Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan.

Introduction The currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion. Methods This prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant. Results In our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population. Conclusion An open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.

Satisfaction in Patients After Rhinoplasty Using the Rhinoplasty Outcome Evaluation Questionnaire.

Introduction Rhinoplasty is a challenging procedure. The goal of the surgery is not only to restore the function and youthful appearance of the nose but also to improve quality of life. With the passage of time, the trend has been changing rapidly from more invasive to less invasive procedures. Although the technical aspects of rhinoplasty are important, patient satisfaction is the factor that dictates the success of the procedure. Materials and methods A total of 118 rhinoplasties were performed in our department between 2016 and 2018. The Rhinoplasty Outcome Evaluation (ROE) questionnaire was used to study the patients' satisfaction level. Ninety out of 118 patients took part in this study. Rhinoplasty was done using an open technique in all cases. The ROE questionnaire was filled preoperation and six months postoperation. Data analysis was done using SSPS statistic version 20 (IBM Corp., Armonk, NY, US). Results The main reasons for rhinoplasty in our patients were: aesthetic 23.3% (n=21), functional 25.5% (n=23), and a combination of both in 51% (n=46) patients. The mean ROE score of all patients preoperation was 30.5 (males: 31.3, females 29.8) and the mean score postoperation was 79.5 (males 78.2, females 80.9) at six months with no statistical differences (CI 17.11 - 12.59, P=0.762). However, both genders showed a statistically significant improvement between the preoperative and postoperative scores (mean difference = 49.3, CI 63.25 - 35.34, P<0.01), indicating an overall good satisfaction level after surgery. The satisfaction level of patients was inversely proportional to their level of understanding and knowledge of the surgical procedure. This difference was statistically significant ( CI 7.36-10.42, P<0.01). Minor corrections or modifications were done in eight patients under local anesthesia, with no significant difference in ROE scores as compared to those who had single surgery (CI 0.7 - 1.6, P=0.92). There was no statistically significant difference in the before and after surgery ROE scores among patients operated by different surgeons as well (P=0.82). Conclusion Our study shows that rhinoplasty, despite being a complex procedure, has proven benefits in terms of functional as well as aesthetic outcomes. The ROE questionnaire proves to be a valid tool for estimating patient satisfaction in our population. There is a need for further training and education of surgeons in Pakistan to improve the functional and aesthetic disabilities of nasal deformities.

Functional Outcomes of Secondary Procedures in Upper Extremity Replantation and Revascularization.

Introduction Traumatic amputation of the upper limb has significant associated morbidities and disabilities. After successful replantation surgery, the micro-surgeons' tasks are far from over. The replanted and revascularized segments have numerous functional restrictions and need various corrective secondary procedures. The aim of our study was to compare the functional results after secondary procedures by administering the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire to patients who had successful upper limb replantation and revascularization. Materials and methods This prospective observational study involved 40 patients who had a partial or complete amputation of the upper limb and underwent secondary procedures to correct function after successful replantation and revascularization surgery. The patients' functional outcomes after various secondary procedures were recorded using the QuickDASH questionnaire. Results The mean QuickDASH score for thumb injuries was 42.3 pre-surgery but improved to 29.5 after secondary procedures, which was statistically significant (CI 11.12-14.87, p<0.01). The mean difference in the QuickDASH scores for finger injuries was also statistically significant: 45.5 preoperation and 33.7 postoperation (CI 9.89-13.70, p<0.01). For wrist injuries, the mean QuickDASH score was 52.8 presurgery and was 46.3 postoperatively (CI 1.81-6.58, p=0.0023). The QuickDASH scores of the patients with arm and forearm injuries showed no statistically significant improvement, with a preoperation score of 58.3 declining to 55.2 (p=0.98). The overall replantation and revascularization scores were 49.725 and 41.175 pre and postoperation, respectively (CI 8.35-8.75, p<0.01). Conclusion The study finds that the level and mechanism of injury are important predictors of the functional outcomes of the replantation and revascularization of amputated upper-limb appendages. Most replanted and revascularized upper limbs have numerous functional limitations, and achieving good functional results requires one or more secondary procedures, whose type depends on various factors such as the injury type and mechanism. The QuickDASH results for functional outcomes before and after secondary procedures indicate that it is an easy-to-use, reliable, and effective measure of functional outcomes.

Laparoscopic Sleeve Gastrectomy versus Lifestyle Modification in Class I Obesity in Pakistani Population: A Prospective Cohort Study.

Introduction The American Society of Metabolic and Bariatric Surgery has stated that bariatric surgery is indicated in Class I obesity patients with one or more comorbidities. However, other weight loss options, such as diet plus exercise, are available to patients with a body mass index (BMI) ranging from 30 to 35 kg/m2. This study aimed to prospectively compare the results of Class I obesity patients undergoing laparoscopic sleeve gastrectomy (LSG) or using a weight control program (WCP). Methods A prospective analysis was conducted of patients with Class I obesity and comorbid diabetes and hypertension, with follow-ups at 6, 12, and 18 months. Subjects were divided into two groups: the LSG group of patients who had undergone LSG, and the WCP group who adhered to a WCP. The percentage of excess BMI loss (%EBMIL) and comorbidity remission (diabetes mellitus and hypertension) were tracked with measurements of hemoglobin A1C (HBA1C) levels and systolic blood pressure. Self-esteem was also tracked using the Rosenberg Self-Esteem Scale (SES) at 0 and 18 months. The overall patient satisfaction score was calculated using a visual analogue scale. Results Of the 150 patients enrolled in the study, 106 were included in the LSG group, and 103 were included in the WCP group. The reduction in HBA1C was more pronounced in the LSG group, and the differences between the two were statistically significant after 6, 12, and 18 months (LSG 5.6 ± 0.47 vs. WCP 6.5 ± 0.64, CI 1.04-0.73, P < 0.05). At 12 and 18 months, there were statistically significant reductions in systolic blood pressure after LSG (LSG 134.2 ± 7.16 vs. WCP 145.63 ± 5.94, CI 13.2-9.6, P < 0.05). Self-esteem levels measured by the Rosenberg SES increased for all participants, while patient satisfaction score was higher in the LSG group than that in the WCP group (P < 0.05). The %EBMIL at 6 months in the LSG group was 35.48%, compared to the WCP group at only 7.23%. At 12 months, the %EBMIL had increased twofold in the LSG group, at 68.19%, compared to 14.53% in the WCP group. At the final 18-month follow-up, the %EBMIL in the LSG group was 99.60% but was only 25.70% in the WCP group (P < 0.05). Conclusion Our study elucidates a clear superiority of LSG over any structured WCP with regard to weight reduction, improvement in glycemic control, and reduction in blood pressure in Class I obesity patients. Additionally, patients having LSG reported markedly improved self-esteem and satisfaction when compared with those who undertook a WCP.