Department Of General Surgery Research Articles

AHP SO02 - A Quality improvement project to improve the Nutritional teaching within the General Surgery Department

Abstract Background Malnourished patients have greater incidences of post operative complications which can prolong hospital stay. Dietitians improve the nutritional status peri-operatively to reduce complications and accelerate recovery in hospital. Given that the doctors working in surgery are junior doctors who work on a rotational basis, means that they have little time to get to know the roles of the MDT, hence they are faced with the challenge of having little knowledge of complex nutritional needs of the surgical patient. The aim of the quality improvement project is to improve the nutritional teaching within the General surgery department to improve clinical practice. Method Using Plan-do-study-act (PDSA) Methodology, a Multi-disciplinary-team was created to identify ways to improve our nutritional knowledge. An initial survey was collated and distributed throughout the department to establish the current knowledge of nutritional challenges. From the initial survey, a need to improve the teaching of nutrition to the department was highlighted. The plan implemented itself in the form of informal teaching and educational resources to provide teaching to the department. Further questionnaires were used to assess the value of the teaching sessions. Pre/Post-teaching session surveys were used to assess the participant progress and satisfaction of the teaching session. Results The initial survey showed that on average the individuals sampled had a neutral/basic knowledge of the nutritional topics. In addition the survey addressed a need for surgical nutritional teaching to which 100% of respondents answered ‘Yes’. 100% of the respondents gave a 7/10 above or higher rating for how much they would benefit from the teaching and 100% of the cohort either requested teaching sessions alone or both a teaching session and information booklet. Following these interventions; a Pre/ Post-teaching survey was conducted to provide insight of how the department responded to the teaching, which was overall well received. Conclusion The role of nutrition is an important factor that affects surgical outcome and having clinical knowledge of nutritional needs and complications allows us to improve our clinical practice and patient care. The project identified a need for educational improvement and the project has allowed the department to establish regular quarterly nutritional teaching for rotational training and provided educational resources that have been demonstrated to be an effective intervention within the department. The project provided an overall positive engagement to improve our nutritional knowledge and will undoubtedly have a marked impact on quality of care, patient outcomes and their experience.

HPB SO57 - Imaging in Acute Pancreatitis: Are We Getting It Right?

Abstract Background Guidelines indicate that routine use of imaging is unwarranted in patients with acute uncomplicated pancreatitis presenting with abdominal pain and increased serum amylase or lipase levels without signs of severe disease. Moreover, early CT scans may fail to accurately reflect disease severity and provide no diagnostic advantage. Method We performed a retrospective clinical audit at a district general hospital in the United Kingdom to find out the current practice regarding the use of imaging in patients presenting with acute pancreatitis. The patients were studied from January 2023 to March 2023 for the 1st cycle, and from April 2024 to May 2024 for the 2nd cycle. The list was identified by the clinical audit department – adult patients who presented to the A&E with symptoms of acute pancreatitis were included. Results Between January - March 2023, 44 patients presented to A&E with symptoms of acute pancreatitis. Of these, 25 (56%) had a CT-scan within 72-hours, with 80% showing evidence of acute pancreatitis —1 with pancreatic necrosis, 7 with intra-peritoneal fluid, & 5 with peri-pancreatic fat-stranding. The study revealed poor compliance with standards, prompting efforts to raise awareness. Findings were shared at the departmental audit meeting, & posters were displayed in A&E and GeneralSurgery departments. In the 2nd-cycle (April-May 2024), 32 patients presented, with 14 (53%) having a CT-scan within 72-hours & all had serum amylase levels checked, with 11 within normal limits. Conclusion This closed-loop clinical audit demonstrated that with appropriate measures and improved awareness of current guidelines, there can be increased compliance to the guidelines by the clinicians. This, in turn, reduces the risk of radiation exposure to patients and optimizes the use of CT scans.

HPB SO56 - Prompt prescription of fluids and analgesia for acute pancreatitis and evaluation of subsequent laparoscopic cholecystectomy: A Quality Improvement Project

Abstract Background Pancreatitis is a common presentation for General Surgery department nationally. Treatment of these patients are timely initiation of analgesia and fluid resuscitation. Patients with gallstone pancreatitis should have inpatient cholecystectomy as per the NICE Guidance. Delays in treatment of acute pancreatitis can worsen mortality and morbidity rates. We aim to assess if patients have been given fluid, analgesia, VTE prophylaxis promptly upon admission and if they had laparoscopic cholecystectomy in the index admission for those with gallstone pancreatitis. Method Single centre retrospective cohort of patients, above 18 years old, who presented to general surgery services from November 2022-23. Patients need to have radiological evidence of pancreatitis or raised amylase above 150. Patients were evaluated for prompt prescription of analgesia, fluids and VTE prophylaxis within 24 hours based on our ePrescription system. Evaluation of laparoscopic cholecystectomy service was also performed to assess if patients had the surgery during the indexed admission or within 30 days of discharge. Results 99 patients with median age of 60 was included. Only 3 patients required higher levels of care in HDU or ITU. The median length of stay was 5 days. 96% had analgesia prescribed, 91% had VTE prescribed but only 81% had fluids. Of those who did not have fluids within 24 hours, the average lenght of stay was 5.5 days and only 1 patient needed to be admitted to intensive care unit. 26 patients had gallstone pancreatitis but 15% had laparoscopic cholecystectomy performed. Our readmission rate was 6% and 30-day mortality was 1%. Conclusion Delays in the prescription of fluids and analgesia are still present, with a proportion of patients not getting the appropriate treatment for acute pancreatitis. We will use a tailored prescription set for acute pancreatitis to ensure prompt prescriptions are done for patients. This will be re-evaluated to assess its effectiveness. Further evaluation is required to look at reasons for patients not getting cholecystectomy promptly after admission for acute pancreatitis.

