Clinical presentation and management of adult choledochal cyst: a retrospective review

Objectives: To determine the mode of presentation and commonest surgical procedures done for adult choledochal disease in a tertiary care hospital

Methodology: A retrospective review conducted in Lady Reading Hospital, Peshawar, from January 1995 to January 2005 with one year of follow up. All patients above 13 years of age with choledochal cyst were considered for the study. Mode of clinical presentation and commonest surgical procedures were recorded

Results: Of the total 23 patients collected, 08 [34.78%] were males and 15 [65.22%] were females. Regarding mode of clinical presentation, pain right hypochondrium with raised serum bilirubin and ALT levels was found in 21.73% of patients. Complete cyst excision was possible in 69.56% of the patients. Complete cyst excision followed by Roux-en-Y common hepatico-jejunostomy was performed in 30.43% and common hepatico-dudenostomy in 26.08%

Conclusion: The most common mode of clinical presentation of choledochal cyst was pain right hypochondrium with raised serum bilirubin and ALT levels. The commonest surgical procedure was complete cyst excision with Roux-en-Y common hepatico-jejunostomy

Postoperative outcome of early laparoscopic and open cholecystectomy for acute calculous cholecystitis

Objective: to assess the optimal timing of intervention and post-operative morbidity for acute calculous

Cholecystitis

Study design: cross sectional study

Place and Duration of study: surgical unit Hayatabad Medical Complex Peshawar, from February 2015 to January 2016

Methodology: a total of 110 patients having age range of 20-55 year were included. Patients having common bile duct stones, clinically jaundiced and associated co morbid diseases, were excluded. Patients were divided into two groups having 55 patients in each group. Group A patients underwent early laparoscopic / open cholecystectomy within 72 hours of presentation while group B patients had delayed laparoscopic / open cholecystectomy after 72 hours of presentation. In both the groups laparoscopic cholecystectomy was attempted initially but in difficult cases decision was made to convert to open procedure. Postoperative morbidity of both groups was compared

Results: mean age of the study population was 40.5+2.5 year. Male to female ratio was 1: 8.2. Biliary leak occurred in 1.8% patients in group A and 5.5% in group B. Common bile duct injuries occurred in 1.8% versus 3.6% patients and conversion rate was 3.6% against 12.7% in group A and group B respectively. Hospital stay in group A patients was 2.5 days as compared to 4.5 days in group B. Overall complication rate was 7.2% and 29.1% for groups A and B

Conclusion: early laparoscopic cholecystectomy within 72 hours significantly decreased the conversion rate, postoperative morbidity and the length of hospital stay

experience with continent urinary diversion

Objective: to find out frequency of urinary continence and surgical complications of using cecum and right colon as reservoir with appendix as a continent catheterizable conduit in various urological conditions in adults

Study design: retrospective study

Place and Duration of study: department of Surgery, Hayatabad Medical Complex and Khyber Teaching Hospital, from January 2005 and December 2015

Methodology: this is a review of records of patients who underwent continent urinary diversion. Reservoir was constructed from cecum and right colon using Le Bag technique. Appendix was used as a catheterizable port applying Mitrofanoff principle. Patients were followed up for six months at two months interval

Results: a total of 85 patients underwent continent diversion and 78 patients completed the study protocol. Four patients were lost to follow up and three died. Out of 78 patients, 48 were males and 30 females, with age range from 05 year to 68 year. Thirty-eight [48.71%] patients presented with transitional cell carcinoma, and 12 [15.38 %] had exstrophyepispadias complex. Reservoir formation using right colon with appendix for Mitrofanoff was performed in 53[67.94%] patients. Eleven [14.10%] patients underwent bladder augmentation procedure with Mitrofanoff and in 14 [17.94%] patients appendix alone was used for diversion. Thirty-two [41.02%] patients developed complications which included incisional hernia [n=7 - 8.97%], calculous formation [n=1 - 1.28%] and subacute intestinal obstruction [n=2 - 2.56%]

Conclusion: use of appendix as a catheterizable conduit is a good option in achieving continent urinary diversion

Partial cystectomy and omentoplasty for liver hydatid cyst

Objective: To evaluate the results of partial cystectomy and omentoplasty in the management of hepatic hydatid disease

Study design: Descriptive case series

Place and Duration of study: Department of Surgery, Hayatabad Medical Complex Peshawar, from March 2011 to February 2015

