Noman Shahzad

Intramural gas in stomach along with acute calculus cholecystitis: an unusual association.

Intramural gas in stomach is a rare finding, but differential diagnosis of this condition into gastric emphysema and emphysematous gastritis is clinically important because of vastly different aetiologies and prognosis. Emphysematous gastritis is caused by gas producing micro-organisms inside the stomach wall and is a potentially fatal condition, while, on the other hand, gas enters stomach wall through mucosal breach in the case of gastric emphysema and prognosis is usually good with complete resolution. To date, no case has been reported in the literature showing gas in the stomach wall in a patient with acute calculus cholecystitis. We present a case of a young man with upper abdominal pain, and who, upon diagnostic work up was diagnosed with acute calculus cholecystitis with associated intramural gas in the stomach with no known aetiological factors to be positive. Conservative management with close observation resulted in complete symptomatic resolution.

Determination of Factors Associated with Critical Weight Loss in Oral Cavity Carcinoma Patients: A Retrospective Cohort Study

Introduction  Critical weight loss is defined as an unintentional weight loss of ≥ 5% at 1 month or ≥ 10% at 6 months from the start of treatment. Critical weight loss leads to deterioration of the immune function and reduced tolerance to treatment (surgery ± radiochemotherapy) as well as increased complication rates. Objective  Critical weight loss, defined as a weight loss of ≥ 5% after 1 month or ≥ 10% after 6 months from the start of treatment, is not uncommon in head and neck cancer patients. We aimed to assess the factors associated with critical weight loss during the treatment of oral cavity squamous cell carcinoma patients. Methods  A retrospective cohort study was performed at the Aga Khan University Hospital, in Karachi, Pakistan, on 125 patients. Patients receiving adjuvant therapy were considered exposed, and the outcome was critical weight loss. Results  The mean age of presentation was 46.9 ± 12.8 years in patients undergoing surgery and adjuvant therapy, with 119 (79.3%) of them being male and 31 (20.7%) female. One hundred and twelve patients (81.3%) developed critical weight loss at 6 months from the start of treatment, and the only significant variable associated with critical weight loss was the stage of the disease ( p  = 0.03). Conclusion  A large proportion of patients with oral cancer developed critical weight loss requiring a need for intervention. The overall stage of the disease is a significant predictor of critical weight loss in patients undergoing treatment.

Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: A review article and meta-analysis of randomized controlled trials

Pancreatic fistula is one of the most feared complications after pancreaticoduodenectomy (PD). Results of randomized controlled trials comparing pancreaticogastric anastomosis with pancreaticojejunal anastomosis are not consistent. Furthermore, soft texture of pancreas is an established risk factor for postoperative pancreatic fistula (POPF). There has been no meta-analysis to date to compare pancreaticogastrostomy versus pancreaticojejunostomy in patients with intraoperative soft texture of pancreas. Hence, our primary objective was to determine the role of pancreaticogastrostomy compared to pancreaticojejunostomy after PD in prevention of POPF, especially in patients with soft pancreatic texture. We conducted meta-analysis of randomized controlled trials that had compared pancreaticojejunal anastomosis with pancreaticogastric anastomosis after PD, and pancreatic fistula was among the outcome variables. Ten randomized controlled trials were included in the meta-analysis which comprised of a total of 1629 patients, of which 803 underwent pancreaticojejunostomy, whereas 826 were in the pancreaticogastrostomy group. There was no difference in clinically relevant POPF (CR-POPF) rate in pancreaticojejunostomy versus pancreaticogastrostomy (19.8% vs. 12.8%, P = 0.09) group. POPF rate in patients with soft pancreas was significantly more in pancreaticojejunostomy group as compared to pancreaticogastrostomy group (25.4% vs. 17.3%, odds ratio = 1.71, 95% confidence interval = 1.15–2.53, P = 0.008). Although there is no difference in pancreaticogastrostomy as compared to pancreaticojejunostomy after PD to prevent CR POPF, in a subgroup of high-risk patients with soft pancreatic texture pancreaticogastrostomy has favorable results.

Reducing the donor site morbidity in radial forearm free flaps by utilizing a narrow radial forearm free flap

Background The radial forearm free flap (RFFF) has remained a leading choice of many plastic surgeons as a fasciocutaneous flap due to its versatility, pedicle length, and simple elevation technique. However, donor site morbidity has led many reconstructive surgeons to limit their use of the RFFF and to use other flaps instead. We propose that using a narrow RFFF (nRFFF) decreases the aesthetic and functional morbidity of the donor site. Methods We report our experiences with the nRFFF from April 2012 through May 2015 at the Department of Plastic, Reconstructive, and Hand Surgery at Liaquat National Hospital, Karachi. The donor defects were closed primarily. The Stony Brook Scar Evaluation Scale and comparison with the contralateral hand were used to assess aesthetic and functional outcomes, respectively. Results A total of 24 patients underwent nRFFF procedures during the study period. The donor arm showed excellent motor function in 22 cases (91.7%), and very good function in the remaining two cases (8.3%). The aesthetic outcomes were excellent in four patients (16.6%), very good in eight patients (33.3%), good in 10 patients (41.6%), and fair in two patients (8.3%) who developed a hypertrophic scar. All flaps were successful and there were no cases of partial or complete loss. Conclusions For small to medium-sized soft tissue defects, the nRFFF had acceptable outcomes due to its thinness, pliability, and major reduction in donor site aesthetic and functional morbidity.

Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy to prevent post-operative pancreatic fistula, a dissonance between evidence and practice

Leakage of pancreatic enzymes leading to either formation of abdominal collection or pancreatic fi stula is one the most feared complications after pancreaticoduodenectomy. Owing to high morbidity and cost related to pancreatic fi stula, multiple interventions including various types of pancreaticoenteric anastomosis have been proposed to prevent this complication.

Teaching and practising rectal examination in Pakistan

Digital rectal examination (DRE) is an integral part of physical examination. The teaching and practising of DRE should start early in medical school for mastering the skills to perform DRE by the time of graduation. In recent years it has been observed that medical students are reluctant to learn and practise DRE because of a perception of the reduced importance of DRE as compared with other modalities of investigation. We evaluated the knowledge and attitude of medical students and interns towards the teaching and practising of DRE.