Prophylactic rectal nsaids in the prevention of post-ercp pancreatitis

Objective: To evaluate the effectiveness of rectal non-steroidal anti-inflammatory drugs [NSAIDs] using diclofenac in preventing pancreatitis following ERCP

Methodology: It was a randomized, double blinded, placebo controlled study carried out at Surgical Unit-l, Holy Family Hospital, Rawalpindi from May 2013 to April 2014. A total of 108 patients were included and randomly assigned in each of study and placebo groups. Group I patients received 100 mg of diclofenac per rectally while group II patients received a glycerine suppository per rectally [placebo] before the start of ERCP. Post ERCP pancreatitis [PEP] was diagnosed by clinical evaluation and raised serum amylase levels after four hours of the procedure in both groups [study vs control]

Results: Out of 108 patients 32 were males and 76 were females. Mean age was 46.09 +/- 12.31 in group I, while it was 42.93 +/- 14.69 in Group II. Mean serum amylase level, 4 hours after ERCP, was 184.70 +/- 36.34 in the diclofenac group, while it was 388.20 +/- 57.27 IU/L in the control group. Thirty one patients were diagnosed with Post ERCP pancreatitis, out of which nine patients belonged to the study group and twenty two were of the control group [P = 0.000]

Conclusion: Per-rectal administration of diclofenac suppository prior to ERCP results in significant reduction in the frequency of ERCP induced pancreatitis

Laparosopic assisted Right Hemicolectomy; an initial experience

Experience with Laparosopic assisted Right Hemicolectomy is presented. Prospective study. Surgical Unit-I, Holy Family Hospital, Rawalpindi, Pakistan. 2010 to 2014. 20 patients underwent laparosopic assisted right hemicolectomy. Duration of operation, postoperative pain, duration of post-operative analgesia, and frequency of surgical site infection and length of hospital stay were noted. There were 13 male and 7 female patients with the age range of 25-70 years [45 +/- 11years]. Eleven [11] patients were suffering from carcinoma colon wheras nine [09] were suffering from Tuberculosis. Mean operative time was about 92 minutes. Only four opiod injections were required as post-operative analgesia. Oral intake was started after 24 hours. The mean length of hospital stay was 5.5 days with no case of surgical site infection. Laparoscopic assisted right hemicolectomy is a safe and viable option in our setup

Cholecystectomy; laparoscopic vs open in patients with mild liver cirrhosis and symptomatic gall stones

To compare the operative time, blood loss, postoperative pain and length of hospitalization between open [OC] and laparoscopic cholecystectomy [LC] in Liver cirrhotic patients with Child -Pugh class A and B. Randomised Control Trial [RCT]. This study was conducted at Surgical department, Holy Family Hospital, Rawalpindi from Jan 2010 to Dec 2011. A total of 142 patients having Liver cirrhosis secondary to Hepatitis A and Hepatitis B, who presented in OPD and ER with signs and symptoms of gall stones were randomly allocated into two groups for open [OC] and laproscopic cholecystectomy [LC]. All of them were either in Child-Pugh class A or B. Data on the above two groups [LC and OC] was collected and analyzed for operative time, blood loss and length of hospitalization after operation. The mean blood loss in LC group was 61.33+39.64 ml vs 90.84+29.88 ml in OC group, Mean operation time was 50.49+18.26 min in LC group vs 59.22+15.66 in OC group which is statistically significant [p<.05]. In LC group, the mean hospital stay was 1.8+.97 days, while in OC group is 2.4+.91 days which is also statistically significant. LC [laparoscopic cholecystectomy] is a safe and effective approach for the treatment of symptomatic cholelithiasis in patients with mild cirrhosis with less blood loss, less postoperative pain, shorter operative time and decreased hospital stay

