Ileosigmoid knotting: an unusual cause of intestinal obstruction

Ileosigmoid knot is also known as compound volvulus or double volvulus. It consists of either an intertwining or a knot forming between a loop of ileum and sigmoid colon. This lead to a complex intestinal obstruction and may result in strangulation of one or both the segments of bowel loop. We report a case of pregnant woman who presented with acute abdominal pain. Following resuscitation she was operated and Ileosigmoid knotting was found. Loops of ileum and sigmoid colon were found gangrenous. Resection of ileal loop and stoma was fashioned while resection and anastomosis of sigmoid colon loop was performed. Recovery was uneventful

Outcome of mesh anchoring using stainless steel skin staples versus polypropylene suturing in Lichtenstein's tension free inguinal hernia repair

Objective: to find out the effectiveness of anchoring mesh using stainless steel skin staples versus polypropylene sutures in inguinal hernia surgery with Lichtenstein's technique in terms of operation time, postoperative pain and recurrence of disease

Study design: randomized controlled trial

Place and Duration of study: department of Surgery ward 26 surgery, Jinnah Postgraduate Medical Centre Karachi, from February 2014 to January 2016

Methodology: patients above 18 year of age who underwent inguinal hernia repair using mesh were included. They were randomly assigned in to Group A in which the mesh was secured using stainless skin staples and Group B where mesh was anchored using polypropylene [Prolene] 2/0 sutures. The operative time was recorded in both the groups. All the patients were followed up in outpatient department for recording the postoperative pain on the visual analogue scale [VAS]

Results: sixty-four patients fulfilling the inclusion criteria were included. They were randomly divided into two groups of 32 patients each. The mean age of Group A and B patients was 45.85 +/- 13.50 year and 48.56 +/- 14.56 year respectively. Total operation time and from mesh placement to skin closure was found significant in favor of group A [p <0.001]. At 7[th] postoperative day in Group A twelve patients had no pain, Fifteen had mild, four with moderate and one patient had severe pain. In Group B ten patients reported no pain, fourteen had mild, five moderate and three with severe pain. Three patients in group A and four in Group B developed seroma postoperatively. Wound infection developed in one patient in group B. There was neither mesh related infection nor recurrence of hernia in either of the groups

Conclusion: operation time was shorter in patients where staples were used. Postoperative pain was also less in intensity in this group

Effective diagnosis of acute appendicitis - comparison of RIPASA and Alvarado scoring systems

Objective: To compare the diagnostic usefulness of RIPASA and Alvarado score in identifying patients with acute appendicitis presenting with right iliac fossa pain

Study design: Cross sectional analytical

Place and Duration of study: Department of Surgery Unit III, Jinnah Postgraduate Medical Centre [JPMC] Karachi, from December 2013 to December 2015

Methodology: All patients above 15 year age of either sex with right iliac fossa pain, were included in the study. All patients were clinically assessed and scored as per Alvarado and RIPASA scoring systems. Decision for appendectomy was based on the surgeon's clinical judgment. The scoring systems were used for the study purpose. The histopathological findings were compared with the scores of the two systems

Results: Using RIPASA scoring criterion, 172 [86%] patients were suspected to have acute appendicitis. Out of these 164 patients had acute appendicitis on histopathology report [true positive - TP] where as 8 were false positive [FP], 16 false negative [FN] and 12 true negative [TN] for acute appendicitis. Using Alvarado score, only 22 [11%] were suspected to have acute appendicitis. A total 21 patients were confirmed true positive [TP] based on histopathology, only one false positive [FP], 159 false negative [FN] and 19 true negative [TN]. The sensitivity of RIPASA score was 91.11%, specificity 60%, PPV 95.34%, NPV 42.85%, diagnostic accuracy 88% and rate of negative appendicectomy was 10.25%. Sensitivity of Alvarado score was 11.67%, specificity 95%, PPV 95.45%, NPV 10.67%, diagnostic accuracy 20% and negative appendicectomy rate was 0.132%

Conclusion: The RIPASA score was reliable and sensitive diagnostic tool to make diagnosis of acute appendicitis

