Tuberculous intestinal perforation: a nightmare for the surgeons

Introduction: The incidence of abdominal tuberculosis has been steadily increasing over the past 20 years. The situation is worse in underdeveloped countries like Pakistan where poverty, overcrowding, unhygienic environment and recent outbreaks of multidrug resistant tuberculosis [MDR-TB] have posed more challenges for the management of abdominal tuberculosis. Tuberculous intestinal perforation is an even bigger challenge for the surgeons

Objectives: To reduce the morbidity and mortality related to tuberculous intestinal perforation vide application of Modified New Scoring system based upon simple pre-operative and intraoperative criterias

Patients and Methods: This descriptive study was conducted at surgical ward II, SZMC/Hospital, Rahimyar Khan, from 1[st] March 2009 to 31[st] August 2010 and 13 patients of tuberculous intestinal perforation were included in this study. Based on Modified New Scoring system, patients were divided into three groups. Group I were managed with primary closure, Group II with ileostomy, Group IIIA with peritoneal tube drainage and Group III B with tube enterostomy

Results: Overall, 12 [92%] patients developed wound infections, 2 [15.3%] presented with fecal fistula after surgery and were re-explored, and 3 [23%] patients developed burst abdomen due to fecal fistula or severe sepsis. The overall mortality was 2[15.3%] in this study which is less than other national/international studies

Conclusion: Modified new scoring system is practical to categorize the patients on the scale of severity of disease and to offer precise guideline to the surgeons for damage control with minimum injury and with good initial promising results

Arming the witches-a betrayal of professionalism

It is harvesting season of crop sowed in the last decade under the umbrella of Prime Minister Health Program as we are facing the complications of illegal abortions done by the health workers .It is to emphasize to the health workers and Health Program organizers to disengage from the practice objectives are to; estimate the frequency of its complications, discuss types of complications encountered with its mortality and morbidity and demonstrate the ways of its notification and prevention. All patients admitted with peritonitis due to illegal abortions were included in the study during one year period. Results showed alarming increase of illegal abortions complications [53% of total peritonitis cases] with most common injuries to colon or small bowel. Mortality was 6% and morbidity 94%. Conclusion were made that extensive technical and ethical training of health workers and surgeons are needed along with resurrection of regional ethical committee to look after the affairs

Gynaecomastia; management and causative factors

To determine the causative factors and management of Gynaecomastia. Observational case series study. Surgical Unit-1 Bahawal Victoria Hospital Bahawalpur, from 1st January 200 till 31st December 2007. Thirty male patients having breast swelling were included in this study. Relevant history was obtained. Appropriate | physical examination was performed. Necessary investigations were done and after making a diagnosis appropriate treatment was done. A total of 30 patients were studied in the study period of 18 months. Those male patients who were having breast lesion other than benign enlargement [e.g. Ca. Breast, Breast/Abscess] were not included in the study. Necessary investigations were done. Subcutaneous I Mastectomy was performed. The most common age group developing gynaecomastia was of 20-30 years [60%]. Bilateral gynaecomastia was observed in 76.66% and unilateral gynaecomastia in 23.33%. Idiopathic gynaecomastia was observed in 73.33% cases. Medical treatment was given with tamoxifen 10mg twice a day for the period of three months in 6 case [20%] and this remained effective in 5 case [83.33%]. Subcutaneous mastectomy was performed in 17 cases [56.66%]. Post-operative complications were seen in 4 cases [23.52%], the most common complication being wound hematoma in 2 cases [11.76%]. Most of the patients [88.9%] were fully satisfied with the results of subcutaneous mastectomy. Gynaecomastia is the most common benign lesion of the male breast. As far as physiological gynaecomastia is concerned, patients should be observed for at least 2 years from the onset of their condition. In most of the cases spontaneous resolution occurs. Surgical treatment should be planned in whom spontaneous resolution does not occur. Surgery remains the mainstay of therapy and is frequently indicated for psychological and cosmetic reasons

Significance of noninvasive investigations in diagnosis of peripheral vascular disease and management

Peripheral vascular disease [PVD] is a condition characterized by atheroscerotic occlusive vascular disorder of tile lower extremities and functionally it is defined as arterial narrowing causing a mismatch between the oxygen supply and demand resulting in symptoms of claudication, exercise limitations or tissue loss. To observe the prevalence and presentation and to review tile noninvasive approaches for the evaluation and treatment of patients presenting with peripheral vascular diseases. Department of Surgery. Bahawal Victoria Hospital, Bahawalpur. Twenty patients were in included in this prospective randomized study during tile period from July 2003 to June 2005. The relative frequency of PVD at BVH Bahawalpur was 1.2%. The majority of patients [60%] were in the 4[th] decade of life and male [90%]. The smoking was exclusively the major predisposing risk factor [90%]. The common [90%] presentation of patients was intermittent claudication with 60%, gangrenous disease with an average duration of 4 years. The lower limbs were involved in 90% cases with 70% bilateral disease. Majority [90%] of the patients was diagnosed clinically and the objective severity of the disease was assessed with Doppler sonography in all the patients. The ABI was <0.5 in 85% cases. The duplex scanning was needed only in 10% patients. Smoking remains exclusively the only major risk factor. Much time and money can be saved by evaluating and treating these patients by noninvasive approaches but prevention is the best therapeutic strategy achieving by abstinence from the smoking

