Ileostomy stoma wound; purse-string closure

The objective of the study was to compare the frequency of infection in stoma site skin wound closure done by purse string suture and linear suturing techniques. Randomized control trial. Surgical Unit-I, Allied Hospital, Punjab Medical College, Faisalabad. From 1st Jan, 2014 to 31st March, 2015 [15 Months]. Total number of sixty patients of both sexes with benign disease were included using non-probability consecutive sampling technique after approval from hospital ethics committee. All patients were admitted through OPD and a written informed consent was taken. They were divided into two groups [30 each]. The two techniques of ileostomy stoma wound closure used were linear closure and purse-string closure. Data was analyzed using SPSS v10. Chi-square test was used to compare the outcome [wound infection] in both groups. P-value less than 0.05 was taken as significant. Comparison of infection in stoma site skin wound closure done by purse string suture and linear suturing techniques was done which shows presence of infection in 36.67%[n=11] in Linear closure and 10%[n=3] in Purse-string closure group while remaining 63.33% [n=19] and 90%[n=27] respectively case had no infection, p value was calculated as 0.01 which shows a significant difference. The frequency of infection in stoma site skin wound closure done by purse-string suturing technique is significantly less than linear suturing technique

Relation of breast cancer with parity and breastfeeding

Objective: The purpose of this study was to evaluate the relationship of breast cancer with parity and breastfeeding in local settings since no such studies have been carried out previously. The results of such study can provide data for comparison from other parts of country and international research

Study Design: Observational study

Place and Duration: Department of Surgery Allied Hospital Faisalabad between October 2013 and October 2014

Methods: A sample of 500 breast cancer patients diagnosed clinically and histopathologically was included in the study after informed consent. Patients were interviewed using a questionnaire. We observed the variables of age, parity, menstrual history and months of breastfeeding for each child. Analysis was done using SPSS version 12. 0

Results: In present study, 500 patients of breast cancer were included with age ranging from 28 years to 80 years. Most common age group was 40 to 50 years. 91.8% females with breast cancer were multiparous and all 91.8% females gave history of breastfeeding their children. 48% of the females breastfed for more than 5 years, 40% of them for 1to5 years and 3.8% of them for less than 1 year. Only 8.2% females who were either unmarried or had no issues did not breastfeed at all

Conclusion: In our local settings, multiparity and breastfeeding do not alter the risk of breast cancer and thus other risk factors must be studied

Comparison of excision and primary closure [primary closure] versus modified Limberg flap [modified limberg flap] repair in the treatment of sacrococcygeal pilonidal sinus disease [sacrococcygeal pilonidal sinus disease]

Objective: To compare excision with primary closure and excision with modified limberg flap repair in the treatment of sacrococcygeal pilonidal sinus disease

Design: Quasi experimental study. Setting and duration of study: Surgical Unit-I at Allied Hospital, PMC, Faisalabad, from April 2011 to July 2012

Methods: A total of 60 patients with sacrococcygeal pilonidal sinus disease, 30 underwent Excision with primary closure, and 30 had Excision of sinus with modified limberg flap repair

Results: Though modified limberg flap group was associated with comparatively longer operative time [48.57 vs 32.57 minutes] and longer hospital stay [5.90 vs 4.17 days]. However, post op analgesic requirement in either groups was comparable [33.3% vs 40%]. There was a significant difference in recurrence rate in both groups [20% vs 3.3%]

Conclusion: For the surgical treatment of sacrococcygeal pilonidal sinus disease, modified limberg flap repair is a better technique due to less chances of recurrences, in maiaging sacrococcygeal pilonidal sinus disease

Pancreatic trauma; 3 years experience at allied hospital, Faisalabad

Introduction: Pancreatic injuries remain a clinicalenigma. Minor injuries are easy to treat but ifmissed are associated with significant morbidity and mortality. Blunt trauma to upper abdomen is oftenassociated with pancreatic injury. Isolated injury topancreas is rare. There are different protocols ofmanaging the pancreatic trauma. In this article weare presenting different cases of pancreatic traumamanaged by us according to severity of injury

