Surgical Problem Research Articles

Клинический случай успешного применения конформной лучевой терапии в лечении базальноклеточного рака слёзных путей

Though basal cell carcinoma of the lacrimal ducts is a rare disease, the early detection and management for the tumor can give favorable treatment results. At present time common treatment standards for the disease do not exist. However, most authors, previously faced the problem, recommend their colleagues to perform combined treatment with radiation therapy and the surgery, the priority of treatment procedures is not important. But at the same time, radical surgery in in locally advanced tumors often causes surgical problems, high trauma and extensive postoperative defect. When the surgery is used for l treatment of locally advanced tumors, the intervention increases the amount of surgical procedures, and can cause high trauma and extensive post-surgical defect. Because the disease is more often found in younger patients, it is a topical problem to look for the organ-saving treatment technology that determines the vital forecast, the patient’s future life and the quality of his/her life. The use of independent adaptive teletherapy has made it possible to deliver a high dose of ionizing radiation to the tumor and reduce its impact on the surrounding healthy tissue. No complications of treatment or signs of progression were observed during the 15-month follow up period. Thanks to the use of modern equipment for radiation therapy and new medical technologies, it has been possible to achieve the complete tumor regression and maintain a high quality of life for patients, despite the high risk of complications.

Fibula Hemimelia: Amputation versus reconstruction systematic review and meta-analysis

There is no universal agreement on the best course of action for treating lower limb abnormalities, which can be managed with either amputation or limb reconstruction. In patients with lower limb abnormalities, this meta-analysis compared patient satisfaction and surgical complications between amputation and limb reconstruction. A systematic search was done to find studies contrasting lower limb amputation and limb repair. MEDLINE, Cochrane Registry of Clinical Trials, EMBASE, PubMed, Google Scholar, CINAHL, and Elsevier Scopus databases were searched using keywords (amputation and reconstruction) and (Fibula hemimelia or Fibula deficit or Fibular deformity) (therapy or treatment or management). Patient satisfaction and surgical complications were the main results. The odds ratio (OR) for patient satisfaction and the percentage of surgical problems per limb were calculated using a random-effects model. The meta-analysis includes seven trials that covered 202 patients in total. With an OR of 6.8, patients who had limb amputations reported higher levels of treatment satisfaction than those who had limb reconstructions. Additionally, the OR of 28 showed that the rate of surgical complications was much lower in the amputation group compared to the limb reconstruction group. In comparison to patients who underwent limb reconstruction, patients who had amputations reported higher levels of satisfaction and a lower risk of postoperative complications. According to these findings, amputation might be a better course of action for some patients with lower limb abnormalities.

DUCMA 2.0 project: Update on the current situation of the outpatient surgery units in Spain

IntroductionAmbulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. MethodsMulticenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. ResultsIn total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). ConclusionsGreater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.

Common pediatric surgical conditions and associated health-seeking behaviors in Pakistan: An urban and rural comparative assessment.

Approximately five billion people do not have access to necessary surgical treatment globally and up to 85% of children in LMICs are affected with conditions requiring surgical care by the age of 15 years. It is crucial to identify common surgical conditions in children in Pakistan to inform healthcare professionals and policymakers for effective resource allocation. This representative cross-sectional household survey conducted on children aged 5-10 years assessed existing surgical diseases and healthcare-seeking behaviors in the two largest provinces (Sindh and Punjab) of Pakistan. The data was collected through a validated cross-sectional survey tool [Surgeons OverSeas Assessment of Surgical Need (SOSAS)]. Caregivers were asked about their child's recent and past surgical conditions in six distinct anatomical regions and pictures were taken of identified conditions after appropriate consent for further diagnosis. Health-seeking behaviors including the kind of treatment sought, the nature of care received, and the reasons for not receiving care were noted. 13.5% of children surveyed reported a surgical condition, with a similar distribution across urban (13.2%) and rural (13.7) areas and the most common cause was trauma. The greatest number of surgical conditions were found to be on the head and neck region (57.7%), while the back accounted for the least number of conditions (1.7%). Our results outline a need for organizing all entities (governmental, non-governmental, and private) involved in child health to ensure efficient resource allocation to cater to existing surgical problems.

