Determinants of delayed presentation in breast cancer

To find out the factors which influence delayed presentation of breast cancer. A prospective study. The study was conducted in the department of surgery at Allied Hospital Faisalabad for a period of one year from 01-11- 2008 to 30-11-2009. With an informed consent, study was conducted on 75 patients of breast cancer who presented late in Allied Hospital Faisalabad for their treatment. Diagnosis of breast cancer in all the patients was established by tissue biopsy. Every patient was interviewed on a structured questionnaire to find out the determinants of delayed presentation from the date of first symptom recognition to the start of treatment. Extent of delayed presentation in our study ranged from 3 to 18 months with mean duration of 8 months. Patient delay showed a major influence on delayed presentation and its determinants were painless lump breast, negative family history of breast cancer, negative history of benign breast disease, increasing age above 40 years, lack of awareness about breast cancer, poor economic class, psychosocial and cultural beliefs, rural background, number of siblings 4 or above, lack of female doctors and illiteracy. Pre-hospital system delay showed a minor attribution to delayed presentation and it was associated with delayed or non-referral to consultants, mal-treatment by health care providers other than breast surgeons, false negative/misinterpretation of mammograms and false negative results of fine needle aspiration cytology. Locally advanced breast cancer [LABC/Stage III] was found in 62.7% patients, while, 12% patients had metastatic breast cancer [MBC/Stage IV]. Rest of the 25.33% patients had early breast cancer [EBC/stage I and II]. Delay of more than 6 months was found in 48 [64%] patients and out of them 60% had advance stage, while only 4% patients were observed in stage II [EBC]. Delay of 3 to 6 months was noted in 27 [36%] patients and among them 3 [4%], 13 [17.3%] and 11[14.7%] patients had stages I, II and III respectively. Delayed presentation of breast cancer is mainly attributed to patient delay rather than the system delay and longerd elays in presentation adversely influence the stage of breast cancer

Thyroidectomy with safe vocal cord functions

To compare the prevalence of vocal cord dysfunctions due to recurrent laryngeal nerve [RLN] injuries in thyroidectomy with and without identification of RLN. A prospective comparative study. The study was conducted in the Department of Surgery, Allied Hospital Faisalabad from October 1[st], 2008 to September 30[th], 2009. With an informed and explained consent, the study was conducted on two groups of patients who had thyroidectomy for the treatment of primary goitre. Patients were distributed on alternate basis irrespective the type of goitre into groups A and B for [thyroidectomy with identification of RLN] and [thyroidectomy with out identification of RLN] respectively. Patients of both groups were compared for the prevalence of post- operative vocal cord dysfunctions in association with recurrent laryngeal nerve injuries. Groups A and B had 52 and 53 patients respectively. Post-thyroidectomy vocal cord functions were remained safe in all the patients of group A. However, 3 [5.66%] patients of group B showed altered vocal cord functions in post operative follow up. Prevalence of RLN injuries in Group A and B remained 0% and 3 [2.97%] respectively. Out of three RLN injuries in group B, 2[1.98%] were transient and 1[0.99%] was permanent. Preservation of vocal cords functions and recurrent laryngeal nerves in thyroidectomy is more likely with the exposure and identification of RLN up to larynx

Role of fine needle aspiration cytology for neoplastic evaluation of nodular goitre

To see the accuracy of fine needle aspiration cytology [FNAC] for neoplastic lesions in nodular goitre. A prospective comparative analytic study. The study was conducted in Pathology Department, Punjab Medical College Faisalabad in association with the Department of surgery, Allied Hospital Faisalabad from September 1[st], 2008 to May 31[st], 2010. With an informed and explained consent, the study was conducted on 117 patients of primary euthyroid nodular goitre who underwent thyroid surgery. Preoperative diagnosis in all the patients was established by fine needle aspiration cytology and thyroid function tests. After thyroid surgery, excised tissue was sent for histopathology to confirm the diagnosis. Cytological diagnosis was compared with histological diagnosis to see the accuracy of fine needle aspiration cytology for neoplastic lesions. Among the 117 patients, FNAC showed neoplastic and non-neoplastic lesions in 27 and 90 patients respectively. While, histological diagnosis revealed neoplastic lesions in 24 patients and non-neoplastic lesions in 93 patients. Sensitivity, specificity and accuracy of FNAC for neoplastic lesions in nodular goitre remained 79.17%, 91.4% and 88.89% respectively. Fine needle aspiration cytology plays a pivotal role in pre-operative differentiation between the neoplastic and non-neoplastic lesions of nodular goiter

Impact of pneumoperitoneum on hepatic functions after laparoscopic cholecystectomy [LC]

