Tube thoracostomy in penetrating thoracic injuries

Objective: To determine the frequency of tube thoracostomy in penetrating thoracic injuries at a tertiary care hospital

Study design: Cross sectional study

Place and Duration of study: Department of Surgery Unit III, Civil Hospital / Dow University of Health Sciences Karachi, from March 2012 to March 2014

Methodology: All patients who presented with penetrating chest injuries due to firearm, stabs etc were treated according to ATLS protocol. Tube thoracostomy was performed when indicated. Chest tube was passed under local anesthesia

Results: A total of 100 patients included in this study. There were 92 males and 8 females. Mean age of the patients was 30+7.29 year. Mechanism of injuries included gunshot injury [n=62], stabs [n=24] and shrapnel injury [n=14]. Pneumothorax was diagnosed in 39 patients, haemothorax in 35, sucking wound of the chest in 20 patients and major vascular injury in 4 patients. Associated extra thoracic injuries were present in 26 patients. Tube thoracostomy was performed in 78 patients. Twenty-two patients underwent thoracotomy

Conclusions: Majority of patients with penetrating chest injuries were managed by tube thoracostomy. No mortality occurred in this series

Complications of onlay and sublay mesh plasty in ventral abdominal hernia repair

Objective: To find out the frequency of seroma, wound infection and wound disruption in patients of ventral abdominal hernia operated with onlay and sublay mesh plasty

Study design: Cross sectional study

Place and Duration of study: Department of General Surgery Dow University of Health Sciences and Civil Hospital Karachi, from January 2010 - December 2014

Methodology: Ventral abdominal hernia patients were selected randomly for the procedure of onlay and sublay mesh plasty. Fifty patients each were operated with either of the techniques. Postoperatively patients were observed for the complications; seroma, wound infection and wound dehiscence. All patients were followed for a period of two weeks

Results: A total of one hundred patients were enrolled. Fifty of them had onlay and fifty underwent sublay mesh plasty for ventral abdominal hernia. There were 18 [18%] males and 82 [82%] females with male to female ratio of 1:4.5. Minimum age was 22 year and maximum 55 year. There were 55 [55%] para umbilical hernia, 14 [14%] umbilical, 14 [14%] epigastric and 17 [17%] incisional hernia. Maximum number of cases of wound infection were noted in onlay mesh plasty group [n=16, 16%] while in sublay group only six [6%] had this complication

Conclusion: Sublay mesh plasty technique for ventral abdominal hernia repair had less frequency of complications

Perforation of gallbladder after admission in a young male patient

Gallbladder perforation is a rare but life threatening condition, and difficult to diagnose. A 30-year old male patient, with no known co-morbid, presented in emergency room with sudden onset of pain in the right hypochondrium. On examination there was tenderness in the right hypochondrium and right lumbar regions. Ultrasound abdomen showed thickwalled gallbladder containing multiple calculi and pericholecystic fluid suggestive of acute calculous cholecystitis. Patient was put on conservative treatment. After 24 hours patient deteriorated clinically. Urgent ultrasound showed collection in Morrison's pouch. Patient was operated and perforation at fundus of gallbladder found. Cholecystectomy was performed. Patient recovered smoothly and discharged home in good condition

Aspiration of breast abscess through wide bore 14-gauge intravenous cannula

To aspirate breast abscess through a wide bore [14-gauge] intravenous [I/V] cannula and determine its efficacy in terms of the number of recurrences and number of aspirations. Case series. Dow University of Health Sciences and Civil Hospital and Bantva Hospital, Karachi, Pakistan, from January 2009 to December 2011. Patients with breast abscesses confirmed on ultrasound without skin ulceration were selected. The soft area of breast abscess with positive fluctuation was marked and fixed with index finger and thumb. A 14-gauge cannula was inserted. Pus was aspirated through a 50 cc syringe, repeated till no aspirate could be obtained. All patients were followed weekly for 4 weeks, clinically for size of lump, local tenderness and temperature, while complete resolution was confirmed on ultrasound, as resolution of the lesion. A total of 55 patients were included in this study. Mean age was 29 +/- 5.58 years while ranging from 20 - 40 years. Complete resolution of abscess was seen in 31 [56.4%] cases by single aspiration. Second aspiration was required in 24 [43.6%] patients and third aspiration in single setting was required in one case only. Recurrence after the second aspiration occurred in 08 [14.5%]. Incision drainage was required in 7 [12.7%] patients. Percutaneous aspiration of breast abscess through a wide bore [14-gauge] I/V cannula is a simple alternative to incision and drainage

Indications and outcome of small and large bowel stomas in emergency intestinal surgery

