Histopathological Spectrum of gall bladder specimens after cholecystectomy

To determine the histopathological pattern of gall bladder specimens in patients undergoing cholecystectomy. This was a retrospective study carried out mainly at a private university hospital and two other non-teaching private hospitals of Hyderabad city over a period of three years from June 2005 to May 2008. Histopathology reports of all those patients who underwent cholecystectomy [open or laparoscopic] were analyzed. The records of these patients were scrutinized with particular emphasis on presentation, preoperative ultrasonographic findings, operative findings and histopathology results. A total of 282 specimens of gall bladder were subjected to histopathology during the study period. Among them 75 were of males and remaining 207 were of females. Chronic cholecystitis was the most dominant histopathology finding seen in about 64.5% patients followed by acute cholecystitis / empyema in 33.6% of patients whereas carcinoma of gall bladder was found in only about 1.4% of the patients. The commonest histopathological feature in this study was chronic cholecystitis

An audit of thyroid surgery: the Hyderabad experience

To make an audit of thyroid surgery performed in two private hospitals at Hyderabad. Descriptive study. This study was carried out at two private hospitals, mainly at Isra University Hospital, Hyderabad over a period of three years from April 2005 to March 2008. 140 patients with goiter were operated after complete investigative work up during the above mentioned period. Various complications of thyroid surgery and histopathology reports were noted and compared with national and international literature. The benign lesions were 89% while 11% lesions were malignant. Papillary carcinoma was the most common malignant lesion while colloid goiter was the most common benign lesion. The overall complication rate was 10.7%, hypocalcaemia being the most frequent complication followed by recurrent laryngeal nerve [RLN] injury. Colloid goiter is the most common benign lesion of the thyroid gland while papillary carcinoma is the most common malignant lesion of thyroid gland. The major complications of thyroid surgery were hypocalcaemia and RLN injury

Post thyroidectomy complications: the Hyderabad experience

Thyroidectomy is a very common surgical procedure worldwide and is performed by surgeons with varied training. The outcome and complication rates are largely dependent on surgeon's skill and experience, the extent of surgery, indication of surgery and number of thyroid surgeries performed at that particular centre. The objective of this study was to determine the frequency of postoperative complications after thyroid surgery in Hyderabad, Pakistan. It was a descriptive study and was carried out at 2 private hospitals including a teaching University Hospital over a period of 3 years from April 2005 to March 2008. All patients with goitre, who underwent any sort of thyroid surgery, were included in this study. Patients' bio-data including name, age sex, clinical status of thyroid, thyroid function tests, ultrasound, fine needle aspiration cytology and operative procedure, findings, post operative complications and histopathology reports were recorded. Data were analysed using SPSS 16.0. The overall postoperative complication rate was 10.7%. Postoperative hypocalcaemia was the most frequent complication observed in 3.5% of all patients followed by recurrent laryngeal nerve [RLN] injury noted in 2.8% patients. The less common complications were bleeding, seroma formation and wound infection. Majority of these complications were associated with total thyroidectomy, male gender, and in patients with age more than 30 years. The commonest post thyroidectomy complication was hypocalcaemia. Male gender, old age, and extensive thyroid surgery were associated with increased complication rate

Retained surgical foreign bodies: can these be prevented?

To determine the frequency and modes of presentation of retained surgical foreign bodies. This study was carried out mainly at a private teaching hospital i.e. Isra University Hospital and four other non-teaching private hospitals of Hyderabad city over a period of five years from June 2004 to May 2009. A total of 15 patients with retained surgical foreign body were found during the above mentioned study period. Female patients were more common than male patients. Gynaecological procedures were more frequently associated with surgical retained foreign bodies. Most [60%] of the causative procedures were performed as emergency procedures. Retained sponge was the most frequent foreign body [60%] followed by gauze piece. Discharging sinuses and abdominal masses [33.3% each] were the most frequent presentations followed by intestinal obstruction [20%]. Retained surgical foreign body is a rare but well known iatrogenic complication of surgery mostly seen in procedures done as emergency. Discharging sinuses, abdominal mass and intestinal obstruction are the most common modes of presentation. Proper frequent double sponge count and use of radioopaque markers are the major preventive measures to safeguard against this dangerous complication

Do the instructions to authors of Pakistani Medical Journals convey adequate guidance for authorship criteria?