Objectives: 1.To define comonest mode ofpresentation of patients with pancreatic trauma. 2.To suggest appropriate investigations in suspectedpancreatic injuries. 3. To suggest the treatmentstrategy in different types of pancreatic injuries

Study Design: Descriptive prospective studyconducted in Surgical Unit III, Allied HospitalFaisalabad from Feb 2008 to Dec 2011

Results:Forty eight [48] patients [10 children, 38 adults]included with median age 11 and 35 respectively.Male to female ratio 5:1. Blunt trauma wasmechanism of injury in 62.5% of cases mainly dueto road traffic accident. Serum amylase was raisedin 59% of cases. CT scan was diagnostic in most ofthe hemodynamically stable patients. Roux-en-YPancreatojejunostmy, distal pancreatectomy andWhipple's procedure were performed dependingupon the grade of injury. Postoperative pancreaticfistula formed in 26% of cases, which was managedconservatively. Overall mortality was 37.5%

Conclusion: Pancreatic injuries commonly occurdue to blunt abdominal trauma. High index ofclinical suspicion is required for timely decionmaking. CT Scan is useful in hemodynamicallystable patients. Early diagnosis and timelymanagement according to the severity of injuryimproves morbidity and mortality

Enteric ileal perforation primary repair versus loop ileostomy

Objectives: The aim of this study was to record the outcome of enteric ileal perforation, managed by primary repair versus ileostomy in terms of post-operative complications, mortality rate and hospital stay

Design and Duration: Quasi experimental study from January, 2009 to August, 2010

Setting: Surgical Unit-V, District Headquarters [Teaching] Hospital, Punjab Medical College, Faisalabad

Methodology: During the period of study 46 patients of enteric ileal perforation were divided in two groups on consecutive sampling basis. Detailed data of each patient including presentation, operative findings, procedures performed, post-operative outcome and histopathology was entered on a specially designed proforma. The main outcome measures found significant were post-operative complications, hospital stay and mortality rate. The data was compiled and analyzed by using SPSS-1B

Results: 46 Patients of enteric ileal perforation were studied during the period of 20 months, divided equally in 2 groups, Group A [loop ileostomy] and Group B [primary repair]. An increased rate of post-operative complications was seen in Group B [primary repair] when compared with Group A [loop ileostomy] with 21.74% patients landed up in peritonitis secondary to leakage from primary repair and 17.39% ended up with controlled feacal fistula formation. Mortality rate was twice higher in Group B [primary repair] when compared with Group A [loop ileostomy]. A ratio of 1:2.75 days was observed between hospital stay of Group A [loop ileostomy] to Group B [primary repair]

Conclusion: Enteric ileal perforation still represents a disastrous complication of enteric fever and constitutes a good number of patients presenting in surgical emergency with acute abdomen. Exteriorization of perforation in the form of loop ileostomy is more appropriate option for such patients as compared to primary repair of the perforation when compared in terms of postoperative complications, hospital stay and mortality rate

Determinants of delayed presentation in breast cancer

To find out the factors which influence delayed presentation of breast cancer. A prospective study. The study was conducted in the department of surgery at Allied Hospital Faisalabad for a period of one year from 01-11- 2008 to 30-11-2009. With an informed consent, study was conducted on 75 patients of breast cancer who presented late in Allied Hospital Faisalabad for their treatment. Diagnosis of breast cancer in all the patients was established by tissue biopsy. Every patient was interviewed on a structured questionnaire to find out the determinants of delayed presentation from the date of first symptom recognition to the start of treatment. Extent of delayed presentation in our study ranged from 3 to 18 months with mean duration of 8 months. Patient delay showed a major influence on delayed presentation and its determinants were painless lump breast, negative family history of breast cancer, negative history of benign breast disease, increasing age above 40 years, lack of awareness about breast cancer, poor economic class, psychosocial and cultural beliefs, rural background, number of siblings 4 or above, lack of female doctors and illiteracy. Pre-hospital system delay showed a minor attribution to delayed presentation and it was associated with delayed or non-referral to consultants, mal-treatment by health care providers other than breast surgeons, false negative/misinterpretation of mammograms and false negative results of fine needle aspiration cytology. Locally advanced breast cancer [LABC/Stage III] was found in 62.7% patients, while, 12% patients had metastatic breast cancer [MBC/Stage IV]. Rest of the 25.33% patients had early breast cancer [EBC/stage I and II]. Delay of more than 6 months was found in 48 [64%] patients and out of them 60% had advance stage, while only 4% patients were observed in stage II [EBC]. Delay of 3 to 6 months was noted in 27 [36%] patients and among them 3 [4%], 13 [17.3%] and 11[14.7%] patients had stages I, II and III respectively. Delayed presentation of breast cancer is mainly attributed to patient delay rather than the system delay and longerd elays in presentation adversely influence the stage of breast cancer

