Complex fistula-in-ano: surgical management and outcome

Objective: To assess the outcome of the surgical management of patients with complex fistula-in-ano

Study design: Case series

Place and Duration of study: Department of General surgery Jinnah Postgraduate Medical Center Ward 2 Karachi, from January 2009 to December 2012

Methodology: An analysis of patients with complex fistula-in-ano treated with different operative techniques Resultswas done. The techniques included two stage seton fistulotomy, three stage seton fistulotomy, fistulectomy with sphincter repair, drainage of supralevator abscess and colostomy. Patients were followed-up through colorectal OPD with special emphasis on postoperative bleeding, healing, recurrence and fecal incontinence

Results: Out of total 123 patients with different types of anal fistulae there were 58 [47.1%] complex and 65 [52.8%] low anal fistulae. There were 105 [85.3%] males and 18 [14.6%] females. Out of 58 complex fistulae, 28 [48.2%] patients had inter-sphincteric, 12 [20.6%] transsphincteric, 10 [17.2%] suprasphincteric, 06 [10.3%] extrasphincteric and 02 [3.4%] horseshoe fistulae. Forty-one [70.6%] patients were treated with two-stage seton fistulotomy technique, 5 [8.6%] with three stage seton fistulotomy, 11 [18.9%] with fistulectomy with sphincter repair, and in 01 [1.7%] patient colostomy was made. Overall complication rate in two stage seton fistulotmy was 9.7% and 18.1% in fistulectomy with sphincter repair

Conclusion: Complex fistulae may be successfully treated by various techniques, but the two-stage seton fistulotomy technique was an effective method for this type of fistula

Anterior decompression and fixation with webb-morley procedure in dorsolumbar spinal injury

To evaluate the neurological outcome of anterior decompression and fixation with Webb-Morley procedure in dorsolumbar spinal injuries. A case series study. The Neurosurgery Department, Jinnah Postgraduate Medical Centre, Karachi, from May 2008 to July 2010. Patients with post-traumatic unstable dorsolumbar spine having compression of the spinal cord with bony fragments of the fractured vertebra were included in the study. Patients below the age of 15 years and patients with bed sores and unfit for anaesthesia were excluded. Plain X-rays and magnetic resonance imaging [MRI] were done. All patients were treated for dorsolumbar fractures by anterior decompression and fixation with Webb-Morley procedure. All patients were assessed clinically by the Frankel's grading before and after surgery. Among 60 patients, 41 were males and 19 were females. Mean age was 37.2 +/- 4 years. Major cause of trauma was road traffic accident. The commonest level of the fracture was at the dorsolumbar junction i.e. 71.66% [n = 43]. About 19 [31.66%] patients improved to the Frankel's grade-E, while 41.66% [n = 25] improved to grade-D after surgery. There was no postoperative mortality. According to the current study, anterior decompression and fixation with Webb-Morley procedure is an effective and safe approach. Those patients who had complete motor deficit showed no improvement in power but those who had partial motor deficit, had excellent improvement

Outcome of cloward technique in cervical disc prolapse

To determine the association of pre-operative assessment of MRI findings, neurological status and symptoms with postoperative Cloward surgical outcome in cervical disc prolapse. Descriptive study. The Neurosurgery Department of Jinnah Postgraduate Medical Centre [JPMC], Karachi, from May 2008 to May 2009. Patients presenting with neck pain, brachialgia, limb weakness and spasticity were clinically examined for pre-operative neurological status of power, reflexes and sensation. The exclusion criteria were, cervical disc prolapsed patients, planned for smith-Robinson and micro-discectomy, traumatic cervical disc prolapse and cervical spondylosis. Neuroradiological investigations included cervical spine X-rays and MRI. All patients were surgically treated for cervical prolapsed intervertebral disc with anterior cervical discectomy and interbody fusion with Cloward technique. Postoperative neck immobilization was done with cervical collar for 7-8 weeks. Drain was removed on first postoperative day while check plain cervical X-rays were taken on third day. Results were analysed using chi-squre test with significance at p < 0.05. There were 30 patients including, 27 [90%] males and 03 [10%] females with mean age of 44.3 years. The commonest symptom was neck pain. The duration of symptoms ranges from 2 to 6 months. On MRI, prevalent levels of cervical disc prolapse were C 5-6 [43.3%] and C 6-7 [23.3%]; 26 [86.6%] patients had disc herniation causing thecal effacement with cord compression and 04 [13.3%] patients showed ischemia of cord. Single-level Cloward surgery done in 26 [86.3%] patients while two-level Cloward surgery performed in 04 [13.3%] only. About 83.3% patients improved and 13.3% did not while 01 patient was re-operated. No complications and mortality was related to the surgical procedure. Statistically different variables identified, related to outcome were pre-operative neurological status [p=0.001] and spinal cord involvement on MRI [p=0.001]. Cloward technique for cervical disc prolase was simple and safe surgical procedure with favourable results and few complications; 100% fusion occurred after Cloward surgery, even without instrumentation. Outcome was significantly affected by pre-operative neurological status and cord involvement