1. The Utility of Intra-operative Gallbladder Scoring System (G10) in Private Hospitals from March 2021 to January 2022

Presenter: Maryrose T. Paguyod, MD

Laparoscopic cholecystectomy has become the standard of care in the management of gallstone disease with a slightly increased risk for bile duct injury. It is therefore essential that a standard grading system can be utilized and thus predict whether cholecystectomy can be completed laparoscopically or warrants the need for bailout procedure to prevent biliary injury. This study includes all patients who underwent laparoscopic cholecystectomy in Capitol University Medical Center and Maria Reyna Xavier University Hospital from March 2021 to January 2022. Total of 220 patients underwent laparoscopic cholecystectomy but only 173 patients were included due to incomplete data. Age, BMI, sex and G10 scoring were collected. This scoring system focuses on four components: the gallbladder’s operative appearance, whether distended or contracted, ease of access including limited access due to adhesions from prior surgery, the presence of sepsis in the peritoneal cavity, either biliary peritonitis or purulent fluid, and/or a cholecystoenteric fistula, and the degree of gallbladder adhesions. Descriptive statistics and univariate analysis were used to determine the need for bailout procedure in laparoscopic cholecystectomy. It was found that each year increase in age raises the odds of doing bailout surgery by 8.2% (OR: 1.0823, p = 0.009), while higher G10 scores nearly triple the odds (OR: 2.9227, p < 0.0001). The G10 scoring system is a practical scoring system with easy to remember assessment variables. G10 score of greater than 3 with increasing age shown to have increased chance of employing bailout procedure.

2. Clinicopathologic Predictors of Hormone Receptor and HER-2 Status of Patients with Invasive Breast Carcinoma: A Multicenter Study

Presenter: Winnie Joy C. Maramag, MD

This study aimed to determine the clinicopathologic predictors of hormone receptor [Estrogen Receptor (ER)/ Progesterone Receptor (PR)] and Her-2/Neu status of patients with breast cancer. The was an analytical, cross-sectional study with a three-year review of breast cancer patients in the three hospitals of Cordillera Consortium. Multinomial logistic regression analysis was used to determine the association of the clinicopathologic variables such as age, sex, time interval to diagnosis, cancer stage, site, focality and laterality of primary tumor, clinical lymph node status, distant metastasis, recurrence, cancer type, histologic grade, tumor size (T stage), lymphovascular invasion and pathologic nodal stage (N stage) with the hormone receptor and HER-2 status. A total of 143 patients were included in this study. The results showed that laterality (p 0.0154), histologic grade (p 0.0004), and tumor size (T stage) (p 0.049) are associated with the molecular subtypes. Luminal A, luminal B and basal-like subtypes were mostly located on the left while Her-2 enriched was mostly right-sided.

All well differentiated tumors were luminal A. Luminal A and Luminal B were mostly moderately differentiated. While Her-2 enriched and basal-like were mostly poorly-differentiated type. Only Her2-enriched had T0 or complete disappearance of tumor (Complete Pathologic Response) among those given with neoadjuvant chemotherapy. In this cohort, there was no recorded tumor of ≤2cm under the basal-like. The clinicohistopathologic features of breast cancer such as laterality, histologic grade, and tumor size can be used as an adjunct to predict the molecular biology of invasive breast carcinoma patients.

3. Adaptation to Filipino Version of the Vascular Access Quality of Life (VASQoL) Measure

Presenter: Zanria Harilen J. Caberos, MD

Objective:
To evaluate the reliability and validity of the Filipino version of the Vascular Access Quality of Life (VASQoL) measure.

Methods:
The Vascular Access Quality of Life (VASQoL) measure was translated to the Filipino language and, subsequently back translated to the English version by professors from the university. This translated questionnaire was face validated by a vascular surgeon, both adept in using both Filipino and English language. Pre-test was done on 10 subjects to assess cross cultural applicability of the questionnaire. Reliability was tested on 24 patients who were all diagnosed with Stage V Chronic Kidney Disease (CKD).