Total thyroidectomy in benign multinodular goitre

Total thyroidectomy is the standard surgical procedure for thyroid malignancy. Many surgeons do not perform total thyroidectomy in cases of Benign Multinodular Goitre [BMNG] owing to the fear of recurrent laryngeal nerve [RLN] damage and postoperative risk of hypoparathyroidism. Long term thyroxin therapy with its side effects is an additional factor. We conducted this study to assess total thyroidectomy as a safe option for managing BMNG. Surgical Unit-I and Surgical Unit-Ill, Allied Hospital, a tertiary care hospital affiliated with Punjab Medical College, Faisalabad. Duration of study was two years from January 2008 to January 2010. A total number of 196 consecutive patients undergoing total thyroidectomy [TT] for BMNG were included in this study. Patients with thyroid malignancy or suspicion of malignancy were excluded. Preoperative assessment included baseline biochemical workup and thyroid function tests. Preoperative serum calcium and indirect laryngoscopy [IDL] was performed in all the patients. Postoperative assessment included serum calcium estimation after 24 hrs and 07 days of TT. IDL was considered in any patient with suspected RLN palsy. Drain output was recorded at 24 hrs after TT. Total number of 196 patients were included with 49 male and 147 female [male to female ratio of 1:3]. Age ranged from 14-60 yrs [mean:37 yrs]. One thirty six patients undergoing TT had non-toxic MNG while 60 patients had toxic MNG controlled on antithyroid drugs. Drain output ranged from 10-100 ml in 24 hrs. No patient developed permanent RLN palsy. Seven patients [3.5%] had temporary unilateral RLN palsy. Fifty six patients [28.5%] developed temporary hypocalcemia. None of the patients developed permanent hypocalcemia. Two patients developed seroma formation which was aspirated with wide bored needle. Two patients got superficial wound infection which recovered with oral antibiotics. Postoperative hemorrhage requiring re-exploration did not occur in any patient. Postoperative stay ranged from 2-4 days. Most of the patients were discharged 48 hrs after surgery. There was no postoperative mortality. Total Thyroidectomy is a safe method for treating Benign Multinodular Goitre in experienced hands with low postoperative complications and morbidity

Hernioplasty;sublay technique for incisional hernia

Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. It may be repaired using open suture, open mesh or laparoscopic mesh techniques. To examine the results of open mesh repair using "sublay technique" of hernioplasty. Surgical Unit-I, Department of Surgery at Allied Hospital, a tertiary care teaching hospital affiliated with Punjab Medical College, Faisalabad. Sixty patients [male: 16, female: 44] were operated for incisional hernia. Open mesh repair was done. Polyproplene mesh was placed over closed posterior rectus sheath layer and over the rectus abdominis, were available. Anterior rectus sheath was closed in front of the implanted mesh. All the patients received injectable third generation cephalosporin for 48 hrs postoperatively. Postoperative recovery in terms of seroma formation, wound infection, intraabdominal adhesions leading to intestinal obstruction, enterocutaneous fistula formation and recurrence were the main factors noted and analyzed statistically. Mean postoperative hospital stay was 03 days. Only one patient developed wound infection. None of the patients developed seroma formation, intestinal obstruction or enterocutaneous fistula. Maximum follow up till this study is 14 months. No recurrence has been reported so far. Open mesh repair using "sublay technique" does not carry risk of enterocutaneous fistula, carries low risk of seroma formation and wound infection. Proper technique is not associated with recurrence

