Frequency of carcinoma in gall bladder specimens sent for histopathology in a university hospital

OBJECTIVE: To find out the frequency of carcinoma of gall bladder in the cholecystectomy specimen sent for histopathology

DESIGN: Retrospective study

SETTING: Department of surgery, Liaquat University Hospital, Jamshoro and Depart of Pathology, Liaquat University of Medical and Health sciences Jamshoro

DURATION: From January 2007 to December 2008

METHOD: A retrospective histopathological analysis of specimen collected after cholecystectomies during January 2007 to December 2008 along with patient's notes, hospital records were analyzed. In addition demographic details were also collected. Data was entered into SPSS 13 and analyzed

RESULTS: 521 cases that were operated for cholelithiasis, nineteen were found to have carcinoma of gall bladder with incidence of 3.64%. The age ranged from 35 to 70 years, with mean age of 54 years in females and 55 years in males. Male to female ratio was 1:3.75. Adenocarcinoma [89.47%] was the most common histological variant

CONCLUSION: We conclude that carcinoma Gallbladder is having a high incidence of 3.64%, occurring at an early age with female preponderance. Since preoperative clinical examination and other radiological investigations cannot diagnose it efficiently in asymptomatic cases, therefore we suggest every gallbladder specimen should be routinely subjected to histopathology for early and curable management

Frequency of normal appendicectomy in a tertiary care hospital

To determine the frequency of normal appendicectomy in a tertiary care hospital. prospective observational study. This study was carried out in Surgical Unit-I, Liaquat University Hospital Hyderabad, from Oct 2010 to Oct 2011. This study consisted of hundred patients admitted through the outpatient department, as well as from casualty department of Liaquat University Hospital Jamshoro/Hyderabad. Detailed History was taken from all the patients with special reagard to the Pain in RIF, Pain starting around umbilicus, nausea, vomiting, fever and Altered bowel habits. Detailed Clinical examination of the patient was done. Site of right iliac fossa was especially examined for assessment of tenderness and recorded in proforma. Systemic review was also done to see any co-morbidity. All patients underwent base line and specific investigations especially ultrasound of abdomen as diagnostic modality for assessment of acute appendicitis. Inclusion criteria were all these patients who after counseling for this study and gave written consent. Irrespective of their age and sex admitted in Surgical Unit-I through outpatient department/ casualty and diagnosed as case of acute appendicitis. Exclusion criteria included all history of previous operation on lower abdomen. Follow up of all these patients was done. Results were prepared with help of tables and graphs. Data was analyzed through SPSS software. Out of 100 patients included in this study 65 were male [64%] and 36 patients were female [36%]; with male to female ratio of 1.7:1. There was wide variation of age ranging from a minimum of 10 year to 70 year. The mean age was 26.78 year. Symptoms of patients were pain in RIF in 99 [99%], pain starting around umbilicus in 42 examination of patients revealed tenderness at Mc Burney's point in 99 [99%] patients, while guarding was present in 80[80%] patients, rebound tenderness was present in 84[84%] patients and 33 [33%] patients had fever. Ultrasonographic findings revealed Wall thickness of appendix in 58[58%] patients where as normal appendix in 42[42%] patients, Free fluid in the R.I.F and pelvis was found in 36[36%] patients, Thickening of the surround intestinal lobes was seen in 40[40%] patients and Mass ob abscess formation in 8[8%] patients. Operative and histopathological findings were acute appendicitis in 59[59%] patients where as normal appendix in 21[21%] patients, adherent to bower or omentum was found in 7[7%] patients, pus was seen in 5[5%] patients and perforated 3[3%] patients. In conclusion, we found 21% of appendices to be histopathologically normal after emergency appendicectomies performed in this hospital. There was no mortality

