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

Frequency of anomalies associated with chest deformity in physically fit male candidates reporting for military recruitment

To identify the frequency of anomalies associated with chest deformity in physical fit male candidates reporting for military recruitment. Observational. Department of Thoracic Surgery, CMH Rawalpindi from 1[st] Jan 2008 to 31 Dec 2011. Normal healthy physically fit young adolescents being recruited for army were scrolled and those exhibiting chest deformity were isolated and subjected to evaluation. Convenience sampling was carried out. All cadidates of chest wall deformity thereafter underwent a thorough physical checkup, pulmonary function tests and echocardiography. A total of 3735 candidates of chest deformity reported at our center for evaluation over this duration. Single deformity patients 3380 [90.5%], mixed deformity patients 355 [95%]. We found that none of the candidates had any derangement of the lung function tests or electrocardiographic abnormality despite their deformity. However echocardiography detected an abnormality in 161 [4.3%] individuals who were otherwise asymptomatic. Chest deformity should be excluded before physical tests, in all the male candidates reporting for enrolment. If slightest of doubt exists that a candidate has chest deformity then he should be evaluated with echocardiography to exclude cardiac abnormality. Although the associated frequency is only 4.3% but this can subsequently result in a grave event like death

Solitary pulmonary nodule a rare case

A middle aged man presented with a solitary pulmonary nodule. He had a diagnostic dilemma as the CT guided FNAC was inconclusive. The frozen section exam reported it to be malignant so a lobectomy was performed for this lesion. The final histopathology report confirmed it to be a very rare tumor of extra skeletal synovial sarcoma

Fistulotomy vs. fistulectomy in the treatment of simple low anal fistula of male patients

Objective: To compare the efficacy of fistulotomy versus fistulectomy in the treatment of low lying anal fistula in male patients

Study Design: Randomized clinical trial

Place and Duration of Study: Surgery Department, CMH Multan and CMH Malir, from Aug 2008 to Oct 2013

Patients and Methods: Study was done on 262 patients. Patients with anal fistula were divided by simple random allocation into groups A [fistulotomy] and B [fistulectomy]. The patients with simple low anal fistula without any comorbids were included in the study and the patients with recurrent fistula, high fistula or those having any comorbid were excluded from the study. Data was analysed using SPSS 17. Descriptive statistics applied for both quantitative and qualitative variables. Mean and standard deviation for quantitative and frequencies and percentages for qualitative data

Results: Total 262 patients were selected having low lying anal fistula and operated as group A - fistulotomy and group B - fistulectomy, each group constituted of 131 patients each. The operating time was found to be shorter for group A [14.29+3.24 minutes] and group B [25.92 +3.60 minutes]. The group A patients were discharged earlier [3.73 + 0.65 days] than group B [4.88 + 0.35 days]. In group A incidence of postoperative bleeding [0.8%], infection [2.2%] and recurrence was [10.7%]. While in group B bleeding [3.1%], infection [3.8%] and recurrence was [15.3%]. Severity of postoperative pain [as assessed by Numeric Rating Scale] was higher in group B as compared to group A. The healing time was shorter in group A [4.04 + 0.33 weeks] as compared to group B [4.57 + 0.497 weeks] and the patients of group A returned to normal activity earlier [10.9 + 2.05 weeks] than group B patients [15.54 + 0.51 weeks]

Conclusion: In male patients suffering from simple low lying anal fistulas, fistulotomy has a definitive superiority over fistulectomy and is recommended to be adopted as primary surgical modality for the treatment

Video assisted thoracoscopic surgery [vats]; two years experience at thoracic surgery department, combined military hospital Rawalpindi

To review the experience of video-assisted thoracoscopic surgery [VATS] with 202 different cases focusing on indications, operative procedures, side effects and complications. Descriptive Study. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi, for 2 years from January 2009 till January 2011. Two hundred and two video-assisted thoracoscopic surgeries [VATS] were performed over 2 years. There were 131 [64.9%] males and 71[35.1%] female patients. Total two hundred and two patients were selected who were divided into two groups: diagnostic and therapeutic group. The mean age of the patients was 40.25 years [SD +/- 12.58] with an age range of 13-77 years. There were 131 males [64.9%] and 71 [35.1%] females. The main indications of video-assisted thoracoscopic surgery were diagnostic in 118 patients and therapeutic in 84 patients. Sixty one patients underwent VATS for indeterminate pleural effusion and a definitive diagnosis was made in 90.2% patients. Definitive diagnosis was made in all sixty six patients who underwent VATS for wedge resection/forceps biopsy of pulmonary nodules, mediastinal masses and interstitial lung disease. VATS thymectomy was performed on 13 patients while 3 patients underwent VATS sympathectomy. Conversion to thoracotomy was required in 8.4% [17/202] of the patients. Adhesions were the most common indication of conversion. There was no operative mortality. The overall median duration of chest tube drainage was 4 days and median postoperative hospital stay was 5 days. Postoperative complications were encountered in 5.9% patients [12/202 patients]. No perioperative mortality was encountered in either group. This review indicates that VATS can be performed with minimal morbidity for therapeutic purposes as a current approach for thoracic surgery. It is a safe procedure in many intrathoracic diseases and is associated with less postoperative pain and hospital stay than open thoracotomy