To evaluate the indications and outcome of small and large bowel stomas made during emergency intestinal surgery. Cross sectional study. Dow University of Health Sciences Civil Hospital Karachi, from January 2006 to December 2012. All emergency exploratory laparotomies performed for intestinal surgery, managed by stoma were included in this study. Decision for making stoma was based upon etiology, condition of the gut and judgment of the operating surgeon. Total numbers of patients were 200 [male 114, female 86] with mean age of 32.7 year. Trauma was the most common etiology. Firearm injury was the commonest mode [n=67, 33.5%] followed by stab wounds and blunt trauma [n= 12, 6.0%]. Patients also presented with perforation leading to peritonitis [n=65, 32.5%] and intestinal obstruction [n=52, 26%]. Tuberculosis was diagnosed in 5 [26.5%] patients, typhoid perforations in 35 [17.5%] and malignancy in 30 [15%] cases. The mortality in this series was 10%. Wound infection occurred in 42 [21%], burst abdomen in 10[5%] and enterocutaneous fistula and stoma retraction noticed in 6 [3%] patients. Stoma formation was a helpful adjunct surgical procedure performed in emergency intestinal surgery for various conditions with satisfactory outcome

Profile of patients with colorectal cancer

To document the profile of patients with colorectal cancer, modes of management and outcome. Cross sectional prospective study. This study was conducted at DUHS and CHK Pakistan from July 2007 to June 2012. Diagnosis was confirmed on histopathology through procto-sigmoidoscopy and colonoscopic biopsy. Abdominal ultrasounds and CT scan were used to stage the disease. Treatment was planned according to the presentation. Surgical procedure was decided according to the site and stage of the tumor. Neoadjuvant chemo-radiation was given for advance and adjuvant therapy for early tumors. A total of 72 patients were included in the study. Majority of patients [n=29 - 40%] presented with advance disease [stage IV]. Carcinoma rectum was diagnosed in 40 [55.5%] cases, sigmoid colon carcinoma in 12[16.6%], caecal cancer in 10[13.8%], ascending colon [n=6 - 8.3%], transverse colon and anal canal [n=2-2.7%] each. Anterior resection [APR] was performed in 20 [27.7%] cases, low anterior resection in two [2.7%], abdomino perineal resection in eight [11%], laparoscopic assisted APR in two [2.7%], Hartmann procedure and only stoma formation in ten [13.8%] each. Histopathology confirmed poorly differentiated adenocarcinoma in 36 [50%] patients. Overall mortality was 9.7% [n=7]. Majority of the patients diagnosed with carcinoma rectum were young and presented with advance disease

Profile of breast cancer patients

To report the profile of patients with breast cancer. Cross sectional study. Department of General Surgery, Dow University of Health Sciences Civil Hospital and Bantva Hospital Karachi, from March 2007 to February 2010. Diagnosis was based on history, clinical examination, Trucut biopsy, FNAC, excision biopsy, frozen sections where applicable. Surgical procedure was tailored according to disease related variables. Induction chemotherapy was given to the patients who present with advance disease, while adjuvant chemotherapy was used in patients with early tumor. Data was collected and recorded; SPSS version 16 was used to analyze the data. This study included 105 patients. Mean age of the patients was 41.9 year. Majority of the patients were with tumor in advance stage. There were 61 [58%] patients in stage III, while 25 were in stage IV [23.8%]. Distant metastases were found in bones [n=16], lungs [n=6] and liver [n=3]. Modified radical mastectomy and axillary clearance was performed in 70 [66.6%] patients. Modified radical mastectomy and axillary sampling was done in 18 [17%] patients. Histopathology confirmed invasive intraductal carcinoma in 99 [94%] cases. Majority of the patients present late with advance disease in younger age group. Modified radical mastectomy was the operative procedure performed in most of the patients

Recurrent abscesses following an intra muscular injection of diclofenac sodium

Two young females and one obese male presented with multiple discharging sinuses due to recurrent injection abscesses that burst spontaneously following intramuscular [IM] injections of diclofenac sodium. These abscesses were formed in relation to repeated IM injections given in order to relieve the pain. Multiple discharging sinuses led to disfigurement of the arm that was managed by wide local excision. Skin loss was dealt with skin grafting. Learning the proper technique of administering an intramuscular injection, alternating the injection site and change of analgesic can help to minimize the possibility of these complications from tissue necrosis