To analyze authorship guidance in the instructions to authors provided by Pakistani medical journals. This study of Pakistan Medical and Dental Council [PMDC] indexed journals was conducted at Isra University, Hyderabad in June-July 2009. Instructions to authors of these journals were evaluated for the authorship guidance by two investigators separately. Analyses of discrepancies between two investigators were resolved by mutual discussions and consensus was achieved. Out of PMDC indexed 49 journals, instructions to authors of 37 [75.5%] journals were evaluated for the authorship guidance. Among these 37 journals, only six [16.2%] provided the proper International Committee of Medical Journals Editors [ICMJE] wording of authorship criteria whereas 17 [45.9%] just mentioned the links to general requirements for manuscripts submitted to the biomedical journals. About one third of the journals neither provided any authorship criteria nor any link to the general requirements for manuscripts submitted to biomedical journals. The authorship guidance provided by instructions to authors of PMDC indexed journals is less than satisfactory and needs substantial improvement

Thyroid scintigraphy: an overused investigation

Thyroid disorders are commonly encountered in general surgical practice. The purpose of this study was to determine how closely thyroid scintigraphy was ordered according to its indications in patients with thyroid diseases and the magnitude of its impact on the management. This cross-sectional study was carried out mainly at Isra University Hospital, Hyderabad over a period of 3 years from May 2005 to April 2008. All patients presenting with thyroid swelling and undergoing any type of thyroid operation were included in the study. Special emphasis was made on the indication of thyroid scintigraphy in these patients and its impact on the treatment. Out of 140 patients, 98 had thyroid scintigraphy done. Among these only 26 patients [26.5%] had it according the indication. In remaining 72 patients, thyroid scintigraphy did not reveal any added information to help in treatment plan. Thyroid scintigraphy is an overused investigation in thyroid patients. Routine use of thyroid scintigraphy in all goiter patients should be discouraged

Complications of laparoscopic cholecystectomy at Isra university hospital, Hyderabad

The main objective was to determine the complications of laparoscopic cholecystectomy [LC] and its causes at sra University Hospital, Hyderabad. This was a retrospective study carried out from July 2005 to June 2007. Data of all patients undergoing laparoscopic chotecystectomy during the study period and fulfilling the selection criteria was collected and analyzed retrospectively. A total of 216 patients underwent laparoscopic cholecystectomy with an overwhelming majority of females. The overall complication rate was 5%. The complications included bleeding [4/216, 1.8%] from cystic artery and gall bladder bed, port site infection [4/216, 1.8%], bile duct injury [2/216, 0.9%] and colonic injury [1/216, 0.4%]. The common causes of these complications were accidental injury to cystic artery, gross spillage of infected bile and erroneous clipping of common bile duct. Bleeding and Port site infections were the commonest complications followed by common bile duct and colonic injuries. The commonest cause of bleeding was cystic artery injury whereas the commonest cause of port site infection was gross spillage of infected bile

Spectrum of benign breast diseases

To determine the frequencies of various benign breast diseases [BBD] in female patients in three private hospitals of Hyderabad. This is a prospective cohort study of all female patients visiting the surgical clinic with breast problems. This study was conducted at Isra University Hospital Hyderabad and two other private hospitals of Hyderabad over a period of about three years starting from March 2004 to February 2007. All female patients visiting the surgical clinic with breast problems were included in the study. Patients with obvious clinical features of malignancy or those who on work up were diagnosed as carcinoma were excluded from the study. A total of 275 patients were included in the study. About 44% [120/275] patients belonged to 3[rd] decade of life [age between: 21-30 years] followed by 33% from 4[th] decade [age between: 31 - 40 years]. Fibroadenoma was the most common benign breast disease, seen in 27% [75/275] of patients, followed by fibrocystic disease seen in about 21% [57/275] patients. Benign Breast Diseases [BBD] are common problems in females of reproductive age. Fibroadenoma is the commonest of all benign breast disease in our set up mostly seen in 2[nd] and 3[rd] decade of life. Fibrocystic disease of the breast is the next common BBD whose incidence increases with increasing age

