Intestinal obstruction caused by postoperative adhesions: 5 years'experience at a teaching hospital

Objective: The objective of this study was to determine the common abdominal surgical procedure causing postoperative adhesive intestinal obstruction, and outcome of its surgical management

Study Design: Retrospective as well as prospective analysis

Place and Duration of Study: This study was conducted in the Department of Surgery, Khawaja Muhammad Safdar Medical College, Sialkot from June 2010 to November 2015

Materials and Methods: Patients operated on for intestinal obstruction with at least one abdominal surgical scar were included in the study. A total of 152 patients were eligible, all ages were eligible irrespective of gender. A minimum of 6 months follow up was set for inclusion in the study. Patients with intestinal obstruction presenting with surgical scars for renal, ureteric and urinary bladder surgery were not included as these surgeries did not involve opening of peritoneum. Patients with Crohn's disease, ulcerative colitis, known malignancies, a past history of abdominopelvic irradiation were excluded. Patients with less than 6 months follow up were excluded from the study

Results: Out of 152 patients, 74 [48.68%] surgeries for appendicular pathologies, 18 [11.84%] lower segment caesarean section and 9 [5.92%] total abdominal hysterectomy were the main pathologies causing obstruction; while patients had recurrence in 11[7.23%] and 8[5.26%] mortality

Conclusion: Operated adhesive postoperative intestinal obstruction proves to be a clinical entity with high incidence and specific risk factors of recurrence: age <40 years, presence of adhesion or matted adhesion, and postoperative surgical complications. Infected cases of appendicitis, enteric perforations, lower segment caesarean section and total abdominal hysterectomy are the main causes and the treatment may lead to stoma formation, recurrence and mortality

Patients' satisfaction after stapled hemorrhoidectomy versus doppler guided hemorrhoidal artery ligation

Objective: Assessment of the patient's satisfaction undergoing treatment for haemorrhoids, after stapled haemorrhoidectomy and haemorrhoidal artery ligation methods of surgery at Khawaja Muhammad Safdar Medical College, Sialkot, Pakistan

Study Design: Prospective and analytic study

Place and Duration of study

This study was conducted at the Department of Surgery, Khawaja Muhammad Safdar Medical College, Sialkot from from December 2012 to June 2015

Materials and Methods: All patients presenting in surgical out patients department above 18 years with third degree haemorrhoids were included in the study. Data of 82 patients [stapled haemorrhoidectomy n=55 and haemorrhoidal artery ligation n=27] was collected from December 2012 to November 2015. Patients were distributed in two groups depending upon the surgical procedures carried out

Full detailed history, examination, and investigations were performed

Patients with grade III hemorrhoids underwent the RAR procedure [Recto Anal Repair] i.e

Doppler guided haemorrhoidal artery ligation [DG-HAL] combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures. Results of treatment were assessed by regular follow up. Recording of variables and feedbackof the patients with minimum 3 months follow up, was made and analysed

Results: Out of 82 patients included in our study, Male patients were more in number in our study while 43 years came out to be, of the mean age. Something coming out from the anal canal, painful evacuation of bowels, bleeding per rectum and constipation are the chief presenting complaints

Conclusion: Generally, patients with piles except having severe prolapsed haemorrhoids had postoperative pain, lesser complications and acceptable results in long term can be achieved, in patients undergoing Doppler Guided Haemorrhoid Artery Ligation and Recto Anal Repair. Haemorrhoid artery ligation is a procedure associated with much less pain, in comparison to the stapled haemorrhoidectomy and patients can resume normal routine job, early

Long-term complications still require to be seen and assessed by studies with longer follow up. A lot depends on treating surgeon, his experience, skill and acumen

Prevalence of pityriasis versicolor and its association of abo blood groups in opd patients of islam teaching hospital sialkot

Objective: The study was carried out to determine the prevalence of pityriasisversicolor and its association with ABO blood groups in out patients' department of Dermatology at Islam teaching hospital Sialkot

Study Design: Prospective analytical

Place and Duration of Study: This study was carried out the Department of Dermatology, Islam Teaching Hospital, Sialkot; from December 2012 to December. 2015

