experience of laparoscopic modified heller cardiomyotomy for achalasia cardia

Objective: The study was carried out to ascertain the outcome of laparoscopic modified Heller's myotomy for achalasia cardia and to determine the morbidity associated with it

Study Design: Descriptive cross sectional study

Place and Duration of Study: The study was conducted in Combined Military Hospital [CMH] Rawalpindi over a period of 4 years, from Jan 2010 to Aug 2014

Material and Methods: This study was carried out on patients undergoing surgical repair of laparoscopic Heller myotomy for cardiac achalasia at Combined Military Hospital Rawalpindi over a period of four years [2010-2014]. Patients undergoing laparoscopic-modified Heller myotomy at a thoracic referral and surgical training center. Eighteen cases of achalasia cardia based on clinical, barium and endoscopic findings were included in the sample using non probability purposive sampling technique. Pseudo achalasia, sigmoid esophagus were excluded. Laparoscopic modified Heller myotomy was done in all patients. Data were analyzed with the help of SPSS 20.0

Results: Age ranged between 14 years to 40 years with mean age of 28 years. The most frequent symptom was dysphagia [95%], followed by regurgitation of ingested food [60%], weight loss [40%] and chest pain [20%]. Mean operating time was forty minutes. There was no perioperative mortality. We applied Dor patch in 4 patients. Three patients had mucosal tear on large myotomy, diagnosed per operatively and repaired. There was no conversion to open procedure. There was marked improvement in symptoms especially dysphagia and there was no post operative reflux

Conclusion: Modified Heller myotomy by laparoscopic approach is a safe and effective procedure with acceptable results. It is easy to perform and improves the symptoms of the suffering individual

Is chest tube clamping necessary before removal? an experience with 2661 cases of tube thoracostomies

Objective: The aim of this study was to evaluate outcome of chest tube removal without clamping and relying only on clinical or radiological status for removal

Study Design: Retrospective descriptive study

Place and Duration of Study: The study was conducted in CMH Rawalpindi over a period of four years

Material and Methods: All patients of tube thoracostomies during Jan 2010 to Dec 2013 were included. Sample size was 2661. 1061 intubations were done for trauma, effusions and pneumothoraces, 905 in thoracostomies, 443 in VATS procedures like decortications, apical staplings, pleural biopsies and thymectomies and 252 in miscellaneous procedures such as open pleural biopsies, thoracoplasties and chest wall resections and reconstructions. Chest tube removal was based on absence of air bubbling in chest bottle, clinically or radiologically expanded lung, less than 6 cm excursion of column of chest tube and fluid output of <50ml [pus] and <100ml [clear fluid]. It was ensured in all cases that chest tube was not blocked and all tubes were removed by a thoracic surgery trainee. Chest tube was not clamped in any patient before removal to see respiratory distress

Results: Tube thoracostomies were performed in a vast variety of procedures. 1940 [72.9%] were males and 721 [27.1%] were females. Mean age was 37 years. In 1529 [57.4%] intubation was done on the right side. In 34 [1.27%] there was recurrent fluid collection. Recurrent pneumothorax was seen in 18 [0.67%] while tension pneumothorax was seen in 4 [0.15%]. Collective complication rate was in 56 [2.1%]. There was no mortality

Conclusion: Current worldwide practice of clamping chest tube before removal to judge respiratory distress can be challenged by our study. Emphasis is laid on clinical judgment, absence of air leak and minimal excursion sign of well expanded lung before removal of chest tube

Correlation between obesity and severity of cholecystitis

Objective: The aim and objective of this study is to assess the relationship between obesity and severity of Cholecystitis

Study Design: Observational / descriptive study

Place and Duration of Study: This study was conducted in the Punjab Employees Social Security Hospital Rawalpindi and AzmatRasheed Hospital Rawalpindi from 1[st] January 2015 to 31[st] Dec 2015

Materials and Methods: 84 patients of symptomatic gall stone disease were included in the study. BMI was calculated and recorded at the time of admission.Patients having BMI > 25kg/m[2] were put in category of overweight/Obese and those having BMI < 25kg/m[2] were considered to be of normal weight