Prospective basic clinical audit using minimal clinical data set

Audit is a means of quality control for medical practice by which the profession should regulate its activities with intention of improving overall patient care. Objective of this study was to report 1 year basic clinical audit of a general surgical ward and comparison of results with available data. All patients admitted and managed in department of surgery unit-II, Liaquat University Hospital, Jamshoro/Hyderabad from January to December 2007 were included in the study for basic clinical audit. Data of all surgical patients admitted during this period were retrieved from the departmental register. Details of surgical procedures and complications were recorded from the patients' charts. Total number of patients was 1434, out of which 844 [58.85%] were males and 590 [41.14%] were females. Majority [70.02%] of the patients were between 16 to 50 years of age. Elective surgeries were performed in 487 [33.74%] and emergency surgeries in 430 [29.79%] cases, whereas rest of the 526 patients [36.28%] were managed conservatively. Consultant was the primary surgeon in less than 50% of the procedures compare to post graduate trainees and registrars. The most common surgeries performed in elective wing were inguinal hernia repairs [25.66%] and cholecystectomies [22.99%]. In emergency wing, most of the surgeries were exploratory laparotomies [38.13%] and appendicectomies [22.79%]. Average duration of hospital stay in elective wing was 1-10 days and in emergency wing it was 2-21 days. There was an overall complication rate of 6.3% and a mortality rate of 2.44% respectively. We conclude that surgical audit has potential benefits for patients, clinicians, and provision of services for a continuous education, research and improved practice habits and should be perform on yearly basis. We also recommend the proper computerised audit programs and committees for its monitoring and evaluation

thyroidectomy safe after identification of recurrent laryngeal nerve - fact or fiction

Injury to recurrent laryngeal nerve remains a common complication of thyroid surgery. It is argued whether routine dissection leads to increase risk of palsy or otherwise. To assess recurrent laryngeal nerve injury risk during thyroidectomy with and without routine identification of the recurrent laryngeal nerve during surgery. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad over 3 years. The frequency of recurrent laryngeal nerve injury following surgery for benign, nontoxic thyroid disease was studied in consecutive patients undergoing hemithyroidectomy, subtotal thyroidectomy or near total thyroidectomy. Patients with benign and non toxic goitre were included in the study while those with toxic goitre and malignancy were excluded. A total of 88 patients were included in the study. They were divided into two groups, group A included patients in whom dissection of recurrent laryngeal nerve was done as standard procedure while in group B, the nerve was not exposed. There were 34 unilateral and 54 bilateral explorations. The mean age of patients in the two groups was almost same, with preponderance of females [M:F ratio 1:17]. The incidence of recurrent laryngeal nerve injury was not significant in both groups [p=0.502], but the incidence of nerve injury in patients who underwent near total thyroidectomy was 17.6% compared to 0.17% in patients who had hemithyroidectomy, indicating that it is not the exploration but the extent of thyroid resection that is a risk factor for recurrent laryngeal nerve injury. Dissection of nerve does not significantly reduce the risk of recurrent laryngeal nerve injury therefore, routine exploration of the nerve during thyroid surgery is not recommended in an expert hand

Fissurectomy with posterior midline sphincterotomy for management of chronic anal fissure

To determine the efficacy and safety of fissurectomy with posterior midline Sphincterotomy in the management of chronic anal fissure in terms of symptomatic relief, complications and recurrence. Observational case-series. Department of Surgery, Liaquat University Hospital, Jamshoro/Hyderabad, for a period of 3 years from January 2005 to December 2007. A total of 136 patients with chronic anal fissure were recruited for this study. All subjects underwent elective fissurectomy and posterior Sphincterotomy. Surgery was performed either under spinal or general anaesthesia. Symptomatic relief and early postoperative complications were recorded. The patients were followed for 18 months. Follow-up included assessment for complications such as pain, incontinence, keyhole deformity, and recurrence. All patients presented with pain during and after defaecation. Forty [29.4%] patients presented with bleeding per rectum. One hundred and sixteen [85%] patients complained of perianal swelling while 8 [5.9%] patients complained of perianal itching. Retention of urine was the most common postoperative complication, seen in 10 [7.4%] cases. It occurred within the first 24 hours after operation and all cases required catheterization. Six [4.4%] patients complained of moderate to severe postoperative pain in the first 24 hours, requiring narcotic analgesics. Transient incontinence of flatus and faeces occurred in 5 [3.7%] and 3 [2.2%] cases respectively. One patient presented with a recurrent anal fissure after 8 months but responded to conservative treatment. Given the low rate of complications and almost negligible rate of recurrence, fissurectomy with posterior midline Sphincterotomy is still a treatment of choice for the management of chronic anal fissure

Postoperative complications of reversal of loop ileostomy

Objectives: to determine the morbidity associated with reversal of loop ileostomies

Methods: this was a prospective interventional study conducted at Liaquat University Hospital Jamshoro, from September 2005 to August 2007. All patients who had their loop ileostomies reversed during the study period were included. The various postoperative complications were noted during postoperative hospital stay

