Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33–85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4–18 months), 12 months (IQR, 6–19 months) and 14 months (IQR, 6–20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

Diagnosis and Management of Isolated Superior Mesenteric Artery Dissection: A Systematic Review and Meta-Analysis

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33–85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4–18 months), 12 months (IQR, 6–19 months) and 14 months (IQR, 6–20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.

Functional outcome in patients with Supra Tentorial Hypertensive Intracerebal Hemorrhage after surgical intervention

Objectives: To determine the functional outcome in patients with supratentorial intracerebral hemorrhage after surgical intervention

Study Design: Retrospective descriptive study

Place and Duration of Study: This study was carried out at the department of Neurosurgery, Combined Military Hospital Rawalpindi [CMH], from Jan 2015 to Dec 2015

Material and Methods: Retrospectively the records of eighty two patients with a diagnosis of supratentorial hypertensive intracerebral bleed on computed tomography scan [CT] brain, who were surgically managed in our department over one year period, were collected and evaluated. All the patients had undergone clinical examination, baseline investigations including complete blood counts, urea, creatinine, electrolytes, prothrombin time [PT], partial thromboplastin time [PTTK], electrocardiography [ECG] and chest x-ray. In case of deranged coagulation profile platelets or fresh frozen plasma were transfused preoperatively. Outcome of patients was assessed by Glasgow outcome scale [GOS] at 3 months after surgery. A GOS score of 4 and 5 was considered favorable outcome and score of 1, 2 and 3 was considered unfavorable outcome, and these were noted in proforma. Descriptive statistics for age, gender, hospital stay and clinical outcome were calculated by using SPSS version 20

Results: Eighty two patients of supra tenteorial bleed were operated over the study period. The mean age of patients was 44.82 +/- 9.25 years and the average hospital stay was 13.21 +/- 4.41 days. Fifty six patients [68.3 percent] were male while 26 [31.7 percent] were female. Favorable outcome at three months was observed only in 24 patients [29.26 percent] while unfavorable outcome in 58 [70.73 percent] cases

Conclusion: Unfavorable results at three months after surgery were observed in 70.73 percent of patients in our sample suggesting poor functional outcome in early evacuation of supratentorial bleed

Frequency of headache with 25G or 27G quincke needles after spinal anesthesia in patients undergoing elective cesarean section

Objectives: Post-dural puncture headache [PDPH] is an iatrogenic complication of spinal anesthesia which results from puncture of the dura mater. The signs and symptoms of PDPH are thought to be caused due to loss of cerebrospinal fluid, traction on the cranial contents and reflex cerebral vasodilation. The patient's age, sex and the size of the dural perforation are the two most important factors affecting the frequency and severity of PDPH. We aimed to compare the frequency of post-dural puncture headache [PDPH] with 25G quincke needle and 27G quincke needle in spinal anesthesia in patients undergoing elective cesarean section

Methodology: This randomized controlled trial was carried out in our anesthesiology department over a period of six months from 1st December 2014 to 30th May 2015. A total of 124 parturients, ASA physical status I to II undergoing cesarean section were included in this study. Patients with infection at the site of injection, severe hypovolemia, coagulopathy, raised intracranial pressure, severe aortic and mitral stenosis, severe preeclampsia, placenta previa grade II-IV, placenta accreta and twin pregnancy were excluded from the study. Enrolled parturients were divided into two groups A and B, with 62 patients in each group. In Group-A and Group-B, Quincke spinal needles 25G and 27 G were used respectively to administer spinal anesthesia in the sitting position at the L3-4 or L4-5 intervertebral spaces. PDPH was assessed after 6, 12, 24 and 48 hours of surgery. Qualitative variable are presented as frequency and percentages while quantitative variable like age was presented as mean +/- SD. Sample t-test was applied on quantitative variable age. Chi-square test was applied for comparison of PDPH. A P- value < 0.05 was considered statistically significant

