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.

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

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