Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Thyroid-like follicular carcinoma of kidney: case presentation and literature review

Published in August 202

Preventing Inadvertent Parathyroidectomy during Thyroid Surgery - A Literature Narrative

Incidental parathyroid injury or removal is a serious complication of thyroid and neck surgeries, leading to temporary or permanent hypocalcemia, which have significant short or long term morbidity respectively. A variety of techniques, both imaging and operative, have been described in the literature to prevent this mishap; among these, those most supported by clinical data include the use of carbon nanoparticles, and meticulous capsular dissection. This review aims to explore the various techniques for parathyroid preservation that have been introduced till date, and to give key recommendations regarding techniques that can be used by surgeons in different neck surgeries

An outcome of emergency vascular surgery performed by General Surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

Objective: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality. Method: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20. Results: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8+11.5 years (range: 14-63 years). Mean duration of hospital stay was 11+3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003). Conclusion: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention. Key Words: Vascular surgery, Artery repair, Venous graft, Vascular anastomosis

The study of frequency of malignancy and its types in surgical jaundice; a tertiary care experience

Objective: To determine the frequency of malignancy and its types in patients presenting with surgical jaundice in a tertiary care setting. Method: The cross-sectional study was conducted at the North Surgical Ward, Mayo Hospital, Lahore, Pakistan, from May 8 to November 8, 2020, and comprised patients of either gender with a diagnosis of surgical jaundice made on the basis of history, clinical examination, haematological and biochemical reports and radiological investigations. All patients were managed as per the guidelines for surgical jaundice with injection vitamin K intramuscular, hydration with intravenous fluids, avoidance of constipation by lactulose or neomycin, vitals and urine output monitoring and prophylactic antibiotics. Demographic data as well frequency of malignancy were noted using a predesigned proforma. Data was analysed using SPSS 21. Results: Of the 95 patients, 51(53.7%) were male and 44(46.3%) were female. The overall mean age was 49.96±16.54 years (range: 18-80 years). A total of 19(20%) cases had body mass index <30. Malignancy was identified in 50(52.6%) cases; 14(28%) gallbladder, 4(8%) head of pancreas, 9(18%) peri-ampullary carcinoma, 7(14%) cholangiocarcinoma, 6(12%) Klastkin tumour, 5(10%) hepatocellular carcinoma, and 5(10%) metastatic tumour. Conclusion: More than half of the surgical jaundice cases had malignancy, gallbladder being the most affected site. Key Words: Surgical jaundice, FNAC, Peri-ampullary carcinoma, Klastkin tumour, Hepatocellular carcinoma

Comparison of outcome of compression dressing for two days Vs seven days after varicose surgery

Incompetence of the great saphenous vein (GSV) is a global issue and the most prevalent cause of chronic venous disease of the leg. Clinical manifestations range from moderate to severe, including tiredness, heaviness, and irritation, as well as hyperpigmentation and leg ulcers. A study was conducted to address this controversy,(1) i.e. to determine the outcome of compression dressing after varicose vein surgery in terms of postoperative pain, on the Surgical floor, of Mayo Hospital, Lahore, from October 1, 2020, to April 1, 2021. A total of 60 patients with Primary varicose veins were enrolled in this study, fulfilling the inclusion criteria after obtaining approval from the ethical committee of the hospital. The patients were divided in two groups. Group A wore compression dressing for two days after surgery and Group B wore compression dressing for seven days after surgery. All the patients received 1gm Paracetamol I/V eight hourly followed by tablet Paracetamol 500mg P/O eight hourly. Then the outcome of compression dressing was analysed in the form of mean postoperative pain. The mean pain score was assessed on one week. Data were entered in SSPS v23.0. Stratification of pain score was done against age, gender, and grades of varicose veins. A comparison of the two groups was done by applying a t-test. A p-value of 0.05 was considered significant. Prescribing compression stockings for longer than two days after Trendelenburg’s procedure leads to reduced pain and improved physical function during the first week after treatment. Keywords: Trendelenburg’s procedure, Great saphenous vein, Compression stockings

Isolation of oleanolic acid from Lavandula stoechas and its potent anticancer properties against MCF-7 cancer cells via induced apoptosis

Medicinal plants are natural resources of diversified therapeutic metabolites. Lavandula stoechas has been used traditionally for the management of different metabolic disorders. However, studies on the anticancer characteristics of certain bioactive compounds present in this plant are very limited. In view of this, the aim of the present study was to isolate oleanolic acid (a triterpenoid) from L. stoechas and assess its anticancer trait against breast carcinoma cells (MCF-7) via induced apoptosis. Initially, oleanolic acid was isolated from the ethyl acetate fraction of L. stoechas using standard extraction protocols. Furthermore, the structure of compound was established using mass spectrometry, FT-IR, 1H NMR, and 2D NMR (HSQC) techniques. In vitro antiproliferative effect of oleanolic acid was assessed against breast carcinoma cells (MCF-7 and MDA-MB-231) and non-cancerous cells (BHK-21) using the MTT assay. Oleanolic acid showed prominent cytotoxicity of 72.44 ± 3.33 and 78.55 ± 2.67 % against MCF-7 and MDA-MB-231 cells with IC50 values of 13.09 and 160.22 µg/mL, respectively. Moreover, the compound showed negligible toxicity against the BHK-21 cell line. Furthermore, the apoptotic features in oleanolic acid-treated MCF-7 cells were determined using fluorescent microscopy, which showed typical nuclear condensation, increased ROS generation, and the loss of outer mitochondrial membrane potentials. The levels of activated caspases in MCF-7 cancer cells were estimated using a fluorescent kit, showing a significant increment in caspase-9 and caspase-7 for oleanolic acid-treated MCF-7 cells. Moreover, oleanolic acid showed down-regulation of the Bcl2 and PDGF genes. Our findings demonstrated the pivotal role of oleanolic acid as pronounced anticancer agent against MCF-7 cell lines by inducing apoptotic mechanism via intrinsic pathway