Results: In males proportion of complicated acute cholecystitis was significantly higher in non-obese patients and was around [21%] as compared to obese [7%] with significant statistical difference. On the other hand no significant statistical difference was found between female non-obese and obese patients

Conclusion: Contrary to common belief, complication rate in obese males is less as compared to males of normal weight. While in females, no such difference is noted in complication rate of gall stone disease between obese and non-obese females

Histopathological evaluation of gastro protective effect of Berberis vulgaris [Zereshk] seeds against aspirin induced ulcer in albino mice

The present study was carried out to investigate the antiulcer activity of Berberis vulgaris [Zereshk] seeds in albino mice. After acclimatization, animals were divided into six equal groups. Aspirin 150mg/kg was used to induce gastric ulcer in all groups except normal control. Omeprazole 20mg/kg was used as synthetic anti ulcer drug in study. Three dose levels of B. vulgaris seed powder 300mg/kg, 600mg/kg and 900 mg/kg were used respectively orally. Histopathological analysis was carried out to evaluate the gastroprotective activity of B. vulgaris seed powder. Results of the study showed that in case of aspirin treated mice gastric luminal mucosa villi were decreased in height or were absent. In the glandular region there was connective tissue proliferation and also infiltration of cells. Similar infiltration of cells was present on muscularis mucosa. In esophageal region tumor cells were present. However three dose levels of B. vulgaris significantly reduced thetissue proliferation, infiltration of cells and sloughing induced by aspirin. Highest dose of B. vulgaris [900mg/kg] showed similar results as synthetic antiulcer drug omeprazole

Diabetic patients; clinical profile with endstage renal disease on haemodialysis

To study the clinical profile of diabetic patients on haemodialysis with a view to identify common clinical features and the trend of compliance with treatment and follow up. Haemodialysis unit Fatima Memorial Hospital, Lahore, from January to August 2011. Method: Data collected from all patients above 14 years of age through medical history, record, examination and fundoscopy. Out of total 76 patients on haemodialysis 50[65.7%] had DM and of these 42[84%] also had hypertension. Among diabetics 28 [56%] were male and 22 [44%] female. Mean age was 56.68 +/- 9.09. Among these 15[30%] were illiterate and 27 [54%] belonged to lower social class. Ever smokers were 18[36%]. Mean duration of diabetes since diagnosis was 10.9 +/- 5.99. Mean duration of hypertension 8.28 +/- 8.07, Duration of onset of dialysis 6 months to 8 years with mean 2.16 +/- 1.47. Retinopathy was found in 29[58%], 18[36%] had diabetic and 11[22%] had hypertensive changes. Both fasting and random blood sugar levels were monitored by 28 [56%]. None had regular follow up with HbA1c levels or urine for protienuria prior to onset of haemodialysis. Compliance with dietary advice and treatment claimed by 24[48%] and 36[72%] respectively. History of intake of Hakeem and homeopathic medications was found in 16[32%] and 10[20%] respectively. 65.7% of ESRD were diabetics. Majority were in 6th decade of life. Retinopathy was present in 58%. Low trend was observed towards compliance with treatment and follow up

experience of corrective surgery of 37 cases of chest deformity

The study was carried out to ascertain the cosmetic outcome of corrective surgery for pectus deformity and to determine the morbidity associated with it. Quasi-experimental study. The study conducted in CMH Rawalpindi and CMH Quetta from 2007 to 2012. Total number of cases operated for chest deformity was 37. Modified Welch procedure with sub perichondrial resection was done with a strut of prolene mesh in a majority of exacavatum repairs and k wires in few. Pectoroplasty was subsequently carried out in all patients. Midline incision was made in a majority of patients. Subjmammary incision was made in some female patients with a lower deformity due to better cosmetic outcome. Inclusion criterion was patients with chest deformity without any cardiac and spinal deformity. Age range was between 4 years to 12 years with mean age of 8 +/- 2.3 years. twenty four [65%] deformities were of excavatum and 9 [24%] were of carinatum type. Four [11%] cases were of unilateral asymmetrical deformity. Mean operating time was 95 +/- 11 minutes. Transfusion was required in only 1 [3%] o the cases. There was no perioperative mortality. Four [11%] patients had formation of seroma and 3 [8%] developed pneumothorax which was aspirated without placement of chest tube. Two [5%] had surgical site infection. Fifteen [41%] patients were satisfied and 21 [57%] reported excellent results. Chest deformity correction is safe and effective procedure with acceptable cosmetic results. It is easy to perform and improves self image of the suffering individual