Results: The ages of patients were between 18 to 40 years. Mean age of the patients in Group-A was 27.77 +/- 4.82 y and 27.74 +/- 4.30 y in Group-B. Nine patients [14.5%] of Group-A experienced PDPH as compared to 2 patients [3.2%] of Group-B. There was statistically significant difference [p = 0. 027] between the groups

Conclusion: We conclude that 27G quincke spinal needle has definite advantage over 25G quincke spinal needle in terms of frequency of PDPH in spinal anesthesia for cesarean sections

Complications of total extraperitoneal [TEP] repair for adult inguinal hernia

Objectives: To evaluate results of laparoscopic total extra peritoneal repair for inguinal hernia in terms of complications. Setting: Surgical Unit 3, Allied Hospital, Faisalabad. Period: From March 2013 to February 2016. Study Design: Simple Descriptive Study

Patients and Methods: 114 patients over the age of 30 years underwent TEP repair for unilateral reducible inguinal hernia. Complications assessed included pain score assessment, analgesia requirement, time taken to return to normal activity and complications like intraperitoneal injury, conversion to open procedure, seroma and hematoma formation and surgical site infection

Results: Out of the 114 patients, 6 [5.26%] needed TEP converted to open and none suffered from serious complication during the procedure. 8 [7.01%] developed postoperative hematoma, 7 [6.14%] developed seroma and 5 [4.38%] developed surgical site infection. Postoperative pain assessment at 8 hours after surgery showed 42[36.8%] patients required extra analgesia while 13[11.4%] patients required extra analgesia 24 hours after surgery

Microbiology of bile in symptomatic uncomplicated gallstone disease

To determine the microbiology of the bile culture and antimicrobial susceptibility in patients with symptomatic gallstone disease in our setup. A descriptive study. Surgical Department Combined Military Hospital [CMH] Kharian from Oct, 2010 to Jun, 2011. A total of 106 patients underwent cholecystectomy due to symptomatic gallstones and their bile was cultured for aerobic and anaerobic bacteria and culture sensitivity was performed. Data was analysed by using statistical package for social sciences [SPSS] version 13. Bile culture was negative in 81 patients [76.4%] and was positive in only 25 patients [23.6%]. Escheria Coli was the most common cultured organism in 10 [40%] patients, Klebsiella in 5 [20%] patients, Pseudomonas in 5 [20%] patients, Proteus in 2 [8%] patients, Staphlococcus aureus in 2 [8%] patients and mixed organisms were cultured in 1 patient [4%]. Cefoperazone with sulbactum and Amikacin were the most effective prophylactic antibiotics. Bile in majority of patients with symtomatic uncomplicated gallstone disease is sterile. E. coli is the most commonly cultured organism and cefoperazone with sulbactum and amikacin are the most appropriate antibiotics in our setup

Outcome of stapled haemorrhoidectomy versus open milligan morgan haemorrhoidectomy at allied hospital

Objective: to compare the postoperative outcome of stapled haemorrhoidectomy and conventional Milligan Morgan's haemorrhoidectomy at Allied Hospital

Study Design: simple comparative study

Place of Study: Surgical Unit 1, Allied Hospital Faisalabad

Duration of Study: January 2011 to September 2012

Sample size: 50 patients

Material and Methods: fifty patients of 3rd and 4th degree hemorrhoids were selected for admission from the outpatient department. Patients with additional anal disease [e.g. fissure, abscess, fistula, ano-rectal cancer etc.] were excluded. Two groups of twenty five each were made. Group A for stapled haemorrhoidectomy and Group B for Milligan- Morgan haemorrhoidectomy [MMH]. The operative time was measured in minutes. Postoperative pain was assessed through visual analogue scale [VAS]. Bleeding was measured as mild, moderate and profuse. Other postoperative complications during hospital stay like urinary retention, anal stenosis etc. were noted. T-test, chi-square test and repeated measured analysis of variance were applied to compare the variables