Result: seventy-nine patients fulfilled the selection criteria during the study period. Typhoid perforation was most common indication of loop ileostomy construction and reversal account for more than three-fourth of all cases majority of them were males [75.94%]. Mean interval for ileostomy reversal was 90 days. Thirteen patients [15.6%] developed postoperative complications after reversal of loop ileostomy, most of these were settled on conservative treatment. Postoperative wound infection [9.6%] was the most common complication. Only four patients [4.8%] had surgical intervention to manage these complications

Conclusion: loop ileostomy reversal is associated with low morbidity

Use of single layer extra mucosal interrupted suture intestinal anastomosis: three year experience

Objective: to see the outcome of single layer extramucosal interrupted suture gut Anastomosis

Study design: prospective analytical

Setting and methods: this study was carried out in the Department of Surgery Unit-I Muhammad Medical College Mirpurkhas, from August 2004 to July 2007. A total of 72 patients were included in this study in which gut anastomosis was performed with single layer extramucosal interrupted suture. Patients of all ages and sex groups were included in whom end-to-end anastomosis was required in small and large intestine. Polyglactin [Vicryl 2/0 and 3/0] material was chosen on round body needle

Results: end-to-end anstomosis in 72 patients was done in cases of ileal perforation 37 / 72 [51.38%] and right hemicolectomy 09/72 [12.50%]. Intussusception was the cause in 11/72 [15.27%] cases, mass at recto-sigmoid junction was found in 02/72 [02.77%] strangulated inguinal hernia in 07/72 [09.72%] patients, jejunal diverticulosis in 01/72 [01.38%], caecal volvulous in 02/72 [02.77%] and sigmoid volvulous in 02/72 [02.77%] cases. Anastomosis leakage occurred in only 02/72 cases. Mortality remained 1/72 [01.38%]

Conclusion: single-layer extramucosal interrupted suture gut anastomosis is safe method of hand sewing technique. It is suitable for all anastomosis in the gastrointestinal tract

Transurethral resection of prostate versus Transvesical approach: frequency of postoperative urinary incontinence: two year study

Objective: to compare the results of transvesical prostatectomy with transurethral resection of prostate in respect to the presentation and severity of postoperative urinary incontinence

Design: comparative study

Place and duration of study: this study was carried out in two tertiary care centers Liaquat University of Medical and Health Sciences Jamshoro from where all cases of TRUP were collected and Muhammad Medical College Mirpurkhas where all transvesical prostatectomies were performed. It was a two years study from April 2004 to March 2006

Patients and methods: two groups were made and 50 cases were kept in each group by adopting non-probability convenient sampling technique. Patient underwent TURP were kept in group A and transvesical prostatectomy group was titled as group B. Patients having associated stricture urethra, urinary bladder stones or bladder diverticulum and later on proved as carcinoma of prostate were excluded from the study. Urinary incontinence in patients after both procedures was compared

Results: from group A 07 [14%] patients developed incontinence postoperatively and all had stress type of incontinence. While in group B 11 [22%] patients developed urinary incontinence; among them 05 [45.45%] had stress incontinence and 06 [54.55%] developed continuous urinary leakage. Rate of recovery after conservative measures remained rapid with group A as compared to group B

Conclusion: frequency and severity of postoperative urinary incontinence is more with transvesical approach. But the facility of TURP is not freely available. Therefore improvement in the technique of open prostatectomy is mandatory

Perforated ileal duplication cyst: a diagnostic dilemma

Alimentary tract duplications are rare congenital anomalies. We report a case of a 14-year-old boy, who presented with acute abdomen, with features favouring acute appendicitis. Laparotomy revealed perforated ileal duplication cyst. Resection of ileum along with cyst and anastomosis was undertaken, and proximal ileostomy performed. Postoperative recovery was uneventful and ileostomy was reversed successfully. Histopathology revealed the presence of gastric mucosa at the site of perforation

Mucoepidermoid carcinoma of parotid presenting as unilocular cyst

An interesting case of a 09 years old girl is reported who presented with a painless, mobile, spherical, fluctuant and brilliantly translucent swelling in front of left ear. The fine needle aspiration revealed turbid dark yellow colour fluid. This cystic swelling was completely excised and the specimen on histopathology was reported as low grade Mucoepidermoid carcinoma. Recovery was uneventful. This unusual presentation of Mucoepidermoid carcinoma as a preauricular cyst is one of the rare unique reported case

Diagnostic accuracy of Alvarado scoring system in acute appendicitis

Objective: Acute appendicitis is one of the commonest surgical emergency. There are different scoring systems in use to diagnose the appendicitis. Aim of this study was to document the diagnostic accuracy by application of Alvarado Scoring System in clinical practice for acute appendicitis. Design: Descriptive case series. Setting: Surgical Unit-II, Liaquat University Hospital Hyderabad, Sindh - Pakistan; from January 2003 to September 2004