Management of primary spontaneous pneumothorax by video assisted thoracoscopic surgery [VATS]

To evaluate the outcome of treatment of primary spontaneous pneumothorax by VATS. Case Series. Dept. of thoracic Surgery Combined Military Hospital Rawalpindi between April 2007 to Dec 2009. This study included 20 patients with primary spontaneous pneumothorax who were treated by VATS apical stapling and pleural abrasion/ pleurectomy. All patients were operated under one lung ventilation. Three ports of 10mm were used and apical stappling / bullectomy was done with linear cutting stapler [ethicon, autosuture]. This was combined with pleural abrasion/ pleurectomy, Chest was drained via a single chest tube. We had 21 procedures on 20 patients. There were 18 males and 2 females [9:1]. Mean age was 26.4 years. Indications included persistent air leak 7, recurrent attack 12, contralateral recurrence 1 and professional hazard 1. Mean hospital stay was 3.2 days. Complications included minor port site infection 5, intercostals neuralgia 3, delayed lung expansion 2 cases and persistent apical space in 1 case. There is no recurrence. VATS was a reliable approach for managing primary spontaneous pneumothorax with low morbidity

Video assisted thoracoscopic surgery [VATS] lung biopsy for non-responsive patients of interstitial lung disease [ILD]

To study the results of VATS [Video Assisted Thoracoscopic Surgery] Lung Biopsy in Interstitial Lung Disease [ILD] case series. Department of Thoracic Surgery, CMH Rawalpindi from Jan 2009 to Mar 2010. All those patients of ILD [Interstitial Lung Disease] were included who failed to improve after a period of observation including those on empiric therapy, all patients in which BAL [Bronchoalveolar Lavage] and TBLB [Transbronchial Lung biopsy] was inconclusive and all those patients fit to undergo thoracoscopic surgery. Patients excluded were elderly patients, those with systemic disorders frequently associated with ILD and those with known neoplasm likely to have lymphangitic dissemination. We used three thoracoscopic ports, all biopsies were sent for histopathology examination, single chest tube was placed in all cases and it was removed once the airleak ceased. All complications encountered were noted. Fourteen patients were registered during study period. Biopsy showed that 9 had ILD, and 5 did not have ILD. Only complication was a prolonged airleak for 2 days in 2 patients. No mortality was encountered. Thoracoscopic surgical biopsy can be accomplished safely in most cases where there is a diagnostic dilema for interstitial lung disease

Pattern of somatic symptoms in anxiety and depression

To determine the pattern of somatic symptoms in anxiety and depressive disorders. Cross Sectional Comparative study. Department of Psychiatry Military Hospital Rawalpindi. From May to November 2002. Patients were divided in Group I of anxiety and group II of depression. Fifty patients considered in each group by convenience sampling. The organic basis of their symptoms was ruled out. The patterns of their somatic symptoms and other information like educational and economic status were recorded on Semi Structured Proforma. The patient's diagnosis was made on schedule based ICD-10 research criteria. The severity of anxiety and depression was assessed by using HARS and HDRS respectively. The pattern of somatic symptoms in both groups was then analyzed by the urdu version of Bradford Somatic Inventory. Patterns of somatic complaints were then analyzed by chi square test. Out of 100 patients we placed 50 each in group I [anxiety] and group II [Depression]. Males were higher in depression whereas females were higher in anxiety disorder group. P-value for headache was 0.017 while in rest of the somatic symptoms it was insignificant ranging from 0.4 to 1. We found that the patterns of somatic symptoms are present in both the groups of anxiety and depression like symptoms related to musculoskeletal and gastrointestinal system were commonly observed in cases of depression whereas symptoms related to autonomic nervous system and cardiovascular system is more significantly somatized in patients of anxiety. A larger sample is required for further studies to get better results

Tracheal schwannoma: a rare tracheal tumour

Primary tracheal tumours are histologically similar but 100 times less common than main stem tumours. We report a case of primary tracheal schwannoma in a middle aged man. He had chronic cough for 2 years, and developed hemoptysis and stridor in the days preceding to presentation. He was treated by resection of the tumour and primary anatomosis of the trachea. The patient recovered well after surgery and had a near normal PEFR after one and a half year of follow-up and bronchoscopic examination excluded any recurrence