Methodology: The study included patients diagnosed to have hydatid cyst involving right lobe of liver using ultrasound and CT scan abdomen. Patients having hydatid cyst in the left lobe of liver or other viscera were excluded. Postoperatively complications like bile leak were noted

Results: Partial cystectomy and omentoplasty for hepatic hydatid disease produced satisfactory results with minimum complications and short hospital stay

Conclusion: A total of 26 patients with liver hydatid cyst underwent partial cystectomy and omentoplasty. Male to Female ratio was 2.7:1. Mean age of the patients was 44.51 year. The operating time was from 45-90 minutes. Postoperatively 02 [7.7%] patients had bile leak, 03 [11.5%] had wound infection and 01 [3.8%] patient developed recurrent hydatid cyst in the liver. The average hospital stay was 5.4 days. There was no postoperative mortality

Postoperative outcome of early oral feeding following elective colonic anastomosis

To assess the safety of early oral feeding after colonic anastomosis. Descriptive case series. Department of Surgrey Lady Reading Hospital Peshawar, from September 2009 to April 2011. Preoperative evaluation included history, physical examination and base line investigations. A limited bowel preparation was done in all the patients. Postoperatively 10-60 ml of sips were allowed 3 hourly after recovery from anesthesia. Free oral fluid intake was allowed on postoperative day-1, semisolids on day-2 and 3 as tolerated and full oral diet allowed on day-4. In case of two episodes of vomiting and absence of bowel sounds, patients were kept nil by mouth and nasogastric tube was placed. Out of total 101 patients, 77 [76.24%] were males and 24 [13.76%] females [M:F 3.2:1]. The age range was from 25 year to 77 year with mean age of 49.5 +/- 2.3 year. The time of passge of first flatus was 2 to 6 days [mean 2.4 days], and the time of first passage of stool was 4-9 days [mean 4.6 days]. Twenty two [21.78%] patients did not tolerate feeding. They developed vomiting and abdominal distension. Postoperative complications included wound infection [7.92%], electrolyte imbalance [4.95%], respiratory tract infection and aspiration pneumonia [5.94%], anastomotic leaks [0.99%] and wound dehiscence [1.98%]. The hospital stay was 3-8 days [mean 5.4 days]. Early oral feeding after colonic surgery was safe and well tolerated by majority of the patients

Use of circumferential fasciocutaneous penile skin flap in the reconstruction of complex urethral strictures

To find out stricture free rate of penile circumferential fasciocutaneous skin flap use in complex urethral strictures Descriptive case series. Surgical Unit Khyber Teaching Hospital and Hayatabad Medical Complex Peshawar, from January 2000 to December 2009. All patients with complex urethral strictures, more than 4 cm long, were included. Patients were followed-up for two years and on each visit ascending urethrogram was performed. A total of 48 patients with complex urethral strictures were managed. The average length of the stricture was 06 cm [range 04-12cm]. Total operation time was 01-03 hours [mean 02 hours]. Late postoperative complications included recurrent strictures [25%], urethrocutaneous fistula [4.2%], erectile dysfunction [8.3%] and mild postmicturition dribbling [8.3%]. The overall success rate at the end of two years follow-up was 75%[n=36]. Circumfrential fasciocutaneous penile skin flap for urethroplasty is a good option for managing complex urethral strictures with acceptable postoperative morbidity

Frequency of incidental gallbladder carcinoma following cholecystectomy for symptomatic gallstone disease

To determine the frequency of incidental carcinoma of the gallbladder in specimens following routine cholecystectomy. Descriptive case series. Department of Surgery, Hayatabad Medical Complex Peshawar, from February 2008 to January 2011. All patients with symptomatic gallstone disease of either gender having age range between 12-70 year were included. Patients with diagnosed gallbladder malignancy, gallbladder mass, empyema gallbladder and gallstones associated with obstructive jaundice were excluded. Following cholecystectomy all the specimens were sent for histopathological examination. Two hundred and sixty patients including 65 males and 195 females [M: F ratio 1:4] aged 12-70 year and having a mean age of 41.7 year [ +/- SD 2.4], were studied. Commonest presentations were pain right hypochondrium and a positive Murphy's sign [87.71%] followed by dyspepsia[55%], nausea, vomiting [40%], pyrexia [31.92%] and weight loss [05%]. Eleven [4.23%] patients had a diagnosis of malignancy of gallbladder at histopathology examination. Mean age for patients with malignancy was 55.25 year with a male to female ratio of 01:10. Well differentiated adenocarcinoma was reported in 45.45% cases, moderately differentiated in 36.36%, poorly differentiated in 09.09% and undifferentiated in 09.09% patients. Routine histopathology of gallbladder following cholecystectomy is helpful in early detection of carcinoma gallbladder