To find out the alterations in hepatic functions after laparoscopic cholecystectomy and the possible mechanisms behind such effect. A prospective analytic study. The study was conducted in surgical unit-1; Allied Hospital Faisalabad, from January 1st, 2009 to June 30th, 2009. With approval from the institutional ethical committee and informed consent, as per inclusion and exclusion criteria, 100 patients for laparoscopic cholecystectomy were included in the study. The blood samples of the patients were collected to test liver enzymes; bilirubin, alanine aminotransferase [ALT] aspartate aminotransferase [AST] and alkaline phosphatase [ALP] once preoperatively and then on 2nd and 10th post operative days. The preoperative values were compared with that of postoperative values. During LC intraabdominal pressure for pneumoperitoneum was maintained at 14 mmHg of CO2 and the duration of CO2 insufflation was measured. Forty eight hours after LC, levels of ALT, AST and bilirubin were found to be increased [ALT: 51.11 U/L, P<0.001; AST: 53.79 U/L, p < 0.001 and Bilirubin: 1.38mg/dl P < 0.001 which were statistically significant. Moreover, these hepatic enzymes were significantly increased in patients who had longer durations of CO2 insufflations. The changes in alkaline phosphatase measurements were found to be non significant. The levels of hepatic functions returned to normal or near normal values in samples of 10th post operative day. Transient alterations in hepatic functions are frequently observed after uneventful laparoscopic cholecystectomy, which clinically appear to be insignificant. CO2 Pneumoperitoneum seems to be the main reason for theses changes but other factors may also contribute

Evaluation and determination of prognostic factors in typhoid ileal perforation

To determine the prognostic factors of typhoid ileal perforation. A prospective study. The study was conducted in the departments of A and E and surgery at Allied Hospital Faisalabad, from September 1st, 2008 to August 31st, 2009. With informed consent, the study was conducted on 56 who underwent laparotomy for peritonitis due to typhoid ileal perforation as per inclusion and exclusion criteria. The ileal perforations were managed by either primary simple transverse closure or primary defunctioning loop ileostomy. The prognostic evaluation was assessed by the impact of pre operative prognostic factors and per operative findings on post operative complications and mortality. For statistical significance, the data was analyzed by SPSS. Among the total 56 patients, thirty four [61%] patients were managed by primary simple transverse closure while 22 [39%] patients had primary defunctioning loop ileostomy. The age and sex had no effect on the prognosis of typhoid ileal perforation. Mortality rate was 5.4%. Different post operative complications and their rates were burst abdomen 23%, residual intra abdominal abscess 16%, fecal fistula 7% and septicemia 5.4%. Twenty eight [50%] patients developed wound infection which reflected only morbidity. Mortality remained nil in all those cases who had early presentation, admission-operation interval shorter than 12hours, size of perforation less than 1cm, amount of pus/fecal fluid less than1000ml and had primary simple closure. Three mortalities [5.4%] occurred among the cases with primary loop ileostomy due to a significant impact of pre operative and per operative prognostic factors on post operative complications and had a significant association with late presentation, admission-operation interval longer than 12hours, multiple perforations with size more than 1cm, amount of pus/fecal fluid greater than 1000ml. Late presentation, longer admission-operation interval, multiple perforations, size of perforations more than 1 cm and massive amount of intra peritoneal feco-purulent fluid significantly and adversely affect the prognosis of typhoid ileal perforation irrespective the surgical procedure used to manage the perforation

Incisional hernia repair by preperitoneal [sublay] mesh implantation

Incisional Hernia is a common surgical condition with a reported incidence of 2-11% following all laparatomies. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion. To evaluate the technique of preperitoneal [sublay] mesh repair of incisional hernias. This retrospective study of consecutive 50 cases was done from January .2004 to January 2006 using a computerized database. Preperitoneal [sublay] mesh implantation was done in all the 50 cases. Follow up of 12-24 months was carried in the OPD and on telephone with regards to postoperative complications, hospital stay and recurrences if any. In our study of fifty patients, eighty percent of females [n= 40] outnumbered twenty percent males [n=10]. The female to male ratio was 4: 1 and the highest incidence was in the 5th decade of life. The main presenting feature was swelling of the abdomen in all the fifty patients [100%] in the vicinity of the previous operative scar. In sixty percent of patients [n=30], the most common incision leading to incisional hernia was the midline incision of abdomen followed by Pfannensteil's incision in fourteen percent [n=7] and paramedian incision in twelve [n=6]. Major wound infection occurred in two patients [4%] only but without the removal of mesh. Forty patients [80%] attended for follow up ranging from 12 months to 24 months. Twenty seven patients [67.5%] attended OPD for follow up and thirteen patients [32.5%] replied the questions on phone. No recurrence was noted in follow up group. Based on this study, we conclude that preperitoneal [sublay] mesh repair is the ideal technique for incisional hernia. Though still there are few publications regarding this technique of repair

Sclerosing peritonitis

We have already reported four cases of sclerosing peritonitis in 2001[1]. This is a further reporting of two more cases of this rare syndrome treated by the authors in last two years. One had measles 10 days before her symptoms, other was taking anti tuberculosis drug for carries spine. We believe that none of above reason i.e. measles and A.T.T could be the cause of sclerosing peritonitis in these two cases and they were just co incidental

