Laparoscopic cholecystectomy for empyema gall bladder

Objective: To describe the experience of treating empyema gall bladder with laparoscopic cholecystectomy. Study Design: Descriptive observational study

Place and Duration of Study: The study was carried out at Combined Military Hospital [CMH] Peshawar, from Feb 2012 till May 2014 for a period of twenty eight months

Material and Methods: Twenty eight patients were enrolled in the study who fulfilled the criteria for empyema and were willing for laparoscopic cholecystectomy, chances of conversion to open cholecystectomy and risk of complications involved. We defined the operative difficulty levels according to the intra-operative findings. Level 1-adherent ornentum, level 2-oedematous gall bladder wall, level 3-necrotic gall bladder wall, level 4-adherent gut and level 5 - adherent Hartmann's pouch and oedematous Calot's triangle having no defined planes. The results were noted in terms of time taken for the operation and complications of the operative procedure. Results: Twenty eight patients of empyema gall bladder underwent laparoscopic cholecystectomy. Mean age was 46.2 +/- 7.1 years. Average duration of symptoms was 4.1 +/-2.3 days. Two patients had level-I operative difficulty, 6 patients had level-II difficulty, 9 patients had level-3 difficulty, 2 patients had level-IV difficulty and 9 patients had level-V difficulty. In 21[75%] patients total cholecystectomy was performed, anterior partial cholecystectomy was done in 2 patients [7.1%] and 5 patients [17.9%] were converted to open cholecystectomy. One patient [3.5%] had Stresburgh Bismuth type D injury and was managed by open exploration and T-tube placement. No mortality was encountered in the study group

Conclusion: The technique of laparoscopic cholecystectomy can be used effectively for treating empyema gall bladder specifically in American Society of Anaesthesiologists [ASA] I and II patients. Further randomized controlled trials can elaborate its efficacy. This will not only prove to be cost effective but it will also add to the comfort of the patient

Surgical site infection; evaluation of causative organisms involved

Wound infection can be defined as invasion of organisms through tissues following a breakdown of local and systemic host defenses. The basic principles of wound care and antisepsis introduced during the past century improved surgery dramatically. Evaluation of causative organisms which evolved in the surgical site infection [elective abdominal surgery] at surgical unit of Liaquat university hospital Jamshoro. This prospective observational study was contains 103 patients undergoing elective, abdominal surgery were included in this study. Surgical wound categories i.e. clean, clean contaminated, were included. Prophylactic antibiotics were given in all cases. Primary closure of wounds was employed in all cases. Follow up period was 30 days postoperatively. All cases were evaluated for postoperative fever, redness and swelling of wound margins, collection and discharge of pus. Cultures were taken from all the cases with any of the above findings. The mean age of the patient was 37 years with male to female ratio of 1:5:1. The overall rate of wound infection was 13.04%. Most frequently involved pathogen was E.col 33.33% followed by Staph Aureus 20%, Klebsiella 20%, proteus 13.33%, Pseudomonas 6.66% and no organism was isolated in 6.66% cases. Most effective antibiotics were cephalosporins, quinolones and aminoglycosides' whereas septran, erythromycin and tetracycline's were ineffective. Surgical wound infections are quite common. Time of postoperative hospital stay was twice longer in infected case. Male sex, old age, anemia, longer duration of operation and wound class were significant risk factors. Most common organims are found in this study E-Coli, Kllebcella and Staph Aureus, these are mostly sensitive to cephalosporins, quinolones and aminoglycosides

Infratemporal, masticator space infection and orbital abcess following carious maxillary first molar extraction in a four month pregnant patient. A case report

Odontogenic infections lead to life-threatening complications once they reach potential fascial spaces due to decreased immunity in pregnancy. It may also occur due to patient negligence, delayed diagnosis and mismanagemnet. Infratemporal space infection is a rare but a serious sequel of odontogenic infection. We report the case of a 20 year old, four months pregnant patient with carious left maxillary first molar with fascial space infection. Following extraction of this tooth and despite appropriate antibiotics the patient developed infection in the infratemporal and masticator space, followed by a orbital abscess