Scalpel versus diathermy for midline abdominal incisions

To compare the incision time, blood loss, post-operative complications [wound infection] and post-operative pain in midline laparotomies incisions made using scalpel versus diathermy. Randomised controlled trial. Department of General Surgery Ward 26, Jinnah Postgraduate Medical Center [JPMC] Karachi, from June 2012 to June 2013. A total of 220 patients were enrolled in the study after taking informed consent. These patients were randomly assigned to Group A [Scalpel incision group] and Group B [Diathermy incision group] using opaque labeled envelopes. The surgeon was informed of the type of incision before the surgery started. There was a significant statistical difference in terms of incision time [p = 0.001], blood loss [p=0.014], post-operative pain [p=0.001, 0.012 and 0.021 on day 1, 2 and 3 respectively] and post-operative analgesics requirement [p=0.021]. On the other hand there was no significant statistical difference in terms of postoperative complications [wound infection] and length of hospital stay. Diathermy incision in midline laparotomy was significantly superior to the scalpel because of reduced incision time, less blood loss, less early postoperative pain and reduced analgesic requirements

Open lichtenstein repair versus laparoscopic transabdominal preperitoneal repair for inguinal hernia

To compare open Lichtenstein with laparoscopic transabdominal preperitoneal [TAPP] inguinal hernia repair. Randomized controlled trial. Surgical Ward Jinnah Postgraduate Medical Center Karachi, from October 2012 to March 2013. This study was carried out on eighty patients, divided into 2 equal groups of 40 patients each. Group I, was offered Lichtenstein hernia repair and in group II, laparoscopic transabdominal preperitoneal approach was performed. Mean operative time, duration of hospital stay, pain score and infection rate were compared between two groups. All the patients included in this study were males. The mean age of the patients was 44.9 +/- 18.02 year in group I and 38.9 +/- 18.21 year in group II. Operative time and hospital stay were statistically insignificant but pain and wound infection had significant differences. The mean VAS score was found higher in group I than group II [p value 0.0048]. It was 6 +/- 1.89 in group I and 3.6 +/- 1.35 in group II. There were three cases [7.5%] of wound infection in group I whereas in group II there were no case of wound infection [p=0.0405]. The laparoscopic hernia repair is a preferable procedure. It has less postoperative pain and less wound infection

Biliary ascariasis- atypical infestation of ascaris lumbricoides

Ascaris lumbricoides is the most frequent parasitic infestation in developing countries. Its usual habitat is small intestine. The less frequent sites are biliary tree, gall bladder, appendix and pancreas. This is a report of 36 year old woman who presented with the symptoms of acute cholangitis in whom at endoscopic retrograde cholangiopancreatography, worm was removed from bile duct through duodenal papilla

Comparison of modified radical mastectomy using harmonic scalpel and electrocautery

To compare the intraoperative and postoperative outcome of modified radical mastectomy [MRM] using harmonic scalpel versus electrocautery. Comparative study. Department of Surgery, Jinnah Postgraduate Medical Center [JPMC] Karachi, Surgical ward 26, from December 2010 to June 2012. This study included fifty females undergoing modified radical mastectomy. Twenty-five were operated with harmonic scalpel and twenty-five with electrocautery. Operative time, blood loss, total drainage volume [axillary and flap drains] and days for which the drains were placed, pain score, volume of sermoa, hematoma, frequency of flap necrosis and lymphedema were compared. There were no statistical differences between the two groups as regard to operative time [p=0.264], seroma [p=0.247], hematoma [p=0.235], flap necrosis [p=1.000] and lymphedema [p=1.000]. Furthermore there was no statistically significant difference in terms of pain relief [p=0.197]. There was a highly significant difference [p<0.001] in relation to blood loss, drainage volume of flap drain and duration of placement of flap drain only. Hospital stay was not shortened because all patients were routinely discharged after three days following removal of the drains. Use of harmonic scalpel in mastectomy significantly reduced blood loss, total drainage volume and days but did not lower operative time, seroma formation, postoperative pain and total hospital stay.

