General Surgery Outpatient Clinic Research Articles

Surgical pathologies in children presenting for non-medical circumcision

Objectives: Circumcision is the most commonly performed surgical procedure in the world. In this study, we determined the frequency of additional surgical pathologies in patients presenting for non-medical circumcision.Material and Method: Children presenting to a secondary healthcare facility between June 2013 - June 2014 for non-medical circumcision were included in this study. Patients’ ages, presenting at outpatient clinics were noted together with the results of physical examinations.Results: A total of 2088 children presented for non-medical circumcision. Their average age was 5.2 years. 56.3% of patients presented to the Pediatric Surgery outpatient clinic, 25.3% presented to the Urology outpatient clinic and 18.3% presented to the General Surgery outpatient clinic. Additional surgical pathologies were noted in 3.9% of patients and these were: phimosis (n=36), inguinal hernia/hydrocele (n=12), buried penis (n=10), undescended testis (n=9), retractile testis (n=5), hypospadias (n=3), megameatus (n=2), umbilical hernia (n=2) and varicocele(n=2). The surgical plans for 37 (1.8%) patients changed due to the findings at examination.Conclusion: Changes in surgical plans were required for 1.8% of patients. It is therefore important that all patients, including those presenting with a request for circumcision, have a detailed physical examination.Keywords: Circumcision, Physical examination, Incidence

Diyabetik Ayakta Eğitimin Etkisinin Araştırılması: Türkiye’den Bir Müdahale Çalışması

Introduction: Diabetic foot wounds are one of the most important causes of long duration hospitalizations regarding diabetic patients. Lower extremity amputation risk is 15 to 40 times higher in diabetics compared to normal population. Methods for preventing diabetic foot wounds are providing good blood glucose regulation, appropriate shoe wearing, foot care, toe-nail care, regular foot examinations and patient education. We aimed to investigate the effects of education level of the patients and the caregivers on the diabetic foot wound. Methods: 67 patients having diabetic foot wound applying to General Surgery, Internal Medicine and Diabetes outpatient clinics of Izmir Tepecik Education and Research Hospital in 2009 and 57 caregiver caring for these patients were analyzed prospectively with a face to face questionnaire for a correlation between education levels of patients and caregivers and Wagner staging of patients’ diabetic foot wounds and foot examination findings. Results: It was found that education levels of patients and caregivers did not affect Wagner staging of the wounds (p=0.167), but patients with regular follow-up and previously educated for diabetic foot wounds had a lower stage of wound (p=0.021). Conclusion: Education level of patients and caregivers was not found to be effective on the stage of the wound, but regular clinical follow-up and patient education had an decreasing effect on the stage of wound. Whatever the patients’ education levels are, educations on diabetic foot care and providing regular follow up of patients at risk for diabetic foot will decrease the rates of extremity amputations.

Study of the relationship between colorectal cancer and vit D defficiency

Background Colorectal cancer is currently the third most common cancer in both men and women. The high prevalence of vitamin D deficiency, combined with the discovery of increased risk for certain types of cancer in those who are deficient, suggests that vitamin D deficiency may play a role in the development and progression of colon, breast, ovarian, and prostate cancers. Many studies suggest a possible relationship between sufficient vitamin D status and lower risk for cancer. Aim of the work The aim of this study was to determine vitamin D status in a sample of Egyptian patients with cancer of the colon. Study design We conducted a case–control study on 40 participants, 20 cases of colon cancer and 20 healthy adults matched for age. The cases were recruited from the general surgery wards and outpatient clinics at Ain Shams University Hospital, before surgical intervention or receiving oncological treatment. All participants were subjected to full medical history taking and thorough clinical examination. Fasting blood samples were drawn in the morning for evaluating haemoglobin, total Ca, phosphorus, Mg++, alkaline phosphatase, alanine transaminase, aspartate transaminase, carcinoembryonic antigen, and 25 hydroxyvitamin D. For the patients, chest radiography, pelvic and abdominal ultrasound, and colonoscopy and biopsy were performed. Results Egyptian patients with cancer of the colon showed a statistically significantly lower serum concentration of vitamin D (6.4 ± 3.912 ng/dl) compared with healthy controls (14.4 ± 9.838) ( P = 0.002). There was a highly significant difference between the two groups as regards alkaline phosphatase, with a mean of 381.500 ± 73.721 in patients with cancer of the colon and a mean of 194.300 ± 88.838 in healthy controls ( P < 0.001). Conclusion Vitamin D is lower in Egyptian patients with colorectal cancer, which may point to the possible protective role of vitamin D against cancer colon.