Materials and Methods: All patients reporting to our OPD during a period of 3 years were included. The patients with mixed infections were excluded and those did not get their blood grouping and less than 3 months treatment and follow up were excluded from the study. All rashes were examined with wood's lamp. Skin scrapings were taken for KOH examination. Blood samples of all the patients were sent for blood group typing. Data of patients was analyzed using SPSS version 22

Results: Out of 6423 patients attending skin OPD, 197 patients were diagnosed as having Pityriasis versicolor; only 170 patients fulfilled the inclusion criteria. Male to female ratio 71: 29. Most of the patients fell in age group 15-50 years. Commonest rash was in multiple areas while followed by Upper trunk only

The prevalence of pityriasisversicolor was more with blood group B and O

Conclusion: The pattern of distribution of rash is most commonly mixed while upper trunk involvement is next in our patients. The study depicts strong association of Pityriasis Versicolor with blood group B and O

Satisfaction of outpatients and inpatients with psychiatric services at Allama Iqbal Memorial Hospital, Sialkot

Objective: The objective of the current study was to assess satisfaction of outpatients and inpatients with psychiatric services and to compare the satisfaction level of both groups of patients to understand areas to be improved in delivery of psychiatric care

Study Design: Observational / descriptive / cross sectional study

Place and duration of study: This study was conducted at the Department of Psychiatry and Behavioural Sciences, Government Allama Iqbal Memorial Teaching Hospital affiliated to Khawaja Muhammad Safdar Medical College Sialkot, Pakistan from August 2015 to July 2016

Material and methods: Sample size was 600 patients; including 300 outpatients and 300 inpatients. Patients aged 18 years or above, from both genders, who gave written informed consent, were consecutively included in the study. Excluded from the study were the patients with mental retardation, delirium, impairment of cognition, severe medical illness and severe psychotic symptoms. Demographic information of the patients was taken on a pre- designed proforma. Urdu version of the Client Satisfaction Questionnaire 8 [CSQ-8] was administered to assess patient satisfaction. The results were analyzed using SPSS version 21

Results: Among the outpatients there were 67.7% patients mostly satisfied, 22% mildly satisfied and 10.3% dissatisfied. While in the inpatients there were 68% mostly satisfied, 22.3% mildly satisfied and 9.7% dissatisfied with the psychiatric services. Only age was significantly associated with satisfaction

Conclusion: Most of the outpatients and inpatients were satisfied with the psychiatric services. The outpatients and inpatients were almost equally satisfied. Older patients were more satisfied than the younger patients. Other demographic variables like gender, marital status, education and economic status did not influence the satisfaction

Placenta previa; risks and morbidity

Objective: To evaluate and determine the risk factors and outcome of placenta previa in patients undergoing cesarean section at Islam Teaching Hospital. Sialkot

Study Design: Case control, Observational and comparative study

Place and Duration of Study: This study was carried out at theDepartment of Obstetrics and Gynaecology,Islam Teaching Hospital, Islam Medical College, Sialkot from September 2010 to December2014

Materials and Methods: Our study included all the patients who underwent caesarean section for singleton pregnancy after 28 weeks of gestation during the study period, data was collected and analyzed retrospectively for determining risk factors and patients were followed prospectively to see the morbidity and outcome of cesarean section in patients with placenta previa labeled as Group I and patients without placenta previa labeled as Group II. The patients who had normal vaginal delivery were not included in the study. Data was recorded using SPSS version 20 and frequencies were calculated. Statistical analysis and significance was done using OpenEpi calculators. Pvalue was calculated using two by two table and relevant Fischer and mid-P extracttests. P value <0.05 was usedto show significantdifference

