Light microscopy and molecular identification of Sarcocystis spp. in meat producing animals in Selangor, Malaysia

One thousand and forty-five tissue samples of skeletal muscles, tongue, heart, diaphragm and esophagus were collected from 209 animals (43 sheep, 89 goats and 77 cattle) from an abattoir in Selangor between February and October, 2013. Each sample was divided into three pieces with each piece measuring 2-3 mm3. Each piece was then squeezed between two glass slides and examined microscopically at x 10 magnification for the presence of sarcocystosis. Three positive samples from each animal species were then fixed in 10% formalin for histological processing. Seven positive samples collected from each animal species were preserved at -80°C or 90% ethanol for gene expression studies. Microsarcocysts were detected in 114 (54.5%) animals by light microscopy (LM). The infection rates in sheep, goat and cattle were 86, 61.8 and 28.6% respectively. The highest rate of infection was in the skeletal muscles of sheep (64.9%) and goats (63.6%) and in the heart of cattle (63.6%). The cysts were spindle to oval in shape and two stages were recognized, the peripheral metrocytes and centrally located banana-shaped bradyzoites. 18S rRNA gene expression studies confirmed the isolates from the sheep as S. ovicanis, goats as S. capracanis and cattle as S. bovicanis. This, to the best of our knowledge, is the first molecular identification of an isolate of S. ovicanis and S. capracanis in Malaysia. Further studies with electron microscopy (EM) are required in the future to compare the features of different types of Sarcocysts spp.

Oesophagectomy for carcinoma esophagus- Peshawar experience of 270 cases in 4 years

To audit the results of 270 Oesophagectomies done for Carcinoma Oesophagus over a 4 year period. This observational descriptive study was conducted at Department of Cardiothoracic Surgery, Lady Reading Hospital and Khyber Medical Centre Peshawar from Sep 2002 to Sep 2006. Computerized clinical data of 270 cases of Oesophagectomy for Carcinoma Oesophagus was retrospectively analyzed. All patients had apart from routine investigations, Barium studies, Endoscopy and biopsy, CT Thorax/Upper abdomen with Oral and I/V Contrast and Abdominal ultrasound. Detailed examination of clinical record was made to determine the surgical outcome. Out of 270 cases 189 were Males 81 were Females with a mean age of 51.6 years. The age range was 17-80 years. In out of two hundred and seventy cases one hundred and sixty two [162/270] [60%] cases had lower one third tumors, one hundred and five [105/ 270] [38.88%] cases had middle one third tumors while three [3/270] [1.11%] tumors were just below the thoracic inlet. Of the one hundred and sixty two lower one third tumors stomach involvement was present in eighty one [81/162] [30%] cases. Adenocarcinoma was present in one hundred and seventeen [117/270] [43.33%] cases, Squamous cell carcinoma was present in one hundred and forty four [144/270] [53.33%], Adenosquamous was six [6/270] [2.22%], Carcinoma in situ was two [2/270] [0.74%] and Leiomyoma was one [1/270] [0.370%]. Morbidity was 28/270 [10.370%] and comprised anastomotic leaks 09, aspiration pneumonia 06, wound infection 03, hoarseness 03, and strictures 03,. Thirty day mortality was 14/270 [5.185%] and included aspiration pneumonia-respiratory failure 02, myocardial infarction 03, anastomotic leak 03, tracheal injury 02 and presumed pulmonary embolism 04. Two hundred and seventy cases in four years is a very high volume of Oesophageal work load for malignancy. Our morbidity of 10.370% and mortality of 5.18% shows that such major operations can be done safely in thoracic centers

Determinants of success of decortication

Background: To find out different factors which lead to failed decortication and to evaluate their management and outcome

Study Design: Retrospective observational descriptive study

Place of Study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 2003 to Sep 2006