Results: a majority of patients[combined in both groups] had third degree haemorrhoids. The mean length of operative time was found statistically insignificant between stapled and open groups [34 vs 36 minutes]. In Group A 23 [92%] patients were discharged in 24 hrs while 2 [8%] patients were discharged after 24 hrs. In Group B 9 [36%] patients were discharged in 24 hrs and 16 [64%] patients were discharged after 24 hrs. In group A 19 [76%] patients were having mild bleeding, 5 [20%] moderate bleeding and 1 [4%] profuse bleeding. In Group B 7 [28%] patients were having mild, 16 [64%] moderate and 2 [8%] profuse bleeding. In Group A 15 [60%] patients were having mild pain, 7 [28%] moderate and 3 [12%] severe pain on visual analogue scale. In Group B 4 [16%] patients were having mild pain, 15 [60%] moderate and 6 [24%] severe pain. The proportion of postoperative anal stenosis, prolapsed recurrence, persistent pain, recurrent bleeding and urinary retention was higher in MMH than stapled haemorrhoidectomy group

Conclusion: there was a significant difference between stapled haemorrhoidectomy and Milligan Morgan's for bleeding, pain and hospital stay. However the mean length of operative time was insignificantly different

Intralesional bleomycin sclerotherapy: an effective treatment of cystic hygroma in children

To study the outcome of intralesional sclerotherapy with injection Bleomycin in cystic hygroma in children. A case series. The department of Pediatric Surgery at Military Hospital, Rawalpindi, Pakistan from Jan 2011 to Dec 2012. All patients with peripheral cystic hygroma [CH] presenting to us, were enrolled in the study. The cyst was aspirated in the operation theater under sedation. Injection bleomycin 0.5 mg /kg diluted in 10-15 cc of distilled water was injected in the cyst at multiple sites. Injection was repeated after every month depending upon the response. A total of 30 patients reported to the department with superficial cystic hygroma, 12 were males [40%] and 18 were females [60%], age ranged from 15 days to 8 years. Cervico-facial was the most common site. Results were assessed in terms of excellent [complete resolution], good [> 50% reduction in size] and poor [< 50% reduction in size]. In 2 patients, complete resolution was achieved after maximum seven shots of intra-lesional bleomycin injections [IBI], while 18/30 [60%] resolved after single dose. Twenty seven patients [90%] resolved completely, 2 [6.6%] had good response, 1 [3.3%] showed poor response. Minor complications were noted which were treated by symptomatic treatment. No major side effects or recurrence were noted in maximum 2 years follow up. Intralesional bleomycin sclerotherapy is safe and effective as primary treatment in cystic hygroma

Single scrotal incision orchidopexy for palpable undescended testis

To retrospectively asses the results of single scrotal incision orchidopexy [SSIO] performed at our centre with ligation of the patent processus vaginalis in children having palpable undescended testes [UDT]. Quasi-experimental with retrospective data. Department of Paediatric surgery Military Hospital Rawalpindi, from April 2007 to December 2011. After making a single transverse incision at superior scrotal border, the testis was identified; gubernaculum and the sac were dissected to the highest level and divided. The testis was places into the scrotum and fixed to the scrotal fascia/skin. All patients were assessed at 2 weeks, 2 months and 6 months post operatively, and then yearly. A total of 38 orchidopexies were performed in 33 patients. The patients' age ranged from 14 months to 7 years [mean: 2.1 years]. Bilateral UDT were found in 5 patients [15.1%]. Operative time ranged from 20 to 45 minutes [mean: 36 minutes]. The single scrotal incision technique was successful in all 38 cases [100%]. All testes were easily fixed in the scrotum. Two patients [5.2%] developed scrotal haematoma and one patient [2.6%] developed stitch abscess. All showed good anatomical and cosmetic results up to a minimum of six months of follow-up. Single scrotal incision orchidopexy for palpable undescended testis is a simple and safe technique. It has shown to consume shorter time and give good cosmetic results