BN SO13 - Re-Audit of Biliary Pancreatitis Management: Enhancing Compliance with Timely Laparoscopic Cholecystectomy

Abstract Background Biliary acute pancreatitis requires timely management to prevent complications. Guidelines recommend laparoscopic cholecystectomy within two weeks of admission. A previous audit in our surgery department showed only 32.6% compliance with this guideline. This re-audit aimed to evaluate improvements in compliance, identify barriers, and provide insights for enhancing patient care. By retrospectively analyzing patient data from January to November 2023, we assessed progress and highlighted areas needing further improvement to align with established guidelines and ensure better patient outcomes. Method A retrospective analysis was conducted on a cohort of 32 patients admitted to the general surgery department with a diagnosis of biliary acute pancreatitis between January 2023 and November 2023. Patient records were reviewed to gather data on the timing of laparoscopic cholecystectomy performed within two weeks of the index admission. The compliance rate from this period was compared to a previous audit to assess improvements. Key barriers to timely intervention, such as the availability of ultrasound slots, hot gallbladder lists, and pre-assessment clinics, were also identified and analyzed. Statistical methods were used to confirm the significance of observed changes. Results he re-audit revealed a significant improvement in compliance with guidelines for the management of biliary acute pancreatitis. The percentage of patients undergoing laparoscopic cholecystectomy within two weeks of admission increased from 32.6% in the initial audit to 64.5% in the re-audit. However, the analysis identified persistent barriers to timely intervention, including limited availability of ultrasound slots, insufficient "hot gallbladder" surgical lists, and fear of difficulty of acute laparoscopic cholecystectomy. These findings highlight both the progress made and the areas needing further attention to enhance compliance and patient care. Conclusion The re-audit demonstrated a notable improvement in adherence to guidelines for the management of biliary acute pancreatitis, with a significant increase in timely laparoscopic cholecystectomy. Despite this progress, persistent barriers such as limited ultrasound availability, insufficient "hot gallbladder" lists, and pre-assessment clinics need to be addressed. Continuous evaluation and targeted interventions are essential to further enhance compliance, reduce complications, and improve patient outcomes. Ongoing efforts to refine clinical practices will help achieve the highest standards of care for patients with biliary pancreatitis.

Prevalence of Helicobacter Pylori Infection Among Dyspepsia Patients in a Tertiary Care Hospital of Puducherry

Background: Dyspepsia is a relatively common clinical condition characterized by chronic / recurrent upper abdominal pain or discomfort. Dyspeptic individuals were found to be infected with H-pylori than asymptomatic individuals. Though most individuals are asymptomatic, H. pylori plays a key role in the etiology of many upper gastrointestinal disorder. Materials and Methods: This cross-sectional prospective analytical study was done in Department of General surgery, IGMCRI Pondicherry from February 2022 to June 2022. Both male and female patients attending surgery OPD of age 20 to 60 years with upper gastrointestinal symptoms like dyspepsia and epigastric pain were subjected to upper gastrointestinal endoscopy and scopy findings noted and a Rapid urease test done for them. Results: The prevalence of H-Pylori was found to be 53%. Gender wise distribution shows more prevalence among females (61%) compared to males (44%). Of the total patients, 72% presented with abdominal pain, 34% presented with associated nausea, vomiting and 50% presented with regurgitation, 47% presented with bloating sensation. 11% present with other associated symptoms like malena and dysphagia. 9 patients with dyspepsia had ulcers in the antral wall and duodenum with 33% RUT positivity. 11 of them presented with pangastritis with 72% RUT positivity, 47 of them had antral gastritis with 66% RUT positivity, and 15 of them were found to have normal endoscopic findings with 33% RUT positivity.47% of the patients with esophageal varices and 20% of the patients with ulceroproliferative growth showed RUT positivity. Conclusion: This study validates that more than half the patients with dyspepsia in our population are H-pylori positive. Early referral for Upper GI endoscopy can help diagnose the same and associated clinical condition and initiate an early anti-H. Pylori regimen to achieve quicker symptom relief in these patients.