Practice of surgeons regarding examination of pathological specimens in operating room

The debate of routine versus selective submission of specimens for histopathology makes it important to know the present practice of surgeons. The objective of this study was to determine the proportion of general surgeons examining the gall bladder and appendix specimens in operating room before submission for histopathology. This questionnaire based survey was conducted for the general surgeons working in the city of Hyderabad, Pakistan during May-June 2008. The data was entered and analysed in SPSS 11.0 software statistical program to determine the impact of designation, hospital category and experience on the responses of surgeons. Overall, 42 out of 47 qualified general surgeons working in Hyderabad, Pakistan responded the questionnaire. About 23.8% and 4.8% reported to be always examining gall bladder and appendix specimens respectively in operating room. About 66.7% and 40.5% reported to be submitting every gall bladder and appendix specimen respectively for histopathology. Lack of practice and poverty were reported as the common causes of not examining the specimen in operating room and not submitting every specimen for histopathology respectively. About 25.8% and 81.8% from public and private sector hospitals respectively reported to be submitting every appendix specimen for histopathology. About 88.2% and 52% of surgeons having experience of five years or less and experience of more than five years respectively reported to be submitting every gall bladder specimen for histopathology. There is widespread variation in the practice of general surgeons regarding operating room examination as well as submission of specimens for histopathology

diagnostic value of fine needle aspiration cytology in thyroid nodules

The purpose of this study was to determine the diagnostic value of fine needle aspiration cytology [FNAC] for thyroid nodules. Descriptive study. This study was carried out at two private hospitals including a teaching university hospital i.e. Isra University Hospital, Hyderabad over a period of three years from April 2005 to March 2008. All patients with thyroid nodule [solitary and dominant], diagnosed on the basis of history, clinical examination and radiological investigations were included in this study. FNAC was performed by standard technique before undergoing operation for thyroid nodule and then the resected specimens were submitted for histopathology. The data was analyzed to determine the sensitivity, specificity, accuracy and positive and negative predictive values of FNAC for thyroid nodules. Overall, 142 patients underwent FNAC during the three years study period. Final histopathology confirmed benign lesions in 78 out of 84 FNAC proven benign lesions while 11 out of 12 FNAC proven malignant lesions were confirmed on final histopathology. The sensitivity and specificity of FNAC were found to be 65% and 98% respectively. The diagnostic accuracy was 92.8% whereas positive and negative predictive values were 91.6% and 93% respectively. FNAC is a highly sensitive, specific and accurate procedure for the diagnosis of the thyroid nodules. It plays a useful role in planning the surgical management of thyroid nodules as it helps significantly in differentiating between benign and malignant lesions

Trichobezoar: an uncommon surgical problem

Trichobezoar is an uncommon condition characterized by impaction of swallowed hair in the gastrointestinal tract. This is a case report of young psychiatric male presenting with well defined left hypochondriac mass. Upper GI endoscopy and CT scan were used to confirm the diagnosis of trichobezoar. The patient underwent exploratory laparotomy and a huge trichobezoar was removed. Along with the surgical follow up, patient also received psychiatric treatment postoperatively

Appropriate cut-off value of alvarado scores for patients undergoing appendectomy at Isra university hospital, Hyderabad

To determine the frequencies as well as the appropriate cut-off value of Alvarado scores in patients undergoing appendectomy at Isra University Hospital, Hyderabad-Sindh, Pakistan. A descriptive study. Isra University Hospital, Hyderabad, from September 2007 to September 2008. One hundred consecutive patients fulfilling the selection criteria during the above mentioned period were included in this study. After the detailed history, clinical examination and relevant investigations, the Alvarado score was calculated for each patient. After appendectomy, the relationship of operative and histopathological findings with Alvarado score as well as cut-off points for the decision of appendectomy was analyzed. The majority of patients were between the ages of 15 to 30 years with male to female ratio of 2.2:1. The commonest operative finding was acutely inflamed appendix followed by perforated appendix. Gangrenous appendix and normal looking appendix. A majority [57%] of the patients had Alvarado scores of eight or more. None of the patients having a score of four or less was operated. Normal and perforated appendices were not found in patients having Alvarado scores of eight or more and seven or less, respectively. In this study, 8%, 16%, 19%, 22%, 26% and 9% of the patients undergoing appendectomy had Alvarado scores of five, six, seven, eight, nine and ten, respectively. An Alvarado score of seven was the most appropriate cutoff value for the decision to perform appendectomy