Enteric duplication in children: clinical presentation and outcome

<p><b>INTRODUCTION</b>Enteric duplication (ED) is an anomaly with varied presentations and possible involvement of the alimentary tract. Once diagnosed, resection of the lesion and the involved part of the gut is usually required. The aim of this study was to evaluate the clinical presentations, diagnostic investigations, management and outcomes of patients with ED.</p><p><b>METHODS</b>This was a descriptive case study conducted at the Department of Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January 2005 to January 2011. The medical records of all patients diagnosed with ED were retrospectively analysed with respect to age, presentation, investigations, site and type of lesion, surgical procedures, histological findings and complications.</p><p><b>RESULTS</b>A total of nine patients were managed during the study period. The patients' ages ranged from three months to five years. Four out of nine EDs were rectal duplications. Three EDs were of the cystic type, five were of the tubular type and one was a complex mixed anomaly. Patients presented with varied symptoms, with the two most common being the presence of an abdominal mass and bleeding per rectum. Diagnosis was mainly achieved based on magnetic resonance imaging and computed tomography, although Meckel's scan provided accurate diagnosis in three of the nine patients. All the cysts were resected without any major complications, and patients were event-free during the five-year follow-up.</p><p><b>CONCLUSION</b>EDs should be kept in mind when examining patients with an abdominal mass and bleeding per rectum. Meckel's scan can provide accurate diagnosis of EDs with bleeding. Prompt diagnosis and management results in satisfactory outcomes.</p>

Relation of oxidant-antioxidant imbalance with disease progression in patients with asthma

Asthma is a chronic airway disorder which is associated to the inflammatory cells. Inflammatory and immune cells generate more reactive oxygen species in patients suffering from asthma which leads to tissue injury. To investigate the role of oxidant-antioxidant imbalance in disease progression of asthmatic patients. In this study, 130 asthmatic patients and 70 healthy controls were documented. For this malondialdehyde level, total protein carbonyls, sulfhydryls, activity of superoxide dismutase [SOD], catalase, glutathione peroxidase [GPx], total blood glutathione, and total antioxidant capacity [FRAP] were measured. Analysis of the data was done using unpaired student t test and one-way ANOVA analysis. P < 0.05 was considered significant. The present work showed that the systemic levels of MDA [4.19 +/- 0.10 nmol/ml, P < 0.001] and protein carbonyls [1.13 +/- 0.02 nmol/mg, P < 0.001] were found to be remarkably higher in asthmatic patients while protein sulfhydryls [0.55 +/- 0.01 mmol/l, P < 0.05] decreased as compared to controls [2.84 +/- 0.12 nmol/ml, 0.79 +/- 0.02 nmol/mg and 0.60 +/- 0.02 mmol/l, respectively]. We also observed decrease in activities of SOD [2047 +/- 50.34 U/g Hb, P < 0.05], catalase [4374 +/- 67.98 U/g Hb, P < 0.01], and GPx [40.97 +/- 1.05 U/g Hb, P < 0.01] in erythrocytes compared to control [2217 +/- 60.11 U/g Hb, 4746 +/- 89.94 U/g Hb, and 48.37 +/- 2.47 U/g Hb, respectively]. FRAP level [750.90 +/- 21.22 micromol/l, P < 0.05] in plasma was decreased, whereas total blood glutathione increased [0.94 +/- 0.02 micromol/l, P < 0.05] as seen in control [840.40 +/- 28.39 mol/l and 0.84 +/- 0.04 mmol/l]. This work supports and describes the hypothesis that an imbalance between oxidant-antioxidant is associated to the oxidative stress which plays a significant role in severity of the disease

Comparison and agreement between venous and arterial gas analysis in cardiopulmonary patients in Kashmir valley of the Indian subcontinent

