Short term outcome of laparoscopic ventral rectopexy for rectal prolapsed

Objective: To find out the short term outcomes of effectiveness and safety of laparoscopic ventral rectopexy for rectal prolapsed

Methods: It was a descriptive case series study of 31 consecutive patients of rectal prolapse in Colorectaldivision of Ward 2, Department of General surgery, Jinnah Post Graduate Medical Center, Karachi, from November 2009 to November 2015. These patients were admitted through outpatient department with complains of something coming out of anus, constipation and per rectal bleeding. All patients were clinically examined and baseline investigations were done. All patients underwent laparoscopic repair with ventral mesh placement on rectum

Results: Among 31 patients, mean age was 45 years range [20 - 72]. While females were 14[45%] and males 17[55%]. We observed variety of presentations, including solitary rectal ulcers [n=4] and rectocele [n=3] but full thickness rectal prolapse was predominant [n=24]. All patients had laparoscopic repair with mesh placement. Average hospital stay was three days. Out of 31 patients, there was one [3.2%] recurrence

Port site minor infection in 3[9.7%] patients, while conversion to open approach was done in two [6.4%], postoperative ileus observed in two [6.4%] patients

One[3.2%] patient developed intractable back pain and mesh was removed six weeks after the operation. One[4.8%] patient complained of abdominal pain off and on postoperatively. No patient developed denovo or worsening constipation while constipation was improved in 21 patients [67%]. Sexual dysfunction such as dysperunia in females and impotence in males was not detected in follow up

Conclusions: This study provides the limited evidence that nerve sparing laparoscopic ventral rectopexy is safe and effective treatment of external and symptomatic internal rectal prolapse. It has better cosmetic and functional outcome as advantages of minimal access and comparable recurrence rate

Outcome of four years experience in laparoscopic ventral hernia repair

To find out the short term outcomes of laparoscopic ventral hernia repair [LVHR] during the last four years. It was a descriptive and prospective case series of 53 consecutive patients out of 107 at Department of General Surgery, Jinnah Post Graduate Medical Center, Unit II, Karachi, from January 2009 to December 2012. These patients were admitted through out patient department with complain of lump, pain and discomfort. Most of the patients were obese. All patients were clinically examined and baseline investigations done. Fifty three [49.5%] patients underwent laparoscopic repair with mesh placement and remaining 54 by open surgical repair. Among 53 patients, mean age was 46 years range [30 - 55]. While females were 33[62.2%] and males 20[37.7%]. We observed variety of hernias, in which midline and epigastric hernia were predominant. The commonest symptom was lump and dragging sensation. The duration of symptoms ranged between 6 months to one year. About 53 patients [49.5%] had laparoscopic repair with mesh placement. Average hospital stay was two days. Out of 53 patients, 4 [7.5%] had cellulitis at trocar site, seroma in 2[3.7%], 2[3.7%] patient complained of persistent pain postoperatively, port site minor infection was in 2[3.7%] patients, while conversion to open approach was done in 2 [3.7%], postoperative ileus was observed in one [1.8%] patients. This study provides the evidence that, laparoscopic repair with mesh placement in ventral hernia is safe and effective approach compared to open surgical procedure. It has a low complication rate, less hospital stay and low recurrence

Outcome of open prostatectomy

To determine the outcome of open prostatectomy in the general surgery department of rural setup. Descriptive case series. Department of Surgery, Fatima Hospital and Baqai Medical University Karachi, from June 2004 to May 2011. All patients with bladder outlet obstruction due to benign prostatic hyperplasia [BPH], operated by transvesical route were included. The parameters evaluated were improvement in International Prostate Symptom Score [IPSS], peak urinary flow [Qmax], postvoid residual urine [PVRU], blood transfusion rate, operative time, duration of catheterization, hospitalization and postoperative complications. There were 107 patients in the series. Mean age was 67 +/- 6 year [SEM=1]. The IPSS improved from 26.53 +/- 3.920 preoperatively to 9.13 +/- 1.797 postoperatively, PVRU from 136.094 +/- 31.802 to 18.86 +/- 5.694, and Qmax from 9.032 +/- 1.940 to 19.952 +/- 2.555. The postoperative complication rate was 46.7%. It included hemorrhage requiring transfusion [n=13 -15%], urinary tract infection [n=10 - 9.3%], wound infection [n=7 - 6.5%], clot retention [n=5 -4.7%], temporary urinary incontinence [n=3 -2.8%], bladder neck stenosis [n=3 - 2.8%], urethral stricture [n=2 -1.9%], suprapubic urinary fistula [n=2 - 1.9%], and epididymo-orchitis [n=1 - 0.9%]. The mortality rate was 0.9%. The mean operative, catherterization and hospitalization duration were 56.23 +/- 9.77 minutes, 7.12 +/- .81 days, and 8.41 +/- 2.28 days, respectively. Open prostatectomy is still a good option for BPH where endourology facilities are not available

