Etiological factors and treatment outcome of genital and perineal necrotizing fascitis [Fournier's gangrene]

To analyze clinical and laboratory parameters in patients with Fournier's gangrene [FG] and to assess factors that determine mortality. A retrospective review of 82 patients with FG from January 2007 to December 2011 was made. They were divided into two groups: those who survived [survivors] and those who did not [non survivors]. We analyzed clinical and laboratory data. The mortality rate remained 36.6% [30/82 patients]. Increased heart and respiratory rates, elevated serum creatinine, pre-existing kidney disease, and higher extent of affected body surface were associated with higher mortality. Severe sepsis on admission and hypotension < 90 mm Hg] were also predictive for higher mortality. The median FG severity index [FGSI] score was higher in non survivors [22 vs 12, p < 0.0001]. Besides standard clinical and laboratory parameters included in the FGSI calculation, higher extent of affected body surface area and presence of hypotension on admission were positively associated with mortality. Early clinical identification and prompt aggressive treatment are essential for reducing mortality and morbidity in patients

Frequency of malignancy in clinically benign open transvesical prostatectomy- a study of 100 cases

Enlargement of prostate can be benign and malignant. Though differentiation between the two can be made on clinical grounds and surgery but still some cases can be missed if not subjected to histopathology. To find out the frequency of malignancy in patients operated for clinically benign open transvesical prostatectomy. Study type settings and duration: It was a prospective observational study conducted in the Department of surgery [Surgical Unit-I], Ghulam Muhammad Mahar Medical College and Hospital, Sukkur from January 2011 to December 2011. Patients presented with the history of prostatic symptoms were evaluated in surgical out-patient's department using digital rectal examination and ultrasound. The findings were recorded in a proforma and those having enlarged prostate weighing above 40gm underwent prostate specific antigen testing. Patients having no malignant findings on history, digital rectal examination and whose prostate specific antigen levels were below 10 ng/dl underwent open transvesical prostatectomy and all specimens were sent for histopathology. Those with suspicion of malignancy either on history or digital rectal examination or high prostate specific antigen were excluded from the study, also the glands below 40 gm in volume were excluded and referred for transurethral resection. All specimens were sent for hisopathology. Out of 100 cases, 41 were between 56 to 65 years of age. The mean age was 58 years. Acute urinary retention requiring catheterization was seen in 36 cases while 18 patients had symptoms suggestive of inguinal hernia but on examination had enlarged prostate. Prostate specific antigen was done in 07 patients with suspicion of malignancy but its value was below 10 ng/dl therefore they were included in the study. On ultrasound the gland volume ranged from 40 to 85 gm and residual post-voidal urinary volume ranged from 100 to 450ml. On histology 06 patients were found to have adenocarcinoma of prostate including 01 patient in whom mucosa of the gland was fixed but as the prostate specific antigen was below 10 ng/dl so the patient was kept in study group. Gleason score ranged from 4 to 9. Direct rectal examination is not a reliable test to detect early malignant changes in prostate and all specimens should be subjected to histopathology. Policy message: Histopathology of all operated and biopsied materials should be done to complete diagnosis

Comparison of laparoscopic appendicectomy [LA] versus open appendicectomy [OA] [a prospective randomizing audit of 1000 cases]

