comparative study of the results of the anal fissurectomy and lateral internal sphincterotomy for chronic anal fissure

To compare the results of surgical treatment of chronic anal fissure resistant to conservative management, after anal fissurectomy or lateral internal sphincterectomy. One hundred forty five patients with chronic anal fissure failed to heal with medical treatment admitted in the Department of Surgery Unit II Liaquat University Hospital Jamshoro Sindh Pakistan, from January 2007 to June 2009 were studied. Patients were divided into two groups, 67 patients underwent Fissurectomy [F], and 78 patients underwent open lateral internal sphinterotomy [LIS]. We assessed the patients after median follow up of 12 months, for persistence of symptoms [pain, bleeding], complications and recurrence. All patients become symptoms free within 10 days of surgery. Urinary retention was noted in 3[2.06%] patients, 2[2.98%] in fissurectomy [F] and 1[1.28%] in lateral internal sphincterectomy [LIS] group. Incontinence to flatus was noted in 2[2.98%] patients of 'F' group and 1[1.28%] patient of 'LIS' group. Faecal soiling was noted only in 1[1.49%] patient of 'F' group. Recurrence occurred in 3[4.41%] patients of 'F' group, no recurrence seen in 'LIS' group. Wounds healed within six weeks. Sixty two [91.17%] patients of 'F' and 77[98.71] patients of 'LIS' group were satisfied with treatment. In the treatment of chronic anal fissure lateral internal sphincterectomy is the best surgical technique with very few complications and better patient satisfaction

Open versus close pneumoperitoneum: a pursuit for safer technique

Pneumoperitoneum is a prerequisite in all laparoscopic procedures. This is a very vital step and is still a matter of concern and a subject of further evaluation. Two basic methods commonly used with some modification are closed [veress needle] and open [Hasson] techniques and none of technique has proved to be better than other. We carried out this study to compare the two techniques in terms of access related complications and time consumed during creation of pneumoperitoneum and closure of port wounds. A comparative randomized prospective study was conducted in department of surgery. 475 patients were finally evaluated, 223 were randomized for open [Hasson] while 232 for closed [veress] technique. In open technique slight modification was used by making incision at junction of umbilical stalk and linea alba, while standard veress needle technique was used in closed group. Operative and post operative complications were recorded and analyzed. Mean time required to create pnemoperitoneum was significantly less with open group [6.61 +/- 3.89 minutes] compared to closed group [8.18 +/- 3.39 minutes]. Time required to close port wounds was also significantly less with open group as compared to closed group [7.41 +/- 1.87 versus 10 +/- 2.44 minutes]. No mortality and major complication regarding vascular and solid organ injury was recorded in both groups. Failure of procedure was observed in 4 cases [1.72%] in closed group and one case [0.44%] in open group. Bowel injury was recorded in two cases in closed group however it was not significant statistically. Other minor injuries were not significant on comparing both groups. Open technique is safe and quicker. We recommend this method in all cases of laparoscopy requiring access into abdominal cavity

Breast lumps in adolescent and young female: are all benign?

Objective: To analyze the pattern of presentation and pathology of breast lump in adolescents and young female patients

Methods: Medical records of female patients below 30 years presenting with palpable breast lump at Liaquat University Hospital during August 2008 to July 2009 were retrospectively reviewed. Patients having acute mastitis, inflammatory carcinoma and recurrent malignant or benign lesions were excluded from study

Results: A total of 214 patients were included in study. Mean age was 22.11 years. Approximately 46% of the patients were at the age 20 or less. Most common mode of presentation was painless lump in 61.22% followed by pain and lump in 20.56%.The histopathology of resected specimen showed that fibroadenoma was the most common lump while benign phylloides was the least common. Carcinoma breast was identified in 25 cases, of which 3 cases were at age 20 or less. The commonest histopathology was infiltrating duct cell carcinoma [60%], followed by lobular carcinoma [16%], scirrhous carcinoma [12%] and medullary carcinoma in 8 %. The Paget's disease was found in 4%

Conclusion: We found an increased frequency of breast cancer in comparatively younger age. These findings suggest that any female patient with palpable breast lump should preferably be managed by surgeon with special interest and training in breast diseases