Laparoscopic Mesh Repair of Giant Morgagni-Larrey Hernia With Three Ports: A Case Report

Introduction: A bilateral anterior parasternal hernia is commonly called a Morgagni-Larrey hernia. Morgagni hernias are rare in adults, accounting for 3% of all treated diaphragmatic hernias. This article reports a giant bilateral Morgagni-Larrey hernia, repaired with a laparoscopic reduced-port technique. Case Presentation: An 83-year-old female was admitted to the general surgery outpatient clinic with gastrointestinal, respiratory symptoms, and retrosternal pain. A computed tomography (CT) scan showed a 12-cm retrosternal hernia defect on the right and a 3-cm defect on the left of the diaphragm The stomach and colon were herniated from the right defect and the omentum was herniated from the left defect to the thorax. The hernia contents were pushed back to the abdomen and the defects were repaired with single sutures through a three-port laparoscopic procedure. A composite mesh material was placed and fixed with pro-tack (Covidien). The patient was discharged on the fourth postoperative day without any complaints. Conclusions: Transabdominal laparoscopic Morgagni-Larrey hernia repairs with reduced number of ports are safe and feasible.

The burden of attending a pediatric surgical clinic and family preferences toward telemedicine

Background/PurposeIndirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives. MethodsA survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period. ResultsA total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200km, and 32.9% spent over 4hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p<0.01). Most were comfortable with medical communication using technology; and 34.3%–42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p<0.001) and distance traveled (p<0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing. ConclusionsMany families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit.

Surgeons’ Approaches and Professional Perspectives on Breast Masses: A National Survey in Turkey

General surgeons' approaches to breast masses in their daily practices and their perspectives for issues on breast diseases and breast surgery are investigated through a survey. Answers of 524 general surgeons for the survey "Approach to breast diseases and breast surgery" between November 2012 and February 2013 were assessed. Demographic features, approaches to the breast masses, and answers for the clinical scenerios of surgeons were questioned. Surgeons were asked about management of breast cancer and the future role of surgeons for oncoplastic breast surgery and breast diseases. Participants were representing 14.6% of all general surgeons in Turkey. The survey revealed that breast diseases are the most common cause for admission in general surgery outpatient clinics. Needle biopsies were employed by 241 (60%) respondents. Three hundred and seventy-one (71%) participants indicated that breast cancer management could be accurately conducted by the general surgeons. Two hundred and seventy-three (52%) respondents think that oncoplastic breast surgery should be performed by a general surgeon and 241 (41%) respondents predict that the role of general surgeons for breast diseases and breast surgery will decrease in the future. Basic approaches towards breast masses need to be improved in our country despite the highest frequency of breast diseases in outpatient admissions. The views and opinions of surgeons on breast diseases and the course of breast surgery in different regions and different communities need to be defined and clarified.

Mastalgia-Cancer Relationship: A Prospective Study.

Mastalgia is an important symptom affecting approximately 70% of women and it disrupts the quality of life especially due to the worry of having cancer. In our study, the type and severity of mastalgia symptom of patients who presented to the outpatient clinic with mastalgia complaint were assessed along with their physical examination findings and radiology results. The purpose of the study is to demonstrate the relationship between mastalgia and malignity when assessed in combination with the risk factors of patients. The age, family history, menopausal status, age at the first childbirth, menarche, presence/absence of hormone replacement therapy, type of mastalgia, comorbidities and examination findings of 104 patients, who presented to the General Surgery outpatient clinic with mastalgia symptom, were recorded and assessed in the light of radiological study results. With respect to the mastalgia types of the patients, 38.5% had cyclic pain, 57.7% non-cyclic pain and 3.8% other types of pain. Mild mastalgia was present in 46.2% of the patients, moderate mastalgia in 24% and severe mastalgia in 29.8% of them. According to the BIRADS category, 48.1% of the patients were identified to have BIRADS 1 mass lesions, 39.4% BIRADS 2, 9.6% BIRADS 3 and 2.9% BIRADS 5 mass lesions. The patients who were identified to have BIRADS 5 mass lesions described non-cyclic and severe pain in the post-menopausal period. They had palpable masses along with the pain symptom. Our study suggests that mastalgia symptom does not per se result in suspicion of malignancy, but physical examination and radiological imaging should also be used as needed for confirmation. Studies with a larger patient population are needed to shed light on the mastalgia epidemiology and its relationship with cancer.