Acute cholecystitis; laparoscopic cholecystectomy

Laparoscopic cholecystectomy has been accepted as the treatment of choice for symptomatic gallstones. Its efficacy and timing in cases of acute cholecystitis is still under debate. This study was undertaken to evaluate our experience with early cholecystectomy as a safe effective treatment of acute cholecystitis. Record of all the patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis was reviewed. Patients were divided into two groups on the bases of onset of symptoms to surgical intervention: less than 72 hours in the early group [n = 15] and more than 72 hours in the late group [n = 25]. Conversion to open procedure was insignificantly less [3 out of 15 in early group and 8 out of 25 in late group] [20% versus 32%] in the early treated patients [p-value 0.411]. Furthermore the operative time [75 versus 95 minutes] postoperative hospitalization [2 versus 4 days] and total hospital stay [4 versus 6 days] were significantly reduced in patients undergoing early laparoscopic cholecystectomy. Laparoscopic cholecystectomy is a safe effective technique for acute cholecystitis in experienced hands with lower conversion rate shorter operative time and reduced hospitalization

Clinico-epidemiological study of tetanus at district headquarter hospital, Faisalabad

To study age, sex and regional frequency of tetanus. To define the status of immunization against tetanus. To find the outcome of the treatment provided. All the consecutive patients above 10 years of age with the clinical evidence of tetanus presenting at DHQ Hospital, Faisalabad were included in the study. Detailed history of the illness was obtained from the relatives. Physical examination carried out specifically looking for any evidence of injury. Associated co-morbid factors were noted and managed accordingly. Careful management of the tetanus was done in a separate unit with limited facilities. A total of 40 patients presented during one year of study with the clinical evidence of Tetanus. 28 patients were in between 10-30 years of age, 12 were of more than 40 years of age. There were 29 [72,5%] males and 11 [27.5%] females. Most of the patients [87.5%] belonged to rural areas and only 12.5% were from the urban areas. 25 patients had no knowledge about their tetanus immunization status. 15 patients gave history of tetanus immunization in the past but none of them had a booster dose within last 10 years. Male population belonging to rural areas is the commonest victims of tetanus. Most of them are affected during the 2[nd] and 3[rd] decades of life. There is a complete lack of knowledge about the tetanus immunization. Standard management of tetanus at dedicated centers with facilities for artificial ventilation can save many lives

Iatrogenic bile duct injuries; experience at Allied Hospital, Faisalabad

This retrospective study was conducted in Surgical Unit-III, Allied Hospital, Faisalabad. This study was conducted in order to define the frequency and type of bile duct injury both during open and laparoscopic cholecystectomy and to suggest most feasible method of managing these patients with the facilities available. Total number of fifteen cases was collected. Twelve patients were female and three were male with a median age of 38years. Ten cases were operated at some other hospital and five cases had biliary injury at Allied Hospital. Eight patients had biliary tract injury during open cholecystectomy while seven patients sustained such injury during laparoscopic cholecystectomy. Injury was recognized in three patients while operating whereas in 12 cases it went unrecognized. Unrecognized injuries presented in the postoperative period as obstructive jaundice in 03, increased drain output in 04, peritonitis in 03 and cholangitis in 02 patients. Ultrasound, CT, drain contrast studies were the main radiological investigations used in addition to essential biochemical profile of the patients. Classification of the injury was according to Strasberg classification. Primary repair over T-Tube was done in 03 patients whose injury got recognized at the time of primary surgery. Roux en Y hepaticojejeunostomy was performed in 07 patients, T-Tube drainage was provided in 04 and simple intraperitoneal drainage was offered in 01 patient. Cholangitis occurred in 02 patients requiring systemic antibiotics. One patient died due to intraabdominal sepsis. Follow up ranged from 6-18 months. Liver function tests, T-Tube cholangiogram and HIDA Scan were used in selected patients. Tear in CBD is the most common type of injury recognized. Roux -en-Y hepaticojejunostomy is the choice. The prevention is in identifying the anatomy during operation

