Role of orally administered Gastrografin in small bowel obstruction after unsuccessful conservative treatment

Orally administered gastrografin is a hyperosmolar water soluble contrast medium. It is commonly used for the diagnosis of small bowel obstruction but it also has a therapeutic role in small bowel obstruction [SBO]. The purpose of this study was to determine the diagnostic and therapeutic role of gastrografin in cases of small bowel obstruction who didn't respond to conservative treatment. This retrospective study was carried out from Jan 2004 to Oct 2009, in which 110 patients with diagnosis [clinical and radiological] SBO were included. An initial trial of conservative treatment was given after excluding the bowel ischemia. Every patient was observed for twenty four hours to assess the response to conservative treatment. After 24hours non-responding patients were given 100 ml of gastrografin through Ryle's tube and transit of contrast was followed by repeated abdominal radiographs taken at 4,8,12 and 24 hours after administration of gastrografin. In partially obstructed patients in whom contrast appeared in large bowel no further intervention was performed. Laparotomy was performed in remaining patients in whom gastrografin failed to reach the large bowel within 24 hours. From Jan 2004 to Oct 2009, 110 patients [men =62 and women = 48] with small bowel obstruction were included in the study. The mean age of our patients was 34.1 years [15 - 40 years]. In 22% [25] patients had bowel strangulation and they were operated soon after admission. Non operative treatment was continued in 10% [12] of patients who responded to the conservative treatment in first 24hrs. Twenty eight [25%] patients had history of single surgery while 10 [9%] of patients had history of more than one operation in the past. Gastrografin was given to 73 patients who didn't respond to conservative treatment in 24hrs. Thirty four percent [25 out of 73] patients were operated for complete obstruction after gastrografin administeration. Forty five [61%] patients had partial obstruction after gastrografin administration and complete resolution of obstruction occurred in all of them except three patients who were operated for persistent obstruction. We found 92% reduction in the operative rate after gastrografin administration. No complications were noted with the use of gastrografin. After unsuccessful routine conservative treatment gastrografin can be used safely and it can reduce the operative rate. In this study out of 73 patients who were administered gastrographin, obstruction was completely resolved in 42 patients [57.5%]. It also helps in predicting the need for surgery thus it shortens not only hospital stay but also reduces the potential morbidity of late surgery due to prolong and unsuccessful non operative treatment.

Audit of splenectomy at Jinnah postgraduate medical centre, Karachi

Objective: Splenectomy is often performed in patients with heamatalogical diseases or trauma who are at high risk of complications. Our aim is to perform an audit on splenectomy in order to determine the reasons for the operation, its complication and compliance with the recent recommendations for post-splenectomy patients at Jinnah Postgraduate Medical Centre. Design: It is a Descriptive study conducted in surgical ward 2 at Jinnah Postgraduate Medical Centre from June 2003 to June 2008. Methods: A retrospective review of hospital records of surgical ward 2 of consecutive splenectomy patients with a mean follow up of 12 months. Results: Fifty-five patients underwent splenectomy in 6 years duration. The mean age was 26.7 years. The indication for splenectomy was mainly heamatological diseases and trauma. Vaccination was done in 83.6% patients. Twelve patients had postsplenectomy complications, although there were no cases of OPSI. Mean hospital stay was 6.4 days. Conclusion: We still lack compliance with the standard guidelines for post-splenectomy patients. There is space for an improvement of the vaccination rate and prophylactic antibiotic. Patients should be counselled for the risk of OPSI and should have a splenectomised card for prompt treatment. There is need for careful documentation of this important health risk and counselling of patients in the discharge summaries

Laparoscopic colonic surgery: early experience

The paper reports early experience with laparoscopic colonic surgery in relation to indications, tumour size, operative time, duration of analgesic requirement postopera-tively, return of bowel activity, postoperative complications and mortality. A multicentre case series study at Jinnah Postgraduate Medical Centre, Orthopedic and Medial Institute, SIUT and South City Hospital between February 2007 and February 2010. Clinical and operative records of all laparoscopic-assisted colonic procedures performed between February 2007 and February 2010 were studied. 80 laparoscopic-assisted colonic surgeries were performed during this period. There were 74 cases of carcinoma, 5 cases of tuberculosis and 1 case of polyp. Laparoscopic-assisted procedures included right hemicolectomy in 54 cases, left hemicolectomy in 15 cases, sigmoid colectomy in 6 cases, segmental resection of splenic flexure in 2 cases, transverse colostomy in 3 cases. Eight cases were converted to open surgery; six because of locally advanced disease, one because of bleeding and one because of failure to localize the tumour. Mean operative time was 150 minutes. The mean tumour size was 6cm. Mean duration for analgesic requirement was 2.5 days. Mean time to return of bowel activity was 2.7 days with a mean hospital stay of 5 days. Intraoperative traction injury to the small bowel was encountered in 1 patient. Postoperatively 2 patients had local wound infection and 2 patients developed pulmonary infection. Laparoscopic-assisted colonic procedures are associated with a smaller wound, quicker return of bowel activity, reduced consumption of analgesics, a shorter hospital stay and low rates of pulmonary infection. Laparoscopic colonic surgery is feasible and a logical progression towards acquisition of advanced laparoscopic skills with good results

Is nasogastric decompression necessary in elective enteric anastomosis?