Surgery for ingrowing nail is an effective treatment choice in an urban region

Objectives: The aim of this study is to evaluate the risk factors and treatment outcomes of patients with ingrowing nails in an urban region. Methods: This descriptive prospective study was performed in a General Surgery outpatient clinic in an urban region for 6 months. The data about sex, risk factors, age, history of previous medication were obtained. Body mass index, the ratio of second toe to the length of hallux, the ratio of the diameter of hallux to width of hallux nail were calculated. The ingrowing nails with stage II and III were treated by Winograd method. The patients were followed for recurrences and complications for nearly 6 months. Results: Total 61 patients were treated. Female to male ratio was 33/28. The man age was 24.8±11.8. The mean BMI was 28.5±5.3. Tight shoes, improper nail trimming were the leading etiological factors. Total 44 patients had a history of at least one time antibiotic usage history. Symptoms were found to be increased after pregnancy (66.7%). Lateral localization was significantly higher in patients with longer second toe than the hallux. There were 5 postoperative infections (8.2%) and only one (1.6%) recurrence. Conclusion: Ingrowing nail is an important problem because of increased risk factors in urban region. Winograd method which is an easy method with low recurrence and high patient satisfaction can be preferred.

Biliary stent migration presenting as a recurrent pilonidal abscess with underlying rectocutaneous fistula

A 53-year-old patient was admitted to the gastroenterology department for the management of a benign biliary stricture secondary to chronic alcoholic pancreatitis. He underwent sphincterotomy and placement of a 10Fr×10cm plastic biliary stent. Endoscopic follow-up 2 months later revealed spontaneous migration of the stent and no further intervention was performed. The patient was admitted to the general surgery outpatient clinic 7 years later for the management of a recurrent pilonidal abscess. Excision of the abscess revealed a long fistulous track towards the coccyx with a plastic stent inside it (● Fig.1a,b); the findings indicated a rectocutaneous fistula secondary to biliary stent migration. In addition, computed tomography scan showed a 1-cm defect of the sacrococcygeal junction in contact with the rectum (● Fig.2). Postoperatively, the patient was treated with antibiotics and vacuum-assisted closure therapy and went on to make an excellent recovery. His follow-up over 4 years was unremarkable. Complications of stent placement are well known and include migration with fistula formation between a variety of organs, such as: duodenocolic fistula [1], duodenoscrotal fistula [2], enterosplenic fistula [3], enterocutaneous fistula [4], and colovaginal fistula [5]. However, to the best of our knowledge recurrent abscess secondary to a rectocutaneous fistula has not been described previously.

Quality of life after stapler haemorrhoidectomy evaluated by SF-36 questionnaire.

Hemorrhoids are normal elements of the anal canal anatomy and they become symptomatic with potential factors such as gravity or strain. When symptomatic, hemorrhoidal disease can be costly measured in time away from productive activities. The aim of the study was to assess changes in the quality of life of patients after hemorrhoidectomy using Short Form-36. Thirty patients, 24 male and 6 female (age 28 to 65), who were diagnosed with grade III and IV internal hemorrhoidal disease at the general surgery outpatient clinic and treated with stapled hemorrhoidectomy were enrolled in the study. They filled out Short Form-36 a week before surgery and four weeks after surgery. Post-Hoc tests were evaluated with Bonferroni correction after Kruskal Wallis analysis. Wilcoxon test, Student-t-test and Mann-Whitney U test were used for statistical analysis using SPSS 15. Physical health (Physical functioning, Physical role restriction, Bodily pain) scores were significantly improved after surgery. Success of hemorrhoidectomy operations can be evaluated by postoperative recovery, incidence of complications or relapses. Quality of life questionnaires are another method to evaluate the success of the treatment from the patient's perspective.

