Difficult laparoscopic cholecystectomies. Is conversion a sensible option?

OBJECTIVE: To assess the overall impact of conversion of laparoscopic cholecystectomy to open cholecystectomy. METHODS: The observational descriptive study was conducted at Liaquat University Hospital, Jamshoro, Pakistan, and various private hospitals in the same town by the same surgeon from June 2011 to June 2013. All patients over 20 years of age and of either gender with symptomatic gallstone disease admitted and operated by laparoscopic technique were included. After initial work-up, laparoscopic cholecystectomy was performed by the conventional four-port technique. The variables studied included demographic details, duration of operation, operative complications, and incidence of conversion to open operation, post-operative complications and length of hospital stay. Data was analysed using SPSS 20. RESULTS: Of the 936 patients, 839(89.63%) were females and 97(10.36%) were males with an overall mean age of 39.88±8.66 (range: 29-65 years). Of the total, 108(11.53%) patients presented with a solitary gallstone; the remaining 828(88.46%) had multiple gall stones. Besides, 297(15.34%) had complicated gall stone disease. Tenderness in the right hypochondrium was observed in 897(95.83%) patients, while tenderness with palpable, tender gallbladder with fever and leucocytosis in 39(4.1%). Overall, 120(12.82%) patients presented with co-morbidities comprising diabetes mellitus in 43(4.59%), hypertension in 11(1.17%), ischaemic heart disease in 36(3.84%) and chronic obstructive pulmonary disease in 30(3.20%) patients. Further, 33(3.52%) patients were shifted from laparoscopic dissection to open cholecystectomy. CONCLUSIONS: A low threshold for conversion to open cholecystectomy can save the life of patients as continued dissection in difficult situation can lead to life-threatening complications.

Investigating symmetrical influence of economic expansion, oil price, and industrial production on trade deficit: a policy pathway toward three neighboring Asian states.

The intense objective of the present study is to investigate the symmetrical effectiveness of economic expansion, inflation rate, oil price, interest rate, and industrial production on trade deficit of the three neighboring states (China, Pakistan, and India). Westerlund bootstrap LM (Lagrange multiplier) panel co-integration test, Dumitrescu Herlin method, PMG-ARDL model, quantile regression, and quarterly data of last 15 years (2006Q1 to 2020Q4) have been utilized to envisage outcomes. Initial measurements validate the existence of stable co-integration and uni-directional causality among variables. Nevertheless, PMG-ARDL measures evaluates that in both long and short span of time, except industrial production all other regressors (economic expansion, inflation rate, oil price, and interest rate) positively influences the trade deficit in three neighboring states. Furthermore, robust estimates of quantile regression also authenticate the correctness of the above discuss relationship in study economies by evaluating positive (negative) impact of economic expansion, inflation rate, oil price, and interest rate (industrial production) on trade deficit. Thus, in policy pint of view, to lessen trade deficit hazard in studied economies, it is necessarily needed to encourage industrial production, replaced fossil fuel using outdated gadgets with advance green technology instruments, control inflation, and interest rate in single digit through strong budgetary and monetary policies and maintain economic expansion with appropriate and comprehensive taxation system.

Anatomical variations and congenital anomalies of extra hepatic biliary system encountered during laparoscopic cholecystectomy.

