Gastric volvulus in adults in a tertiary care hospital Karachi, Pakistan: A case series.

Gastric volvulus is a rare surgical emergency which is rare in children and occasionally presents in adults. It results due to pathological malrotation of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and carries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed.

Assessing the Adherence of Operative Notes for Laparoscopic Appendectomy with the Royal College of Surgeons Guidelines.

 Objective: To determine the frequency of adherence of laparoscopic appendectomy operative notes with the Royal College of Surgeons (RCS) guidelines at the tertiary care centre.  Study Design: A clinical audit report. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi between January and June 2018. METHODOLOGY: Operative notes of laparoscopic appendectomy, written by residents of general surgery from trainee levels R1 to R5 during the study period, were included in the study. Each component from RCS guidelines, was assessed. The response to every question in proforma was marked either as Y=Yes or N=No. Overall score of more than 70% was chosen arbitrarily as a qualifying standard for an adequate operative note. Data were analysed by using SPSS (version 21). A p-value of <0.05 was considered significant. RESULTS: A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Most of these, i.e. 46% notes, were written by year one residents; 47.1% operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intraoperative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.    Conclusion: Only a quarter of the studied documentation fulfilled the criteria for adequacy of practice. Residents need to be educated and familiarised with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve the performance.           Key Words: Operative notes, Good medical practice, Acute appendicitis, Laparoscopic appendectomy, RCS guidelines.

Acute necrotizing pancreatitis: Has conservative management replaced surgery? Perspective from a tertiary care centre in Pakistan: A cross-sectional study.

BACKGROUND: The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality. METHODS: A cross-sectional study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis to the Aga Khan University Hospital in between the year 2008-2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those patients with necrotizing pancreatitis who were conservatively managed. Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analyzed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant. RESULTS: A total of n = 110 patients were included in the study with 68% (n = 75) males and 32% (n = 35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n = 54) patients with forty percent (n = 44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute. CONCLUSION: Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Therefore surgeons of the developing world need to evolve and adapt to these new measures for better outcomes in patient management.

Adenoma detection rate as a quality indicator for colonoscopy: a descriptive cross-sectional study from a tertiary care hospital in Pakistan.

Background and study aims Adenoma detection rate (ADR) is validated for measuring quality of colonoscopy, however there is lack of colorectal cancer (CRC) screening program in South Asia. The purpose of this study is to analyze and review the polyp detection rate (PDR) and ADR and provide insight into the factors that influence them in Pakistan. Patients and methods This retrospective, cross-sectional study was performed at the Aga Khan University Hospital, Karachi, Pakistan, on patients ≥ 18 years, who underwent colonoscopy between January 1, 2017 and June 30, 2018. Results Of 1985 patients, 59 % were male and 41 % female, with mean age of 47.8 ±â€Š16.2 years. The most common indication for colonoscopy was bleeding-per-rectum (28.0 %) and overall PDR and ADR were 17.9 % and 9.9 %, respectively. There was no significant difference between genders for either PDR ( P  = 0.378) or ADR ( P  = 0.574). Significantly higher PDR and ADR were found for patients ≥ 50 years ( P  < 0.001), as well as for suboptimal bowel preparation [PDR (25.7 %; P  = 0.007) and ADR (18.6 %; P  = 0.014)]. Interestingly, endoscopists with < 500 colonoscopy-procedural-experience reported a higher PDR (21.6 %; P  = 0.020) and ADR (14.4 %; P = 0.049), corresponding to a significantly higher PDR (20.6 %; P  = 0.005) and ADR (11.7 %; P  = 0.02) for endoscopists in practice for ≤ 10 years. Conclusions We have noticed low PDR and ADR, which require further investigation and research. In addition, we believe there should be a different baseline ADR and PDR as a quality indicator for colonoscopy in our region, where no internationally recommended colonoscopic screening programs have been implemented.

Developing role models in clinical settings: A qualitative study of medical students, residents and clinical teachers.