In this study comparison between Laproscopic and Open Appendisetomy with regard the length of operation, complication, conversion rate, postoperative hospital stay and time of return of normal activity has been made in order to assess the benefits and feasibility of the procedures. Prospective Randomizing study. This study is carried out at Shaheed Mohtrama Benazir Bhutto Medical University [SMBBMU] Hospital and At Sachal Medical Centre Larkana with effect from Jan: 2001 to Jan: 2011. All patients with diagnosis of acute appendicitis were enlisted and randomized to either laparoscopic appendisectomy [LA] or Open appendisectomy [OA]. All patients received pre-operative contibiotic. The operative time was calculated beginning with incision or insetion of Trocar till the wound was fully closed. Patients those were converted from LA to OA were considered separately. Assessment regarding the return to normal activity and work determined by questioning during the postoperative follow-up. This randomized study of 1000 cases in which 450 cases underwent OA and 550 patients scheduled for the LA procedure but successfully performed 505 and remaining 55 underwent Lap-Converted open appendisectomy. From this study reveals that the common presentation of appendicitis is simple appendicitis next is perforated appendicitis, while the reasons for lap converted open cases were of appendicular mass, perforated appendicitis, gangrenous appendicitis but 2 cases were noted of having normal appendix with pelvic inflammatory disease [PID]. The conversion rate remains higher in our study. Operative time in OA/LA remain 81/40 minutes. Wound infection rate in OA/LA remain 5.4%/3.0% Hospital stay in OA/LA 5-6/1-2 days. Patient return to normal activity in OA/LA group 14days/7 days. However early return to job found in LA than OA group of patients. After the long assessment of this study also compared with world literature that the LA is superior because of less pain; minimum wound infection, less operative time. Having the, cosmetically acceptable small scar, less hospital stay and early return to normal activity and job. Therefore this is mature time to say that LA is superior procedure in our setup while can replace open appendisectomy [OA]

Abdominal tuberculosis: varied presentations

To study various clinical presentations and out come of management of abdominal tuberculosis. Prospective cross-sectional study. This study was conducted at the Surgical Unit-1 Ghulam Mohammad Maher Medical College Hospital Sukkur and Al-Khair Hospital Sukkur from January 2007 to December 2010. The 65 patients admitted throughout patient department and emergency with abdominal catastrophes. Ages ranged between 14 to 70 years. Out of 65 patients 37 were males and 28 were females. All the patients were evaluated with history, examination and investigations. 34 patients were operated and the resected tissue sent for histopathology to conform the diagnosis of tuberculosis. Out of 65 cases of abdominal tuberculosis, 37 were male and 28 female. The mean age was 30.9 years with SD 14.19 [range 14 to 70 years]. The mean duration of symptoms at presentation was 6 months [range 1 month to 24 months]. 35 [52.3%] out of 65 patients were admitted with different complications in which 10 [29.4%] presented with peritonitis due to gut perforation, 9 [26.5%] with sub-acute intestinal obstruction, 8 [23.5%] with abdominal mass, 5 [14.7%] with acute appendicitis and 2[5.9%] with umbilical fistula. Surgery was performed in all these patients, Stricturoplasty done in 13 [38.3%], Ileostomy in 8 [23.5%], resection anastomosis in 5[14.7%], Right Hemicolectomy in 5 [14.7%] and adhesionolysis and biopsy in 3 [8.8%] patients. Diagnosis in these patients was confirmed with biopsy. Morbidity and mortality in this group was 40.2% and 17.6% respectively. Early diagnosis of the abdominal tuberculosis is possible only by the specific investigations like PCR. As these are not available in the remote areas of Sindh so the general surgeons in the peripheral tertiary care hospitals have to face such patients with complications. Early diagnosis of ATB can be made by high index of clinical suspicion to symptoms of abdominal pain, weight loss, low grade fever and vague ill health of more than one month duration and refractory to conventional treatment associated with raised ESR, positive Montoux test. To above symptomatology if empirical ATT is started early many of the complications of ATB can be avoided

Over view of laparoscopic cholecystectomy at [SMBBMU] University Hospital Larkana 1920 cases

