Intra-operative predictors of difficult cholecystectomy and conversion to open cholecystectomy - a new scoring system

Objective: To evaluate the intra-operative scoring system to predict difficult cholecystectomy and conversion to open surgery

Methods: This descriptive study was conducted from March 2016 to August, 2016 in the Department of Surgery, Shalimar Hospital. The study recruited 120 patients of either gender, age greater than 18 years and indicated for laparoscopic cholecystectomy [LC]. Intra-operatively all patients were evaluated using the new scoring system. The scoring system included five aspects; appearance and adhesion of Gall Bladder [GB], distension or contracture degree of GB, ease in access, local or septic complications, and time required for cystic artery and duct identification. The scoring system ranges from 0 to 10, classified as score of <2 being considered easy, 2 to 4 moderate, 5-7 very difficult, and 8 to 10, extreme. Patient demographic data [i.e. age, gender], co-morbidities, intra-operative scores using the scoring system and conversion to open were recorded. The data was analysed using statistical analysis software SPSS [IBM]

Results: Among one hundred and twenty participants, sixty seven percent were females and the mean age [years] was 43.05 +/- 14.16. Co-morbidities were present in twenty percent patients with eleven diagnosed with diabetes, six with hypertension and five with both hypertension and diabetes. The conversion rate to open surgery was 6.7%. The overall mean intra-operative scores were 3.52 +/- 2.23; however significant difference was seen in mean operative score of converted to open and those not converted to open [8.00 +/- 0.92 Vs. 3.20 V 1.92; p-value = 0.001]. Among eight cases converted to open, three [37.5%] were in very difficult category while five [62.5%] were in extreme category. Moreover, age greater than 40 years and being diabetic were also the risk factors for conversion to open surgery

Conclusion: The new intra-operative scoring system is a valuable assessment tool to predict difficult laparoscopic cholecystectomy and conversion parameters to open surgery and its utility could improve patient's clinical outcome indicated for laparoscopic cholecystectomy

Tuberculosis of open cholecystectomy wound

Tuberculosis of the wound is a rare entity. A 50-year lady presented with an "on and off discharging wound" from the postoperative wound site of open cholecystectomy, which was done 7 years ago. Patient did not respond to standard antibiotic treatment regimens; and also the culture remained equivocal during this period. We explored the wound and found a mass in subcutaneous tissue. Resection of mass was done and wound left open for closure by secondary intention. Histopathology of the resected mass revealed tuberculosis. Patient was started on anti-tuberculous therapy [ATT]. Patient responded to the ATT therapy, with satisfactory healed wound at one month follow-up visit. Thus, surgeons should keep in mind the increased possibility for the tuberculous etiology of wound infection in chronic, non-healing wounds

Frameless stereotactic biopsy of intracranial lesions: evaluation of efficacy and complications

Objective: Frameless stereotactic biopsy has been shown in multiple studies to be a safe and effective procedure for the diagnosis of brain lesion. In this study the authors will evaluate the safety of the procedure and associated complications including neurological deficits in our set up of developing countries

Methods: Forty two patients with different brain lesions were biopsied using frameless stereotactic procedure between the periods of March 2009 - March 2014 for the assessment of diagnostic yield and related complications

Results: During the study period, forty two patients were biopsied for the evaluation of the complications related to the biopsy site. Neurological decline occurred in 1 patient. A higher number of needle passes was associated the presence of a postoperative hematoma. Infection occurred in one patient and overall diagnostic yield was 95%

Conclusion: Frameless stereotactic biopsy is a safe and effective method of tissue diagnosis for small lesions located in the eloquent and non-eloquent region of brain. With careful planning, frameless biopsy remains a valuable and safer tool for diagnosis of brain lesion, independent of the location of these lesions