Current pattern and diagnosis of small bowel obstruction in the patients of rural areas

Objective of this study to determine the clinical presenting factors including diagnosis and risk factors of the patients those admitted with small bowel obstruction. Observational study. This study was carried out at the Departments of General Surgery, Peoples Medical University and Health Science Nawabshah and Isra University Hospital Hyderabad from March 2013 to Aug 2013. After admission detailed history, physical examination, ultrasound, X-ray abdomen erect and supine and all routine baseline laboratory investigations were carried out. CT scan was done in the selected patients. Final diagnosis was done by laparotomy which was attempted after thorough initial assessment and investigations. Total 50 patients were included in the study of the rural areas of the Sindh, from all of them male were in majority. On the clinical presenting features Nausea, Constipation and Abdominal pain were most common with the percentage of 92%, 80% and 78% while other presenting features as; Vomiting, Abdominal tenderness, Abdominal distension, Fever, Epigastrium pain, Rectal bleeding and Rebound tenderness were with the percentage of 40%, 42%, 22%, 38%, 30%, 16%, 10% and 26% respectively. On the diagnosis adhesion was found as most common. In the conclusion of this study adhesion found as most common and leading cause of small bowel obstruction

Role of laparoscopy in blunt abdominal trauma

To evaluate the role of laparoscopy in the diagnosis and management of blunt abdominal trauma. This descriptive, prospective study was conducted in the departments of surgery, Ghulam Mohammad Mahar Medical College, Sukkur and Chandka Medical College, Larkana, Pakistan from June 2010 to May 2012. It included 32 patients with blunt abdominal trauma admitted in emergency at GMMMC, Sukkur and at CMC Larkana. Initially, all were resuscitated with iv fluids, analgesics, iv antibiotics and blood transfusion, if required and then investigated by ultrasound abdomen, plain x-ray abdomen and chest and other routine investigations. Laparoscopy was performed in hemodynamically stable patients not showing free gas under the diaphragm in plain x-ray abdomen and ultrasound showing hemoperitoneum. The patients with penetrating abdominal wounds, non-traumatic abdominal emergencies and iatrogenic injuries were excluded. Out of 32 parents, 29 were male and only 3 were female. The age ranged from 12 to 60 years. The organs injured were spleen in 5 [15.6%] patients, liver in 17 [53.12%], omental bleeding in 2 [6.25%], small bowel mesenteric bleeding in 6 [18.75%] and associated Jejunal [injuries in 2 [6.25%] patients. Only 3 [9.37%] patients with Grade-iii liver injury developed post- operative collection, 1 [3.12%] patient developed biliary fistula and 1 [3.12%] developed right sided pleural effusion. No post-operative bleeding or mortality was recorded. Laparoscopy could be useful in selected patients with blunt abdominal trauma as a diagnostic and therapeutic tool, thus avoiding unnecessary laparotomies

Frequency of HBs Ag and anti-HCV in trauma patients

This study was carried out to determine the frequency of Hepatitis B and C Viral infection in patients undergoing emergency surgical operations after trauma, and to evaluate the associated risk factors. Descriptive Study. This study was conducted at General Surgical, Orthopaedic and Paediatric Surgery Department of Ghulam Muhammad Mahar Medical College Hospital Sukkur from May-2011 to April-2012. All the patients who were admitted in the Surgical and orthopaedic department for emergency surgical operations followed by trauma were included in the study. The patients were screened for HBsAg and Anti-HCV using immunochromatography [ICT] method. Those who were weak positive by ICT were further confirmed by Enzyme Linked Immunosorbent Assay [ELISA]. 592 patients were admitted in Surgical and orthopaedic department during a period of last one year for emergency operations after trauma and were screened for HBsAg and Anti-HCV. Out of these 592 patients 472 [79.7%] were males and 120 [20.27%] were females. Mean age of these patients was 40 years. After screening, 33 [5.57%] patients were found HBsAg positive and 117 [19.76%] were Anti-HCV positive, while 09 [1.5%] were positive for both. Hepatitis-B was found in 21 [2.3%] males and 12 [1.3%] females, while Hepatitis-C was predominantly found in 68 [7.44%] males and 49 [5.36%] female patients. Parenteral injections by Quacks, previous surgery, blood transfusion and shaving by barbers were found to be the risk factors. High frequency of HBs Ag and Anti-HCV was found in trauma patients undergoing emergency surgery. Our message is that "Prevention is better than cure". So it is essential to prevent the spread of Hepatitis B and C by screening every patient before surgery and counseling of patients

