Role of C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy.

INTRODUCTION: Cholelithiasis is one of the most common diseases encountered in gastroenterology. Laparoscopic cholecystectomy can be labelled as difficult if the surgery continues for more than 60 minutes or if the cystic artery is injured before ligation or clipping. Predicting difficult laparoscopic cholecystectomy can help the surgeon to be prepared for intraoperative challenges such as adhesions in triangle of Calot, injury to cystic artery or gall stone spillage; and improve patient counseling. METHODS: In this cross-sectional study, we evaluated 269 patients with diagnosed cholelithiasis and planned for laparoscopic cholecystectomy in the general surgery department of Civil Hospital Karachi. After approval of the institution review board of the Civil Hospital, the data of all the patients was collected along with informed consent. The patients were selected via nonprobability, consecutive sampling. RESULTS: The prevalence of difficult LC during procedure was 14.5% (39/269). Contingency table showed the true positive, negative and false positive and negative observation and using these observation to compute accuracy. Sensitivity, specificity, PPV, NPV and accuracy of serum c-reactive protein (CRP) in predicting the difficult laparoscopic cholecystectomy in patients of cholelithiasis was 87.2%, 97%, 82.9%, 97.8% and 95.5% respectively. Effect modifiers like age, gender and BMI were controlled by stratification analysis and observed that diagnostic accuracy was above 90% in all stratified groups as presented in the following tables. 175 (65.06%) of 279 patients were females indicating female predominance. In general, 41 patients (15.05%) had CRP serum levels greater than 11 mg/dL out of which 34 patients had to undergo difficult laparoscopic cholecystectomy (DLC), while 223 out of 228 patients with serum CRP levels of less than 11 mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders. CONCLUSION: C Reactive Protein is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high C Reactive Protein CRP levels in serum have more chances of complication intraoperatively and increased chances of conversion from laparoscopic to open surgery. Preoperative C Reactive Protein (CRP) with values >11 mg/dL was associated with the highest odds of presenting difficult laparoscopic cholecystectomy (DLC) in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population.

Impact of COVID-19 on surgical residency programs in Pakistan; A residents' perspective. Do programs need formal restructuring to adjust with the "new normal"? A cross-sectional survey study.

BACKGROUND: Due to high-risk exposure of surgical residents to coronavirus, surgical residency programs have changed their training methods and working hours drastically. The purpose of this study is to find out the positive and negative impacts of the pandemic on surgical residency programs and on the lives of surgical residents. MATERIALS AND METHODS: A cross-sectional study was conducted on 112 surgical residents of a tertiary care hospital in Pakistan, with a mean age of 30.5 years from all the departments of surgery using a self-made, validated 40-point questionnaire comprising three sections. The last section also included modified Maslach Burnout inventory. RESULTS: Of all the residents, 97 (86.6%) stated that their surgical hands-on duration is adversely affected by the pandemic. As for clinical exposure, 92 (82.1%) trainees responded that their clinical exposure is affected too. Among all the subjects, 69 (61%) were concerned about transmitting it to their family members and 43 (38.4%) affirmed on being afraid of dying because of their direct exposure. On the brighter side, the average number of working hours per week for surgical residents were reduced from 81.10 ± 6.21 to 49.16 ± 6.25 (p < 0.001) due to the outbreak. Modified Maslach Burnout inventory score was 8.33 ± 2.34 after the outbreak, showing statistically significant reduction in burnout among the surgical residents (p < 0.001). CONCLUSION: The changes in the surgical residency programs amidst the pandemic has reduced the working hours, hands-on and clinical exposure of the surgical residents. Moreover, the situation has provided an opportunity to explore efficient methods of learning that can lead to lesser burnout. However, psychological burdens of surgical residents like fear of acquiring the infection should be appropriately addressed.