Xanthogranulomatous cholecystitis [XGC] - A diagnostic dilemma

INTRODUCTION: Xanthogranulomatous cholecystitis [XGC] is an unusual form of chronic cholecystitis characterised by marked thickening of the gallbladder wall and accumulation of lipid laden macrophages. It is frequently misdiagnosed preoperatively with gallbladder carcinoma. The aim of this study was to assess the preoperative clinical and radiological characteristics, operative findings and histological features of patients with XGC based on the experience of a single institution. In addition a literature search was performed to identify previously reported cases

PATIENTS AND METHODS: This retrospective study was conducted from January 2009 to December 2014. 1,989 consecutive patients who underwent elective cholecystectomy at the Surgical Unit-I, Liaquat University Hospital, Jamshoro, Pakistan were included in this study. Seventeen patients were identified to have XGC on histopathology

RESULTS: Seventeen [0.8%] cases of XGC were identified in 1,989 cholecystectomy specimens performed. The female to male ratio was 7.5:1. The average age in our series was 51.6 [range from 18 to 77 years]. Two [11.7%] cases, suspected of malignancy during preoperative work-up, were reported as XGC on histopathology

CONCLUSION: Preoperative differentiation between XGC and carcinoma of the gallbladder remains challenging due to similarities in clinical presentation, radiological and operative findings

In view of this there should be a low threshold for conversion from a laparoscopic to an open procedure

Therapeutic ERCP in patient with situs inversus totalis and ampullary diverticulum

Situs Inversus Totalis [SIT] is a rare entity with complete transposition of all viscera, making endoscopic and surgical procedures challenging and complicated. We describe a rare case of a 55 years old man with SIT and ampullary diverticulum presenting with cholangitis and deranged liver function tests due to common bile duct stones. Therapeutic Endoscopic Retrograde Cholangiopancreatography [ERCP] was planned to relieve biliary obstruction and removal of stones. Procedure was started after informed consent in usual left semi-prone position but rotation of scope to 180 degrees and shortening under fluoroscopic guidance was done to attain and maintain desirable ampullary position and cannulation was done with standard sphincterotome followed by sphincterotomy and sphincteroplasty. ERCP was performed successfully despite difficulties of dual pathology and the patient made uneventful recovery

Single dose versus 24 - hours antibiotic prophylaxis against surgical site infections

OBJECTIVE: To observe the effect of single dose antibiotic is it as efficient as a 24-hour regimen in preventing SSIs in adults undergoing clean, clean contaminated and contaminated elective surgical procedures

STUDY DESIGN: Random, prospective SETTING AND DURATION: Department of general Surgery, Liaquat University Hospital, Jamshoro, Pakistan from May 2011 to April 2012

PATIENTS AND METHODS: A total of 208 patients undergoing general surgical operations were included in the study. The patients were randomly divided into two groups

The single-dose group received 2 grams of ceftriaxone intravenously, whereas the 24-hour group received 2 grams of ceftriaxone intravenously at the time of induction of anaesthesia, followed by 1 g at 8 and 16 hours postoperatively

RESULTS: The administration of ceftriaxone in a single dose regimen was associated with higher rate of SSIs compared with rates for patients receiving the 24-hour regimen [9.6% vs. 6.7%]

CONCLUSION: Multiple doses of prophylactic antibiotics over 24 hours should be used instead of single doses in surgical prophylaxis in clean-contaminated and contaminated procedures

Prevalence of helicobacter pylori infection in patients with perforated peptic ulcer

Objectives: to determine the prevalence of Helicobacter pylori infection in patients with perforated peptic ulcer

Patients and methods: this prospective study was conducted in the Department of Surgery, [Surgical Unit-II], Liquate University of Medical and Health Sciences, Jamshoro. All patients were evaluated by full history, clinical examination and relevant laboratory investigations including. X-ray chest and abdomen, ultrasound abdomen, serum anti H-Pylori, biopsy and histopathology for detection of helicobacter pylori infection and perforation. The data was collected through pre-designed proforma and analyzed by SPSS version 10.00

Results: during study period 75 patients were diagnosed as case of perforated peptic ulcer. Male [73%] outnumber female [27%]. Majority of patients were more than 30 years of age with mean age of 44.6 years SD +/- 9.89. The serological test for helicobacter pylori was positive in all 75 cases; however histopathology of biopsy yields H. pylori in 50 [66.6%] cases. On exploratory laparotomy perforated duodenal ulcer was found in 50 [67%] patients while 25[33%] patients had perforated gastric ulcer

Conclusion: the biopsy proven prevalence of perforated peptic ulcer, one of the life threatening complications of H. Pylori, was is 67% in this study

Diagnostic accuracy of Alvarado scoring system in acute appendicitis

Objective: Acute appendicitis is one of the commonest surgical emergency. There are different scoring systems in use to diagnose the appendicitis. Aim of this study was to document the diagnostic accuracy by application of Alvarado Scoring System in clinical practice for acute appendicitis. Design: Descriptive case series. Setting: Surgical Unit-II, Liaquat University Hospital Hyderabad, Sindh - Pakistan; from January 2003 to September 2004

Methods: All the patients with suspected appendicitis were admitted in the ward. A profroma was designed and relevant findings were documented. These were observed regarding the increase or decrease in severity of symptoms and hence the change in the initial score according to Alvarado Scoring System was documented at the time of admission. Decision regarding surgical intervention was made on the basis of change in the score

