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

Incidence of abdominal tuberculosis in 186 cases of acute abdomen presenting in our surgical emergency department

Among 186 cases of Acute Abdomen, determining the frequency of abdominal tuberculosis patients with their outcome. A prospective case study from January, 2009 to June 2010. Surgical Unit-V District Headquarters [Teaching] Hospital, Faisalabad. Detailed data of each patient including presentation, operative findings, procedure performed, post operative outcome and histopathology was entered on a specially designed Performa, compiled and analyzed. During the period of study, 186 patients presented in the surgical emergency with complaints of acute abdomen out of which 54 [29.03%] were of abdominal tuberculosis. Mean age of presentation was 27.3 years. Operative findings showed predominance of ileocaecal hypertrophic tuberculosis [tuberculous mass] in 18 [33.33%] patients, followed by tuberculous adhesions, ileal strictures and plastic gut.The surgical procedures were performed according to their intra-abdominal findings out of which right hemicolectomy with ileocolic end to end anastomosis in 18 [33.33%] patients remained the commenest procedure performed followed by segmental ileal resection anastomosis, ileostomy and stricturoplasty. 20 [37.04%] patients reported to have post-operative complications in which wound infection in 7 [12.96%] remained the highest occurring postoperative complication followed by intra-abdominal collection, anastomotic leakage and septicemia. Mortality rate among the patients of abdominal tuberculosis in this study remained 5.56%. Complicated abdominal tuberculosis is the most common pathology of acute abdomen. By proper management of pre-complicated abdominal tuberculosis, this disastrous stage of disease resulting in so morbidity and mortality can be reduced

Risk factors of preseptal and orbital cellulitis

To estimate the frequency and major risk factors of preseptal and orbital cellulitis. A cross-sectional analytical study. The Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from July 2003 to December 2006. All consecutive patients between ages 6 and 40 years, admitted to the institute with the diagnosis of preseptal and orbital cellulitis were included in the study. The patients were divided into two groups. Group I included patients with ages 6-16 years and group II with ages 17-40 years. The clinical features, diagnosis and risk factors were entered on a specially-designed proforma. The risk factors included were trauma, insect bite, localized or systemic infection and postsurgical. Odd ratio and p-values were calculated for potential risk factors. The frequency of orbital cellulitis was 0.1% of total admission. Out of 26 patients, 42.30% patients were in group I and 57 in group II. In group I, insect bite was the most common risk factor identified in 40% of patients with preseptal cellulitis and trauma as a common cause in 50% with orbital cellulitis. In group II, trauma was the leading cause in 50% of patients with preseptal cellulitis and sinusitis as a common cause in 18.1% with those of orbital cellulitis. In both groups the p-values were found insignificant [p > 0.5]. Complications included cicatricial ectropion in 44.4% and orbital abscess in 41.1%. For preseptal cellulitis, insect bite was the most common cause in group I and trauma was the leading cause in group II. For orbital cellulitis, trauma was important cause in group I and sinusitis in group II

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

Puerperal breast abscesses; percutaneous ultrasound guided drainage compared with conventional incision and drainage

The aim of this study was to compare the management of puerperal breast abscess by ultrasound guided percutaneous drainage v/s incision and drainage with special attention to resolution time and complications. Allied Hospital Faisalabad. Jan 2005- June 2007. 60 patients with puerperal breast abscess were studied. Patients were divided into two groups randomly after informed consent. In Group A; patients were treated with percutaneous drainage under local anesthesia while Group B patients were treated by conventional incision and drainage, and results were compared with reference to resolution time and complications rate using student's t-test. By percutaneous method abscess healed in 5-8 days time. Recurrent abscess was found in one case [3%], milk fistula formation in one case [3%] and no residual abscess was found. There was no scar formation, induration or distortion of the breast parenchyma. Breast-feeding was interrupted in four patients [13%] only due to milk fistula [one case], recurrent abscess [one case] and patient's own preference [two cases]. On the other hand by conventional method healing took 15-25 days with pain and discomfort of daily dressings, scarring and cessation of breastfeeding in most of the cases. Percutaneous ultrasound guided placement of suction drainage catheter in puerperal breast abscess for 5-8 days is less invasive, high resolution rate, scarless, low complication rate and preserves the function of breast-feeding as compared to conventional incision and drainage

