Role of shearwave elastography in the search of unknown primary cancer in breast and abdominopelvis

Objevtices: Shearwave elastography has recently got approval for its use in clinical imaging. It has got its established accuracy in assessing liver fibrosis, where biopsy for the staging of cirrhosis has been minimized. There is emerging data showing its superiority in detecting breast and other cancers as compared to conventional imaging methods. This study aimed to analyse role of shearwave elastography in detection of primary impalpable lesions in breast and abdomino-pelvic regions and those missed on conventional imaging modalities

Setting: Shearwave Elastography Unit, Liaquat University of Medical and Heath Sciences, Jamshoro, Pakistan

Design and methods: The study is an observational pilot project including the patients presented to surgery and oncology departments with metastatic cancer suggested on conventional imaging or cytology of the metastatic site but primary sites were not known and suspected to be in the region of breast, abdomen or pelvis. Shearwave elastography was applied as supplementary tool to re-do B-mode ultrasound. Aixplorer Ultrasound System Multiwave version 8.2.0 [Supersonic Imagine S.A., Aix-en-Provence, France] was used in this study. This study selectively includes the patients who were called on experimental basis to see the effectiveness of the system on trial basis, the calculation of the sensitivity, specificity, positive predictive value and negative predictive values were not determined

Results: There were seven patients including four with axillary lymph nodes and three having liver metastases. In patients with axillary lymph nodes mammogram and conventional ultrasound failed to show primary breast lesions, histopathology of the axillary lymph nodes suggested infiltrating ductal carcinoma. In patients with liver metastases conventional ultrasound abdomen and CT scan failed to reveal primary lesions. Shearwave assisted B- mode ultrasound suggested a solid mass in a complex cyst in the kidney in one patient and in the other there were multiple benign cysts and a solid mass however the third patient with liver mass found to have primary from gall bladder. These findings were later confirmed on histopathology or cytology

Conclusion: Shearwave elastography is an emerging non invasive technology showing potential role to supplement B-mode ultrasound in detecting unknown primary cancerin breast and abdomino-pelvic region

Haemorrhoidectomy with internal sphincterotomy: a useful method to relieve post operative pain

OBJECTIVE: This study was designed to compare short term outcome of post operative pain in patients operated for haemorrhoidectomy alone and haemorrhoidectomy with internal sphincterotomy

METHODOLOGY: This comparative observational study conducted at Liaquat University Hospital Jamshoro during August 2012 to July 2014. One hundred and sixteen patients of 3rd or 4[th] degree hemorrhoids were enrolled in the study. Patients were divided into two comparable groups. Group A underwent open haemorrhoidectomy along with lateral sphincterotomy whereas group B was operated for open haemorrhoidectomy alone. Postoperative pain was analyzed by using visual analogue score at 24 hours, 48 hours and on 10th post operative day

RESULTS: Total 116 patients were included in the study. Fifty eight patients in each group

The mean age of the patients was 42+/- 10.2. Male were 77 [66.4%] and 39 [33.6%] were female. Male to female ration was 2:1. During follow-up periods, patient in group A experienced less postoperative pain as compared to group B [p value is

CONCLUSION: Lateral internal sphincterotomy combined with haemorrhoidectomy significantly reduces postoperative pain without increasing morbidity

Calculus nephrectomy: dilemma of developing countries

Objectives: to determine the frequency of simple nephrectomy in patients presenting with Urolithiasis

Material and methods: this is a retrospective study of patients presented at University hospital with urolithiasis during January 2007 to December 2010. The data were collected for patients who underwent nephrectomy for stone disease

Results: total number of patients admitted with urolithiasis was 2600. Out of these, 88 [3.38%] patients underwent simple nephrectomy for non-functioning kidney. Mean age of patients was 32.5 years, males were 62 [70.45%] and females were 26 [29.55%]. Flank pain was predominated symptom in 88% of patients. Mean duration of symptoms was 2.4 years. Mean size of stone was 4.1cm. Seventy patients had stones in renal pelvis