Pattern and presentation of carcinoma stomach

To determine the clinical profile of carcinoma stomach. A case series. A single unit of the Department of General Surgery, Dow University of Health Sciences and civil Hospital, Karachi, from April 2006 to April 2010. Patients with gastric cancer confirmed on histopathology were included in the study. Patients diagnosed with acid peptic disease and benign gastric ulcer were excluded. Variables studied were, age, gender, mode of presentation, presenting complain, endoscopy findings, palpable supraclavicular lymph node, histopathology, stage and treatment. Data was analyzed for descriptive statistics. Total number of patients were 15, including 9 males [60%] and 6 females [40%]; male female ratio was 1.5:1. Mean age was 48.6 +/- 4.47 years, ranging from 26-65 years. Majority of the patients [n=9, 60%] were presented through outpatient department, while the rest presented through emergency. Common presenting complains were vague upper abdominal pain, mass, ascites, peritonitis and hematemesis. On endoscopy tumour was found at the cardiac end in 5 patients [33%], at pylorus and antrum in 6 patients [40%], linitis plastica in 2 patients [13.3%], only body and body and pylorus were involved in 1 patient [6.7%] each. Ten patients [66.6%] presented at stage IV and 3 patients [20%] in stage III. Surgical resection was possible in 5 patients [33.3%]. Total gastrectomy was performed in one patient [6.7%], while subtotal gastrectomy was undertaken in 4 patients [26.7%]. Palliative gastrojejunostomy was performed in 4 [26.7%] and feeding gastrostomy and endoscopic stenting in 2 patients [13.3%] each. Chemotherapy was given to 8 patients [53.3%] patients while radiotherapy to 2 patients [13.3%]. Histopathological diagnosis was diffuse infiltrating adenocarcinoma in 10 [66.6%], infiltrating intestinal type in 3 [20%] and gastric lymphoma in 2 [13.3%] patients. Morality was 13.3%. Majority of the patients with gastric carcinoma were young males, presenting with advanced stage disease. Only 33% tumours were resectable while 53.3% tumours were managed by palliative treatment. Overall morality was 13.3%

Granulomatous mastitis: a case series

To find out the clinical and management profile of granulomatous mastitis [GM]. A case. This study was carried out at Civil Hospital and Dow University of Health Sciences, Karachi and Tuberculosis Clinic at Bantwa Hospital, Karachi, from January 1999 to January 2009. Histopathologically diagnosed cases of GM were studied. Data included, detailed history, examination, clinical diagnosis, ultrasound, mammogram and fine needle aspiration cytology [FNAC]. All patients were initially given antibiotics and corticosteroid for a period of 10 days. All patients were followed for a period of 6 months. Recurrent cases were managed by wide excision and followed for another period of 6 months. Percentage, mean and range values were determined on SPSS version 10. The mean age of the 22 patients was 37.6 years [range=22-52 years]. Right breast was affected in 54.5% and left breast in 45.5% patients. Eighteen [82%] were non-lactating. Patients presented clinically with painful breast lump in 54.5%, painless lump in 45.5% and additional discharging sinuses in 18%. Clinical diagnosis was chronic mastitis in 40.9%, tuberculosis of breast in 36.3% and malignancy in 22.7% patients. Mammography showed an ill-defined mass in 45.5% and asymmetrical density in 31.8%. Diagnosis was confirmed in all patients on histopathology. Recurrence was noted in 2 patients, managed by wide excision, and followed for another period of 6 months without evidence of complications. GM is an uncommon chronic inflammatory disease of the breast. Usually involving a single non-lactating breast in reproductive age group. It clinically mimics tuberculosis and carcinoma. Mammography remains non-conclusive. Excision and wide excision biopsy are both diagnostic and therapeutic in majority of cases. Treatment includes short course of steroids and antibiotic along with close regular surveillance

Spindle cell tumour presenting as an abdominal mass

Hyalinizing spindle cell tumour with giant rosettes [HSTGR] is a rare and recently described tumour that arises most commonly from the peripheral and deep soft tissues. It can present as a large abdominal mass. We report the case of a 60 year old man who presented with abdominal distention. CT scan showed a mass occupying the whole of the abdomen and pelvis. Exploration of abdomen revealed a jelly like mass about 20 x 20 cm in size. Mass was excised completely and confirmed as spindle cell tumour between grade I-II on histopathology

Primary adenocarcinoma of duodenum

Primary duodenal adenocarcinoma [PDC] of the distal half of duodenum is extremely rare. We report a case of a young male with adenocarcinoma of third and fourth part of duodenum presenting with long standing proximal small bowel obstruction with associated weight loss and anemia. Esophago-gastro-duodeno-scopy showed a fungating intraluminal growth in third and fourth part of the duodenum. Computed tomography also showed a solid mass in the third and fourth part of the duodenum. Computed tomography also showed a solid mass in the third and fourth part of the duodenum. Segmental resection of the third and fourth part of the duodenum was performed with single layer extra mucosal duodeno-jejunal anastomosis

