Surgical Management of Pericaecal Hernia in a Virgin Abdomen.

Internal hernia is an uncommon cause of mechanical small bowel obstruction. This case report details a 66-year-old Chinese male with no prior abdominal surgeries who presented with colicky abdominal pain, abdominal distension, and vomiting. Initial investigations were unyielding, but escalating symptoms prompted a diagnostic laparoscopy. Laparotomy then revealed a closed-loop obstruction through a lateral type pericecal hernia, with a segment of ischemic jejunum. Adhesion bands in the right iliac fossa and a congenital hernia orifice in the mesentery were identified and addressed. The patient recovered well postoperatively. This discussion explores the Meyer's classification of pericecal hernias, potential etiologies, clinical manifestations, diagnostic considerations, and the choice between laparoscopic and open surgeries. This case underscores the importance of a high index of suspicion, prompt surgical intervention, and the diagnostic utility of laparoscopy in managing pericecal hernias.

ChatGPT versus human in generating medical graduate exam multiple choice questions-A multinational prospective study (Hong Kong S.A.R., Singapore, Ireland, and the United Kingdom).

INTRODUCTION: Large language models, in particular ChatGPT, have showcased remarkable language processing capabilities. Given the substantial workload of university medical staff, this study aims to assess the quality of multiple-choice questions (MCQs) produced by ChatGPT for use in graduate medical examinations, compared to questions written by university professoriate staffs based on standard medical textbooks. METHODS: 50 MCQs were generated by ChatGPT with reference to two standard undergraduate medical textbooks (Harrison's, and Bailey & Love's). Another 50 MCQs were drafted by two university professoriate staff using the same medical textbooks. All 100 MCQ were individually numbered, randomized and sent to five independent international assessors for MCQ quality assessment using a standardized assessment score on five assessment domains, namely, appropriateness of the question, clarity and specificity, relevance, discriminative power of alternatives, and suitability for medical graduate examination. RESULTS: The total time required for ChatGPT to create the 50 questions was 20 minutes 25 seconds, while it took two human examiners a total of 211 minutes 33 seconds to draft the 50 questions. When a comparison of the mean score was made between the questions constructed by A.I. with those drafted by humans, only in the relevance domain that the A.I. was inferior to humans (A.I.: 7.56 +/- 0.94 vs human: 7.88 +/- 0.52; p = 0.04). There was no significant difference in question quality between questions drafted by A.I. versus humans, in the total assessment score as well as in other domains. Questions generated by A.I. yielded a wider range of scores, while those created by humans were consistent and within a narrower range. CONCLUSION: ChatGPT has the potential to generate comparable-quality MCQs for medical graduate examinations within a significantly shorter time.

Case report on a rare complication after transanal total mesorectal excision (TaTME) for rectal malignancy vesicorectal fistula.

INTRODUCTION AND IMPORTANCE: Transanal Total Mesorectal Excision (TaTME) represents the latest surgical approach in rectal cancer management. We present a rare case of vesicorectal fistula (VRF) following a complication of TaTME surgery. CASE PRESENTATION: A 67-year-old male underwent a Hartmann's procedure for perforated rectosigmoid cancer in 2019. He was lost to follow-up and re-presented in 2021 with synchronous cancer of the transverse colon and rectum. A two-team surgical approach was utilized: open subtotal colectomy (transabdominal approach) with concurrent excision of rectal stump (TaTME approach). Intraoperatively, an inadvertent bladder injury was identified and repaired. 8 months later, he re-presented with the passage of urine per rectum. Imaging and endoscopy revealed a VRF with cancer recurrence at the rectal stump. CLINICAL DISCUSSION: VRF is an uncommon complication of TaTME that carries a significant physical and psychological impact on the patient. While shown to be a safe and useful technique, the long-term oncological outcomes of TaTME are still awaited. Unique complications have been reported with TaTME, including gas embolism and injuries to the genitourinary structures, in which the latter caused the eventual VRF formation in our patient. CONCLUSION: Revisional surgery for recurrent disease is challenging and can result in rare complications, especially in patients with distorted anatomy and when new surgical techniques are utilized. Radiotherapy further causes unpredictable tissue healing quality. The challenge remains for proper patient selection with individualization of surgical approaches, while keeping a close eye on the oncological outcomes of the patient.

COVID-19 and the impact on surgical training and education in Singapore.

The COVID-19 pandemic has affected surgical education and training significantly. The main impact to surgical residency training is the reduction in number of patients (in caseload and case mix) and the conversion of face-to-face meetings into virtual ones for CME and clinical governance-related events. Assessment of surgical residents by examination (namely the Joint Specialty Fellowship Examination with the College of Surgeons of Hong Kong and the Royal College of Surgeons of Edinburgh) was cancelled at the peak of the pandemic, with resumption after acceptable COVID compatible adjustment was made to the format. The migration of CME events into a web-based one has resulted in greater connectivity with more audience. The potential and challenges of virtual format in surgical education include strategy and resources for sustainability; choice of optimal model for effective learning and surgical skills acquisition. In a post-COVID world, the model of blended learning is likely to remain.

Bowel ulceration following tocilizumab administration in a COVID-19 patient.

Tocilizumab, a monoclonal antibody against interleukin-6, has been used to treat cytokine release syndrome (CRS) in a subset of patients with severe COVID-19 disease. Acute ulcerative bowel disease has been only rarely documented in patients treated for rheumatological conditions. The gastrointestinal side effects seen when used in the context of COVID-19 are unknown. We present a case of COVID-19 CRS in which acute terminal ileum and perforated caecal ulceration evolved after tocilizumab exposure. We raise awareness of a possible causal relationship between even a single dose of tocilizumab and gut ulceration in patients with COVID-19. Any such drug enteropathy relationship requires watchful monitoring during upcoming trials of tocilizumab in patients with COVID-19.

Singapore's anatomical future: quo vadis?

The disciplines of anatomy and surgery are not dichotomous since one is dependent on the other. Traditionally, surgeons predominantly taught gross and clinical anatomy. In this review, we examine the context of how human anatomy is taught nowadays. In essence, we discovered that there are certain discernable trends consistently observable between the American and British systems. In Singapore, the British Russell Group first influenced its education landscape but now more so by the American Ivy League. Singapore now has three medical schools all offering differing anatomy curricula, which serves as an opportune time for it to consider if there is a best approach given that the practice of surgery is also evolving in parallel. This review discusses the various pedagogies and issues involved, and will serve as a forum and stimulus for discussion. By tweaking the curriculum correctly and the lessons learnt, future doctors and surgeons in training will receive a better anatomical education, not just in Singapore but the world in general. Key recommendations include the use of body painting, clay, plasticine to facilitate the learning of anatomy, and the implementation of a body donation program. Furthermore, strategic mergers with key stakeholders will also ensure the survival of the discipline.