Requirement of Biliary Decompression Prior to Pancreatoduodenectomy for Distal Malignant Biliary Obstruction

The role of biliary decompression prior to definitive surgery in patient with distal malignant obstruction remains controversial.Many authors put their views in favor; because of improvement of liver functions and reticulo-endothelial function after decompression resulting in uneventful postoperative outcome and many others are against because of increase the risk of postoperative morbidity and mortality. We found the patients who underwent prior biliary decompression had unusual development of organisms in their bile which are found frequently resistant to usual antibiotics and most of them developed postoperative complications. Several other studies concluded in between that preoperative drainage should be performed in selected patients; delaying of surgery for any cause, presence of severe cholangitis, severe jaundice and poor nutrition and where hepatic resection is required along with pancreatoduodenectomy. We therefore concluded that biliary decompression should not routinely be performed except in special situations in patients with distal malignant biliary obstructionbefore pancreatoduodenectomy. Journal of Surgical Sciences (2020) Vol. 24 (2) : 66-69

Radical Surgical Excision and Use of Axillary Flap for Intractable Axillary Hidradenitis Suppurativa

Background: Current treatments for hidradenitis suppurativa (HS) include prolonged courses of antibiotics, retinoids, immunosuppressants, and biologics. Severe cases that are resistant to prolonged medical treatment pose a therapeutic challenge. We propose radical excision and reconstruction with axillary flap as a treatment option for such cases. Objectives: The purpose of the study was to see the outcome after radical surgical excision and coverage with axillary flap for intractable Hidradenitis suppurativa. Methods: This prospective observational study was carried out from July, 2014 to June,2016. Patients admitted at the Plastic Surgery Department of Dhaka Medical College Hospital with intractable Hydradenitis suppurativa were included the study population. Result:Among 20 cases, 12 cases were female and 8 cases were male. Maximum dimension of the soft tissue defect was 15x6.5 cm2 = (97.5 cm2). Maximum dimension of the flap was 17x7 cm2 = (119 cm2).Flap survived completely with minimum donor site morbidity. Result of reconstruction of 90% of the patients exhibited excellent outcome. In 10% patient’s outcome was considered good. Conclusion:With a suitable flap coverage option, the management paradigm of intractable Hydradenitis Suppurativa should shift from prolonged medical treatment to allowdecisive radical excision, which will improve the quality of life for patients. Axilary flap is the flap of choice to cover the defect. Journal of Surgical Sciences (2020) Vol. 24 (2) : 51-56

From the Desk of Editor in Chief Vol 24(2)

not available Journal of Surgical Sciences (2020) Vol. 24 (2) : 83

Society News Vol 24(2)

not available Journal of Surgical Sciences (2020) Vol. 24 (2) : 84

Obituary Vol 24(2)

not available Journal of Surgical Sciences (2020) Vol. 24 (2) : 85

Guidance for surgical care during the COVID-19 pandemic

not available Journal of Surgical Sciences (2020) Vol. 24 (2) : 41-42

Nipple Skin Sparing Mastectomy and Immediate Reconstruction with implant using Acellular Dermal Matrix (ADM)in a Patient with TP53 mutation - First Experience in Bangladesh

A 28-year-old lady presented with 3.5 cm lump in her right breast and normal axilla. Histopathologically the lump revealed as invasive duct cell cancer (IDC), Grade II with ER negative, PR positive and HER2 equivocal. On genetic testing, BRCA1 & BRCA2were found negative but p53 was positive with pathogenic variant. She received neoadjuvant chemotherapy while waiting for genetic testing. As she had TP53 mutation and considered high risk for developing contralateral breast cancer, bilateral mastectomy and immediate reconstruction with implant using acellular dermal matrix was performed on 9th of March,2020 at our Breast Unit during 2nd live surgery & workshop on oncoplastic breast surgery, organized by Breast Care Unit and Research Centre, Department of Surgery, Anwer Khan Modern Medical college. This is the first reported case of a breast cancer patient with TP53 mutation who has undergone nipple skin sparing mastectomy with immediate implant/ADM reconstruction and creates a milestone in the history of modern breast cancer management in Bangladesh. Journal of Surgical Sciences (2020) Vol. 24 (2) : 77-82