Laparoscopic orchidopexy

Case series. Pediatric surgical department of B V Hospital [QAMC] Bahawalpur and Allied Hospital Faisalabad. From April 2005 to Mar 2007. Cryptorchidism is most frequent presentation in pediatric population. Laparoscopy has become [Gold Standard] in the diagnosis and therapy of nonpalpable undescended testis. We present our two year experience in the management of 40 cases at two centers. The age of the patients ranged from 9 months to 12 years. Laparoscopy was done to localize the testis prior to surgery. Thirty four patients underwent one stage laparoscopic orchidopexy, 7 patients had open orchidopexy and 3 needed two stage Fowler-Stephen orchiodopexy. Laparoscopy is a valuable tool in both diagnosis and treatment of nonpalpable testis

Ultrasound, Ct-scan, and laparoscopy, diagnostic observations on non-palpable testis

To evaluate the comparative diagnostic efficacy of Ultrasound, CT-Scan, and Laparoscopy in the diagnosis of non-palpable undescended testes in pediatric patients. Comparative study. Surgical and pediatric surgical department of B V Hospital [QAMC] Bahawalpur and Allied Hospital Faisalabad. From April 2006 to April 2007. A total forty boys with non palpable testis were subjected to Ultrasound, CT-Scan and diagnostic laparoscopy in a period of one year. The patients above 12 years and with cardiovascular anomalies were excluded from the study. Laparoscopy was performed under general anesthesia and findings were compared with Ultrasound and CT-Scan. Sensitivity and specificity of each were calculated. Diagnostic accuracy of Ultrasound was 25%, CT-Scan was 64% and Laparoscopy was 100%. Sensitivity was found to be 20%, 63% and 100% and specificity was 10%. 50% and 100% for Ultrasound, CT-Scan and Laparoscopy, respectively. Diagnostic laparoscopy is far more superior as compared to Ultrasound and CT-Scan in the diagnosis of non palpable testis

Puerperal breast abscesses; percutaneous ultrasound guided drainage compared with conventional incision and drainage

The aim of this study was to compare the management of puerperal breast abscess by ultrasound guided percutaneous drainage v/s incision and drainage with special attention to resolution time and complications. Allied Hospital Faisalabad. Jan 2005- June 2007. 60 patients with puerperal breast abscess were studied. Patients were divided into two groups randomly after informed consent. In Group A; patients were treated with percutaneous drainage under local anesthesia while Group B patients were treated by conventional incision and drainage, and results were compared with reference to resolution time and complications rate using student's t-test. By percutaneous method abscess healed in 5-8 days time. Recurrent abscess was found in one case [3%], milk fistula formation in one case [3%] and no residual abscess was found. There was no scar formation, induration or distortion of the breast parenchyma. Breast-feeding was interrupted in four patients [13%] only due to milk fistula [one case], recurrent abscess [one case] and patient's own preference [two cases]. On the other hand by conventional method healing took 15-25 days with pain and discomfort of daily dressings, scarring and cessation of breastfeeding in most of the cases. Percutaneous ultrasound guided placement of suction drainage catheter in puerperal breast abscess for 5-8 days is less invasive, high resolution rate, scarless, low complication rate and preserves the function of breast-feeding as compared to conventional incision and drainage

Lower G.I.T. bleeding; Role of sigmoidoscopy

To find out the most common cause of lower Gastrointestinal tract bleeding in our setup as diagnosed with sigmoidoscopy 2. To measure the frequency of colorectal carcinoma with special reference to age and sex distribution 3. To compare the assessment of findings in prepared and unprepared gut on sigmoidoscopy. Prospective, descriptive study. Eight months study [January 2002 to June 2003]. Surgical Unit Ill, Allied Hospital/PMC Faisalabad. 50 cases presented with mild to moderate lower GIT [Gastrointestinal tract] bleeding and underwent sigmoidoscopy and biopsy and histopathology reports were studied. The most common cause of lower GIT bleeding as diagnosed by sigmoidoscopy was non specific colitis [46%] followed by colorectal carcinoma [18%], ulcerative colitis [16%] and a small percentage of benign rectal polyps, villous adenoma, and carcinoid tumour. Colorectal carcinoma was an important cause of lower GIT bleeding. In this study most of the cases of colorectal carcinoma presented in younger age group [55.5% < 40 year age group]. Male to female ratio was found to be 2:1. Sigmoidoscopy in unprepared gut had good results as compared to prepared gut. Faecal matter obscured the vision in any two cases only in unprepared cases. Rigid sigmoidoscopy is an early and valuable initial diagnostic procedure for the detection of cause of lower GIT bleeding, especially in a case of colorectal carcinoma, as early detection saves human life in this case

Sclerosing peritonitis: a report of 4 cases

Represent 4 cases of a rare disease of sclerosing peritonitis treated by us in last 15 years. Tuberculosis was found out to be the cause in two but no specific cause could be ascertained in other two cases. All were treated by laparotomy, Excision and removal of the thick plastic membrane encasing the whole small intestine. All had perfect recovery without any complication and recurrence