To evaluate the safe technique in patient with cholelithiasis either simple or with acute cholecystitis and to highlight the better method in which patient can be prevented from future complication. Experimental Study. This study was conducted at University Hospital of Shaheed Mohtrama Benazir Bhutto Medical University, Larkana with effects from Jan 2005 to Jan 2011. Total number patient 1920 underwent lap chole, while 184 were admitted in acute state from casualty and Out Patient Department of university hospital. The mean age was 11-75 years, male and female ratio 1:3 with regard the 184 in acute cholecystitis among those patients reach to hospital within 24hours were 85, from 24-48hours were 65 patients while from 48-72 hours were 34 patients. While remaining patient were managed as elective cases. The operative time taken in elective cases were 30 minutes but in acute cases it was 90 minutes so average time was 60 minutes. The overall conversion rate is 2.86% but in acute case the conversion rate 8.15%. Post operative average hospital, stay remain's 1 day in elective cases but in acute Cholecystitis where conversion to open were performed the hospitalization minimum 6 maximum 7 days. The wound infection seen in 49 cases [2.8%]. Lap chole is a reliable and safe in management of cholecystitis either with or without cholelithiasis having simple or acute cholecystitis, while certain factors are responsible for conversion include delayed arrival more than 72 hours, empyema and bleeding while contradictory to international literature our study suggest that conversion rate is high in acute rather than elective Cholecystitis. So it is concluded that emergency lap chole is a safe and cost effective due to on time surgery and patient can be prevented from future complication. Therefore early lap chole is safe and can be performed in simple and complicated Cholecystitis while literature have proved that lap chole also safe in pregnant lady with certain limitation of like height of fundus

When to operate and abdominal gunshot wounds

Violence has become part and parcel of the daily routine of living, the prospective study of 86 patients, sustaining abdominal gunshot wounds was designed to evaluate the pattern, presentation and treatment outcome. Descriptive study. This study was conducted at the department of Surgery, Ghulam Muhammad Mahar Medical College Sukkur from January 2011 to January 2012. patients presenting with abdominal firearm wounds at accident and emergency department were included in this study, clinically all were evaluated, resuscitated and their findings were recorded on proforma. Patients with signs of acute abdomen [peritonitis]/ shock underwent midline emergency laparotomy, others having minimal or equivocal abdominal signs were selected for observation [non-operative management] group. Total number of patients included was 86, all were males, they belonged to age varying from 15-70 years. 54 [62.8%] were below the 40 years of age, in 44 [51.1%] cases instrument of attack used by assailant was pistol/shotgun, 45[52.3%] cases were victims of armed robbery, in 75 [87.2%] entrance wounds were present in anterior abdominal wall where as in 11[12.1%] were present posterirly, 67 [77.9%] underwent emergency laparotomy and 19 [22%] were observed initially. Two patients belonging to observation group showed failure, needed delayed laparotomy and both had positive laparotomy. Gunshot wounds of abdomen can be safely managed non-operatively, in the absence of abdominal tenderness haemodynamic instability or inevaluable factors as head injury and heavy intoxication. Success of non operative management depends upon continuous monitoring and frequent clinical examination

Effectiveness of ablative partial nail excision with phenolization in advanced stage onychocryptosis [ingrown toe nail]

To determine the effectiveness of ablative partial nail excision with phenolization in advanced stage onychocryptosis [ingrown toe nail]. Study type, settings and duration: An interventional study carried out at Department of Surgery, Ghulam Muhammad Mahar Medical College, Teaching Hospital, Sukkur from January 2009 to December 2009. Patients coming to the surgical department with advanced stage [stage-II and III] or recurrence of ingrown toe nail were included in the study. Patients with stage-I disease, diabetics, with trauma and vascular causes were excluded. All patients were operated as day cases with partial nail excision and chemical ablation with phenol. Results: A total of 56 patients underwent the procedure. There were 44[78.5%] males and 12[21.4%] females. Forty six patients were operated for the first time while 8[14.2%] patients were recurrent cases who were operated previously elsewhere. Post operatively and after chemical ablation, 41[73.2%] patients showed improvement with quite good pain relief and reduced swelling on third day, 15[26.7%] patients improved in two weeks. At 2 months 22[39.2%] patients were lost to follow up. Recurrence was observed only in 7[12.5%] patients after four and a half months. Delayed wound healing for upto three weeks was noticed in 3[5.3%] patients while moderate to severe pain requiring strong analgesics for one month was seen in 6[10.7%] patients. Majority of patients n=36 [64.2%] became symptoms free in 10 days. Partial nail excision with phenolization is a simple and effective procedure with low recurrence rates for patients with advanced ingrown toe nail

