Effect of Electrocoagulation and Direct Pressure Application on Bleeding from Liver Bed During Laparoscopic Cholecystectomy.

OBJECTIVE: To compare the efficacy of electrocoagulation and direct pressure application in controlling haemorrhage from the liver bed during laparoscopic cholecystectomy. STUDY DESIGN: Randomized controlled trial. Place and Duration of the Study: Department of General Surgery, Sir Ganga Ram Hospital, Lahore, Pakistan, from July 2021 to December 2021. METHODOLOGY: A total of 218 patients of either gender, aged 18 to 60 years and with bleeding from the liver bed during laparoscopic cholecystectomy were randomly allocated to two groups of haemorrhage control techniques. In group A, electrocoagulation was used and in group B, direct pressure was applied to the bleeding area for 5 minutes. Efficacy in controlling bleeding was compared in both groups. RESULTS: The mean age of all study participants was 44.6 + 13.5 years. The majority of the patients were females (89%). The mean body mass index (BMI) of all participants was 25.3 ± 3.09 kg/m2. Intraoperative bleeding was secured in 86.2% of patients in Group A vs. 81.7% of patients in Group B. However, the difference was not statistically significant (p=0.356). In 27 (12.4%) cases, bleeding could not be controlled by both of these techniques. In these cases, endosuturing was applied in 19 (70.4%) cases, spongostan in 6 (22.2%) cases, and endo-clips in 2 (7.4%) cases. Intraoperative drain and conversion to open procedure was required in 1 patient each, both belonging to the direct pressure application group. CONCLUSION: The efficacy of electrocoagulation in securing haemorrhage from the liver bed is better than the direct pressure application technique. KEY WORDS: Laparoscopic cholecystectomy, Haemorrhage, Electrocoagulation, Surgical hemostasis, Liver bed.

A Profile of Colorectal Tumors Presenting as Emergency.

OBJECTIVE:  To determine the factors, management and outcome of colorectal tumors presenting at Emergency Department, Mayo Hospital, Lahore. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Accident & Emergency Department, Mayo Hospital, Lahore, from August 2017 to July 2019. METHODOLOGY: Conducted on 40 consecutive patients who presented in the Accident and Emergency Department, Mayo Hospital, Lahore; determined to have colon or rectal cancer as the cause of intestinal obstruction or perforation, were studied. Data was abstracted from patient charts. Studied variables included patient's demographic data, indication for admission, surgical procedure done, complications, histopathology and mortality rate. RESULTS: Forty patients underwent operations of colon and rectum during the study period. Mean age at presentation was 37.8 ± 16.7 years. Intestinal obstruction (75%) was the main presenting symptom. Ascending colon was the main site involved (50%), followed by recto-sigmoid mass (15%) and rectal mass (12.5%); 80% patients subjected to the stoma formation. Electrolyte imbalance and wound infection were the most common medical and surgical complications. Adenocarcinoma was the most common tumor on histopathology (92.5%). After surgery 87.5% patients survived and 12.5% patients expired. Factors significantly associated with worse outcome were greater ASA score (p=0.004), absence of screening colonoscopy in the past (p=0.013) and postoperative medical complications (p<0.001). CONCLUSION: Colorectal tumor cases continue to present in emergency in a high number. Male gender, young age and ascending colon cancers were more frequent among such cases. Most patients had to undergo stoma formation in emergency. Mortality is significantly associated with higher ASA score, absence of screening colonoscopy and postoperative medical complications. Key Words: Colorectal carcinoma, Adenocarcinoma, Ascending colon, Wound infection, Emergency, Young males, Screening colonoscopy, ASA score.

Psychological impact of COVID-19 pandemic on postgraduate trainees: a cross-sectional survey.