Results:
A total of 24 patients were recruited in the study with a mean age of 50.6, ranging from 15 to 77 years old. Slightly higher population of female versus male participants. For both test and retest, the internal consistency of the VASQoL was unacceptable with Cronbach’s alpha of 0.5209. Test-retest reliability showed almost perfect agreement except for one item (Q7) with substantial agreement.

Conclusion:
The evaluation of the Filipino version of the VASQoL measure has revealed shortcomings in terms of reliability, suggesting that it may not be a dependable tool for assessing the experiences of patients with CKD undergoing hemodialysis (HD) in the Filipino population.

4. Incidence and Correlates of Stent Migration in Adult Patients Undergoing Self Expanding Metal Stenting for Central Airway Obstruction: A Retrospective Cohort Study of Filipino Patients in a Tertiary Hospital in the Philippines

Presenter: Ruari K. Lee, MD

Background:
One of the most common complications of Self Expanding Metal Stent (SEMS) insertion for Central Airway Obstruction (CAO) is Stent Migration. This study aims to identify significant clinical factors associated with stent migration.

Methods:
A retrospective cohort study of all patients who underwent SEMS insertion for CAO in the said tertiary hospital in the Philippines from January 2012 to July 2022 was done. Patient, operative and stent factors were obtained. Incidence rates for stent migration and repeat intervention, and unadjusted hazards ratio were computed and analyzed for the different clinical factors.

Results:
This study had 61 patients, with 65 SEMS placed. Nine patients had stent migration within 30 days, while nine patients had stent migration after 30 days. Incidence rate of stent migration within 30 days was 0.0074 per person-day (CI 0.0047-0.012), and incidence rate of stent migration at any time after insertion was 0.0050 per person-day (CI 0.0026-0.0096). Incidence rate for repeat intervention was 33.33%. No significant clinical factors were associated with stent migration within 30 days (all p > 0.05). For stent migration at any time after insertion, obesity (patient BMI range of 25.3 to 30.7) had a 252% increase in hazard for stent migration (HR = 3.52; 95% CI 1.12-11.11; p =0.032), while procedure duration of ≥ 110mins had a 80% decrease in hazard for stent migration (HR = 0.2; 95% CI 0.04-0.97; p = 0.046).

Conclusion:|
Obesity and procedure duration of ≥ 110 mins were significant factors for stent migration. Causality remains to be established

5. Pre-operative Oral Calcium, with or without Vitamin D, Supplementation in Preventing Post-operative Hypocalcemia Among Post-total Thyroidectomy Adult Patients: A Systematic Review and Meta-analysis

Presenter: Allan B. Castro, MD

Introduction:
Despite advancements in surgical techniques aimed at preserving parathyroid function, postoperative hypocalcemia (PoH) remains a challenge following elective total thyroidectomy. Management typically involves postoperative calcium supplementation; however, some studies suggest preoperative calcium and/or vitamin D supplementation may prevent PoH. This paper analyzed existing studies to determine efficacy of preoperative calcium, with or without vitamin D, in preventing hypocalcemia in total thyroidectomy patients. Level of Evidence: Meta-analysis, Level IV

Methods:
A systematic review and meta-analysis was conducted with PROSPERO Registration No. CRD42024426410. Searches were performed on PubMED, PubMED Central, Embase, Cochrane Library, and HERDIN without date or language restrictions. Relevant studies underwent multiple screenings, with accepted individual studies assessed for bias or quality. Meta-analysis was performed using SPSS version 24.

Results:
A total of 345 studies were initially identified. Following deduplication, exclusion, and quality appraisal, 8 studies were included for analysis. Random effects model was utilized for all analysis due to heterogeneity in data. Results indicate that preoperative calcium, with or without vitamin D supplementation, correlated with higher postoperative calcium levels (z = 3.09, p<0.001), reduced incidence of laboratory (z= 2.05, p = 0.03) and clinical hypocalcemia (z= 2.94, p < 0.001), and shorter hospital stay (z= 2.32, p = 0.01).