Acute appendicitis: gaining time in mass casualty scenario

To find out group of drugs best to gain time before appendicectomy in patients of acute appendicitis in mass causalities scenario. Quasi-Experimental. Place and Duration of study: A post earthquake, resource constrained hospital taking care of dependant population of three districts at CMH RawlaKot from 15 Jan 2007 to 15 Jan 2008. Ten patients were selected in each group by convenience sampling. Patients were divided into five groups Group I No Antibiotics, Group II Ampicillin / Gentamicin / Metronidazole, Group III Ceftriaxone / Metronidazole, Group IV Ampicillin / Sulbactum, Group V Cefoperazone / Sulbactum. Group I was taken as control where the appendectomy delay was according to the natural history of the disease. Group II, III, IV and V who had to be triaged and placed on antibiotics regimen before operation. Extreme care was taken so that this approach was only adopted in patients where the delay in appendectomy was inevitable. All patients were operated 24 to 72 hours after onset of symptoms. The grade of operative difficulty was assessed objectively and average difficulty scores were compared between the groups In the one year period 431 appendectomies were performed out of which 50 patients were included in the study. These 50 comprised of 10 patients in each group. Overall male to female ratio was 27:23. Overall average age was 25.14 + 7.54. In Group I an average delay before presentation 57.6 + 12.39 hrs. In Group II to V the overall delay from start of symptoms till operation was 55.63 + 8.37 hrs. The cumulative ease to operative was experienced in group V. In scenario of mass / multiple casualty, the antibiotic containing sulbactum will be best empirical therapy to gain time for patients of acute appendicitis. The one having Cefoperazone has got a definitive edge over the rest

Gastropleural fistula: an unusual sequel of blunt chest trauma

In the October 2005 Earthquake in mountainous Azad Kashmir and adjacent areas in Pakistan, a young female sustained crush injury chest and upper abdomen. She remained hospitalized with lower chest pain. All initial investigations were normal and she was discharged symptom-free on conservative management. Six months later, she developed acute left sided chest pain and dyspnoea. Provisional diagnosis of empyema was made on X-ray, and tube thoracostomy was done. Diagnostic VATS revealed gastropleural fistula secondary to necrosis of herniated stomach. Resection of necrosed stomach, repair of diaphragm and decortication and transthoracic repair with lower thoracoplasty two months later was performed but both were unsuccessful. After another 02 months, a Roux-en-Y gastrojejunostomy at fistula site was fashioned which proved curative

Tissue repair for inguinal hernia: should they be deleted from literature?

This is a pilot study to evaluate the status of herniorrhaphy procedures in the modern day surgery. Mar 1995 to Mar 2005 Military hospitals Descriptive and Analytical All entitled patients were included in this study and only those non-entitled patients were included who came for regular follow up. All the patients were booked at first admission and their record was maintained. They were subjected to herniorrhaphy by a modified Bassini's procedure. They were called for follow up at 3 months, 6 months then annually for 2 years. A total of 210 patients were operated for inguinal hernia by tissue repair over the period of study. Out of these 164 patients were operated by pure tissue repair, of which 148 were followed up completely and were included in the study. The average age was 50.16 +/- 19.12 years. The mean operation time was 20 +/- 5.84 minutes. Mean Hospital stay was 3 +/- 0.6 days. Recurrence was noted in 1 [0.68%] patient in a follow up period of 2 +/- 0.46 years. Tissue repairs hold good even today in the deserving patients and should be undertaken without hesitation where necessary. We should not hesitate in deciding for easier and cheaper alternatives when available

Mass Casualty management after a suicidal terrorist attack on a religious procession in Quetta, Pakistan

To determine the effectiveness of hospital management, considering triage system, hospital staff response, medical resources availability, and surgical management depending upon the nature and pattern of injuries in a mass casualty incident. Descriptive. Combined Military Hospital, Quetta, Pakistan in March 2004. All injured by gunshot or blast in a terrorist attack and reported to the hospital were included in this study. Patients were triaged by the triage team using "triage sieve" into priority I, II, III, and IV. Priority I patients were further triaged by using "trauma index" to prioritize for surgery. Phase I included life saving, Phase II limb saving surgery and Phase III for debridement. All data was recorded and analyzed. Hospital received 161 casualties among whom 20 were brought in dead, and 141 patients were admitted to the hospital. Mean age was 26.63 +/- 13.97.The cases were categorized as Priority-I 22.7%, Priority-II 14.72%, Priority-III 50.31% and Priority-IV 12.27%. Maximum casualties reached within the first 2 hours. Eighty-eight patients had pre-dominantly splinter injuries and 53 patients had dominantly gunshot wound injuries. In priority I, the trauma index was 15.55 +/- 5.74. Six patients having trauma index 20 or above could not even be resuscitated. Seventyfive percent of staff reported to the hospital within 15 minutes. Only 30% of reserve medical store was consumed. Total management cost to the hospital was Rs. 362,1856/- [British Pounds approx 32,052/-.] calculated by the hospital rates for treatment of non-entitled patients. Death rate in hospital survivors was 4%. Mass casualty management in a terrorist act requires prompt hospital response, appropriate triage, efficient surgical approach, and dedicated postoperative care. A good response can help to decrease mortality rate in salvageable injuries

