Surgery Commons^™

Process Improvement For Endovascular Thrombectomy In Patients Presenting With Acute Ischemic Stroke, Richard F. Schmidt, Md, Michael J. Lang, Md, Robin Dharia, Md, Fred Rincon, Md, Thomas Zdanowski, Rn, Msn, Robin D'Ambrosio, Rn, Msn, Stavropoula Tjoumakaris, Md, M. Reid Gooch, Md, Pascal Jabbour, Md, Nabeel Herial, Md

House Staff Quality Improvement and Patient Safety Conference (2016-2019)

Aims

1. Critically evaluate the existing stroke activation and ET protocols for compliance with new 2018 metrics and guidelines.
2. Review DTP times under the existing protocol to assess for potential inefficiencies or gaps in care delivery, specifically addressing differences between processes at JHN compared to ED/Gibbon.
3. Make changes to the existing stroke alert protocol to better reflect current guidelines, streamline care, and ultimately improve process metrics (DTP times).
4. Establish a system for recursive continuous analysis of AIS patients to identify protocol gaps, inefficiencies and areas for further intervention.

The Causes And Effects Of Attrition From Post-Graduate Residency Programs At The Aga Khan University Hospital, Nairobi., Dennis Wamalwa

Master of Medicine in General Surgery

Background: Resident attrition is a global problem affecting most postgraduate residency training programs. It not only disrupts the educational and workload balance in the program but also results in loss of valuable time invested by the resident who has to leave before completion. AKUHN has similarly been affected with a worrying increase in resident attrition numbers over the last few years. There is however a lack of local studies on resident attrition which would inform measures to address modifiable risk factors for resident attrition and thus prevent future attrition. Objectives: To explore factors attributable to attrition amongst residents in Aga …

Ultrasound-Guided Introital Drainage Of Pyometrocolpos, I Kim, Ranjith Vellody, Hans G. Pohl, Karun Sharma, Kabir Yadav

Radiology Faculty Publications

Pyometrocolpos can be caused by congenital malformations such as distal vaginal atresia and imperforate hymen. Patients usually present with obstructive urinary tract infections, acute kidney injury, or sepsis. Percutaneous drainage of the infected fluid can help treat the patient; however, recurrence is of concern. In this case report, we present a case of a child with recurrent pyometrocolpos due to distal vaginal atresia despite initial percutaneous drainage. To our knowledge, this is the first report of ultrasound-guided introital drainage of pyometrocolpos with relief of symptoms obviating the need for repeat drainage or immediate surgery. © 2017

Unicameral Bone Cysts: Current Concepts, Shahryar Noordin, Salim Allana, Masood Umer, Mujahid Jamil, Kiran Hilal, Nasir Ud Din

Section of Orthopaedic Surgery

Unicameral bone cysts (UBC) or simple/solitary bone cysts are benign fluid filled cavities that enlarge over time, resulting in thinning of the bone. Usually these cysts are reported in the metaphyseal areas of long bones with open physes. 85% of UBCs occur almost exclusively in children and adolescents. UBCs are more aggressive in the first decade of life and correspondingly the recurrence rate for these patients is four times that for adolescents. The proximal humerus and femur account for almost 90% of these cases. UBCs are classified as active when they are within 1 cm of the physis and latent …

Early Versus Late Intramedullary Nailing For Traumatic Femur Fracture Management: Meta-Analysis, Ayman El-Menyar, Mohammed Muneer, David Samson, Hassan Al-Thani, Ahmad Alobaidi, Paul Mussleman, Rifat Latifi

NYMC Faculty Publications

INTRODUCTION: There is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN). METHODS: English language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used …

Trevo Stent-Retriever Mechanical Thrombectomy For Acute Ischemic Stroke Secondary To Large Vessel Occlusion Registry., Osama O Zaidat, Alicia C Castonguay, Raul G Nogueira, Diogo C Haussen, Joey D English, Sudhakar R Satti, Jennifer Chen, Hamed Farid, Candace Borders, Erol Veznedaroglu, Mandy J Binning, Ajit Puri, Nirav A Vora, Ron F Budzik, Guilherme Dabus, Italo Linfante, Vallabh Janardhan, Amer Alshekhlee, Michael G Abraham, Randall Edgell, Muhammad Asif Taqi, Ramy El Khoury, Maxim Mokin, Aniel Q Majjhoo, Mouhammed R Kabbani, Michael T Froehler, Ira Finch, Sameer A Ansari, Roberta Novakovic, Thanh N Nguyen

Articles, Abstracts, and Reports

BACKGROUND: Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.

