performed through a midline incision. The left kidney was removed along with intact Gerota fascia, left adrenal gland and lymph nodes alongwith aorta.

A ruptured seventeen weeks' ectopic pregnancy: A case report.

Ectopic pregnancy is a common condition with a prevalence of 2% in all pregnancies. Implantation of the developing blastocyst outside the uterine cavity leads to ectopic pregnancy. About 95% of ectopic pregnancies occur in the different segments of the fallopian tubes. Usually, an ectopic pregnancy grows up to 1.5-3.5 cm and any size greater than this leads to rupture. We present a case of ruptured ectopic pregnancy in which the foetus had a crown-rump length(CRL) of 12 cm was retrieved. To our knowledge, this is the largest foetus recovered from a ruptured ectopic pregnancy at the ampulla of fallopian tube reported in the literature. Timely diagnosis and proper management is the key to reduce morbidity associated with it.

Comparison of the outcome of mesh hernioplasty under local anaesthesia in patients with age less than 60 years VS more than 60 years in terms of wound complications and urinary retention.

OBJECTIVE: To compare the outcome of mesh hernioplasty performed under local anaesthesia in relatively young and older patients regarding wound complications and urinary retention. METHODS: This comparative study was conducted at Mayo Hospital, Lahore, Pakistan, from 17th Feb 2017 to 17th feb 2018, and comprised patients who underwent mesh hernioplasty. Demographic profile was noted and the patients were divided into <60 and >60 age groups. Surgical method used was Lichtenstein mesh repair under local anaesthesia. Outcome was documented in terms of urinary retention at 8 hours post-operation, wound seroma and haematoma at 24 hours and wound infection after 5 days of surgery. Data was analysed using SPSS 20. RESULTS: Of the 102 patients, there were 51(50%) in each of the two age groups. Among patients <60 years, urinary retention developed in 4(7.8%) compared to 6(11.8%) in the other group. Frequency of the wound complications, including wound haematoma, seroma and wound infection, were seen in 3(5.9%), 2(3.92%) and none respectively in the younger group compared to 2(3.92%), 2(3.92%) and none respectively in patients aged >60 years. CONCLUSIONS: The results in patients aged <60 years and >60 years were comparable in terms of urinary retention and wound complications.

Surgical smoke; an occupational hazard.

Surgical smoke is part of the environment during operative and invasive procedures. Electric diathermy is a very important tool for a surgeon and is used in every surgical treatment nowadays. It assists the surgeon to dissect the tissue or enables securing haemostasis in lesser time and with larger delicacy. But at the same time, it has harmful effects on surgeon as well as patients. Although there is a substantial amount of evidence and guidelines from various authors and societies, yet there are no clear policies and preventive measures towards surgical smoke handling. This article presents potential harmful effects of surgical smoke and aims to build guidelines for the surgical personnel based on current evidence in literature.

Exploring Postoperative Cognitive Dysfunction and Delirium in Noncardiac Surgery Using MRI: A Systematic Review.

Surgical patients are at high risk of developing postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). POCD and POD are associated with increased morbidity and mortality and worsening functional outcomes leading to severe socioeconomic consequences for the patient and the society in general. Magnetic resonance imaging (MRI) offers a unique opportunity to study the anatomy and function of the brain. MRI thus plays an important role in elucidating the neuronal component of POCD and POD. Our aim has been to systematically gather MRI findings that are related to POCD and POD. Systematic searches were conducted in PubMed, EMBASE, and PsycINFO: MRI studies investigating patients with POCD as identified by perioperative cognitive testing or patients with delirium identified postoperatively by the Confusion Assessment Method. A total of ten eligible papers were included with a total of 269 surgical patients, 36 patient controls, and 55 healthy controls who all underwent MRI examination. These studies suggested that reduction of thalamic and hippocampal volumes and reduction of cerebral blood flow may be associated with POCD, while presurgery/preexisting and postoperative white matter pathology may be associated with POD. However, the evidence from these studies is rather weak. Future MRI studies are warranted to verify the current findings.

Is heat pain detection threshold associated with the area of secondary hyperalgesia following brief thermal sensitization? A study of healthy volunteers - design and detailed plan of analysis.

