Is there need for a transformational change to overcome the current problems with postgraduate medical education in India.

In spite of the existence of a dual system of postgraduation, one under the Medical Council of India (MCI) and the other on a parallel track under the National Board of Examinations, postgraduate medical education in India is beset with several problems. For example, the curriculum has not been revised comprehensively for several decades. The diploma course under the MCI has become unpopular and is largely a temporary refuge for those who do not get admission to degree courses. The level of skills of the outgoing graduate is falling and the increase in the number of seats is taking place in a haphazard manner, without reference to the needs. In spite of increase in seats, there is a shortage of specialists at the secondary and tertiary care levels, especially in medical colleges, to share teaching responsibilities. Further, the distribution of specialists is skewed, with some states having far more than others. To remedy these ills and fulfil the requirements of the country over the next two decades, a working group appointed by the erstwhile governors of the MCI was asked to suggest suitable modifications to the existing postgraduate system. After an extensive review of the lacunae in the present system, the needs at various levels and the pattern of postgraduate education in other countries, it was felt that a competency-based model of a 2-year postgraduate course across all specialties, the use of offsite facilities for training and a criterion-based evaluation system entailing continuous monitoring would go a long way to correct some of the deficiencies of the existing system. The details of the proposal and its merits are outlined for wider discussion and to serve as a feedback to the regulatory agencies engaged in the task of improving the medical education system in India. We feel that the adoption of the proposed system would go a long way in improving career options, increasing the availability of teachers and dissemination of specialists to the secondary and primary levels, and improving the quality of outgoing postgraduates.

Influence of timing on performance of laparoscopic cholecystectomy for acute biliary pancreatitis.

Aim: Gallstone disease is the most common cause of acute pancreatitis. Cholecystectomy is mandatory to avoid recurrence of pancreatitis. Our objective was to evaluate the results of laparoscopic cholecystectomy (LC) in patients with gall-stone induced pancreatitis . Methods: All patients presenting to us within the time frame from February 2004 to June 2008 with acute biliary pancreatitis were included in the study. The severity of pancreatitis was assessed by Ranson’s criteria. ERCP and endoscopic sphincterotomy was performed when the common bile duct (CBD) was dilated (>6 mm) with either calculi or sludge as seen on imaging. Patients with successful ERCP with predicted demanding laparoscopic cholecystectomy were discharged instead for an elective LC, 4-6 weeks later. Patients with mild pancreatitis (with Ranson’s score of 3 or less) and predicted uncomplicated LC underwent surgery at the same admission. The difficulty of the procedure was determined by the presence of adhesions in the gallbladder area, dissection in Calot’s triangle, tackling the dilated cystic duct, intra-operative bleeding, and the need for a drain. Results: A total of 26 patients (12 male and 14 female; age range 23-75 years) with acute biliary pancreatitis comprised the study group. Eleven patients with suspected choledocholithiasis underwent ERCP and clearance of the CBD was done in all of them. Nine patients (2 ERCP and 7 non-ERCP) underwent early LC in the same admission. Seventeen patients (9 ERCP and 8 non-ERCP) were predicted as difficult cases for LC and underwent delayed LC. No patient had recurrent pancreatitis in the interval period. Conclusion: There was no significant difference in the operative difficulty between early and delayed LC when patients were selected for timing of LC based on pre-defined criteria.

Laparoscopic orchidectomy for undescended testis in adults.

BACKGROUND: Impalpable testis is a significant diagnostic and therapeutic challenge in adults, for both radiologist and surgeons, with few reports in literature addressing this problem in adults. Laparoscopy is a reliable and definitive procedure obviating the necessity of advance investigation and subsequent inguinal exploration in adults. AIMS: To study the utility of laparoscopy as combined diagnostic and therapeutic modality for undescended testis in adults. SETTINGS AND DESIGN: Prospective study from a single surgical unit of a large tertiary referral centre during August 2000 to January 2002. METHODS AND MATERIAL: Nine patients of unilateral undescended testis with average age 22.7 years (range 13-31 years) underwent diagnostic laparoscopy and orchidectomy subsequent to detailed clinical, ultrasound and examination under anaesthesia (EUA) procedure. All patients were operated with one 10 mm umbilical camera port, one suprapubic port and 1 lateral port. RESULTS: None of the patients had palpable testis or an inguinal cough impulse on clinical examination and during EUA. In only 3(33.3%) patients, the ultrasound could locate the testis situated at the deep ring. On laparoscopy all testes were identified, 4 were present at the deep ring, 3 were intra-abdominal and 2 had blind ending vas entering the deep ring. Mesh plug was inserted in the internal ring in these 2 patients, after dissecting the peritoneum. None of the patients had intra or post-operative complications and all were discharged on the next day. CONCLUSION: Laparoscopy is one of the most satisfactory methods for the diagnosis and management of non-palpable testis in adult cryptorchid patients.