Conclusion:
Results from the conducted meta-analysis support the proposed practice of providing calcium with or without vitamin D supplementation among patients who are to undergo total thyroidectomy procedures to prevent postoperative hypocalcemia.

6. Prediction of Malignancy in Thyroid Nodules Using the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS): A Local Multicenter Study

Presenter: Regimar S. Benito, MD

Objective:
To determine the predictive value of ACR-TIRADS in detecting malignancy in thyroid nodules.

Methods:
This is a retrospective, multi-center, cross-sectional analysis of patients who underwent ultrasound and thyroidectomy at three Cordillera Consortium hospitals between January 2019 and December 2021. Ultrasound reports were reviewed and correlated with histopathology reports to determine features associated with malignancy.

Results:
A study of 117 patients with thyroid nodules found significant differences in ACR-TIRADS subcategories. The risk of malignancy for TIRADS categories 1, 2, 3, 4, and 5 were 10%, 9.5%, 21.9%, 43.9%, and 76.97%, respectively. ACR-TIRADS demonstrated a high sensitivity of 92.1% and negative predictive value (NPV) of 90.3% as a rule-out test, and a specificity of 96.2% with a positive predictive value (PPV) of 76.9% as a rule-in test using TIRADS 5 as malignant. Correct classification of malignant nodules increased by cut-off value with the highest at 73.5% at the ≥5 cut-off value.

Discussion:
Thyroid nodules were more common in females under 55 years old. Certain sonographic features of thyroid nodules, such as being solid or predominantly solid, hypoechoic, lobulated/irregular, and having punctate echogenic foci, were associated with malignancy. The risk of malignancy at Cordillera Consortium hospitals was notably higher in this study. The ACR-TIRADS test yielded results consistent with previous studies, with TR 1 and 2 indicating benign nodules and TIRAD 3-5 indicating malignant nodules.

Conclusion:
Due to a higher risk of malignancy, it is recommended to be more aggressive in performing biopsies for thyroid nodules at Cordillera Consortium hospitals. ACR-TIRADS is a reliable screening tool and is recommended as a confirmatory test (TIRADS 5) for thyroid malignancy. Biopsies are still recommended for TIRADS 3, 4, and 5 nodules to avoid unnecessary procedures and confusion among surgeons.

7. Use of Electrothermal Device for Iliac Vessel Dissection in Kidney Transplantation at National Kidney and Transplant Institute: An Initial Experience

Presenter: Datu Nasser A. Pendatun III, MD

Background:
Worldwide, kidney transplantation is done as a renal replacement therapy for end-stage kidney disease patients. Lymphocoele is a common complication following renal transplantation, with an incidence varying between 0.6% and 33.9%. The use of the electro thermal bipolar sealing device (LigaSure) has proven superior to other vessel sealing techniques in several reports. As such, LigaSure device is expected to provide an alternative method to the standard silk-tie method during kidney transplantation.

Objectives:
To describe our experience on using Ligasure device in kidney transplantation at the National Kidney and Transplant Institute.

Methods:
A prospective descriptive cross sectional research design among patients who underwent iliac vessel dissection using Ligasure device during kidney transplantation. Clinical outcomes were determined including operative time during iliac vessel dissection using LigaSure device, total and average JP drain output. Incidence of lymphocoele was observed by performing an allograft ultrasound on post-operative day 14, 60 and 90.

Results:
Ultrasonographically, none of the patients in this study developed a lymphocele. Average use of Ligasure device during iliac vessel dissection was 16.92 minutes. Average daily JP drain output was 123mL and average JP drain output prior to JP drain removal was 25.44mL.

Conclusion:
We did not observe any incidence of lymphocoele among patients wherein Ligasure device was used during iliac vessel dissection. Routine use of Ligasure device can be done without the risk of lymphocoele formation and can serve as an alternative from the traditional silk-tie method during iliac vessel dissection.