METHODS: Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), …

A Rare Case Of Clostridium Septicum Aortitis With Colon Adenocarcinoma, Niti Shahi, Mariano Arosemena, Jeontaik Kwon, Paul J. Dimuzio, Babak Abai, Dawn M. Salvatore

Department of Surgery Faculty Papers

Clostridium septicum aortitis is a rare, highly morbid condition typically accompanied by malignant disease, such as hematologic cancer or colon adenocarcinoma. Presenting symptoms commonly described include acute onset of abdominal pain, nausea, and fevers. Prompt diagnosis of infectious aortitis is critical to prevent deadly complications, such as sepsis and vascular catastrophe. The described management largely involves surgical resection of the infected aorta, débridement, and arterial revascularization through extra-anatomic bypass or aortic graft placement.

Ultrasound-Guided Peripheral Nerve Blocks In High-Risk Patients, Requiring Lower Limb (Above And Below Knee) Amputation, Faisal Shamim, Malika Hameed, Nadeem Ahmed Siddiqui, Shemila Abbasi

Department of Anaesthesia

A case series of five high-risk patients with lower limb ischemia, sepsis, altered coagulation, and multi-organ dysfunction requiring emergent or urgent lower limb amputation is presented. Use of peripheral nerve blocks for below and above knee amputations is quite uncommon which provides better hemodynamic stability and pain management, especially in the very sick patients. The surgeries were successfully carried out under ultrasound-guided combined femoral and sciatic nerve blocks. All five patients obtained adequate level of block at the area of amputation. There were no complications related to anesthetic management. Patients remained hemodynamically stable and pain-free during surgery and postoperatively. Combined …

Two To Nine Year Review Of Breast Conservation Therapy (Bct) For Breast Carcinoma: Clinico-Pathological Features And Survival In A Single Centre In East Africa, George Orerah

Master of Medicine in General Surgery

Introduction: Breast conservation therapy compares to mastectomy in terms of overall survival and disease free survival. However it’s utilization in most parts of the sub-Sahara Africa is minimal with various factors cited: patient preference, provider preference and adverse effects of or limited access to radiation therapy. The aim of this study was to determine the clinico-pathological profile and outcomes of breast cancer patients treated with breast conservation therapy or mastectomy at a single referral centre. Methods: The Aga khan university hospital is one of the institutions in East Africa, where breast conservation therapy is practiced. We retrospectively analysed the details …

Osteoporosis And Its Perspective In Pakistan: A Review Of Evidence And Issues For Addressing Fragility Fractures, Aysha Habib Khan, Lena Jafri, Sibtain Ahmed, Shahryar Noordin

Department of Pathology and Laboratory Medicine

Despite major advances in osteoporosis diagnosis and treatment, low rates of investigating and treating osteoporosis in patients with fragility fracture are reported in Pakistan. Cost of therapies, time and cost of resources for diagnosis, concerns about medications and lack of clarity regarding the onus of responsibility to undertake this care, are some of the barriers to osteoporosis identification and treatment. Data from our part of the world on osteoporosis as well as on fragility fractures is sparse. This review addresses the current screening and diagnostic strategies for osteoporosis and reviews the existing literature to highlight the issues prevalent in our …

