Patients' satisfaction after stapled hemorrhoidectomy versus doppler guided hemorrhoidal artery ligation

Objective: Assessment of the patient's satisfaction undergoing treatment for haemorrhoids, after stapled haemorrhoidectomy and haemorrhoidal artery ligation methods of surgery at Khawaja Muhammad Safdar Medical College, Sialkot, Pakistan

Study Design: Prospective and analytic study

Place and Duration of study

This study was conducted at the Department of Surgery, Khawaja Muhammad Safdar Medical College, Sialkot from from December 2012 to June 2015

Materials and Methods: All patients presenting in surgical out patients department above 18 years with third degree haemorrhoids were included in the study. Data of 82 patients [stapled haemorrhoidectomy n=55 and haemorrhoidal artery ligation n=27] was collected from December 2012 to November 2015. Patients were distributed in two groups depending upon the surgical procedures carried out

Full detailed history, examination, and investigations were performed

Patients with grade III hemorrhoids underwent the RAR procedure [Recto Anal Repair] i.e

Doppler guided haemorrhoidal artery ligation [DG-HAL] combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures. Results of treatment were assessed by regular follow up. Recording of variables and feedbackof the patients with minimum 3 months follow up, was made and analysed

Results: Out of 82 patients included in our study, Male patients were more in number in our study while 43 years came out to be, of the mean age. Something coming out from the anal canal, painful evacuation of bowels, bleeding per rectum and constipation are the chief presenting complaints

Conclusion: Generally, patients with piles except having severe prolapsed haemorrhoids had postoperative pain, lesser complications and acceptable results in long term can be achieved, in patients undergoing Doppler Guided Haemorrhoid Artery Ligation and Recto Anal Repair. Haemorrhoid artery ligation is a procedure associated with much less pain, in comparison to the stapled haemorrhoidectomy and patients can resume normal routine job, early

Long-term complications still require to be seen and assessed by studies with longer follow up. A lot depends on treating surgeon, his experience, skill and acumen

Placenta previa; risks and morbidity

Objective: To evaluate and determine the risk factors and outcome of placenta previa in patients undergoing cesarean section at Islam Teaching Hospital. Sialkot

Study Design: Case control, Observational and comparative study

Place and Duration of Study: This study was carried out at theDepartment of Obstetrics and Gynaecology,Islam Teaching Hospital, Islam Medical College, Sialkot from September 2010 to December2014

Materials and Methods: Our study included all the patients who underwent caesarean section for singleton pregnancy after 28 weeks of gestation during the study period, data was collected and analyzed retrospectively for determining risk factors and patients were followed prospectively to see the morbidity and outcome of cesarean section in patients with placenta previa labeled as Group I and patients without placenta previa labeled as Group II. The patients who had normal vaginal delivery were not included in the study. Data was recorded using SPSS version 20 and frequencies were calculated. Statistical analysis and significance was done using OpenEpi calculators. Pvalue was calculated using two by two table and relevant Fischer and mid-P extracttests. P value <0.05 was usedto show significantdifference

Results: During the specified period 46 patients were those whose pregnancy was complicated by placenta previa while 734 patients who underwent cesarean section were not having antenatal or peroperative evidence of placenta previa. The maternal age >35years was present in 27 patients in group 1 and 234 patients in group11 so placenta previa is associated with age greater than 35 years [OR 3.036, 95%CI 1.655-5.572, P value 0.0001700]. The multivariate retrospective analysis showed that independent factors of prior LSCS [OR 2.33, 95% CI 1.272-4.271, P value 0.003940] previous history of D and C [OR 2.341, 95% CI 1.029 -4.936, P value 0.02163 ] and malpresentation[OR 4.142, 95% CI 1.852-8.725, P value 0.0005307] were associated with placenta previa.Placenta previa was associated with adverse maternal outcome. In our study postpartum haemorrhage occurred in 20 patients of group I as compared to group II [43.47% vs 5.3%, P value <0.05 ]. But massive blood transfusion [transfusion of more than 4 units of blood ] was required in 8 patients in group 1 as compared to 22 patients in group II [17.4% vs 3.0%, P value <0.05]. Cesarean Hysterectomy was done in 4 patients in group I and no caesarean hysterectomy was required in group II [8.6% vs 0.00%, P value <0.005]. In 3 patients, indication of hysterectomy was placenta accreta with previous history of cesarean section. In one patient there was fibroid uterus along with placenta previa; so fibroid uterus was a confounding factor in our study so that cesarean hysterectomy percentage is somewhat more in our study. In all 3 cases of placenta accreta, there was history of previous cesarean section so that there is 15% chance of placenta accreta in patients with previous history cesarean section along with placenta previa. The placenta previa was also associated with adverse fetal outcome as perinatal mortality [17.4% vs 2.9%, P value<0.05], low APGAR score at 5 min [19.6% vs 7.1%, P value <0.05] congenital anomalies [10.8% vs 4.1%, Pvalue<0.05 ] was high in group I patients. Placenta previa was not associated with intrauterine growth restriction [4.3%vs 2.6%, P value 0.2379]

