Early post-operative outcome of pre-pectoral implant-based immediate total breast reconstruction with Polyglactin 910 (Vicryl™) mesh - low cost solution for a low-middle income country.

BACKGROUND: The incidence of breast cancer in Pakistan has been rising with approximately one third of these patients requiring mastectomy. Among breast reconstruction treatment options, the use of Acellular Dermal Matrix (ADM) for pre-pectoral breast implant surgery has proven effective with improved cosmetic outcome. However, due to high cost it cannot be regularly implemented in a developing country like Pakistan. An alternative to ADM, Polyglactin 910 (Vicryl™, Ethicon) mesh has been introduced in pre-pectoral breast reconstructive surgery which has shown to be almost 10 times lower in cost. We set out to determine the frequency of early postoperative complications when using Polyglactin 910 mesh for pre-pectoral implant-based breast reconstruction surgery. METHODS: A single centre, retrospective, chart review was conducted, and a total 28 women were included in the study. Thirty-two pre-pectoral implant-based mastectomies with Polyglactin 910 mesh were performed. Early post-operative outcomes (within 12 months of procedure) including duration of antibiotic use, post-operative infection, implant displacement, flap necrosis, seroma formation, wound dehiscence, hematoma formation, capsular contracture and reconstruction failure, were recorded. RESULTS: Only 4 (12.5%) women experienced early post-operative morbidity. One patient developed a wound dehiscence, which eventually led to reconstruction failure and removal of the implant. Another patient had seroma formation and flap necrosis. None of the patients developed postoperative implant displacement, hematoma formation or capsular contracture in the early post-operative period. CONCLUSION: This study reveals that early post-operative outcomes with Polyglactin 910 mesh in breast reconstructive surgery are few, thus making it a cost effective, reliable, and safe treatment option, especially in developing countries like Pakistan.

Ligation of intersphincteric fistula tract: A retrospective, single centre, individual surgeons' experience for the management of complex fistula in ano.

Objectives: To identify early treatment outcomes among patients having undergone ligation of intersphincteric fistula tract for complex fistula-in-ano in a tertiary care setting. METHODS: The single-centre retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from January 2016 to January 2021 of adult complex fistula-in-ano patients who underwent ligation of intersphincteric fistula tract procedure. All surgeries were done by a single surgeon. Pre- and post-operative Wexner continence scores were measured, and various factors, including change in continence, complete wound healing, postoperative infection and recurrence, were assessed. Data was analysed using SPSS 23. RESULTS: Of the 20 patients, 15(75%) were females and 5(25.0%) were males. The overall mean age was 38.4±13.8 years. The median duration of surgery was 65 minutes (interquartile range: 57-99 minutes). There were 2(10%) patients who showed a change in continence after surgery to flatus alone. Complete healing was noted in 11(55%) patients. Recurrence was noted in 8(40%) patients; trans-sphincteric fistula-in-ano in 2(10%) patients, and inter-sphincteric fistula in 6(30%). Body mass index had a significant association with the change in continence (p=0.028). CONCLUSIONS: There was a comparable risk of recurrence after ligation of intersphincteric fistula tract surgery, but among those without recurrence, the post-operative outcomes were optimal and no faecal incontinence was noted.

Operating room black box: GIMMICK or a patient safety tool?

The Operating Room Black Box (ORBB) is a relatively recent technology that provides a comprehensive solution for assessing technical and non-technical skills of the operating team. Originating from aviation, the ORBB enables real-time observation and continuous recording of intraoperative events allowing for an in-depth analysis of efficiency, safety, and adverse events. Its dual role as a teaching tool enhances transparency and patient safety in surgical training. In comparison to traditional methods, like checklists that have limitations, the ORBB offers a holistic understanding of clinical and non-clinical performances that are responsible for intraoperative patient outcomes. It facilitates systematic observation without additional personnel, allowing for review of numerous surgical cases. This review highlights the potential benefits of the ORBB in enhancing patient safety, its role as a surgical training tool, and addresses barriers especially in resource-constrained settings. It signifies a transformative step towards global surgical practices, emphasizing transparency and improved surgical outcomes.

Comparison of pre and post Foley catheter Bishop's Score: A retrospective record review at Aga Khan University Hospital Karachi, Pakistan.

Objective: To compare pre and post Foley's catheter Bishop Score during labour induction. Methods: This study was a retrospective study conducted at the Aga Khan University Hospital Karachi, Pakistan after approval from ethical review board. All women who underwent induction of labour with Foley's Catheter at gestation of 37 weeks or more from September 2014-October 2015 were included. Data was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 19.0. The comparison between pre and post Foley's catheter Bishop Score during labour induction will be calculated by Wilcoxon sign test. Results: There were 981 cases of inductions of labour, 749 (76.3%) received Foley's catheter, in combination with prostaglandins and oxytocin. About 68% were vaginal deliveries while 32% underwent C-section. Two third of women had bishop <4. Overall, Bishop score improved significantly in all patients with the catheter however, maximum benefit was seen in patients where the catheter was placed for 10-12 hours. Conclusion: Foley's is the better and safer option. In view of our results, It has been recommended to keep the Foley's for 10-12 hours to get significant improvement in bishop score.

Pharmacological basis for the medicinal use of Alcea rosea in airways disorders and chemical characterization of its fixed oils through GC-MS.