effects of duration of propofol injection on hemodynamics

The aim of study was to see whether increasing the time of injection of standard dose of Propofol during induction can prevent fall in blood pressure in female patients; as is commonly observed with this anesthetic agent. Comparative, non-interventional, prospective, and randomized and single blind study. The study was carried out on female in-patients admitted and surgically operated at a specialized, tertiary care hospital and was completed with in 6-months. The hemodynamic effects of Propofol were compared in three groups of patients undergoing minor surgical procedures. Each group comprised of 25 patients. A 2 mg/kg Propofol was administered for 30, 60 and 120 seconds in patients of group-A, group-B and group-C respectively. Baseline heart rate, systolic blood pressure, diastolic blood pressure and mean arterial blood pressures were recorded before induction of anesthesia. The same hemodynamic variables were recorded after induction at one-minute intervals for 10-minutes. Anesthesia was maintained with 1.5% enflurane and 60% nitrous oxide in oxygen. Complications such as pain on injection, dystonic movements, erythema, laryngeal spasm, episodes of desaturation, hypoventilation and the number of additional boluses required to induce hypnosis were also recorded. The fall in blood pressure was statistically insignificant between the three groups of patients. The incidence of dystonic movements was the highest in group-A while pain on injection was highest in group-C. Additional boluses of Propofol to induce hypnosis were required for patients in group-B and group-C. Varying the speed of injection of Propofol during induction of anesthesia in adult female patients does not cause any major difference in the drop of their heart rate, systolic blood pressure, diastolic pressure and mean arterial pressure

Significant variablables associated with epilepsy

To study the characteristics of the epileptics and the risk factors contributing to the development of epilepsy. Design: Descriptive study. Place and Duration of Study: Epilepsy Clinic at Ahbab Hospital, Lahore, from June 2002 to August 2002. Subjects and Data was collected from 158 subjects, 89 males and 69 females, suffering from epilepsy. The information about socio-demographic characteristics and family history of illness, perinatal morbidity, birth place and mother's age at the time of delivery was obtained using a pre-tested questionnaire. Data was analyzed on SPSS version 10. Majority of the subjects were single [77.84%], 1st born among their siblings [25.95%], belonged to low social class [50.63%], and unemployed [25.31%]. The major risk factors were family history of illness [23.52%] and positive medical problem around birth [12.66%]. The presence of family history of illness, positive medical problem around birth and advanced maternal age at birth were associated with early onset of epilepsy. Vulnerability for the epilepsy also increases among hospital deliveries. Although the present study has identified various risk factors, yet the results need to be further confirmed through case-control studies

Trans-myocardial revascularization by laser, two-year follow-up

The objective of this study was to investigate the effects of Transmyocardial Revascularization by Laser [TMRL] in patients of ischemic heart disease. 50 patients of ischemic heart disease NYHA class III, IV who were not suitable for other methods of revascularization like CABG, PTCA ['No Option' patients] were offered TMRL. These patients were symptomatic on maximum medical treatment. 50 patients of angina NYHA class III, IV [mean 3.44 +/- 0.50] were offered TMRL. Their angina class improved to mean 1.88 +/- 0.74 at 6 month [p=0.00585] and persisted at mean 0.96 +/- 0.77 at 2 years [p =0 0.0150]. Their ETT mean value before operation was 5.036 +/- 1.54 minutes and at 2 years mean was 6.56 +/- 1.79 minutes [p=0.8318]. Kaplan Meier symptoms free survival rate was 83.1% at 6 months [14 censored] and 77.3 at 2 years [24 censored]

Evaluation of oral midazolam as pre-medication in day care surgery in adult Pakistani patients

A placebo controlled randomized double blind study was designed to assess the suitability of oral Midazolam as a premedication in day care surgery in adult Pakistani patients. Fifty ASA I and II patients aged between 20-60 years received either Midazolam 7.5 mg or placebo approximately one hour prior to surgery. Midazolam 7.5 mg produced significant anxiolysis and sedation [p<0.001] in comparison to placebo after one hour of premedication. There was a significant difference [p<0.001] in the mean heart rate and blood pressure in both groups after 1 hour of premedication with a lesser rise in blood pressure and heart rate in the Midazolam group. Psychomotor performance assessed by 'n' deletion test was impaired by Midazolam [p<0.001] and recall of pictures revealed differences [p<0.05] in the groups at one hour after premedication. However, at four hours after surgery there were no differences in both groups. These findings indicate that rapidly acting oral Midazolam in doses of 7.5 mg provided safe and effective premedication in terms of anxiolysis, sedation, amnesia and psychomotor performance and is suitable for day surgery