Transabdominal Pre-Peritoneal Versus Totally Extraperitoneal Laparoscopic Techniques for Inguinal Hernia Repair in Eastern Nepal

Background: Inguinal hernia is one of the most common surgical problems in the world, with a high risk in men. The treatment modalities have evolved from open to laparoscopic procedures. Laparoscopic procedures are getting attention and widespread utilization among surgeons. The choice between the two procedures is still a debate between the surgeons. This study aims to compare the transabdominal pre-peritoneal approach to the totally extraperitoneal approach in its perioperative outcomes. Materials and Methods: A prospective analytical study was conducted on 86 adult patients, who underwent laparoscopic inguinal hernia reduction between June 2022 to June 2023 at Nobel Medical College Teaching Hospital in Biratnagar, Nepal. The patients were randomized into two groups of 43 participants each and were analyzed on different variables. Results: All of the 86 patients included in the study were male. Among them, 30.23% of patients had direct inguinal hernia. There were 12.79% of patients with bilateral hernias. There was a statistically significant difference in the duration of operation among the patients undergoing totally extraperitoneal and transabdominal preperitoneal hernia repair. Total duration of hospital stay was shorter in totally extraperitonealand postoperative pain was slightly lesser in totally extraperitoneal procedure. The intraoperative and postoperative complications among totally extraperitoneal and transabdominal preperitoneal hernia repair were comparable. There was no conversion to open procedure or recurrence of hernia during the study period. The return to daily life took longer in the transabdominal preperitoneal procedure than in the totally extraperitoneal hernia repair. Conclusion: Totally extraperitoneal hernia repairhas an advantage over transabdominal preperitoneal hernia repairin terms of shorter operative time, postoperative pain, duration of hospital stays, and return to daily life.

Proyecto DUCMA 2.0. Puesta al día sobre la situación actual de las unidades de Cirugía Mayor Ambulatoria en España

IntroductionAmbulatory surgery is a safe and efficient management system to solve surgical problems, but its implementation and development has been variable. The aim of this study is to describe the characteristics, structure and functioning of ambulatory surgery units (ASU) in Spain. MethodsMulticenter, cross-sectional, observational study based on an electronic survey, with data collection between April and September 2022. ResultsIn total, 90 ASUs completed the survey. The mean overall ambulatory index is 63%. More than half of the ASUs (52%) are integrated units. Around half of the units provide training for physicians (51%) and for nurses (55%). The most frequently used quality indicators are suspension rate (87%) and the rate of unplanned admissions (80%). ConclusionsGreater coordination between administrations is needed to obtain reliable data. It is also necessary to implement quality management systems in the different units, as well as to develop tools for the adequate training of the professionals involved.

A PROSPECTIVE STUDY ON PREDISPOSING FACTORS FOR VARIOUS VENTRAL HERNIA CASES IN A TERTIARY CARE HOSPITAL

Ventral hernias may arise from an area of weakness in anterior abdominal wall such as umbilicus, sites of previous surgery or from the areas where musculature is weak. They are commonly dealt surgical problem in our day to day clinical practice associated with various complications/recurrence. This prospective study was conducted to analyze various risk factors responsible for ventral hernia formation and in formulating targeted effective preoperative optimization of those risk factors thereby improving post-operative outcomes. Among various predisposing factors, females (63.33%), history of previous surgery (55%), old age (38.3%) formed the majority in this study. Prevention of ventral hernia and targeted preoperative optimization has gained popularity in recent times to achieve better post-operative outcomes.

Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population.

Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated. A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated. Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018). Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Whole task simulation in surgical training: A hybrid method of teaching undergraduate medical students