Restless legs syndrome in end stage renal disease patients undergoing maintenance hemodialysis

To study the frequency of restless legs syndrome in patients of end stage renal disease undergoing maintenance hemodialysis.Cross sectional descriptive study. Department of medicine, CMH multan from November 2010 to April 2011. One hundred and ninety four [n=194] patients of end stage renal disease who had been on maintenance hemodialysis for at least 3 months, were included in the study after full informed consent and using consecutive sampling. Patients having dementia, psychiatric illness, pregnancy, hypothyroidism, parkinson's disease and alcoholics were excluded from the study. Patients who fulfilled all four diagnostic criteria for restless legs sydrom as proposed by international restless syndrome study group [IRLSSG], by direct questioning were diagnosed as having restless legs syndrome. The frequency of restless legs syndrome was found to be 12.4% in patients undergoing hemodialysis [10.5% in males verus 16% in females].The mean duration of hemodialysis was higher among RLS positive patients [12.88 +/- 5.543 months] as compared toRLS negative patients[6.94 +/- 4.610 months]. RLS is a frequent, under-diagnosed co-morbidity in patients undergoing maintenance hemodialysis

Subcutaneous versus subcutaneous and intraperitoneal local anaesthetic in the management of post appendicectomy pain

To compare the efficacy of subcutaneous only and combined subcutaneous and peritoneal infiltration of 0.5% bupivacaine during appendicectomy for the management of early post operative pain. Randomized controlled study. Department of Surgery, CMH Kohat from 13[th] December 2007 to 20[th] December 2008. Sixty patients of acute appendicitis, divided into two groups of 30 each, were included in the study. Group A was given 0.5% bupivacaine subcutaneously, whereas group B was given the anaesthetic subcutaneously as well as intraperitoneally during appendectomy. In group A, 24 [80%] were VAS [visual analogue scoring] 3 [uncomfortable] and 6 [20%] were VAS 2 [mild pain] whereas in study group B, 11 [36.6%] were VAS 3, 19 [63.3%] were VAS 2 and 19 [63.3%] were VAS 2 during 1st 12 hrs postoperatively [p=0.001]. In 12-24 hrs post operatively, 15 [50%] patients were VAS 3 in group A and same number was VAS 2 and in group B, only 3 [10%] were in VAS 3 and 27 [90%] were VAS 2 [p=0.001]. A combination of subcutaneous and peritoneal infiltration with bupivacaine is superior in relieving post appendectomy pain so patients require less dosage of analgesics in early post operative period along with early mobilization

Ondansetron versus combined dexamethasone and metoclopramide in prevention of nausea and vomiting after laparoscopic cholecystectomy

To compare the efficacy of combined metoclopramide and dexamethasone with ondansetron in preventing nausea and vomiting after laparoscopic cholecystectomy. Randomized controlled trial. Surgical Unit I Combined Military Hospital Rawalpindi, from 1[st] June 2010 to 3[rd] January 2011. A total of 120 patients were observed for 24 hours after elective laparoscopic cholecystectomy for nausea and vomiting and divided into two groups of 60 patients each. Nausea and vomiting was rated by the patients according to a three point scale [O=no nausea and vomiting, 1= nausea, 2= retching or vomiting]. Early postoperative nausea and vomiting was not present in 31[51.7%] patients of group 1 and 40[66.7%] of group 2 [score = 0]. In 11[18.3%] patients of group 1 and 12 [20.0%] of group 2 only nausea was present [score = 1], while 18[30.0%] patients in group 1 and [13.3%] in group 2 scored 2.The late postoperative nausea and vomiting was not present in 21[35.0%] patients in group 1 and 37[61.7%] in group II [score = 0]. In 28 [46.7%] patients in group 1 and 22[36.7%] in group 2 nausea was present [score = 1] while 11[18.3%] patients of group 1 and 1[1.7%] in group 2 scored 2. Ondansetron was effective as compared to combined metoclopramide and dexamethasone in prevention of post-laparoscopic cholecystectomy nausea and vomiting