Simultaneous duct ectasia of accessory and normally located breast

Accessory breast and duct ectasia are common clinical problems in their own right. However, their coexistence is a rare entity. Duct ectasia is a dilation in one or more of the larger lactiferous duct filled with a stagnant brown or green secretion, which may or may not discharge through the nipple. This material acts as an irritant and leads to periductal mastitis. Duct ectasia may present with subareolar mass, nipple discharge, nipple retraction, non-cyclical mastalgia or mammary fistula. Surgical options are microdochectomy or cone excision of major ducts. This case report describes the presence of duct ectasia in both accessory breast situated in the axilla and ipsilateral normal breast simultaneously

Spectrum of breast tuberculosis

To determine the presentation of breast tuberculosis, diagnostic methods and surgical treatments. A case series. This study was conducted at Dow University of Health Sciences and Tuberculosis Clinic at Bantwa Hospital, Kharadar, Karachi, from April 1999 to March 2007. Clinically diagnosed patients of breast tuberculosis, confirmed by laboratory work-up, were included in this study. Detailed history and examination of both breast and axillae were the primary diagnostic measures. Complete blood counts, ESR, Mantoux test, ultrasound, mammogram, fine needle aspiration cytology, staining for acid-fast bacilli both smear and culture were performed. Core biopsy for lumps more than 5 cm and wide excision biopsy for the lump less than 5 cm were the methods applied. Pre-designed research proforma was filled and descriptive statistics of age, site, side, clinical presentations, investigations were recorded and surgical treatment done. Anti-tuberculosis treatment was given to all patients. Thirty patients were studied with mean age of 28.4 years ranging from 16-48 years. Bilateral breast involvement was seen in 2 patients with 14 cases involving the right and left breast. Lymph node involvement was present in 7. Pulmonary tuberculosis was seen in 4 patients. Multifocal disease was present in 27 patients. The clinical presentation was with lump in 6, discharging sinuses in 14, cold abscess in 8, and non-healing ulcer in 2 patients. There were 5 lactating mothers. Montoux test was positive in 5, AFB smear and culture were positive in 3. Only AFB culture was positive in 4. Five patients required core biopsy for diagnosis of confirmation of lump more than 5 cm and wide excision biopsy was required in 7 patients with lump less than 5 cm. Despite antituberculous treatment, surgical management was required in 21 [70%] cases. Tuberculosis of the breast, simulating the carcinoma breast and granulomatous mastitis very closely and are difficult to be differentiated without tissue diagnosis. Surgical management is more often required

Use of seton on ganglion of the wrist

To find out the role of Seton on ganglion of the wrist. Interventional study. Surgical unit II, Sindh Government Lyari General Hospital, Karachi. Number of patient selected for this study were 105. They were having swelling of wrist weather on the dorsal or ventral surface. All patients were treated with the ligature of silk no 1 on needle. This silk ligature on needle passed through the ganglion. After suturing the ganglion jelly like material was aspirated by applying a pressure of thumb and index over the ganglion and triamcinolone injected. The ligature was left for ten days. There were 80 females and 25 male patients. Most of the ganglions were present on the dorsum of the wrist. Highest number of patients were in their third decade. Rcurrence was noticed in 13.6%. This procedure found to be simple, economic can be carried out in out patient department procedure and leaves no scar

Presentation of enlarged lymph nodes

To find out the pathology of enlarged lymph nodes, their clinical presentation, diagnosis and treatment. Descriptive study. Surgical Department, Sindh Govt Lyari General Hospital, Karachi. Total number of patients studied were 400 [262females, 138 males]. Male tofemale ratio was 1:1.89. Most of the patients were in younger age group. 40% were in the second decade, followed by 3rd decade, 23.2%. Majority had history of lump [92.5%], low gradefever [50.0%], cold abscess [49.25%], cough [48.0%], non healing ulcer [22.5%], discharging sinuses [21.5%], anorexia and weight loss [18.25%]. Associated pulmonary tuberculosis was present in few cases. Commonest group of lymph nodes affected were cervical, 74.5% followed by axillary lymph nodes 10.5%. Pathology found was tuberculosis 63% followed by reactive changes 11.25%, chronic non specific lymphadenitis 10.50%, non Hodgkin lymphoma 6.25%, Hodgkin's disease 5.50% and metastatic carcinoma 3.50%. This study concludes that highest number of patients were in the second decade with female predominance. Commonest pathology noticed was tuberculosis followed by non specific lymphadenitis