Comparative study of efficacy of continuous versus partial interrupted method of midline laparotomy wound closure for contaminated cases of typhoid perforation

Background: The controversy exists in the literature about the best method of midline suturing in contaminated cases like typhoid, tuberculosis and old traumatic intestinal perforations

Objective: To compare the laparotomy wound closure techniques in contaminated cases of typhoid perforation regarding burst abdomen and wound dehiscence

Methodology: This was randomized control type of study in which all the patients fulfilling inclusion criteria were included. This study was conducted in surgical ward of Bahawal Victoria Hospital Bahawal Pur. The cases with minimal peritoneal contamination, planned laparotomies for benign abdominal lesions/ tumours and simple, non contaminated laparotomies were excluded from this study. All the cases were initially received in the general surgical emergency department and later referred for surgical consultation. A detailed history and clinical examination was conducted by two general surgeons. All the included patients had an acute presentation and required immediate intervention. The data was noted on a proforma. All included patients were divided in two groups; A and B. Patients of both groups were equal in number i.e fifty patients in each group. Patients of group A underwent continuous method of closure and patients of group B underwent interrupted closure. Outcome parameters included were time required for closure and postoperative wound dehiscence

Results: Regarding the results of study the difference in wound dehiscence was significant [ p<0.05] between the two groups, group A, 22% and group B, 4%. Results about time required for closure found less than 30 minutes 92% in group A and 62% in group B, the difference was statistically insignificant [p >0.05]

Conclusion: Continuous method has advantage of being faster and time saving but in regarding the wound dehiscence in contaminated cases it was found that more patients, with continous closure has dehiscence

Medical therapy versus lateral internal anal sphincterotomy

Background: Anal fissure is painful condition, with reduced quality of life for patients

Objective: To evaluate the efficacy of medical therapy versus lateral internal sphincterotomy for the treatment of patients with acute and chronic anal fissure

Patients and Methods: This was a comparative prospective study of 122 patients of acute and chronic anal fissure, conducted at Bahawal Victoria Hospital Bahawalpur, during a period of 2 years from 1[st] July, 2011 to 30[th] June, 2013. Medical therapy [Group A] was advised to 122 patients [32 patients with acute anal fissure and 90 patients with chronic anal fissure] with pain killer, stool softener, high fibre diet and 0.2% glyceryltrinitrate ointment applied at fissure site, thrice a day for eight weeks. The lateral internal sphincterotomy [Group B] was done in 47 patients. Patients with inflammatory bowel disease, pregnant women and patients taking nitrates for other condition were excluded. The patients were followed up, to assess fissure healing, complications and compliance for 6 months

Results: 29 [90.63%] patients with acute anal fissure and 46 [51.11%] patients with chronic anal fissure were cured by medical therapy and 45 [95.74%] out of 47 patients who did not respond to medical therapy were cured with lateral internal anal sphincterotomy [LIAS]. Headache was the main complaint in medical group while postoperative anal itching [10.64%], fecal soiling of clothes [8.51%] and transient flatus incontinence 3 [6.38%] were main complaints and one [2.13%] patient of permanent fecal incontinence was seen in group B

Conclusion: As the medical therapy is simple, achieves satisfactory healing rates, the authors suggested this as the first line of treatment for anal fissures as it could be prescribed by the general practitioner in the absence of any additional anal pathology. Patients unresponsive to medical therapy can then be referred for lateral internal sphincterotomy

Fatal toxic epidermal necrolysis induced by sodium valproate

A 26 years old manual labourer from Azad Jammu Kashmir presented with four days history of an extensive exfoliation of skin involving the entire body. Histology of the lesion showed epidermal necrolysis. The patient was a recently diagnosed case of epilepsy and had been started on therapy with sodium valproate three weeks ago. Following admission in our center, intensive care and wound care were instituted according to standard protocols. Despite all therapeutic measures the patient kept on deteriorating and developed multi-organ failure with pneumonia. He died on 7[th] day of hospitalization

burnt child: an epidemiological profile and outcome

To determine the epidemiologic pattern and outcome of childhood burns by finding the presenting features of the burn victims, causes / circumstances of burn injury, involvement of body area, need for hospitalization, duration of hospital stay and mortality. Case series. The Burns Care Centre [BCC], Pakistan Institute of Medical Sciences [PIMS], Islamabad, from January 2008 to June 2010. All children of either gender with burn injuries who were managed at the centre after primarily presenting to the study centre were included. Children over 15 years were excluded. Lund and Browder chart was used to calculate the total body surface area [TBSA] burnt. Children with extensive and critical burns, high voltage electric burns and those needing any surgical interventions were admitted for indoor management. Data were recorded on a proforma. A total of 1725 children were included in the study. Out of those, 66.84% [n=1153] were males and 33.15% [n=572] were females. The mean age was 5.04 +/- 2.78 years. Majority [67.47%] of children were aged 3-6 years. Scalds were the commonest burns [70.31%]. Household environment was the commonest site of acquisition of burns [91.47%]. Winter was the most frequent season of sustaining burn injury [63%]. The commonest anatomic regions affected were hands / upper limbs [65.68%]. Overall the affected mean TBSA was 9.37 +/- 9.61%, while for the hospitalized children it was 27.07 +/- 10.84%. Two hundred and ninety seven children [17.21%] were admitted. The mean hospital stay was 15.59 +/- 5.61 days. The mortality rate was 9.09% for the hospitalized children and 1.56% for the entire study sample. Male gender, age of 3-6 years and winter season were found to have an increased frequency of childhood burns. Scalds were the commonest type of injuries, and hands/ upper limbs were the most frequently affected body parts. There is a need to revisit the health care system and institute focused burn prevention strategies consistent with our local circumstances