Open haemorrhoidectomy versus rubber band ligation

To assess the results of open haemorrhoidectomy and rubber band ligation in terms of post operative pain and bleeding in 3rd degree haemorrhoids. A comparative study. Surgical unit Hayatabad Medical Complex Peshawar, from July 2009 to June 2010. A total of 100 patients were included. These were randomly divided in two groups; A and B and each group had 50 patients. Group A patients underwent open haemorrhoidectomy while group B patients had rubber band ligation procedure. Post operative complications like pain and bleeding between the two groups were compared. Out of 50 patients in group A, 72% [n=36] had pain and 20% [n=10] had post operative bleeding, while in group B pain was present in 08% [n=4] and post operative bleeding in 04% [n=2] patients. P values for pain [0.007] and bleeding [0.04] were significant in favour of group B. Rubber band ligation is a safe and quick procedure. It is associated with less intensity postoperative pain and bleeding as compared to open haemorrhoidectomy

Abdominal transpubic perineal urethroplasty for complex posterior urethral strictures: an experience of 10 years

To document the outcome of abdominal transpubic perineal urethroplasty for complex posterior urethral strictures. Descriptive case series Surgical unit Hayatabad Medical Complex and Khyber Teaching Hospital Peshawar, from March 1999 to February 2009. Abdominal transpubic perineal urethroplasty is an acceptable surgical approach in patients with complex posterior urethral stricture. Patients with complex posterior urethral stricture were included in this study. Pre operative evaluation included history, physical examination and laboratory investigations. Antegrade/retrograde urethrograms and cystourethroscopy were performed to evaluate bladder neck, and stricture site and length. Surgery was performed in lithotomy position through lower abdominal and perineal approaches. Patients were followed for 2 years. At each visit, ascending and descending urethrograms were performed and post operative complications were recorded. Results were graded as successful and failure based on stricture free rate at the end of 2 years A total of 28 patients were managed The age range was 14-36 year with a mean age of 27.3 + 2.4 year. Urethral stricture was associated with false passages in 17.88% cases, periurethral cavity in 10.71% and urethrocutaneous fistula in 7.14% cases. Mean operation time was 3.5 hours and mean hospital stay was 6 days. Postoperative complications were recurrent stricture [17.86%], urethrocutaneous fistula [7.14%], perineal haematoma [7.14%], impotence [10.71%] and wound infection [10.71%]. During follow up 89.29% patients were stricture free at the end of 2 years Abdominal transpubic perineal urethroplasty is an acceptable surgical approach in patients with complex posterior urethral stricture

Post operative outcomes of open versus closed haemorrhoidectomy

To compare the therapeutic results of open haemorrhoidectomy with closed one in terms of post operative pain, bleeding and wound healing. This experimental study was carried out in the surgical unit, at Hayatabad Medical Complex Peshawar from March to August 2009. Fifty patients of 2[nd], 3[rd] and 4[th] degree haemorrhoids having no systemic illnesses were included in this study. Patients were randomly divided in two equal groups. Group A included patients undergoing open haemorrhoidectomy and group B catered for patient with closed haemorrhoidectomies. Post operatively these patients were followed up in the OPD for 02 months and were evaluated for post operative pain, bleeding and wound healing in addition to other complications like urinary retention and anal fissure. The mean age of the sample was 45.5 +/- 2.3 years. In group B, 08 [32%] patients had mild pain, 10 [40%] had moderate and 02 [08%] had sever pain post operatively as compared to 13 [52%] patients with mild, 11[44%] with moderate and 06 [24%] with severe pain in group A [p < 0.05]. Similarly early post operative bleeding was noted in 15 [60%] patients in group A and 06 [24%] patients in group B [p < 0.05]. Wound healing time was just over 02 weeks in group B as compared to more than 04 weeks in group A [p < 0.05]. Closed haemorrhoidectomy technique is much better than open technique for 2[nd], 3[rd] and 4[th] degree haemorrhoids

