Is there difference in chronic pain after suture and stapler fixation method of mesh in ventral hernia? a randomized controlled trial

Background and Objective: Chronic pain occurs in 20-30% of patients after hernia surgery. As a consequence of this chronic pain, almost one third of patients have limitations in daily activities. Frequency and severity of this pain varies with different techniques of hernia repair. The objective of this study was to compare polypropylene suture and skin staples for securing mesh in uncomplicated ventral hernioplasty in terms of acute and chronic postoperative pain and to compare the time taken for mesh fixation between polypropylene sutures and skin stapler in ventral hernioplasty

Methods: This study was conducted in Surgery Department of Dow University Hospital, Dow University of Health Sciences, Ojha Campus and included 53 patients from Jan 2015 to Dec 2016, after taking informed consent. All patients were operated under general anesthesia by the same surgical team. Patients were randomized into two groups; in one group mesh fixed with 2/0 polypropylene suture while in other group mesh stapler was used. Time taken to apply mesh was noted in minutes from laying the mesh over anterior rectus sheath to completion of fixation by either method. The severity of post-operative pain was measured with VAS [1-10] after one week, one month and after one year after surgery. Data was analysed using SPSS version 17

Results: Patient characteristics and operative outcome were similar in the two groups and statistically non-significant in both. Early postoperative pain was more after suture fixation but it was not statistically significant. Mean +/- SD pain score was after one week 3.47 +/- 2.7 after sutures while 2.91 +/- 1.88 after stapler. After four weeks, 0.40 +/- 0.49 after suture while 0.35 +/- 0.48 after stapler fixation. In both study groups 30-34% of the patients felt some pain in follow-up after one year. Severity of pain was 0.60 +/- 0.62 after suture while 1.65 +/- 1.94 after stapler fixation which is statistically significant as well [p<0.007]. Mean operative time was 15.33 +/- 6.33 minutes for suture fixation while 1.56 +/- 0.41 minutes for fixation by staples, p-value < 0.001

Conclusion: The method of fixation does not appear to cause significant difference in early postoperative pain but chronic pain is more after stapler fixation of mesh. However, operative time was reduced significantly in staple fixation group as compared to suture fixation group

Association between vitamin D deficiency and breast Cancer

Objective: To determine the association between vitamin D deficiency and breast cancer

Methods: This case control study included 94 female patients aged 20-75 years of any marital status and parity. Newly diagnosed 42 breast cancer patients who presented to surgical OPD of Dow University Hospital from Jan 2016 to June 2016 were included into the study as "cases" after informed consent. Age matched 52 females who presented to OPD for complain other than breast pathology were included as the "control group". The sociodemographic of both cases and controls and histopathological characteristics of cases were recorded. Serum 25-[OH]2D levels were studied by the ELISA technique and recorded in ng/ml. Vitamin D deficiency was considered at serum level less than 20ng/ml

Results: Mean age was 40.1 Years for controls and 47.6 Years for cases. Mean height, weight and BMI did not differ between cases and controls. Serum Vitamin D levels were significantly lower in cases [85.7%] than controls [55.8%]. The unadjusted and adjusted ORs for breast cancer in cases and controls showed a statistically significantly increased risk of breast cancer with low vitamin D concentration [p value0.003]. After adjustment for age, parity, BMI, sun exposure, economic status and education status the ORs [95% CIs] for breast cancer risk was 7.8 [1.99 - 30.58] for women with vitamin D concentrations <20ng/mL

Conclusion: Findings of our study conclude that vitamin D deficiency is associated with risk of breast cancer

Sentinel lymph node identification by blue dye in patients with breast carcinoma

Objective: To determine the diagnostic accuracy of methylene blue dye to detect axillary lymph node metastases in patients with breast carcinoma by taking histopathology as gold standard

Methods: This quasi experimental study was done at Department of Surgery of Dow University Hospital Karachi during January 2013 to September 2015 after the approval of Hospital Ethical Committee. A total number of 85 patients with biopsy proven carcinoma were included in the study. 1% methylene blue dye was infiltrated in the peri tumoural area of the diseased breast. The blue stained node called sentinel lymph node [SLN] was recognized and carefully dissected out. SLN and mastectomy with axillary clearance specimen was sent for histopathology in two separate bottles and the report of the histopathology was compared