8. Development and Content Validity of a Low-Fidelity Simulator for Transanal Pull Through in Pediatric Surgery

Presenter: Emmanuel Alexis B. Narreto, MD

Introduction:
Simulation based training, which is hypothesized to increase skill proficiency among trainees, is currently gaining popularity in pediatric surgical training. High-fidelity simulators are expensive and not easily replicable in low to middle income countries; thus, the use of low-fidelity simulators are being suggested. This type of educational technique may have a role in complex procedures such as pull-through procedure among patients with Hirschsprung’s disease. This study aimed to ascertain the development and associated validity of low-fidelity simulators for transanal pull-through among pediatric patients.

Methods:
This is a validation study of a low-fidelity simulator for transanal pullthrough in pediatric surgery. The model was assembled by carefully harvesting the anus, colon and rectum from a pig cadaver, ensuring the tissues remained intact including the perianal skin. These tissues were then mounted onto a specially designed basket that simulates the human pelvic cavity. The prototype model underwent initial testing to ensure anatomical accuracy and durability. A panel of five pediatric surgeons were tapped for content validation.

Results:
The overall validity index of the simulator was 1.00 which was high. All panel experts agreed on the anatomical realism, educational value, and alignment with training objectives. Some positive feedback on its use included its ability to accurately simulate the surgical procedure and its potential to reduce the learning curve for trainees. Another feedback is that it can help clinicians feel more prepared and comfortable when performing the procedure on actual patients after practicing on the simulator. No negative feedback were reported.

Conclusion:
The study showed that the use of an animal simulator for practicing transanal pullthrough in pediatric surgery is feasible and valid. This model has the potential to be adapted for educational purposes and hands-on training before doing actual case surgeries. The realistic anatomy and tactile feedback provided by the simulator can help trainees improve their skills and confidence in performing transanal pull through.

9. Comparative Outcomes of Laparoscopic Versus Open Appendectomy in Patients at a Pediatric Surgery Referral Center in the Philippines

Presenter: Daniel Ernest L. Florendo, MD

Background:
Appendicitis is the most common acute surgical disease in children. Due to a nonspecific presentation and progression of the disease, a significantly higher presentation of appendiceal perforation may be expected in young children. With perforation there is an elevated risk of intraabdominal abscess, wound infection, post-operative ileus, higher rates of readmission and longer length of stay. Laparoscopic appendectomy is the recommended first line treatment however many centers from developing countries are still in the early stages of adopting such an approach and do appendectomies in an open manner. This study outlines our institution’s experience with a laparoscopy-first approach in managing pediatric appendicitis. Surgical outcomes from laparoscopic and open procedures during the study period will be compared.

Methods:
This retrospective cohort analysis encompasses all pediatric appendicitis cases at our institution from 2022 to 2023. As a major pediatric surgery referral center, there were a total of 273 cases during that period. Patient records were reviewed for surgical approach and outcomes.

Results:
The mean patient age was 11.87 years with a male:female ratio of 1.84. Average duration of symptoms prior to consult was 2.47 days. Most of the patients had complicated appendicitis (57.8% ruptured, 10.2% gangrenous). For the surgical approach, 42.9% underwent open appendectomy (OA) and 57.1% had LA with a conversion rate of 7.14%. Irrespective of disease severity, LA was superior to OA in terms of time to resume feeding (2.84 vs 4.07 days), post-op length of stay (5.29 vs 6.95 days), and surgical site infection rate (3.3% vs 16.2%). Operative times were not statistically different, with cases performed by fellows being faster than their resident counterparts by a few minutes. Other morbidities for LA included intraabdominal abscess (1.9%) and postoperative adhesions requiring adhesiolysis (1.3%), while the OA group reported 1 case each for adhesions, intraabdominal abscess, and incisional hernia.

Conclusion:
This study highlights the advantages and complications of laparoscopic appendectomy in the pediatric population as implemented in a tertiary government center. It also provides preliminary data on a significant cohort of patients with complicated appendicitis who underwent laparoscopic management in the local setting.