Comparison of wide open excision and karydakis procedure for pilonidal sinus disease

To compare the outcomes of wide open excision and Karydakis procedure in terms of postoperative complications, hospital stay and recurrence rate. Comparative interventional study. Surgical unit Hayatabad Medical Complex Peshawar, from April 2006 to March 2009. A total of 40 patients with pilonidal sinus were admitted through OPD. Patients with osteomyelitis of sacrum, fistula with anal canal or rectum, and those who were lost during follow up, were excluded. Patients were divided into 2 groups. In group A [20 patients] wide open excision was done whereas in group B [20 patients] Karydakis procedure performed. Patients were followed up in OPD for 6 months and postoperative outcomes were recorded. Out of 40 patients, 36 [90%] were males and 4 [10%] females [M:F = 9:1]. Age range was 15 to 40 year with mean age of 26.5 year +/- 2.4 year. In group A, postoperative complications encountered were pain [75%], bleeding [10%], wound infection [25%], scar pain [30%] and numbness [15%] at the site of surgery. While in group B, postoperative morbidity included pain [25%], hematoma/seroma formation [10%], wound infection [15%], scar pain [15%], numbness [20%] and wound dehiscence [10%]. Average hospital stay was 5.6 days in group A and 2.5 days in group B. Recurrence rate was 25% following wide open excision and 5% after Karydakis procedure. Karydakis procedure is better than wide open excision in terms of less postoperative complications, reduced hospital stay and low recurrence rate

Experience of rubber band ligation for haemorrhoidal disease

To assess symptomatic relief in haemorrhoidal disease using rubber band ligation. Surgical unit, Hayatabad Medical Complex, Peshawar from July 2007 to June 2009. All patients presenting with rectal bleeding or prolase underwent proctoscopy to determine the cause of bleeding. Only patients with 1[st], 2[nd] and 3[rd] degree haemorrhoids [bleeding and prolapse] were selected for the study and they underwent rubber band ligation in two sessions, 6 weeks apart. Patients were followed in the OPD at 3 months and one year when their subjective and objective symptoms were noted followed by rectal examination and proctoscopy. Therapeutic response was assessed by symptomatic improvement in bleeding and prolapse of hemorrhoids and any complications. A total of 105 patients underwent rubber band ligation. There were 65[62%] males and 40[38%] females with a male to female ratio of 1.6:1. Age of the patients ranged from 21-65 years [ +/- 2.4SD]. Twenty three [21.9%] patients had 1[st] degree, 50[47.6%] had 2[nd] degree and 32[30.5%] had 3[rd] degree haemorrhoids. Forty-eight patients [45.7%] presented with prolapse, 33[31.4%] had both bleeding and prolapse and 23[21.9%] had bleeding only. At 3 months of follow up rubber band ligation cured 76[72.4%] patients, improved 13[12.4%] and failed in 7[6.7%] patients. At one year follow up, recurrence of bleeding and prolapse occurred in 16[15.2%] patients having 3rd degree haemorrhoids. Overall success was achieved in 89[84.8%] cases. Complications were seen in 20[19.1%] patients which were of mild to moderate nature and no serious/ life threatening complications were noted. Rubber band ligation is a rapid and safe non operative procedure for treating 1[st], 2[nd] and early 3[rd] degree haemorrhoids on out patient basis

Surgical management of carcinoma caecum

To determine the magnitude of carcinoma caecum and its surgical management in the department of Surgery, Hayatabad Medical Complex Peshawar-Pakistan. This case series study was conducted at surgical Unit Hayatabad Medical Complex Peshawar from July 2006 to June 2009. A total of 32 patients of carcinoma of caecum were included that were admitted either through OPD as elective cases [22 patients] or in emergency [10 patients]. In elective cases, diagnosis was made on colonoscopic biopsy while those who presented in emergency either with intestinal obstruction or with the suspicion of acute appendicitis, were diagnosed on the resected specimen histopathology. Out of 32, 25 patients [78%] were male and 7 [22%] female, with a male to female ratio of 3.6:1. Their mean age at the time of presentation was 65 +/- 2.8 years. Right hemicolectomy with side to side or end to end ileotransverse anastomosis was performed in 23 cases [71.89%]. In 3 cases [9.37%] ileotransverse bypass without resection was carried out as the tumour was locally advanced. In 3 other cases [9.37%], only omental biopsy was taken as the carcinoma was so advanced that any curative or palliative resection was not possible. In emergency situation, right hemicolectomy with exteriorization of bowel ends was done in 3 cases [9.37%]. Postoperative morbidity included wound infection 12.50%, faecal fistula 9.37% and intraabdominal collection 6.25%. Majority of the patients were having operable disease, however late presentation is very common. Surgical intervention may prove to be a better option in such cases