Results: During the specified period 46 patients were those whose pregnancy was complicated by placenta previa while 734 patients who underwent cesarean section were not having antenatal or peroperative evidence of placenta previa. The maternal age >35years was present in 27 patients in group 1 and 234 patients in group11 so placenta previa is associated with age greater than 35 years [OR 3.036, 95%CI 1.655-5.572, P value 0.0001700]. The multivariate retrospective analysis showed that independent factors of prior LSCS [OR 2.33, 95% CI 1.272-4.271, P value 0.003940] previous history of D and C [OR 2.341, 95% CI 1.029 -4.936, P value 0.02163 ] and malpresentation[OR 4.142, 95% CI 1.852-8.725, P value 0.0005307] were associated with placenta previa.Placenta previa was associated with adverse maternal outcome. In our study postpartum haemorrhage occurred in 20 patients of group I as compared to group II [43.47% vs 5.3%, P value <0.05 ]. But massive blood transfusion [transfusion of more than 4 units of blood ] was required in 8 patients in group 1 as compared to 22 patients in group II [17.4% vs 3.0%, P value <0.05]. Cesarean Hysterectomy was done in 4 patients in group I and no caesarean hysterectomy was required in group II [8.6% vs 0.00%, P value <0.005]. In 3 patients, indication of hysterectomy was placenta accreta with previous history of cesarean section. In one patient there was fibroid uterus along with placenta previa; so fibroid uterus was a confounding factor in our study so that cesarean hysterectomy percentage is somewhat more in our study. In all 3 cases of placenta accreta, there was history of previous cesarean section so that there is 15% chance of placenta accreta in patients with previous history cesarean section along with placenta previa. The placenta previa was also associated with adverse fetal outcome as perinatal mortality [17.4% vs 2.9%, P value<0.05], low APGAR score at 5 min [19.6% vs 7.1%, P value <0.05] congenital anomalies [10.8% vs 4.1%, Pvalue<0.05 ] was high in group I patients. Placenta previa was not associated with intrauterine growth restriction [4.3%vs 2.6%, P value 0.2379]

Conclusions: Advanced maternal age, previous caesarean section, previous history of D and C and malpresentation are associated with increased risk of placenta previa. Placenta previa is definitely associated with adverse maternal as well as neonatal outcomes. The obstetrician should be vigilant in antenatal as well as peripartum care of such patients in order to manage the associated complications and to decrease maternal and fetal morbidity and mortality

How common is the paediatric asthma in sialkot?

This study was conducted to see the parental feedback regarding the prevalence of asthma symptoms in their children. A cross sectional study. This study was conducted in a local school from December 2012 to March 2013. This is a questionnaire based descriptive cross-sectional study. We selected a local school in which there are around 500 students. We had 238 questionnaires back out of 500, showing response rate of 47.6%. We found that 38 students had asthma, almost 16%, and there was male predominance. Night cough was the most common complaint in these students. Parental asthma was noted in 18% of the asthmatics. This questionnaire based study revealed asthma to be more common in this part of Pakistan. More studies are required to see the validity of the observation. Asthma being more common and an important health concern, requires prompt health education of the public and health professionals as well as further research work

Treatment and incidence of recurrence of varicose veins of lower limbs

To study the presentation of varicose veins of lower limbs, treatment in our patients; and to see the causes of recurrent varicose veins at Islam Medical College, Sialkot, Pakistan. Observational and descriptive study. This study was carried out at the Department of Surgery, Combined Military Hospital, Sialkot; from June 2007 to August 2010.Department of Surgery, and Islam Teaching Hospital, Sialkot from September 2010 to September 2013. Adult patients referred by general practitioners with varicose veins of lower limb were included in the study. Data of sixty seven patients with varicose veins of lower limb was collected from June 2007 to September 2013. Patients were distributed in four groups depending upon the surgical procedures carried out. Full detailed history, examination, and investigations were done. Results of treatment were assessed by regular follow up. Data of only those patients was included who could complete follow up for at least 6 months. Out of 67 patients included in our study, 25 cases were having recurrence; 8[32%] was recurrent cases from pervious surgeries from somewhere else and 17[68%] cases were diagnosed with recurrence after surgery at our hospitals. So, the incidence of recurrence in our cases exclusive remained to be 29%. Failure or recurrence in "Ligation" only was 38.5%, in ligation and reverse stripping was 30.7%, stab avulsions was 44.44% and in patients who underwent ligation, reverse stripping and stab avulsions was 12.5% after follow up of minimum 6 months. The patients are still on followup and the percentages are likely to increase with time as varicosities could be obvious. The anomalous double great saphenous veins, neovascularisation or missed tributaries of great saphenous vein during surgery and deep venous thrombosis before and after surgery were the most observed finding of recurrence. The recurrence of varicose veins was more in leg only as compared to both leg and thigh. Saphenofemoral ligation with below knee stripping and stab avulsions combined has the least frequency of recurrence, while Trendlenberg operation alone has the highest