Frequency of common bile duct injury in laparoscopic cholecystectomy

The aim of the study is to review the frequency of Common Bile Duct [CBD] injury in laparoscopic cholecystectomy [LC] and its management in our set up. This descriptive study was conducted at Surgical Department, Rawalpindi Medical College and the author's Surgical Clinics from January1998 to December 2012. Two thousand patients undergoing laparoscopic cholecystectomy were included in the study. The cases were operated between January 1998 and December 2012. The important variables included were frequency of CBD injury and its management. There were 1723 females and 277 males with mean age 45.04 +/- 11years. 67.8% patients had chronic cholecystitis with cholelithiasis and were admitted through Out Patient Department whereas 32.2% patients were admitted through A and E department. Abdominal ultrasound showed multiple calculi in 1535 [76.7%] patients and 435 [23.3%] patients had single calculus preoperatively. Empyema was found in 245[12.2%] cases whereas adhesions were present in 783[39.1%] patients. Conversion rate to open cholecystectomy was3.4 %. Seventeen cases had CBD injury [0.85%]. 14 cases [82.3%] were diagnosed in traoperatively whereas 3 cases [17.7%] were diagnosed postoperatively. In 13 cases [76.5%] CBD repair was done over T. tube. Mean operating time was 30 minutes. The frequency of CBD injury in LC in our setup was less than 1%and is comparable to international experience. Most of the cases were diagnosed in traoperatively. Repair over T. tube is commonest method employed for management of CBD injury with favorable results

Laparoscopic vs Lichtenstein hernia repair: a local experience

To compare the operative time, the postoperative pain scores, duration of hospital stay and wound infection rates between Lichtenstein and totally extra peritoneal [TEP] laparoscopic hernia repair for direct inguinal hernias. Comparative study. This study was conducted at surgical unit 1, Benazir Bhutto hospital and surgical unit 1, Holy Family hospital, Rawalpindi from 1[st] July 2007 to 31[st] December, 2010. A total of hundred patients were divided into open and laparoscopy groups and their age, sex, operative times, pain scores, duration of hospital stay and wound infections were compared and analyzed. Mean age was 60.7 [ +/- 9.2] years for open group and 59.7 [ +/- 9.3] for the laparoscopic group. Time for surgery was 48.9 minutes in open and 49.0 minutes in the laparoscopic group. Pain scores at 2 hours and 24 hours after surgery were significantly less in laparoscopic group as compared to open group. Hospital stay was 39.6 hours in open versus 31.4 hours in the laparoscopic group, which was also significant. There was no case of wound infection in either groups, requiring operative intervention or mesh removal. The laparoscopic approaches to hernia repair have clear advantages, including lesser post operative pain and shorter hospital stays

Appendicectomy; laparoscopic VS open

The objective of this study was to compare length of hospital stay, pain scores and the rate of wound infections between laparoscopic and open appendectomy. Randomized Controlled trial. This study was conducted in surgical unit I Holy Family hospital, Rawalpindi from 1st June 2009 to 31st May 2010. The patients were divided into open and laparoscopy groups and their age, sex, time of discharge, pain scores and wound infection rates were compared and analyzed. Total of 160 patients were included in the study, 80 in each group. There were 58% male and 42% female patients. Mean age was 22.78 years [ +/- 6.2]. Post operative pain scores were significantly less in the laparoscopic group [p<0.05]. The length of hospital stay in open group was 35.10 hrs [ +/- 5.4] hours and in the laparoscopic group was 38.70[4.8] hrs with a p value of 0.592. Wound infection was 0.037% in open and 0.025% in the laparoscopic group. Laparoscopic appendectomy is superior in terms of less morbidity and shorter post operative hospital stay in the setting of an overworked tertiary care surgical floor of a Pakistani hospital

comparison of open and laparoscopic ventral hernia repairs

To compare the outcome of open versus laparoscopic ventral hernia repair in terms of duration of surgery, post operative pain and length of hospital stay. A comparative study was carried out at in-patients presenting at Surgical Departments of Benazir Bhutto Hospital, Holy Family Hospital and author's clinics. A total of 100 patients were included in the study and the patients were divided randomly in Group A and Group B, having 50 patients in each group, Group A representing open mesh repair group and Group B laparoscopic repair group. Patients of both groups were observed per-operatively for duration of surgery, postoperatively for length of hospital stay and intensity of postoperative pain. There was no statistically significant difference between two groups for duration of surgery [P >0.96]. Pain was calculated at 2 and 24 hour, using visual analogue scale. Less pain was noted in Group B. Difference of pain score was statistically significant at 2h and 24h [P0< .05]. Average duration of postoperative stay in hours was more in Group A [39.6 hrs] as compared to Group B [31.4 hrs] [P < 0.05]. Laparoscopic ventral hernia repair is beneficial due to less post operative pain and short duration of post operative hospital stay but duration of surgery remained same in both the settings

prospective study of factors predicting postoperative pulmonary complications [PPC] in patients undergoing noncardiothoracic surgery under general anaesthsia in a developing country