Obesity and gastrointestinal quality of life: A hospital-based survey

Objective: We tried to find whether obesity worsens gastrointestinal (GI) quality of life score among patients with GI symptoms. Materials and Methods: This descriptive study was performed in general surgery outpatient clinic in a slum part of a city. Body mass index (BMI) of the patients was measured. The patients with GI symptoms were included. The demographic data obtained. GI quality of life score questionnaires were performed. Results : The prevalence of being overweight and obesity were 32.4% and 40.1% respectively. There 442 patients with GI symptoms among 1250 outpatient admissions. The mean age, BMI and GI quality of life index scores of the patients were 46.3 (18-87), 31.1 (18.8-44.4) and 89.9 (63-121) respectively. The percentage of obese and overweight patients was significantly higher than the percentage of patients with normal weight. The quality of life decreased significantly in overweight and obese patients when compared with normal weight patients. Conclusion : The prevalence of obesity among females and older age was higher. Obesity is worsening the GI quality of life.

2728 – Evaluation of self-esteem, body perception and social skills in individuals diagnosed with gynecomastia

Gynecomastia is a medical condition that affects men. Physical symptom is an abnormal enlargement of the mammary glands. Men who have this condition often end up feeling too embarrassed to be seen and it can greatly interfere with their personal life and social skills. This study attempts to evaluate the hypothesis that surgical approaches to correct simply the view are not enough to improve the quality of patients’ lives. 30 patients who were admitted to general surgery outpatient clinic with complaints of large breast and diagnosed with gynecomastia were enrolled in this study. Social Skills Rating Scale (SSRS), Body Image Scale (BIS), Coopersmith Self-Esteem Inventory (SEI) were applied preoperatively to patients with grade 1 and 2 gynecomastia. Scales were repeated postoperatively on the third month. Preoperative and postoperative scores of BIS were significantly different. In a similar vein, preoperative and postoperative scores of Coopersmith SEI were significantly different, too. Coopersmith SEI and BIS scores were low in the preoperative period and higher in the postoperative period. However, in terms of SSRS there was not a statistically significant difference between preoperative and postoperative period. Results indicate that presence of gynecomastia even at the level of grade-1 and 2 is effective on self-esteem, body image and social skills. The results also show that for the treatment of individuals diagnosed with gynecomastia surgical interventions alone can be inadequate. In these patients, after the surgical treatments, the addition of individual training programs to improve social skills may be useful.

One-Week Experience in the General Surgery Outpatient Clinic for Preclinical Medical Students

To evaluate whether the early introduction of observership in general surgery outpatient clinic for preclinical students could increase their interest in general surgery and ease their concerns, and to assess its potential effect on their careers in general surgery. A structured observership program was conducted at the Peking Union Medical College. A total of 83 preclinical students were observed in the general surgery outpatient clinic. Students were given a format survey before and after the observership. All students completed the early observing experience in general surgery. All students thought it worthwhile and recommended more such observership. Students had more interest in general surgery and higher possibility in choosing general surgery as a career. Their level of comfort and confidence in future clerkship was also improved. Most of the students thought the observership could improve their communication with surgeon teachers and patients. The observership in general surgery outpatient clinic for preclinical medical students can increase their interest and career possibility in general surgery. It can also significantly boost their confidence and comfort in their future surgical clerkship and improve communication with surgeon teachers and patients.

Socio-demographic factors and reasons associated with delay in breast cancer presentation: A study in Nigerian women

We evaluated the effects of selected socio-demographic factors on late presentation and reasons why our breast cancer patients delay reporting for treatment. All female breast cancer patients referred to one of the general surgery out-patient clinics of Lagos State University Teaching Hospital between January 2009 and December 2010 were interviewed. Relevant socio-demographic and clinical data were obtained and reasons for patient delay documented. Univariate and multivariate logistic regression analyses were conducted to calculate odd ratio for delay. A total of 201 patients were enrolled. Mean duration of symptoms was 12.12 months (SD ± 5.18). Delay for more than 3 months before initial medical consultation was observed in 164 patients (81.6%). Increased risk of late presentation was associated with single women (OR = 2.054), primary level of education (OR = 3.059), negative history of benign breast disease (OR = 1.648) and pre-menopause (OR = 1.861). Ignorance of the nature of illness, belief in spiritual healing, fear of mastectomy and belief in herbal treatment were the leading reasons for delay. Women with higher risk of late presentation should be the target group during interventions aimed at raising breast cancer awareness. Reasons for patient delay should also be addressed.