10. A Microbiological Profile of Acute Burn Wounds Received Within 24 Hours Post-Injury in a Tertiary Hospital in the Philippines

Presenter: Jose Paolo P. Albaño, MD

Introduction:
Burn wound infection is a significant risk factor in the morbidity and mortality of burn wound patients. Previous studies in our institution showed bacterial colonization in burn patients seen beyond 24 hours post-injury. The microbiological profile of burn wounds seen within 24 hours, including the presence and risk factors for wound colonization, has not been determined in our Burn Center.

Objectives:
To identify the presence and risk factors for burn wound colonization in burn patients seen less than 24 hours after injury and determine the microbiological profile and antibiotic susceptibility patterns in colonized burn wounds.

Methods:
One hundred eighty-nine burn patients who were seen at and admitted to the UP Philippine General Hospital ATR Burn Center within 24 hours of the burn injury from June 2021 until July 2023 were included in the study. Demographic and clinical data were collected upon admission. A total of 635 swab samples were collected from 189 patients and were sent for identification of aerobic organisms by standard culture methods and antibiotic sensitivity tests using the Kirby-Bauer disc diffusion method. Association of patient characteristics (area of injury, time received post-injury, previous hospital care, place of injury, percent burn injury, etiology, mode of transport, and type of dressing prior to admission) were determined using Chi square test of independence.

Results:
Out of 189 burn patients seen within 24 hours after injury included in the study, 58.73% (n=111) of patients, and 49.29% (n=313) of swabs showed bacterial colonization. Burn wound colonization was associated with area of injury/body region (χ² 5=16.29, p=.0061), time received post-injury (χ² 3=24.62, p<0.0001, post hoc Fisher’s test for 6-12 hours vs. within the first 6 hours: p<0.0001), place of burn injury (χ² 2=18.17, p=0.0001, post hoc Fisher’s test work vs. home: p=0.0006, work vs. outdoors: p=0.0015), percent burn injury (χ²4=21.40, p=0.0003, post hoc Fisher’s test 25-49% vs. 0-9%: p=0.004, 50-75% vs. 0-9%: p=0.002), and etiology of burn injury (χ²2=37.05, p<0.0001, post hoc Fisher’s test scald vs. flame: p=0.0012, electrical vs. flame: p<.0001). From 313 positive samples, 357 isolates were identified. Staphylococcus (58.8%) was the most common organism isolated. It was noted that out of the total isolates, 15 (4.2%) were identified to be methicillin-resistant S. aureus (MRSA) while 5 isolates (1.4%) were methicillin-resistant S. epidermidis (MRSE). Streptococcus (10.4%) and Acinetobacter (6.2%) were the second and third most common organisms, respectively. Other groups identified were Aeromonas, Bacillus, Enterobacter, Pseudomonas, Klebsiella, and diphtheroids. Frequency of bacterial isolates differed across body regions, time received post-injury, percent burn injury, and etiology of burn injury. Resistance to one antibiotic was observed in 36.84%, 6.25%, and 63.64% of Staphylococcus, Streptococcus, and Acinetobacter isolates tested, respectively. Resistance to more than 1 antibiotic was observed in 48.68% of Staphylococcus isolates and 50.0% of Streptococcus isolates tested. Among the 51 S. aureus isolates, 29.1% were methicillin-resistant S. aureus (MRSA).

Conclusion:
In burn patients seen within 24 hours after injury, about half of burn wounds and more than half of patients showed the presence of microbial growth. Potential risk factors for positive microbial growth in a burn wound during this timeframe were area of injury/body region, place of injury, time received post-injury, percent TBSA burn, and etiology of burn injury. The most common isolate was Staphylococcus spp. More than half of Staphylococcus isolates showed antibiotic resistance, with a significant number showing multidrug resistance. More than a quarter of S. aureus isolates were methicillin-resistant S. aureus (MRSA). These results suggest that bacterial isolates can colonize burn wounds even within 24 hours post-injury and may exhibit antibiotic resistance.