BACKGROUND: Several factors are believed to influence the development and experience of pain. Human clinical pain models are central tools, in the investigation of basic physiologic pain responses, and can be applied in patients as well as in healthy volunteers. Each clinical pain model investigates different aspects of the human pain response. Brief thermal sensitization induces a mild burn injury, resulting in development of primary hyperalgesia at the site of stimulation, and secondary hyperalgesia surrounding the site of stimulation. Central sensitization is believed to play an important role in the development of secondary hyperalgesia; however, a possible association of secondary hyperalgesia following brief thermal sensitization and other heat pain models remains unknown. Our aim with this study is to investigate how close the heat pain detection threshold is associated with the size of the area of secondary hyperalgesia induced by the clinical heat pain model: Brief thermal sensitization. METHODS AND DESIGN: We aim to include 120 healthy participants. The participants will be tested on two separate study days with the following procedures: i) Brief thermal sensitization, ii) heat pain detection threshold and iii) pain during thermal stimulation. Additionally, the participants will be tested with the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale questionnaires. We conducted statistical simulations based on data from our previous study, to estimate an empirical power of 99.9 % with α of 0.05. We define that an R(2) < 0.25 and predictive intervals larger than +/-150 cm(2) are indications of a weak association. DISCUSSION: The area of secondary hyperalgesia may serve as a quantitative measure of the central sensitization induced by cutaneous heat stimulation, and thus may be a biomarker of an individual's pain sensitivity. The number of studies investigating secondary hyperalgesia is growing; however basic knowledge of the physiologic aspects of secondary hyperalgesia in humans is still incomplete. We therefore find it interesting to investigate if HPDT, a known quantitative sensory test, is associated with areas of secondary hyperalgesia following brief thermal sensitization TRIAL REGISTRATION: Clinicaltrials.gov (Identifier: NCT02527395 ). Danish Research Ethics Committee (Identifier: H-8-2014-012). Danish Data Protection Agency (Identifier: 30-1436).

Interhemispheric differences of fMRI responses to visual stimuli in patients with side-fixed migraine aura.

Migraine sufferers with aura often report photosensitivity and visual discomfort outside of attacks and many consider bright or flickering light an attack-precipitating factor. The nature of this visual hypersensitivity and its relation to the underlying pathophysiology of the migraine aura is unknown. Using fMRI measurements during visual stimulation we examined the visual cortical responsiveness of patients with migraine with aura. We applied a within-patient design by assessing functional interhemispheric differences in patients consistently experiencing visual aura in the same visual hemifield. We recruited 20 patients with frequent side-fixed visual aura attacks (≥90% of auras occurring in the same visual hemifield) and 20 age and sex matched healthy controls and compared the fMRI blood oxygenation level dependent (BOLD) responses to visual stimulation between symptomatic and asymptomatic hemispheres during the interictal phase and between migraine patients and controls. BOLD responses were selectively increased in the symptomatic hemispheres. This was found in the inferior parietal lobule (P = 0.002), the inferior frontal gyrus (P = 0.003), and the superior parietal lobule (P = 0.017). The affected cortical areas comprise a visually driven functional network involved in oculomotor control, guidance of movement, motion perception, visual attention, and visual spatial memory. The patients also had significantly increased response in the same cortical areas when compared to controls (P < 0.05). We discovered a lateralized alteration of a visually driven functional network in patients with side-fixed aura. These findings suggest a hyperexcitability of the visual system in the interictal phase of migraine with visual aura.

The effect of sumatriptan on cephalic arteries: A 3T MR-angiography study in healthy volunteers.

AIM: To explore a possible differential effect of sumatriptan on extracerebral versus cerebral arteries, we examined the superficial temporal (STA), middle meningeal (MMA), extracranial internal carotid (ICAextra), intracranial internal carotid (ICAintra), middle cerebral (MCA) and basilar arteries (BA). METHODS: The arterial circumferences were recorded blindly using high-resolution magnetic resonance angiography before and after subcutaneous sumatriptan injection (6 mg) in 18 healthy volunteers. RESULTS: We found significant constrictions of MMA (16.5%), STA (16.4%) and ICAextra (15.2%) ( P ≤ 0.001). Smaller, but statistically significant, constrictions were seen in MCA (5.5%) and BA (2.1%) ( P ≤ 0.012). ICAintra change 1.8% was not significant ( P = 0.179). The constriction of cerebral arteries was significantly smaller than the constriction of extracerebral arteries ( P < 0.000001). CONCLUSION: Sumatriptan constricts extracerebral arteries more than cerebral arteries. We suggest that sumatriptan may exert its anti-migraine action outside of the blood-brain barrier.