Roux-en Y duodenojejunostomy for larger duodenal defects

Objective: To find the outcome of lateral duodenojejunostomy for larger duodenal defects due to different surgical conditions

Study design: Case series

Methodology: The clinical records were traced from the unit and hospital clinical record room. The data was collected and analyzed for the outcome of the procedure

Results: A total of six patients were managed with the surgical technique. All patients were allowed oral sips on 3[rd] postoperative day. One patient out of six needed ICU care of 42 days. Patient stay in ICU was of 42 days. Postoperative complications including anastomosis leak occurred in one patient. Nausea and vomiting was reported in two and wound infection in two patients. Mean hospital stay of the patients was 16.67 days

Conclusion: Roux-en Y duodenojejunostomy is a safe technique for the reconstruction of larger duodenal defects involving >50% [2/3[rd]] of the duodenal circumference

Small intestinal obstruction caused by a phytobezoar: a case report

Phytobezoar is a concretion formed in the stomach or intestine and composed chiefly of undigested compacted vegetable or fruit fibers. A case of Phytobezoar causing acute small intestinal obstruction in absence of prior gastric surgery or other predisposing factors is presented. The patient was managed surgically i.e., enterotomy

Fournier's gangrene: a review of 15 cases

To report the outcome of surgical management of Fournier's gangrene. This retrospective study evaluated 15 patients with Fournier's gangrene who had been managed in the Surgical Department of Khyber Teaching Hospital from July 2005 to June 2006. Their medical records were thoroughly studied. Study variables like co morbidities/risk factors, clinical features and surgical procedures were analyzed to determine their influence on the outcome. All 15 patients were males with an age range of 41-65 years [mean: 52.46 years]. According to their medical record concomitant weakening illnesses like diabetes mellitus, malnutrition, malignancy and immunosuppression were common risk factors. Six [40%] patients who survived and 3 [20%] patients who died had at least one of the aforementioned co morbid conditions. The most frequent co morbid condition was diabetes mellitus affecting 5 [33.33%] patients. E.coli, hemolytic streptococci and staphylococcus aureus were the common pathogens isolated. After admission they were resuscitated, parenteral broad spectrum antibiotics were started and extensive multiple debridments were done. Hospital stay ranged from 9 to 35 days with a mean hospital stay of 21.66 days. Mortality rate was 3 [20%] patients. Early recognition, timed presentation followed by aggressive resuscitation, proper intravenous antibiotics as well as extensive multiple debridments are significant factors to affect the outcome in the surgical treatment of Fournier's gangrene

Transabdominal repair of vesicovaginal fistula: an experience of 27 cases

To review the causes of vesicovaginal fistula and outcome of its repair through transabdominal approach. This is a descriptive cross sectional study which was conducted in Surgical "D" unit, Khyber Teaching Hospital Peshawar from January 2004 to December 2009. The record of all cases of vesicovaginal fistula that had undergone transabdominal repair was reviewed. Complex vesicovaginal fistula cases were excluded. Operative findings and procedure's details were obtained from operation notes. Post-operative follow up findings after one week, three weeks, forty days and three months were noted for every case. A total of 27 cases had undergone transabdominal repair for vesicovaginal fistula with age ranging from 26 to 63 years. Twenty two cases developed vesicovaginal fistula as a result of obstructed labour and five as a result of Gynaecological surgery [post-hysterectomy]. Mean post-operative hospital stay was seven days. Failure of repair was seen in one case only. Five cases were lost during follow up. Eight [29.63%] cases developed urinary tract infection, and two [7.40%] cases developed transient urinary stress incontinence. This study suggests that obstetrical trauma is the commonest cause for developing vesicovaginal fistula and the transabdominal approach gives satisfactory results in its repair

standard of informed consent in elective surgery - an observational study from a tertiary healthcare facility

To evaluate the practice and patient's perception of informed consent before elective surgery in Tertiary Health Care setup. This questionnaire based observational study was conducted in Surgical Department of Khyber Teaching Hospital Peshawar from April 2009 to August 2009. Standard questionnaires were handed over during their stay in the hospital to the patients who had undergone elective surgery. Independent variables of our study were age, educational level and socioeconomic status. Dependent variables were knowledge about the disease, treatment options, alternatives, what if no treatment, type and risk of anesthesia and postoperative complications and their management, the consent taking authority, their satisfaction about the information given and whether the consent form was signed by the patients themselves or their attendants. In our study on 37 [24.33%] patients the consent was obtained by the concerned surgeon while in 113 [75.33%] patients consent was taken by some junior doctors [trainee medical officers or house surgeons]. Disease was explained to 105 [70%] patients and various treatment options to 67 [44%] patients. One hundred thirty five [90%] patients were informed about the complications of their surgical treatment. Contrary to our expectations 110 [73.33%] patients expressed their satisfaction with the information given to them about their surgical management. Informed consent was signed by all [100%] the patients. The current informed consent practice in our surgical setup is deficient as far as the international, legal and ethical standard is concerned. We think further measures should be taken to involve the concerned surgeon and enhance patient's understanding of informed consent for surgery