Arterial blood gas [ABG] analysis is routinely performed for sick patients but is fraught with complications, is painful, and is technically demanding. To ascertain agreement between the arterial and peripheral venous measurement of pH, pCO[2], pO[2], and bicarbonate levels in sick patients with cardiopulmonary disorders in the valley of Kashmir in the Indian subcontinent, so as to use venous gas analysis instead of arterial for assessment of patients. Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, a 650-bedded tertiary care hospital in North India located at an altitude of 1584 m. One hundred patients who required ABG analysis were admitted. Peripheral venous blood was drawn within 5 min of an ABG measurement, and the samples analyzed immediately on a point of care automated ABG analyzer. Finger pulse oximetry was used to obtain oxygen [SpO[2]] saturation. Data were analyzed using Pearson correlation and bias [Bland Altman] methods. The venous measurements of pH, pCO[2], pO[2] and bicarbonate, and the digital oxygen saturation were highly correlated with their corresponding arterial measurements. Bland Altman plots demonstrated a high degree of agreement between the two corresponding sets of measurements with clinically acceptable differences. The difference in pO[2] measurements was, however, higher [-22.34 +/- 15.23] although the arterial saturation and finger oximetry revealed a good degree of agreement with clinically acceptable bias. Peripheral venous blood gas assessment in conjunction with finger pulse oximetry can obviate the routine use of arterial puncture in patients requiring ABG analysis

Amoebic liver abscess; incodence and outcome

Amoebic liver abscess is a common infection in third world countries like ours due to poor sanitary arrangements. It presents with severe pain and high grade fever and if not diagnosed and treated promptly, may lead to complications and mortality. To estimate the incidence, need for aspiration and treatment outcome. Case series study. At respective consultations centers in Faisalabad. From 1[st], January, 2007 to 31[st] December 2008. All patients suspected of the diagnosis of liver abscess whether presenting to physicians or surgeon were referred for ultrasonography for the confirmation of the diagnosis. Basic biodata, coexisting medical or surgical diseases and relevant investigation were recorded, and patient was assessed for the need to aspirate the abscess. After initial treatment patients were reassessed for the need to aspirate the abscess on third, tenth and twentieth day both clinically and ultrasonically. We had 188 cases in the study. There were 128 [68%] males and 60 [32%] females. Majority, 156 [76.6%], of the abscesses were single, 40 [21%] had double and 4 [2%] had three abscesses. 166 [83%] were situated in the right lobe, 28[15%] in the left lobe and 4 [2%] had abscess in both lobes. 16 [9%] were aspirated at presentation due to their size or position. Only 4 [2%] were aspirated at first follow-up on third day due to non resolution of pain or fever or increase in size. All the patients who were not lost from follow up responded to standard treatment of metronidazole. Amoebic liver abscess is a common diagnosis in our setup. Patients presents with right upper quadrant pain and fever. Clinical background and ultrasonogram give a reasonable suggestion about amoebic etiology. If initial aspiration is not indicated due to size larger than 5cm. or proximity to surface or nonresolution of symptoms or lesion in left lobe, conservative treatment with oral or intravenous metronidazole is successful

Comparison of frequency of heamaturia with rapid and slow decompression of urinary bladder in the management of chronic urinary retention

The objective of this study was to compare frequency of haematuria after slow decompression and rapid decompression of urinary bladder in the management of chronic urinary retention. Quasi experimental study. This study was carried out in Combined Military Hospital Quetta from May 2007 to Nov 2007. Sixty patients fulfilling the inclusion criteria were randomly assigned to two equal groups. Group A was subjected to intermittent clamping of Foley catheter and group B was subjected to no clamping of Foley catheter. On insertion of Foley catheter sample of urine was taken in a test tube and saved. A second sample was also taken in another test tube after one hour of complete decompression of either group and compared with original sample for occurrence of haematuria. Frequency of haematuria was calculated after both the procedures and recorded. confounding variables were traumatic catheterization and patients who were taking anticoagulants or having bleeding disorders. These were controlled by including only those cases where catheter was passed atraumatically by registrar surgery. The frequency of haematuria was found to be equal in both groups. Rapid decompression of the urinary bladder in cases of chronic urinary retention is a safe and convenient method of decompressing the urinary bladder in patients of chronic urinary retention, without any increase in frequency of haematuria