OBJECTIVE: To assess the frequency of anatomical variations of extrahepatic biliary system in patients undergoing laparoscopic cholecystectomy. METHODS: This is an observational study performed in the Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro for a period of four years from January 2004 to December 2007. All diagnosed patients of cholelithiasis undergoing routine laparoscopic cholecystectomy were assessed for anatomical/congenital extra hepatic biliary and vascular anomalies. Structures mainly assessed for anomalies were gall bladder, cystic duct, supraduodenal part of Common Bile Duct (CBD), cystic artery and hepatic artery which are routinely handled during laparoscopy. However, assessment of variations and anomalies, of hepatic ducts, portal vein, retroduodenal and pancreatic parts of CBD were not done due to possibility of iatrogenic injuries. RESULTS: Three hundred cases of cholelithiasis comprising 255 (85%) females and 45 (15%) males with mean age of 39.85 +/- 18.82 years were included in the study. Patients mainly presented with upper abdominal pain including pain in right hypochondrium (71.67%), pain in right hypochondrium and epigastrium (19%) and pain in epigastrium alone (9.33%) as main symptoms. Operative findings revealed variations in 61 (20.33%) patients mainly involving cystic artery (10.67%), cystic duct (4.33%), right hepatic artery (2.67%) and gallbladder (2%). Postoperatively 3.67% revealed bleeding and 1.67% biliary leak from drain as main complications related to anatomical variations giving rise to 1% morbidity, however, no mortality was seen in this series. CONCLUSION: Congenital anomalies and normal variants of biliary tree, are not common but may be of significance during laparoscopic surgery as failure to recognize them leads to iatrogenic injuries and can increase morbidity and mortality.

Comparison of the learning of two notations: A pilot study.

INTRODUCTION: MICAP is a new notation in which the teeth are indicated by letters (I-incisor, C-canine, P-premolar, M-molar) and numbers [1,2,3] which are written superscript and subscript on the relevant letters. FDI tooth notation is a two digit system where one digit shows quadrant and the second one shows the tooth of the quadrant. This study aimed to compare the short term retention of knowledge of two notation systems (FDI two digit system and MICAP notation) by lecture method. METHODS: Undergraduate students [N=80] of three schools participated in a cross-over study. Two theory-driven classroom based lectures on MICAP notation and FDI notation were delivered separately. Data were collected using eight randomly selected permanent teeth to be written in MICAP format and FDI format at pretest (before the lecture), post-test I (immediately after lecture) and post-test II (one week after the lecture). Analysis was done by SPSS version 20.0 using repeated measures ANCOVA and independent t-test. RESULTS: The results of pre-test and post-test I were similar for FDI education. Similar results were found between post-test I and post-test II for MICAP and FDI notations. CONCLUSION: The study findings indicated that the two notations (FDI and MICAP) were equally mind cognitive. However, the sample size used in this study may not reflect the global scenario. Therefore, we suggest more studies to be performed for prospective adaptation of MICAP in dental curriculum.

Diagnostic laparoscopic findings in chronic pelvic pain.

OBJECTIVE: To assess the cause of pain on diagnostic laparoscopy in women with chronic pelvic pain and equivocal clinical and ultrasound examination. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Red Crescent General Hospital, Hyderabad, Sindh, from January 2007 to December 2009. METHODOLOGY: All the women presenting with chronic pelvic pain for more than 6 months duration, without any obvious pathological findings on clinical as well as on ultrasound examination were recruited. Women with chronic pelvic pain and having pelvic pathological lesions detected on clinical and/or ultrasound examination were excluded. Clinical, ultrasound, and laparoscopic data was collected and analyzed on SPSS version 14. The results were described as frequency, proportion, compared by chi-square test with significance at p < 0.05. RESULTS: Highest frequency of chronic pelvic pain was observed in women aged between 26 - 35 years (62.4%), 53 out of 85 women. Most of these women were married (90.6%) and nulliparous (47.1%). Pain was reported as dull and sharp by 35 women (41.2%), infertility (n = 46, 54.1%) and dyspareunia (n = 45, 52.9%) were the commonest co-existent complaints. On laparoscopic examination, pathological lesions were detected in 65, tuberculosis in 17 (20%) endometriosis in 11 women (12.9%), pelvic inflammatory diseases and pelvic adhesion in 8 (9.4%) women each and ovarian cyst in 6 women (7.1%). CONCLUSION: Positive laparoscopic yield was high in women with pelvic pain. Pelvic tuberculosis was the most common pathology detected followed by endometriosis, pelvic inflammatory disease and adhesions.