To compare the efficacy of internal sphincterotomy with topical 0.2% glyceryl trinitrate ointment after hemorrhoidectomy for pain relief

To compare the efficacy of internal sphincterotomy with topical 0.2% glyceryl trinitrate ointment after hemorrhoidectomy for pain relief. Randomized controlled trial. Department of surgery, Combined Military Hospital Rawalpindi. Individual patients undergoing hemorrhoidectomy were randomized to either undergo internal sphincterotomy [Group A] or apply 0.2% glyceryl trinitrate [Group B]. internal sphincter was divided up to dentate line through one of hemorrhoidectomy incisions. For 2[nd] group the first dose of 0.2% GTN ointment was applied at the end of hemorrhoidectomy. They were advised sitz bath 4 times daily and stool softener. Post operative pain was measured using visual analogue scale [VAS] on 1[st], 2[nd] post op day and after a week and the average score was noted. VAS of pain far last visit was compared between the groups. Post operative pain was comparatively less in group A as compared to group B [p = 0.014]. In patients undergoing hemorrhoidectomy, addition of surgical internal sphincterotomy results in lesser pain in the postoperative period as compared to those receiving topical application of 0.2% glyceryltrinitrate ointment

Primary pancreatic tuberculosis: a rare and elusive diagnosis

Primary pancreatic tuberculosis is an extremely rare entity, even in tuberculosis endemic areas. A 22-year-old male presented with features of obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head for which he underwent a pancreatoduodenectomy. Histological examination of the specimen showed caseating granulomas. Antituberculous medicines were started and he remained well 18 months after surgery. Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. A high index of suspicion is vital to avoid surgeries in this medically treatable, often misdiagnosed condition

Serous cystadenocarcinoma of pancreas

Serous cystic neoplasms of pancreas are relatively rare tumours. Malignancy in these tumours is even more rare which is confirmed by metastasis to other organs or by perineural, vascular or surrounding soft tissue invasion. A 60 years old lady presented with vague upper abdominal pain. Computed tomography scan showed multiloculated cystic mass in the body of pancreas measuring 9 x 6 x 5 cm and not involving spleen. Pancreatectomy specimen showed a multicystic tumour having sponge-like appearance which showed vascular and soft tissue invasion of surrounding stroma on microscopic examination and was diagnosed as serous cystadenocarcinoma of pancreas

Video assisted thoracoscopic surgery [vats]; two years experience at thoracic surgery department, combined military hospital Rawalpindi

To review the experience of video-assisted thoracoscopic surgery [VATS] with 202 different cases focusing on indications, operative procedures, side effects and complications. Descriptive Study. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi, for 2 years from January 2009 till January 2011. Two hundred and two video-assisted thoracoscopic surgeries [VATS] were performed over 2 years. There were 131 [64.9%] males and 71[35.1%] female patients. Total two hundred and two patients were selected who were divided into two groups: diagnostic and therapeutic group. The mean age of the patients was 40.25 years [SD +/- 12.58] with an age range of 13-77 years. There were 131 males [64.9%] and 71 [35.1%] females. The main indications of video-assisted thoracoscopic surgery were diagnostic in 118 patients and therapeutic in 84 patients. Sixty one patients underwent VATS for indeterminate pleural effusion and a definitive diagnosis was made in 90.2% patients. Definitive diagnosis was made in all sixty six patients who underwent VATS for wedge resection/forceps biopsy of pulmonary nodules, mediastinal masses and interstitial lung disease. VATS thymectomy was performed on 13 patients while 3 patients underwent VATS sympathectomy. Conversion to thoracotomy was required in 8.4% [17/202] of the patients. Adhesions were the most common indication of conversion. There was no operative mortality. The overall median duration of chest tube drainage was 4 days and median postoperative hospital stay was 5 days. Postoperative complications were encountered in 5.9% patients [12/202 patients]. No perioperative mortality was encountered in either group. This review indicates that VATS can be performed with minimal morbidity for therapeutic purposes as a current approach for thoracic surgery. It is a safe procedure in many intrathoracic diseases and is associated with less postoperative pain and hospital stay than open thoracotomy

Management of primary spontaneous pneumothorax by video assisted thoracoscopic surgery [VATS]