Evaluating anatomical subunit approximation technique for unilateral cleft lip repair

To evaluate the outcome of anatomical subunit approximation in unilateral cleft lip of different severity. Seventy four consecutive patients with cleft lip were seen in the outpatient department of Plastic and Reconstructive Surgery at Hayatabad Medical Complex, Peshawar and Plastic Surgery unit at Said Anwar Medical Centre, Peshawar, from 1[st] June 2007 to 31[st] December 2008. The severity was assessed and all of them were operated using David Fisher's anatomical subunit approximation technique. Postoperatively the vertical height of the lip was compared on the cleft and non cleft side along with symmetry of Cupid's bow and philtral column, the alignment of white roll, quality of the cutaneous lip scar, vermilion fullness and vermilion notching. The nose was evaluated by noting the nasal tip symmetry; alar rim level; alar base height and width; and nostril sill size, both pre and post operatively. Seventy two patients showed adequate vertical height and good nostril size, alar base height. Two patients showed 1.0 mm discrepancy of the vertical height as compared to the non cleft side. These belonged to the severe complete cleft lip category. This technique has shown good results in achieving vertical height and nostril size symmetry especially in incomplete and mild to moderate severity of complete cleft lip

Anterolateral thigh flap: versatility and anatomic variations

To determine the pattern of the cutaneous perforator of the lateral circumflex femoral artery in anterolateral thigh perforator flap. Antero lateral thigh flap has become one of the most commonly used flap for the reconstruction of various soft tissue defects. The anterolateral thigh flap is known for variations of its vascular pedicle. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. Reconstruction of 13 composite defects in 13 consecutive patients by free microvascular anterolateral thigh flap at the Department of Plastic and Reconstructive Surgery, Hayatabad Medical complex, Peshawar. Thirteen patients were operated and free microvascular anterolateral thigh flap was used. In 12 patients the main vascular supply was through the descending branch of the lateral circumflex artery [LCFA]. One patient has a vascular supply through the transverse branch of the lateral circumflex femoral artery. Transmuscular perforators [mostly 3,] were found in all the patients, commonly arising from descending branch of lateral circumflex femoral artery

Distally based sural fasciocutaneous flap for soft tissue reconstruction of the distal leg, ankle and foot defects

Soft tissue management around the lower third of the leg and foot presents a considerable challenge to the reconstructive plastic surgeon. The options in this region are limited. A durable flap is the preferred option for coverage of such defects. This descriptive study was conducted at Hayatabad Medical Complex and Said Anwar Medical Centre Peshawar over a period of 4 years to evaluate the efficacy of distally based Sural flap in coverage of the lower third of leg, ankle and foot defects, in 25 patients. A descriptive study was conducted at the department of Plastic and Reconstructive Surgery at Hayatabad Medical Complex and Said Anwar Medical centre Peshawar. 25 patients with soft tissue defects over the distal leg and foot were included in this study. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied. Out of 25 flaps, 20 showed complete survival [80%]. Partial flap loss was found in 2 patients [8%], marginal flap necrosis in 2 patients [8%] and complete loss in 1 patient [4%]. The distally based sural flap is a versatile and reliable flap for the coverage of soft tissue defects of the distal lower extremity. The procedure is done as a single stage; the dissection is easy with short operating time and minimal morbidity

Maxillofacial trauma: Current practice in management at Pakistan institute of medical sciences

This study was carried out to determine the aetiology, pattern and management of maxillofacial injuries at PIMS, Islamabad. This descriptive study was conducted at Plastic Surgery Department, PIMS Islamabad from 1st February 1998 to 30th April 2002. All the adult patients presenting with maxillofacial injures were included where as patients less than 12 years of age and only facial lacerations were excluded. Similarly isolated nasal bone fractures were also excluded because these patients were routinely managed by ENT department. Age, sex, presentation, aetiology, associated injuries and treatment modalities undertaken in these patients were recorded. In 164 patients 254 fractures were noted. Most were male [86%], ranging in age from 13'71 years with a male to female ratio of 6:1 respectively. The most frequent [48%] cause noticed was road traffic accidents followed by assault. Mandible was the commonest to be involved in such injuries followed by maxilla. Most of the patients [32%] had associated facial injuries. Various treatment modalities were practiced. Maxillofacial fractures should be managed by open reduction and internal fixation as early as possible