Puerperal sepsis: presentation, management and outcome: a hospital based study

Puerperal sepsis is a major cause of morbidity and mortality in Pakistan, but due to scarce data its magnitude is underestimated. To describe the presentation, management, and outcome in patients admitted with puerperal sepsis. Descriptive prospective study, carried out at Gynae/Obs Unit-1 of Ghulam Mohammad Mahar Medical College Hospital, Sukkur from 1[st] July 2007 to 31[st] December 2009. All the patients who met with the criteria of puerperal sepsis i.e. high grade temperature more than 38 °C, foul smelling vaginal discharge, open perineal wound / abdominal stitches were included in the study. The patients presenting with other postpartum obstetric reasons like post-partum haemorrhage, urinary tract infection, Mastitis, retained placenta were excluded. A total of 245 patients were admitted for postpartum problems, of whom 144[59%] were diagnosed as puerperal sepsis. Majority 122[85%] of the cases were between 21-40 years age, and multiparas were at a higher risk. Mode of delivery was vaginal in 133[92.4%] patients, while delivery was conducted at home by untrained birth attendants in 113[78%] patients. Anemia and prolonged neglected labour were commonly reported problems while, common presenting symptoms included high grade fever in 137[95%], foul smelling vaginal discharge in 46[32%], and abdominal distension in 32[22%] cases. More serious presentations like septicemia, multiple organ failure were seen in 26[18%] cases. Besides, antibiotics, 24[16.6%] needed dilatation and evacuation while, laparotomy was performed in 15[10.4%]. Mortality was seen in 18[12.5%] cases while, 28[19.4%] had prolonged hospital stay > 8 days. Puerperal sepsis is a leading cause of maternal morbidity and mortality in our setup which can be controlled by proper antenatal care, delivery by trained birth attendants, early referral and good antibiotic cover. Trained birth attendants and health care providers should be trained to detect early signs and symptoms of puerperal sepsis and its prompt treatment in order to reduce maternal morbidity and mortality

Abdominal tuberculosis: varied presentations

To study various clinical presentations and outcome of management of abdominal tuberculosis. This prospective study was conducted in the Surgical Unit-1 Ghulam Mohammad Maher Medical College Hospital Sukkur and Al-Khair Hospital Sukkur, from July 2006 to June 2009. The 65 patients admitted through out patient department and emergency with abdominal catastrophes. Ages ranged between 14 to 70 years. Out of 65 patients 37 were males and 28 were females. All the patients were evaluated with history, examination and investigations. 34 patients were operated and the respected tissue sent for histopathology to conform the diagnosis of tuberculosis. Out of 65 cases of abdominal tuberculosis, 37 were male and 28 female. The mean age was 30.9 years with SD 14.19 years [range 14 to 70 years]. The mean duration of symptoms at presentation was 6 months [range 14 month to 24 months]. 34 [52.3%] out of 65 patients were admitted with different complications in which 10 [29.4%] presented with peritonitis due to gut perforation, 9 [26.5%] with sub-acute intestinal obstruction, 8 [23.5%] with abdominal mass, 5 [14.7%] with acute appendicitis and 2 [5.9%] with umbilical fistula. Surgery was performed in all these patients, Stricturoplasty done in 13 [38.3%], Ileostomy in 8 [23.5%], resection anastomosis in 5 [14.7%], Right Hemicolectomy in 5 [14.7%] and adhesionolysis and biopsy in 3 [8.8%] patients. Diagnosis in these patients was confirmed with biopsy. Morbidity and mortality in this group was 40.2% and 17.6% respectively. Early diagnosis of the abdominal tuberculosis is possible only by the specific investigations like PCR. As these are not available in the remote areas of sindh so the general surgeons in the peripheral tertiary care hospitals have to face such patients with complications. Early diagnosis of ATB can be made by. high index of clinical suspicion to symptoms of abdominal pain, weight loss, low grade fever and vague ill health of more than one month duration and refractory to conventional treatment associated with raised ESR, positive Montoux test. To above symptomatology if empirical ATT is started early many of the complications of ATB can be avoided