OBJECTIVE: To explore how positive role modelling attributes can be developed in students, residents and clinical teachers. METHODS: The qualitative study using focus group discussions was held at Aga Khan University, Karachi from March to May 2018, and comprised medical students, residents and clinical teachers. Overall 11 focus group discussions were conducted till data saturation was achieved. Content analysis was used to analyse the data which was transcribed verbatim. RESULTS: Of the 116 subjects, 60(51.7%) were medical students, 35(30.2%) were residents and 21(18%) were clinical teachers. Of the 11 focus group discussions, 4(36.5%) each were held with the students and the residents, while 3(27%) were held with the teachers. Five major themes that emerged from the study included definition of role models, attributes of role models, role modelling as a learnt behaviour, challenges in developing role models, and recommendations for developing positive role models. A number of attributes of positive and negative role models were identified by the participants. All the participants including students, residents and teachers appreciated the importance of role modelling in developing professionalism among health professionals and medical students. Factors hindering development and demonstration of positive role modelling were also identified and possible solutions were suggested. CONCLUSIONS: Clinical teachers needed to be made cognizant of their role as positive role models in developing professionally competent physicians. The medical institutions needed to develop and implement policies that would enhance positive role modelling by the teachers and facilitate learning of positive attributes at all levels.

Empathy in clinical practice: a qualitative study of early medical practitioners and educators.

OBJECTIVE: To explore the reasons for decline in empathy among physicians and to identify strategiesfor fostering empathetic clinical practice. METHODS: The qualitative study was conducted at the Aga Khan University Hospital, Karachi, from February to June 2017, and comprised focus group discussions involving separate sessions with medical students, residents and clinical teachers. Content analysis was used to analyse the verbatim transcripts for identification of codes which led to derivation of themes from the data. Consolidated criteria for reporting qualitative research was used to assess the quality of the study. RESULTS: Of the 109 subjects, 57(52.3%) were medical students, 30(27.5%) residents and 22(20.2%)clinical teachers. Of the 9 focus group discussions, 4(44.4%) were held with the students, 3(33.3%) with residents and 2(22.2%) with the teachers. Four themes that generated were delineating empathetic clinical practice, reasons for decline, challenges for promoting empathetic clinical practice, and recommendations for developing and facilitating empathetic clinical practice. All the participants unanimously agreed that there was a decline in empathetic clinical practice. Primary challenges included increased workload and time constraints inhibiting empathetic practice.. CONCLUSIONS: It is essential to teach empathetic clinic practice to students and residents during medical training while continuous professional development should reinforce the significance of empathetic clinical practice among medical practitioners and educators.

Is pelvis x-ray essential in stable trauma patients? Step towards lowering the treatment cost.

OBJECTIVE: To determine the diagnostic accuracy of clinical examination in detecting pelvic fractures in patients with blunt trauma.. METHODS: The cross-sectional prospective study was conducted at Aga Khan University Hospital, Karachi, from January to June 2015, and comprised alert, awake blunt-trauma patients. Pelvis examination findings were compared to routine pelvic X-rays. SPSS 19 was used for data analysis.. RESULTS: Of the 133 patients, 122 (92%) were males. Overall mean age was 37 ±14.2 years. There were 14 (10%) patients who were true positives with pelvic fracture diagnosis on both clinical examination and pelvic X-ray, while 14 (10%) were false negative on examination. Clinical examination missed 2 patients with evidence of fracture on X-ray and were considered false positive. Besides, 103 (77.4%) patients were true negative as both clinical exam and X-ray showed no evidence of fracture. CONCLUSION: Omitting pelvic X-ray in the recommended protocol can avoid unnecessary financial burden and reduce undesirable radiation exposure..

Cost effectiveness of Glove Endobag in Laparoscopic Cholecystectomy: Review of the available literature.

Laparoscopic cholecystectomy is the most common procedure performed worldwide and remains the gold standard for symptomatic gallstones. The most common complication obser ved during this procedure is gallbladder perforation resulting in spillage of stones and bile into peritoneal cavity. In order to avoid such complications, gallbladder is commonly extracted in an endobag. The current literature review was conducted to assess the efficacy and cost-effectiveness of glove endobags. PubMed and Google Scholar databses were searched to find relevant studies from January 1990 to December 2017. Search terms used were 'glove endobag' and 'laparoscopic cholecystectomy'. Literature suggests glove endobag is an effective and comparatively inexpensive compared to commercially prepared endobags.

Factors Associated with Premalignant Epithelial Changes in Chronic Calculous Cholecystitis: A Case-Control Study.