Obstructive jaundice; experience at teaching hospital

[1] To find out the commonest causes of obstructive jaundice [2] To find the age group most affected by obstructive jaundice and male to female ratio in these cases [3] to define the ratio of malignant and benign conditions leading to obstructive jaundice. [4] To suggest the best possible mode of treatment. Descriptive study. Allied and DHQ Hospitals Faisalabad. Novemberl999 to September 2004. 62 patients admitted through outpatient and emergency departments were included. All the patients were subjected to clinical evaluation and available investigations to reach the provisional diagnosis, which was confirmed by operative finding and histopathological reports. The maximum cases of obstructive jaundice due to benign cause were observed in the age group of 31-50 years whereas malignant jaundice maximally affected the age group of 31-60years. Male to female ratio was 1:2.44. Choledocholithiasis was the commonest benign cause of obstructive jaundice. Carcinoma gall bladder was the commonest malignancy causing obstructive jaundice. CBD exploration and stone extraction was employed to treat the cases of Choledocholithiasis. Majority of the cases with malignant jaundice were offered internal biliary drainage through bilioenteric anastomosis or external biliary drainage using T-tube. Choledocholithiasis is the commonest benign cause of obstructive jaundice. Carcinoma gall bladder is the commonest malignancy causing obstructive jaundice. Curative surgery is only possible for treatment in benign cases. Palliative surgery in the form of external or internal biliary drainage could be employed in malignancy due to advanced stage of disease at the time of presentation

Foreign body rectum

A case report of 16 years old male is presented who was brought to the emergency with a foreign body [a medium sized steel glass] in the rectum introduced after the act of sodomy

Serum tumor markers

With the advent of new generations of chemotherapeutic agents and advances in radiation therapy in the management of malignancies, an understanding of tumor markers is becoming increasingly important. These soluble molecules in the blood are usually glycoproteins detected by monoclonal antibodies. Each tumor marker has a variable profile of usefulness for screening, determining diagnosis and prognosis, assessing response to therapy, and monitoring for cancer recurrence. Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumor markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of Prostate-Specific Antigen [PSA], tumor markers do not have sufficient sensitivity or specificity for use in screening. Cancer Antigen [CA] 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer. Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 1.9-9 may be helpful in establishing the nature of pancreatic masses. CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy. Alpha-fetoprotein [AFP], a marker for hepatocellular carcinoma, sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy. Testing for the beta subunit of human chorionic gonadotropin [b-hCG] is an integral part of the diagnosis and management of gestational trophoblastic disease. Combined AFP and b-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumors, and in monitoring the response to therapy. AFP and b-hCG also may be useful in evaluating potential origins of poorly differentiated metastatic cancer. PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary. This review article describes the use of common tumor markers in primary care practice. Particular emphasis is given to when these tests should be ordered and to common factors that influence the interpretation of tumor marker levels

Anastomotic leak after small gut surgery

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. [1].To define factors associated with leakage of small gut anastomosis. [2] To find technique of small gut anastomosis associated with lowest risk of anastomotic dehiscence. Retrospective, Descriptive 02 Years [May 2003 to May 2005] This study was conducted at Surgical Unit-II, Allied Hospital, Punjab Medical College, Faisalabad from Dec 2003 to May 2005. A total number of 36 cases were included in this study comprising of both adult male and female patients developing anastomotic dehiscence following resection and end to end anastomosis of small gut. Peritonitis was the risk factor identified in 69% of the patients. Hypovolemic shock both preoperatively and in the immediate postoperative period was noted in 56% cases while 83% of the patients with anastomotic dehiscence had haemoglobin concentration less than 10g%. High concentration of blood urea was noted in 42% of the cases. It turned to normal as soon as the hypovolemia was corrected in these cases. Small gut anastomosis done in emergency setting [75% cases] was associated with increased risk of anastomotic dehiscence as compared to the dehiscence noted in 09 cases [25%] operated on elective list. Three different techniques were used for small gut anastomosis. The rate of anastomotic leakage ranged from 19-45%. Peritonitis, hypovolaemia and low hemoglobin alone or in combination are associated with increased risk of small gut anastomotic leakage especially after emergency surgery. Single layered extramucosal interrupted anastomosis was associated with less risk of dehiscence than the full thickness and continuous extramucosal anastomosis