Changing practice of rectal cancer surgery in Pakistan

To describe the presentation and pathology of rectal cancer, and to evaluate the local experience after total mesorectal excision at a tertiary care hospital in Pakistan. A retrospective study of two hundred cases of carcinoma rectum that had undergone total mesorectal excision at Liaquat University Hospital Jamshoro Pakistan was carried out from January 1998 to December 2007.The cases were admitted through outpatient and emergency departments. The demographic details of each patient and variables such as clinical presentation, tumor location, Dukes staging, TNM staging, operations and complications were recorded on proformas. Each patient was followed up at two months for one year, every four months for three years and annually thereafter. Male to female ratio being almost equal 1.6:1, Age ranged from 14-70 years. Site of tumor at upper one third 25%, middle one third 30% and lower one third 45%. Majority of patients [more than 62%] were in Dukes B Group. There were no postoperative deaths, complications occurred in a total of 59 [29.5%] patients, which were mostly colostomy related [13.0%]. The abdominal wound infection 5%, anastomotic dehiscence 1.0%, urinary tract infection 5%, and impotence occurred in 1.5%. In 20% patients' local recurrence was detected. Total mesorectal excision is a safe and feasible technique for rectal cancer surgery with acceptable perioperative morbidity and adequate local disease control

Gynaecomastia: management in a developing country

Gynaecomastia is a benign enlargement of male breast. It is common in the general population, resulting from various pathophysiological mechanisms. The aim of this study was to describe the presentation and outcome of treatment for gynaecomastia at a University Hospital in Pakistan. A three year retrospective study was carried out of one hundred men with gynaecomastia. Patients were evaluated in detail clinically and by appropriate investigations. They were counseled and kept on hormonal therapy for three months. Surgery was considered for patients with long standing gynaecomastia, failed medical therapy and for cosmetic reasons. Post operative complications and patient's satisfaction was assessed. Most [90%] cases were idiopathic. Other causes were liver cirrhosis in 4 cases, testicular tumour in two, thyrotoxicosis in one and drug induced [use of cimetidine and Kushta] in two. Carcinoma of the breast was diagnosed in one patient. Most of the patients had bilateral, non tender lump in the breast. Three cases of idiopathic gynaecomastia resolved on danazol. Eighty-eight cases underwent surgical treatment. The mean age of patients who underwent surgery [n=88] was 30.5 +/- 9.59 years. Most of the patients belonged to 21-30 years age group. Major indications for surgery were failure of medical treatment [45.5%] and cosmetic reasons [34.0%]. Mean operating time for subcutaneous mastectomy was 42.2 +/- 3.70 [36-48] minutes. Mean hospital stay after subcutaneous mastectomy was 5.2+2.44 [2-10] days. The only postoperative complication noted was wound infection [24%]. Seventy -two [81.8%] were satisfied with the results of their surgical treatment. Gynaecomastia is the common condition affecting male breasts and most common cause of gynaecomastia is idiopathic. Secondary gynaecomastia may regress in size by treating the primary cause. Idiopathic gynaecomastia do not respond to danazol so they needed surgical treatment. Subcutaneous mastectomy through a periareolar skin incision is a valid procedure for treatment for gynaecomastia and provides satisfactory cosmetic and provides satisfactory cosmetic results

Malignancy in nodular goitre

To highlight diagnostic difficulties and evaluate the outcome of malignancy in nodular goiter. Case series. This study was conducted in the Surgical Unit-III and Unit-IV at Liaquat University Hospital Jamshoro, from January 2001 to December 2004. Nodular goiter patients admitted for treatment were studied with the help of a pre-designed proforma for recording the personal history, blood chemistry and FNAC results. The results of FNACs were further compared with the tissue histology postoperatively. During the four year study period 14 patients had malignancy out of total 149 cases of nodular goiter admitted. Twelve patients were diagnosed on FNAC. These patients were operated and near total thyroidectomy was done. Two patients diagnosed to have carcinoma on tissue biopsy [FNAC did not pick the malignancy] were re-admitted and had near total thyroidectomy. One patient with lymphoma was referred to Department of Oncology for radiotherapy. All patients with neoplasm postoperatively were referred to oncology department for further management to suppress the TSH. Near total thyroidectomy is the surgery of choice to decrease the recurrence rate in thyroid malignancies