Postoperative outcome of mesh hernioplasty under local anaesthesia as a day case procedure

To evaluate the outcomes of inguinal hernia mesh repair under local anaesthesia as a day case surgery. Descriptive case series. Surgical unit, Hayatabad Medical Complex Peshawar, from September 2007 to August 2008. Patients having direct/indirect inguinal herniae of either side who underwent Lichtenstein repair under local anaesthesia as a day case procedure were included. Patients below 20 years of age were excluded. Similarly those patients having acute complications of hernia like obstruction and strangulation were also excluded. Patients were followed up in the OPD for 02 years and any positive findings noted during this time period, recorded. All 135 patients were male with mean age of 52.5 years [ +/- 2.4 years SD]. Fifty-eight [42.96%] patients had direct inguinal hernia [right side 35 cases and left side 23 cases]. Seventy-seven had indirect inguinal hernia [right side 45 cases and left side 32 cases]. Postoperative complications included urinary retention in 08 [5.93%] cases, seroma formation in 06 [4.44%], wound infection in 10 [7.41%], scrotal oedema in 07 [5.19%] and chronic neuralgic pain in 02 [1.48%] cases. Three [2.94%] patients developed recurrence during the follow up period. Inguinal hernia mesh repair can be performed safely and effectively under local anaesthesia with minimal postoperative complications and acceptable results

Causes of mechanical intestinal obstruction in adults

To investigate the causes of mechanical intestinal obstruction in adults at surgical C unit Lady Reading Hospital Peshawar. This case series study was conducted at surgical C unit, of Lady Reading Hospital Peshawar, Pakistan from July 2006 to June 2007. In this study a total of 93 patients were included; who underwent exploratory laprotomy. These patients were diagnosed on the basis of clinical history, examination and radiological findings. After resuscitation, exploratory laprotomy was performed to confirm the diagnosis and relieve the obstruction. Laprotomy findings were recorded and where necessary specimen was sent for histopathology for definitive diagnosis. In this study of 93 cases, 100% patients presented with pain and abdominal distension. Other symptoms were less frequent. Males were 50 [53.76%] and females 43 [46.24%] with a male to female ratio of 2:1. 72. Tuberculosis [36.55%] was the leading cause of mechanical intestinal obstruction followed by carcinoma of the large gut [22.58%] and postoperative adhesions [21.51%]. Five [5.37%] patients had obstructed herniae and four [4.31%] had malignancy of the small gut. Three [3.22%] patients were with Meckle's diverticulum while 2 [2.15%] each had appendicular adhesions, intussusception and sigmoid volvulus. The causes of intestinal obstruction are variable in different parts of the world. Tuberculosis was the leading cause of dynamic intestinal obstruction in this study

early closure of stoma warranted in the management of temporary loop ileostomy?

To assess the outcome of closure of temporary loop ileostomies by comparing frequency of post operative complication. This was an experimental study conducted at the surgical A unit of Lady Reading Hospital between Jan 2005 and Dec 2009. All patients who were primarily operated and ended up with temporary loop ileostomy were admitted via the out-patient department. Consecutively allocated into group A whose stomae were closed at 8 weeks and group B whose stomae closed at 4 weeks. Postoperative complications including wound infection, anastamotic leak, dehiscence etc. were recorded and statistical analysis done using version 13.0 SPSS for windows. Group A included 155 patients and Group B 156 patient with male predominance in both groups [p=0.869]. The mean age in both groups was similar 33.6 years and 32.7 years respectively. Anastamotic leak rate and wound dehiscence was lower in early closure group but p value was insignificant. The frequency of wound infection was higher in the early stoma closure group [p=0.001]. The mean hospital stay was similar. Apart from wound infection the frequency of complication following early closure [4 weeks] of temporary loop stoma is similar to delayed closure. Thus delayed closure of stomae should be abandoned