Validity and Execution of Stress Ulcer Prophylaxis in Surgical Patients: A Single-Center, Retrospective Cohort Analysis in Islamabad, Pakistan

Introduction: Stress ulcer prophylaxis (SUP) is recommended in critically ill patients to prevent stress-related mucosal damage, however, there is inconsistent adherence to established standards and guidelines for those who receive SUP medications outside of this patient group. The present study aimed to evaluate the appropriateness of SUP medications for surgical patients at the tertiary care hospital in Islamabad, Pakistan. Methodology: A 1-year, retrospective cohort study was conducted, using a convenience sampling approach, involving patients undergoing surgical procedures at the Surgical Wards of a tertiary care hospital located in Islamabad. Data collection was performed using a pre-designed checklist, with main areas including demographic characteristics, data on their presenting complaint, SUP medications (dosage, route of administration and duration) and presence of stress ulcer risk factors.Results: n=418 patient records were assessed: the majority of the patients were female (62.6%; n=262), with a mean age was 53.6±11.7 years, treated at the General Surgery department (81.8%; n=342). All patients managed for SUP were prescribed PPIs; the most commonly used PPI was omeprazole, both orally (37.7%; n=158) and parenterally (39.7%; n=166). The majority of patients (72.2%; n=302) were prescribed SUP for an appropriate indication or an associated risk. 46.1% (n=193) received SUP as a discharge medication with no records showing a follow-up, and there was no clear evidence that suggested that SUP had been stopped. Conclusions: This study highlights the irrational prescribing of PPIs in non-critical patients and the improper continuing of PPI prescriptions after discharge in a real-world setting, indicating the need to address suggested protocols for rationalizing the use of SUP and limiting the use of PPIs for appropriate purposes.

Open donor nephrectomy via singular pararectal extraperitoneal mini-incision: single-center experience with 425 consecutive cases

BackgroundLaparoscopic techniques have been successfully implemented for living kidney donation. However, open surgical procedures also yield excellent perioperative outcomes. Endoscopic donor nephrectomy is associated with minimal trauma but is difficult for right-sided nephrectomies. Here, an open nephrectomy approach using a singular pararectal extraperitoneal mini-incision (SPEM) and the perioperative results are presented to elucidate whether open surgery is still justified in the modern era of endoscopic surgery.MethodsIn this single-center retrospective study, all living kidney donations performed at the Department of General, Visceral and Transplant Surgery of the Hannover Medical School from January 2007 to December 2017 were assessed. Donor characteristics, operation time, transfusion requirements, perioperative complications, and graft outcomes were analyzed.ResultsOut of a total of 1681 kidney transplantations, 425 living kidney donations (25.2%) were performed. Donors were primarily female (273; 64.2%) and had a median age and body-mass index of 53 (24–76) years and 25.3 (16.8–36.4) kg/m2, respectively. The left kidney was harvested in 50.1% (211) of cases. Median operative time was 95 (48–212) min. Intraoperative transfusion was not required in any of the donors. Intraoperative complications were observed in 2.6% of cases (11), with injury of the donor kidney (5; 1.2%) and acute hemorrhage (3; 0.7%) being the most common complications. Postoperative complications were hematomas (32; 7.7%), seromas (28; 6.7%), and wound infections (7; 1.7%). Except for a single surgical revision owing to colon perforation (1; 0.002%), no other major complications (Clavien–Dindo ≥ IIIa) were observed in any of the donors. The donor’s and recipient’s median estimated glomerular filtration rate at discharge was 55 (29–114) and 51 (14–129) ml/min/1.73 m2, respectively. Initial nonfunction occurred in seven cases (1.6%).ConclusionsUnlike the endoscopic technique, SPEM is equally suitable for right- and left-sided nephrectomy. SPEM nephrectomy is safe and results in minimal trauma. Despite performing SPEM nephrectomy in the era of endoscopic surgery, this technique provides excellent results with regard to donor and graft outcomes.

Streamlining the Non-operative Management of Adhesive Small Bowel Obstruction: A Closed-Loop Audit Evaluating the Introduction of a Standardised Gastrografin Protocol in a District General Hospital.

Introduction Adhesive small bowel obstruction (ASBO) is a common cause of admissions to general surgery services. Water-soluble contrast (WSC), such as Gastrografin® (GGF), can be utilised in the conservative management of patients with ASBO, with predictive and possible therapeutic value. We audited the non-operative management of ASBO in the general surgery department of East and North Hertfordshire NHS Trust, a district general hospital. Following the introduction of a hospital-wide protocol standardising the use of GGF in patients with ASBO, a re-audit was conducted to assess its impact. Methods A retrospective audit of ASBO patients who received GGF was conducted in two cycles: before and after the implementation of the protocol. Data were collected between February and June 2022 for group 1 (pre-protocol) and between August and November 2023 for group 2 (post-protocol). Results Forty-eight patients were included in the analysis across both groups: 31 in group 1 (pre-protocol) and 17 in group 2 (post-protocol). The success rate of this non-operative trial with GGF increased from 77%(24/31) in group 1 to 88% (15/17) in group 2. The median duration of conservative management was two days in both groups. The median time from CT scan to GGF administration decreased from 24 hours in group 1 to 19 hours 22 minutes in group 2, and the interval between GGF administration and first abdominal radiograph decreased from 9 hours in group 1 to 6 hours 25 minutes in group 2. Conclusion Our closed-loop audit suggests that by streamlining the non-operative management pathway of adhesive small bowel obstruction, our standardised protocol is safe and possibly improves efficiency within a district general hospital setting.