INTRODUCTION: Gallstones are known to be associated with premalignant changes in the gallbladder epithelium that range from atypical hyperplasia, metaplasia, dysplasia to carcinoma. Recognition of factors associated with these changes in patients with gallstones can potentially be helpful in identifying patients to whom prophylactic cholecystectomy can be offered to reduce the chances of developing carcinoma. OBJECTIVE: To identify factors associated with premalignant epithelial changes including atypical hyperplasia, metaplasia, and dysplasia in gallbladder mucosa in patients with chronic calculus cholecystitis. MATERIALS AND METHODS: This was retrospective case-control study conducted over a period of 10 years from 2004 to 2014. Cases were patients with reported histopathological premalignant epithelial changes along with chronic calculus cholecystitis, and controls were patients without premalignant epithelial changes but chronic calculus cholecystitis. Controls were twice the number of the cases. RESULTS: Over study period, 92 patients were reported to have premalignant epithelial changes on gall bladder histopathology for whom 184 controls were selected. Of cases, 61 (66%) patients had atypical hyperplasia, while metaplasia and dysplasia were present in 26 (28%) and 5 (5%) cases, respectively. Mean age was 47.5 ± 14.5 years, and 74% of the study population were female. Wall thickness of more than 3 mm (OR = 4.14, p value < 0.001) turned out to be statistically significant independent variables associated with premalignant lesions in gallbladder mucosa. CONCLUSION: Odds of premalignant epithelial change in gall bladder mucosa in patients with gall bladder wall thickness of more than 3 mm is four times the odds of patients with wall thickness less than 3 mm, and the effect is statistically significant. Prophylactic cholecystectomy should be considered for this group of patients.

T-tube placement as a method for treating penetrating oesophageal injuries.

INTRODUCTION: Penetrating oesophageal injuries are extremely rare. Their timely recognition can be difficult and optimal treatment remains controversial. Early recognition of injury is possible with the help of a high index of suspicion and early radiological and endoscopic examinations. Prompt surgical intervention with primary repair of injury, should be the goal. PRESENTATION OF CASES: We describe two cases of penetrating oesophageal trauma where T-Tube placement through the oesophageal defect, was successfully employed. Both cases proved to be challenging due to time lapse after injury and anatomical location. DISCUSSION: Penetrating injuries to the Oesophagus are rare with a reported incidence of 11-17%, most are due to gunshot injuries or stabbings, cervical followed by the thoracic Oesophagus are most at risk. In delayed presentations and sepsis related multi-organ instability, diversion and drainage are considered appropriate. T-tube placement through defects in difficult situations of delayed presentation is well described in setting of iatrogenic perforations. Their use has been described in penetrating injuries but much less frequently. CONCLUSION: T-tube placement though oesophageal defects can prove to be an effective treatment option to repair both iatrogenic and penetrating injuries of the Oesophagus, whether early or delayed.

Perforated sub-hepatic appendix; rare presentation of a common disease.

An elderly gentleman presented to our emergency with a 10-day history of right upper quadrant pain and nausea with associated tenderness on examination. His white cell counts were raised with predominant neutrophils with ultrasound evidence of a heterogeneous sub-hepatic collection, not associated with fever, diarrhoea or vomiting. He had a similar episode 3 weeks ago, which resolved with antibiotics. Initially thought to be a perforated acute appendicitis or a liver abscess a CT scan was done to further substantiate our finding. This to the contrary revealed a perforated sub hepatic appendix. Patient was treated conservatively with IV fluids and antibiotics and the sub hepatic collection was aspirated under ultrasound guidance. He responded well to treatment and made an uneventful recovery.

Learning the hard way: when a CT scan misleads your diagnosis.

Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very high mortality. Time is of essence and if not promptly recognised these injuries could have devastating consequences. We report a case emphasising the importance of oesophagoscopy in diagnosing oesophageal injuries. A young man presented to our emergency ward as an unwitnessed road traffic accident after receiving first aid from a secondary care facility. At presentation, he was haemodynamically stable with decreased power in lower limbs, and with severe neck and back pain. There was high suspicion of spinal injury, which was later evident on clinical and on radiological findings. A CT scan revealed oesophageal injury, indicated by contrast extravasation, which was convincing enough to proceed without endoscopy. Surprisingly, the apparently convincing injury picked up on CT scan marked by contrast extravasation turned out to be an artefact, which led to a negative surgical exploration.