BACKGROUND: The present study aimed to evaluate psychological impact of COVID-19 outbreak on postgraduate trainees in Pakistan by quantifying the symptoms of depression, anxiety and acute stress disorder and by analysing potential risk factors associated with these symptoms. METHODS: Following Institutional Review Board approval, a cross-sectional study was conducted among 10,178 postgraduate trainees following COVID-19 outbreak through e-log system of College of Physicians and Surgeons of Pakistan. The nine-item Patient Health Questionnaire, seven-item Generalised Anxiety Disorder scale and Stanford Acute Stress Reaction Questionnaire were used to collect data. Statistical analyses were conducted using SPSS.26. Descriptive statistics, Mann-Whitney U test, the χ2 test and logistic regression analysis were performed. The significance level was set at α=0.05. RESULTS: The prevalence of depressive symptoms, generalised anxiety disorder and acute stress disorder were 26.4%, 22.6% and 4.4%, respectively. Female postgraduate trainees, senior trainees and front-line workers reported experiencing more anxiety, depression and acute stress symptoms (p value<0.001). Logistic regression showed that being a front-line and senior staff member and female was associated with higher risk of experiencing symptoms of depression, anxiety and acute stress. CONCLUSIONS: Our study findings raise concerns about the psychological well-being of postgraduate trainees during the acute COVID-19 outbreak in Pakistan. It is necessary to employ strategies to minimise the psychological distress and provide adequate psychosocial support for postgraduate trainees during crisis situation such as COVID-19 pandemic.

Supervisor's Feedback on Progress of E-Logbook System of CPSP: A Cross-sectional Survey.

OBJECTIVE: To determine the feedback of supervisors regarding role of e-logbook in monitoring of training, strengthening supervisor-supervisee relationship and improving overall environment of postgraduate training at College of Physicians and Surgeons Pakistan (CPSP). STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: College of Physicians and Surgeons Pakistan (CPSP) from July to December, 2017. METHODOLOGY: All registered supervisors of CPSP who were monitoring training and had minimum three years postfellowship experience were included. Non-probability consecutive sampling technique was employed. HTML-based questionnaires were sent through e-log. Likert scale was used to rate statements about e-logbook, where "1" was "strongly disagree" and "5" denoted "strongly agree". The data were entered in SPSS version 21 and analysed through its statistical package. RESULTS: A total of 816 supervisors responded to the questionnaires (response rate of 65%). Out of these, 74.3% were males and 25.7% were females with mean age of 52.8 +6.9 years. Majority of the supervisors agreed (62%) or strongly agreed (10%) that e-logbook has helped to improve the supervisor-supervisee relationship. More than half (60%) of the supervisors agreed, whereas some (19.3%) strongly agreed that e-logbook is a better monitoring tool than conventional logbook. The supervisors believed that overall training environment has improved with the introduction of e-log system (51% agreed and 9% strongly agreed). The age of supervisors and duration of supervisorship had no statistically significant effect on the responses of supervisors to various statements about e-logbook. CONCLUSION: Supervisors perceive electronic logbooks as a useful medium for training monitoring and improvement of the relationship between supervisors and their residents. They have shown wide acceptability to the e-log system. E-log should continue as the primary monitoring system of the training programmes of CPSP.

Household costs of breast cancer morbidity: An empirical assessment from Pakistan.

PURPOSE: Health care costs attributable to breast cancer are substantial. In countries with high poverty, lack of public health infrastructure and low availability of health insurance, the economic burden of disease does not accrue solely to health care, but also on patients and their families. This study was conducted to explore the cost burden (i.e. direct medical costs, direct non-medical costs and indirect non-medical costs) incurred by breast cancer patients and their families over diagnosis and treatment. METHODS: Data was collected from 200 breast cancer patients at two hospitals in Lahore, provincial capital of Punjab, Pakistan, by employing purposive sampling technique. Costs were aggregated into three categories and compared with each other as per their weightage. RESULTS: The study found that direct medical care (US$ 1262.18/ Local currency (PKR) 129,717) is the largest expense, followed by direct non-medical (US$ 310.88 / PKR 31,950) and indirect non-medical costs (US$ 273.38 / PKR 28,096). CONCLUSIONS: The results of this study provide rich insight into the financial burden borne by households of breast cancer patients and suggest policy implications.

Supervisors' Perspective on Electronic Logbook System for Postgraduate Medical Residents of CPSP.