PRESCRIPTION AUDIT AT A TERTIARY CARE HOSPITAL – A CROSS-SECTIONAL STUDY

Objective: The aim of this study was to analyze prescribing practices at Silchar Medical College and Hospital (SMCH) through a cross-sectional audit of 600 outpatient prescriptions, adhering to the National Health Mission Prescription Audit Guidelines 2021. Methods: The audit examined prescriptions of patients who visited the Outpatient department (OPD) of Department of General Medicine, Surgery, Orthopedics, Gynecology and Obstetrics, Pulmonary Medicine, Pediatrics, Dermatology, and Psychiatry. The audit evaluated key aspects such as the completeness of patient information, legibility of prescriptions, documentation of clinical details, and adherence to standard treatment guidelines (STG). Results: The prescription audit at SMCH revealed high compliance with essential criteria such as OPD registration and patient gender documentation. However, gaps were identified in areas such as allergy status documentation (0%), legible handwriting (75.7%), and follow-up advice (16.9%). In addition, adherence to STG was observed in 75% of prescriptions, with a concerning finding that there was a lack of facility’s Antibiotic Policy. Conclusion: The study underscores the importance of complete and accurate prescription documentation to ensure patient safety and effective treatment.

Positioning for Emergency Laparoscopic Splenectomy for Traumatic Splenic Rupture.

To determine whether the right-lateral decubitus or supine position is superior for emergency laparoscopy for traumatic splenic rupture. Descriptive study. Place and Duration of the Study: Department of General Surgery, Central Hospital of Shaoxing, Affiliated Hospital of China Medical University, Zhejiang, China, from January 2015 to December 2022. Clinical data of 96 patients who underwent laparoscopic surgery (LS) for traumatic splenic rupture were analysed. The patients were divided into two groups according to surgical position. Group A (n = 42) patients were placed in the right-lateral decubitus position and Group B (n = 54) patients were placed in the supine position. The operation time, intraoperative blood loss, conversion to laparotomy rate, postoperative length of hospital stay, and complications rates were compared between the two groups. Compared with Group B, Group A had a shorter operation time (145.5 ± 24.4 min vs. 169.0 ± 15.3 min, p = 0.0001), less intraoperative blood loss (75.3 ± 35.3 ml vs. 110.3 ± 50.6 ml, p = 0.0002), fewer conversions to laparotomy (2.4% vs. 16.7%, p = 0.023), fewer cases of postoperative pancreatic leakage (7.1% vs. 24.1%, p = 0.027), and fewer complications (23.8% vs. 53.7%, p = 0.003); all differences were significant. There was no statistically significant difference in the postoperative length of hospital stay, hospital cost, or rate of complications such as fever, postoperative abdominal infection, postoperative bleeding or venous thrombosis between the two groups. For patients with traumatic splenic rupture, the right-lateral decubitus position is best for LS. Laparoscopy, Traumatic splenic rupture, Splenectomy, Surgical position.

Positioning for Emergency Laparoscopic Splenectomy for Traumatic Splenic Rupture.

To determine whether the right-lateral decubitus or supine position is superior for emergency laparoscopy for traumatic splenic rupture. Descriptive study. Place and Duration of the Study: Department of General Surgery, Central Hospital of Shaoxing, Affiliated Hospital of China Medical University, Zhejiang, China, from January 2015 to December 2022. Clinical data of 96 patients who underwent laparoscopic surgery (LS) for traumatic splenic rupture were analysed. The patients were divided into two groups according to surgical position. Group A (n = 42) patients were placed in the right-lateral decubitus position and Group B (n = 54) patients were placed in the supine position. The operation time, intraoperative blood loss, conversion to laparotomy rate, postoperative length of hospital stay, and complications rates were compared between the two groups. Compared with Group B, Group A had a shorter operation time (145.5 ± 24.4 min vs. 169.0 ± 15.3 min, p = 0.0001), less intraoperative blood loss (75.3 ± 35.3 ml vs. 110.3 ± 50.6 ml, p = 0.0002), fewer conversions to laparotomy (2.4% vs. 16.7%, p = 0.023), fewer cases of postoperative pancreatic leakage (7.1% vs. 24.1%, p = 0.027), and fewer complications (23.8% vs. 53.7%, p = 0.003); all differences were significant. There was no statistically significant difference in the postoperative length of hospital stay, hospital cost, or rate of complications such as fever, postoperative abdominal infection, postoperative bleeding or venous thrombosis between the two groups. For patients with traumatic splenic rupture, the right-lateral decubitus position is best for LS. Laparoscopy, Traumatic splenic rupture, Splenectomy, Surgical position.