Placement of nasogastric tube is common surgical practice after bowel anastomosis. What is to be achieved by this prophylaxis is gastric decompression, a decreased likelihood of nausea and vomiting, decreased distension, less chance of pulmonary aspiration and pneumonia, less risk of wound separation and infection, less chance of fascial dehiscence and hernia, earlier return of bowel function and earlier discharge from hospital. We conducted a prospective observational study in Surgical Ward 2, Jinnah Postgraduate Medical Centre, Karachi from January 2008 to December 2009 to assess whether routine use of nasogastric decompression in elective enteric anastomosis can be safely omitted. Patients who underwent elective enteric anastomosis were included in this study. These patients were managed prospectively without nasogastric decompression. Outcome were measured in terms of time of passing flatus, nausea, vomiting, abdominal distension, pulmonary complications, wound infection, wound dehiscence, anastomotic leak, length of hospital stay and mortality. Except for incidence of minor symptoms like nausea or vomiting, omission of NG tube did not lead to any serious complication like anastomotic leak, pulmonary complications wound dehiscence or death. Nasogastric decompression can safely be omitted from a routine part of postoperative care after elective enteric anastomosis

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

Rationale for near total thyroidectomy in patients with multinodular goitre

To prove that Near total Thyroidectomy [NTT] with minimal residual tissue is the procedure of choice in patients with Multi-Nodular Goitre [MNG]. Retrospective study from February 2002 to December 2006. Surgical Ward-II, Jinnah Postgraduate Medical Centre [JPMC], Karachi. A total of 521 consecutive patients, operated for simple or toxic MNG were included in this study. Apart from detailed clinical work-up, investigations including thyroid function tests and thyroid scans were carried out in all cases. All patients underwent near total thyroidectomy with preservation of recurrent laryngeal nerves and parathyroid glands. Out of 521 cases, 73 [14%] had carcinoma on histopathological examination of the removed glands; 47 [64%] underwent completion thyroidectomy which was uneventful, while 22 had radioiodine ablation with decreased dosage for provision of minimal residual tissue and four declined further treatment. Near total thyroidectomy is a versatile surgical procedure for patients with MNG, keeping in view the risk of associated occult malignancy. Furthermore, the risk of damage to recurrent laryngeal nerve [RLN] and parathyroids is low in patients undergoing completion thyroidectomy. Hence, a more radical procedure should be adopted for surgical treatment in MNG

Parameters that influence the prognosis of phyllodes tumour

To evaluate the factors that influence the prognosis of patients with Phyllodes tumour. Interventional case series from April 2002 to April 2006. Setting: Department of Surgery, Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi. Patients: Twenty two patients of Phyllodes tumour breast that were operated. Detailed data of all the patients was collected. Diagnosis of Phyllodes tumour was made on good clinical examination, ultrasonography, mammography and trucut biopsy. Primary treatment included wide local excision in 19 cases and mastectomy in three cases. All patients were females with a mean age of 31 years. Left breast was affected more [60%] than the right and a painless lump was the commonest presentation. Patients were divided into three groups after final histopathology report. Ten patients were reported as benign phyllodes who showed no recurrence on follow-up and four patient as borderline phyllodes, who developed recurrence within 12-18 months; while eight patients were reported as malignant phyllodes. The key prognostic factors are status of margins, histological type and the size of the tumour. Trucut biopsy has greater yield of diagnosis and surgery remains the mainstay of treatment for Cystosarcoma Phyllodes

Completion thyroidectomy: Relation of timing with complications

To assess the association of timing with complications following completion thyroidectomy. Prospective, quasi-experimental clinical trial from June 2002 to March 2007. Surgical Unit-2, Jinnah Postgraduate Medical Centre [JPMC], Karachi. A total of 114 patients who underwent completion thyroidectomy. The patients were divided into two groups viz. Group-I [n = 76] where completion thyroidectomy was performed between 10 days and three months and Group-II [n = 38] where completion thyroidectomy was carried out beyond this time. Transient hypocalcaemia was seen in two cases of Group-I and one case of Group-IL while transient recurrent laryngeal nerve paresis was seen in two patients, one in each group. However, there was no statistically significant difference in the outcome between Group-I and IL in terms of complications. Timing does not influence the complication rate after completion thyroidectomy

