Feeding Jejunostomy as a Lifeline for Esophageal Malignancies

Objective: To share experience about enteral nutrition via feeding jejunostomy in patients undergoing esophagectomies or for palliative purposes and compare our findings with similar studies. The objective of this study is to show the safety/viability of the procedure in patients undergoing esophagectomies and as a palliative procedure in inoperable CA esophagus

Study Design: Observational study

Place and Duration of Study: CMH Lahore and CMH Rawalpindi, from 2010 to 2016

Material and Methods: Feeding jejunostomy is a surgical technique for placement of a feeding tube into small intestine mainly for administration of nutrition. Our method was based upon Witzel jejunostomy technique with emphasis on early postoperative commencement of enteral nutrition and achievement of target caloric and protein requirement subsequently. A total of 439 patients who underwent feeding jejunostomy were included. These include patients suffering from any benign or malignant pathology for which esophagectomy was done and those patients who are suffering from inoperable carcinoma and underwent feeding jejunostomy for palliative purposes

Results: Result and price analysis shows that feeding jejunostomy is financially viable as per day nutrition cost for feeding via total parenteral nutrition [TPN] is Rs 8500 +/- 500 [including required daily labs] and for enteral its around 560 +/- 40 Rs/day. None of our patient was put on TPN and none suffered from malnutrition. Percentage of complications rendered were on par with the results from similar studies and meta-analysis

Conclusion: We conclude that feeding jejunostomy is financially viable with minimal complications, that justifies its use and its superiority over TPN

experience of laparoscopic modified heller cardiomyotomy for achalasia cardia

Objective: The study was carried out to ascertain the outcome of laparoscopic modified Heller's myotomy for achalasia cardia and to determine the morbidity associated with it

Study Design: Descriptive cross sectional study

Place and Duration of Study: The study was conducted in Combined Military Hospital [CMH] Rawalpindi over a period of 4 years, from Jan 2010 to Aug 2014

Material and Methods: This study was carried out on patients undergoing surgical repair of laparoscopic Heller myotomy for cardiac achalasia at Combined Military Hospital Rawalpindi over a period of four years [2010-2014]. Patients undergoing laparoscopic-modified Heller myotomy at a thoracic referral and surgical training center. Eighteen cases of achalasia cardia based on clinical, barium and endoscopic findings were included in the sample using non probability purposive sampling technique. Pseudo achalasia, sigmoid esophagus were excluded. Laparoscopic modified Heller myotomy was done in all patients. Data were analyzed with the help of SPSS 20.0

Results: Age ranged between 14 years to 40 years with mean age of 28 years. The most frequent symptom was dysphagia [95%], followed by regurgitation of ingested food [60%], weight loss [40%] and chest pain [20%]. Mean operating time was forty minutes. There was no perioperative mortality. We applied Dor patch in 4 patients. Three patients had mucosal tear on large myotomy, diagnosed per operatively and repaired. There was no conversion to open procedure. There was marked improvement in symptoms especially dysphagia and there was no post operative reflux

Conclusion: Modified Heller myotomy by laparoscopic approach is a safe and effective procedure with acceptable results. It is easy to perform and improves the symptoms of the suffering individual

Clinical assessment compared with chest-x-ray after removal of chest tube to diagnose pneumothorax

Objective: To evaluate clinical judgment in ruling out pneumothorax during the removal of the chest tube by auscultating the chest before removal and after the extubation of the chest tube in comparison to x ray radiological results

Study Design: Descriptive cross sectional study

Place and Duration of Study: Combined Military Hospital [CMH] Lahore Pakistan, from August 2015 to March 2016

Material and Methods: A sample size of 100 was calculated. Patients were selected via non probability purposive sampling. Children under 14 years were not included. The patients with mal-positioned chest tube, surgical site infection, air leak and the patients with more than one chest tube on one side were excluded. A proforma was made and filled by one person. Chest tubes were removed by two trained senior registrars according to a protocol devised. It was ensured that there was no air leak present before removal clinically and radiologically. Another chest x-ray was done within 24 hours of extubation to detect any pathology that might have occurred during the process. Any complication in the patient clinically was observed till the x-ray film became available. Two sets of readings were obtained. Set A included auscultation findings and set B included x ray results

