Circumcision by bone cutter-Is it safe?

Objective: To determine the frequency of complications observed in circumcisions performed using closed method and to ascertain its safety in relation to pediatric penile trauma

Study Design: Quasi-experimental study

Place and Duration of Study: Study was conducted in departments of surgery of combined military hospitals of Cherat, Khuzdar and Malir from Jan 2008 to Dec 2009

Patients and Methods: Two hundred and fifty patients were included through the outpatient department for elective circumcision. Male children from 1 week of age to 1 year were included, circumcision being performed for ritual purpose. Exclusion criteria was those male children having deranged coagulation profile, neonatal jaundice, congenital urogenital abnormalities and any other disease. Circumcision was performed using closed technique by bone cutter

Results: Out of the total 250 cases, the success rate of circumcision without any complication was recorded in 229 [91.6%] cases. The remaining 21 [8.4%] cases developed minor complications. Infection was recorded in 7 children [2.8%].Some degree of bleeding was observed in 10 [4%] cases which require change of dressing in 8 cases and haemostasis by application of stitches in 2 cases. Redo surgery was done in 4 [1.6%] cases for unsatisfactory cosmetic reasons. None of the patients in our study sustained trauma to glans

Conclusion: Although it is not a standard procedure, Close method of circumcision by bone cutter is an established and safe technique if it is performed by trained practitioners. We suggest that training workshops should be organized to adequately train all practitioners of circumcision on the safe methods available

Extrahepatic biliary obstruction; postoperative morbidity and mortality

The objectives of this study are to evaluate the surgical management, both definitive and palliative, in selected patients with biliary obstruction and to find out the postoperative morbidity and mortality in these patients. A descriptive study. Duration of the study is two years conducted from June 2002 to May 2004. The study was carried out at the surgical unit 4 of the Combined Military Hospital and surgical department of the Military Hospital. Thirty eight cases of biliary obstruction were included. A convenient sampling technique was followed. Data analyzed by using SPSS version 10.0 for windows on computer. Descriptive statistics like frequency, percentage, average etc were computed for data presentation. Any inferential test was not found to be applicable for this descriptive type case series. We selected 38 patients with features of extrahepatic biliary obstruction. Out of these [n38] 15 patients [39.5%] suffered from benign diseases while those having malignant diseases were 23 [60.5%]. 19 [50%] patients died within two years of follow up while 19 [50%] were the survivors. Mortality was maximum for the malignant cases. In benign cases only one patient died. Maximum deaths 6 [31.6%] occurred in the period of up to one month of operation. 20 patients had one or another complication of operation and hence the morbidity came out to be 52%. According to our results the mortality and morbidity related to extrahepatic biliary obstruction in our patients was higher compared to other studies which can only be reduced by early detection and treatment

Changing trends in frequency of extended spectrum beta lactamase producing gram negative bacilli in intensive care units of a tertiary care hospital

To determine the frequency of isolation of extended spectrum beta lactamase [ESBL] producing Gram negative bacteria from intensive care units [ICUs] of a tertiary care hospital. Retrospective descriptive study. The study was carried out at the department of microbiology Army Medical College Rawalpindi from Dec 2003 to Nov 2007. This study was carried out from Dec 2003 to Nov 2007. A total of 590 consecutive Gram-negative bacilli were recovered during the four year study period from various samples including urine, blood, pus, sputum, high vaginal swabs [HVS], ascitic fluid, central venous lines [CVP], chest tubes, catheter tips, NBL [nasobronchial lavage], CSF, tissue, endotracheal tube [ETT] tip and pleural fluid in ICUs. Extended spectrum Beta-lactamase detection in these isolates was carried out by Kirby- Bauer double disc synergy method. The frequency of ESBL producing organisms was 84 [66%] [December 03 to November 04], 80[54%] [December 04 to November 05], 80[57%] [December 05 to November 06] and 82 [47%] [December 06 to November 07] [p<0.0001] Our study shows a decrease in the frequency of ESBL producing organisms. However there is an increase in the resistant organisms having same resistance pattern, but not detected as ESBL producers, therefore we need to improve the methods for ESBL detection

Day case management of varicocele

To evaluate the outcome of treatment of varicocele by low ligation under local anaesthesia and to establish the low ligation as a mode of treatment for early mobilization of the patient and early return to work. Descriptive study. Department of Surgery Combined Military Hospital Rawalpindi from June 2002 to Dec 2002. This study included 50 patients with varicocele irrespective of their age treated by low ligation under local anaesthesia in day case settings and were followed for 3 months. The results of the procedure on the symptoms were quite satisfactory. Post operatively complications were seen in only 8 [16%] patients. Post operative hematoma formation occurred in only 1 [2%] patient, wound infection in 2 [4%] patients, transient pain at the site of operation was present in 2 [4%] patients, transient hydrocele developed in 1 [2%] patient, permanent hydrocele developed in 1 [2%] patient, in 1 [2%] of the patient the dilated veins persisted after the operation even at 3 month follow up. This study concludes that low ligation of varicocele as day case surgery is a very useful day case procedure in the treatment of varicocele that can be very safely carried out under local anaesthesia with a very high healing rate and minimal complications

Negative appendicectomy; its prevalence, an experience

To find out the rate of normal appendix in patients operated for clinically, diagnosed acute appendicitis. Prospective study. Department of Surgery, Combined Military Hospital, Rawalpindi from 17 Feb 2001 to 08 Aug 2001. One hundred consecutive patients of acute appendicitis diagnosed clinically were included in the study. All cases of appendicitis were operated within twenty-four hours of admission. All appendicectomies were sent for histopathological confirmation of diagnosis at Armed Forces Institute of Pathology Rawalpindi. The mean age for patients was 30.6 year. Pain started in right iliac fossa in forty eight patients [48%], Paraumbilical in thirty eight patients [38%], in epigastrium in thirteen patients [13%] and right lumbar region in one patient [1%]. Right iliac fossa tenderness was present in all hundred cases [100%] and rebound tenderness was present in seventy patients [70%]. Temperature was normal in thirty-nine patients [39%] and raised in sixty-one patients [61%]. Total Leucocyte Count more than 11000/cmm was found in sixty-six patients [66%]. Appendicectomy was done in all cases and histopathology revealed seventy-nine inflammed appendices [79%] and twenty-one [21%] normal appendices. History and clinical examination is still the most reliable method in the diagnosis of acute appendicitis to reduce incidence of negative appendicectomy. However ultrasound and diagnostic laparoscopy are especially helpful to exclude acute appendicitis in women of childbearing age to avoid negative appendicectomy