3D vs. 2D-4 K: Performance and self-perception of laparoscopic novices in a randomized prospective teaching intervention using standard tasks and box trainers

ObjectiveThe use of three-dimensional (3D) laparoscopy in surgical practice and training has been an area of research and discussion. Studies have suggested that 3D vision can improve speed and precision compared to traditional two-dimensional (2D) displays, while other authors found no benefits on the learning curves of laparoscopic novices. Modern two-dimensional laparoscopy with a resolution of 3840 × 2160 pixels (2D-4 K) seems to improve laparoscopic view and helps learners orient without stereopsis. However, evidence comparing these systems for laparoscopic training is limited. Therefore, the impact of viewing mode (2D-4 K vs. 3D) on learning and task proficiency remains unclear.DesignWe performed a two-hour teaching intervention on basic laparoscopic skills for novices. In this parallel group randomized study, we randomly assigned learners to 2D-4 K or 3D teaching and performed tasks of increasing difficulty and complexity using standard laparoscopy box trainers. Before the last and most challenging task, learners had to crossover to the other laparoscopy setup. Our hypothesis was that learners would be faster and more precise when using a 3D setup. The primary endpoint was task proficiency measured by speed and failure rate. Secondary outcomes were performance using the viewing mode of the other group without familiarization, self-perception, and career aspirations before and after the teaching intervention, expressed on a Likert scale.SettingThe study was performed by the Department of General, Visceral and Thoracic Surgery at the German Armed Forces Hospital Ulm, which is an academic teaching hospital of the University of Ulm.ParticipantsThirty-eight laparoscopic novices, including medical students and junior residents, participated voluntarily in this teaching intervention. Group allocation was performed via the virtual coin flip method. Apparently, participants and tutors were not blinded to group assignment. No formal approval by the ethics committee was needed for this noninvasive study in compliance with the World Medical Association Declaration of Helsinki as discussed with the ethics committee of the University of Ulm.ResultsThirty-eight laparoscopy novices were randomized in the study. The 3D group (n = 19) was significantly faster than the 2D-4 K group (n = 19) (p = .008) in a standard box trainer model, with 134.45 ± 41.45 s vs. 174.99 ± 54.03 s for task 1 and 195.97 ± 49.78 s vs. 276.56 ± 139.20 s for task 2, and the effect was consistent throughout the learning curve. The failure rate was not significantly affected by the viewing mode. After crossover to the other laparoscopy system, precision and time were not significantly different between the groups. Learners rated the difficulty of laparoscopy lower on a Likert scale after having two hours of basic laparoscopy training. The study was funded by the hospital’s teaching budget.ConclusionsLaparoscopic novices can benefit from a 3D laparoscopy training setup. Exclusive 3D training prior to a complex task on a 2D-4 K setup does not negatively affect the learner’s performance.

A study to compare abdominal wall closure with interrupted vs. continuous sutures using polydioxanone in patients undergoing emergency exploratory laparotomy

Background: Wound closure in emergency surgeries can be done either by interrupted or by continuous sutures with each having its own advantages and disadvantages. In this paper we shall try to compare the advantages and adverse effects of both these methods of wound closure. Methods: A prospective comparative study involving 50 patients undergoing emergency laparotomies was conducted in Department of General Surgery, MMIMSR, Mullana from October 2022 to April 2024 (18 months). We compared two abdominal wall closure techniques using polydioxanone (PDS), patients, aged 18-75 years, were alternatively assigned to one of two groups: Group I received interrupted PDS sutures, while Group II received continuous PDS sutures. Postoperatively, pain and complications like infections were observed and analysed statistically. Results: In our study, we compared abdominal wall closure techniques in emergency exploratory laparotomy patients. The mean age was similar in the two groups, 43.68 years vs 43.08 years respectively in group I and II. Wound infection occurred in 44% of patients in the interrupted suture group and 60% in the continuous suture group, with a significant difference favouring the interrupted method. The mean wound closure time (33.24 vs 18.32 minutes) and post operative pain were more in the interrupted suture group as compared to the continuous suture group. Conclusions: The interrupted suturing method proved to be more effective in preventing complications, it did require more time to perform. However, after thoroughly reviewing the available data, no definitive evidence was found to support the superiority of either techniques.

Necrotizing fasciitis: treatment concepts & clinical outcomes – an institutional experience

