The complex role of post-operative magnesium on the long term serum calcium and parathyroid hormone levels in patients undergoing total and near-total thyroidectomy.

Objective: To assess the role of hypomagnesaemia in the development of permanent hypocalcaemia following thyroidectomy. METHODS: The prospective cohort study was conducted from April 3, 2017, to January 2, 2020, at Surgical Unit 1, Benazir Bhutto Hospital, Rawalpindi, Pakistan, and comprised of patients of both genders undergoing total and near total thyroidectomy. Post-operative calcium and magnesium levels were noted, and the patients were followed up after 6 months and fasting serum calcium, magnesium and parathyroid hormone levels were checked. Signs and symptoms of hypocalcaemia were noted. Data was analysed using SPSS 22. RESULTS: Out of the 62 patients followed up, 57 (91.9%) were females and 5 (8.1%) males. The overall mean age was 38.5 ± 12.1 years Post-operative hypomagnesaemia was seen in 6(9.8%) patients and none developed follow-up hypocalcaemia. Post-operative magnesium levels were significantly negatively correlated with follow-up parathyroid hormone level (p=0.006). Fall in magnesium post-operatively and follow-up magnesium were positively correlated with follow-up parathyroid hormone (p<0.05). Permanent hypocalcaemia was seen in 7(11.4%) patients and it was significantly associated with pre-operative and post-operative calcium levels, post-operative symptoms of hypocalcaemia and readmission for hypocalcaemia after discharge (p<0.05). Follow-up hypomagnesaemia was significantly associated with follow-up hypocalcaemia (p=0.024) and follow-up symptoms of hypocalcaemia (p=0.031). Conclusion: Acute development of mild hypomagnesaemia post-operatively may be beneficial in early positive feedback for parathyroid hormone secretion. Hypomagnesemia 6 months after surgery may be involved in PTH organ resistance. The complex role of hypomagnesemia on PTH levels must be further explored.

Early and late complications of thyroidectomy: A descriptive cohort study in Rawalpindi.

OBJECTIVE: To assess the epidemiology of thyroid disorders and early and late complications following thyroidectomy.. METHODS: The descriptive cohort study was conducted at the Benazir Bhutto Hospital, Rawalpindi, Pakistan, from April 2017 to Janurary 2020, and comprised of patients undergoing total and near-total thyroidectomy. Post-operative complications were noted, and patients were followed up after 6 months to assess long-term complications. Data was analysed using SPSS 22. RESULTS: Of the 75 patients, 70(93.3%) were females and 43(58.1%) were aged <40 years. The most common symptom was neck swelling with hyperthyroidism 20(41.7%) and pressure symptom 20(41.7%). Post-operative complications developed in 26(35.6%) patients, with symptomatic hypocalcaemia being the most common 10(13.7%), followed by hoarseness 6(8.2%). Biopsy results were available for 50(66.6%) patients. Benign pathology was present in 44(88%) patients and 6(12.0%) had malignancy. Follow-up data was available for 62(82.7%) patients among whom symptomatic hypocalcaemia was the leading complication in 33(53.2%), followed by permanent hoarseness in 6(9.7%). CONCLUSIONS: Symptomatic hypocalcaemia and hoarseness were found to be the most common post-operative and long-term complications of thyroidectomy.

Frequency of Hypomagnesaemia following Total and Near-total Thyroidectomy and its relationship with Hypocalcaemia.

OBJECTIVE: To determine the frequency of hypomagnesaemia in patients undergoing thyroidectomy and evaluate its relationship with postoperative hypocalcaemia. STUDY DESIGN: Observational, cross-sectional study. PLACE AND DURATION OF STUDY: Surgical Unit 1, Benazir Bhutto Hospital, Rawalpindi, Pakistan from April 2017 to May 2019. METHODOLOGY: Preoperative and 24-hour postoperative samples for serum calcium and magnesium of 75 patients undergoing total and near-total thyroidectomy were taken.  Postoperative signs and symptoms of hypocalcaemia were documented. Data was analysed on SPSS version 22, using independent and paired t-test, Pearson correlation, linear regression, Chi-square test and Fisher's Exact test. RESULTS: Postoperatively 49 (65.3%) patients developed hypocalcaemia and 8 (10.7%) developed hypomagnesaemia. Postoperative hypocalcaemia was significantly associated with hypomagnesaemia (p=0.03) with a significant positive linear correlation. Ten patients (13.3%) developed symptomatic hypocalcaemia; however, it was not associated with postoperative hypomagnesaemia. Postoperative hypocalcaemia and hypomagnesaemia were significantly associated with preoperative calcium level (p = 0.03 and 0.04, respectively). There was significantly lower calcium level in patients with hypomagnesaemia (p = 0.002) and a significant fall in magnesium level in patients developing hypocalcaemia (p = 0.044). CONCLUSION: Postoperatively hypocalcaemia was prevalent following thyroidectomy, while hypomagnesaemia was not common.  Hypomagnesaemia and a fall in magnesium level after surgery was associated with hypocalcaemia; but not with symptomatic hypocalcaemia. Monitoring of magnesium levels in severe or persistent hypocalcaemia is recommended. While this study proves a relationship between calcium and magnesium, its clinical implication must be further studied. Key Words: Calcium, Magnesium, Postoperative, Hypocalcaemia, Hypomagnesaemia, Thyroidectomy.