Materials and Methods: Clinical record of 300 patients who underwent decortication tor chronic empyema during the last 3.9 years was retrospectively analyzed and their results evaluated. Detailed scrutiny of the computerized clinical record was carried out to analyze the aetiology of failure of the operation. The variables studied were persistent broncho- pleural fistula, poor postoperative efforts by the patients, wound infection, old chest drain site infection, technical failure and nutritional state of the patient

Results: Of the 300 deoortications performed over the period of 3.9 years, 260 patients had a successful outcome in terms of lung expansion and improved pulmonary functions. In thirty patients [19 males, 11 females with age range of 12 to 70 years] decortications failed to achieve the desired results. These patients had to undergo space obliteration procedures for persistent infected space. Twenty three patients had history of tuberculosis and seven patients had nontuberculous empyema. All patients had chronic empyema with duration of more then 12 weeks before the first operation. All patients were nutritionally compromised. Thoracoplasty [compete or partial] was performed in 25 patients to obliterate the persistent infected space. Five patients with recurrent broncho-pleural fistula had an additional procedure of intercostal muscle reinforcement over the fistulae, in addition to thoracoplasty. All patients had successful obliteration of the persistent space with no mortality and minor wound infection in only three patients

Conclusion: Early referral, old drain site infection control, meticulous closure of broncho pleural fistula and space obliteration procedure in combination primarily instead of secondarily, lead to a successful outcome

Use of continuous low pressure suction on chest drain in thoracic surgical unit

To assess the merits and demerits of continuous Low Pressure Suction applied to the chest drain in both preoperative and postoperative thoracic patients. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, ady Reading Hospital Peshawar from Jan 2005 to March 2005. It was a prospective study carried out over the period of three months to assess the benefits of Low Pressure Suction. Patients with Chest trauma, inflammatory disease of the lung and pleura, carcinomas and postoperative patients were included in the study. Patients with multiple trauma and moribund patients were excluded from the study. Postoperative patients were given priority for suction beds. The suction applied to the chest drain ranged from -05 to -20 KPa. It was continuously applied to the chest drain 24hrs a day and 7 days a week and only interrupted at the time of bottle change or patients going to toilets. A total of 180 patients were included in the study, which were divided into two groups depending upon the availability of suction beds. Group I: Included those patients who were put on Continuous Low Pressure Suction. Group II: Included those patients who were not put on Continuous Low Pressure Suction because lack of suction beds. Ninety patients were included in group I and similar number of patients into group II. In group I out of 90 patients 40 were non-operative and 50 were operative. In group II out of 90 patients 55 were non-operative while 35 were operative. Out of operated patients [total 85] full lung expansion was achieved in 42 [84%] in group I and 25 [71.4%] in group II while partial lung expansion was achieved in 08 [16%] in group I and 10 [28.6%] patients in group II. Out of non-operated patients [total 95] full expansion was achieved in 35 [87.5%] in group I and 42 [76.4%] in group II while partial expansion was achieved in 05 [12.5%] patients in group I and 13 [23.6%] in group II. Out of 5 partial expansions in group I suction had to be discontinued in 2 patients because of increasing air leak. Continuous low pressure suction helps to decrease the need for surgery in patients following chest trauma, inflammatory lung disease and decreases morbidity in postoperative patients