Post-operative pulmonary complications after non-cardiothoracic surgery are common and can adversely affect morbidity, mortality and length of hospital stay. Knowledge as regards factors predicting postoperative pulmonary complications in our local setting is imperfect. To study factors predicting post-operative pulmonary complications in developing countries. Data of consecutive 404 patients undergoing non-cardiothoracic surgery under general anesthesia with tracheal intubation was collected prospectively from Jan 2009 to Dec 2010. Chi-square was used for univariate analysis. Multivariate analysis was conducted using forward stepwise logistic regression. The mean age was 36 +/- 18 years with slight male predominence [54% vs 46%]. 22% [n=89] were smokers and the mean Body Mass Index was 23 +/- 4.5 kg/m2 with 35% [n=141] overweight and obese. 5% [n=20] of subjects had pre-existing chronic lung conditions while 23% [n=92] had non-pulmonary chronic conditions. 70% [n=282] of the surgeries were done electively and the mean duration of anesthesia was 78 +/- 44 minutes. The overall postoperative pulmonary complications rate was 8% [n=31] with atelactasis [48%, n=16] followed by bronchospasm [25%, n=8] and pneumonia [16%, n=5] being the commonest complications. The duration of hospital stay was significantly longer [11 +/- 9 days, p=0.00] in patients with post-operative pulmonary complications and 29% [n=9] of them required mechanical ventilation. Logistic Regression analysis identified premorbid chronic chest conditions, emergency surgery and prolonged duration of anesthesia as significant predictors of post-operative pulmonary complications while age, gender, Body Mass Index, smoking history and non-pulmonary premorbids were insignificant in this regard. Post-operative pulmonary complications after non-cardiothoracic surgery are common and lead to increased morbidity and prolonged hospital stay in our setting. We identified pre-existing chest disease, prolonged anesthesia and emergency surgery as significant predictors of post-operative pulmonary complications

Laparoscopic cholecystectomy at Rawalpindi General Hospital a clinical practice audit

To evaluate the practice audit of Laparoscopic cholecystectomy. A prospective, clinical practice audit At Surgical Unit-I, Rawalpindi General Hospital and at the author's Surgical Clinics from January 1998 to December 2007. There were 883 females and 117 males. Mean age was 45.0 +/- 11.0 years. Sixty six point six percent patients had chronic cholecystitis with cholelithiasis and were admitted through Out Patient Department whereas 33.4% were admitted through Accident and Emergency Department with acute cholecystitis. Abdominal ultrasound showed multiple calculi in 745 [74.5%] patients and 255 [25.5%] patients had single calculus preoperatively. Empyema was found in 60[6%] cases whereas adhesions were present in 403[40.3%] patients. In our study conversion rate was 4.8% and frequency of injury to common bile duct was 1.4%. Mean operating time was 40 minutes. Ninety two recent of the patients were discharged within 48 hrs of operation. There was no mortality while post-operative complications were seen in 6% patients. Laparoscopic Cholecystectomy in our set up proved to be a safe procedure having short duration of surgery and short hospital stay

Perforated appendicitis: our local experience

To determine frequency of perforated appendicitis in patients presenting with acute appendicitis and association of perforation with the duration of symptoms in acute appendicitis. Observational study. The study was conducted in surgical unit I at Holy Family Hospital Rawalpindi. One hundred and fifty patients diagnosed as the cases of acute appendicitis were included in the study by a non probability convenience sampling technique. Later on, patients with no signs of inflammation of appendix on operation or histopathological report were excluded from the study. In these patients frequency of perforated appendix, duration of symptoms in patients with perforated appendix and association of perforation with duration of symptoms in acute appendicitis was determined. Among 150 cases, 47 patients [31.3%] had perforated appendicitis while 103 patients [69.7%] had simple acute appendicitis. 90 patients were male while 60 patients were female. 40 patients [85.1%] of perforated appendicitis had symptoms for more than 24 hours while 7 patients [14.9%] of perforated appendicitis had symptoms for less than 24 hours. Complications were high in the perforated appendicitis as compared to non perforated appendicitis. Average stay of the patients with perforated appendicitis was 3.33 days while with non perforated appendicitis was 1.75 days. No mortality was occurred in this study. Timely diagnosis of acute appendicitis and prompt surgical intervention can decrease the frequency and high morbidity due to perforated appendicitis