Results: Out of 100 patients, 60 [60%] were males and 40 [40%] females. The ages of the patients ranged between 17-77 years. Mean age of the patient was 43.27 +/- 17.05 years. In set A out of 100 [100%] no pneumothorax developed clinically. In set B out of 100 patients 99 [99%] showed no pneumothorax on chest x ray, only 1 [1%] showed pneumothorax which was not significant [less than 15% on X ray]. However, the patient remained asymptomatic clinically and there was no need of reinsertion of the chest tube

Conclusion: Auscultatory findings in diagnosing a significant pneumothorax are justified. Hence, if the chest tube is removed according to the protocol, clinically by auscultation we can be sure that no significant pneumothorax developed during extubation, thus there is no need of x-ray after wards

Is chest tube clamping necessary before removal? an experience with 2661 cases of tube thoracostomies

Objective: The aim of this study was to evaluate outcome of chest tube removal without clamping and relying only on clinical or radiological status for removal

Study Design: Retrospective descriptive study

Place and Duration of Study: The study was conducted in CMH Rawalpindi over a period of four years

Material and Methods: All patients of tube thoracostomies during Jan 2010 to Dec 2013 were included. Sample size was 2661. 1061 intubations were done for trauma, effusions and pneumothoraces, 905 in thoracostomies, 443 in VATS procedures like decortications, apical staplings, pleural biopsies and thymectomies and 252 in miscellaneous procedures such as open pleural biopsies, thoracoplasties and chest wall resections and reconstructions. Chest tube removal was based on absence of air bubbling in chest bottle, clinically or radiologically expanded lung, less than 6 cm excursion of column of chest tube and fluid output of <50ml [pus] and <100ml [clear fluid]. It was ensured in all cases that chest tube was not blocked and all tubes were removed by a thoracic surgery trainee. Chest tube was not clamped in any patient before removal to see respiratory distress

Results: Tube thoracostomies were performed in a vast variety of procedures. 1940 [72.9%] were males and 721 [27.1%] were females. Mean age was 37 years. In 1529 [57.4%] intubation was done on the right side. In 34 [1.27%] there was recurrent fluid collection. Recurrent pneumothorax was seen in 18 [0.67%] while tension pneumothorax was seen in 4 [0.15%]. Collective complication rate was in 56 [2.1%]. There was no mortality

Conclusion: Current worldwide practice of clamping chest tube before removal to judge respiratory distress can be challenged by our study. Emphasis is laid on clinical judgment, absence of air leak and minimal excursion sign of well expanded lung before removal of chest tube

experience of corrective surgery of 37 cases of chest deformity

The study was carried out to ascertain the cosmetic outcome of corrective surgery for pectus deformity and to determine the morbidity associated with it. Quasi-experimental study. The study conducted in CMH Rawalpindi and CMH Quetta from 2007 to 2012. Total number of cases operated for chest deformity was 37. Modified Welch procedure with sub perichondrial resection was done with a strut of prolene mesh in a majority of exacavatum repairs and k wires in few. Pectoroplasty was subsequently carried out in all patients. Midline incision was made in a majority of patients. Subjmammary incision was made in some female patients with a lower deformity due to better cosmetic outcome. Inclusion criterion was patients with chest deformity without any cardiac and spinal deformity. Age range was between 4 years to 12 years with mean age of 8 +/- 2.3 years. twenty four [65%] deformities were of excavatum and 9 [24%] were of carinatum type. Four [11%] cases were of unilateral asymmetrical deformity. Mean operating time was 95 +/- 11 minutes. Transfusion was required in only 1 [3%] o the cases. There was no perioperative mortality. Four [11%] patients had formation of seroma and 3 [8%] developed pneumothorax which was aspirated without placement of chest tube. Two [5%] had surgical site infection. Fifteen [41%] patients were satisfied and 21 [57%] reported excellent results. Chest deformity correction is safe and effective procedure with acceptable cosmetic results. It is easy to perform and improves self image of the suffering individual

Transverse testicular ectopia

We present a case of Transverse testicular ectopia of the right testis that presented out surgical out patient department with left inguinal hernia and an impalpable testis in the right sccrotum. Patient was operated. Left herniotomy was performed and right testis was found in the left inguinal canal which was brought to the right scrotum and anchored through suprapubic subcutaneous tunnel