SAARC countries should join hand to guide and monitor progress of postgraduate medical education in the region-Prof. Verma


9th SAARC Surgical conference

SAARC countries should join hand to guide
and monitor progress of postgraduate
medical education in the region-Prof. Verma

Training slots can be identified and
research facilitated- Prof. Majeed Chaudhry

By Mubarak Ali

KARACHI: Invited lectures on status of postgraduate medical education in Pakistan,  Postgraduate medical education in Sri Lanka, Training Co-operation in SAARC countries, Surgeons Advice to Surgeons,  special sessions on  Endocrine, Breast, Urology, Gastroenterology surgery, Trauma, panel discussion on  Evolution of  Minimally Invasive Surgery and its impact on surgical residency training besides workshops  on Laparoscopic Bariatric Surgery, Achalasia and  E learning were some of the salient features of the just concluded 9th SAARC Surgical conference held at Karachi from 13-16th November, 2014. 

Group photograph taken during the 9th SAARC Surgical conference held
at Karachi from 13-16th November, 2014, shows from (L to R) Prof. Ranil Fernando
from Sri Lanka, Prof. Ali Muhammad Ansari, Prof. Naheed Sultan, Chairman
Organizing Committee, Prof. Zafarullah Chaudhry, President, CPSP, Prof. Rakesh
Verma from Nepal, and Prof. Khalid Masood Gondal, DGIR, CPSP.

Prof. Rakesh Verma from Nepal along with Prof. Irshad Waheed and Prof. Sattar Memon chaired the 1st plenary session. Prof. Khalid Masood Gondal, DGIR, CPSP highlighted the various initiatives taken by CPSP to strengthen postgraduate training. CPSP, he stated has introduced E-log system and over ten thousand trainees have been provided separate password of E-log book.  About 90% supervisors have login facility. Over 70% PG”s preferred E-log system. CPSP has got recognition internationally and feedback of surgical residents from International Experts has also endorsed the quality of education being provided at CPSP. Postgraduate medical education by CPSP has been strengthened by adopting an indigenous model of innovating focusing and monitoring of trainers. We are trying to convince the Government to increase facilities at District level, he added.

Prof. Ranil  Fernando   from Sri Lanka  talking about   postgraduate training  in Sri Lanka said that  Sri Lanka is a small country   having 20 million population per capita income of  120-125 US$ per month. Majority depend on State Health.   Ceylon Medical College was established in 1870. In 1976 Institute of Postgraduate Medical Education was established. PGMI Act came in 1980. PGMI is the only institute in Sri Lanka responsible for the specialty training of medical doctors. It is national Institute attached to a University of Colombo. It will be made independent body soon.  Surgery has Board of Study consisting of trainers from the ministry of health and university surgical units.  In addition to the main Board of Study in surgery there are Subspecialty Boards. During training trainees must maintain Log book, develop protocol, should have an article in peer reviewed journal, one oral presentation. Trainee should take part in critical part of training and the current method is called (RITA) which is a formative and summative assessment.  Mid training assessment is also carried out. A candidate is permitted six attempts and if he or she could not succeed their admission is terminated. Our future plan includes  improvement in  the selection  of  examiners, align it with the  end product, improve the quality of training, improve training assessment, to incorporate  more research in to training and improve assessment, he added.

Talking about training co-operation in SAARC countries, Prof.  Majeed Choudhary said that Doors of America, Brittan, European and Australian countries are closing very rapidly for foreign graduates. We need to develop our infrastructure, need sup gradation and lot of funding is needed for it.   Department of Medical education at CPSP has helped   in standardization of training. Private Universities are coming up in India and Pakistan but these have lot of fallacies. Government should be vigilant and ensure that they should not be a just degree distributing universities.  Talking about improvement strategies Prof. Majeed Choudhary said that some attractive incentives should be given to specialists. SAARC platform can be used. Elective one year training in one of the member countries could be very useful.  Centre of excellence should offer short fellowship, teleconferencing from center of excellence, online courses in different specialties. Training slots could be identified   and research could be facilitated through SAARC countries.  SAARC countries should develop guidelines for PG training in surgery.  Let us respect and love each other, let us protect our institution in the region and in our own countries and foil the nefarious desires of the vested interest. Prof. Rakesh Verma in his concluding remarks thanked the organizers for their kind invitation and urged the SAARC countries to join hand to guide and monitor the progress of postgraduate medical education in the region which is the need of the hour.