Conclusion: percentage of calculus nephrectomy among patients of urolithiasis is 3.38%

Efficacy of strictureplasty in tuberculous strictures of small intestine

To assess the efficacy of strictureplasty for tuberculous stricture of small intestine. This is a retrospective descriptive study, conducted at Liaquat University Hospital Jamshoro [LUH] during period of 5 years from July 2004 to June 2009. Sixty patients of small intestinal tuberculosis presented with stricture of small intestine and underwent strictureplasty were the subject of this study. The procedure was done conventionally in all cases, in 70% intestine was closed in two layers while in remaining it was done as single layer. Early complications were seen in 23 cases which included anastomotic leakage with fistula formation [9 cases [15%]], burst abdomen [5 cases [8.34%]] and subdiaphragmatic abscess [9 cases [15%]] The late complications observed after mean follow up of two years include intestinal obstruction that necessitated readmission was seen was in 9 cases [15%], however the re-exploration was required in five cases. Incisional hernia was seen in 9 cases [15%].Though the post operative complications are frequent after strictureplasty yet the procedure is safe and simple for tuberculous stricture of small intestine as it requires minimum expertise, less operative time and above all preserve gut's length

Pilonidal sinus: excision with primary midline closure versus open method

Objective: To compare the efficacy of primary closure versus open method after excision of pilonidal sinus

Design: Comparative study

Setting: Department of Surgery Liaquat University of Medical and Health Sciences, Jamshoro, Sindh - Pakistan, from January 2003 to December 2006 [4 years]

Material and Methods: Cases of chronic pilonidal sinus were included in this study whereas acute sinuses and recurrent sinus were excluded. Patients were conveniently selected for excision with closure and without closure [group A and group B]. Both groups were followed up for 18-months. Efficacy assessed and compared on the basis of operating time, duration of postoperative hospital stay, time off work and recurrence rate

Results: Each group comprised of 20 patients. The mean age of all 40 patients was 27-years [17-42 years]. Males were 37 [92.5%] and females were 3 [7.5%]. Respective observations for both groups were mean operative time 91 min [85-95 min] and 69 min [60-75 min], mean postoperative hospital stay 6 days [4-8 days] and 11 days [9-13 days], mean time of wound healing was 11 days [9-13 days] and 39 days [19-42 days], mean off work time was 21 days [10-26 days] and 42 days [22-46 days]. Recurrence rate was 11.1% and 5.2% in group A and group B respectively

Conclusion: Though it takes longer to excise pilonidal sinus with primary closure and it has higher recurrence rate, it appears more beneficial due to reduced hospital stay, reduced healing time and early return to work

audit of non-idiopathic intussusception in children

Objectives: To outline the causes of non-idiopathic intussusception in children and to document the clinical characteristics of the different etiologies

Methodology: It is a retrospective review of 19 cases of proved secondary intussusception, over a span of 5 years i.e. from January 2004 to December 2008. Data was collected from private as well as from government hospitals in different centers. Patient's age ranges from three months to 12 years. Demographic data, clinical presentations, surgical management and follow up were recorded on pre designed proforma. Baseline blood investigations and radiological tests were noted. Surgery was performed in all patients due to delayed presentation and non availability of image intensifier

Results: Among 19 patients, 13 [68.42%] were boys and 6 [31.57%] were girls with male to female ratio of 2.16:1. The mean age was 2.15 years. Meckel's diverticulum was the most common cause and found in 8 [42.10%] children. Four [21.05%] had lymphoma, 2 [10.52%] had haemangiomas and 2 [10.52%] with polyps of the colon. Round worms, duplication of gut and Henoch-Schonlein's purpura were the other causes of non-idiopathic intussusceptions

Conclusion: Intussusception caused by an underlying disease or secondary to some pathological lead point is not uncommon and it is important to be vigilant for pathological lead points in children of any age

Postoperative complications of reversal of loop ileostomy

Objectives: to determine the morbidity associated with reversal of loop ileostomies