Single Center Observational Study to Evaluate the Safety and Efficacy of Self-expanding Composite Mesh for Repair of Small Umbilical Hernias

Background: There is evidence that mesh repair for umbilical hernias results in fewer recurrences. Early and late complication rates of mesh repair are variable with different techniques of mesh repair. In recent years, several mesh device for the repair of small ventral hernias have been developed, but some reports have been published reporting some adverse outcomes like high recurrences or wound related complications encountered with those mesh devices. The purpose of this study was to evaluate the safety and efficacy of small umbilical hernia(<3cm) repair using self expanding dual mesh. Methods: In this study we used a composite self-expanding mesh with Polypropylene(PP) on one side and expanded polytetrafleuroethylene(ePTFE) on the other side. We introduced this technique in our department at BIRDEM General Hospital and IMC in March 2017 and collected patients data and outcome in an observational study of 25 consecutive patients matching our inclusion criteria until February 2019. In addition to the routine 1st week postoperative follow-up, We did a prospective follow-up at 1 month,6 month and 1 year which included a questionnaire, clinical examination and ultra sonogram after 12 months. Results: The study included 15 female and 10 male patients with age ranging from 25-62 years(Mean- 47) having 16 primary umbilical hernia and 9 umbilical port hernias. The size of gap was <3cm and all except 2 hernias were reducible. In all patients a self expanding dual mesh was used with a diameter of 8cm(18 patients) or 6.4(7 patients) cm. Early complications included superficial wound infection-1(4%), seroma-1(4%), serosanguinous discharge-1(4%) and ecchymosis-1(4%). No major wound problems were noted in 1 month or 6 month follow-up except 1 patient reporting hypertrophied scar. At 1st month follow up 21 patientswere pain free, after 6 month only 1 patient reported mild pain, after 1 year 100% patients were pain free. 24 out of 25 patients ie 96% were very satisfied with the result of their repair. There was no recurrence after one year. Conclusion: Umbilical and umbilical port hernia repair with Self expanding dual mesh is effective and is cosmetically very appreciated by patients as good as laparoscopic repair. Therefore, we recommend using these meshes only for umbilical and umbilical port hernias smaller than 3 cm. For larger or incisional hernias other techniques allowing the use of larger meshes is advocated. Journal of Surgical Sciences (2020) Vol. 24 (2) : 43-50

Surgery Guidelines In Covid-19 Pandemic; Bangladesh Perspective

not available Journal of Surgical Sciences (2020) Vol. 24 (2) : 70-76

Endoultrasound versus Conventional Image Guided (CT/US) Fine Needle Aspiration in Diagnosis of Pancreatic Malignancy

Background:The emergence of endoultrasound (EUS) has shown this modality to be an excellent method of detecting and staging lesions in the pancreas with a low rate of complications. Controversy has arisen about whether the approach with the conventional image (CT/US) guided FNA or endoultrasound (EUS) guided FNA is the preferred method to obtain cells from suspicious mass. Objectives:To assess the diagnostic efficacy of endoultrasound guided fine needle aspiration (EUS FNA) versus conventional imageguided fine needle aspiration (CT/US FNA) in pancreatic malignancy. Methodology:Twentyeight cases of clinically suspected patients of pancreatic malignancy were included in the study. Each enrolled patient underwent to either a conventional image guided fine needle aspiration or endoultrasound guided fine needle aspiration of the pancreatic mass for diagnosis of pancreatic malignancy. Data were analyzed with the help of SPSS version 23. Statistical analysis was done by student t-test and Chi square (÷2) test. Statistical significance was set at p<0.05. Result: Diagnostic accuracy in terms of distinguishing the cytopathology was 57.1% in conventional image(CT/US) guided FNA group and 85.7% in EUS guided FNA group. These values were numerically convincing for preferring EUS guided FNA method but was statistically insignificant. Again, if we consider the diagnosis of malignancy alone the values were 35.7% and 64.3% for CT/US guided FNA and EUS guided FNA respectively. This was also not significant statistically. Conclusion:Numerically EUS guided FNA showed better precision in detecting pancreatic malignancy and thereby its accuracy in yielding adequate tissue sample for cytological evaluation and inference. Journal of Surgical Sciences (2020) Vol. 24 (2) : 57-60