BackgroundA growing body of research shows links between poor teamwork and preventable surgical errors. Similar work has received little attention in the Global South, and in South Asia, in particular. This paper describes surgeons’ perception of teamwork, team members’ roles, and the team processes in a teaching hospital in Sri Lanka to highlight the nature of interprofessional teamwork and the factors that influence teamwork in this setting.MethodsData gathered from interviews with 15 surgeons were analyzed using a conceptual framework for interprofessional teamwork.ResultsInterprofessional teamwork was characterized by low levels of interdependency and integration of work. The demarcation of roles and responsibilities for surgeons, nurses, and anesthetists appeared to be a strong element of interprofessional teamwork in this setting. Various relational factors, such as, professional power, hierarchy, and socialization, as well as contextual factors, such as, patriarchy and gender norms influenced interprofessional collaboration, and created barriers to communication between surgeons and nurses. Junior surgeons derived their understanding of appropriate practices mainly from observing senior surgeons, and there was a lack of formal training opportunities and motivation to develop non-technical skills that could improve interprofessional teamwork in operating rooms.ConclusionsA more nuanced view of interprofessional teamwork can highlight the different elements of such work suited for each specific setting. Understanding the relational and contextual factors related to and influencing interprofessional socialization and status hierarchies can help improve quality of teamwork, and the training and mentoring of junior members.

No abstract

BackgroundDuodenal Peutz–Jeghers polyp is a rare cause of duodenal or biliary obstruction. However, a sporadic Peutz–Jeghers polyp leading to simultaneous biliary and duodenal obstruction has not been reported.Case presentationWe report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical “Peutz–Jeghers polyp”. As there was not enough evidence to diagnose Peutz–Jeghers syndrome this was considered to be a sporadic Peutz–Jeghers polyp.ConclusionRare benign causes such as a duodenal polyp should be considered and looked for in initial imaging, when the cause for concurrent biliary and intestinal obstruction is uncertain, particularly in young individuals.

Objective: Ultrasonography remains the initial imaging modality in the management of biliary disease. This study is designed to evaluate the accuracy of transabdominal ultrasonography in diagnosing biliary pathology in patients with choledocholithiasis. Methods: This was a retrospective study of a continuous sample of patients over a period of 3 years ending in January 2016; these patients were referred for endoscopic management of choledocholithiasis to a tertiary care hospital in Colombo, Sri Lanka. Ultrasound reporting was carried out by different consultant radiologists at both the index and the referring hospitals. The findings of endoscopic retrograde cholangiograms were compared with the ultrasound scan (USS) results. Results: A total of 247 patients were included in the study. USS was 97.4% accurate in detecting intrahepatic duct dilatation (IHDD). Stone counts and the location of stone(s) in the USSs correlated strongly with the number of stones delivered during endoscopic removal and their location in cholangiograms (P < 0.001). The difference in mean diameter of the common bile duct (CBD) of patients with choledochal cysts (CCs) (18.57 mm) and of patients without them (12.39 mm) is statistically significant (P < 0.001). At 14.5 mm, the negative predictive value for a CC is 99.02%. Conclusion: Ultrasonography is a reliable tool in predicting IHDD, stone count, and the location of stones in the biliary tree, particularly in a resource-poor setting. A CBD diameter of 14.5 mm in transabdominal ultrasound scan can be used as a cutoff for predicting extrahepatic CC.

20Background: As the gut microbiome is thought to play a role in the pathogenesis of colorectal 21 carcinoma (CRC) and affected by the diet and the genetic composition, we sought to investigate 22 the patterns of gut microbiota that associate with CRC in a South Asian cohort of patients with 23 CRC. 24 Methodology: The relative abundance of 45 types of gut microbial species were determined in 25 faecal samples of CRC patients (n=24), DM (n=20) and healthy age matched controls (n=44), 26 using a PCR array. Data was analyzed using the specific software for analysis of bacterial DNA 27 quantification. 28 Results: The species Bacteroides fragilis (23.9-fold), Bacteroides thetaiotaomicron (8-fold) and 29 Akkermansia muciniphila (5.9 fold) were several-fold over expressed in patients with CRC 30 compared to healthy individuals, whereas bacterial species of the Phylum Proteobactria were under 31 expressed. There was no difference in the abundance of these 3 species of bacteria with tumour 32 stage or gender and age of patients. Aeromonas species, Enterococcus faecium and Shigella 33 dysenteriae (Proteobacteria) were over 100-fold over abundant in those with DM compared to 34 healthy individuals. Although 70.83% of those with CRC also had diabetes, the relative abundance 35 of microbiota in CRC patients were different to those who had diabetes and no CRC.36 Conclusions: Patients with CRC and DM harbor a markedly different gut microbiota patterns 37 compared to their healthy counterparts. Similar patterns of gut microbial dysbiosis that associate 38 with CRC and DM appear be seen in South Asian populations, compared to Western countries, 39 despite differences in the diet and ethnicity.40 3 41 Background 42Colorectal cancer (CRC) is the third commonest cause of cancer worldwide and is the fourth 43 commonest cancer leading to death [1]. It has been predicted that the deaths due to colonic cancer 44 and rectal cancer will increase by 60% and 71.5%, respectively until year 2035 due to the increase 45 in the aging population [1]. The increase in the incidence of CRC is predicted to rise substantially 46 more in developing countries vs developed countries due to these changes in population 47 56 positive E.coli, enterotoxigenic Bacteriodes fragilis, Fusobacterium nucleatum and Streptococcus 57 gallolyticus [8-12]. While some of these microbes were overabundant in the gut microbiome of 58 patients with CRC, some have been detected specifically in tumor tissue and also in distance 59 metastasis, suggesting that they may play a role in the pathogenesis of this cancer [12]. They are 60 thought predispose to the development of CRC by inducing epigenetic changes and thereby 61 affecting gene transcription, inducing DNA damage and reactive oxygen species and by inducing 62 procarcinogenic cytokines [12]. 4 63 Of the factors that affect the diversity of the gut microbiome, the diet plays a central role. Although 64 the relative abundance of gut microbiota depends on an individual's genetic composition (12%), 65