Methods: this was a prospective interventional study conducted at Liaquat University Hospital Jamshoro, from September 2005 to August 2007. All patients who had their loop ileostomies reversed during the study period were included. The various postoperative complications were noted during postoperative hospital stay

Result: seventy-nine patients fulfilled the selection criteria during the study period. Typhoid perforation was most common indication of loop ileostomy construction and reversal account for more than three-fourth of all cases majority of them were males [75.94%]. Mean interval for ileostomy reversal was 90 days. Thirteen patients [15.6%] developed postoperative complications after reversal of loop ileostomy, most of these were settled on conservative treatment. Postoperative wound infection [9.6%] was the most common complication. Only four patients [4.8%] had surgical intervention to manage these complications

Conclusion: loop ileostomy reversal is associated with low morbidity

Transurethral resection of prostate versus Transvesical approach: frequency of postoperative urinary incontinence: two year study

Objective: to compare the results of transvesical prostatectomy with transurethral resection of prostate in respect to the presentation and severity of postoperative urinary incontinence

Design: comparative study

Place and duration of study: this study was carried out in two tertiary care centers Liaquat University of Medical and Health Sciences Jamshoro from where all cases of TRUP were collected and Muhammad Medical College Mirpurkhas where all transvesical prostatectomies were performed. It was a two years study from April 2004 to March 2006

Patients and methods: two groups were made and 50 cases were kept in each group by adopting non-probability convenient sampling technique. Patient underwent TURP were kept in group A and transvesical prostatectomy group was titled as group B. Patients having associated stricture urethra, urinary bladder stones or bladder diverticulum and later on proved as carcinoma of prostate were excluded from the study. Urinary incontinence in patients after both procedures was compared

Results: from group A 07 [14%] patients developed incontinence postoperatively and all had stress type of incontinence. While in group B 11 [22%] patients developed urinary incontinence; among them 05 [45.45%] had stress incontinence and 06 [54.55%] developed continuous urinary leakage. Rate of recovery after conservative measures remained rapid with group A as compared to group B

Conclusion: frequency and severity of postoperative urinary incontinence is more with transvesical approach. But the facility of TURP is not freely available. Therefore improvement in the technique of open prostatectomy is mandatory

Effects of transurethral resection of prostate on flow rate and voided volume on patients with benign prostatic hyperplasia

Objective: to assess urinary flow rate/uroflowmetry in patients undergoing transurethral resection of the prostate [TURP] for benign prostatic hyperplasia [BPH], during three postoperative months

Study design: prospective observational study

Materials and methods: this study was conducted at Department of Urological Surgery and Transplantation, Jinnah Postgraduate Medical Centre [JPMC] Karachi-Pakistan, between March 2002 and March 2005. Fifty consecutive clinically diagnosed cases of BPH who never went in retention of urine and underwent TURP were included in this study. Preoperative urinary flow rate was measured. Uroflowmetry was postoperatively carried out after every month for three months period and observations were analyzed

Results: mean +/- SD age of the subjects was 63.62 +/- 6.75 years. Preoperatively mean +/- SD values were maximum flow rate 7.60 +/- 2.41 ml/sec, average flow rate 4.44 +/- 1.28 ml/sec and voided volume 165.54 +/- 49.60 ml. Post-TURP mean +/- SD values after three months were maximum flow rate 27.24 +/- 5.11 ml/sec, average flow rate 13.48 +/- 2.08 ml/sec and voided volume 240.32 +/- 49.91 ml. The variation in means of uroflowmetry parameters from first to third post-TURP month found statistically significant [P<0.001]

Conclusion: we conclude that the effects of post-transurethral resection of prostate, all the obstructive uroflowmetry parameters return towards normal levels. It indicates that there is excellent improvement relief in both obstructive and irrelative symptoms

Frequency of peripheral arterial disease in diabetic foot

Objective: to determine the frequency of peripheral arterial disease in patients with diabetic foot