Results: The axillary lymph nodes were positive for carcinoma in 61 cases out of 85[71.7%].Two of the patients had negative sentinel lymph node but positive non sentinel lymph node [false negative], and in three cases sentinel lymph node were involved only but not the rest of the axilla [False positive]. The sensitivity, specificity and accuracy were 96.8%, 86.36% and 94.1% respectively

Conclusion: Methylene blue dye technique is a reliable and safe diagnostic modality for detection of Sentinel lymph node in breast cancer patient because of its high accuracy

Assessment of factors associated with practice of breast self-examination in a tertiary care health setting in Karachi

Objectives: [1] To determine the knowledge, attitude and practice towards breast self-examination [BSE] in tertiary care health setting in Karachi

[2] To assess factors associated with practice of BSE

Study Design: Cross sectional study

Place and Duration of Study: This study was carried out at the Dow University Hospital, Dow International Medical College and Dow Medical College / Dow University of Health Sciences Karachi from July to December, 2014

Materials and Methods: Study participants were medical students, interns, residents, consultants, as well as female patients and their lady attendants visiting General Surgical Out Patient Department. A questionnaire was developed including demographic details, knowledge about BSE, attitude towards and practice of BSE

These questionnaires were filled in by interns and residents of Department of General Surgery

Interviews were done in privacy after taking verbal consent

Data were entered and analyzed using SPSS version 16. Categorical variables about knowledge, attitude and practice are presented as frequencies. Predictors of BSE ie., age groups, level of education, occupation, income, marital status, personal history of benign breast disease and family history of breast cancer are also presented as frequencies

Their association with ever practice of BSE is determined by using chi square test

Results: Total of 729 women were interviewed to achieve a sample size of 500 positive responders, who had heard about BSE, which was 68.6%. Further questioning was done from these women

Majority of participants were young, 74% being less than 30 years of age. Around half of them were graduates and 21% were post-graduates

Sixty four percent respondents belonged to medical profession, while 22.2% were housewives and 13.8% had other professions

Majority belonged to high income group. 61.4% were married and 11.4% had family history of breast cancer. 29% respondents knew correct age to start BSE. Proposed frequency was stated correctly by 49.6%, appropriate time by 42.6%. Around 42% women said they knew how to perform and 36% could verbally explain the procedure correctly. More than 96% women thought that BSE was useful and should be practiced. Only 39.2% women claimed that they practiced BSE, while just 63 of the total 500 women interviewed, were doing it regularly

Level of education, profession, income, marital status and family member with breast cancer were found to be significant factors associated with BSE practice

Conclusion: Although overall awareness about BSE was average but correct knowledge and actual performance were poor. Medical profession, graduate level of education, handsome income, married status and family history of breast cancer were associated with BSE practice

Comparison of hemorrhoidectomy by ligasure with conventional Milligan Morgan's hemorrhoidectomy

Objective: To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy

Methods: This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A [Haemorrhoidectomy by Ligasure] and group B [Milligan Morgan Haemorrhoiectomy]. Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7th post operative day

Results: Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 - 60 years. Third degree Heamorrhoids were present in 37 [67.3%] of patients while remaining 18 [32.7%] had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6 +/- 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34 +/- 25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method

Conclusion: The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups

Ultrasound findings in patients with mastalgia

Objective: To determine the frequency of different ultrasound findings in patients presenting with mastalgia

Study design: Cross sectional study

Place and Duration of study: Department of Surgery, Dow University Hospital Karachi, from January 2016 to June 2016

Methodology: This study included female patients of any marital status and parity who presented to surgical OPD of Dow University Hospital with the complaints of breast pain for more than one month duration. All patients were advised ultrasound breast after history and examination. The ultrasound findings were recorded on a performa