Amyand's hernia as a sliding component of inguinal hernia

The presence of vermiform appendix in inguinal hernia, referred to as Amyand's hernia, is rare occurring in about 1% of inguinal hernias. This is a report of Amyand's hernia, which presented as a sliding component along with enterocele in a right inguinal hernia in a 27-year-old male patient. Appendicectomy and hernioplasty were performed, with an uneventful postoperative recovery

Open renal approach: comparative analysis of sub-costal incision versus trans-costal incision with excision of 12[th] rib

To compare the outcome of sub-costal incision with trans-costal incision and 12[th] rib resection in the surgical approach for benign renal disease. It is a prospective, analytical, comparative study using randomized controlled trial [RCT], conducted at Fatima hospital-Baqai medical university [Karachi], from June 2005 to December 2008. In total 54 patients were enrolled in the study, who either underwent pyelolithotomy or nephrectomy via sub-costal [group A: 27 patients] or trans-costal incision [group B: 27 patients]. Incision time, duration of operation, postoperative pain, duration of hospital stay, and peroperative and postoperative complications were noted. Incision time and duration of operation were longer in group B patients [p-value 0.002 and 0.029 respectively]; pain perception was also markedly high in this group [p=0.001]. Total period to stay in hospital was marginally higher in group B [p=0.212]. Peroperative and postoperative complications were also slightly higher in group B patients [p-value 0.064 and 0.838 respectively]. Sub-costal renal approach provides adequate exposure, is quick, safe and less painful

Testicular carcinoma misdiagnosed as hydrocele: lesson to learn

About 99% of testicular tumors are malignant though they only constitute about 1-2% of malignant tumors in male. They are more readily accessible to examining fingers than a tumour of any other organ in the body, however too often they escape detection until it has metastasised. Worst error is to plunge a trocar and cannula into the enlarge testis or operating from scrotal approach in the belief that it is a hydrocele. Proper pre-operative assessment and diagnosis has the key role in the life expectancy of patient. Hydrocele and testicular tumor both have different operative approaches. For hydrocele scrotal approach and for tumor inguinal approach is recommended. For tumor, if scrotal approach has been adapted it may result in disaster. Two cases of testicular carcinoma initially diagnosed and operated as cases of hydrocele are reported

Gallbladder perforation and stone spillage during laparoscopic cholecystectomy

To determine the frequency of gallbladder perforation and stone spillage during laparoscopic cholecystectomy [LC], and its subsequent complication and management. Descriptive case-series. This is a prospective analysis of laparoscopic cholecystectomies performed at Surgical Unit I, Civil Hospital Karachi, from 1st September 1997 to I5th June 2005. There were 1246 patients in the study, who underwent LC. The inclusion criteria for LC were: patients of all ages and both sexes, symptomatic gallstone disease, recurrent attack while waiting for interval LC, normal levels of blood complete picture and liver function tests, and ultrasound abdomen demonstrating gallstone disease. There were 107 cases of gallbladder perforation, ie a frequency of 8.59%. In 24 of these patients gallstones spillage also occurred, ie a frequency of 1.92%. An effort was made in each case to remove the spilled stones laparoscopically, but in seven patients unretrieved stones were left [ie a frequency of 0.56%]. One patient developed pelvic abscess, presenting with post-operative diarrhea and fever on day 5 and confirmed by ultrasound; it was left to drain in the rectum and treated by broad-spectrum antibiotics. Four patients developed sub-hepatic abscess, presenting with right hypochondria! and shoulder tip pain and fever on day 3; they were confirmed by ultrasound, with subsequent ultrasound guided drainage and broad-spectrum antibiotics. Three patients developed epigastric port site infection; two were treated successfully by daily wound care and appropriate antibiotics after culture and sensitivity. One developed persistent epigastric sinus, and a gallstone was retrieved on exploration. There was no mortality and long-tertn morbidity. Gallbladder perforation and stone spillage are frequent occurrence during laparoscopic cholecystectomy. Active laparoscopic retrieval of spilled stones and thorough irrigation of sub-hepatic area reduces the risk of subsequent complications