Background: The current Competency-Based Medical Education (CBME) curriculum practiced in India accentuates that medical graduates must demonstrate competency in safely diagnosing, investigating, and managing clinical presentations across both community and secondary care settings. Therefore, there is a need for more hybrid teaching methods that simulate real situations. This approach will help newly qualified doctors gain confidence and prepare them for the future. We used the whole task simulation method to teach them one of the most common surgical problems i.e., breast cancer along with communication skills, professionalism, Interprofessional teamwork, asepsis, and safe surgery practices. Methods: The study enrolled 20 final-year MBBS students through purposeful sampling. Following classroom-based teaching on a Breast case, a simulated scenario was given, based on SECO (The Safe and Effective Clinical Outcome) design, and was modified with the addition of a simulated operating room setup. History taking, examination, ordering investigations and interpreting them, pre-operative counseling and consent and operation theatre scenario was done using standardized patient and mannequins. Pre- and post-simulation survey was conducted. Quantitative data were collected through Google Forms to assess their conceptual knowledge and qualitative data by Focused group discussions. Results: Students preferred a shift to this hybrid method of learning in a simulated environment over classical classroom-based teaching. They all felt that getting involved in a real-life situation helps in understanding surgical management better. They also understood the concept of teamwork and effective communication. "I feel it’s the best way to learn clinical medicine. No amount of literature could ever replace the knowledge we get from being in the scenario", was one of the responses given by the participants. Conclusion: Integration of surgical simulated clinics along with the operation room (OR) set up into the undergraduate curriculum could facilitate the acquisition of clinical skills actively and interactively. Such a hybrid method of teaching is an effective tool for teaching communication skills, professionalism, interprofessional teamwork along clinical skills.

Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

To qualitatively assess surgeons' decision making for lip surgery in patients with cleft lip/palate (CL/P). Prospective, non-randomized, clinical trial. Clinical data institutional laboratory setting. The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the 'Standardized Assessment for Facial Surgery (SAFS)' for systematic viewing by the surgeons. The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either 'in person' or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. In general, there was surgeon agreement for the diagnoses/treatments. The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

DENTAL IMPLANTATION AFTER RECONSTRUCTION OF TOTAL AND SUBTOTAL DEFECTS OF THE UPPER AND LOWER JAWS

Medical and social rehabilitation of patients with total jaw defects is an urgent surgical problem for maxillofacial surgeons. Cicatricial deformities, functional disorders of anatomical structures after resection are a difficult task for reconstructive surgery. It is impossible to achieve positive results without the use of digital technologies, a review of the methods of «digital dentistry» (CAD-CAM modeling and 3D printing) on clinical examples.The aim of the study was to investigate the necessity of using digital technology in prosthetic patients with subtotal and total jawbone defects.Materials and methods. The review provides examples of complex dental rehabilitation of patients with a detailed description of clinical and laboratory procedures, photographs and X-ray studies.Results. An illustrative clinical example confirms the high value and significant role of computer simulation in complex clinical cases and situations. The presented technique made it possible to restore the former quality of life of patients, which indicates its high development today.Conclusions. Clinical examples confirm the effectiveness of the use of digital dental technologies, prosthetics on implants in maxillofacial surgical dentistry. In the future, these methods will be improved through the introduction of new materials, workflow optimization and improved design accuracy using CAD-CAM and 3D modeling technologies.

Introduction of pediatric laparoscopic inguinal hernia repair in Guatemala

PurposeIntroducing new surgical techniques in a developing country can be challenging. Inguinal hernias in children are a common surgical problem, and open repair is the standard surgical approach. Laparoscopic repair has gained popularity in developed countries because of similar results. This study aimed to determine the outcomes following the introduction of laparoscopic repairs in Guatemala.MethodsThis retrospective analysis of prospectively collected data from all patients under 18 years who underwent laparoscopic repair at Corpus Christi Hospital in Patzun, Guatemala, from September 5th to September 8th, 2022.ResultsA total of 14 patients were included in the study. A board-certified pediatric surgeon and a Guatemalan physician performed all cases. The mean patient age was 7.6 years; 7 boys and 7 girls. All patients were interviewed at 7 days, 30 days, and 6 months. There were no postoperative infections, pain requiring re-evaluation, gonadal atrophy, or hernia recurrence.ConclusionUnder controlled circumstances with limited but proper equipment and disposables, laparoscopic inguinal hernia repairs can be introduced and performed in a developing country with a risk complication profile comparable to that in developed countries. This study provides promising evidence of laparoscopic repair feasibility and safety where surgical resources are limited.