unique presentation of unexploded ordnance in a patient

Rocket injuries in the war are common,but the retained unexploded rocket injury is quite rare and uncommon. We report an unusual case of unexploded rocket in knee area that required removal with unique safety measures, so as to prevent patient from potentially catastrophic situation

Solitary thyroid nodule, frequency of malignancy at combined military hospital Rawalpindi

To determine frequency of malignancy in solitary thyroid nodule. Case-series study. The study was conducted at Department of Surgery, Combined Military Hospital Rawalpindi, from April 2002 till April 2003. Sixty patients with clinical solitary thyroid nodule fulfilled the selection criteria and were included in the study. Thyroid function tests, ultrasonography and thyroid scanning was done. Finally FNAC and histopathology were done in all the operated cases and record was evaluated. Out of 60 cases studied, 8 [13.33%] were found to have malignant lesions. The remaining 52 [86.67%] cases had benign pathology. Male patients with solitary thyroid nodule showed a higher incidence of malignancy 17.65% as compared to females 11.63%, Maximum malignant cases [50%] were found between the ages of 31 to 40 years. Papillary carcinoma was the most common malignancy [50%] found in our study. The incidence of malignancy in solitary thyroid nodule is quite high [13.33%]. So people should be educated to attend thyroid clinics for early diagnosis and adequate treatment

Draining of subphrenic abscess into pericardial cavity - an incidental finding

The direct extension of a subphrenic abscess into the pericardial cavity is a rare finding. We report a 13 year old boy with Past History of Abdominal surgeries presenting with Right Upper quadrant pain, fever, chest pain and shortness of breath. An abdominal USG diagnosed a subphrenic abscess and an EGG demonstrated diffuse ST and T wave changes depictive of Acute Pericarditis. Echo guided drainage of thick pus from the pericardial cavity was performed which followed USG guided drainage of subphrenic abscess and finally Exploratory Laparotomy and drainage of subphrenic abscess + Mediastonotmy and Pericardiostomy + diaphragmatic repair was performed

Spinal surgery in earthquake victims

Objective of present paper is to document the operations performed in earthquake spinal injury patients and to analyze the results of surgery. This is a quasi-experimental study. This study was conducted at the department of Orthopaedic and Spinal surgery at Combined Military Hospital [CMH], Rawalpindi. Study started after earthquake in Pakistan on 8[th] of October 2005 and ended in August 2006. 250 patients with spinal injury were admitted at the three main army hospitals at Rawalpindi [CMH, MH and AFIRM] after earthquake on 8[th] October 2005. Out of these, 110 patients underwent 120 major spinal operations. 12 patients were received from other units for revision surgery. 75% of the patients were civilians and 25% were army personnel and their families. Average age was 28 years and range was 8-65 years. 56% patients were females and 44% were males. 46% patients had complete neurological deficit and 54% had incomplete neurological deficit. Most common associated injuries were fractures of tibia and fibula. Most common level of injury was at T12/L1 [55%]. After surgery almost all patients had rehabilitation at AFIRM. Post-operatively excellent [>75%] or good [50-75%] correction of deformity was achieved in 90% of patients. 92% patients had mild or no pain, post-operatively. Neurological improvement was seen in all patients with incomplete deficit except four. Some patients with complete deficit also showed improvement. Overall there was 1.5 AIS improvement per patient. At last follow up 46% patients were walking independently and 51% were independent in wheel chair. Spinal surgery in patients with unstable spines after major disaster should be carried out by properly trained surgeons as soon as possible and in a setup where facilities for proper rehabilitation are available as it carries best prognosis for these high risk and at times paralyzed patients