Use of intranasal splints to prevent post operative nasal Synechia formation

This study was conducted to see the effect of intranasal splints in preventing post operative nasal synechia in patients who underwent intranasal surgery. Observational and descriptive study. This study was carried out at the Department of ENT, Islam Teaching Hospital, affiliated to Islam Medical College, Pasrur road, Sialkot, Pakistan: from June 2007 to December 2013. Fifty four patients coming to Islam Teaching Hospital Sialkot from September 2012 to December 2013 were selected. Intransal splints were used in all patients after the intransal surgery. Nasal pack was removed on 1[st] or second post operative day. Intranasal splints were removed on 7[th] post operative day in the clinic without anesthesia. Follow up was done on 7[th] post operative day, 2 weeks and then monthly for 3 months. In this study there were 36 cases [66.7%] were among male patients and 18 cases [33.3%] were among female patients. The Maximum age of the patients in this study was 45 years and minimum age of the patients was 9 years and mean age was 25.70. There were 2 cases [3.7%] of septal abscess drainage, 2 cases [3.7%] of septal hematoma drainage, 8 cases [14.8%] of Septoplasty, 2 cases [3.7%] septoplasty and bilateral partial inferior turbinectomy, 6 cases [11.1%] of septoplasty plus bilateral partial inferior turbinectomy, 4 cases [7.4%] of septoplasty plus left inferior turbinectomy and septoplasty plus manipulation of fractured nasal bones, 2 cases [3.7%] of septoplasty plus nasal cauterization, 20 cases [37%] of septoplasty plus right inferior turbinectomy, 2 cases [3.7%] of septoplasty plus right inferior turbinectomy plus trimming of right middle turbinate and septoplasty plus right intranasal polypectomy. There were 10 patients [18.5%] in which the nasal pack was removed on 1[st] day and 44 patients [81.5%] in which nasal pack was removed on 2[nd] day. Intranasal splints made of intravenous fluid bottle soft plastic are well tolerated and they were effective in preventing nasal synechia formation

Small bowel diverticular disease; how often we come across in exploratory laparotomy

1]. To see the prevalence of small bowel diverticulosis in patients presenting with acute abdomen. 2]. To know presentation and complications of diverticulosis in teaching hospital in Sialkot region of Pakistan. Introduction: Small bowel diverticular disease may be complicated by small bowel obstruction. Multiple diverticulosis represents an uncommon pathology of the small bowel. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction, and acute pancreatitis appear in 10-30% of the patients, increasing the morbidity and mortality rates. This pathology which is uncommon is much higher in our study in patients undergoing exploratory laparotomy in district level hospitals in Sialkot region of Pakistan. Prospective and observational. Combined Military Hospital, Sialkot [June 2005 to August 2010]. Islam teaching hospital, Sialkot [September 2010 to September 2012]. 260 consecutive patients undergoing exploratory laparotomy for obstruction, peritonitis, pain and mass abdomen were included in the study. Patient with established cause of obstruction were excluded. The data including demographic information, presentation, operative findings, complications and follow up were entered in structured proforma. Patients with less than three months of followup were also excluded from study. Small bowel diverticuli were encountered in 24 [9%] out of 260 patients including; 8 [3%] Meckel's, 9 [3.5%] jejunal, 3 [1.2%] duodenal and 4 [1.5%] Heal diverticuli. These patients with diverticuli presented as intestinal obstruction, peritonitis, mass abdomen, vague abdominal pain and one patient with fresh bleeding per rectum. The indications of surgery were peritonitis 6 [25%], intestinal obstruction 13 [54.2%], abdominal mass 3[12.5%], nonspecific abdominal pain 1 [4.2%] and fresh bleeding per rectum of obscure origin 1 [4.2%]. Complications encountered as Intestinal obstruction due to adhesion formation in 8; obstruction due to congenital bands attached to diverticuli in 3; diverticular perforation in 2; peritonitis due to diverticulitis in 2,bleeding from arteriovenous malformation within the jejuna diverticuli in 1 and mass formation due to volvulus in 1. Three duodenal diverticuli and 4 jejunal diverticuli were found as silent pathologies synchronous with other active pathologies