Pattern of dermatophytes among dermatological specimens at AFIP, Rawalpindi

To determine the types and prevalence of dermatophytes from the clinical specimens received at Armed Forces Institute of Pathology [AFIP]. Study design is descriptive. The study was carried out at the Department of Microbiology, AFIP Rawalpindi from June 2009 to May 2010. Total of 400 different clinical specimens were dealt during the study period. After direct microscopy, they were inoculated on Sabouraud's dextrose agar with and without antimicrobials. The plates were incubated at 220C and examined twice weekly up to four weeks for any fungal growth. Species identification was done through colony morphology and microscopic examination of lactophenol blue preparation. Out of total specimens, 221[55.25%] yielded fungal growth. The overall yield of dermatophytes from different specimens was in the order of nail [78%], followed by skin [18.3%] and hair [3.3%]. Mycological infections have growing importance because of the increasing population of immune-compromised patients warranting a high index of suspicion

Cause of death in exhumed bodies: an experience in upper Sindh, Pakistan

Exhumation is conducted around the globe when foul play is suspected. In developed world and in some developing countries this procedure is also carried out for identification purposes as well as in insurance claims, and some other civil suits. To determine the cause of death in exhumed bodies. Prospective, descriptive. The Study was conducted in the department of Forensic Medicine, Chandka Medical College, Larkana [CMCL] from Jan:2001 to Dec:2010. A total of 125 bodies were exhumed in various districts of upper Sindh by exhumation board, constituted by Director General Health Services Hyderabad. At the site of graveyard, bodies were digged out. After identification of deceased by near relatives, the bodies were thoroughly examined, viscerae taken for histopathological and chemical analysis, and cause of death determined by consensus in almost all cases. The most common cause of death was firearm injuries 37 [29.6%], followed by blunt trauma 15 [12%], sharp weapon injuries 09 [7.2%], drowning 09 [7.2%], poisoning 07 [5.6%] strangulation 06 [4.8%], infanticide 06 [4.8%]. In about 1/3 of cases cause of death could not be decided due to advanced stage of decomposition. Majority of victims were young males and firearm injury was the commonest cause of death

Ambu bag as a source of Acinetobacter baumannii outbreak in an intensive care unit

This case report describes an outbreak of multidrug resistant Acinetobacter baumannii in the intensive care unit of a tertiary care hospital. Three patients were infected on the same day from an Ambu bag which was used on all the patients. The outbreak was immediately identified and the source was traced within one week. Appropriate measures were taken and a continuous surveillance was carried out resulting in reporting of no such case from the intensive care unit in the last 6 months

Pattern of haemotological disorders diagnosed by bone marrow examination at a paediatric hospital in Larkana Pakistan

Bone marrow examination is an integral part for establishing the diagnosis of haematological disorders in association with clinical and other routine laboratory tests. To evaluate the frequency and pattern of haematological disorders in children at a tertiary care hospital in Larkana. Descriptive study. The study was conducted at children hospital and pathology department of Chandka Medical College Larkana from Jan: 2008 to Dec: 2010. Marrow aspirates were collected from children under the age of 15 years as per guidelines recommended by international council for standardization in haematology [ICSH]. Smears obtained were stained with Romanowsky stains and examined under light microscope. Bone marrow examination reports of 271 patients ranged from 2 months to 15 years, with male /female ratio of 1.6:1 were analyzed. Malignant disorders were seen in 36.5% and non malignant disorders in 59.8% of ratio 1.6:1 were analyzed. Malignant disorders were seen in 36.5% and non malignant disorders in 59.8% of children. Amongst the malignant haematological disorders, acute lymphoblastic leukaemia [ALL] cases were 64 [23.65] and was found to be most common disorder, followed by lymphoma 7 [2.6%] cases and acute myeloid leukaemia [AML] 6 cases [2.2%]. In non malignant disorder, aplastic anaemia was the most common 40 [14.8%] cases, followed by iron deficiency anaemia 30 [11%] cases. The megaloblastic anaemia was least common seen only in 8 [3.0%] cases. Other non malignant disorders were idiopathic thrombocytopenic purpura [ITP] 71 [26.2%] cases and malaria 4 [1.5%] cases. Appropriate diagnosis can not be made in haemotological disorders of childhood without bone marrow examination