Post-thyroidectomy sore throat: a common problem

To determine the frequency of postoperative sore throat after thyroidectomy under general anaesthesia with endotracheal intubation. This study was carried out at two private hospitals including a teaching University hospital i.e. Isra University Hospital, Hyderabad over a period of three years from April 2005 to March 2008. All patients who underwent different types of thyroid surgeries during above mentioned period were included in this study. All relevant data especially age, sex, weight, American Society of Anesthesiologist's [ASA] physical status of patient, type and duration of Surgery, operative duration, number of intubation attempts and size of cuffed endotracheal tube [ETT] used were recorded on a standard form. The patients were asked direct questions on first post operative day regarding sore throat. Post operative sore throat was observed in 112 [80%] patients. The ETT having diameter of 7.5 mm or more, extensiveness of thyroidectomy, age of more than 35 years and operative duration of more than one hour were the statistically significant factors contributing in the occurrence of post thyroidectomy sore throat. There was no statistically significant impact of gender and number of intubation attempts on the occurrence of post thyroidectomy sore throat. Postoperative sore throat is a common complication after thyroid surgery. Larger size of ETT, more extensive surgery, increased age and prolong operation are the main contributing factors for the occurrence of post operative sore throat

Mortality in necrotizing fasciitis

The objective of this study was to determine the mortality rate in patients presenting with Necrotizing Fasciitis. This prospective study was conducted at ward 26, JPMC Karachi over a period of two years from March 2001 to Feb 2003. All patients above the age of 12 years diagnosed to be having Necrotizing Fasciitis and admitted through the Accident and emergency department were included in this study. After resuscitation, the patients underwent the emergency exploration and aggressive surgical debridement. Post-operatively, the patients were managed in isolated section of the ward. The patients requiring grafting were referred to plastic surgery unit. The patients were followed up in outpatients department for about two years. Over all, 25 male and 5 female patients fulfilled the inclusion criteria and were included in this study. The common clinical manifestations include redness, swelling, discharging abscess, pain, fever, skin necrosis and foul smelling discharge etc. The most common predisposing factor was Diabetes mellitus whereas the most commonly involved site was perineum. All patients underwent aggressive and extensive surgical debridements. The common additional procedures included Skin grafting, Secondary suturing, Cystostomy and Orchidectomy. Bacteroides and E. coli were the main micro-organisms isolated in this study. Bacteroides was the most common microorganism isolated among the eight patients who died. Necrotizing Fasciitis is a potentially life threatening emergency condition and carries the mortality rate of about 26.6%. The major contributing factors to increase the mortality missed initially diagnosed, old age, diabetes mellitus truncal involvement and late presentation. Anorectal involvement of disease carry worse prognosis. Hyperbaric oxygen therapy and proper use of unprocessed honey reduced the mortality rate

Appendectomy; comparison between laparoscopic and open method

The purpose of this prospective study was to compare length of hospital stay, in hospital complications and operative time between laparoscopic appendectomy [LA] and open appendectomy [OA]. This prospective study was carried out at King Khalid Hospital, Najran, Kingdom of Saudi Arabia over a period of 26 months from July 2002 to August 2004. Patients were randomly divided into laparoscopic and open appendectomy groups and length of stay, operative time and in hospital complications were noted. 60 patients underwent laparoscopic appendectomy and 65 underwent open. Operating time was longer in laparoscopic group but length of stay was shorter in laparoscopic group. Wound infection was the common complication in both group but it was higher in patients who underwent open appendectomy. Laparoscopic appendectomy can be performed with morbidity similar to open appendectomy and may actually have decreased wound infection rate

Laparoscopic cholecystectomy: Conversion rate and its causes at Isra university hospital, hyderabad