Alcea rosea L. also known as Althea rosea belongs to the Malvaceae family. This medicinal herb, traditionally used to treat several conditions including airway disorders like asthma and chronic bronchitis. This study evaluated the bronchodilatory effects and possible mechanism of A. rosea on guinea-pig tracheal tissues. Moreover lipophilic profiling of A. rosea has been carried out by using Gas-Chromatography-Mass-Spectrometry. A total of 19 compounds have been identified from the plant, n-hexane fraction. These compounds have been further confirmed from their Van den Dool and Kratz (I) Indices. Major class of metabolite identified from the plant includes fatty acid, saturated and unsaturated fatty acid esters. Hydrocarbons have also been detected from the n-hexane fraction. These fatty acid esters have not been reported previously by GC-MS and were identified first time from the flowers of Alcea rosea. In-vitro experiments were performed on guinea-pig tracheal tissues, mounted in Kreb's solution at 37°C and bubbled with carbogen. In isolated guinea-pig trachea, A. rosea inhibited carbamylcholine and K+ (80 mM)-induced contractions, potentiated isoprenaline concentration-response curves (CRCs) and suppressed Ca2+ CRCs. These results suggest that A. rosea cause bronchodilation through dual inhibition of phosphodiesterase enzyme and Ca2+ influx, which substantiate its potential in airways disorders.

Axillary synovial sarcoma recurrence involving brachial plexus, a rare case report from Pakistan.

INTRODUCTION: Synovial sarcomas are rare tumors, and the incidence of axillary synovial sarcoma involving the brachial plexus has been reported as 2.9 % among all axillary soft tissue tumors. However, the recurrence of axillary synovial sarcomas has not been reported in literature. CASE PRESENTATION: A 36-years-old Afghan female presented in Karachi, Pakistan with a history of persistently increasing, recurrent, right axillary mass for 6 months. Initially diagnosed as a spindle-cell tumor on excision in Afghanistan, she had received ifosfamide and doxorubicin, but the lesion recurred. On examination, it was a 5 × 6 cm, hard mass palpable in right axilla. After radiological work-up and a multidisciplinary team discussion, she underwent complete excision of the tumor with successful preservation of brachial plexus. The final diagnosis was reported as monophasic synovial sarcoma FNCLCC Grade 3. DISCUSSION: Our patient presented with a recurrent right axillary synovial sarcoma that was involving the axillary neurovascular bundle and brachial plexus, which was initially diagnosed as a spindle cell sarcoma. Pre-operative core-needle biopsy was unable to provide a definitive diagnosis. MRI scan was useful in delineating the proximity of the neurovascular structures. Re-excision of the tumor was performed which is the mainstay of treatment for axillary synovial sarcomas, combined with radiotherapy depending on the disease grading, staging and patient factors. CONCLUSION: Axillary synovial sarcoma recurrence with involvement of the brachial plexus is an extremely rare presentation. Our patient was successfully managed through a multidisciplinary approach with complete surgical excision and preservation of the brachial plexus followed by adjuvant radiotherapy.

Case report: Axilla fibroadenoma - An atypical presentation.

Introduction: Fibroadenoma is the most common benign breast tumor among women between 15 and 35 years, however, a fibroadenoma arising from accessory breast tissue is a rare occurrence. Case presentation: We encountered this uncommon presentation in a 37 years old female with a gradually increasing left axillary lump associated with discomfort. On ultrasound it was a 17.3 mm × 10.6 mm x 17.5 mm well defined solid nodule with internal vascularity, BiRADS IVa lesion. Core biopsy revealed fibroepithelial lesion and the patient electively underwent excisional biopsy. Histopathology confirmed the diagnosis of fibroadenoma, which was completely excised. Clinical discussion: Approximately half of all breast lumps in women are diagnosed as fibroadenomas, making it the most common benign breast mass. Nonetheless, an axillary mass has several differentials such as lymphadenopathy, lipoma or sebaceous cyst, while a fibroadenoma developed from ectopic breast tissue in the axilla is an unusual condition. Masses in axilla like ectopic breast tissue are clinically significant as they undergo physiological changes like the normal breast tissue like pain and discomfort during pregnancy, lactation and menstruation. This tissue may also undergo pathological changes and may pose a diagnostic challenge. Conclusion: Axillary lumps pose a diagnostic dilemma and accessory breast tissue related pathologies should be considered.

Knowledge, awareness, and practices of cervical cancer, its risk factors, screening, and prevention among women in Karachi, Pakistan.

BACKGROUND: Cervical cancer has a high mortality rate worldwide; in Pakistan it kills more than 7000 women every year. Prevention is possible through vaccination against human papilloma virus, the causative agent of cervical cancer, or by screening for premalignant lesions through routine Pap smear tests. We have studied the knowledge and practices regarding cervical cancer, its risk factors, screening and prevention and the role of human papilloma virus vaccination and Pap smear testing, among young women of Karachi. METHODS: Information was gathered using a modified version of Cervical Cancer Awareness Measure Toolkit version 2.1 from 384 women aged 15 to 50 with no medical background attending outpatient clinics of AKUH, Karachi. Data entry was done through EpiData and analysis was done using SPSS version 22.0. RESULTS: Our respondents' mean age was 30 (±7.6) years. Out of the 61.2% of women who had heard about cervical cancer, 47.0% had heard about Pap smear test and among them, 73% had gotten a Pap test. A total of 25.5% of women out of the 61.2%, knew that a vaccine existed for prevention and out of them only 9.8% had vaccinated against human papilloma virus. CONCLUSION: Majority of women in our study belonged to a higher socioeconomic class and were mostly educated but their knowledge and practices regarding prevention and screening of cervical cancer were poor. This reflects that the knowledge levels as a whole would be considerably lower in the city's general population.