BackgroundA severe infection of the skin and soft tissues, Necrotizing Fasciitis (NF), spreads quickly along the deep fascia. This study aimed to characterize the clinicopathological features, analyze the implicated bacteria’s antibiotic sensitivity, evaluate surgical management, and assess the diagnostic accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in Necrotizing Soft Tissue Infection (NST).MethodsThis single-center prospective observational study was conducted in the Department of General Surgery, Kasturba Medical College, Manipal, with 171 proven cases of NSTI between 2019 and 2021. Clinico-demographic data and laboratory investigation values were collected at two-time points (at admission and 72 h after admission). Imaging data, LRINEC score, culture results, and antibiotic sensitivity were recorded. Appropriate descriptive and analytical statistics were used for the statistical analysis.ResultsOf the 171 patients, 150 were male (87.7%). The mean age was 57.6 ± 13.1 years. The presenting features in all the cases were pain, swelling, and fever. Diabetes mellitus (DM) is the most common comorbidity. The lower extremities were the most commonly affected sites. Streptococcus pyogenes showed significant growth in 25.41% of the samples. Ceftriaxone sensitivity was seen in 41/141. A score of ≥ 8 was obtained in 118/171 (69%) patients, suggesting a higher severity and significant risk for NSTI. The Area Under the Curve of Receiver Operating characteristic Curve (ROC) for establishing diagnostic accuracy for LRINEC was 0.694. Mortality was significantly higher in the patients with higher LRINEC scores and elevated procalcitonin. The mortality rate was higher in patients who underwent surgery within 12 h.ConclusionNecrotizing fasciitis is a soft tissue infection with a high mortality rate. The clinical features and determinants of mortality in patients with NF are highlighted in this study. At the outset, a high index of suspicion was critical. Using prognostic evaluation techniques in daily clinical practice will assist medical professionals in providing adequate on-time care and significantly lowering mortality. The AUC for LRINEC score, although significant, is low. LRINEC score is not to be used to determine whether surgical intervention should be expedited or anticipated. Its role is to aid in prognosticating the outcome of the individual patient. Our study concludes that early extensive surgical debridement remains the single most crucial intervention in patients diagnosed with necrotizing fasciitis (NF), regardless of disease severity and the LRINEC score.

Diagnostic value of T-tube cholangiography and choledochoscopy in residual calculi after biliary surgery

BackgroundT-tube cholangiography and choledochoscopy are commonly used techniques for detecting residual bile duct stones after biliary surgery. However, the utility of routine cholangiography before T-tube removal needs further investigation. This study aims to evaluate the diagnostic efficacy of various methods for detecting residual calculi following biliary surgery.MethodsWe retrospectively analyzed the clinical data of 287 adult patients who underwent common bile duct exploration with T-tube drainage, followed by T-tube cholangiography and choledochoscopy, at the Department of General Surgery, Xuanwu Hospital, Capital Medical University, between 2017 and 2022. Exclusion criteria were patients with bile duct tumors, incomplete medical records or loss to follow-up, and patients with contraindications to T-tube or choledochoscopy. McNemanr test and Kappa test were used to compare the results and consistency between choledochoscopy and T-tube cholangiography. All patients underwent both cholangiography and choledochoscopy six to eight weeks after laparoscopic cholecystectomy combined with common bile duct exploration and T-tube drainage. The results of T-tube cholangiography and choledochoscopy for each patient were recorded, analyzed, and compared.ResultsAmong the 287 patients, T-tube cholangiography detected residual stones in 38 cases, which were confirmed by choledochoscopy in 29 cases. Conversely, of the 249 patients without evidence of residual stones on T-tube angiography, 11 patient was later found to have retained stones through choledochoscopy. There was no significant difference between the results of T-tube cholangiography and choledochoscopy (P = 0.82), indicating a high level of agreement between the two methods (Kappa value: 0.70) (95% CI, 0.65–0.76).ConclusionThere is no significant difference in the diagnostic accuracy between T-tube cholangiography and choledochoscopy for detecting residual bile duct stones after surgery (P = 0.82). The two methods demonstrated a high level of consistency (Kappa value: 0.70) (95% CI, 0.65–0.76). The choice of diagnostic method for postoperative residual bile duct stones should be based on the specific condition of the patient.

Pattern of Surgical Antibiotic Prophylaxis in a Tertiary Care Hospital of Bangladesh

Background: Surgical Site Infection (SSI) is a common form of hospital-acquired infection and major cause of postoperative illness accounting for approximately a quarter of all nosocomial infections. As a result, surgical antibiotic prophylaxis is now considered essential to conventional surgical procedure in order to reduce surgical site infections and improve postoperative recovery. The misuse and overuse of antibiotics has led to an increase in treatment costs and the emergence of antimicrobial resistance. The goal of the study is to identify the pattern of prophylactic antibiotic prescriptions for different surgical operations. Materials and methods: A retrospective observational study was conducted among 600 patients undergoing different surgeries in a tertiary care hospital of private setting in Dhaka, Bangladesh from July 2023 to December 2023. The demographic data, types of surgery, types of therapy, choice of antibiotic along with dosage formulations were collected. Results: Out of 600 patients, 245 (41%) were male and 355 (59%) were female. Highest bulk of patients were from Department of General Surgery (47.5%), followed by Department of Obstetrics & Gynecology (24.16%) and Department of Otolaryngology (16.7%). Surgical prophylactic antibiotic was used in all 600 patients, and all antibiotics were given in intravenous route (100%). Almost 505 patients (84.2%) had received ceftriaxone as antimicrobial agent. Ceftriaxone with metronidazole or gentamicin and Cefuroxime with metronidazole or amikacin drugs combination were given to 75 (12.5%) and Cefuroxime, Amikacin, Metronidazole drugs combination were given to 20 patients (3.3%). 3rd generation cephalosporin, Ceftriaxone, was the most commonly prescribed antibiotic as monotherapy (94.3%), followed by 2nd generation cephalosporin, cefuroxime (4%). Conclusion: Ceftriaxone was the preferred antibiotic for surgical prophylaxis. Existence of an antimicrobial guideline along with antibiotic stewardship program in every hospital could be helpful for prescribers to play role in containment of antimicrobial resistance. EWMCJ Vol. 12, No. 1&2, January-July 2024: 70-74