Study design: prospective descriptive study

Place and duration: this study was conducted at Medical Unit-IV Liaquat University Hospital, Jamshoro/Hyderabad from February 2007 to August 2008

Patients and methods: diabetic patients with non-healing foot ulcer, were selected for the study by non-probability purposive sampling technique. Ankle brachial index [ABI] was calculated; peripheral arterial disease [PAD] was diagnosed when ankle brachial index was less than 0.9 and further graded as mild, moderate and severe as per recommendations of American Diabetes Association. Frequencies with proportions in different grades were calculated

Results: a total of 67 diabetic foot patients were included, amongst which 51 [76.1%] were males and 16 [23.9%] were females. Peripheral arterial disease was found in 30 [44.78%] patients, among them 18 [60%] had mild, 12 [40%] had moderate and none had severe peripheral arterial disease

Conclusion: ankle brachial index [ABI] is a simple and cheap technique for the diagnosis of peripheral arterial disease [PAD]. The PAD is one of the major risk factors for diabetic foot, which can be prevented by monitoring ABI in at-risk patients

Diagnostic accuracy of Alvarado scoring system in acute appendicitis

Objective: Acute appendicitis is one of the commonest surgical emergency. There are different scoring systems in use to diagnose the appendicitis. Aim of this study was to document the diagnostic accuracy by application of Alvarado Scoring System in clinical practice for acute appendicitis. Design: Descriptive case series. Setting: Surgical Unit-II, Liaquat University Hospital Hyderabad, Sindh - Pakistan; from January 2003 to September 2004

Methods: All the patients with suspected appendicitis were admitted in the ward. A profroma was designed and relevant findings were documented. These were observed regarding the increase or decrease in severity of symptoms and hence the change in the initial score according to Alvarado Scoring System was documented at the time of admission. Decision regarding surgical intervention was made on the basis of change in the score

Results: A total of 227 patients with clinical features suggesting acute appendicitis was admitted in the ward. Among them, 150 [66.07%] were males and 77 [33.92%] were females. Age ranged from 10-62 years. Main symptoms at presentation included pain in right iliac fossa 67.8%, fever 66.9% and nausea and vomiting 49.7%. Thirty two patients were received with Alvarado Score of 1-4 and three out of them required surgery. Thirty five patients were in the score of 5, twenty three out of them required surgery. One hundred sixty patients were in the score of 6 and above, all of them required surgery. Out of 185 patients who underwent surgery, 178 patients had appendicitis. The negative appendicectomy rate was 3.78%

Conclusion: It is concluded that according to Alvarado the patients with score up to 4 probably do not require surgery and among the patients with score up to 5, most of them need surgery while the patients with the score of 6 and above will require surgery

Selective nasogastric decompression after elective laparotomy

Objective: This study was conducted to evaluate the need or other wise for use of nasogastric decompression after elective laparotomy, as many studies suggest that routine nasogastric decompression is unnecessary after elective laparotomy and may in fact be associated with an increased incidence of complications. Despite these reports the nasogastric tube is routinely used for decompression, believing that its use significantly decreases the risk of post-operative nausea, vomiting, aspiration pneumonia, wound dehiscence and anastomotic leakage. Design: Descriptive case-series. Place and Duration of Study: Surgical Unit-II, Liaquat University Hospital Jamshoro from July 2005 to July 2007

Patients and Methods: Seventy patients were included in this study. A proforma was designed and all the findings were recorded. All the patients were observed regarding the development of complications like, post-operative nausea, vomiting, pulmonary complications, abdominal distention and return of bowel sounds

Results: Out of 70 studied cases 45 [64.2%] were males and 25 [35.7%] were females. Age ranged from 10 years to 70 years and mean age was 33 years. Postoperative pulmonary complications like atelectasis and pneumonia were seen in 3 [4.2%] out of 70 patients. The commonest operation performed was reversal of ileostomy and resection with end-to-end anastomosis. Postoperative nausea and vomiting were seen in 10 [14.2%] cases

Conclusion: The study did not support the routine use of nasogastric decompression