To evaluate the outcome of treatment of primary spontaneous pneumothorax by VATS. Case Series. Dept. of thoracic Surgery Combined Military Hospital Rawalpindi between April 2007 to Dec 2009. This study included 20 patients with primary spontaneous pneumothorax who were treated by VATS apical stapling and pleural abrasion/ pleurectomy. All patients were operated under one lung ventilation. Three ports of 10mm were used and apical stappling / bullectomy was done with linear cutting stapler [ethicon, autosuture]. This was combined with pleural abrasion/ pleurectomy, Chest was drained via a single chest tube. We had 21 procedures on 20 patients. There were 18 males and 2 females [9:1]. Mean age was 26.4 years. Indications included persistent air leak 7, recurrent attack 12, contralateral recurrence 1 and professional hazard 1. Mean hospital stay was 3.2 days. Complications included minor port site infection 5, intercostals neuralgia 3, delayed lung expansion 2 cases and persistent apical space in 1 case. There is no recurrence. VATS was a reliable approach for managing primary spontaneous pneumothorax with low morbidity

Tracheal resection and end-to-end anastomosis for tracheal stenosis: etiology and outcome

To know the etiology of tracheal stenosis and asses outcome of tracheal resection and end-to-end anastomosis for tracheal stenosis. Descriptive prospective case series. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi and Quetta from May 2005 to March 2010. Twenty two patients were included in the study who underwent tracheal resection followed by primary tracheal reconstruction by same surgical team. Etiology was ascertained on the basis of available history and per-operative findings. End-to-end tracheal anastomosis was done using vicryl 3/0. Outcome of surgical technique was assessed using peak expiratory flow rate [PEFR] and flexible bronchoscopy. Twenty two patients were managed over a period of five years, of which 17 [77.3%] were male and 5[22.7%] female. Mean patient age was 27.31 +/- 9.61 years. Seven [31.8%] patients had New York Heart Association grade [NYHA]-III and 15 [68.2%] had NYHA grade-IV dyspnoea. Seventeen [77.3%] had stridor. All patients were already being managed by pulmonologists, ENT specialists or intensivists. Twelve [54.5%] had grade-V stenosis [91-100% luminal obstruction] and 9 [40.9%] had cervical tracheal stenosis and 3[13.6%] had mediastinal tracheal stenosis. Six [27.3%] patients had partial cricoid resection followed by thyrotracheal anastomosis, 13[59.1%] patients underwent cervical tracheal anastomosis and 3 [13.6%] patients required mediastinal tracheal anastomosis. Patients were followed up post-operatively for the development of immediate and delayed complications. The follow up was carried out for a minimum period of 6 months to a maximum period of 2 years. Postoperative complications included neck pain, lung collapse, and superficial skin infection. Tracheal resection with end-to-end anastomosis is a safe, reliable and permanent procedure for the treatment of tracheal stenosis

Video assisted thoracoscopic surgery [VATS] lung biopsy for non-responsive patients of interstitial lung disease [ILD]

To study the results of VATS [Video Assisted Thoracoscopic Surgery] Lung Biopsy in Interstitial Lung Disease [ILD] case series. Department of Thoracic Surgery, CMH Rawalpindi from Jan 2009 to Mar 2010. All those patients of ILD [Interstitial Lung Disease] were included who failed to improve after a period of observation including those on empiric therapy, all patients in which BAL [Bronchoalveolar Lavage] and TBLB [Transbronchial Lung biopsy] was inconclusive and all those patients fit to undergo thoracoscopic surgery. Patients excluded were elderly patients, those with systemic disorders frequently associated with ILD and those with known neoplasm likely to have lymphangitic dissemination. We used three thoracoscopic ports, all biopsies were sent for histopathology examination, single chest tube was placed in all cases and it was removed once the airleak ceased. All complications encountered were noted. Fourteen patients were registered during study period. Biopsy showed that 9 had ILD, and 5 did not have ILD. Only complication was a prolonged airleak for 2 days in 2 patients. No mortality was encountered. Thoracoscopic surgical biopsy can be accomplished safely in most cases where there is a diagnostic dilema for interstitial lung disease

Tracheal schwannoma: a rare tracheal tumour

Primary tracheal tumours are histologically similar but 100 times less common than main stem tumours. We report a case of primary tracheal schwannoma in a middle aged man. He had chronic cough for 2 years, and developed hemoptysis and stridor in the days preceding to presentation. He was treated by resection of the tumour and primary anatomosis of the trachea. The patient recovered well after surgery and had a near normal PEFR after one and a half year of follow-up and bronchoscopic examination excluded any recurrence