To determine the conversion rate of laparoscopic cholecystectomy [LC] and its causes at Isra University Hospital, Hyderabad, Pakistan. This was a retrospective study carried out at Isra University Hospital, Hyderabad from July 2005 to June 2007. All patients who were scheduled for LC for symptomatic gall stones were included in the study. Those with history of pancreatitis, jaundice, common bile duct dilatation, choledocholithiasis and gall bladder mass were excluded. A total of 216 patients underwent LC during the study period. The mean operating time was 45 minutes and average hospital stay was two days. The conversion rate was 4%, with commonest cause being dense adhesions. Laparoscopic cholecystectomy was a safe method of treatment with very low conversion rate

Superiority of laparoscopic appendectomy over open appendectomy: the hyderabad experience

To compare the out come of laparoscopic and open appendicectomies in terms of operative time, analgesic requirement, postoperative complications, hospital stay, return to normal activity and condition of scar. This prospective study was carried out in Department of Surgery, Liaquat University Hospital Hyderabad/ Jamshoro from September 1997 to August 2000. One hundred consecutive patients of age ranging from 15-45 years with features suggestive of acute appendicitis were equally divided into laparoscopic appendectomy [LA] and open appendectomy [OA] groups, after taking informed consent. LA was done with the help of three trocar/cannulae creating pneumoperitoneum with CO2 whereas OA was performed by Lanz incision. The data were analyzed by Student t-test and Chi square tests using SPSS version 10. The operating times in OA and LA were 20-70 minutes [mean 30] and 25-95 minutes [mean 55] respectively. Increased doses of analgesics, antibiotics and antiemetics were required in OA, as compared to LA. The mean postoperative hospital stay in LA group was 1.4 days [range 1-3 days] whereas it was in OA group, it was 3.5 days [range 2-6 days]. 2 LA is safe and has major benefits like less postoperative pain, decreased wound infection, early hospital discharged, early return to work and a better cosmetic scar than OA

Cost effectiveness of topical glyceryl trinitrate versus lateral internal sphincterotomy for chronic anal fissure

To compare the cost effectiveness of initial use of topical glyceryl trinitrate [GTN] before lateral internal sphyncterotomy against the sphincterotomy as primary treatment modality for chronic anal fissure. This prospective randomized study was conducted at Isra University Hospital, Hyderabad between November 2004 and October 2005. Fifty patients fulfilling the criteria were randomized into two equal groups. One group was treated with topical GTN ointment and other group with lateral internal sphincterotomy. Patients were followed up for one year. In case of failure of treatment or recurrence in GTN group, the patients were subjected to lateral sphincterotomy. The total expenditures of treatment in both groups were separately calculated and compared. Pain relief was observed in 92% of the patients in both the groups after 6 weeks. Complete healing of fissure was observed in 92% and 88% of the patients in GTN group and sphincterotomy group respectively after 6 weeks. Recurrence was observed in 16% of the patients in GTN group and non in sphincterotomy group after one year. The sphincterotomy was avoided in 76% of the patients in GTN group during one year. The total expenditure of GTN group was Pakistani Rupeed [PKR] 139500 and of sphincterotomy group was PKR 387500; about 2.8 time the expenditure of GTN group. The initial use of topical GTN before sphincterotomy against the sphincterotomy as primary treatment modality for chronic and fissure is cost effective and provides substantial monetary benefit

Gastric outlet obstruction: change in etiology

To assess the results of the management of Acute Pancreatitis. Retrospective descriptive study from Jan. 2003 to Dec. 2005. Surgical Ward-2, Jinnah Postgraduate Medical Centre, Karachi. 62 patients with the diagnosis of Acute Pancreatitis. The demographic variables, cause and outcome of the cases were observed and recorded. Out of the total 62 patients, 37 had cholelithiasis; other causes were alcoholism, abdominal trauma, worms, instrumentation [ERCP] and drugs. All patients were classified according to APACHE-II scoring system into acute oedematous pancreatitis, severe acute pancreatitis and acute necrotizing pancreatitis. Forty eight patients developed complications including ARDS, anuria, hypotension, paralytic ileus and pseudocyst formation. Four cases died due to multiorgan failure. Current recommended principles in the management of Acute Pancreatitis are based on identification of patients having severe disease and the group at risk for the development of complications. APACHE-II is a helpful scoring system and CT scan is an effective diagnostic tool in difficult cases