Planned external fixation to locked intramedullary nailing conversion for open fractures of shaft of femur and tibia

To determine the outcome of initial external fixation and then conversion to intramedullary nailing in patients having open fracture of shaft of femur or tibia. Design: Descriptive study. Place and Duration of Study: Combined Military Hospital [CMH], Quetta, from July 2002 to July 2004. Subjects and Out of 59 patients with fractures of shaft of tibia and femur, 16 were selected for the study who had open fractures in Gustilio type I, II and III. They were initially managed with external fixators and later on converted to planned locked intramedullary nailing. Interlocking nailing was done on routine operation list in the third week after Ex Fix [external fixator] was removed. Record of patients was kept, and was statistically analyzed on SPSS. Out of the16 patients, 12 had fractures of femur and 4 had fractures of tibia. Male to female ratio was 7:1. Mean duration of external fixation was 6.22 weeks. Six patients underwent closed interlocking nailing and 10 patients with open method. Fifteen fractures [94%] united within 6 months, and one fracture had delayed union. Two patients had superficial wound infection and one patient had deep infection. Immediate external fixation followed by early closed interlocking nailing is a safe and effective treatment for open fractures of shaft of femur and tibia

Recurrent acute / chronic appendicitis an independent clinical entity

A multicenter descriptive study was carried out at CMH Abbottabad and PAF Hospital Sargodha. [Both hospitals are secondary referral centers] to determine whether chronic and recurrent appendicitis really exist in our population or not. Duration of study was from Feb 1996 to May 2001. All patients who underwent appendicectomy were included in the study and were divided into two groups, Group A with first episode of appendicitis and Group B with 2 or more episodes of abdominal pain. The patients were followed up for the relief of symptoms and this was assessed against the histological evidence of appendicitis. A total of 525 patients were included in the study out of which 67 had recurrent abdominal pain that was relieved after appendicectomy. The no of patients operated for recurrent abdominal pain fell with each passing year at both centers. However the annual number of patients undergoing appendicectomy remained same throughout the study period at both centers. It is concluded that in the evaluation of a patient with abdominal pain, a history of prior similar episodes of pain should never dissuade one from considering the diagnosis of recurrent acute appendicitis or chronic appendicitis

Management of inguinal hernias

This cohort comparative non-randomized study was done at CMH Pano Aqil from Jan 2000 to Jun 2001. Main objective was to evaluate technique related postoperative complications in inguinal hernia surgery. A total 100 patients with various types of inguinal hernia were admitted. They were divided in two groups with 50 patients in each group. Lichtenstien repair was done in group one and modified Shouldice repair in group two. However another current method i.e. laparoscopic herniorraphy was not included in this study due to non-availability of equipment and expertise for this technique. As longterm complications e.g. recurrence are claimed to be negligible in these methods so, only short term complications were considered in this study. Their incidence was found less in Liechtenstein technique than in modified Shouldice repair

Varied presentation of abdominal tuberculosis

To study the varied presentations of abdominal tuberculosis that have presented as acute abdomen. This is a case control analytic non-randomized study conducted at Surgical Unit 1, Department of Surgery, Combined Military Hospital [CMH], Rawalpindi Jun 2000 to Jun 2002. An analysis was done of the clinical presentation of patients who presented with acute abdomen and were diagnosed to be suffering from abdominal tuberculosis on histopathology report. A total of 33 patients were included in the study. History of intermittent low-grade fever was observed in 28/33 patients whereas there was no fever in 5 patients. 2/33 patients were on anti tuberculosus therapy for pulmonary tuberculosis. Perforation was diagnosed in 10/33 cases, intestinal obstruction in 9/33 cases, peritonitis in 6/33 cases, mass abdomen in 5/33 cases, inflammation of abdominal organs in 2/33 cases and 1/33 had a diagnostic explorative laparotomy as no diagnosis could be reached preoperatively. Abdominal tuberculosis is one of the most important surgical problems of Pakistan. This disease has varied presentation and so should be considered in the differential diagnosis of all the acute abdominal conditions