Surgical scheduling to smooth demand for resources

With the growing demand for healthcare resources, pressure on efficient usage of available bed capacity is increasing. Peaks in bed demand corresponds to overcrowding in upstream units such as emergency department or operating rooms. With a balanced schedule in elective surgeries integrated into the master surgical schedule, peak traffic can be leveled across the week without changing resource capacity. Hence, overcrowding is reduced without turning away any patients or increasing bed capacity.This study formulates the integration of master surgical and elective surgery scheduling problems as an Integer Programming model to minimize the fluctuation in the required ward beds for elective inpatients admitted for surgery to the hospital, by changing the day of surgery. This demonstrates the opportunities for smoothing the expected patient demand for beds by adjusting the operating room schedule. This decision is made at the tactical level. The model has been examined using data on the elective patient demand for beds in the hospital during typical weeks driven from Hamilton Health Sciences in Ontario, Canada. The integer programming model has been solved using GAMS/CoinCBC MIP Solver. The model enhances bed management by not only smoothing but also reducing the peak demand. The optimal schedule reduces the peak patient demand for bed by about 3–19% for the test samples. The model can be extended to cover the demand for other resources such as ICU beds.

A Comparative Study of Computed Tomography Findings versus Intraoperative Findings of Level of Tegmen Plate in Chronic Otitis Media: An Observational Study.

To compare the computed tomography findings with intraoperative findings of the level of tegmen plate with respect to the superior most part of the lateral semicircular canal in patients with Chronic Otitis Media. This study was attemptted to provide an objective assessment of the level of tegmen mastoideum. The level of tegmen plate with respect to the superior most part of the lateral semi-circular canal was measured preoperatively using HRCT scan of slice thickness of 0.6mm with a software - RadiAnt DICOM Viewer 64-bit version in sagittal plane. The distance between these two planes was measured intraoperatively using micro ear straight pick and Vernier Calipers. 75 participants (thirty-three male & forty-two female) with chronic otitis media underwent computed tomography preoperatively and surgery. No significant difference was found in the height of tegmen measured preoperatively using HRCT temporal bone and intraoperatively (p value - 0.16). The tegmen plates were classified as low lying (2.0 -2.49mm), intermediate lying (2.49-2.99mm) and high lying (3.0 -3.49mm). Computed tomography findings of tegmen height correlates well with the intraoperative findings. An objective assessment of the level of tegmen mastoideum can provide the surgeon an idea of the severity of low lying level of tegmen to be expected and hence likely surgical problems. Based on this study, a classification system of level of tegmen plate has also been proposed.

Challenges and hurdles in managing giant inguinoscrotal hernia: A case report

IntroductionA giant inguinal hernia is described as an extension of the hernia below the midpoint of the patient’s inner thigh in the standing position. It is relatively rare but severely affects a patient’s quality of life and imposes specific challenges to the surgeons.AimThe aim of this paper is to describe the management of giant inguinal hernia and its related challenges.Case studyA 51-year-old man, a chronic smoker, and a labourer at a construction site complained about a rapidly growing reducible right groin swelling with heaviness, and discomfort. He was counselled for surgical intervention a year earlier but defaulted on follow-up. There was a right giant inguinoscrotal swelling extending beyond the mid-thigh on standing position. He underwent inguinal hernioplasty successfully without any intra- or post-operative complication.Results and discussionChallenges in managing giant inguinal hernias include loss of domain and a higher risk of cardiovascular compromises, intra- and post-operatively. Compared to other inguinal hernias, a giant inguinal hernia is also at a higher risk of surgical site infections, scrotal haematoma, and hernia recurrences.ConclusionsA giant inguinal hernia is a rare and challenging surgical problem for surgeons. Meticulous perioperative managements are important in ensuring such patients with a promising outcome.

Effects of novel Coronavirus (COVID-19) on presentation, management, and outcomes of acute cholecystitis at an academic tertiary care center cholecystitis management during COVID-19

BackgroundThe COVID-19 pandemic necessitated adjustments to nearly all aspects of healthcare, including surgical care. The effects of these adjustments have not been well studied on acute surgical problems conventionally managed non-electively in large, tertiary care centers. MethodsA retrospective analysis of admitted patients with acute cholecystitis at a US academic tertiary care center was performed. We compared the presentation, management, and 30-day outcomes of patients admitted during a 2-month time period during early COVID, to a pre-COVID control group of admitted cholecystitis patients over a 2-month span. ResultsThe study cohort captured 24 patients, while the control cohort encompassed 53 patients. A non-significant trend toward non-operative management in the COVID cohort is reported. There was no delay in time-to-surgery or complication rate. No surgically managed patient developed COVID within 30 days of operation. ConclusionsOperative management of acute cholecystitis during the COVID-19 pandemic, with pre-operative testing and personal protective equipment guidelines, remained safe and effective.