Results: A total of 227 patients with clinical features suggesting acute appendicitis was admitted in the ward. Among them, 150 [66.07%] were males and 77 [33.92%] were females. Age ranged from 10-62 years. Main symptoms at presentation included pain in right iliac fossa 67.8%, fever 66.9% and nausea and vomiting 49.7%. Thirty two patients were received with Alvarado Score of 1-4 and three out of them required surgery. Thirty five patients were in the score of 5, twenty three out of them required surgery. One hundred sixty patients were in the score of 6 and above, all of them required surgery. Out of 185 patients who underwent surgery, 178 patients had appendicitis. The negative appendicectomy rate was 3.78%

Conclusion: It is concluded that according to Alvarado the patients with score up to 4 probably do not require surgery and among the patients with score up to 5, most of them need surgery while the patients with the score of 6 and above will require surgery

Management of acute organophosphorus insecticide poisoning: an experience at a university hospital

Objective: To document the management and subsequent outcome of patients with organophosphorus [OP] poisoning in intensive care unit of a university hospital. Design: Descriptive, retrospective study. Setting: Intensive Care Unit of Liaquat University Hospital Hyderabad, Sindh - Pakistan, from May 2004 to October 2006

Methods: Medical records of patients of OP poisoning admitted to intensive care unit of our hospital from May 2004 to October 2006 were reviewed. Diagnosis was confirmed from the history and clinical findings. Management, complications and subsequent outcome were noted

Results: Total 111 patients of OP poisoning were admitted in the ICU during the study period. Majority of patients i.e. 67[60.4%] were males and 44 [39.6%] were females. Mean age was 25.26+/-8.52 years with 85.6% within the age limit of 12-30 years. Majority of patients [89.2%] had suicidal attempt. In 94.6% patients, ingestion was the route of exposure. Mean ICU stay was 2.3+/-3.2 days while 20[18%] patients needed mechanical ventilatory support. Overall mortality rate was 9%

Outcome of ileostomy in the management of ileal perforation

Objective: To evaluate the role of a defunctioning ileostomy in the prevention of morbidity and mortality in patients with small bowel perforation. Design: A prospective randomized study. Place and Duration of Study: Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro / Hyderabad between October 2005 and September 2006

Subjects and Methods: Total 108 patients who underwent laparotomy for ileal perforation were included

Results: There were 67 males and 41 females. The age of patients ranged from 15 to 72 years with 80% of the patients being in age group of 17-70 years. Typhoid was the commonest cause for ileal perforation which was seen in 69 [63.8%] patients, followed by intestinal tuberculosis which was present in 23 [21.3%] patients. Out of a total of 108 patients, a proximal defunctioning ileostomy was constructed to protect the primary repair or the intestinal anastomosis in 57 patients [group I]. In the remaining 51 patients, primary repair or intestinal anastomosis was done without a defunctioning ileostomy [group II]. Two [3.5%] patients in group I and 7 [13.7%] patients in group II died postoperatively. Six of the 51 patients in group II who underwent primary closure of perforation or resection and end-to-end anastomosis without a defunctioning ileostomy developed postoperative faecal fistula. None of the patients with defunctioning ileostomy developed this complication

Conclusion: We conclude that construction of a temporary ileostomy to provide defunctioning for repair of ileostomy perforations reduce the incidence of fatal complications like faecal fistula. Ileostomy, however, is associated with a number of ileostomy-specific complications. We recommend that defunctioning ileostomy should be preferred over all other surgical options in cases of ileal perforations

Selective nasogastric decompression after elective laparotomy

Objective: This study was conducted to evaluate the need or other wise for use of nasogastric decompression after elective laparotomy, as many studies suggest that routine nasogastric decompression is unnecessary after elective laparotomy and may in fact be associated with an increased incidence of complications. Despite these reports the nasogastric tube is routinely used for decompression, believing that its use significantly decreases the risk of post-operative nausea, vomiting, aspiration pneumonia, wound dehiscence and anastomotic leakage. Design: Descriptive case-series. Place and Duration of Study: Surgical Unit-II, Liaquat University Hospital Jamshoro from July 2005 to July 2007

Patients and Methods: Seventy patients were included in this study. A proforma was designed and all the findings were recorded. All the patients were observed regarding the development of complications like, post-operative nausea, vomiting, pulmonary complications, abdominal distention and return of bowel sounds

Results: Out of 70 studied cases 45 [64.2%] were males and 25 [35.7%] were females. Age ranged from 10 years to 70 years and mean age was 33 years. Postoperative pulmonary complications like atelectasis and pneumonia were seen in 3 [4.2%] out of 70 patients. The commonest operation performed was reversal of ileostomy and resection with end-to-end anastomosis. Postoperative nausea and vomiting were seen in 10 [14.2%] cases

Conclusion: The study did not support the routine use of nasogastric decompression

Caudal epidural for postoperative analgesia in male children

Objective: To assess the duration and safety of single dose caudal epidural with bupivacaine for postoperative analgesia in children

Design: A descriptive study

Setting: Chandka Medical College Hospital, Larkana from February 2002 to September 2004

Patients and Methods: One hundred and seventy six boys, ASA-I, between the ages of 2 to 8 years, scheduled for inguinal or penile surgery, were randomly assigned in a prospective fashion to receive single shot caudal epidural with bupivacaine 0.25%, 0.75ml.kg-1, and studied for postoperative pain relief. Pain was evaluated by using faces pain scale. Analgesia was administered when pain scale was 3-4. Postoperative complications were also noted

Results: Mean duration of analgesia was 10.43 +/- 3.4 hours. Time for micturation was 161.79 +/- 83.2 minutes while time to stand was 161.21 +/- 69.65 minutes. Haemodynamic and respiratory parameters remained stable during the observation period. Frequency of postoperative nausea and vomiting was 7% while urinary retention occurred in 1.4% patients

Conclusion: Caudal epidural analgesia with bupivacaine 0.25% in a dose of 0.75ml.kg-1 provides safe and effective postoperative pain relief in children undergoing inguinal and penile surgery, with very few complications