Laparoscopic Roux-en-Y gastric bypass versus single anastomosis sleeve ileal bypass for the treatment of morbidly obese patients: a prospective randomized comparative study

Background: Bariatric surgery has proven to be the most effective long-term treatment of morbid obesity, after bariatric surgery, weight loss and remission of obesity-related comorbidities is significantly higher than after non-surgical measures. The present study aimed to compare single-anastomosis sleeve ileal (SASI) bypass and Roux-en-Y gastric bypass (RYGB) in terms of weight loss, remission of comorbidities, complications, and nutritional status. Methods: This prospective randomized comparative study was carried out at gastrointestinal and laparoscopic surgery unit, General Surgery Department, Tanta University Hospitals, during the period from October 2020 to October 2022 and included 40 morbidly obese patients who accepted to participate in the study and signed an informed consent. Patients were randomly assigned into 2 equal groups by the closed envelope method, group I: were submitted to laparoscopic RYGB, group II: were submitted to laparoscopic SASI bypass. Results: The mean age of RYGB group was 39.20±6.56 years, compared to 34.75±7.91 in SASI group. A highly statistically significant difference was present in operative time between both groups; RYGB Group had operative time mean of 194.25±27.11 minutes, compared to 153.15±23.74 minutes in SASI group. Both procedures were followed by a significant decrease in body mass index at 12 months and were comparable in terms of excess and total weight loss. Improvement in comorbidities after the two procedures was similar. Conclusions: RYGB and SASI bypass cause weight loss by both restriction and malabsorption mechanisms. Early results with the two procedures are encouraging with acceptable weight loss, comorbidity improvement rates with disadvantages as malnutrition, biliary reflux and dumping, yet the risk of malnutrition was more likely after SASI bypass.

COMPARATIVE STUDY ON OUTCOME OF OPEN FISTULECTOMY VERSUS LIFT PROCEDURE FOR UNCOMPLICATED PERIANAL FISTULAS

Perianal fistulas, particularly trans sphincteric types, pose a significant challenge in terms of management, often requiring surgical intervention. Traditional open fistulotomy has been a common procedure, but newer techniques like the ligation of the intersphincteric fistula tract (LIFT) procedure are being explored for improved outcomes, particularly in terms of preserving continence. This study aims to compare the outcomes of open fistulotomy versus the LIFT procedure in patients with trans sphincteric perianal fistulas. Objective: To compare the clinical outcomes, healing times, recurrence rates, and continence status between patients undergoing open fistulotomy and those treated with the LIFT procedure for trans sphincteric perianal fistulas. Methods: A prospective comparative study was conducted in the General Surgery Department of Nishtar Medical Hospital, Multan, from May 2024 to August 2024. A total of 150 adult patients with trans sphincteric perianal fistulas were enrolled using consecutive sampling. The patients were randomly divided into two groups: Group A (n = 75) underwent the LIFT procedure, and Group B (n = 75) underwent fistulectomy. Postoperative follow-up was conducted weekly until wound healing and at three months after healing to assess pain scores, recurrence rates, healing time, and continence status. Statistical analysis was conducted using SPSS Version 25, with a significance level set at p < 0.05. Results: Among the participants, 6 patients (8%) in Group A and 8 patients (10.7%) in Group B experienced recurrent fistulas, showing no significant difference between the groups. Postoperative pain scores were similar between both groups. However, the healing time was significantly shorter in Group A (27.2 days) compared to Group B (48.1 days) (p < 0.05). Recurrence rates were higher in Group A (16%) compared to Group B (2.7%) (p < 0.05). Incontinence was observed in 10.7% of patients in Group B, while no incontinence was reported in Group A (p < 0.05). Conclusion: The LIFT procedure offers better outcomes in terms of continence preservation and shorter healing time compared to open fistulotomy in the management of trans sphincteric perianal fistulas. However, open fistulotomy showed lower recurrence rates. These findings suggest that the LIFT procedure may be preferable in patients for whom preserving continence is a priority, while open fistulotomy may be a better option in cases where recurrence prevention is the main concern.