Significance of defecography and the role of rectocele in constipated patients

Backround: Chronic constipation is a common, chronic and frequent problem of the general population. The aim of this study is to assess the efficacy of defecography in diagnosing the etiology of constipation and the relation between constipation and rectocele. Material-method: We have investigated 250 patients who have been admitted to our general surgery out-patient clinic with complaint of constipation using Rome III criteria and diagnostic defecography. Results: Out of 250 patients who were evaluated with defecography only 24 had normal findings. 136 patients were found to have rectocele. Conclusion: We propose that rectocele is an important etiology of constipation, and defecography should be considered early in the diagnosis of rectocele.

The relationships between objective and subjective ratings of disfigurement severity, and psychological adjustment

Although the role of the objectively and subjectively rated severity of appearance problems is often debated, the impact of severity upon psychological adjustment has yet to be explored fully. In this study, 400 patients with a range of physical differences in appearance were recruited through general plastic surgery outpatient clinics and waiting lists. Patients completed the Derriford Appearance Scale 24 (DAS24), a measure of psychological distress and behavioural dysfunction related to self-consciousness of appearance. Severity in the outpatient group was objectively rated by plastic surgeons, and severity amongst the waiting-list group was subjectively rated by the patients themselves. Multiple regression modelling demonstrated a linear relationship between subjective adjustment and severity, with greater perceived severity associated with poorer adjustment. Similar modelling demonstrated a weak but statistically significant quadratic relationship between objectively rated severity and adjustment for normally visible, but not for normally non-visible differences of appearance. Moderate, rather than mild or severe objective severity was most related to poor adjustment.

Outpatients revisited: subjective views and clinical decisions in the management of general surgical outpatients in south west England.

To assess the scope for reducing unnecessary outpatient reattendances, using a benchmark an acute specialty at a site recognised to have an especially low ratio of repeat to new attendances. This was a survey of the re-attendance workload at general surgery outpatient clinics over a three month period. Patient re-booking and discharge rates for different grades of staff; clinicians' perception of the ability of the GP to have managed the patient; perception of the value of individual re-attendances; reason given for discharging/re-booking; and outcome of attendance for patients in relation to diagnostic category were determined. General surgery outpatients clinics with re-attendance rates that were 50% below average, in Taunton and Somerset Hospital, a non-teaching district general hospital. Altogether 454 patients who made 470 second or subsequent visits (re-attendances) within the same episode of outpatient care. Thirty eight percent (178/470) of visits were perceived as manageable by the GP, 45% (79, 17% of total re-attendances) of which were also thought to have been of marginal or little value. A substantial group of patients was being followed up largely for reasons of convention and traditional policy. Re-booking rates were higher among junior staff. Subjective views of the value of attendance at the hospital outpatient clinic and the ability of the GP to have seen the patient varied systematically between consultants and junior staff. Judgements varied to some extent according to the diagnostic group. The numbers of patients being followed up equivocally at most general surgical outpatient departments will be 50% more an average than those in this benchmark department. A department seeing 2000 new patients per annum will have 3600 reattendances, 25.5% (918) of which may be avoidable on the basis of these results. A variety of approaches can be used to increase the proportion of patients seen appropriately by GPs. In some cases this might be achieved without the intensive commitment required to plan and develop shared care protocols or new formal discharge guidelines, but by encouraging GPs to manage some patients, increasing of hospital clinicians' access to knowledge of local general practices, and internal clinic review of 'routine' follow up policies as shown in this study. This type of review of outpatient practice can also help prioritise conditions likely to repay the effort of developing and implementing clinical management guidelines and local protocols.

An overview of housing provision in Papua New Guinea: The role of the private sector

Indirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives.A survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period.A total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200 km, and 32.9% spent over 4 hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p < 0.01). Most were comfortable with medical communication using technology; and 34.3%–42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p < 0.001) and distance traveled (p < 0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing.Many families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit.