Outcomes of laparoscopic cholecystectomy in acute cholecystitis

Objective: To study the morbidity and mortality of early laparoscopic cholecystectomy in acute cholecystitis by comparing its results with laparoscopic cholecystectomy in chronic cholecystitis and simple cholelithiasis

Study Design: Quasi-experimental study

Place and Duration of Study: Pakistan Naval Ship [PNS] Shifa Hospital Karachi and Combined Military Hospital [CMH] Lahore Pakistan, from Nov 2009 to Jan 2013

Material and Methods: Total 398 patients with symptomatic gall stone disease were included in the study after exclusion of patients with upper abdominal surgery, perforated gallbladder with abscess formation, cardiopulmonary disease, equipment failure and those with choledocholithiasis. Cholecystectomy was performed using a three port technique in most of the cases. On the basis of per-operative findings regarding degree of inflammation of gallbladder, all patients were divided into three groups irrespective of duration of symptoms i.e. acute cholecystitis group, chronic cholecystitis group and no inflammation group. The collected data included age, sex, diagnosis, history of previous surgery, co-morbidities, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications. Statistical comparison was performed using the chi square test. Statistical significance with value of p was less than 0.05 was considered significant

Result: Out of 398 patients, 31.2% had acute cholecystitis, 10.1% had chronic cholecystitis and 58.8% had no inflammation of gall bladder. Complication rates and conversion rates were higher in chronic cholecystitis group as compared to acute cholecystitis group and no inflammation group. Similarly, mean hospital stay was also highest in chronic cholecystitis group

Conclusion: Early laparoscopic cholecystectomy was found safe in acute cholecystitis in expert hands and should be performed in all cases of acute cholecystitis rather than delayed interval cholecystectomy

Injection sclerotherapy versus rubber band ligation for second degree hemorrhoids

Objective: To compare the efficacy of injections Sclerotherapy [IST] and rubber band ligation [RBL] for the treatment of 2nd degree haemorrhoids in terms of improvement in symptoms severity score [SS score] in OPD patients

Study Design: Randomized controlled trial

Place and Duration of Study: It was conducted in surgical OPD of CMH Kohat, from 15th October 2010 to 10th April 2011

Material and Methods: A total of 116 patients with symptomatic 2nd degree haemorrhoids were randomly divided into two groups, RBL and IST [58 patients each] respectively and a baseline symptoms severity score was noted for each patient. Patients in RBL group were treated with RBL while in IST group were treated with IST. The outcome measures were relief of symptoms and improvement in SS score

Results: In RBL group, baseline SS score was 4.67 +/- 2.01 which reduced to final mean SS score of 1.34 +/- 0.96 whereas in IST group the baseline SS score was of 4.31 +/- 2.13 which reduced to a final mean SS score of 1.6 +/- 0.97. 44 [75.95%] patients had complete recovery and control of bleeding in RBL group; whereas in IST group 32 [55.1%] of the patients had this response by the end of two weeks

Conclusion: Rubber band ligation was found to have better patient outcomes as compared to injections sclerotherapy in treatment of 2nd degree hemorrhoids

Intestinal obstruction caused by postoperative adhesions: 5 years'experience at a teaching hospital

Objective: The objective of this study was to determine the common abdominal surgical procedure causing postoperative adhesive intestinal obstruction, and outcome of its surgical management

Study Design: Retrospective as well as prospective analysis

Place and Duration of Study: This study was conducted in the Department of Surgery, Khawaja Muhammad Safdar Medical College, Sialkot from June 2010 to November 2015

Materials and Methods: Patients operated on for intestinal obstruction with at least one abdominal surgical scar were included in the study. A total of 152 patients were eligible, all ages were eligible irrespective of gender. A minimum of 6 months follow up was set for inclusion in the study. Patients with intestinal obstruction presenting with surgical scars for renal, ureteric and urinary bladder surgery were not included as these surgeries did not involve opening of peritoneum. Patients with Crohn's disease, ulcerative colitis, known malignancies, a past history of abdominopelvic irradiation were excluded. Patients with less than 6 months follow up were excluded from the study

Results: Out of 152 patients, 74 [48.68%] surgeries for appendicular pathologies, 18 [11.84%] lower segment caesarean section and 9 [5.92%] total abdominal hysterectomy were the main pathologies causing obstruction; while patients had recurrence in 11[7.23%] and 8[5.26%] mortality

Conclusion: Operated adhesive postoperative intestinal obstruction proves to be a clinical entity with high incidence and specific risk factors of recurrence: age <40 years, presence of adhesion or matted adhesion, and postoperative surgical complications. Infected cases of appendicitis, enteric perforations, lower segment caesarean section and total abdominal hysterectomy are the main causes and the treatment may lead to stoma formation, recurrence and mortality