Short-term effects of laparoscopic sleeve gastrectomy combined with reconstruction of the acute His angle on postoperative gastroesophageal reflux disease

Objective: To compare the short-term efficacy of laparoscopic sleeve gastrectomy (LSG) combined with sharp His angle reconstruction (LSG-His) versus traditional LSG. Methods: In this retrospective cohort study we collected clinical data of patients with obesity who had undergone LSG or LSG-His in the Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, from January to June 2022. After excluding patients with incomplete follow-up data and those with hiatal hernia, 83 obese patients, of which 39 who had undergone LSG (LSG group) and 44 who had undergone LSG-His (LSG-His group), were included in the study. The basic steps in LSG-His are the same as in conventional LSG. After continuous suturing of the gastric staple line, one stitch is placed between the proximal side of the gastric greater curvature staple line and the proximal side of the gastric fundus posterior wall with the left diaphragm, and another stitch between the right side of the gastric fundus and the esophagus, reconstructing the sharp His angle. Clinical data, postoperative complications, and follow-up data on weight loss and gastroesophageal reflux disease (GERD) symptoms 1-, 3-, 6-, and 12-months post-discharge were compared between the two groups. GERD symptoms were assessed using the Gastroesophageal Reflux Disease Questionnaire and Reflux Diagnostic Questionnaire. Results: There were no significant differences between the two groups in baseline characteristics, length of hospital stay, hospitalization costs, intraoperative bleeding, postoperative nausea and vomiting, dysphagia, or postoperative complications (all P>0.05). Compared with the LSG group, the LSG-His group had significantly longer operative times (92 [80, 100] minutes vs. 80 [70, 100] minutes, U=2.227, P=0.026), higher postoperative 24-hour pain scores (5.2±1.8 vs. 4.3±1.9, t=-2.065, P=0.041), and higher rates of morphine use (70.5% [31/44] vs. 46.2% [18/39], χ²=4.519, P=0.025). The incidence of new-onset GERD 12 months postoperatively was significantly lower in the LSG-His than the LSG group (10.7% [3/28] vs. 61.3% [19/31], χ²=14.00, P<0.001). According to changes in Gastroesophageal Reflux Disease Questionnaire and Reflux Diagnostic Questionnaire scores, the LSG-His group also had significantly lower rates of exacerbation of GERD (2/16 vs. 5/8, χ²=4.27, P=0.021) and higher rates of GERD remission (12/16 vs. 2/8, χ²=3.62, P=0.032) than did the LSG group. Additionally, excess weight loss rates were significantly higher in the LSG-His group at 3 months [(54.7± 18.7)% vs. (46.5±15.0)% , t=-2.166, P=0.033], 6 months [(73.8±24.7)% vs. (64.0±19.1)% , t=-2.018, P=0.047], and 12 months [(82.9±26.7)% vs. (72.2±19.3)%, t=-2.063, P=0.042] than in the LSG group. Conclusion: Compared with LSG, LSG-His is safe and feasible and achieves better short-term control of postoperative GERD and more effective weight loss. Further large-scale, long-term, prospective studies are needed to confirm the long-term efficacy of LSG-His.

Clinical characteristics and prognosis of brain metastasis in locally advanced rectal cancer

Objective: To investigate the clinical characteristics of brain metastases after radical surgery for locally advanced rectal cancer (LARC). Methods: The clinical characteristics of LARC with brain metastases treated in the Department of General Surgery, Peking Union Medical College Hospital from 2013 to 2023 were retrospectively analyzed. The inclusion criteria were rectal adenocarcinoma within 15 cm of the anal verge and having undergone radical surgery, and the exclusion criterion was primary malignant tumor of the brain. The main outcomes were overall survival (OS), disease-free survival (DFS), and disease-specific overall survival (determined as the interval between occurrence of brain metastasis to death from any causes). The Kaplan-Meier method was used for survival analysis. Results: We identified 4500 patients with LARC, 20 (0.4%) of whom had brain metastases. The mean age of patients with brain metastases was 63.8±9.3 years. They comprised five women and 15 men. The brain was the first site of metastasis in four patients (20%) whereas 18 patients had heterochronous extracranial metastases before brain metastasis. Two patients also had multi-organ metastases. The most common manifestations of brain metastases were dizziness and headache (five patients, 25%), sudden onset of limb weakness (four, 20%), sudden speech impairment (two, 10%), and polyopia (two, 10%). The metastases were diagnosed during follow-up in three patients (15%). Four of the patients were asymptomatic (20%). Treatment approaches included surgical resection (six patients, 30%), chemoradiotherapy (nine, 45%), and palliative (five, 25%). The median follow-up time was 45.5 (4-112) months until October 2023. 1y-OS, 3y-OS, and 5y-OS were 95.0%, 62.9%, and 43.3%, respectively. 1y-DFS, 3y-DFS, and 5y-DFS were 55.0%, 25.0%, and 5.0%, respectively. With brain metastasis as the starting point, the median duration of survival was 16 (10.2-21.8) months. Conclusion: The incidence of brain metastasis is relatively low in patients with LARC, who often have multiple synchronous extracranial metastases. Brain metastases lack specific manifestations and more often occur in male patients. Surgical intervention or combined radiotherapy and chemotherapy may improve disease-specific survival to a certain extent. However, the overall prognosis remains poor.