Management of diabetic foot ulcers

To see the management options of diabetic foot ulcers in our patients, its presentation and the prognostic factors involved in planning the treatment in the Department of Surgery, Islam, Teaching Hospital Sialkot, Pakistan. Retrospective analytical and observational. This study was conducted at Islam Teaching Hospital Sialkot from September 2010 to January 2013. One fifty [150] cases of diabetic foot ulcers were included in this study. All patients were randomly selected attending to islam Teaching Hospital OPD and emergency. The results were shown in Table No.1 to Table No.4 and graph No.1. In patients of diabetic foot ulcers, the treatment doesnot end with infection controlled, healed amputation stumps and prothetic legs fitted; but it continues as reulcerations, involvement of healthy sides etc remains the feared consequences. The patient with diabetic foot infections and ulcers is a surgical patient throughout life as of a physician

Morbidity associated with treatment of chronic anal fissure

Objective: To assess the effectiveness of different modes of treatment of chronic anal fissure as regards improvement of symptoms and complications

Methods: This prospective study included 129 consecutive patients with chronic anal fissures presented to the Surgical Outpatients' Department of Islam Teaching Hospital Sialkot, Pakistan; from September 2010 to November 2012. Patients were distributed in three groups. In "OBG group", patients had attended Gynae/Obs OPD and got treated and were then referred to surgical OPD for failure of treatment or recurrence. Patients who presented with history of treatment by GPs were included in "GP Group". "SGR Group" included those who directly reported to surgical OPD for treatment. Patients were managed both pharmacologically as OPD patients and surgically as admitted patients. Patients were instructed to apply small amounts of 0.2% GTN paste in soft white paraffin, to the anoderm with finger tips three times a day. Patients were evaluated at two-week intervals and at each visit the symptoms control, adverse effects and fissure status were recorded. If there was symptomatic relief or the fissure healing was in progress, the treatment was continued for a total duration of eight weeks. Operated patients were nursed in wards after surgery i.e Internal Anal Sphicterotomy. They were advised to report to OPD weekly for one month or earlier if they experienced any symptoms suggestive of complications. Patients were declared cured in case of complete symptomatic relief with fissure healing. Success, failure and associated problems were recorded and analysed to get results

Results: This study included 129 patients who could be followed up for a minimum of three months. These patients were referred by gynaecologist i.e. 22 [17%] for treatment failure while 5 patients with wrong diagnosis were not included in statistical analysis; similarly 41 [32%] patients were referred by general practitioners and 9 patients with wrong diagnosis were excluded. Sixty six patients i.e. 51% were those who directly reported to surgical OPD and had no previous treatment. With surgical treatment, pain, bleeding per rectum and constipation showed significant improvement as compared to GTN ointment application. Fissure healing was 100% in surgical group as compared to 74% in medical group. Complications were recorded and were found to be headache with medical treatment; while the most feared complication with surgical treatment i.e. permanent incontinence was not encountered in our study

Conclusion: Topical glyceryl trinitrate is economical, has a good healing rate, and faecal incontinence has not been reported. Its effectiveness, however, depends on patients' compliance which may be poor in view of associated headaches and a local burning sensation. It is first line of treatment for anal fissure but lateral internal sphincterotomy is superior, more effective and curative than the chemical sphincterotomy. Surgery is reserved for people with anal fissure who have tried medical therapy for at least one to three months but failed

Synchronous adenocarcinoma of gall bladder and ampulla of vater

A case of synchronous adenocarcinoma of gall bladder and ampulla of Vater is presented, which was preoperatively diagnosed as carcinoma of ampulla of Vater. Whipple's resection was performed. Intraoperatively there was no evidence of any synchronous tumour on gross examination but histopathology report turned out to be that of adenocarcinoma of gall bladder and ampulla of Vater

Fat embolism and fat embolism syndrome; management trends

Fat Embolism and the associated Fat Embolism Syndrome is a serious and potentially life threatening condition. It tends to occur usually after fractures or intramedullary instrumentation of long bones. Non-traumatic conditions such as Diabetes Mellitus severe Burns, SLE, sickle cell disease and Pancreatitis can also lead to Fat Embolic syndrome. Young adults are commonly affected. Presentation consists of an asymptomatic interval followed by pulmonary and neurological manifestations combined with petechial haemorrhages. The diagnosis largely depends on high index of suspicion and exclusion of other conditions. Treatment of this condition remains supportive. Mortality associated with this condition is significant, ranging from 10-20%