Results: A total of 70 female patients, aged 15-60 year, were included. Mean age of the patients was 30.07 year. Mean duration of breast pain was 5.3 months. Ultrasonographic imaging findings showed fibroadenoma in 22 [31.4%], a simple cyst in 18 [14.3%], malignancy in 1 [1.4%] and 6 [8.6%] patients had duct ectasia. Mastitis was shown in 3 [4.3%] and 1 [1.4%] had abscess on ultrasound. Other patients [n=27 - 38.6%] had completely normal breast on ultrasound, among them 81.5% had cyclic and 18.5% noncyclic breast pain. Out of 22 [31.4%] patients in whom ultrasound reported fibroadenoma; in 18 [81.8%] there was a single lump while remaining 4 [18%] had multiple lumps in single or both breasts. Ten patients had a cystic lesion reported on ultrasound, out of which 7 had 2 or more cysts while 3 had a single cyst

Conclusions: Patients presenting with mastalgia may have different pathologies. Ultrasound helps to determine the exact cause so that appropriate treatment for the cause of breast pain can be provided

Operations; cancellation on the intended day of surgery

To find out reasons for cancellation of operation on the day of surgery in the Surgical Department of Civil Hospital Karachi. Observational study. All operation theatre bookings of the Civil Hospital Surgical Department from July 2010 to October 2010 have been studied by using the 'daily operating theatre lists'. Frequency of cancellation, type of surgeries cancelled and their reasons studied. Out of total 455 cases, 97 [21%] surgical operations were cancelled on the day of surgery, highlighting patients' non-compliance as a major contributing reason, followed by the lack of operating room time and other causes. Among the less contributing factors were patient expiry on table, failure to administer anesthesia and delay in operation due to exams [engagement of patients in undergraduate exam in the college]. Patients non-compliance is a major challenging factor that causes a large number of cancellations of operations in the Civil Hospital Karachi

Computer based assessment [CBA]: perception of residents at dow university of health sciences

During the past few years, Computer-based assessment [CBA] has gained popularity as a testing modality. This assessment offers several advantages over paper based assessment [PBA] testing. The objective of this study was to find out residents' perception of this method of assessment. The post graduate residents of Dow University of Health Sciences in the field of Surgery, Medicine, Gynecology and Obstetrics experienced their first formative Computer-based assessment [CBA] in year 2013.Immediately after formative CBA, an anonymous paper based questionnaire was distributed amongst the residents and response was sought for their self-perceived computer usage competence before starting residency, perceptions regarding CBA method and to determine their preference for PBA or CBA in future assessment preferences. Total 173 residents completed the questionnaire. More than half of residents, 56.1% had no prior experience of CBA. Three fourth, 76.4% of the residents were less than confident before sitting in CBA, while after completing CBA, 64.8% were either confident or extremely confident for CBA. Most common problem encountered by students was logging in 28.9%. More students [53.2%] believed that paper assessment took longer to complete than CBA. Majority of the students [61.8%] rated CBA as better than PBA despite experiencing it for the first time. Resident's perception for CBA is good and they recommend its use in future assessment as well. However, to take maximal advantage of this technology, faculty should be trained to develop questions not only with text and pictures but with audio and video support

Students' perception of surgical objective structured clinical examination [OSCE] at Dow University of Health Sciences

To determine the student's perception of reliability and validity of Surgical Objective Structured Clinical Examination [OSCE] in Dow University of Health Sciences. Total 109 third year students of Dow International Medical College voluntarily and anonymously completed a self-administered questionnaire at the end of the OSCE examination from January 2012 to March 2013. Main outcome measures were student perception of examination attributes [which included the quality of instructions and organization, the quality of performance, authenticity and transparency of the process]. OSCE was considered as a fair examination method by 76% students. More than half of the students rated this examination as one covering wide range of knowledge [86%], clinical competence [72.5%], and well administered and structured [85-87%]. Sixty six percent students highlighted OSCE as tool that is reliable and valid in measuring their clinical competencies. OSCE as a tool to evaluate clinical competence among surgical students was highly appreciated by the students. Student believes that this assessment method cover broad knowledge component and clinical competence

