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

Post-cholecystectomy biliary injuries: diagnosis and management

To evaluate the management strategies following Bile Duct Injuries. Retrospective and prospective analysis from July 2002 to Oct. 2005. Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi. All patients who were admitted with Iatrogenic Biliary injuries. The patients were clarked and their clinical features noted. After appropriate preparations they were treated on the basis of Bismuth Classification. A total of 21 patients presented with Iatrogenic Biliary injuries over a period of three years. There were 15 females and six males with a median age of 40 years. Fourteen patients had laparoscopic cholecystectomy while seven had open cholecystectomy. Six cases belonged to our unit while 15 were referred from other institutes. Sixteen patients presented with biliary leak, out of which two resolved, two had ultrasound guided aspiration and two ERCP stenting done, while 10 underwent peritoneal lavage with drain placement. One patient from lavage group required ERCP stenting while one patient that underwent stenting initially developed stricture and had to undergo Roux-en-Y hepaticojejunostomy. Five patients had biliary stricture at presentation, three were Bismuth Type I, one was Type III and one Type IV. These patients were treated with Roux-en-Y hepaticojejunostomy. Two had to undergo re-exploration, one needed lavage and the other revision hepaticojejunostomy. Three patients expired in the early postoperative period. Strategies need to be developed for dealing with bile duct injuries, with a view to reduce morbidity and mortality as early recognition and timely management improves the outcome of these patients

audit of the management of acute pancreatitis in a general surgical ward

To assess the results of the management of Acute Pancreatitis. Retrospective descriptive study from Jan. 2003 to Dec. 2005. Setting: Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi. 62 patients with the diagnosis of Acute Pancreatitis. The demographic variables, cause and outcome of the cases were observed and recorded. Out of the total 62 patients, 37 had cholelithiasis; other causes were alcoholism, abdominal trauma, worms, instrumentation [ERCP] and drugs. All patients were classified according to APACHE-II scoring system into acute oedematous pancreatitis, severe acute pancreatitis and acute necrotizing pancreatitis. Forty eight patients developed complications including ARDS, anuria, hypotension, paralytic ileus and pseudocyst formation. Four cases died due to multiorgan failure. Current recommended principles in the management of Acute Pancreatitis are based on identification of patients having severe disease and the group at risk for the development of complications. APACHE-II is a helpful scoring system and CT scan is an effective diagnostic tool in difficult cases

experience of total mesorectal excision in surgery for rectal cancer

To evaluate the results following total mesorectal excision in rectal cancers. Place and Duration of Study: Surgical Ward 2, Jinnah Postgraduate Medical Centre [JPMC], Karachi. From January 2003 to December 2005. Fifty consecutive patients with histological diagnosis of rectal cancer were included in this study. In all cases tumor staging was carried out with ultrasound [US] and CT scan. Carcino-embryonic antigen [CEA] level was also done. They underwent surgery in the form of abdomino-perineal resection [APR], low anterior resection, ultra low anterior resection and Hartmans procedure. Total mesorectal excision [TME] was done in 42 patients and their postoperative morbidity and mortality were recorded. Out of 50 patients 6 were irresectable. These patients had evidence of disseminated disease on US and CT scan. Forty two were resectable. Age range was 14-60 years. Thirty patients were between 20-40 years. Male to female ratio was 4:1. Thirty three patients had tumor at anorectal junction, four patients had tumor at 7 cm from anal verge, in five the tumor was not palpable as it was in the mid rectum. APR was carried out in thirty-three patients, low anterior resection in the four, ultra low anterior resection in four, with covering ileostomy in all cases of low and ultra low anterior resection. One patient had Hartmans procedure. In 42 patients curative surgery was done. With limited follow up over a period of two years one patient who had APR developed local recurrence. Total mesorectal excision in rectal cancer surgery is known to give less postoperative morbidity and good local disease control. Appropriate training in total mesorectal excision should be given to surgeons under training in order to achieve standard surgical outcome

variant of Bouveret's syndrome

Bouveret`s syndrome is gastric outlet obstruction caused by impaction of a large gall stone in the duodenal bulb, through a cholecystoduodenal fistula. In this case, which is a variant of Bouveret's syndrome, a 58 years old lady presented with right upper quadrant abdominal pain and vomiting. Investigations, including MRCP, revealed a large stone impacted in the duodenal bulb and another one at the duodenojejunal junction causing dilatation of the stomach and the duodenum. She underwent laparotomy with cholecystectomy, closure of cholecystoduodenal fistula and an enterotomy to remove the stone impacted at the duedenojejunal junction