Conclusions: Advanced maternal age, previous caesarean section, previous history of D and C and malpresentation are associated with increased risk of placenta previa. Placenta previa is definitely associated with adverse maternal as well as neonatal outcomes. The obstetrician should be vigilant in antenatal as well as peripartum care of such patients in order to manage the associated complications and to decrease maternal and fetal morbidity and mortality

Morbidity associated with treatment of chronic anal fissure

Objective: To assess the effectiveness of different modes of treatment of chronic anal fissure as regards improvement of symptoms and complications

Methods: This prospective study included 129 consecutive patients with chronic anal fissures presented to the Surgical Outpatients' Department of Islam Teaching Hospital Sialkot, Pakistan; from September 2010 to November 2012. Patients were distributed in three groups. In "OBG group", patients had attended Gynae/Obs OPD and got treated and were then referred to surgical OPD for failure of treatment or recurrence. Patients who presented with history of treatment by GPs were included in "GP Group". "SGR Group" included those who directly reported to surgical OPD for treatment. Patients were managed both pharmacologically as OPD patients and surgically as admitted patients. Patients were instructed to apply small amounts of 0.2% GTN paste in soft white paraffin, to the anoderm with finger tips three times a day. Patients were evaluated at two-week intervals and at each visit the symptoms control, adverse effects and fissure status were recorded. If there was symptomatic relief or the fissure healing was in progress, the treatment was continued for a total duration of eight weeks. Operated patients were nursed in wards after surgery i.e Internal Anal Sphicterotomy. They were advised to report to OPD weekly for one month or earlier if they experienced any symptoms suggestive of complications. Patients were declared cured in case of complete symptomatic relief with fissure healing. Success, failure and associated problems were recorded and analysed to get results

Results: This study included 129 patients who could be followed up for a minimum of three months. These patients were referred by gynaecologist i.e. 22 [17%] for treatment failure while 5 patients with wrong diagnosis were not included in statistical analysis; similarly 41 [32%] patients were referred by general practitioners and 9 patients with wrong diagnosis were excluded. Sixty six patients i.e. 51% were those who directly reported to surgical OPD and had no previous treatment. With surgical treatment, pain, bleeding per rectum and constipation showed significant improvement as compared to GTN ointment application. Fissure healing was 100% in surgical group as compared to 74% in medical group. Complications were recorded and were found to be headache with medical treatment; while the most feared complication with surgical treatment i.e. permanent incontinence was not encountered in our study

Conclusion: Topical glyceryl trinitrate is economical, has a good healing rate, and faecal incontinence has not been reported. Its effectiveness, however, depends on patients' compliance which may be poor in view of associated headaches and a local burning sensation. It is first line of treatment for anal fissure but lateral internal sphincterotomy is superior, more effective and curative than the chemical sphincterotomy. Surgery is reserved for people with anal fissure who have tried medical therapy for at least one to three months but failed

Management of diabetic foot ulcers

To see the management options of diabetic foot ulcers in our patients, its presentation and the prognostic factors involved in planning the treatment in the Department of Surgery, Islam, Teaching Hospital Sialkot, Pakistan. Retrospective analytical and observational. This study was conducted at Islam Teaching Hospital Sialkot from September 2010 to January 2013. One fifty [150] cases of diabetic foot ulcers were included in this study. All patients were randomly selected attending to islam Teaching Hospital OPD and emergency. The results were shown in Table No.1 to Table No.4 and graph No.1. In patients of diabetic foot ulcers, the treatment doesnot end with infection controlled, healed amputation stumps and prothetic legs fitted; but it continues as reulcerations, involvement of healthy sides etc remains the feared consequences. The patient with diabetic foot infections and ulcers is a surgical patient throughout life as of a physician

Small bowel diverticular disease; how often we come across in exploratory laparotomy