Bowel injuries during laparoscopic cholecystectomy

To determine the frequency, site, cause, presentation, management and mortality of the bowel injuries during laparoscopic cholecystectomy [LC]. Descriptive case-series. This is a prospective analysis of laparoscopic cholecystectomies performed at Surgical Unit I, Civil Hospital Karachi. A total of 1246 LCs were performed from 1st September 1997 to 15th June 2005. There were 1246 patients in the study, who underwent LC. The inclusion criteria for LC were: patients of all ages and both sexes, symptomatic gallstone disease, recurrent attack while waiting for interval LC, normal levels of blood complete picture and liver function tests, and ultrasound abdomen demonstrating gallstone disease. There were 2 cases of bowel injury, ie a frequency of 0.16%. One was serosal injury to colon and the other was duodenal perforation. Both were detected peroperatively, and managed by converting the procedure to open and primary closure of injury; duodenal closure was reinforced with omental patch. Postoperatively, the patient with colonic injury recovered well, but the patient with duodenal injury developed duodenal fistula which was managed conservatively. There was no mortality. Both cases of bowel injury were among the first 50 of the 1246 case-series. At 0.16%, the frequency of bowel injuries during laparoscopic cholecystectomy is small; the risk of such injury is more during the learning curve. Timely detection during the operation results in successful outcome, with little or no mortality

Impetigo contagiosa: therapeutic aspects

In tropical countries pyoderma is a common problem particularly in summer and monsoon. Causative organisms are Staphylococcus aureus, Streptococcus pyogens, Bacillus proteus, pseudomonas and coliform bacilli. Infection of the skin is characterized by discrete thin walled vesicles and bullae which rapidly become pustular then rupture. Impetigo occurs mainly on exposed parts of the body. Lesions occurring on scalp are mostly associated with pediculosis capitis. On rupture of these lesions a thin straw coloured seropurulent discharge is noticed. Sometimes group A beta-haemolyticus infections may follow acute glomerulonephritis. Impetigo occurs most frequently in early childhood. It may simulate different superficial skin conditions like circinate patches of ringworm. It is a common but simple problem, which can be easily cured by topical therapy and if needed systemic antibiotics can be given. Topical corticosteroid ointments should not be used, they worsen the infection

Metoclopramide a drug with versatile therapeutic uses

Metoclopramide a benzamide acts centrally by blocking dopamine D2 receptors in the CTZ and peripherally by enhancing the action of acetylcholine at muscarinic nerve endings in the gut. It increases gastric peristalsis while relaxing the pylorus and first part of the duodenum. It has no action on gastric secretions. It is the prokinetic of choice. The drug is effective in diabetic gastroparesis. Metoclopramide is effective and polar drug for many types of vomiting, postoperative, drug induced, disease associated [especially migraine], radiation sickness, it is less effective in motion sickness. It is also effective in vomiting induced by highly emetic anticancer drugs. Female patients who undergo operative procedures develop nausea which can be controlled by metoclopramide. Postoperative nausea and vomiting can be controlled with the drug. It is also effective in drug induced nausea and vomiting. It is also effective in the treatment of migraine. It has also been advised for hyperemesis gravidarum. Regarding use of metoclopramide during pregnancy to determine its use further studies are required. Its adverse effects include extra pyramidal symptoms. Antimuscarinic drugs; benzteropine given I/v can abolish the reaction. Prolonged use in elderly may produce tardive dyskinesia. Metoclopramide induced pseudotetanus has been reported, methemoglobinemia and sulfhemoglobinemia have also been reported. It is effective in nausea and vomiting induced in various conditions, like postoperative, gynaecological procedures, cytotoxic drugs. It is also effective in migraine it is a good prokinetic agent

Ibuprofen: Adverse Effects

Ibuprofen is the first member of the class propionic acid introduced in 1969. It is better-tolerated analgesic as compared to aspirin. All members belonging to propionic acid group inhibit prostaglandins, easily absorbed on oral administration, enter brain, synovial fluid and cross placenta, largely metabolized in liver by hydroxylation and glucuronic conjugation excreted in urine as well as in bile. It has analgesic, antipyretic and anti-inflammatory effects. It is commonly used in rheumatoid arthritis, osteoarthritis, and other musculoskeletal disorders. It is useful drug but cannot be considered free of adverse effects, the side effects comprise of milder gastric discomfort, nausea and vomiting, headache, dizziness, blurring of vision, tinnitus, depression, rashes, itching and other hypersensitive phenomena. Anaphylactic shock has also been reported, salt retention and hypertension has also been reported in elderly patients. In our study we noticed 10 male and 25 female patients developing gastric discomfort on prolonged use of ibuprofen. Two females patients have been noted developing analgesic headache. 5 male and 2 female observed nausea. 3 males and 2 females reported dizziness. 2 male patients were observed to have fixed drug eruptions