Demography of patients with periocular dermoid cysts

To study the demographics of patients admitted in the hospital with histologically proven periocular dermoid cysts. A retrospective descriptive case series. Department of Ophthalmology Khyber Institute of Ophthalmic Medical Science, Hayatabad Medical Complex, Peshawar from July, 2004 to March, 2007. Clinical characteristics of patients with dermoid cysts admitted to the hospital were retrieved from patient charts. A note was made of its frequency, age, gender and laterality. Other features like site, size, depth, histology and presenting features were also looked for. Patient's age at the time of surgery was also noted. The frequency of dermoid cysts was 40.8% amongst orbital cases. Majority [65.7%] were females and 73.6% patients were below 15 years of age. The disease was right sided in 55.2%. Majority were superficial dermoids [71.0%] followed by conjunctival dermoids [15.7%] and deep dermoids [13.1%]. The most frequent clinical finding was a mass in 84.2%. Most patients [44.7%] were below 10 years at the time of surgery. The disease is more common in females and children. Superficial dermoids are more frequent. Presentation is usually with a subcutaneous mass and treatment of choice is surgical excision

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

Spectrum of ocular surface squamous neoplasia

To describe the pattern of ocular surface squamous neoplasia [OSSN], clinical presentations, the risk factors and treatment options. An observational case series. Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, from April 2003 till August 2006. The study included 36 eyes of 35 patients with biopsy-proven ocular surface neoplasia. The details of patients regarding age, gender, laterally and risk factors were entered into a specially-designed proforma. Each patient was also assessed blomtcroscoplcally for type and complications of ocular surface neoplasia. The frequency of OSSN was 0.37 among admitted hospital patients. Among 36 cases of OSSN, squamous cell carcinoma of the conjunctiva was the most common type of OSSN seen in 63.9%, followed by carcinoma in situ of conjunctiva in 25% and carcinoma in situ of cornea in 11.1%. Male patients outnumbered female [65.7% vs 34.3%] with 71.42% of patients above 60 years of age. The risk factors identified were: old age, ultraviolet B exposure and xeroderma pigmentosa. Treatment consisted of local resection with or without adjuvant therapy in 61.1%, exenteration in 30.5%, enucleation in 5.5% and chemo/radiotherapy in 2.7%. Intraocular invasion was seen in 5.5% and orbital spread in 30.5%. The frequency of OSSN was 0.37% among admitted patients. Identification of exact etiological factors will enable to formulate strategies that are likely to decrease the incidence of this disease and the associated morbidity and mortality

Protosis: etiology and demographic patterns

To determine the demographic pattern of patients presenting with proptosis and its etiology. A cross-sectional descriptive study. Khyber Institute of Ophthalmic Medical Sciences [KIOMS], Hayatabad Medical Complex, Peshawar from July 2001- December 2002. Sixty cases of proptosis presenting at KIOMS were included. Thirtysix patients were male while 24 were female. They were divided into two age groups; 0-15 years [paediatric group] and above 15 years [adult group]. An elaborate work up plan was formulated for all patients, which included detailed history, clinical examination [ocular, orbital and systemic], radiological and histopathological investigations. Neoplasms [33%] were the most common causes of proptosis in all the patients followed by orbital inflammations [23%], orbital infections [20%], structural abnormalities [12%], vascular abnormalities [7%] and trauma [5%]. Neoplasms were the most common cause of proptosis in both paediatric and adult group. Proptosis was the cardinal feature and visual deterioration was present in more than half of the patients. Timely referral, early diagnosis and appropriate management can result in reduction of visual morbidity