Early Oral Feeding Compared With Traditional Postoperative Care in Patients Undergoing Emergency Abdominal Surgery for Perforated Duodenal Ulcer.

Introduction Enhanced recovery after surgery (ERAS) protocols have been widely studied in elective abdominal surgeries with promising outcomes. However, the use of these protocols in emergency abdominal surgeries has not been widely investigated. This study aimed to evaluate ERAS application outcomes via early oral feeding compared to regular postoperative care in patients undergoing perforated duodenal ulcer repairs in emergency abdominal surgeries. Materials and methods We conducted a randomized controlled trial at the Surgical Unit 1 Benazir Bhutto Hospital from August 2018 to December 2019. A total of 42 patients presenting to the emergency department with peritonitis secondary to suspected perforated duodenal ulcer were included in the study. Patients were randomly assigned into two groups. Group A patients followed an ERAS protocol for early oral feeding, and Group B received regular postoperative care (i.e., delayed oral feeding). Our primary outcomes were the length of hospital stay, duodenal repair site leak, the severity of pain (via the visual analog scale), and postoperative ileus duration. Results were analyzed via IBM Statistical Product and Service Solutions (SPSS) Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). and chi-square and independent t-tests were applied. Results Patients who received early oral feeding (Group A) showed a shorter length of hospital stay, lower pain scores, and shorter postoperative ileus duration than patients in the traditional postoperative care group. Also, we noted no duodenal repair site leak in the early oral feeding group. The differences between the two groups were statistically significant (P<0.05). Conclusions Based on our results, ERAS protocols that promote early oral feeding can be applied in patients undergoing emergency abdominal surgery for perforated duodenal repair. Early oral feeding in emergency surgery patients can reduce the patient burden on hospitals. In addition, early oral feeding can promote better outcomes and reduced economic burden for patients. Keywords: Perforated duodenal ulcer, ERAS protocol, randomized controlled trial, duodenal repair site leak, length of hospital stay, VAS score, postoperative ileus.

Effect of Prophylactic Ilioinguinal Neurectomy on Postoperative Groin Pain Following Lichenstein Hernioplasty.

OBJECTIVE: To compare mean postoperative pain post-Lichenstein open hernioplasty with and without ilioinguinal neurectomy at six months. STUDY DESIGN: Randomised controlled trail. PLACE AND DURATION OF STUDY: Surgical Unit-I, Benazir Bhutto Hospital, Rawalpindi, from August 2014 to February 2015. METHODOLOGY: Adult male patients with unilateral reducible inguinal hernia, who consented to the study between the age range of 18-80 years, were included. Recurrent, irreducible or strangulated, or large inguinal-scrotal hernia and those with previous abdominal incision, impaired cognition, peripheral neuropathy, limited mobility and females were excluded. Patients were equally randomised to nerve-preservation and excision groups. Mann-Whitney U-test was applied to find out difference in inguinodynia at 1 and 6 months. RESULTS: There was significant difference in pain at 1 month in the nerve-preservation group (Md=6.00, IQR=4, n=90) and nerve excision group (Md=3.50, IQR=4, n=90), U=2308.00, z=-5.017, p<.001 and at 6 months in the nerve preservation group (Md=2.00, IQR=1, n=90) and nerve-excision group (Md=0.00, IQR=1, n=90), U=3001.00, z=-3.470, p=0.001. CONCLUSION: Prophylactic ilioinguinal neurectomy significantly reduces groin pain at 6 month as compared to nerve preservation group following Lichenstein hernioplasty.

Analysis Of Level Of Satisfaction Of Postgraduate Trainees On Surgical Floor.