OBJECTIVE: To find out the perspective of the supervisors about the role of electronic logbook (E-Logbook) of College of Physicians and Surgeons, Pakistan (CPSP) in monitoring the training of postgraduate medical residents of CPSP. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: College of Physicians and Surgeons Pakistan (CPSP), Karachi, from May to October 2015. METHODOLOGY: An electronic computer-based questionnaire designed in Hypertext Preprocessor (PHP) language was distributed to the registered CPSPsupervisors through the e-log system. The questionnaire comprised of seven close ended questions. The data were entered and analyzed by SPSS version 20. Descriptive statistics were determined. RESULTS: Atotal of 1,825 supervisors responded to the questionnaire. Fifteen hundred and ninety-eight (87.6%) supervisors gave regular feedback for their trainees, 88.2% considered it a better monitoring tool than conventional logbook, 92.5% responded that e-logbook helped in the regular assessment of the trainees, 87.8% believe that quality of training will improve after introduction of e-logbook, 89.2% found e-logbook useful in implementation of outcome-based learning and 88.4% considered e-logbook user-friendly. The main reasons for not providing regular feedback included the supervisors not familiar to e-logbook interface, internet access problems, and busy schedules of supervisors. CONCLUSION: There was a wide acceptability of the e-log system among the supervisors with positive perception about its usefulness. The common reasons that hinder the provision of regular feedback include not being familiar to e-log interface, internet access problem, busy schedule and some consider using e-logbook a cumbersome task. These reasons can be alleviated to provide a better training monitoring system for the residents.

Mortality Prediction in Patients Admitted in Surgical Intensive Care Unit by Using APACHE IV.

OBJECTIVE: To predict the mortality by the mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score of all the patients admitted in a Surgical Intensive Care Unit (ICU) and comparing the score of the survivors and non-survivors. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Surgical Intensive Care Unit, Mayo Hospital, Lahore, from June 2013 to November 2014. METHODOLOGY: All adult patients admitted in the Surgical ICU were included in this study. The demographics and other data of the patients were recorded. The APACHE IV scores of all patients were calculated at the time of admission. The scores of the survivors and the non-survivors were compared for prediction of survival and mortality. RESULTS: The age of these patients ranged from 13 to 70 (mean 38.39) years with 86 (55.48%) males and 69 (44.52%) females. The mean APACHE IV score of these patients was 34.96 ±14.93 ranging from 11 to 63 years. Eighty-three (53.55%) patients survived and 72 (46.45%) died. With respect to gender, 41 (47.67%) males out of 86 and 31 (44.92%) females out of 69 did not survive. The mortality increased with an increase in APACHE IV score and all the patients with score more than 39 did not survive. CONCLUSION: The predicted mortality can be assessed by APACHE IV score, so it is good for application among the surgical ICU patients.

Use of the"bogota bag"for closure of open abdominal wound after exploratory laparotomy - our experience at Mayo Hospital Lahore.

OBJECTIVE: To assess the efficacy of Bogota bag for closure of open abdominal wounds after laparotomy where the primary closure cannot be achieved and other closure techniques are not available. METHODS: The descriptive study was conducted at Mayo Hospital, Lahore, Pakistan, from September 2011 to February2015, and comprised patients who underwent laparotomy and peritoneal cavities and who could not be closed primarily because of various reasons like traumatic loss and oedematous gut. They were managed with Bogota bag for abdominal closure. SPSS 18 was used for statistical analysis. RESULTS: Of the 55 patients, 37(67.27%) were male and 18(32.73%) were female. There was traumatic loss in 34(61.8%), oedematous gut and omentum in 15(27.27%) and gangrenous abdominal wall in 6(10.9%) patients. Bogota bag was applied in all (100%) of them. In 19(34.55%) patients, delayed primary closure was possible, so the Bogota was used temporarily. In 36(65.45%) cases managed with Bogota bag, healing occurred by granulation tissue or skin grafting/flaps were applied and these patients developed hernia. Five (9.09%) patients developed small bowel fistula which was managed conservatively. No patient developed complication due to exposure or abdominal compartment. There were 7(12.8%) postoperative deaths due to the disease process and were unrelated to the closure technique. CONCLUSIONS: Bogota bag was an effective means of closure of open abdominal wound and prevented the complications due to open abdominal wounds or closure under tension.

CPSP/HSE Postgraduate Overseas Rotational Programme: Residents' Perspective.