Phyllodes tumors of breast: a review of 30 cases

To describe clinical features, histopathology, treatment and prognosis of phyllodes tumor of breast. Descriptive case series. Department of Surgery, Jinnah Postgraduate Medical Centre Karachi, from 2005 to 2011. This is a retrospective review of the medical records of patients managed over a period of six years. The data of patients with phyllodes tumor [PT] of breast were analyzed for age at the time of diagnosis, the duration of the illness, tumor size, tumor localization, ultrasound features, preoperative diagnosis, surgical procedure, pathological grading and outcome. Grading of tumor was done according to the World Health Organization [WHO] classification. The age of the patients ranged from 19 year to 66 year [mean age 40 year]. The mean age of occurrence of benign, borderline and malignant tumors was 35.5, 44.5 and 45.6 year respectively. The mean time from onset of symptoms and pathological diagnosis of PT ranged from one to 36 months [mean 15 months]. Tumors occurred in the left breast in 12 cases, and on right side in 16 cases. The upper outer quadrant was involved in 11 [36.6%] cases. The resection margin was recorded as negative in 18 cases. Nine patients underwent postoperative radiation [3 borderline and 6 malignant PTs]. Local recurrence occurred in one benign, 3 borderline and 2 malignant cases. Treatment in the case of recurrent benign PT included lumpectomy. Mastectomy was done in 5 other recurrent cases. Phyllodes tumors of the breast have an unpredictable outcome. A wide local excision, with adequate margin of normal breast tissue, is the preferred initial therapy

Excision with Z-plasty in pilonidal sinus

To measure the outcome of the pilonidal sinus exicision with Z-plasty in terms of postoperative hospital stay, recurrence, wound infection and patient's time off work. Cross sectional study. Department of General Surgery, Ward-26, Jinnah Postgraduate Medical Centre Karachi, from January 2008 to January 2009. Patients with pilonidal sinus above 12 years of age were included in this study. They were diagnosed clinically. Those with abscesses and recurrence of disease were excluded. A total of 40 patients were operated. There were 28 [72%] males and 12 [28%] females. Majority were in the age group of 21 - 30 years [64%]. The operating time ranged between 30-45 minutes [mean 35 + 2]. Mean postoperative stay was 3.5 days [2- 5 days] and return to work was between 7-18 days [mean 12.5 days]. Three patients [7.5%] patients developed wound dehiscence, 6 [15%] had wound infection and recurrence occurred in 2 [5%]. 95% confidence interval[C.I] of overall complication was 13.4-40.1. Excision of pilonidal sinus followed by primary closure with Z-plasty technique had the advantage of early wound healing, short postoperative stay and low risk of recurrence

Outcome of stapled haemorrhoidectomy versus Milligan Morgan's haemorrhoidectomy

To compare the postoperative outcome of stapled haemorrhoidectomy and conventional Milligan Morgan's open haemorrhoidectomy. Comparative study. Surgical Unit 1, Ward-3, Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, from March to September 2006. Sixty patients of late 2nd, 3rd and 4th degree haemorrhoids were selected for admission from the outpatient department after taking informed consent. Patients with concomitant anal disease [e.g. fissure, abscess, fistula, ano-rectal cancer etc.] were excluded. Two groups of thirty each were made, one for Milligan-Morgan open haemorrhoidectomy and another for stapled haemorrhoidectomy, in which excision of a ring of mucosa proximal to the haemorrhoid[s] was done thus, interrupting the blood supply but maintaining continuity of the rectal mucosa. The operative time was measured in minutes. Postoperative pain was assessed through VAS. Bleeding was measured as no, mild, profuse. Other post-operative complications during hospital stay like urinary retention, anal stenosis etc. were noted. Student t-test, chi-square test and repeated measured analysis of variance were applied to compare the variables. The mean age was 40.7 +/- 11.6 years. A majority [53.3%] of patients [combined% in both groups] had third degree haemorrhoid. The mean length of operative time was found statistically insignificant between open and stapled groups [19.6 +/- 5.9 vs. 22.4 +/- 7.2 minutes, p=0.974]. However, the mean length of postoperative hospital stay was significantly less in the stapled than open haemorrhoidectomy group [3.37 +/- 2.2 vs. 2.03 +/- 0.81 days, p=0.003. Mean postoperative pain [observed by VAS] in the stapled group was significantly less than the open haemorrhoidectomy group [4.43 +/- 1.25 vs. 7.37 +/- 0.72]. The proportion of postoperative bleeding, infection, anal tag, urinary retention, tenderness on digital rectal examination and wound discharge was higher in open than stapled haemorrhoidectomy group, but statistically insignificant [p < 0.05]. There was a significant difference between Milligan Morgan's and stapled haemorrhoidectomy for postoperative pain and hospital stay. However the mean length of operative time was insignificantly different

Tubercular fistula-in-ano

To determine the frequency of tuberculosis in recurrent fistula-in-ano. Case series. This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from 1998 to 2007. The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery. Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary, abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months. Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male. The fistulae were low type, single and usually located posteriorly [n=9] with everted margins. Ten were located within 3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months. Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months