Gastropleural fistula: an unusual sequel of blunt chest trauma

In the October 2005 Earthquake in mountainous Azad Kashmir and adjacent areas in Pakistan, a young female sustained crush injury chest and upper abdomen. She remained hospitalized with lower chest pain. All initial investigations were normal and she was discharged symptom-free on conservative management. Six months later, she developed acute left sided chest pain and dyspnoea. Provisional diagnosis of empyema was made on X-ray, and tube thoracostomy was done. Diagnostic VATS revealed gastropleural fistula secondary to necrosis of herniated stomach. Resection of necrosed stomach, repair of diaphragm and decortication and transthoracic repair with lower thoracoplasty two months later was performed but both were unsuccessful. After another 02 months, a Roux-en-Y gastrojejunostomy at fistula site was fashioned which proved curative

Right main bronchial disruption due to blunt trauma

A young soldier was crushed between two vehicles sustaining severe injury to right side of chest leading to multiple rib fractures, tension pneumothorax, bronchopleural fistula, and later on gross surgical emphysema. Rigid bronchoscopy confirmed injury to right upper bronchus. Surgical repair and postoperative care of such a major, although rare, injury was successfully achieved in this small hospital by a team augmented by a specialist from thoracic surgery centre. The risks of transport of a major thoracic injury should be assessed against a possible definitive treatment locally. Fibreoptic or rigid bronchoscopy should be employed as early as possible in all suspected cases of major airways injury. An outreach service by a thoracic surgery centre can be life-saving

Bilateral thoracoscopic sympathectomy

A 34 years male Asian presented from skin department as referral case of bilateral increase in sweating both arms from axilla to palms. He was symptomatic for the last three years and was having different treatment from general OPD and Skin Department in the form of astringent local applications and oral medications. He was clerk by profession and had to use frequent cleaning of sweat during his work that was embaressing and was causing jeopardy to his job. He had no associated clinical features of vasospatic conditions. His base line investigations were normal, additional thyroid function and glucose profile was normal. His chest X-ray was normal with no apparent clinical or radiological evidence of lung parenchymal pathology which would hinder thoracocscopic dissection and approach. He went bilateral thoracoscopic surgical sympathectomy first on right side then on left all procedure was performed in modified decubitans position with patient slightly forward approx 15 degree beyond perpendicular. This allowed the ipsilateral lung to fall away from the posterior located sympathetic chain, first in right position under general anesthesia with double-lumen endotracheal intubation so that the lung on the operative side can be deflated. To enhance exposure of the posterior mediastinum an anterior rotation was given. The pleural space was then inspected using a zero degree 5-mm endoscope fifth intercostals space in midaxillary line. This was supplemented by two 5mm working trocars in third intercoastal space, one anterior and posteriorly. The rib spaces and corresponding segment of the sympathetic chain were then visualized [fig. 1] by an area of bright yellow fat and the overlying parietal pleura incised. Using monopolar cautery the sympathetic ganglia at T2, T3 are isolated and individually excised. Dissection was not carried above the upper border of second rib to preserve 5th stellate ganglion [fig. 2]. Finally the bodies of the second and third ribs are horizontally with cautery from the costovertebral angle laterally for 3 to 4 cm, this divided the accessory fibers. Hemostasis was then obtained and chest tube 28 Fr was passed through the axillary port of the endoscope. The procedure was then repeated on the left side. Lung was fully expanded and underwaterseal was finally checked again. A chest roentgenogram was then obtained postoperatively to confirm adequate expansion of the lungs. The patient was then observed for Homer syndrome. Lung was expanded chest tube was removed very next day with full radiological and clinical expansion. Patient was discharged next days. He had complete recovery of symptoms post operatively

Management of postoperative chylothorax

To evaluate treatment modalities of iatrogenic post operative chylothorax and describe our current approach this study was conducted at CMH/AFIC Rawalpindi from Aug 2001 to Aug 2003. It included the causative evaluation and management modalities. 11 patients were operated for cardiac and thoracic pathology, which resulted in chylothorax. Chylothorax was diagnosed based on clinical appearance and chemical analysis of pleural fluid. Out of 11 patients, 9 had cardiac procedures while 2 had thoracic operations. All Patients had chest intubation. 9 had drainage within 24 hours, 1 at 48 hours, and 1 after 72 hrs. Initial tube thoracostomy drainage was 1000 to 2500 ml/day. S patients responded to conservative tube thoracostomy and TPN. 2 were operated with in 48 hours with ligation of the leaking site. 4 had to undergo the supra-diaphragmatic enmass ligation via right thoracotomy