11. Development and Validation of a Wound Registry Form for Use in a Tertiary Hospital in the Philippines

Presenter: Isabel Luisa O. Acosta, MD

Rationale:
Wound care practices are documented using wound registries to record wound types and characteristics, track wound status, assess impact of interventions, evaluate outcomes, and cost effectiveness. Data from wound registries may also be used for research in wound care and healthcare resource planning. However, a standardized wound registry in the Philippines is lacking, necessitating the creation and development of our own Wound Registry Form, tailored to our experience.

Methods:
This study involved the development and validation of a Wound Registry Form. An initial survey and focus group discussion with wound care practitioners were done to develop the items included in the form. The form underwent content validation with a panel of experts. Pilot data collection with 75 patients was performed to determine the interrater reliability between General Surgery (GS) and Plastic Surgery (PS) residents in a tertiary hospital when assessing patients with wounds.

Results:
A Wound Registry Form containing 36 variables was developed. It demonstrated a high content validity index (1.0), and good interrater reliability. The General Surgery residents and Plastic Surgery residents did not differ significantly in describing the wound, and generally agree on the choice of wound dressing, and other treatment related characteristics –such as frequency of dressing changes, antibiotic use, and septic studies done. However there was a significant difference among the two groups in two aspects –1) wound exudate consistency, with majority of GS residents rating exudates to have high viscosity, while majority of PS residents rating the exudates as of low consistency (p<0.01), and, 2) rationale for the type of dressing use – there is a higher percentage of GS residents considering price and availability primarily, whereas PS residents tend to weigh their dressing choices on the clinical indication for it (p<0.01). No other significant differences were observed between the two groups in terms of other parameters.

Conclusion:
The Wound Registry Form demonstrated high content validity, and good interrater reliability. The form is a reliable data collection instrument that may be used in monitoring wound status and response to treatment, identifying trends in wound healing and management, analyzing interplay of patient and wound factors, determining effectiveness of wound care practices, and may contribute to wound care research and public health in the Philippines. Data from this tool may be used by multiple end users: by clinicians to provide evidence based wound care, by researchers who wish to explore factors contributing to the burden of wounds, by administrators who want to create an enhanced health record systems with standardized documentation of wound data, and by the public, including patients and their families, who wish to be more informed, and more proactive towards their healing.

12. Assessing Appropriateness of a Developed Cephalous Analogue for Simulation Training in Performing a Z-Plasty by Medical Practitioners in the Philippines

By: Anjuli L. Ilagan, MD

Rationale/Objective:
Simulation-based training allows surgeons to practice technical skills in low-stakes environments. This study aimed to evaluate the appropriateness of a locally developed cephalous tissue analogue model for Z-plasty technique training, addressing the lack of standardized simulation training tools in the Philippines.

Methods:
Fifteen board-certified plastic surgeons participated, performing the Z-plasty on the cephalous tissue analogue simulator, which was developed using a gelatin, sorbitol, and glycerin mixture reinforced by a mesh base. The participants watched a standardized Zplasty technique video and practiced on the simulator before providing feedback. Face validity was assessed through a Likert-scale questionnaire, with a passing score of 40/50.

Results:
Of the participants, 93.3% agreed that the model replicated the visual appearance and anatomical orientation necessary for Z-plasty, while 86.6% affirmed its utility in preprocedural planning. However, only 46.7% found the simulator’s tissue elasticity adequate, and 20% agreed that it effectively mimicked the interaction between surgical instruments and tissue. The model was unable to consistently retain sutures, particularly for flap corners.

Conclusion:
The cephalous tissue analogue model successfully simulated incision and visual orientation but requires refinements in tissue elasticity and suture retention to fully meet training needs for Z-plasty. Future efforts will focus on prototype improvements and content validation to better support simulation-based surgical training.

DOI: