Pancreaticjejunostomy or pancreaticogastrostomy to prevent pancreatic fistula formation after pancreaticoduodenectomy

Objective: To compare the results of pancreaticogastrostomy [PJ] with pancreaticojejunostomy [PG] in preventing fistula formation after pancreaticoduonectomy [PD]

Study design: Quasi-experimental study

Place and Duration of Study: The study was carried out in Military and Combined Military Hospital Rawalpindi from August 2008 to March 2015

Material and methods: Patients of both gender aged 45-70 years with confirmed or suspected neoplasms of head of pancreas, periampullary or duodenal tumours were included. After pancreatico duodenectomy the pancreatic reconstruction was carried out either by pancreatico jejunostomy [duct to mucosa type, dunken in type] or double layer pancreatico gastrostmy.The fistula rate was recorded after both the procedures using the definition of International Study Group on Pancreatic Fistula

Results: During this study period, 30 patients underwent pancreaticoduodenectomy. In 21 [71.4%] patients pancreaticojejunostomy was done, [18 duct to mucosa type and three dunken type anastomosis] and in 9 [28.5%] patients pancreaticogastrostomy was carried out. Five [20%] patients [3 in duct to mucosa type and two in dunken type] in the pancreaticojejunostomy group developed pancreatic fistula [grade A=2, grade B=2 and grade C=1] and one patient [11.1%] in the pancreaticogastrostomy group developed postoperative pancreatic fistula [OR= 9.9, 95% CI: 1.06-92.7 p= 0.044]

Conclusion: In patients undergoing PD for pancreatic head, periampullary or duodenal tumours, PG is more effective than PJ in reducing the frequency of post-operative pancreatic fistula

Impact of low versus high vaccum suction drainage on duration of hospital stay after modified radical mastectomy

To determine the efficacy of low pressure vs high vacuum suction drains after modified radical mastectomy in terms of earlier removal and its impact on duration of hospital stay. A randomized clinical trial. The study was conducted at Military Hospital Rawalpindi and CMH Peshawar over a period of 12 months from March 2010 to March 2011. Sixty trucut/biopsy proven, early invasive breast cancer patients undergoing modified radical mastectomy were randomized into groups A [n=30] and B [n=30] to receive high vacuum [400 mm Hg] suction drains or low vacuum suction drains [200 mm Hg] at completion of operation. Drains were recharged to the specified pressure daily and drain output was recorded. Drains were removed when the daily drainage reduced to 30 ml. 28 patients in group A and 27 patients in group B were finally included in the study. Mean hospital stay in low vacuum suction group was 4.96 +/- 0.898 days which was 32.9% shorter than 7.39 +/- 1.397 days for high pressure suction group [p< 0.005]. The use of low vacuum vs high vacuum drains after modified radical mastectomy reduces the hospital stay significantly

Laparoscopic cholecystectomy: a clinical practice audit

To evaluate laparoscopic cholecystectomy by a clinical practice audit at Military Hospital, Rawalpindi. Prospective study. Surgical department Military Hospital from Jul 2011-Dec 2013. A total of 1020 patients who underwent laparoscopic cholecystectomy for acute or chronic cholecystitis and gallstone panereatitis were included in our study while those who had previously undergone abdominal surgeries, those with high risk for general anesthesia, immunocompromised patients, with age greater than 70 years and having comorbidities like cardiac insufficiency, severe asthma, chronic liver disease with ascites and compromised renal functions were excluded from the study. Patients' demographic data, operative time, intra-operative findings, intra-operative difficulties, post-operative complications, conversion rate to open cholecystectomy and post-operative recovery time were recorded. Data was analyzed by using SPSS version 21. Out of 1020 patients 907 were females while 113 were males with male to female ratio of 1:8.02. Age range was 20-70 with mean age of 50 k 10.456 years, 447% patients presented with the clinical features of acute cholecystitis, 540 [52.94%] with chronic cholecystitis and 23 [2.28%] with acute panaeatitis. Mean 1 operative time was 20 minutes in asymptomatic patients, while 40 minutes in acute cholecystitis and 35 minutes in chronic gallstone disease. Gall bladder perforation, bleeding from cystic artery and bile spillage were mostly encountered per-operative difficulties. Only 37 [3.6%] patients were converted to open cholecystectomy. Post-operative complications occur in only 122 [12%] patients. 938 [92%] patients were discharged within 48 hours. of surgery. Laparoscopic cholecystectomy in our setup has comparable results to the data available from other surgical facilities around the world and it has become a gold standard technique for the treatment of non-complicated gallstone disease

Left sided amyand's hernia

The finding of an appendix in the hernial sac is a rare entity known as Amyand's hernia. It is even more rare when it occurs on the left side. We report a rare presentation of Amyand's hernia, where the appendix was found inflamed during surgery for a left sided obstructed inguinal hernia in a 40 years old male. The patient underwent appendicectomy and repair of the hernial sac and had an uneventful recovery. The possibility of the presence of a situs inversus or malrotation, as an underlying cause for the observed pathology, was excluded by X-ray examination

Rapunzel syndrome; a rare cause of upper gastro intestinal obstruction

Rapunzel syndrome is a rare form of trichobezoar that extends into small intestine and beyond. This condition usually occurs in mentally retarded or emotionally disturbed young females. Case of a young female is presented

Should we routinely expose recurrent laryngeal nerve[s] during thyroid surgery?

To compare the frequency of recurrent laryngeal nerve[s] [RLNs] palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. Randomized controlled trial. Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 [4%] patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 [16%] patients, 2 bilateral [4%] injuries requiring tracheostomy and 6 unilateral injuries [12%]. Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B [p = 0.046]. For safe thyroid surgery, recurrent laryngeal nerve[s] should be routinely exposed in its entire course

Primary carcinoma of ectopic breast tissue in axilla

A 30 years old married lady presented with 4 x 5 cm, firm, non-tender, mobile swelling on anterior wall of left axilla. FNAC revealed carcinoma. The examination of breast including axillary tail, arm, chest and abdomen did not reveal any abnormality. Mammogram and MRI of both breasts did not reveal any lesion in the breast including axillary tail. Local wide excision along with axillary clearance was carried out. Final histopathology revealed invasive ductal carcinoma [Grade II] of axillary breast tissue and one, out of the recovered lymph nodes, was involved by the tumour. The immunohistochemistry also confirmed the findings

Healing effects of natural honey on oral minor apthous ulcers among dental patients in quetta

Natural products have been used for several years in folk medicine. Among the natural medicated products, honey has an effective antibacterial potential to reduce oral pathogens and holds promise for the treatment of periodontal diseases, mouth ulcers, and other diseases of the oral cavity. As people are realizing that modern medicine is not the only remedy for infections today, so many of us are looking for the alternative approaches with least possible side effects. The purpose of this cross sectional study was to determine the effects of natural honey on healing of recurrent oral minor apthous ulcers. A total of 20 subjects, with minor oral ulcers [2-5 mm in size] visiting the oral diagnostic clinic of Dental Section, Sandeman provincial hospital, Quetta, for treatment of their painful ulcers were selected for this study, by either application of natural honey dressing or triamcinolone acetonide 0.5% in orabase. The ulcerations almost completely disappeared after three days treatment by natural honey dressing as compared to triamcinolone acetonide 0.5% in orabase. It was concluded that natural honey has an obvious influence on the rate of healing process of oral minor apthous ulcers

Triplication of Gallbladder

Triplication of gallbladder is a very rare congenital anamoly of biliary tract and is unlikely to be revealed unless there are associated symptoms. The modern imaging techniques usually fail to define the exact anatomy. Pre-operative awareness of this anatomic variation can minimize the chances of any damage to the biliary tract. This case report describes a patient with cholelithiasis diagnosed to have double gallbladder on pre-operative ultrasound

Nutritional status and micronutrient levels of children with celiac disease before and after gluten free diet

Celiac disease is an autoimmune inflammatory disorder of small intestine precipitated by ingestion of gluten. Clinical and histological improvement occurs on withdrawal of gluten from the diet. The present study were to identify the trace mineral deficiency in diagnosed celiac children and to assess how far these deficiencies are corrected after strict gluten free diet. The study also assessed the nutritional status of celiac children compared to the healthy controls before and after Gluten Free Diet. Department of Pediatrics Punjab Medical College Faisalabad. January 2004 to March 2005. Interventional case control study. 22 children aged 2 to 14 years diagnosed as Celiac disease on the basis of typical intestinal biopsy findings were included. 15 healthy children served as controls. Anthropometric measurements and serum Zinc Copper Magnesium and Iron along with albumin were done for both patients and controls initially and repeated after 6 months while patients were receiving strict GFD and controls receiving normal diet. The general linear model was used for the analysis of variance using SPSS [2004]. Serum Zinc was below the reference range in 68%. Serum copper and Magnesium in 31%, Iron in 95%and albumin in 59% of the patients. There was a statistically significant increase in serum zinc, iron and magnesium levels [p value, < 0 05] while serum copper and albumin did not show any significant rise after Gluten free diet. Control group did not show any significant change in their trace mineral levels .Celiac patients gained more weight [mean 4.47 versus 2.91 cm] and height [3.34cm versus 1 .022 cm] as compared to the control group. Celiac children receiving strict Gluten free diet and showing good clinical response probably do not need mineral supplementation

Biochemical characterization of the aeromonas species isolated from food and environment

Very few studies have been carried out to comprehensively characterize Aeromonas isolates. This study reports biochemical and enzymatic characterization of 60 isolates belonging to seven Aeromonas species. Seven types of API [Analytab Production Incorporation, France] strips [API 20 E, API 20 NE, Rapid ID 32 E, API 50 CH, ID 32 GN, ID 32 C, Rapid ID 32 A] were used for the biochemical characterization of the isolates. These strips provided an extensive biochemical profile of the isolates. AI 20 E gave reliable results. The H [2] S tubule of this strip was added with gelatin-cysteine-thiosulfate medium and got excellent results for H [2] S production from cysteine. Esculin formulation in ID 32 C was proved most reliable as no false positive or as many false positive and false negative results were given by it. All other strips provided test profile and some of the characteristics in them appeared as significant in differentiation of the various species

Association of tubal ligation or abdominal surgery with other gynecological illness

To determine the association of tubal ligation or abdominal surgery with other gynecological problems. A retrospective study was done in hospital setting of Islamabad and Rawalpindi. Women who had undergone tubal ligation or abdominal surgery were interviewed regarding the data collected has revealed the ligated women were more on risk for gynecological morbidity as compared to abdominal surgery cases. Screening for risk for developing gynecological problems prior to ligation should be done to prevent the chances of developing long term gynecological morbidity along with provision of premenopausal counseling

Symptoms of deperession and anxiety in post-myocardial infarction patients

To assess the frequency of symptoms of depression and/or anxiety following acute myocardial infarction [AMI] and to analyse their association with demographic variables. Design: A cross-sectional analytical, non-interventional hospital based study. Place and Duration of Study: The study was carried out at Punjab Institute of Cardiology [PIC], Lahore, from January 2000 to January 2001. Patients and A total number of 100 inpatients suffering from AMI were studied. After a careful selection of the subjects the Urdu version of Hospital Anxiety and Depression Scale [HADS] was administered to each patient during the period of 5-7 days following AMI to assess symptoms of depression and anxiety. A semi-structured clinical interview was also conducted which included demographic information, psychiatric history and other variables. Results were analyzed by using Statistical Package for Social Sciences [SPSS version 8.0]. Out of 100 subjects, 80 [80%] were males and 20 [20%] were females. Their ages ranged from 30-60 years [mean age, 50.92+8.53]. Overall, symptoms of anxiety and/or depression were found in 50 [50%] patients. More specifically, symptoms of depression were found in 14%, anxiety symptoms in 18% and mixed symptoms [anxiety and depression] in 18% of the patients. Results revealed that patients above 45 years of age [i.e. 46-60 years] were more likely to experience symptoms of depression and/ or anxiety following AMI. A significant association was also found between female sex [p <0.02], lower socioeconomic status [p <0.05] and symptoms of depression and/ or anxiety in these patients. However, no significant association was found in relation to educational status, marital status and origin [urban/rural]. The high proportion of patients with AMI found to be suffering from symptoms of depression and/ or anxiety one week after AMI highlights the essential need to assess these symptoms in all such patients during the post-MI period as they merit appropriate treatment alongwith the other complications of AMI

Is mechanical bowel preparation really necessary in colorectal surgery?

To determine the outcome of colorectal surgery without mechanical bowel preparation. Design: A descriptive, analytical and observational study. Place and Duration of Study: Combined Military Hospital, Kharian and Pano Aqil, from September 1998 to April 2003. Subjects and Forty-seven patients underwent debridement/resection and repair/ primary anastomosis of colon and upper rectum without bowel preparation. Of these,16 patients were operated in emergency. The anastomosis was carried out with polyglactin [vicryl] interrupted, full thickness single layer and no patient had defunctioning colostomy. Third generation cephalosporin, cefotaxime or ceftazidime and metronidazole were given perioperatively, repeated during surgery if lasted for more than 2 hours and continued for 3-5 days postoperatively. Anastomoses were ileocolic in 29.7%, colicocolic in 61.7% and colorectal in 14.8% cases. Anastomotic failure was seen in 4.2% and wound infection in 8.5% cases. There was one mortality [2.1%] due to unrelated cause. Mechanical bowel preparation is not necessary for safe colorectal surgery

Human amniotic membrane as a versatile biological dressing: a preliminary report

The subject of human amniotic membrane as a biological dressing is reviewed and experience of four wounds, three from acute burns and one from trauma is presented. Freeze dried amniotic membrane was used as the material for application next to the wound after the usual surgical cleansing. This process was repeated daily or on alternate days depending on the individual response. Beneficial effects noted included reduction of pain, promotion of healthy granulation and increased tendency of graft take in acute burns. In the chronic post-traumatic ulcer the treatment was not as effective in reduction of bacterial counts as a topical antibiotic [soframycin] used in an adjacent area of the same wound. Its trial as a biological dressing in burns merits consideration in view of this preliminary trial