Identification and preservation of the external laryngeal nerve during thyroid surgery: surgical and anatomic considerations

Iatrogenic injuries of external branch of superior laryngeal nerve [EBSLN] during thyroid surgery are not uncommon due to the possibility of anatomic variations in the relationship of this nerve with superior thyroid vessels and the result may be devastating to those patients who rely on their voices professionally. The study included 2 groups. Group A was a prospective nonrandomized analytical series of all consecutive patients undergoing thyroidectomies for various conditions in Surgical Unit II, Shaikh Zayed Postgraduate Medical Complex, Lahore, Pakistan during a three years period [November 2004 - November 2007]. This group consisted of 133 patients. Male to female ratio was 1:3. Mean age was 35.22 years [range: 17-71 years]. Ninety one [68.42%] patients had bilateral dissection [total, sub-total or neartotal thyroidectomies] and 42 [31.57%] had unilateral dissection [hemithyroidectomy I lobectomy and isthumusectomy]. Thus, a total of 224 superior polar dissections were carried out. Three [3 .296 %] patients out of the 91 patients in the bilateral dissection group had asymmetrical nerves. Eighty one [60.9%] patients had benign disease, 32 [24.06%] had malignancy and 20 [15.03%] had toxic goiter. Nerve could not be identified in 42 [18.75%] polar dissections [positive identification in 182 [81.25%] polar dissections]. Three [2.25 %] patients in this study had clearly documented EBSLN injury as determined by voice changes, patient interview and IDL. In Group B, the anterior neck triangles of 19 embalmed human cadavers [i.e. 38 neck half preparations] of both sexes and variable ages with neither enlarged thyroid glands nor any other signs of abnormality in this region were dissected in the dissection halls of two medical colleges in Lahore. The course and topographical relations [especially in relation to the superior thyroid vessels, superior pole of the thyroid and the cricothyroid muscle] of the EBSLN as well as bilateral asymmetry were noted as for Group A. Nerves were classified according to classification of Cernea et al. Good knowledge of the anatomy and relations of the EBSLN with meticulous dissection and ske letonisation and individual ligation of the superior polar vessels is the key to success

Critical factors effecting morbidity and mortality in patients operated for typhoid ileal perforation

Typhoid perforation is the most important surgical complication of typhoid enteritis and is associated with a significant morbidity and mortality. To determine the factors affecting morbidity and mortality in patients with typhoid intestinal perforation, the complete medical records of a pool of patients from two major teaching hospitals of Lahore were reviewed. A total of 39 patients diagnosed to have typhoid Heal perforation at operation included 27 patients operated in the emergency of South Surgical Ward. Mayo Hospital Lahore from January 1998 to Dec 2000, and 12 consecutive patients operated by the surgical team of Surgical Unit II. Shaikh Zayed Medical Complex. Lahore between December 2000 to May 2005. The average age was 26 years, the male-to-female ratio 4/1. The mean interval from admission to operation was 09 hours [range 05 hours - 03 days]. Eight patients had more than one perforation at the time of operation. Primary repair of the perforation was performed in 22% of the patients, ileostomy [primary repair and proximal loop ileostomy or exteriorization of perforation as a loop ileostomy] in 46%. and resection with end ileostomy and mucous fistula in 32%. No primary end-to-end anastomosis after resection was performed. Postoperative complications occurred more commonly in patients with delayed admission and/or severe peritonitis. Hospitalization was shorter and the postoperative complication rate lower in patients who underwent ileostomy. Three patients developed an enter cutaneous fistula requiring re-operation. The four deaths [10.25% mortality] resulted from overwhelming sepsis. The most significant factors affecting morbidity were prolongation of perforation-operation interval and severe peritonitis. No single operative procedure is best in all cases: therapy should be individualized and tailor made for every patient. Ileostomy appears to be an effective and safe procedure, particularly in patients with severe abdominal contamination and delayed presentation. Early diagnosis, aggressive resuscitates tion with fluid and electrolyte optimization and prompt operation may result in improved survival in these seriously ill patients

Delorme procedure for complete Rectal Prolapse in young adults - an analysis of 7 cases

The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures. Delorme operation is a suitable procedure for elderly and/or medically unfit patients with rectal prolapse. However, good results have also been demonstrated for younger patients, suggesting that the operation may have wider application. From January 2001 to September 2003, 07 young adult patients underwent the Delorme repair of rectal prolapse in our unit with good results. The main outcomes measured were method of anesthesia, morbidity, mortality, recurrence rates, length of follow-up, and incontinence. In the 07 patients, the mean age of the patients was 24 years. The mean operating time was 55 minutes. Four patients were administered general anesthesia and 03 were administered spinal anesthesia. The mean postoperative stay was 05 days. No patients died as a result of th e procedure. Patients were followed up for 3 - 33 months. Preoperative incontinence was present in 02 patients, both of whom improved after the procedure. Postoperative incontinence was seen in only one of these patients but that too seemed to improve with time. No recurrent postoperative prolapse has yet been seen. None of the patients had complications that required operative intervention in the postoperative period. Although, the best operation for rectal prolapse remains a controversial subject, we believe that the Delorme Operation offers a promising option for the treatment of rectal prolapse even in young adults

Natural environmental radioactivity and estimation of radiation exposure from saline soils

The study was conducted for the investigation of amount of radioactivity in the barren and cultivated soil of Bio saline Research Station in Pakka Anna, established by Nuclear Institute for Agriculture and Biology [NIAB] in 1990, 34 km. away from the city of Faisalabad, in the Punjab province of Pakistan. The studies were done on an area of about 100 hectares of two types of virgin and fertilized saline soils. The technique of gamma ray spectrometry was applied using HPGe [high purity germanium] gamma ray detector and a PC based MCA. Activity concentration levels due to 40K, 137Cs, 226Ra and 232Th were measured in 250 saline soil samples collected at a spacing of about 4 hectares at the depth level of 0-25 cm. with a step of 5 cm. depth. Activity concentrations ranges of the concerned radionuclides for both of the soils were as follows: 40K, for virgin and cultivated saline soil was 500-610.2 and Bqkg -1 560.2-635.6 respectively; 137Cs, 3.57-3.63 and 1.98-5.15 Bqkg -1 238U, 26.3-31.6 and 30.3-38.7 Bq.kg -1, and 232Th, 50.6-55.3 and 50.6-64.0 Bqkg -1 respectively. The absorbed dose rate in air lies in the region 63--73 nGyh -1 and 68--83 nGyh -1 for virgin and fertilized soils respectively. This indicates that this region lies in the area of higher radiation background, while comparing with the worlds' average. The slightly higher value of dose in the fertilized farm may be due to the use of fertilizers for cultivation. Before the radiometric measurements, chemical analysis for concentration of Na, Ca and Mg was also carried out along with the measurement of electrical conductivity and pH of the soil samples

Proximal leinorenal shut: an effective treatment of bleeding esophageal varices

This is a prospective study of 23 patients of portal hypertension who were managed by proximal leinorenal shunt. Out of 23 patients, 14 patients were in Child's B, 6 patients were in Child's A and only 4 patients were categorized as Child's C. Only two patients had non cirrhotic portal hypertension and rest of them were post-infective cirrhotic, one being alcoholic. All cirrhotic patients were HBsAg positive and 3 were hepatitis C positive. Fourteen had associated hypersplenism. All patients were managed by proximal leinorenal shunts. Ten patients had emergency surgery and 13 had elective shunts. Mean operative time was five hours and average peroperative blood loss was 1500 ml. Average post- operative hospital stay was 18 days. Maximum follow-up of two years is available. Re-bleeding rate was 17.3%. Post shunt encephalopathy developed in 8.14% patients. One mortality was due to overwhelming sepsis, ten days after surgery and he was in Child's grade B. Remaining three deaths were among Child's grade C. We believe that proximal leinorenal shunt is a good alternative to distal splenorenal shunt. This shunt while preserving the liver perfusion affords adequate decompression