BACKGROUND: Organizations flourish with a satisfied workforce. There is little known information on demographic characteristics and motivators for job satisfaction among Pakistani postgraduate trainees in surgery. Job satisfaction is predicted by intrinsic motivators (personal growth and perceived ability to work) and extrinsic motivators (perceived social support). Work family interference/enhancement and job stressors (workload and long working hours) also impacts job satisfaction; predicting overall life satisfaction. This study aims at examining life satisfaction predicted by personal and professional characteristics.. METHODS: The postgraduate trainees in the public and private hospitals of Rawalpindi and Islamabad were surveyed using validated measures of life satisfaction, personal growth, perceived social support, perceived ability to work, work family interference/enhancement, job stressors, co-workers support, supervisors support, and job satisfaction from September 15 to December 28, 2017. RESULTS: Personal growth, perceived ability to work, availability of social support, and work family enhancement positively correlate to job and life satisfaction. Work life interference and job stressors negatively relate to job and life satisfaction. Job satisfaction is also partially mediated by intrinsic and extrinsic motivators on life satisfaction, whereas job stressors weakened the relationship between job satisfaction and life satisfaction. Long working hours is negatively related to job satisfaction and life satisfaction. CONCLUSIONS: Life satisfaction is predicted by job satisfaction that is characterized intrinsic and extrinsic motivators. Healthcare organizations face challenge of providing reduced working hours, increased salaries, supportive working environment, and increased supervision to enhance the job satisfaction of employees and to improve the functioning of the healthcare environment.

Cystic Pleural Synovial Sarcoma.

Fewer than 40 cases of primary pleural synovial sarcoma have been reported so far with only 3 cases of cystic synovial sarcoma including cases originating from sites other than the pleura. Here, we present an exceedingly rare case of cystic synovial sarcoma originating from the mediastinal side of the visceral pleura in a 25-year man presenting with hemoptysis. On contrast-enhanced computed tomography (CT), cystic synovial sarcoma and cystic thymoma were difficult to be distinguished due to mediastinal location. Histopathological examination showed spindled morphology of tumor cells with hypercellularity and nuclear atypia. As these features are associated with both monophasic fibrous synovial sarcoma and type Athymoma, immunohistochemistry was performed. Adiagnosis of synovial sarcoma was confirmed by detection of CD99 and EMAand negativity of other markers. Fluorescence in situhybridization (FISH) was not done. Surgical excision was done and followed by oncology referral.

Perforated obturator Littr hernia in an elderly woman.

Obturator hernia is an uncommon condition. It carries the highest mortality amongst abdominal wall hernias, usually presenting in elderly, multiparous and thin ladies. Meckel diverticulum is a rare cause of intestinal obstruction and its existence in an obturator hernia is extremely rare; our literature search revealed only two reported cases. We report the case of a 70-year-old woman who presented with signs and symptoms of intestinal obstruction and peritonitis. An exploratory laparotomy led to diagnosis of a strangulated obturator hernia. The sac contents included a Meckel diverticulum with a perforation at its base and a loop of the ileum. The ischemic ileal segment including the Meckel diverticulum was resected and a loop ileostomy was created.

Teleoncology: improving patient outcome through coordinated care.

INTRODUCTION: There are few specialized oncology centers in Pakistan. Teleoncology was introduced for weekly tumor case meetings between the surgery departments of Holy Family Hospital and NORI Hospital using videoconferencing. The team of surgeons, radiologists, and histopathologists of Holy Family Hospital and the oncologists from NORI Hospital are now conducting joint regular multidisciplinary meetings weekly for the well-being of patients of the area. The purpose of this study is to describe the infrastructure, consultative process, technical aspects, and initial evaluation of these meetings. MATERIALS AND METHODS: The surgical oncology patients are discussed every Friday morning since November 2009. A standardized format was adopted for case discussion in these multidisciplinary meetings. The postgraduate trainee presents the case from either side followed by management plan discussion. The oncologists may request a discussion to plan an intervention at Holy Family Hospital, or the surgeons at Holy Family Hospital may present a case that would benefit from multidisciplinary skills. RESULTS: In total, 264 patients were discussed. The mean age of the patients was 51±16.2 years. In 43% of the patients, the joint treatment strategy was refined from the initial proposed treatment. Breast and gastrointestinal tract malignancies were the most common cases, followed by endocrine and skin and soft tissue tumors. CONCLUSIONS: Teleoncology services can be extended easily with little addition to existing infrastructure but significantly reduce the stress for families as they deal with this challenging disease. Moreover, they improve the clinical evaluation and management strategies.

Metastatic involvement of the spleen by endometrial adenocarcioma; a rare asylum for a common malignancy: a case report.

