Choledochorraphy [primary repair] versus t-tube drainage after open choledochotomy

T-tube drainage used to be standard practice after surgical choledochotomy, but there is now a tendency in some canters to close the common bile duct primarily. This study was designed to compare the clinical results of primary closure with T-tube drainage after open choledocotomy and assess the safety of primary closure for future application. This study was conducted at surgical Unit-3, ward 26 Jinnah Postgraduate Medical Centre Karachi, from January 2007 to January 2008. Forty patients were included in this study out of which 20 underwent primary closure and 20 Ttube placements. It was Quasi-experimental, non-probability, purposive sampling. Main outcome measures were operating time, duration of hospital stay, and postoperative complications. SPSS-10 was used for data analysis. The age of patients in the study ranged from 29-83 years. There were 3 male while 37 female patients. Group-1 consisted of 20 patients underwent primary closure after choledocotomy, while Group-2 also consisted of 20 patients underwent T-tube drainage after duct exploration. Mean hospital stay in Group-1 patients was 7.63 days while in group 2 it was 13.6 days. Overall complication rate in group 1 was 15%, biliary leakage in 1 [5%], jaundice in 1 [5%], wound infection in 1 [5%]. No re-exploration was required in Group-1. In Group-2 overall complication rate was 30%, biliary leakage in 2 [2%], jaundice in 1 [5%], dislodgement of T-tube in 1 [5%], wound infection in 1 [5%], and sepsis in 1 [5%] patients. Re-exploration was done in one patient. Primary closure of Common Bile Duct [CBD] is a safe and cost-effective alternative procedure to routine T-tube drainage after open choledocotomy.

Role of orally administered Gastrografin in small bowel obstruction after unsuccessful conservative treatment

Orally administered gastrografin is a hyperosmolar water soluble contrast medium. It is commonly used for the diagnosis of small bowel obstruction but it also has a therapeutic role in small bowel obstruction [SBO]. The purpose of this study was to determine the diagnostic and therapeutic role of gastrografin in cases of small bowel obstruction who didn't respond to conservative treatment. This retrospective study was carried out from Jan 2004 to Oct 2009, in which 110 patients with diagnosis [clinical and radiological] SBO were included. An initial trial of conservative treatment was given after excluding the bowel ischemia. Every patient was observed for twenty four hours to assess the response to conservative treatment. After 24hours non-responding patients were given 100 ml of gastrografin through Ryle's tube and transit of contrast was followed by repeated abdominal radiographs taken at 4,8,12 and 24 hours after administration of gastrografin. In partially obstructed patients in whom contrast appeared in large bowel no further intervention was performed. Laparotomy was performed in remaining patients in whom gastrografin failed to reach the large bowel within 24 hours. From Jan 2004 to Oct 2009, 110 patients [men =62 and women = 48] with small bowel obstruction were included in the study. The mean age of our patients was 34.1 years [15 - 40 years]. In 22% [25] patients had bowel strangulation and they were operated soon after admission. Non operative treatment was continued in 10% [12] of patients who responded to the conservative treatment in first 24hrs. Twenty eight [25%] patients had history of single surgery while 10 [9%] of patients had history of more than one operation in the past. Gastrografin was given to 73 patients who didn't respond to conservative treatment in 24hrs. Thirty four percent [25 out of 73] patients were operated for complete obstruction after gastrografin administeration. Forty five [61%] patients had partial obstruction after gastrografin administration and complete resolution of obstruction occurred in all of them except three patients who were operated for persistent obstruction. We found 92% reduction in the operative rate after gastrografin administration. No complications were noted with the use of gastrografin. After unsuccessful routine conservative treatment gastrografin can be used safely and it can reduce the operative rate. In this study out of 73 patients who were administered gastrographin, obstruction was completely resolved in 42 patients [57.5%]. It also helps in predicting the need for surgery thus it shortens not only hospital stay but also reduces the potential morbidity of late surgery due to prolong and unsuccessful non operative treatment.

Pattern of bacterial pathogens in postoperative wounds and their sensitivity patterns

To identify the common bacterial pathogens involved in postoperative wound infections and their sensitivity patterns. Cross-sectional study. Surgical ward 2, Jinnah Postgraduate Medical Centre Karachi, from December 15, 2008 to December 14, 2009. Wound swabs were collected for patients who developed surgical site infection during the study period. Infected cases were identified using Centre for Disease Control [CDC] definition for surgical site infections. Culture and sensitivity were performed using American Society of Microbiology [ASM] guidelines. During the study period, 82 [7.3%] patients developed postoperative wound infection in the selected ward. The most commonly isolated pathogens were E.coli [33.8%], Pseudomonas aeruginosa [16.9%] and Staphylococcus aureus [15.5%]. Resistance pattern of E.coli isolates showed 100%, 93%, 32% and 12% resistance to ceftriaxone, ofloxacin, amikacin and meropenem respectively. Pseudomonas aeruginosa isolates were 100% resistant to tetracyclin and ceftazidime, 91.6% to ofloxacin, 83.3% to meropenem and 66.7% to amikacin. Staphylococcus aureus exhibited maximum resistance to cloxacillin [100%] followed by ofloxacin [90.9%], tetracyclin [45.5%], amikacin [45.5%], chloramphenicol [36.4%] and vancomycin [0%]. Gram negative organisms were frequently associated with postoperative wound infections in general surgery ward and resistance to multiple drugs was noted