Return of the infectious ghost: tuberculosis

To find out the incidence of Abdominal Tuberculosis, its presentation, morbidity and mortality. Prospective, descriptive study from Jan. 2001 to Dec. 2004. Setting: Surgical Unit III, Bahawal Victoria Hospital, Bahawalpur. All patients who presented with abdominal tuberculosis and were confirmed on histopathology. Patients with tuberculosis at other sites were excluded. The data of the patients was collected and analyzed. A total of 123 patients were inducted in the study. Amongst them 65 [52.85%] were male and 58 [47.15%] female, with most [92] patients between 20-40 years of age. Eighty four patients presented with acute abdominal symptoms; 23 had intestinal obstruction, 49 peritonitis, while 12 patients had mesenteric lymph node abscess or primary tuberculous peritonitis with military tuberculosis. The remaining 39 patients presented with chronic symptoms i.e. subacute intestinal obstruction/abdominal masses. At laparotomy 31 cases had ascites and 49 cases gut perfora-tions [mostly in the ileum], whereas 55 cases had strictures and adhesions formation. Lymphadenopathy was seen in 24 and abscesses in 13 cases. Five patients had masses in the ileocaecal region and two at other places, whereas two patients had hepatomegaly. In the majority [63] of patients an ileostomy was made either alone or with resection and anastomosis, strictureplasty or closure of perforation. In 17 cases only biopsy and in 13 right hemicolectomy was carried out. In the post-operative period high morbidity was noted in the form of wound infection in 54 [43.9%] cases, while intra-abdominal abscesses were found in seven and severe sepsis in eight patients. Faecal fistula due to anastomotic leakage was noted in five cases in which redo surgery was done in the form of ileostomy. Jaundice was seen in six patients, two amongst them had tuberculous liver masses. As far as mortality was concerned, four [3.25%] patients died in this study. Tuberculosis has come back very strongly and with more involvement of extra-pulmonary sites

Is it a diabetic hand?

This is a prospective study conducted in the department of surgery from 1-04-1999 to 31-012002 at BVH Bahawalpur. All the diabetic patients of both types [IDDM or NIDDM] of any age or sex, suffering from infection of hand or Foot were included in the study. A total of 36 diabetic patients had hand infection [Group A] as compared to 207 patients with Diabetic Foot [Group B]. Average age of the patients in Group A was 39.6 years which was quite younger as compare to 57.5 years in Group B. Pain was the dominant presenting complaint [100%] in Group A patients. All these patients were manual workers [Tailors, Carpenters, Farmers, Blacksmiths, Embroidery workers or Housewives] and had minor trauma to their digits during work; which they had neglected for few days or received first aid treatment from a family member or quack. In Hand Group, no patient was in Grade 0, I, or III. During the course of treatment, all the patients [100%] of Hand Group required amputation of one or more digits of the dominant hand including amputation of the thumb in 22 patients. No patient required amputation of the whole hand or forearm. The involvement of thumb or index finger alone or along with other digits in almost all the patients of Hand Group, reflects their common use, in manual work and their more susceptibility to repeated minor trauma. The loss of thumbs in 22 patients reflected high morbidity in terms of loss of hand function though thumb reconstruction is a valid option. Morbidity in terms of hospital stay was quite less in Hand Group but it was 100% in terms of loss of crafted digits. Mortality in Hand Group patients was nil in contrast to 9[4.3%] in the Foot Group. Infection of the hand in Diabetics can be named as DIABETIC HAND without any ambiguity. This can lead to opening up of new era of research for better management of this entity in terms of DIABETIC HAND CLINICS. Surgical management of infection in diabetics should be early, aggressive and specialized to avoid poor outcome in the form of loss of vital craft hand

Positive impact of the new scoring system on the management of typhoid enteric perforations

Typhoid peritonitis is the most common type of peritonitis in the Bahawalpur area. Previously surgical management was haphazard and depended upon the choice of surgeon with high mortality and morbidity. The introduction of a new scoring system has not only helped the registrars and junior consultants in maintaining a uniform treatment policy but also decreased the mortality and morbidity to a considerable extent