1]. To see the prevalence of small bowel diverticulosis in patients presenting with acute abdomen. 2]. To know presentation and complications of diverticulosis in teaching hospital in Sialkot region of Pakistan. Introduction: Small bowel diverticular disease may be complicated by small bowel obstruction. Multiple diverticulosis represents an uncommon pathology of the small bowel. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction, and acute pancreatitis appear in 10-30% of the patients, increasing the morbidity and mortality rates. This pathology which is uncommon is much higher in our study in patients undergoing exploratory laparotomy in district level hospitals in Sialkot region of Pakistan. Prospective and observational. Combined Military Hospital, Sialkot [June 2005 to August 2010]. Islam teaching hospital, Sialkot [September 2010 to September 2012]. 260 consecutive patients undergoing exploratory laparotomy for obstruction, peritonitis, pain and mass abdomen were included in the study. Patient with established cause of obstruction were excluded. The data including demographic information, presentation, operative findings, complications and follow up were entered in structured proforma. Patients with less than three months of followup were also excluded from study. Small bowel diverticuli were encountered in 24 [9%] out of 260 patients including; 8 [3%] Meckel's, 9 [3.5%] jejunal, 3 [1.2%] duodenal and 4 [1.5%] Heal diverticuli. These patients with diverticuli presented as intestinal obstruction, peritonitis, mass abdomen, vague abdominal pain and one patient with fresh bleeding per rectum. The indications of surgery were peritonitis 6 [25%], intestinal obstruction 13 [54.2%], abdominal mass 3[12.5%], nonspecific abdominal pain 1 [4.2%] and fresh bleeding per rectum of obscure origin 1 [4.2%]. Complications encountered as Intestinal obstruction due to adhesion formation in 8; obstruction due to congenital bands attached to diverticuli in 3; diverticular perforation in 2; peritonitis due to diverticulitis in 2,bleeding from arteriovenous malformation within the jejuna diverticuli in 1 and mass formation due to volvulus in 1. Three duodenal diverticuli and 4 jejunal diverticuli were found as silent pathologies synchronous with other active pathologies

Surgical site infection in obstetrics practice

To determine the frequency of surgical site infection [SSI], the etiological factors and its management in elective and emergency cesarean sections. Observational study. Department of Obstetrics and Gynaecology, Islam Teaching Hospital Sialkot, from September 2010 to October 2012. Five hundred patients undergoing elective/emergency cesarean section for various indications were included. A minimum follow-up of three months was made. The patients were divided into two groups. Group -1, comprised of 267 [53%] cases of elective cesarean sections, while in group -2, 233 [47%] cases who were non-booked and presented in emergency, were included. The standard preoperative assessment was done in both the groups.The surgical aseptic technique was same in both the groups including antibiotic prophylaxis. All the patients were admitted for at least 5 days postoperatively and dressings changed on 3[rd] postoperative day and on 5[th] day before being discharged. The follow-up was done on 8-10[th] day including assessment for surgical site infections. A total of 29 [5.8%] patients had surgical site infection. The frequency of surgical site infection in group -1 was 4.8% [n=13] and in group - 16.8% [n=16]. Of the total twenty nine cases of SSI in both the groups, 20 [68%] were superficial in nature, 6 [21%] deep and 3 [10%] occurred in organs/body cavities. Escherichia coli was the most common organism isolated [n=12 - 48%] followed by Staphylococcus aureus in 6 [24%] cases. All the cases of wound infection were noted on outdoor visits i.e. after a week or so of surgery. Length of stay and duration of surgery were found to be minor risk factors responsible for causing surgical site infection

Threatened Miscarriage as a predictor of obstetric outcome

It was to study pregnancy outcome in patients with threatened miscarriage as compared to patients who had no bleeding in early pregnancy. It was a prospective case control/cohort study. This study was carried out in department of Obs. and Gyn. Islam teaching hospital, Sialkot from 1[st] January 2012 to 31[st] December 2012. 100 patients were enrolled randomly to group A, who had vaginal bleeding with closed cervix in first half of pregnancy. 100 asymptomatic age matched controls were enrolled randomly to group B. Data recorded included demographic features and detailed pregnancy outcome. Overall adverse pregnancy outcome was significantly higher in group A as compared to group B [p value <0.05]. 15% of patients had miscarriage in group A, while 2.1% miscarried in group B [p value <0.01]. Similarly 18% patients had preterm delivery in group A as compared to group B with 3.2% rate [p value 0.001]. Threatened miscarriage is associated with adverse pregnancy outcomes. Most significantly miscarriage, preterm delivery and low birth weight of neonates