Implementation Of A Surgical Safety Checklist, Nicole Stathatos

Master's Projects and Capstones

Lack of standardization in the perioperative area leads to variations in practice that can cause preventable errors. In a 200-bed hospital in Northern California with eleven operating rooms preforming approximately 11,000 procedures a year, there was an increase incidence in sentinel events such as wrong site surgery (n=1), wrong patient surgery (n=1), and retained foreign body (n=5). Safety checks observed in the operating room (OR) were preformed differently among each surgical team and sometimes did not occur at all. Through the use of a Surgical Safety Checklist (SSC), efforts were aimed to standardize safety practices in the OR. The goal …

Variant Distal Ulnar Nerve Loop: A Previously Undescribed Anatomical Finding., Mayank Patel, Joe Iwanaga, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

A previously undescribed variant ulnar nerve loop was discovered during the routine anatomic forearm and hand dissection of an adult female. The major finding was that of a large loop traveling around the distal tendon of the flexor carpi ulnaris. The variation presented here appears to be unique. The exact function of such derailed anatomy is not clear but, if found during surgery, might confound normal dissection methods or, when present, could result in varied clinical presentations regarding the sensory or motor examination of the hand.

The Synergistic Effects Of Saxagliptin And Metformin On Cd34+ Endothelial Progenitor Cells In Early Type 2 Diabetes Patients: A Randomized Clinical Trial., Fiona J Dore, Cleyton C Domingues, Neeki Ahmadi, Nabanita Kundu, Yana Kropotova, Sara Houston, Carol Rouphael, Aytan Mammadova, Linda Witkin, Anamil Khiyami, Richard L Amdur, Sabyasachi Sen

Surgery Faculty Publications

AIMS: Type 2 diabetes is associated with endothelial dysfunction leading to cardiovascular disease. CD34+ endothelial Progenitor Cells (EPCs) are responsible for endothelial repair and neo-angiogenesis and can be used as a cardiovascular disease risk biomarker. This study investigated whether the addition of saxagliptin, a DPP-IV inhibitor, to metformin, may reduce cardiovascular disease risk in addition to improving glycemic control in Type 2 diabetes patients.

METHODS: In 12 week, double-blind, randomized placebo-controlled trial, 42 subjects already taking metformin 1-2 grams/day were randomized to placebo or saxagliptin 5 mg. Subjects aged 40-70 years with diabetes for < 10 years, with no known cardiovascular disease, BMI 25-39.9, HbA1C 6-9% were included. We evaluated EPCs number, function, surface markers and gene expression, in addition to arterial stiffness, blood biochemistries, resting energy expenditure, and body composition parameters. A mixed model regression to examine saxagliptin vs placebo, accounting for within-subject autocorrelation, was done with SAS (p < 0.05).

RESULTS: Although there was no significant …

Fifteen Years Experience Of Managing Penetrating Extra-Peritoneal Rectal Injuries, Tanzeela Gala, Noman Shahzad, Ahmed Ibrahim Edhi, Fareed Ahmed Shaikh, Hasnain Zafar

Section of General Surgery

Background: Although civilian injuries are generally less severe, they nevertheless remain a challenging problem for the surgeons. In isolated rectal injury patients, though proximal diversion, pre-sacral drainage, distal rectal wash-out and wound debridement are the various surgical options employed in various combinations, the optimum strategy especially for civilian injuries remains unknown. We reviewed our experience of managing penetrating extra peritoneal rectal injuries.
Methods: We conducted a Retrospective review of Adult patients with penetrating extra-peritoneal rectal injuries. Follow-up information of at least one month was needed for early post-operative complications.
Results: A total number of fifteen patients met …

Department Of Surgery Update, March 2018, Wright State University Department Of Surgery

Department of Surgery Updates

A four page newsletter created by the Department of Surgery documenting changes to the department. This issue contains a message from the chair, a list of important dates, committee meetings, and more.