Laparoscopic cholecystectomy; common bile duct injury after learning curve

To determine the frequency of common bile duct [CBD] injury in laparoscopic cholecystectomy in our settings, in my last 500 cases, after going through the learning curve associated CBD injuries. Descriptive study. Surgical Unit-I, Rawalpindi General Hospital and the author's Surgical Clinics from January 2003 to December 2008. Five hundred patients undergoing laparoscopic cholecystectomy by the same surgeon were included. The important variables included demographic data, intra operative time and findings, frequency of CBD injury and post operative hospital stay. There were 419 [83.8%] females and 81 [16.2%] males with mean age 45.04 +/- 11.03 years. 294 [58.8%] patients had chronic cholecystitis with cholelithiasis and were admitted through Out Patient Department whereas 206 [41.2%] were admitted through Accident and Emergency Department with acute cholecystitis. Abdominal ultrasound showed multiple calculi in 351 [70.2%] patients and 149 [29.8%] patients had single calculus preoperatively. Empyema was found in 97 [19.4%] cases whereas adhesions were present in 182 [36.4%] patients. In our study frequency of CBD injury was 1%. Mean operating time was 35 minutes. 96.8% of the patients were discharged within 48 hrs of operation. Laparoscopic Cholecystectomy in our set up proved to be a safe procedure, having frequency of CBD injury of only 1% and a short hospital stay 493 [96.8%] being discharged in less than 2 days

Laparoscopic cholecystectomy; randomized, controlled trial of bupivacaine injection to decrease pain

To determine if intraoperative instillation of bupivacaine into gall bladder fossa would decrease early postoperative pain after laparoscopic cholecystectomy, Double-blind, randomized, controlled trial. Surgical Unit-l, Holy Family Hospital, Rawalpindi and Surgical Unit-1, Benazir Bhutto Hospital, Two year study. Fifty patients underwent laparoscopic cholecystectomy group-A. They were compared with a control group of fifty patients who had laparoscopic cholecystectomy but did not receive bupivacaine Group-B. Instillation of 10 ml of 0.5% bupivacaine into gall bladder fossa intra operatively after removal of gall bladder. Visual analogue scale [VAS] pain scores assessed 3 times post operatively, at 1, 6 and 24 hours, using similar peroperative and postoperative analgesics in both groups. Mean VAS pain scores [range 0 [no pain] to 10 [severe pain]] at 1 hour and at 6 hours after surgery were 6.5 and 4.2 respectively, in the bupivacaine group [Group-A] compared with 6.2 and 4.5 respectively, in the control group [Group-B] [p =.085 and 0.078,sd=.919 and.495]. VAS scores at 24 hours postoperatively did not differ between the two groups [2.4 VS 2.5][p=.282,sd=.636]. Instillation of bupivacaine into gall bladder fossa has no effect on post operative pain control in elective laparoscopic cholecystectomy

Post thyroidectomy hypocalcemia - does arterial ligation play a significant role?

The aim of this study was to determine if bilateral inferior thyroid artery [ITA] ligation is a causal factor for the occurrence of postoperative hypocalcaemia after subtotal thyroidectomy. Quasi experimental trial. One year study from Jan 2005 to Dec 2005 conducted at surgical department of Rawalpindi General Hospital [UNIT-I]. One hundred patients were included in the study who underwent subtotal thyroidectomy with and without truncal ligation of inferior thyroid artery and were prospectively analyzed comparing postoperative and late serum calcium levels A significant incidence of postoperative hypocalcaemia occurred: more in Group A [48%] as compared to Group B [22%]. This difference was statistically significant shown by the P value < 0.5 on the 1st postoperative day in patients with ligation of inferior thyroid artery. The ligation of the ITA tends to produce hypocalcaemia in patients undergoing subtotal Thyroidectomy

Pattern of intestinal obstruction a hospital based study

To determine the pattern of Intestinal Obstruction in local settings. This is a descriptive study of 100 cases of intestinal obstruction from January 2001 to December 2003. Rawalpindi Medical College, Rawalpindi. 100 cases of intestinal obstruction collected from Rawalpindi General Hospital from January 2001 to December 2003. The data of all patients was analyzed as regards to presentation, treatment and outcome. Total number of cases presented with intestinal obstruction requiring operative management was 100. Among them 81 were males and 19 were females. As far as the age distribution is concerned the age range was 5 months to 82 years. Mean age was 33 years. In our study commonest cause of intestinal obstruction was obstructed inguinal hernia followed by adhesions. Commonest postoperative complication encountered was postoperative fever and wound infection. In our study frequency of mortality was 7 [7%]. Despite all the improvements in the health care system, inguinal hernias are the commonest cause of intestinal obstruction in our setup