Methods: All the patients with suspected appendicitis were admitted in the ward. A profroma was designed and relevant findings were documented. These were observed regarding the increase or decrease in severity of symptoms and hence the change in the initial score according to Alvarado Scoring System was documented at the time of admission. Decision regarding surgical intervention was made on the basis of change in the score

Results: A total of 227 patients with clinical features suggesting acute appendicitis was admitted in the ward. Among them, 150 [66.07%] were males and 77 [33.92%] were females. Age ranged from 10-62 years. Main symptoms at presentation included pain in right iliac fossa 67.8%, fever 66.9% and nausea and vomiting 49.7%. Thirty two patients were received with Alvarado Score of 1-4 and three out of them required surgery. Thirty five patients were in the score of 5, twenty three out of them required surgery. One hundred sixty patients were in the score of 6 and above, all of them required surgery. Out of 185 patients who underwent surgery, 178 patients had appendicitis. The negative appendicectomy rate was 3.78%

Conclusion: It is concluded that according to Alvarado the patients with score up to 4 probably do not require surgery and among the patients with score up to 5, most of them need surgery while the patients with the score of 6 and above will require surgery

Outcome of ileostomy in the management of ileal perforation

Objective: To evaluate the role of a defunctioning ileostomy in the prevention of morbidity and mortality in patients with small bowel perforation. Design: A prospective randomized study. Place and Duration of Study: Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro / Hyderabad between October 2005 and September 2006

Subjects and Methods: Total 108 patients who underwent laparotomy for ileal perforation were included

Results: There were 67 males and 41 females. The age of patients ranged from 15 to 72 years with 80% of the patients being in age group of 17-70 years. Typhoid was the commonest cause for ileal perforation which was seen in 69 [63.8%] patients, followed by intestinal tuberculosis which was present in 23 [21.3%] patients. Out of a total of 108 patients, a proximal defunctioning ileostomy was constructed to protect the primary repair or the intestinal anastomosis in 57 patients [group I]. In the remaining 51 patients, primary repair or intestinal anastomosis was done without a defunctioning ileostomy [group II]. Two [3.5%] patients in group I and 7 [13.7%] patients in group II died postoperatively. Six of the 51 patients in group II who underwent primary closure of perforation or resection and end-to-end anastomosis without a defunctioning ileostomy developed postoperative faecal fistula. None of the patients with defunctioning ileostomy developed this complication

Conclusion: We conclude that construction of a temporary ileostomy to provide defunctioning for repair of ileostomy perforations reduce the incidence of fatal complications like faecal fistula. Ileostomy, however, is associated with a number of ileostomy-specific complications. We recommend that defunctioning ileostomy should be preferred over all other surgical options in cases of ileal perforations

Selective nasogastric decompression after elective laparotomy

Objective: This study was conducted to evaluate the need or other wise for use of nasogastric decompression after elective laparotomy, as many studies suggest that routine nasogastric decompression is unnecessary after elective laparotomy and may in fact be associated with an increased incidence of complications. Despite these reports the nasogastric tube is routinely used for decompression, believing that its use significantly decreases the risk of post-operative nausea, vomiting, aspiration pneumonia, wound dehiscence and anastomotic leakage. Design: Descriptive case-series. Place and Duration of Study: Surgical Unit-II, Liaquat University Hospital Jamshoro from July 2005 to July 2007

Patients and Methods: Seventy patients were included in this study. A proforma was designed and all the findings were recorded. All the patients were observed regarding the development of complications like, post-operative nausea, vomiting, pulmonary complications, abdominal distention and return of bowel sounds

Results: Out of 70 studied cases 45 [64.2%] were males and 25 [35.7%] were females. Age ranged from 10 years to 70 years and mean age was 33 years. Postoperative pulmonary complications like atelectasis and pneumonia were seen in 3 [4.2%] out of 70 patients. The commonest operation performed was reversal of ileostomy and resection with end-to-end anastomosis. Postoperative nausea and vomiting were seen in 10 [14.2%] cases

Conclusion: The study did not support the routine use of nasogastric decompression