Hydatid cyst of unusual sites, an experience at Chandka medical college Larkana

Hydatid cyst occurs throughout world but more in endemic areas where human beings live in close contact with cattle and dogs. Common organs affected by hydatid cyst are liver and lung but rarely occurs in other organs as well. To evaluate the unusual sites of hydatid cyst in human beings, this will help the clinicians in early diagnosis and management. Observational. The study was conducted in the Department of Pathology, Chandka Medical College Larkana from January 1995 to December 2009. Total of 191 patients, admitted in various hospitals of Larkana, and operated for hydatid cyst or incidental findings at hisptopatholgical examination were included. All the fixed biopsies were cut into representative tissue blocks, processed, stained for haematoxylin and eosin and examined under light microscope. Total of 191 cases of hydatid cyst were received in 15 years, out of which 119 [62.3%] cases occurred in liver with mean age 41.27 years +/- 16.27 SD, 44 [23%] in lung with mean age 44.04 +/- 15.81 SD and remaining 28 [14.7%] in other uncommon organs. The presence of hydatid cyst in uncommon sites in Larkana is 14.7%, hence possibility of hydatid cyst in almost every organ of the body should be suspected

Cutaneous malignant tumors: a profile of ten years at LINAR, Larkana-Pakistan

Malignant tumors of skin are a group of malignancies comprising primary and metastatic tumors which involve the skin and its appendages. In this observational study, a total of 300 cases of cutaneous malignant tumors were included, who visited the Larkana Institute of Nuclear Medicine and Radiotherapy [LINAR] for management after confirmation by histopathological examination. Out of 300 cases studied, the males were 195 [65%] and females were 105 [35%], showing M: F ratio of 1.85: 1. The mean age of affected cases was 47 +/- 7.694 years and mostly affected patients were farmers [47%]. The duration of symptoms in majority of cases [27%] was 3-6 months. Most of the patients [71%] had lesions on face, while other parts of body like extremities, scalp and trunk were involved in 13%, 9% and 7%, respectively. Basal cell carcinoma [BCC] was confirmed in 183 [61%] cases, while squamous cell carcinoma [SCC] and malignant melanoma [MM] were found in 96 [32%] and 21 [7%] cases, respectively. BCC was found to be the commonest morphological type amongst the cutaneous malignant tumors. The increasing incidence rate shows an alarming situation for our population. The unawareness of public and medical professionals about the disease and late diagnosis are contributing factors in high morbidity and mortality

Extended-spectrum beta-lactamase production in sbigella flexneri

Emergence of multidrug-resistant strains of Shigella is a growing concern across the globe. Third-generation cephalosporins are used for treating infections caused by multidrug-resistant Shigellae. However, resistance to these cephalosporin antibiotics due to extended-spectrum beta-lactamases, has emerged as a new problem. So far extended-spectrum beta-lactamases producing Shigella has not been reported from Pakistan. We report such a case in Shigella flexneri from an 8-year old girl with acute dysentery

Vancomycin resistant enterococcal sepsis in an acute myeloid leu kemic patient

Neutropenic fever is an important cause of morbidity and mortality during therapy of acute myeloid leukemia. Patients with acute myeloid leukemia are at increased risk of acquiring vancomycin resistant enterococcal infection and its treatment remains problematic. Vancomycin therapy for more than 7 days is usually associated with inducible vancomycin-resistant enterococcal infections. We report a case of vancomycin resistant enterococcal sepsis in a patient of acute myeloid leukemia