Prof. Majeed Choudhary along with Prof. M.  Sarwar chaired the session on Endocrine Surgery. Dr. Ranil Fernando talked about past present and future of Thyroid Surgery. First Thyroid Surgery, he said, was done in 975AD by Paul of Aegina and first credible case was reported from School of Salerno in 13th Century. Till 20th century Thyroid Surgery was performed and sub total thyroidectomy was the standard treatment for benign and malignant diseases of the thyroid.  From the last 70’s and early 80’s several Centers started performing total thyroidectomy for benign diseases. It is very effective procedure but it should be done by experienced surgeons.  Robotic thyroidectomy is effective but is expensive. Mini incision thyroidectomy is effective and newer technologies and techniques will emerge in the days to come, he added.

Prof. Sikandar Ali Sheikh discussed various surgical approaches to Thyroid Glands and how he manages thyroid and the technique which he has developed. Thyroid surgery has evolved cosmetically acceptable. Minimal invasive endoscopic video is also safe and effective, he added. Dr. Ranil Fernando discussed Parathyroid surgery and its current status.  Parathyroid   Glands he stated are small endocrine glands in the neck. Its function is to maintain body’s calcium level within a very narrow range for proper neuromuscular.  It has evolved much in the last two decades. Key to success of surgery is accurate localization of the gland/glands preoperatively. By 1980 open para thyroidoctomy has become well established.   Mini incision parathyroidoctomy is easy but case selection is very critical. It is very important to assess the patient carefully, localize the gland and experienced hand is needed to do the procedure. Parathyroid surgery has dramatically changed in the last ten years, it is safe, effective should be available, he added.

Prof. Abu Fazal along with Prof. Jayasshree S Todkkar chaired the session on Bariatric Surgery. Prof. Jayasshree from India discussed the metabolic aspects of Bariatric Surgery. Obesity, she stated is a global epidemic.  Target to control obesity should be to ease in breath, sleep peacefully, less insulin injections and able to play with grandchildren.  Obesity is a disease, it has to be treated by physicians not by nutritionist. Diabetic trend is increasing rapidly and Asian Indians have increased risk of Diabetes Mellitus. Treatment delayed is treatment denied. Bariatric Surgery she stated is a revolution. Patient lose weight more than any other treatment available up to by 25% of their weight. It is highly treatable in India. Diabetes, hypertension, PCOD, dyslipidemia, fatty liver disease and sleep apnea has improved after Bariatric Surgery. It is safe, it should be performed in center of excellence. A growing consensus is developing in favor of Bariatric Surgery, she added.

Prof. Abu Fazal talked about economical options of Bariatric Surgery for less affording patients.  Bariatric Surgery, he stated,  is a safe, effective and public loves it because it has less pain, early recovery after surgery and scar free. It has its disadvantages like risk of bleeding, leak, strictures and small bowel obstruction, steeper learning curves, training facilities for young surgeons  are non existent, is costly and pouch size unknown. Future of Bariatric Surgery is endoscopic and at present is out of reach of most of the people.

Dr. Farooq Afzal presented the results of one hundred thirty Bariatric Surgery cases performed during the last six years at Services Institute of Medical Sciences, Lahore. He discussed in detail the achievements and the challenges.  Bariatric Surgery, he opined, results in improvement of many obesity-related health conditions, including Diabetes, High blood pressure and High cholesterol etc.  Awareness, training, team infrastructure and cost are the major things to be considered to start this project. Public awareness is needed besides general surgeons with advanced laparoscopic skills and having interest in this field should adopt it.  Development of a team is difficult but it is very important.  Research fund should be identified to start a research project on Bariatric surgery, he added.

Prof. Asadullah Khan along with Prof. Qamar Baloch chaired the Gastrointestinal Surgery session. Dr. Masood Jawaid presented the findings of randomized control trial to assess if there is any difference in chronic pain after suture and stapler fixation method of mesh in ventral hernia? Chronic pain occurs in 20–30% of patients after hernia surgery. As a consequence of this chronic pain, almost one third of patients have limitations in daily leisure activities. Frequency and severity of this pain varies with different techniques of hernia repair.