Palliative surgery for pancreatic carcinoma

To evaluate the role of palliative surgical treatment in patients with advanced pancreatic carcinoma. Case series. Surgical [D] Ward of Khyber Teaching Hospital, Peshawar, from January 2005 to January 2009. The study included patients with pancreatic carcinoma admitted with advanced, unresectable carcinoma of the pancreas. Patients with resectable tumours and with previous history of gastric or biliary surgery were excluded. Palliative procedures were performed after assessment of the tumour and its confirmation as unresectable on ultrasound and CT scan +/- ERCP. Postoperatively all patients were referred to oncologist. Complications and mortality were noted. There were 40 patients, including 24 males and 16 females with mean age 58.72 +/- 6.42 years. The most common procedure performed was triple bypass in 21 [52.50%] patients followed by choledocho-, cholecysto-, hepatico- and gastro-jejunostomy in various combinations. Wound infection occurred in 7 patients and was more common in patients with co-morbidities. Biliary leakage occurred in 03 patients. Postoperative cholangitis occurred in 3 patients while 7 patients had minor leak from the drain site. Four patients developed UTI, while 5 patients had signs of delayed gastric emptying. Two patients had upper gastrointestinal bleeding. Three patients died due to septicemia and multiple organs failure. Rest of the patients were discharged in stable state. The mean hospital stay was 8.40 +/- 3.48 days and median survival was 7.72 +/- 2.39 months. Surgical palliation for the advanced carcinoma pancreas can improve the quality of life of patients and is associated with minimum morbidity and mortality

Total versus sub-total thyroidectomy for multinodular goiter

The aim of the study was to compare total and subtotal thyroidectomy [STT] for benign bilateral multinodular goiter [BBMNG] in terms of the proportion of hypoparathy-roidism and recurrent laryngeal nerve paralysis [RLNP]. Quasi experimental Place and duration of study: Department of Surgery, Khyber Teaching Hospital Peshawar, from 1st October 2007 to 30th September 2008. A total of 60 patients with bilateral multinodular goiter, were divided in to two groups A and B [30 patients in each group]. Group A patients were subjected to IT while group patients to STT. Sample technique used was non-probability purposive. Demographic details, biochemical findings, indications for operation, operating time and complications under study were noted for either group. There was no significant difference in the age, gender, hormonal status or duration of goiter between the two groups [P=0.123, P=0.74, P=0.509 and P=0.6, respectively]. The mean operating time was longer [138 +/- 30 min versus 112 +/- 33 min, P=0.046] for TT vs STT. Either temporary RLNP or HPT occurred in 3 [9.9%] or 6 [20%] of the patients undergoing total compared with 2 [6.6%] or 3 [9.9%] of the patients undergoing SIT [P=0.64 and P=0.278, respectively]. Permanent RLNP was observed in none and HPT in one patient only in TT group compared with none of either complication in STT group [P=0.313 for permanent HPT]. The present study shows that TT can be performed without increasing risk of complications, and it is an acceptable alternative for benign MNG, especially in endemic regions, where patients present with a huge multinodular goiter

Inferior lumbar hernia of petit in a patient with neurofibromatosis type-1

Lumbar hernias are rare lesions that account for less than 1.5% of total hernia incidence. Only 250-300 cases have been reported in literature. Diagnosis may be difficult because they are either asymptomatic or may present with vague complaints. Differential diagnosis includes a lipoma, a fibroma, a retroperitoneal or intra-cavitary tumor, hematoma or a chronic abscess. They may occur in association with defects of the musculoskeletal system including some syndromes. Lumbar hernia in patients with neurofibromatosis has been reported in a very few number of cases. We report a case of 40 year old female with type 1 neurofibromatosis who presented with left lumbar hernia of Petit