Audit of splenectomy at Jinnah postgraduate medical centre, Karachi

Objective: Splenectomy is often performed in patients with heamatalogical diseases or trauma who are at high risk of complications. Our aim is to perform an audit on splenectomy in order to determine the reasons for the operation, its complication and compliance with the recent recommendations for post-splenectomy patients at Jinnah Postgraduate Medical Centre. Design: It is a Descriptive study conducted in surgical ward 2 at Jinnah Postgraduate Medical Centre from June 2003 to June 2008. Methods: A retrospective review of hospital records of surgical ward 2 of consecutive splenectomy patients with a mean follow up of 12 months. Results: Fifty-five patients underwent splenectomy in 6 years duration. The mean age was 26.7 years. The indication for splenectomy was mainly heamatological diseases and trauma. Vaccination was done in 83.6% patients. Twelve patients had postsplenectomy complications, although there were no cases of OPSI. Mean hospital stay was 6.4 days. Conclusion: We still lack compliance with the standard guidelines for post-splenectomy patients. There is space for an improvement of the vaccination rate and prophylactic antibiotic. Patients should be counselled for the risk of OPSI and should have a splenectomised card for prompt treatment. There is need for careful documentation of this important health risk and counselling of patients in the discharge summaries

Is nasogastric decompression necessary in elective enteric anastomosis?

Placement of nasogastric tube is common surgical practice after bowel anastomosis. What is to be achieved by this prophylaxis is gastric decompression, a decreased likelihood of nausea and vomiting, decreased distension, less chance of pulmonary aspiration and pneumonia, less risk of wound separation and infection, less chance of fascial dehiscence and hernia, earlier return of bowel function and earlier discharge from hospital. We conducted a prospective observational study in Surgical Ward 2, Jinnah Postgraduate Medical Centre, Karachi from January 2008 to December 2009 to assess whether routine use of nasogastric decompression in elective enteric anastomosis can be safely omitted. Patients who underwent elective enteric anastomosis were included in this study. These patients were managed prospectively without nasogastric decompression. Outcome were measured in terms of time of passing flatus, nausea, vomiting, abdominal distension, pulmonary complications, wound infection, wound dehiscence, anastomotic leak, length of hospital stay and mortality. Except for incidence of minor symptoms like nausea or vomiting, omission of NG tube did not lead to any serious complication like anastomotic leak, pulmonary complications wound dehiscence or death. Nasogastric decompression can safely be omitted from a routine part of postoperative care after elective enteric anastomosis

Open versus closed method of establishing pneumoperitoneum for laparoscopic cholecystectomy

To compare the efficacy and safety of the Hasson cannula [open] and Veress needle [closed] method to gain access in the abdominal cavity for laparoscopic cholecystectomy. Randomized controlled study. Ward 26, Jinnah Postgraduate Medical Centre, Karachi, from January to December 2007. All patients undergoing laparoscopic cholecystectomy during the study period were enrolled. Younger [< 20 years] and elderly [> 65 years] patients and those with co-morbid conditions were excluded. The remaining were randomized into two study groups. In one group, the Hasson cannula was used, while in the other Veress needle was used to establish pneumoperitoneum. Surgeries were performed by experienced surgeons of the ward. Variables comparing the safety and efficacy of the two methods were studied. There were a total of 60 patients in each group. In the Hasson cannula group 15 [25%] had complications of gas leakage, one developed a port-site hematoma and two patients developed wound infections. No complications occurred in the Veress needle arm. The mean access time in the Hasson cannula group [4.6 +/- 1.1 minutes] was less than that of for the Veress needle arm [5.4 +/- 0.7minutes]. Complications of visceral or vascular injury, port-site hernia or gas embolism did not occur in either arm. Although complications occurred using the Veress needle technique, the Hasson cannula technique was faster. Further studies on larger sample sizes are necessary to establish corroborative evidence and formulate guidelines