Two years audit of thoracic surgery department at Peshawar

The aim of the study was to audit all admissions for significant adverse events as well as to assess academic and research activities of our department during last two years. Design: A descriptive audit comprising of surgical, academic and research aspects. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from June 2002 to June 2004. Materials and Data comprising of patients demographics, number and type of various surgical procedures, hospital stay, various complications and number of deaths that occurred were entered into database. A computerized record of all academic and research projects was kept. Data base analysis was carried out for determining morbidity and mortality. Analysis of surgical audit showed 2160 procedures. Tube thoracostomy was required in 1030 patients while elective procedures were 1130. Elective thoracic procedures were 969 [85.5%] while elective cardiac procedures were 161 [14.2%]. Various procedures performed included, decortication 103 [9.1%], esophagectomy 73 [6.46%], Hydatid cystectomy 38 [3.36%], closed mitral volvotomy 51 [4.5%], PDA ligation 46 [4.07%], pericardectomy 17 [1.5%], lobectomy 59[5.22%], pneumonectomy 11 [0.97%], thoracoplasty 21 [1.85%], while other thoracic and cardiac procedures were 13.3% and 5.6% respectively. Overall mortality was 3% while morbidity was 3.4%. During this period our department had 17 publications; presented 22 papers in various conferences; has produced three fellows in thoracic surgery, one fellow in general surgery and conducted "First National Thoracic Surgery Course". One assistant professor and one senior registrar have been appointed during these two years. Highest priority should be accorded to surgical audit to determine various risk factors for mortality and morbidity and ultimately to improve patient care. Moreover, all academic and research projects should be completed through mutual efforts of all teaching staff to achieve desired standards of teaching and learning. Accountability of the medical profession can only be achieved through surgical audit. It is high time that this becomes a part of our ward routine and teaching programmes

Early surgery for pulmonary tuberculosis

The purpose of our study was to analyze current indications for surgery in tuberculosis and evaluate the outcome of early surgical intervention. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from June 2000 to July 2004. Total number of cases was 132; M: F 105: 27. Age range was 20 to 79 years. Mean age was 48.4 years. The indications for surgical intervention included 5 cases of pulmonary aspergillioma, 9 cases of pneumothorax; 3 cases of pulmonary nodes and masses without histological diagnosis, 15 cases bronchiectasis, 12 cases of massive hemoptysis and 82 cases of pleural empyema while six patients with multi drug-resistant tuberculosis required surgical intervention. The techniques utilized included lobectomy in 45 cases, pleural drainage in 20 cases, segmented pulmonary resection in 32 cases, surgical procedures on the chest wall in 17 cases, pneumonectomy in 10 cases, decortication in 8 cases. In 22 cases two or more procedures were performed on the same patient. In 26[19.6%] cases various complications were noted of which wound infection was the most frequent. There was a mortality rate of 3.3% [4 cases]. Surgical treatment is indicated for the complication of TB and management of MDR TB. Early surgery is beneficial in patients whose disease is still localized and who can tolerate resection surgery; of particular importance is a healthy opposite lung, on which the patient would be dependent during and immediately after surgery

Diaphragmatic injuries, a retospective analysis of 50 patients

This study seeks to define the clinical presentation, the usefulness of diagnostic tests, surgical management approach and outcome of treatment of diaphragmatic injuries in our trauma patients. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from March 2001 to April 2005. In this retrospective study, 50 patients admitted to our department with diaphragmatic injury were evaluated according to the type of injury, diagnostic methods, associated organ injury, treatment, modality, morbidity and mortality. The average age of patients was 32 years. There were 35 [70%] male and 15 [30%0 female patients, 38 [76%] of these patients sustained blunt and 12 [24%] had penetrating chest injury. The diaphragmatic injury was right sided in 4 and left sided in 46 patients. Thirty nine [78%] patients presented in respiratory distress within 48 hours of in jury while 11 [22%] presented with bowel obstructive symptoms months and years after injury. A chest x-ray on admission suggested the diagnosis in 70% of the cases while chest ultrasonography and contrast studies were required in others. Surgery was emergent in 35 [70%], semi-emergent in 9 [18%] and effective in 6 [12%] cases. Surgical approaches were left thoracotomy [40 patients], left thoracolaprotomy [6 patients] and right thoracotomy [4 patients]. The diaphragmatic repair was achieved by direct suture in 45 cases while prolene Mesh was required in 5 cases. The mortality rate was 6% [n = 3]. Recurrence occurred in one [2%], wound infection in 3 [6%], pleural, space, problem in 1 and chest infection in 2 [4%] patients. A high index of suspicion and early surgical treatment determine the successful management of traumatic diaphragmatic injury with or without the herniation of abdominal organs. The surgical approach is individualized. We prefer the thoracic approach adding laporotomy when necess ary