Pattern of pediatric ocular trauma in Hayatabad Medical Complex Peshawar

To determine the pattern and causes of pediatric ocular trauma in Hayatabad Medical Complex, Peshawar. A cross sectional descriptive study Department of Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from January 1999 to June 2004. The medical records of 481 children aged upto 16 years who suffered ocular trauma were reviewed retrospectively. Age and gender distribution, nature and source of trauma, presentation and ocular features were analyzed. Pediatric ocular trauma constituted 43.5% of total traumatic ophthalmic admission. Four children were victims of bilateral trauma. Male to female ratio was 3.3:1.Twenty five percent children were below 5 years of age, 47.8% were between 5 to 10 years of age and 27.2% were between 10 to 16 years. About 51% injuries were of open globe type and 37.6% closed globe, superficial non perforating injuries, burns and adnexal pathologies were present in 11.3%. Domestic injuries were more common [47.2%]. At the time of admission 14.6% eyes were infected, 2.3% required evisceration or enucleation. Majority [67.3%] of the children presented late [one week later] to the hospital. Male children were affected more than female by trauma. Half of ocular trauma resulted in open globe injuries and almost 50% of cases were related to domestic injuries. Majority of cases presented late and were secondarily infected

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

Prospective randomized comparison of dacryocystorhinostomy [DCR] with and without intubation

To compare Dacryocystorhinostomy [DCR] with and without intubation and see, their success rate, surgical duration, cost and postoperative complications. Prospective, randomized, hospital based study. D.H.Q Hospital Lakki Marwat from January 2000 to September 2002. Eighty traditional external DCR procedures with and without intubation were performed. Patients were randomly divided into two groups of 40 cases in each group. Group "A" was labeled as DCR with intubation and Group "B" as DCR without intubation. All the patients were followed for 1 year. Surgical duration, postoperative complications and the success rates were compared. The success rates at one year after surgery was 97.5% for DCR with intubation and 95% for DCR without intubation [not significant]. The surgical duration for DCR without intubation was 45 minutes [shorter] and that for DCR with intubation 55 minutes [longer]. DCR with intubation was more costly as compared to that without intubation. External DCR without intubation yielded equally good results as DCR with intubation. Both procedures were associated with minimal complications. DCR without intubation costs an extra amount of rupees 1800

review of 120 cases of dacryocystorhinostomies [Dupuy Dutemps and Bourguet Technique]

The study was conducted at the DHQ hospital Lakki Marwat from Jan, 1999 to Dec, 2002 to assess the intra and postoperative complications and success rate of external dacryocystorhinostomy [DCR] with suturing of the bridge between anterior flaps of nasal mucosa and lacrimal sac with the muscle layer. Method: We operated upon 120 patients suffering from chronic dacryocystitis [CDC]. Females were 81 [67. 5%] and males were 39 [32.5%]. Majority of the patients were between the age group 40 to 60 years. Indications for dacryocystorhinostomy [DCR] were epiphora, acute on chronic dacryocystitis and a mucocele. All the cases were operated under local anaesthesia with external approach and only anterior flap suturing and engaging it in the muscle layer. These patients were followed for a period of six months. The overall success rate was 98.33%. The successful outcome was defined as symptomatic relief from epiphora and dacryocystitis and a patent nasolacrimal duct upon syringing. Conclusions: Dacryocystorhinstomy is a safe procedure under local anaesthesia. It is associated with minimal complications, which can be easily managed. This technique has a very high success rate and a short learning curve

Corneal complications of vernal catarrh

To identify the magnitude and types of corneal complications of vernal catarrh and the extent of visual impairment caused by them. Design: A cross-sectional study. Place and Duration of Study: Khyber Institute of Ophthalmic Medical Sciences [KIOMS], Hayatabad Medical Complex [HMC], Peshawar, from March, 1999 to May, 2000. Subjects and All cases of vernal catarrh who agreed to an informed consent were included in the study. Patients who were difficult to be examined by a slit lamp were excluded from the study. The diagnosis was made mainly on the basis of history and clinical examination. Slit lamp examination was done in every case together with fluorescein staining of cornea. The variables were recorded and statistically analyzed. Superficial punctate keratitis [45%] was the most common corneal complication. Visual impairment was more pronounced in cases with shield ulcers [14%] and corneal plaques [8%]. A strong association with keratoconus [15%] was also noted. Corneal opacification [9%], hydrops [6%] and pseudogerentoxon [3%] were also found. Corneal complications in VKC are common, potentially serious and may cause marked visual impairment