Nisar Haider Zaidi

Effectiveness of teaching operation notes to surgical residents

Objective: The effectiveness of teaching operative notes in surgical resident training program at King Abdulaziz University Hospital, Jeddah was studied. Materials and Methods: This was a prospective study done at Department of Surgery, King Abdulaziz University Hospital to evaluate the effect of teaching the surgical residents how to write operative notes. Twenty-one residents were asked to write operative notes of appendicectomy. Their operative notes were evaluated for medical record number (MRN), date and time of the operation, preoperative and postoperative diagnosis, names of surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, whether histopathology specimen was sent to the pathology department or not, postoperative orders, whether the patient went to the recovery room in a satisfactory condition or not, and signature of the operating surgeon. Two months of effective teaching of operative notes was given to them. They were again asked to write operative notes of appendicectomy. Notes were collected and studied and comparison was made with previous notes. Legibility of the operative notes was also studied. Results: In our study, we found that there was improvement of 29-39.9% in recording MRN and the date of operation by our residents after they were taught the art of writing operation notes. There was marginal improvement (4.7%) in stating whether it was elective or emergency operation. Documentation of surgeons name, assistants name, and anesthetists name improved to 12.4-32.8%. Writing the name of the procedure and pre- and postoperative diagnosis improved to 31%. Details of the procedure such as position of patient and incision improved marginally to 5.9%. Mentioning the findings and description of the procedure showed no improvement, as it was 100% before teaching. Documenting hemostasis, estimated blood loss, and transfer to recovery room improved to 58.4%; however, there was no improvement in writing post-op orders and histopathology sent to the pathology department.Improvement of signature was only 9%. Conclusion: Effective teaching of how to write operative notes helps in the training of surgical residents.

Re-evaluation of lateral subcutaneous sphincterotomy in treating anal fissure

Background: Anal fissure is a common disease and has a myriad of treatment options. The aim of this study was to re-evaluate lateral subcutaneous sphincterotomy in the treatment of anal fissure. Patients and Methods: We retrospectively studied143 patients with chronic anal fissure at King Abdulaziz University Hospital between March 1995 and April 2011, to determine the outcome of lateral subcutaneous sphincterotomy. These patients were studied using file data, operative notes, post operative course, OPD follow up. Variables studied were age, sex, nationality, History of previous surgery, recurrence, open or closed sphincterotomy, healing of wound, duration of healing [weeks], post op pain, post op bleeding, incontinence of flatus, liquid or solid stool, length of incontinence, duration of surgery, and weather admitted or treated as a day case. Results: In our study the youngest patient was 18 years old and the oldest 67 years old with mean age 42.5 years. Majority were females 65% and males 35%. Saudis were 52.4% and non Saudis were 47.5%. 55.4% of patients had previous surgery. Recurrence occurred in 5.4% of patients. 42.3% underwent closed surgery and 57.7% open surgery. Duration of operation was minimum 4 minutes and maximum 25 minutes with mean duration of 14.5 minutes. 11.9% of patients needed admission while 88.1% were treated as day case. Healing occurred in 72.8% while 27.2% did not have healing of wounds. Majority of wound healed in one week-57.6% and 18.4 had healing in two weeks while longest healing occurred in 52 weeks. Longest follow up was 180 weeks. Post op pain occurred in 50% of cases and no pain in 50% of cases. Post op bleeding occurred in 23.9% of patients. There was no incontinence in 80.4% of cases while 14.1 % of patients had incontinence of flatus, 4.3% of liquid stools 1% incontinence of solid stool. Length of incontinence was one to sixteen weeks. In 16.3% cases incontinence was resolved and in 3.2% cases it did not resolve. 73.9% of patients expressed satisfaction of treatment while 17.3% were partially satisfied and 8.6% patients were not satisfied with the treatment. Conclusion: Lateral sphincterotomy is a safe, effective treatment of anal fissure and evolving as a gold standard treatment for chronic anal fissure.

Primary hepatic carcinoid tumors: A case report and literature review

Primary hepatic carcinoid is a rare disease and requires meticulous workup for the search of primary in other organs. A 56-year-old male, known hypertensive, presented in November 2007 with epigastric discomfort and indigestion on and off for 2 months. There was no history of diarrhea, flushing attacks, or cardiac symptoms. He had no family history of carcinoids or any other chronic disease. On examination, he was afebrile, pulse rate was 83/min, and BP was 166/95 mm Hg. Per-abdominal examination revealed mild tenderness in the epigastrium and enlarged liver. Computerized tomography abdomen showed a capsulated huge liver lesion (11 × 10 × 13 cm) in the left lobe of the liver, displacing the left hepatic artery, while rest of the liver was normal. There was no evidence of carcinoid tumor in any other organ. He was operated and left hepatic lobectomy was done. Histology showed primary hepatic carcinoid. He is being followed up in our OPD till date and has shown no recurrence. Primary hepatic carcinoid is a rare disease which is not associated with the symptoms of carcinoid syndrome in majority of patients, and therefore should be diagnosed after extensive search for primary in the other organs. Ultimate diagnosis should be made by histology and immunohistochemistry.

Colonic Pseudo-Obstruction

Colonic pseudo-obstruction is a condition of distention of colon with signs and symptoms of colonic obstruction in the absence of an actual mechanical cause of obstruction. It is a poorly understood disease that is characterized by functional large bowel obstruction. Intestinal pseudo-obstruction was described in 1938 by the German surgeon W. Weiss who reported mega-duodenum in 6 persons in 3 generations of a German family and described it as an inherited subset of intestinal pseudo-obstruction[2]. A similar condition of pseudoobstruction of intestine was described by Ingelfinger in 1943. Colonic pseudo-obstruction, however, was first described by Sir William Heneage Ogilvie in 1948 and named after him as “Ogilvie’s Syndrome”. His description was based on the findings of two patients who had non-mechanical obstruction due to retroperitoneal involvement of the celiac plexus by malignancy[1]. J. Dunlop in 1949 described a similar condition in men aged 56, 58, and 66 years where large bowel colic was the predominant symptom accompanied by constipation, abdominal distension, and progressive loss of weight, but with no evidence of mechanical obstruction to the intestinal flow[3]. In 1958, Dudley et al used the term pseudo-obstruction to describe the clinical appearance of a mechanical obstruction with no evidence of organic disease during laparotomy[4]. Ogilvie’s syndrome commonly occurs in patients who are critically ill, have electrolyte imbalance, or on anticholinergic medications. If left untreated, life threatening complications like bowel ischemia or perforation may occur in up to 15% of cases with a mortality of 50%[5].