Total fifty three patients were included in the study after taking informed consent. All patients were operated under general anesthesia by the same surgical team. Patients were randomized into two groups; in one group mesh fixed with 2/0 polypropylene suture while in other mesh Stapler was used. The severity of post-operative pain was measured with VAS (1-10) after one week, one month and after one year. Patient characteristics and operative outcome were similar in the two groups and statistically non-significant in both. Early postoperative pain was more after suture fixation but it was not statistically significant. The method of fixation does not appear to cause significant difference in early post-operative time but chronic pain is more after stapler fixation of mesh, Dr. Masood concluded.

Dr. Zubia Masood presented a study conducted in the department of general surgery, at Ziauddin University Hospital Kemari campus to assess the operative notes at a tertiary care hospital and to compare them to the standards set by Royal College of Surgeons of England. It was an observational prospective study over a time period of one month from June to July, 2014. Sixty operative notes including general surgery, urology, orthopedics and neurosurgery were included in this study and were assessed according to published guidelines of the Royal College of Surgeons of England.

All the operative notes were handwritten, out of which 40 (66.7%) were written by the operating surgeon. None of the notes mentioned the time of the surgery and the type of surgery and had no diagrams to illustrate the operative findings. Almost all (96.7%) included the patients name and the procedure performed (95%) and only 66.7% mentioned the operative findings. Incomplete post-operative instructions were present in all the notes that were studied. The study pinpointed several areas that are lacking essential information in the operative notes, including the time of the procedure, type of surgery, instructions for postoperative care, operative diagnosis, findings, and complications during the procedure indicating that the operative notes were incomplete and inadequate in many respects.

Dr. Sami  Ullah  talking about effect of gum   chewing  on the  duration of postoperative  ileus said that sugar free  gums   has promising role in postoperative  ileus and hospital stay is reduced but it is not freely available. Dr. Farid Ahmed Sheikh presented a study about   Esopagogastric Anastomosis: hand sewn single layer vs. stapled. Both are practiced at AKU and there is no significant difference but handmade sutures are conventional and cheaper as compared to stapled. Dr. Safia Bibi and Dr. Muhammad Rashid were other speakers in this session.           

Prof. Rakesh Verma along with Prof. Abual Fazal chaired the session on minimal invasive surgery. Professor Shafiqur Rehman Chairman department of Surgery, Ziauddin Medical University, highlighted the Pitfalls and ethical issues in laparoscopic training from both  the trainer and trainee perspective .The long learning curve in laparoscopic training, teaching and training facilities, availability of busy  consultants, larger number of trainees and motivation from both trainee and trainer are contributing  factors in training pitfalls . He said with the advent of simulation, traditional learning of see one, do one and teach one is not practiced anymore and dedicated time from both trainer and trainee ,use of resources at institutional level as well as peer learning can help to  improve  this issue

Prof. Ayaz Mehmood talked about minimal invasive surgery future in Pakistan while Dr. Shahzad Alam Shah discussed sub facial endoscopic perforators surgery-SEPS is a new life to an old procedure. Dr. Amir Sharif talking about structural training programme of minimal invasive surgery said that lack or resources, organizational structure and late exposures to trainees are the major pitfalls.  Prof. Abdul Aziz Laghari talking about Laparoscopic Training in developing countries said that Hands on basic and skilled courses should be organized for basic and advanced laparoscopic skills. Dr. Shahzad Alam Shah highlighted the laparoscopic –suspended pedicle technique and stated that laparoscopic surgery is rapidly gaining acceptance in our country.

Dr. Awais Naeem addressing the participants said that Global Operative Assessment of Laparoscopic Skills (GOALS) is very easily used to assess he performance and evaluate the surgeons. Dr. Awais Amjad Malik stated that our residents are not skilled in this job. We need enhanced learning in Theater. Simulator provides a safe platform. It is easily working for our residents. Simulation makes learning easier. It improves the learning skills and give them a playing ground, he added.