Precision Medicine For Crc Patients In The Veteran Population: State-Of-The-Art, Challenges And Research Directions., Shyam S Mohapatra, Surinder K Batra, Srinivas Bharadwaj, Michael Bouvet, Bard Cosman, Ajay Goel, Wilma Jogunoori, Michael J Kelley, Lopa Mishra, Bibhuti Mishra, Subhra Mohapatra, Bhaumik Patel, Joseph R Pisegna, Jean-Pierre Raufman, Shuyun Rao, Hemant Roy, Maren Scheuner, Satish Singh, Gitanjali Vidyarthi, Jon White

Surgery Faculty Publications

Colorectal cancer (CRC) accounts for ~9% of all cancers in the Veteran population, a fact which has focused a great deal of the attention of the VA's research and development efforts. A field-based meeting of CRC experts was convened to discuss both challenges and opportunities in precision medicine for CRC. This group, designated as the VA Colorectal Cancer Cell-genomics Consortium (VA4C), discussed advances in CRC biology, biomarkers, and imaging for early detection and prevention. There was also a discussion of precision treatment involving fluorescence-guided surgery, targeted chemotherapies and immunotherapies, and personalized cancer treatment approaches. The overarching goal was to identify …

Sensitivity And Specificity Of Ct Scan In Small Bowel Obstruction Among Children, Huma Faiz Haleopota, Muhammad Arif Mateen Khan, Noman Shahzad

Section of Paediatric Surgery

Objective: To determine the sensitivity and specificity of computed tomography scan for diagnosing small bowel obstruction among children.
Methods: The retrospective diagnostic test accuracy study was carried out at the Aga Khan University Hospital, Karachi, and comprised data of all patients aged 2-16 years who presented with clinical features of small bowel obstruction and underwent computed tomography scan of abdomen from January 2001 to December 2015Data was analyzed using SPSS19.
Results: Of the 98 subjects, 65(66.0%) were males and 33(34.0%) were females. Overall mean age of the patients was 7.67±4.33 years and mean duration of symptoms was 2.84±1.17 days. …

Expression Of Androgen Receptor And Cancer Stem Cell Markers (Cd44 +/Cd24 - And Aldh1 +): Prognostic Implications In Invasive Breast Cancer, Nazia Riaz, Romana Idress, Sadia Habib, Iqbal Azam Syed, El Nasir Lalani

Section of General Surgery

Background: Androgen receptor (AR) has emerged as a significant prognostic marker in early breast cancer (BCa). Association of AR with cancer stem cell (CSC) markers in BCa is unknown. Aim of the present study was to evaluate the immunohistochemical expression of AR, CD44, CD24 and ALDH1 in a cohort of Pakistani patients diagnosed with invasive BCa and to correlate the expression with 5- year disease free survival.
Patients and methods: We evaluated immunohistochemical expression AR, CD44, CD24 and ALDH1 in formalin fixed paraffin embedded archival blocks of 166 cases of primary invasive BCa (stage I-III) and correlated the expression with …

Descriptive Epidemiology Of Karachi Road Traffic Crash Mortality In 2015, Rashid Jooma, Masood Ali Shaikh

Section of Neurosurgery

The Karachi city's Road Traffic Injury Research and Prevention Center (RTIRPC), collects Road Traffic Crash (RTC) data on injuries and fatalities from three major public and private hospitals' emergency departments. In the year 2015, 1021 deaths were recorded; with 871 (85.3%) deaths in males. Cumulatively, 286 (28.0%) deaths were recorded in the 21-30year age group, and for 198 (19.4%) RTC fatal victims, the primary vehicle involved was motorbike. Highest number of fatalities were recorded in the month of January i.e. 153 (15.0%), while the lowest number was recorded for June, with 47 (4.6%) fatalities. RTIRPC is a unique surveillance system …

Simpson Grading As Predictor Of Meningioma Recurrence, Ayesha Quddusi, Muhammad Shahzad Shamim

Section of Neurosurgery

Meningimas are one of the commonest primary brain tumours and the commonest extra-axial primary brain tumour. Despite better understanding of the molecular pathogenesis of the tumours, surgical excision remains the treatment of choice, and in a large proportion of cases, complete excision is curative. Simpson grading for the extent of resection of meningiomas, was introduced more than six decades ago, and has stood the test of time. With modern technological advancements, however, the relevance of Simpson grading has been questioned. Herein we review the recent literature on the relevance of Simpson grading more than sixty years after its introduction.