Outcome of mesh repair for incisional hernia

To determine the results of incisional hernia repair with prosthetic mesh. It is a retrospective descriptive study, conducted at Surgical "D" ward Khyber Teaching Hospital, Peshawar from January, 2002 to October, 2006. A total of 121 patients were included in this study. Those patients with incisional hernia, who were repaired with mesh and completed the minimum of 9 months of follow up, were included. Patients who were clinically diagnosed to have incisional hernia were admitted and after necessary preparation, were operated and defect in the abdominal wall was closed by a synthetic mesh. During the early post operative and follow up period, patients were looked for complications like seroma, infection, chronic discharging sinus formation and recurrence. Out of 121 patients, 73 were female and 48 were male. In most of the patients the incisional hernia resulted from emergency procedures. In 35 [28.9%] patients, there was post operative seroma formation, 17 [14%] patients had wound infection. one [0.8%] patient developed subcutaneous heamatoma due to unidentified bleeding which later on required evacuation under general anesthesia. Eight [6.6%] developed recurrence of hernia out of which some patients were treated by repeat Mesh repair. In 12 [9.9%] patients there was mild to moderate skin margin necrosis and in these cases debridement was a proof of successful treatment. Partial wound dehiscence was found in 3.3% of patients. Incisional hernia is more common in midline laparotomy wounds specially performed in emergency conditions and onlay mesh repair procedure has high acceptable outcomes

Comparative study of laparoscopic versus open cholecystectomy

To compare our results of Laparoscopic Cholecystectomy with Open Cholecystectomy regarding case selection, technical difficulties, duration of surgery, operative complications, post operative complications, post operative hospital stay, morbidity and mortality, patient's attitude after operation, operative expenses, total expenses and general impression in the society. Comparative study carried out from January 2002 to December 2005. Department of Surgery, surgical 'D' Ward, Khyber Teaching Hospital, Peshawar. This study was conducted on two hundreds patients, one hundred patients were submitted to Laparoscopic Cholecystectomy and the other hundred to traditional Open Cholecystectomy. These patients were admitted in our unit through Out-door department or in emergency as acute cholecystitis. All patients were thoroughly assessed and necessary investigations carried out. After consent all patients were operated on the next operation list. The patients were randomly assigned to either one of the procedures. There was no significant difference in the selection of patients in the two groups. No mortality was seen in both the groups, but complications were more in the open procedure than the laparoscopic one. There isles pain, less hospitalization, early mobilization and early return to work in the laparoscopic surgery. Laparoscopic Cholecystectomy is a superior procedure in comparison to Open Cholecystectomy as regards to the results. Hence it is recommended as the first choice operation

longmire procedure: is it worthwhile?

To evaluate the peripheral intrahepatic cholangiojejunostomy [Longmire procedure] for the palliative treatment of jaundice in patients with irresectable malignant tumours of the liver hilum. In a retrospective study, indications, surgical technique, perioperative complications, and efficacy of treatment were analyzed for 17 patients who had received a Longmire peripheral intrahepatic cholangiojejunostomy between May 2000 and August 2004. The Longmire procedure was exclusively palliative in all 17 cases. The 30-day mortality in the study group was 11.6% [n=2/17], and the mean survival was 6.2 months. In patients surviving more than one month, a marked and persistent decrease in cholestasis was achieved in 86.6% cases. The Longmire peripheral intrahepatic cholangiojejunostomy is a feasible and a worthwhile procedure and offers a reasonably effective palliative treatment for patients with irresectable tumors of the liver hilum

Total Thyroidectomy for benign bilateral multinodular goitre in an endemic region

To assess the safety and efficacy of total thyroidectomy as the primary treatment modality for all patients presenting with a benign bilateral multinodular goitre and to highlight its importance in an endemic region. A retrospective study from June 1998 to December 2005. Setting: Department of Surgery, Khyber Teaching Hospital, Peshawar. 106 patients who underwent total thyroidectomy for bilateral benign multinodular goitre. The data of all the above mentioned patients was recorded and analyzed. Amongst the total 106 patients, the female to male ratio was 5:1. Most patients were euthyroid biochemically. The most common indication for thyroidectomy was compressive symptoms. In the vast majority of patients the final diagnosis was benign adenomatous colloid goitre; the incidence of occult carcinoma was 8.4%. The incidence of permanent unilateral recurrent laryngeal nerve injury and permanent hypoparathyroidism was 1.8% and 0.9% res-pectively. There were no postoperative deaths in this series. The results of this study confirms the safety and efficacy of total thyroidectomy for all patients presenting with bilateral multinodular goitre. This is particularly relevant in endemic regions, where patients present with large, longstanding goitres, which grossly involve both lobes, with virtually no normal thyroid tissue. This approach avoids disease recurrence and the increased morbidity associated with secondary operations

Combined open prostatectomy and pre peritoneal repair of concurrent inguinal hernia