OBJECTIVE: To get direct upward feedback from the residents of first batch of CPSP/HSE Postgraduate Scholarship Programme. STUDY DESIGN: Mixed methods qualitative research study. PLACE AND DURATION OF STUDY: CPSP, Regional Office, Lahore, in June 2015. METHODOLOGY: It is a mixed-method study that was conducted in June, 2015. Data was collected through an email survey with 33 medical residents doing their rotation in Ireland; and focus group discussions were carried out with 8 residents, who had successfully completed their rotation. Data were collected through pre-designed questionnaires comprising of open- and close-ended questions. The data were entered into SPSS version 21 and analyzed. RESULTS: The mean age of residents was 29.9 &plusmn;1.1 years, 7 (21.2%) were females and 24 (72.7%) respondents were males. Residents agreed that HSE programme has improved their evidence-based decision making (mean score of 3.3 &plusmn;1.2) and enhanced professionalism (mean score of 3.6 &plusmn;1.1). They disagreed that training has polished their procedural skills (mean score 2.4 &plusmn;1.2). The identified strengths of the programme are: adopting a systematic approach towards patients, evidence-based decision making, better exposure and opportunities, financial stability and development of communication skills. The weaknesses are: less exposure to procedural skills, difficulty in synopsis and dissertation writing and difficulty in adjustment with rotational schedules. CONCLUSION: Residents of CPSP/HSE Programme believed that CPSP/HSE has improved their professionalism, communication skills and increased their future opportunities for career growth. Better communication between CPSP focal person and residents will help sort out many minor but important issues.

E-Log System in Monitoring of Residency Program: Trainees' Perspective.

OBJECTIVE: To record residents' perspective about the utility of newly introduced E-Log system at the College of Physicians and Surgeons Pakistan (CPSP). STUDY DESIGN: Sequential mixed method design using survey questionnaire and in-depth interviews. PLACE AND DURATION OF STUDY: CPSP, Regional Center, Lahore, from March to June 2014. METHODOLOGY: Data was collected from registered trainees through a web-based survey questionnaire on a scale of 1 to 7 about the utility of E-log system. In-depth interviews were conducted with 7 students using non-probability purposive sampling. The interviews were tape recorded and subsequently transcribed. Quantitative data was analyzed using SPSS version 20 and qualitative data was analyzed using content analysis by identifying themes and patterns. RESULTS: Atotal of 4399 responses were received. Motivation was 4.61 ± 1.98; 4.33 ± 2.00 remained acknowledgment of control of one's training by the new system. Ease of use got a mean score of 4.56 ± 2.15. CONCLUSION: The overall acceptance of the students regarding E-Log system was high. Scheduling IT workshop at the start of training will add to the student satisfaction regarding utility of E-Log system.

Postgraduate trainee performance with structured assessment techniques in competency-based model of training.

OBJECTIVE: To determine the effect of changes in curriculum and structured assessment on the performance of candidates at the end of the first phase of residency program by comparing pass percentages of candidates with older residency program. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: From 2007 to 2009 at the College of Physicians and Surgeons Pakistan. METHODOLOGY: Results of midterm assessment (intermediate module, IMM) for the years 2006-2007 (Historical group) in 9 specialties were compared with those of years 2008-2009 (Interventional group) after implementation of curricular changes. The changes were evaluated with structured assessment technique. Results for the IMM exams for years 2006 to 2009 were included in the study. Percentage changes in results of both groups were subjected to statistical analysis. RESULTS: The average pass percentage for theory examination in the Historical group was 52.6% + 13.87, and 59.96 + 14.88 in Intervention group. The pass percentage in old-residency program for the clinical examination was 61.6% (ranging from 48.0% to 78.4%) which was less when compared with the new residency system that was 73.9% (ranging rom 61.5% to 82.45%). CONCLUSION: The curricular changes and structured assessment at set competency standard resulted in better performance and higher pass percentages of candidates at midterm assessment.

Stray bullet in inferior vena cava.

A young boy presented in emergency with history of being hit by a stray bullet injuring the right hypochondrium. Ultrasound of abdomen showed hemoperitoneum and the radiograph showed bullet in the pelvis. Exploratory laparotomy showed injuries to liver and cystic duct with tract leading retroperitoneally into the inferior vena cava. The bullet was found wandering inside the vena caval lumen. Stray bullets are presumed to remain limited to the soft tissues. However, the trajectory, impact velocity and the involved region ultimately determine the outcome and influence management.