Congenital hernias of the diaphragm in children

Congenital diaphragmatic hernia [CDH] is a major congenital malformation. Different types have been described. Bochdalek hernia [BH] remains most prevalent with high mortality rates. Other variants are less common and carry good prognosis. Although, the diagnosis can be made antenatally, the presentation may be delayed. There is paucity of national literature on CDHs. We present our experience with these challenging paediatric malformations. Medical records of 18 patients [<14 years] treated by the group of authors between October 1998 and April 2002 were retrospectively reviewed and demographic data, clinical presentation, morbidity and outcome were studied. There were 13 [72%] children with Bochdalek hernia, 2 [11%] with eventration of the diaphragm, 2 [11%] with hiatus hernia and 1[6%] with a Morgagni hernia. The lesions were more common in girls and all the defects were left sided. The average age at the time of presentation of BH was 23 hours [2 to 72 hours] commonly presenting with cyanosis and respiratory distress. Associated anomalies were documented in 10 [77%] cases; six had multiple malformations and four died before surgery. In other types of CDHs, the mean age at presentation was 39 [18-60] months and they mostly presented with recurrent respiratory tract infections and/or mild gastrointestinal symptoms. Diagnosis was made on history, physical examination, plain x-ray chest, and gastrointestinal contrast study, when required. 14 [78%] children were operated and a sac was present in 5. Post-operative complications occurred in 5 [55%] patients with Bochdalek hernia, which were managed conservatively. The overall survival rate was 67% [n=12]. The different types of CDHs presented from neonatal age to later childhood with distinct symptoms. Surgery was safe and effective. Higher morbidity and mortality was observed in newborns with Bochdalek hernia

Malignancy in nodular goitre

To highlight diagnostic difficulties and evaluate the outcome of malignancy in nodular goiter. Case series. This study was conducted in the Surgical Unit-III and Unit-IV at Liaquat University Hospital Jamshoro, from January 2001 to December 2004. Nodular goiter patients admitted for treatment were studied with the help of a pre-designed proforma for recording the personal history, blood chemistry and FNAC results. The results of FNACs were further compared with the tissue histology postoperatively. During the four year study period 14 patients had malignancy out of total 149 cases of nodular goiter admitted. Twelve patients were diagnosed on FNAC. These patients were operated and near total thyroidectomy was done. Two patients diagnosed to have carcinoma on tissue biopsy [FNAC did not pick the malignancy] were re-admitted and had near total thyroidectomy. One patient with lymphoma was referred to Department of Oncology for radiotherapy. All patients with neoplasm postoperatively were referred to oncology department for further management to suppress the TSH. Near total thyroidectomy is the surgery of choice to decrease the recurrence rate in thyroid malignancies

Pattern of acute pancreatitis: the Liaquat University hospital experience

To determine the aetiological factors, presentation and management of acute pancreatitis and to assess the outcome of different forms of management in our set up. A case series. Liaquat University Hospital, Jamshoro/Hyderabad - Sindh from January 2002 to December 2004. The data of 45 consecutive patients admitted with acute pancreatitis was collected through a proforma and assessed with reference to aetiological factors, clinical presentation and management in each case. Majority [60%] of the patients belonged to 30-40 years of age. Thirty-six [80%] patients presented in emergency. The most common aetiological factor for acute pancreatitis was gallstones and the pain, nausea and vomiting were the main symptoms. Serum amylase [>3 x normal] was seen in 36[80%] patients. Prediction of severity was identified through Ranson score. It was <3 in 27[60%], 3 in 13[28.9%] and 4 in 5[11.1%] patients. The mortality was 13.33% but the morbidity remained high with the sequelae of resolution in >50% cases. Acute pancreatitis in our set up shows a lower frequency of this disease when compared to the world literature. However, when compared with aetiology and presentation, the pattern remains the same. Meanwhile, due to adoptation of Western way of life, the incidence seems to be increasing. Due to patient's delayed arrival, the diagnosis depending upon the level of serum amylase seems to be misleading

Persistent mullerian duct syndrome with transverse testicular ectopia

A case report of a 3 months old male child is presented, who had right inguinal hernia with left impalpable testis. During herniotomy we found both testes on right side [transverse testicular ectopia] with presence of mullerian duct structures

Carcinoma of caecum presenting as mega intussusception and rectal mass

Carcinoma of colon and rectum are second commonest cancer cause of death in United Kingdom. Because, right colon has a large caliber, a thin and distensible wall and faecal content is fluid, so, carcinoma of right colon may attain a large size before it gives specific symptoms. Any complication like acute appendicitis or intussusception may draw early attention, when curative resection is possible. In this report, an unusual presentation of carcinoma of caecum is reported