Vitamin, E: therapeutic uses

Alphatochopherol has vitamin E activity, wheat green oil is the richest source, it is also present in cereals, nuts, spinach and egg yolk. It was de clared that female rats required an unrecognized substance essential to sustance normal pregnancy. Some times during pregnancy death of the foetuses occurred in animals who were deficient of that substance later on vitamin E was referred to as antisterility vitamin. Vitamin E acts as antioxidant protecting unsaturated lipids in cell membrane. In animals vitamin E deficiency shows structural and functional abnormalities of many organs. Morphological alterations reveal biochemical defects involving fatty acid metabolism. Though it is called the antisterility factor but it does not have any value in treatment of sterility and habitual abortions in humans. There is interest of vitamin E in neurological diseases in humans. Vitamin E is essential nutrient necessary for the optimal development and maintenance of integrity and function of human nervous system and skeletal muscles. Clinical vitamin E deficiency has been implicated only in certain neuromuscular diseases in children. Vitamin E has been found to enhance the absorption of Vitamin A, found useful in intermittent claudication, fibrocystic breast disease and nocturnal muscle cramps, vitamin E has been promoted in menopausal syndrome, toxemia of pregnancy, ischaemic heart disease, several skin diseases, post herpetic neuralgia and scleroderma. It has also been found useful in retinopathy Higher levels of Vitamin E have lower risk of breast cancer. It is useful in athero sclerosis, cerebrovascular disorders, anaemia of premature infants, retrolental fibroplasias, bronchopulmonary dysplasia and intraventricular haemorrhages It inhibits aggregation of blood platelets. Vitamin E needs further and more trials to achieve its benefits. This is a review article

Treatment of miliaria rubra with ascorbic acid: an open pilot study

Miliaria rubra [prickly heat] is one of the most common and quite distressing skin disease of the tropics. It produces burning and itching. The condition is well recognized both by the patients and the physicians. It presents in the form of pruritic, erythematous papulovesicles on the skin. The primary treatment is to keep the patient in cold and airy atmosphere which unfortunately, is not easily practicable in tropical settings. Ascorbic acid in the dose of 1G daily for one week was tried on eighty cases of various age groups ranging from 10-50 years. Severe symptomatic cases turned to moderate and moderate to slight. Further studies to ascertain the role of ascorbic acid in the management of miliaria rubra are recommended

Scabies: a common skin problem often misdiagnosed

Scabies is a common skin problem and is caused by a parasite sarcoptes scabiei. The affected patient develops pruritic papules. The sites of predilection are chiefly the inter digital webs of the hands, the wrist, the flexures, of the arms, the axillae, the nipples, area around the umbilicus, lower abdomen, genitals and the buttocks. The disease spreads in epidemics and is transmitted from one person to another, unhygienic situations are basic factors for the spread of this infestation. Delayed treatment of the primary cases may flare-up the problem. Sufficient survey of the epidemiological problem is necessary. Very important matter is misdiagnosis of the disease, it has been misdiagnosed as eczema, allergic dermatitis, pyogenic infections etc. Irrational use of corticosteroids have contributed in flaring-up of the disease. The disease can be easily treated with crolamiton cream, Benzyl benzoate emulsion, and sulphur ointment. There are many other drugs topical available for its treatment. Only oral drug available is ivermectin single dose of which gives good results. All preventive and Therapeutic measures are necessary, good diagnostic acumen is needed in practitioners of medicine

Nucleolar organizer regions in normal bone marrow

The silver colloid technique for nucleolar organizer regions [AgNORs] was applied to bone marrow smears in 20 cases of normal morphology marrow. The AgNORs were recorded in the form of 'clusters' and 'dots'. Each developing cell type of myeloid and erythroid series revealed a different pattern of 'clusters' and 'dots'. 'Clusters' associated with proliferation while mature, non-dividing forms contained only 'dots'. 'Clusters' and 'dots' have different biologic significance and the method should be adopted while evaluating marrow smears