RIPASA score: a new diagnostic score for diagnosis of acute appendicitis

To determine the usefulness of RIPASA score for the diagnosis of acute appendicitis using histopathology as a gold standard. Cross-sectional study. Department of General Surgery, Combined Military Hospital, Kohat, from September 2011 to March 2012. A total of 267 patients were included in this study. RIPASA score was assessed. The diagnosis of appendicitis was made clinically aided by routine sonography of abdomen. After appendicectomies, resected appendices were sent for histopathological examination. The 15 parameters and the scores generated were age [less than 40 years = 1 point; greater than 40 years = 0.5 point], gender [male = 1 point; female = 0.5 point], Right Iliac Fossa [RIF] pain [0.5 point], migration of pain to RIF [0.5 point], nausea and vomiting [1 point], anorexia [1 point], duration of symptoms [less than 48 hours = 1 point; more than 48 hours = 0.5 point], RIF tenderness [1 point], guarding [2 points], rebound tenderness [1 point], Rovsing's sign [2 points], fever [1 point], raised white cell count [1 point], negative urinalysis [1 point] and foreign national registration identity card [1 point]. The optimal cut-off threshold score from the ROC was 7.5. Sensitivity analysis was done. Out of 267 patients, 156 [58.4%] were male while remaining 111 patients [41.6%] were female with mean age of 23.5 +/- 9.1 years. Sensitivity of RIPASA score was 96.7%, specificity 93.0%, diagnostic accuracy was 95.1%, positive predictive value was 94.8% and negative predictive value was 95.54%. RIPASA score at a cut-off total score of 7.5 was a useful tool to diagnose appendicitis, in equivocal cases of pain

Complications of laparoscopic cholecystectomy: an analysis of 400 consecutive cases

To analyze the complications of first 400 laparoscopic cholecystectomies [LC] for patients with symptomatic gall stone disease at a tertiary care hospital. Quasi-experimental study. PNS Shifa Karachi and CMH Lahore, Pakistan from Nov 2009 to Jan 2013. A prospective analysis of complications occurring in first 400 consecutive laparoscopic cholecystectomies by a single consultant/ unit at a tertiary care hospital was made. Out of total 421 patients presenting with symptomatic gall stone disease in a single unit, 21 cases that underwent open cholecystectomy were excluded from the study. Laparoscopic Cholecystectomies were performed using three port and four port technique and data including age, sex, diagnosis, number of trocar placements, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications was collected on personal computer and analyzed using Statistical package for social sciences [SPSS] version 13. Total 400 patients were included in study with median age of 44 years. Female to male ratio was 5.3: 1. Depending upon the preoperative diagnosis and laparoscopic findings, patients had diagnosis of Chronic cholecystitis/ biliary colic 68.25%, acute cholecystitis 23.75%, empyema gall bladder 7.25%, gallstone pancreatitis 0.5% and mucocele gallbladder 0.25%. Median operating time was 30 min. Median hospital stay was 1 days [range 1- 20 days]. Conversion rate was 1.25%. Postoperative complications included bleeding 0.5%, biliary peritonitis due to cystic duct leak 0.25%, biloma 0.25%, sub hepatic abscess 0.25%, subcutaneous fat necrosis right flank at drain site 0.25%, umbilical trocar site infection 2%, keloid at umbilical port site 0.25% and incisional hernia at umbilicus 0.25%. There was one hospital death due to myocardial infarction on 2[nd] post-operative day. Laparoscopic Cholecystectomy is associated with some serious complications which can be avoided with adequate training of surgeons as well as knowledge of mechanism of typical complications

Gall stone ileus: a rare cause of small bowel obstruction

Gallstone ileus is a rare disease and accounts for 1-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We present a case report of a 55 year old lady diagnosed as having gall stone ileus and was treated with emergent laparotomy and enterolithotomy with fistula repair at a later stage

Pre-analytical errors in a peripheral hospital laboratory

To analyse pre-analytical errors which account for the major contribution towards laboratory errors. Cross-sectional descriptive study. Combined Military Hospital Kohat, Pakistan from 1[st] January to 30[th] June 2012. For six months laboratory staff was asked to register rejections and causes for rejection of all samples; including in-patient samples from wards as well as out-patient samples collected in the laboratory. In addition all samples where disparity was noted by the clinicians in the laboratory results were also included for analysis. Suspected samples were reanalyzed, tests were also repeated on fresh samples of the patients and a critical appraisal was made. Among a total of 328418 analyses, clinicians/laboratory staff notified 350 questionable findings, 270 of which were confirmed errors. Out of total 270 errors, 77% were pre-analytical, 8% were analytical, 15% were post analytical errors. Out of total pre-analytical errors 8% were incorrect samples, 21% were misidentifications, 51% were faulty sampling techniques and 20% were incomplete/illegible laboratory request forms. The pre-analytical phase in the total testing process currently appears to be more vulnerable to errors than the other phases. Consequently, the pre-analytical phase should be the main target for further quality improvement. Therefore identifying the critical steps in the pre-analytical phase is a prerequisite for continuous quality improvement, further error reduction and thus for improving patient safety

Small bowel diverticular disease; how often we come across in exploratory laparotomy

1]. To see the prevalence of small bowel diverticulosis in patients presenting with acute abdomen. 2]. To know presentation and complications of diverticulosis in teaching hospital in Sialkot region of Pakistan. Introduction: Small bowel diverticular disease may be complicated by small bowel obstruction. Multiple diverticulosis represents an uncommon pathology of the small bowel. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction, and acute pancreatitis appear in 10-30% of the patients, increasing the morbidity and mortality rates. This pathology which is uncommon is much higher in our study in patients undergoing exploratory laparotomy in district level hospitals in Sialkot region of Pakistan. Prospective and observational. Combined Military Hospital, Sialkot [June 2005 to August 2010]. Islam teaching hospital, Sialkot [September 2010 to September 2012]. 260 consecutive patients undergoing exploratory laparotomy for obstruction, peritonitis, pain and mass abdomen were included in the study. Patient with established cause of obstruction were excluded. The data including demographic information, presentation, operative findings, complications and follow up were entered in structured proforma. Patients with less than three months of followup were also excluded from study. Small bowel diverticuli were encountered in 24 [9%] out of 260 patients including; 8 [3%] Meckel's, 9 [3.5%] jejunal, 3 [1.2%] duodenal and 4 [1.5%] Heal diverticuli. These patients with diverticuli presented as intestinal obstruction, peritonitis, mass abdomen, vague abdominal pain and one patient with fresh bleeding per rectum. The indications of surgery were peritonitis 6 [25%], intestinal obstruction 13 [54.2%], abdominal mass 3[12.5%], nonspecific abdominal pain 1 [4.2%] and fresh bleeding per rectum of obscure origin 1 [4.2%]. Complications encountered as Intestinal obstruction due to adhesion formation in 8; obstruction due to congenital bands attached to diverticuli in 3; diverticular perforation in 2; peritonitis due to diverticulitis in 2,bleeding from arteriovenous malformation within the jejuna diverticuli in 1 and mass formation due to volvulus in 1. Three duodenal diverticuli and 4 jejunal diverticuli were found as silent pathologies synchronous with other active pathologies

Comparison of conventional gauze therapy with vacuum assisted closure wound therapy in acute traumatic wounds

To compare the Vacuum Assisted Closure [VAC] wound therapy with Conventional Gauze Therapy [CGT] in management of acute traumatic wounds on the basis of time taken to achieve a vital red wound ready for definitive surgical closure. Randomized control trial. Department of Surgery Combined Military Hospital Rawalpindi from Mar 2009 to Sep 2009. This study included 82 patients of acute traumatic wounds. Patients were randomly allotted to group A, in which wound was treated with new method of vacuum assisted closure [VAC] wound therapy and to group B, in which wound was managed by conventional gauze therapy [CGT]. Outcomes were measured by the presence of vital red wound ready to be closed by surgical intervention. Patients with concomitant systemic pathology were not included in study. Comparison between the two groups revealed mean time for wound healing 13 days in group A and 16.9 days in group B with significant difference [p value =0.029]. Vacuum assisted closure wound therapy is an effective method in reducing time of wound healing for definitive surgical closure

Tissue repair for inguinal hernia: should they be deleted from literature?

This is a pilot study to evaluate the status of herniorrhaphy procedures in the modern day surgery. Mar 1995 to Mar 2005 Military hospitals Descriptive and Analytical All entitled patients were included in this study and only those non-entitled patients were included who came for regular follow up. All the patients were booked at first admission and their record was maintained. They were subjected to herniorrhaphy by a modified Bassini's procedure. They were called for follow up at 3 months, 6 months then annually for 2 years. A total of 210 patients were operated for inguinal hernia by tissue repair over the period of study. Out of these 164 patients were operated by pure tissue repair, of which 148 were followed up completely and were included in the study. The average age was 50.16 +/- 19.12 years. The mean operation time was 20 +/- 5.84 minutes. Mean Hospital stay was 3 +/- 0.6 days. Recurrence was noted in 1 [0.68%] patient in a follow up period of 2 +/- 0.46 years. Tissue repairs hold good even today in the deserving patients and should be undertaken without hesitation where necessary. We should not hesitate in deciding for easier and cheaper alternatives when available

Primary intrathoracic goiter - a rare mediastinal tumor

Primary intrathoracic goiter is a rare presentation of thyroid disease. Its removal usually necessitates thoracotomy or sternotomy. This patient having a primary intrathoracic goiter presented with posterior mediastinal mass that was removed through a right lateral thoracotomy