Possible Reasons for Failure and Surgical Problems in Complex Chiari Cases

Possible Reasons for Failure and Surgical Problems in Complex Chiari Cases

A107Mental Health Simulation for Foundation Doctors: Bridging the gap of placement variation

There is significant variation of foundation programme tracks across the United Kingdom, giving a range of clinical exposure to newly qualified doctors [1]. Common themes in tracks can be identified to include acute/emergency, community, general medicine, surgery and psychiatry components. In the deanery, many Foundation Trainees (FTs) on psychiatry will have up to 3 additional simulation days devoted to psychiatry themes and this is felt to be an especially effective way to supplement education on psychiatry consultation skills [2]. FTs who do not have psychiatry posts will not have the opportunity to attend this training. Typically, mandatory foundation simulation training focuses on human factors related to acute medical and surgical problems [3]. Our education department has developed a pilot programme to support simulation training on key mental health consultations to support well rounded training of FTs. Half day sessions have been delivered to small groups of FTs who do not have psychiatry posts. Faculty has included experienced simulation faculty and psychiatry doctors and the scenarios conducted in a small group format with professional actors playing patients for increased realism of scenarios. The participants rotated between 3 key scenarios covering essential themes of mental state examination, psychiatry team liaison, patient risk assessment and explaining mental health presentations. 2 sessions have been delivered for a total of 18 FTs. FTs showed insight to a number of challenges related to mental health presentations they had experienced outside of psychiatric settings and this formed the outline of the learning objectives for the session. The participants further reflected on discussions in their feedback from the session and portfolio. The sessions were well received, with improvement in confidence in managing these consultations demonstrated in pre and post course survey comparison from the majority of participants. Given the initial success of the session, the team is building a database of local faculty for continuity of the course and looking to secure relevant funding from HEE to provide further sessions for the FTs in the next academic year. This simulation pilot has shown promise to be a useful addition to supplement the education of FTs for mental health consultations applicable in all areas of their clinical practice. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Hospital preparedness and response to the Freetown oil tanker explosion - A case study of A Tertiary Hospital in Sierra Leone

Oil tanker explosions are a fairly common cause of disaster in sub–Saharan Africa. These disasters may have secondary effects on health service delivery due to collapse of routine health service provision as staff concentrate on taking care of the disaster victims. This might suggest that our hospitals and health systems are not fully prepared to cope with these situations. The article aims to share our experience in managing tanker explosions in terms of disaster preparedness and response, access to drugs and medical supplies, access to laboratory facilities and the medical and surgical problems commonly encountered as well as possible recommendations.

A comparative study of the outcome of displaced fractures neck of femur treated with unipolar prosthesis and fenestrated bipolar prosthesis in active elderly patients

Background: Fractures of the neck or femur are among the most serious surgical problems affecting older groups. These fractures constitute a large burden on families and society due to the inability to stand and walk. Objectives were to compare the functional outcomes of unipolar (Austin-Moore) versus uncemented bipolar hemiarthroplasty in displaced fractures neck femur among these active elderly patients. Methods: This prospective interventional study was carried out at NITOR, Dhaka, Bangladesh in total 60 patients. Among them, 30 patients were treated with unipolar and 30 patients were treated with fenestrated bipolar prosthesis through a lateral approach. Results: There was no significant age difference between the two groups. Regarding the functional outcome, 6 (20%) patients in the unipolar group and 11 (36.67%) patients in the bipolar group had excellent outcomes. About the same number of patients had good outcomes 36.67% in the unipolar and 43.33% in the bipolar group; the fair and poor outcome was more in the unipolar group than the bipolar group. So, the final outcome after 6 months of operation, 57.57% of patients had satisfactory results in the unipolar group whereas 80% of patients had satisfactory results in the bipolar group. The average Harris hip score was 77.14±14.58 in the unipolar group and 84.63±10.15 in the bipolar group and the p=0.01 which is below 0.05. So, the result is statistically significant. Conclusions: Uncemented bipolar hemiarthroplasty with a fenestrated stem can give better functional outcomes for displaced intracapsular femoral neck fractures in active elderly patients compared to Austin-Moore prostheses.