Isolated splenic lymphoma: an elusive preoperative diagnosis.

Four patients underwent splenectomy for various clinical and radiological diagnoses and were found to have primary splenic lymphoma at surgery and histology. The diagnosis was classical Hodgkin's lymphoma, mixed cellularity type (one case); marginal zone B-cell non-Hodgkin's lymphoma (one case); and large B cell type non-Hodgkin's lymphoma (two cases). The first two patients had multiple nodules in the spleen measuring 0.1-0.5 cm while large cell lymphomas had large nodules (largest measuring 11 cm x 7 cm x 4 cm). The diagnoses were confirmed by immunohistochemical analysis. Mean follow up of these patients was 11 months; all patients received chemotherapy. One patient died, of causes not related to the disease process.

Paraesophageal mediastinal drainage with diversion for delayed presentation of esophageal perforation.

Esophageal perforation is a serious condition; a delay of more than 48 hours in initiation of treatment leads to increased morbidity and mortality. Management of such patients is a surgical dilemma. We successfully managed 4 patients (2-iatrogenic, 1-tuberculous, 1-Boerhaave's syndrome) with delayed presentation of esophageal perforation by esophageal exclusion and paraesophageal mediastinal drainage, achieving good control of mediastinal sepsis, healing of perforation and at the same time avoiding thoracotomy and subsequent second surgery.

Giant prosthesis for reinforcement of visceral sac for complex bilateral and recurrent inguinal hernias: a prospective evaluation.

AIMS: To evaluate giant prosthesis for reinforcement of visceral sac (GPRVS) as a treatment for complex bilateral and recurrent inguinal hernias. SUBJECTS AND METHODS: The prospective study carried out in a single surgical unit at a tertiary health care center involved consecutive series of 31 patients with complex bilateral and recurrent inguinal hernias who underwent GPRVS. All were men and the mean age was 58 years (range 49-95 years). Factors predicting high risk for recurrence included a large hernia ( greater, similar5cms, 32%, 10/31 patients), failure of one or more previous repairs (45%, 14/31 patients), chronic obstructive pulmonary disease (25%, 8/31 patients) and poor muscle tone (70%, 22/31 patients). Operative time, length of postoperative stay, complications and death were the main outcome measures. RESULTS: Mean -/+ SEM operative time was 65 -/+ 11 minutes (range 45-115 minutes). Mean -/+ SEM length of stay was 3.5 -/+ 0.7 days (range 2-5 days). There were 4 minor complications, but no mesh infections and death. Follow up was obtained for a mean period of 14.6 months (range 12-23 months); there were no recurrences. CONCLUSION: GPRVS provides a definitive and safe cure for repair of complex bilateral and recurrent inguinal hernias because of its simplicity, ease of the procedure, good results and low recurrence rate.

Isolated massive splenic peliosis.

We report a patient with isolated splenic peliosis. She presented with massive splenomegaly; contrast-enhanced CT scan showed multiple hypodense, well-circumscribed shadows in the spleen. Splenectomy specimen showed multiple cysts with white fibrous walls ranging from 1-4 cm in size, containing gelatinous fluid. The patient is asymptomatic at 6 months' follow up.

Shouldice's herniorrhaphy versus Moloney's darn herniorrhaphy in young patients (a prospective randomised study).

AIMS: Shouldice's repair (SR) and Moloney's darn repair (DR) are commonly practised repairs for hernias in the young age group with acceptably low recurrence rates. The SR is considered technically challenging and difficult, while the DR is gaining popularity in recent years. Therefore, there is a need to compare these repairs. MATERIAL AND METHODS: To compare these techniques a total of 50 cases (age group 18-40 years) were randomised to two groups (SR 25, DR 25). These were well matched for age, the side and the type of hernia. Both groups were studied with respect to operative time; postoperative pain at 6,12 and 24 hours (evaluated by pain scale 1-10) need for analgesia, ambulation (evaluated by a four-point scale), complications and return to work. RESULTS: The SR required a longer time (average 81 minutes) compared to DR (average 43 minutes). Patients undergoing SR complained of pain of a higher scale at 6, 12 and 24 hours post surgery and had a significant higher need for analgesia on day 1 and 2 (p < 0.05). Ambulation grades were significantly better in the DR group on the first postoperative day (p < 0.05). There was no significant difference in the two groups with respect to postoperative complications, return to work, and recurrences rate (2-year follow-up). CONCLUSION: The SR and DR are comparable for young patients having a primary hernia. However, DR is superior in terms of the time taken, post-operative pain, need for analgesia and early ambulation.

Spontaneous oesophageal perforation due to mediastinal tuberculous lymphadenitis - atypical presentation of tuberculosis.

Spontaneous non-traumatic oesophageal perforation secondary to bursting of a mediastinal tuberculous abscess into the oesophagus is rare. The diagnosis is delayed, as perforation remains localised due to mediastinal lymph nodes. Patient can be effectively managed by paraoesophageal drainage of the mediastinal abscess and oesophageal diversion.

Synchronous primary adenocarcinoma of small and large bowel.

Synchronous cancer of the small and large bowel is rare. We report a 45-year-old woman with synchronous primary cancer of the jejunum and descending colon who presented with intestinal obstruction.

Wandering spleen causing splenic flexure volvulus and obstruction.

A 48-year-old woman presented with symptoms of distal bowel obstruction. On examination she had abdominal distension and a lump in the left lumbar and iliac regions. X-ray revealed distension of the colon with dilated small bowel. Exploration revealed an enlarged ptotic spleen whose pedicle caused obstruction of the colon. There was concomitant partial volvulus of the splenic flexure around the splenic pedicle. The splenic vein was thrombosed. Splenectomy was performed.

Fetus in fetu.

Fetus in fetu occurs due to aberration of monozygotic twinning. A 16-year-old boy presented with abdominal pain and mass. Laparotomy revealed an anencephalic fetus within an encapsulated retroperitoneal mass. Pathologic examination confirmed rib formation with a primitive vertebral column with bone marrow. There was no other organogenesis.

A study of stress in medical students at Seth G.S. Medical College.

BACKGROUND: It is usually observed that medical students undergo tremendous stress during various stages of the MBBS course. There is a high rate of suicide among them. METHODS: To determine incidence of stress and factors controlling stress in medical students at various stages of MBBS course at Seth G S Medical college, 238 students (First year 98, Second 76, Third 64) were asked to complete a questionnaire on personal data (gender, stay at hostel, mode of travel, time spent in travel every day, medium of study in school, place of school education.), Stress inducing factors, Zung's depression scale, ways of coping, stress relievers, perceived social support and personality type. Statistical tests used were ANOVA, critical ratio and Student's 't' test. RESULTS: Majority of medical students (175/238--73%) perceived stress. Stress was found to be significantly more in Second and Third MBBS students rather than First MBBS levels (p < 0.05). Stress was not found to differ significantly on the basis of sex, stay at hostel, model of travel, time spent in travel every day, medium of study in school, place of school education. Stress was found to be significantly more in students having more than 95% of marks at 12th Standard as compared to others. Academic factors were greater perceived cause of stress in medical students. There was no significant difference in the students at different levels of MBBS regarding academic factors and social factors as a stress inducing factors. Physical factors were found to be significantly more in Second and Third MBBS students as compared to First MBBS students. Emotional factors were found to be significantly more in First MBBS students as compared to Second & Third MBBS students. Stress was more common in medical students who have dominant strategy of coping as positive reappraisal, accepting responsibility and planful problem solving. Stress was less common in medical students at Seth G S Medical College who have dominant strategy of coping as escaping and distancing from difficult situation. Family and Friend as perceived social supports were more in Second MBBS than First MBBS medical students. Stress was not found to be significantly more in students having their personality factor contributing to stress (Type A--52/67) as compared to others (Type B--123/171). This indicates that the stress was not trait oriented but was process oriented (p = NS). CONCLUSION: Stress in medical students is common and is process oriented. It is more in second and third year. Academic factors are greater perceived cause of stress in medical students at Seth G S medical college. Emotional factors are found to be significantly more in First MBBS. It is dependent on person's ways of coping and social support.

Fetus in fetu or a retroperitoneal teratoma--a controversy revisited. A case report and review of literature.

A 25 year old man male presented with a lump in the left side of the abdomen. Ultrasonography revealed an echogenic retroperitoneal mass with hyperechoic areas within it suggestive of bone. CT scan confirmed the presence of a large retroperitoneal mass with bone within it. On exploration there was a large encapsulated retroperitoneal lump. There was a soft tissue mass within the lump surrounded by a yellow pultaceous material admixed with pus. Examination of the specimen showed a bone at the cephalic end with teeth embedded within it. There were two limb buds near the cephalic end. The whole specimen was covered with skin with all its appendages. There was coelomic cavity present. The distinction between fetus in fetus and teratoma has for long been the subject of controversy. According to the criteria described by Willis, there should be a vertebral axis present to make the diagnosis of fetus in fetu. But there have been a few reports where cases have been described as fetus in fetu even in the absence of a vertebral axis. A review of the literature concerning this controversy is briefly given.