To determine whether concurrent inguinal hernia in patients undergoing open prostatectomy can be safely and effectively repaired by the preperitoneal approach. A retrospective descriptive study from 1994 to 2004. Surgical Department of Khyber Teaching Hospital, Peshawar. Four hundred and ninety eight patients with Benign Prostatic Hypertrophy. All the patients had their history taken, and thorough examination and appropriate investigations done. They underwent open prostatectomy and pre peritoneal repair of the inguinal hernias. Postoperative complications including wound infection, pelvic collection, secondary hydrocoeles, nerve injuries, persistent groin pain, testicular atrophy, hernia recurrence, etc. were assessed during each follow-up visit. Out of the 498 patients that underwent open prostatectomy during the study period, 47 [9.4%] underwent additional 53 preperitoneal hernioplasties; in six patients the hernias were bilateral. In 39 [73.5%] cases the hernias were indirect and in 14 [26.5%] direct. Apart from two [3.7%] recurrences no other postoperative complications were noted that were attributable to the hernia repair. Hernia repair can be performed safely and expeditiously during open prostatectomy using the pre peritoneal approach. This approach avoids a potential future operation as well as the potential complications of unrepaired hernias

Experience of day care surgery at Peshawar

To evaluate the results of Day Care Surgery in our set-up. Retrospective study from Jan. 2003 to May 2005. Surgical 'C' Unit of Khyber Teaching Hospital, Peshawar. A total of 190 patients who underwent Day Care Surgery were included in this study. All patients were evaluated and counselled before hand, and asked to come on a given date. On the day of surgery they were shifted to the Operation Theatre, operated, kept under observation and sent home the same day with the advice to contact the concerned surgeon in case of any problem or complication. The patients were followed-up on the 3rd and 7th days, and examined for evidence of any local or distant complication. The patients were once again followed within a months time. Out of 190 patients, there were 131 male and 59 female patients, with an age range of two months to 65 years. All patients went home following surgery the same day except two, who were apprehensive and had to he kept for night. Twelve made telephone calls and were given advice. Five patients were readmitted with vomiting. two with severe pain and two with reactionary hemorrhage, and were discharged home the next day. One patient with hernia repair was readmitted after two days with scrotal oedema and treated. Day Care Surgery in uncomplicated cases is safe and cost effective. Majority of the patients were satisfied with this approach of early discharge

Mini-cholecystectomy: experience of 324 cases

To determine the frequency of patients with symptomatic gallstones in whom a cholecystectomy could safely be accomplished through a 5 cm or less "mini-lap" incision. This is a retrospective study of 324 consecutive cases of symptomatic gallstones that underwent cholecystectomy through a 5cm or less transverse sub-costal incision, from June 1996 to June 2001, a total period of five years. The study was conducted at the surgical department of Khyber Teaching Hospital, Peshawar. A "mini-lap" cholecystectomy was possible through a 5cm or less incision in 289 [89%] cases, compared to 35 [11%] cases, where the incision required extension beyond 5 cm. The total morbidity recorded was 8.7%. The incidence of bile duct injury was 0.3%, because of a single patient who developed a post-operative bile duct stricture necessitating a re-laparotomy and a hepatico-jejunostomy. There was a single postoperative death recorded, giving a mortality of 0.3%. The study clearly confirmed that a "mini-lap" cholecystectomy, which boasts many advantages over conventional open cholecystectomy, is a safe and viable alternative to laparoscopic cholecystectomy and can be performed in the vast majority of patients with symptomatic gallstones

Subcostal gridiron incision for biliary surgery

This retrospective study audited all the extrahepatic biliary operations performed through a subcostal muscle splitting incision between January, 1979 and June, 1995. Of the 400 patients subjected to biliary surgery 340 [85%] were females and 60 [15%] males. One hundred and eighty [45%] patients presented with symptoms of acute and 220 [55%] with chronic cholecystitis. Most [95%] of the operations were performed electively. Simple cholecystectomy was performed in 320 [80%] patients and 72 [18%] had common bile duct exploration for stones. Of these 67 had choledochoduodenostomy and 5 a polythene tube drainage of common bile duct. The overall morbidity of the procedure was 13.5% of which 3.5% were procedure related complications and 10.0% general complications. Only two deaths occurred during the study giving a mortality of 0.5%. This technique has greatly reduced the hospital stay, the amount of blood loss during operation and post operative pain. No patient had incisional hernia or wound dehiscence and all the patients were back to work early. The results of this study suggest that this incision may be used with advantage elsewhere

unusual case of splenic artery aneurysm

Aneurysms of the splenic artery are very rare, but if diagnosed before rupture, they can safely treated. A case of a 35- year old multigravida with a large pulsatile mass in the upper abdomen which was diagnosed as a splenic artery aneurysm and successfully resected is being presented. To our knowledge, and after review of the literature, an aneurysm of this size has never been reported