Tube thoracostomy in penetrating thoracic injuries

Objective: To determine the frequency of tube thoracostomy in penetrating thoracic injuries at a tertiary care hospital

Study design: Cross sectional study

Place and Duration of study: Department of Surgery Unit III, Civil Hospital / Dow University of Health Sciences Karachi, from March 2012 to March 2014

Methodology: All patients who presented with penetrating chest injuries due to firearm, stabs etc were treated according to ATLS protocol. Tube thoracostomy was performed when indicated. Chest tube was passed under local anesthesia

Results: A total of 100 patients included in this study. There were 92 males and 8 females. Mean age of the patients was 30+7.29 year. Mechanism of injuries included gunshot injury [n=62], stabs [n=24] and shrapnel injury [n=14]. Pneumothorax was diagnosed in 39 patients, haemothorax in 35, sucking wound of the chest in 20 patients and major vascular injury in 4 patients. Associated extra thoracic injuries were present in 26 patients. Tube thoracostomy was performed in 78 patients. Twenty-two patients underwent thoracotomy

Conclusions: Majority of patients with penetrating chest injuries were managed by tube thoracostomy. No mortality occurred in this series

Complications of onlay and sublay mesh plasty in ventral abdominal hernia repair

Objective: To find out the frequency of seroma, wound infection and wound disruption in patients of ventral abdominal hernia operated with onlay and sublay mesh plasty

Study design: Cross sectional study

Place and Duration of study: Department of General Surgery Dow University of Health Sciences and Civil Hospital Karachi, from January 2010 - December 2014

Methodology: Ventral abdominal hernia patients were selected randomly for the procedure of onlay and sublay mesh plasty. Fifty patients each were operated with either of the techniques. Postoperatively patients were observed for the complications; seroma, wound infection and wound dehiscence. All patients were followed for a period of two weeks

Results: A total of one hundred patients were enrolled. Fifty of them had onlay and fifty underwent sublay mesh plasty for ventral abdominal hernia. There were 18 [18%] males and 82 [82%] females with male to female ratio of 1:4.5. Minimum age was 22 year and maximum 55 year. There were 55 [55%] para umbilical hernia, 14 [14%] umbilical, 14 [14%] epigastric and 17 [17%] incisional hernia. Maximum number of cases of wound infection were noted in onlay mesh plasty group [n=16, 16%] while in sublay group only six [6%] had this complication

Conclusion: Sublay mesh plasty technique for ventral abdominal hernia repair had less frequency of complications

Perforation of gallbladder after admission in a young male patient

Gallbladder perforation is a rare but life threatening condition, and difficult to diagnose. A 30-year old male patient, with no known co-morbid, presented in emergency room with sudden onset of pain in the right hypochondrium. On examination there was tenderness in the right hypochondrium and right lumbar regions. Ultrasound abdomen showed thickwalled gallbladder containing multiple calculi and pericholecystic fluid suggestive of acute calculous cholecystitis. Patient was put on conservative treatment. After 24 hours patient deteriorated clinically. Urgent ultrasound showed collection in Morrison's pouch. Patient was operated and perforation at fundus of gallbladder found. Cholecystectomy was performed. Patient recovered smoothly and discharged home in good condition

Bile duct injury: management and outcome

To describe the management and outcome of bile duct injury. Descriptive case series. Surgical Unit II Civil Hospital, Dow University of Health Sciences Karachi, from July 2008 to June 2011. Patients who sustained bile duct injury were included in this study. Mode of admission, type of injury, procedures for reconstruction and outcome were recorded. There were sixteen patients with bile duct injury. Twelve [75%] patients were females and four [25%] males. Mean age was 40 year. In six [37.5%] patients injury occurred in our unit during surgery while four [25%] patients were referred from other tertiary care hospitals. Three [18.75%] patients were sent from district hospitals, one [6.25%] patient from taluka hospital and two [12.5%] from other private hospitals. Nine [56.25%] patients sustained injury during open cholecystectomy and in five [31.25%] during laparoscopic cholecystectomy. Ten patients [62.5%] underwent end to end repair over T-Tube. Two patients [12.5%] underwent hepaticojejunostomy. Morbidity noted in 37.5% [n=6] and mortality was 18.75% [n=3]. Bile duct injury occurred more with open cholecystectomy and end to end repair over T tube was most frequently used procedure. Mortality remained significant

Atypical presentation of appendicitis: diagnosis and management

To identify the patients with atypical features of acute appendicitis and to describe their management so as to avoid unnecessary delay in surgery. Descriptive study. Surgical Unit V, Civil Hospital and two private hospitals at Karachi, from July 2005 to June 2007. All patients who presented with right sided lower abdominal pain in whom provisional diagnosis of acute appendicitis made, were admitted for observation and further workup. The presenting symptoms, physical findings and total white count were entered on a proforma. Ultrasound, CT scan and laparoscopy were performed in atypical cases where available. A total of 318 patients were managed of whom 217 presented with classical features of appendicitis and 101 patients had atypical presentation. Diagnostic accuracy of ultrasound was 85%, CT scan 91% and laparoscopy 100%. One hundred and eighty patients had appendectomy in classical group and 80 patients in atypical group. Laparoscopic appendectomy was done in 26 patients. Nine patients required laparotomy. Ultrasound, CT scan and laparoscopy play an important role in diagnosis and management of atypical cases of appendicitis

Mortality in necrotizing fasciitis

The objective of this study was to determine the mortality rate in patients presenting with Necrotizing Fasciitis. This prospective study was conducted at ward 26, JPMC Karachi over a period of two years from March 2001 to Feb 2003. All patients above the age of 12 years diagnosed to be having Necrotizing Fasciitis and admitted through the Accident and emergency department were included in this study. After resuscitation, the patients underwent the emergency exploration and aggressive surgical debridement. Post-operatively, the patients were managed in isolated section of the ward. The patients requiring grafting were referred to plastic surgery unit. The patients were followed up in outpatients department for about two years. Over all, 25 male and 5 female patients fulfilled the inclusion criteria and were included in this study. The common clinical manifestations include redness, swelling, discharging abscess, pain, fever, skin necrosis and foul smelling discharge etc. The most common predisposing factor was Diabetes mellitus whereas the most commonly involved site was perineum. All patients underwent aggressive and extensive surgical debridements. The common additional procedures included Skin grafting, Secondary suturing, Cystostomy and Orchidectomy. Bacteroides and E. coli were the main micro-organisms isolated in this study. Bacteroides was the most common microorganism isolated among the eight patients who died. Necrotizing Fasciitis is a potentially life threatening emergency condition and carries the mortality rate of about 26.6%. The major contributing factors to increase the mortality missed initially diagnosed, old age, diabetes mellitus truncal involvement and late presentation. Anorectal involvement of disease carry worse prognosis. Hyperbaric oxygen therapy and proper use of unprocessed honey reduced the mortality rate