Efficacy and timing of single dose dexamethasone as prophylactic antiemetic in major surgeries

To determine the efficacy of single dose intravenous dexamethasone, administered one hour before surgery as prophylactic antiemetic. Single blinded, randomized, placebo controlled, interventional study. Usman Memorial Hospital Karachi, from January 2006 to June 2008. Patients admitted for elective general and gynecological surgery, having ASA I or II class were selected. They were randomly allocated to receive either 2 ml [8 mg] dexamethasone or 2 ml of normal saline, one hour before surgery. Surgery was performed under general anesthesia by a single anesthetist. Wound site was infiltrated with 20 ml of 0.5% bupivacaine. Injection ketorolac 30mg I/V was given prior to extubation and 30 mg I/V twice daily thereafter. Supplemental analgesia was provided with injection nalbuphine 10 mg diluted and supplemental anti emetic used was dimenhydrinate 50 mg I/V as required. Episodes of nausea and vomiting and drugs used were recorded on case files by nurse or doctor in the post-operative ward for 24 hours, who were blinded to pre-operative drug used. Any adverse events were also noted. Data was entered and analyzed using SPSS version 15. A total of sixty female patients were enrolled. They were divided into two groups, thirty in each [test group and placebo group]. Mean age of the patients was 42 years in both the groups. 61.7% patients had cholecystectomy, 15% had herniorrhaphy, 16.7% underwent abdominal hysterectomy and 6.6% had benign ovarian cystectomy. Duration of operation and anesthesia were comparable in both the groups. In the entire 24 hours period after surgery nausea occurred in 30% patients in test group A as compared to in placebo group B 77% [p=0.000], while vomiting in10% of test group versus 40% of placebo group [p=0.007]. Timed observations revealed that nausea occurred in 23% versus 70%, 10% versus 30% and 0% versus 6.7% in the first 6 hours, 6 - 12 hours and 12 - 24 post-operative hours respectively. Similarly vomiting occurred in 6.7% versus 40%, 0% versus 6.7% and 3.3% versus 3.3% patients. The number of episodes of nausea and vomiting were significantly reduced in the test group as was the need for supplemental antiemetics. Dexamethasone given as single I/V injection of 8 mg one hour before surgery is an effective drug for prophylaxis of post operative nausea and vomiting

audit of cholecystectomy

To evaluate the results of Cholecystectomy in our practice. Prospective, descriptive study from January 2006 to December 2006. Hamdard University Hospital and private hospitals. A total of 150 patients who underwent cholecystectomy were included in this study. The dats of all the patients who underwent cholecystectomy was entered on a proforma and analyzed. Out of the total 150 patients, 75% were females and 25% males, with an age range of 20 to 76 years. The duration of symptoms was from one day to three years. Laparoscopic Cholecystectomy was attempted in 118 [78.66%] patients and completed in 104 [88.13%] patients; 13 [11.11%] patients required conversion, while in one case the procedure was abandoned due to abdominal tuberculosis. The remaining 32 patients underwent planned open cholecystectomy for various reasons. The comparison of our work with national and international studies showed that Laparoscopic Cholecystectomy in our set up is up to the accepted standard. More emphasis is needed to properly train young surgeons in the field of Laparoscopic surgery

Patient's preference for the route of Postoperative Analgesia

To find out the preferred route [injectable or rectal] for postoperative analgesia in our patients. Cross sectional study conducted on 100 patients.Department of Surgery, Hamdard University Hospital, Karachi.100 patients who underwent the operations of herniorrhaphy, cholecystectomy and appendicectomy. Patients were given the choice of having post-operative analgesia either through injectable [intramuscular, intravenous] or rectal route, and the data analyzed.The results showed that 74% patients preferred injectable, while only 24% preferred rectal route for post-operative analgesia. The reason for rejection of the rectal route was doubt about its efficacy in 45 cases, shyness in 14 and unawareness in 11 patients. Four patients gave no reason or any comment.It is therefore concluded that rectal route should be used cautiously, and if it is necessary a specific consent should be taken pre-operatively to protect against litigation, in case an adverse situation develops