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

Danazol versus oil of evening primrose in the treatment of mastalgia

To evaluate the efficacy of Danazol and Oil of Evening Primrose [OEP] in the treatment of Mastalgia, and to note their undesirable effects during the course of treatment. An open, non-randomized, comparative study, carried out from Nov 2004 to Nov 2005. Department of General Surgery, Surgical Unit-Ill [Ward 26], Jinnah Postgraduate Medical Centre, Karachi. A total of 100 female patients with moderate to severe breast pain who visited the Out-patient Surgical Department of Jinnah Postgraduate Medical Centre, Karachi. After clinical evaluation, investigations and informed consent, all patients were assigned to two groups alternatively. Mastalgia in all the patients was gauged before and during the treatment according to the Cardiff Breast pain Score [CBS]. Patients with discrete lumps, nipple discharge, lactation, pregnancy and breast abscess were excluded from the study. Group-I [n = 50] patients were given Danazol 100mg b. i. d per oral and Group-II [n = 50] Efamol [Oil of evening primrose] 500mg b. i. d per oral for three months periods. All patients were seen at 4 and 12 weeks, their level of mastalgia assessed and information sought about adverse effects of the drug. Out of the 100 patients, 70% belong to the age group 15-25 years, 20% to 26-35 years and 10% beyond 35 years of age. The overall response with Danazol was 76% in contrast to 68% response in the patients treated with OEP The patients who were treated with Danazol showed 32% distressing but reversible side effects as compared to 12% in OEP which were not distressing and also reversible. Danazol offers good pain control in mastalgia but with distressing side effects, where as Oil of Evening Primrose [OEP] also showed good pain control but without mtich distressing side effects

Correlation of macroscopic assesment in acute appendicitis with histopathology findings

To assess the observational accuracy for gross appendicular morphology at surgery by comparing it with the microscopic examination results, in order to develop clinical guidelines for improving this assessment especially with the emerging role of diagnostic laparoscopy.Retrospective, descriptive study over a period of one year.Ward 26 of Jinnah Postgraduate Medical Centre, Karachi. All patients admitted with the diagnosis of Acute Appendicitis and were operated upon. Macroscopic assessment of the appendices at operation were divided in four grades. Appendectomies were performed in all the patients and the specimens sent for histopathological examination. The reports were then compared with the gross description.The observational accuracy was 89% as compared to histopathological accuracy which was 96% amongst the total 358 patients suspected of acute appendicitis on clinical grounds. The clinical examination was false positive in 3.6% cases.Careful clinical examination is reliable; observational description of the surgeons can be improved by grading the pathological appearances of the appendix

Abdominal tuberculosis Surgeons perspective

The aim was to analyze the clinical presentation and outcome of therapeutic procedures in abdominal tuberculosis. Design: Descriptive study. Place and Duration: Surgical Unit III, Department of Surgery, Jinnah Postgraduate Medical Centre Karachi, of 4 years. All admitted patients [83] with following criteria were included. A. Clinically suspected abdominal tuberculosis supported by investigation and later responding to anti tuberculous drugs. B. Gross morphological operative findings; and histologically proven caseating chronic granulomatous inflammation. Median follow up was 9 months. Young females of low-income group were the common sufferers. Abdominal pain, intestinal obstruction and peritonitis were common presentations. Surgical interventions like loop ileostomy, resection anastomosis and adrenolysis were done in 53% due to peritonitis or intestinal obstruction. 47% patients responded adequately to anti tubercular therapy. In 20%, procedural complications were seen. Diagnosis of abdominal tuberculosis can be made on clinical grounds complications of abdominal tuberculosis can be averted with early commencement of drug therapy. Ileostomy is life saving procedure in malnourished patients. Leaving wound open for delayed primary closure not only allows continuous inspection of parties but also helps easy drainage of abscess if pus accumulates subsequent to surgical intervention or overlooked perforation

Tuberculosis with medullary carcinoma of thyroid; A clinical association, strange by st and ards

18 years old girl presented with right dominant lobe thyroid gl and in euthyyroid state. Radioisotope scanning revealed cold nodule and tine needle aspiration cytology reported follicular neoplasm. Subsequent histopathological examination revealed medullary carcinoma with tuberculosis. The medical literature abounds with evident association between chronic inflammatory process and neoplasia, considering chronic inflammation as risk factor for later. We searched the local and international medical literature in English language to find any association between neuro endocrine tumors and granulomatous inflammation. However to our knowledge no such association has so far been described, even in the form of clinical case report in any core medical journal

Opsite strapping for the treatment of infantile umblical hernia

A study was conducted to evaluate the efficacy of "Opsite" strapping for the Umblical Hernia. Opsite is a low allergy adhensive membrane, used during Surgical Operations. It also has advantages over commonly used sticking plaster, for being resistant to water and urine and also allows inspection of hernia. "Opsite" strapping was found to be effective in keeping the hernia reducea till the ring closed in 70% children below 2 years of age with umbilical ring defect of O.5 cm and above. In 11% there were skin complications of strapping. In some patients who developed minor skin abrasions, strapping was continued till the closure of ring. The abrasions healed as the strapping continued