BACKGROUND: Metastatic involvement of the spleen by solid tumors is a rare clinical entity; those coming from endometrial adenocarcinomas are exceptionally rare. Spleen is an uncommon site for metastatic deposits due to its specific anatomy and microenvironment. Typically, splenic metastasis from endometrial carcinomas present months to years after curative surgery, chemotherapy or radiotherapy. The most common complaint in symptomatic patients is abdominal pain localized to the left hypochondrium. Most however, are asymptomatic only to be picked up on vigilant routine ultrasonography or computerized tomography during follow up. We report the case of a 54-year-old woman who presented to us after 50 months of total abdominal hysterectomy and bilateral salpingo-oophorectomy for an endometrial adenocarcinoma. She had severe abdominal pain localized to the left hypochondrium as the presenting complaint. To the best of our knowledge, this is the 1st case to be reported from Pakistan with 14 cases reported prior to our report. All past cases report the endometroid variant of endometrial adenocarcinoma as the primary tumor and our patient was a victim to the same variant. CASE PRESENTATION: A 54-year-old, nulliparous widowed woman presented with severe abdominal pain in the left hypochondrium for the last 4 months. The pain radiated to the left shoulder and was exacerbated with deep breathing. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy done 50 months back for stage 1a endometroid endometrial adenocarcinoma. Clinical examination revealed tenderness in the left hypochondrium but no visceromeglay was appreciable. Ultrasonography and computerized tomography revealed a space-occupying lesion within the spleen with associated splenomegaly. Computed tomography further suggested a large splenic abscess however the patient did not have fever, vomiting or leukocytosis which are the hallmarks of a splenic abscess. A splenectomy was performed for her complaints. On histopathology a metastatic adenocarcinoma was identified consistent with the primary tumor. The tumor was CK7, CA-125 and epithelial membrane antigen positive (EMA). The patient was then referred for further chemotherapy. CONCLUSION: From this case we conclude, that although very rare, the spleen is a potential site for metastasis in endometroid endometrial adenocarcinoma. Since most patients are asymptomatic, routine examinations and imaging can identify its presence and avoid complications. If the practice is employed with vigilance, we may expect the clinical event to be diagnosed more frequently. The standard treatment is a classic splenectomy followed by chemotherapy.

Role of nasogastric intubation after small bowel anastomosis.

OBJECTIVE: To determine advantages and disadvantages of postoperative nasogastric intubation after small bowel anastomosis. STUDY DESIGN: Quasi experimental. PLACE AND DURATION OF STUDY: Surgical Unit-I, Holy Family Hospital, Rawalpindi, from December 2003 to December 2006. METHODOLOGY: A total of 112 patients, undergoing small bowel anastomosis were equally divided in group I and II with and without postoperative nasogastric intubation respectively. Variables compared were number of patients having episodes of vomiting, change in abdominal girth, the time for onset of bowel sounds, time to begin per oral fluids, length of hospitalization and postoperative complications. RESULTS: In group-I, nasogastric tube was removed on an average after 3.1 days. Average postoperative nasogastric output was 357, 154 and 64 ml/day for day 1, 2 and 3 respectively. There was no statistically significant difference between two groups in abdominal girth before and after operation, frequency of vomiting, time taken for onset of bowel sounds and start of oral sips after operation, frequency of wound infection, anastomotic leak and mortality (p>0.05). Length of postoperative hospital stay and frequency of postoperative respiratory complications were more in group-I as compared to group-II (p<0.05). CONCLUSION: Nasogastric decompression does not provide added advantage after small bowel anastomosis.

Classification and management of chest trauma.

OBJECTIVE: To classify the predominant pattern of injuries following blunt and penetrating chest trauma and to assess the adequacy of treatment strategies, complications and mortality associated with such injuries. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Surgical Unit I, Holy Family Hospital, Rawalpindi, from December 2000 to December 2003. PATIENTS AND METHODS: One hundred consecutive patients with thoracic trauma either blunt or penetrating, admitted in the ward were evaluated. Their injuries were classified, treatment strategies outlined and complications and mortality were documented on a specially-designed proforma. RESULTS: Out of the 100 patients presenting in emergency, 44% presented with blunt and 56% with penetrating trauma. Pneumothorax was detected in 39% of the patients, hemopneumothorax in 29%, hemothorax in 12%, flail chest in 9 %. Two had involvement of the heart and major vessels, 4 % had injury to the diaphragm and 5 % had multiple trauma. During treatment, 3% of all the patients were managed conservatively, 83% of patients required chest intubations, 6% needed ventilatory support and 8 % required thoracotomy. Complications were experienced in 28% of the patients of which 9% had pneumonias, 14% empyema and 5 % suffered from wound infections. The overall mortality was 7 %. CONCLUSION: This series showed the pattern of injuries following blunt and penetrating chest trauma. Furthermore, it was found that chest intubation and simple resuscitation was adequate for majority of the cases.