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

Frequency of intestinal tuberculosis in operated cases intestinal obstruction

To review the cases of intestinal tuberculosis in operated cases of intestinal obstruction. Prospective/retrospective descriptive study. Surgical ward-2, Jinnah Postgraduate Medical Centre, Karachi from 1st March, 2000 to 28th February, 2002. Total 246 patients of intestinal obstruction were operated in this period, amongst them 62 patients were found to be intestinal tuberculosis. All these patients were admitted through Accident and Emergency Department. Intestinal tuberculosis as a cause of intestinal obstruction was found in 62 [25.2%]patients. Mean age was 27.36 years. There were 32 [51%] male and30 [49%] female. Symptoms and signs of intestinal obstruction were found in all patients while peritonitis secondary to intestinal obstruction was found in 18 [29.03%] patients. Other symptoms of tuberculosis such fever, night sweats, weight loss was also present in significant number of these patients. After relevant investigations exploratory laparotomy was performed. Small intestinal stricture was commonest cause of intestinal obstruction found in 38 [61.29%] patients Mass in right iliac fossa found in 18 [29.03%] patients Six [9.67%] pa- tients had adhesions as a cause of intestinal obstruction with strictures as an incidental finding. Perforation of the small bowel secondary to intestinal obstruction was found in 18 [29,03%] patients. Stricturoplasty was the commonest procedure performed in 20 [32.25%] patients. Right hemicolectomy was second commonest procedure after stricture-plasty performed in 16 [25.80%n] patients. Other procedures performed include resection of the strictured or perforated segment followed either by end to end anastomosis or by end ileostomy. Me- senteric lymph nodes found enlarged in all patients and taken for biopsy. Antituberculous therapy was given to all patients. Frequency of intestinal tuberculosis is significantly high in our population and it is increasing at alarming rate

Predicting factors of Seroma formation after Breast cancer surgery

To determine the frequency of seroma formation, and the role of hypertension, diabetes mellitus, neoadjuvant chemotherapy and nodal dissection in the development of seroma after breast surgery. Hospital based prospective study with descriptive design [interventional descriptive] from April 2002 to March 2005. Setting: Department of General Surgery [Ward-2], Jinnah Postgraduate Medical Centre, Karachi. 160 patients of Carcinoma Breast who underwent elective surgery. Patients were divided into two groups viz. those who developed seroma [Group-A] and those who did not [Group-B]. The data was tabulated on SPSS version 10.0. Demographic data was represented in frequencies. The effect of various risk factors [hypertension, diabetes mellitus, nodal status, tumour histology] was calculated and presented as relative risk [RR]. Out of 160 patients, there were 157 females and three males, with a sex ratio of 53F:1M. Their ages ranged from 23 to 100 years. A total of 144 patients underwent modified radical mastectomy and 16 breast conservation. Seroma formed in 28 [17.5%] cases. Out of 36 hypertensive patients 22 developed seroma [RR=12.72], while amongst the 28 diabetics two and amongst the 64 patients that received neoadjuvant chemotherapy 12 developed seroma. The total number of axillary lymph nodes in patients who developed seroma ranged from 4-28 as compared to non-seroma group with 4-30; an average of nine [0-25] positive nodes were seen in both the groups. Seroma formation is a common complication of the modified radical mastectomy. The only factor that appeared to contribute to seroma formation in this series was hypertension. Neoadjuvant chemotherapy marginally increased the risk, but diabetes had no role in seroma formation

Conservation surgery in cases of carcinoma breast

Breast conservation surgery is now widely used in place of mastectomy for small tumors. This interventional descriptive study was conducted in Surgical Ward II, Jinnah Postgraduate Medical Centre, Karachi to assess the results of surgical treatment and radiation therapy in the management of early breast cancer. A total of 150 patients were seen with Carcinoma Breast between April 2001 to April 2004, the diagnosis being made on mammography, FNAC and trucut biopsy. Out of these Breast conservation surgery was possible only in 20 patients; 60% had a tumor size of 2-3 cms and 70% a histological grade of II. In addition to axillary dissection all patients received radiotherapy, while chemotherapy was given to 15 patients. None of the patients had a recurrence in the 8-36 months follow up. We conclude that conservation surgery has a definite place in the management of Stage I and II of Carcinoma breast. However, long term follow-up is needed to establish its efficacy in terms of recurrence rates and survival, and is worth-exploring

Transhiatal esophagectomy for carcinoma esophagus - early experience

Over a period of eighteen months, [June, 89 to Dec, 90] 19 patients underwent Transhiatal Oesophagectomy for carcinoma. Thirteen were males and 6 females, age varying from 32 to 80 years with an average of 48.6 years. Dysphagia was present in all patients, the duration varied from 1.5 to 6 months, average 3.5 months. Pre-operative endoscopy and biopsy was done in all cases. Lesion was located in upper thoracic oesophagus in 6, middle 9 and lower 4. Histology revealed squamous cell carcinoma in 18 and adenocarcinoma in one. Transhiatal oesophagectomy without thoracotomy and cervical oesophagogastric anastomosis was carried out. The stomach was placed in the posterior mediastinum in 13 and retrosternal in 6 cases. Liver metastasis were present in 3, palpably enlarged nodes in 7 and the tumor was adherent to tissues in the mediastinum in 6 cases. Four patients died in hospital, 2 due to myocardial infarction, one due to massive haemetemesis, and the cause of death could not be established in one. Satisfactory relief of dysphagia was achieved in all cases. Oesophagectomy without thoracotomy is safe and better tolerated than the traditional trans-thoracic operations. The experience of one surgical unit is presented