Sleeve gastrectomy

The aim of our work is to present Experience of Sleeve Gastrectomy at Centre of Bariatric Surgery of Dow University of Health Sciences. All patients were assessed multidisciplinary team before operation. Indications for LSG were BMI 35kg/m[2] with comorbidites and BMI >40kg/m[2] without comorbidities. Standard surgical technique adapted. Gastric division by a cutting stapler. The whole staple line was observed for bleeding and tested for leak. Total 10 patients were studied of which were four males and six females, Median age of was 40 years. Pre-operative median BMI was 52.2kg/m[2] [range from 46 to 61kg/ m[2]]. Median post-operative BMI of 9 months was 34.33kg/m[2] [range from 28 to 40]. Out of 10 patients, observed complications of bleeding was seen in one case and wound infection occurred in 2 cases. Considerable weight loss observed in LSG

Laparoscopic cholecystectomy; per-operative factors responsible for difficulty in performance and conversion

Objective: The objective of this study is to determine the per-operative factors responsible for difficulty in performing laparoscopic cholecystectomy and lead to conversion

Study Design: Prospective analysis study

Place and Duration of study: This study was carried out in General Surgery Department of Dow University Hospital Ojha Campus and Civil Hospital Karachi, from Jan 2011 to July 2012

Methodology: This study consisted of one hundred and forty six patients with gallstone disease. All patients had full clinical examination and right hypochondrium was especially examined for assessment of murphy's sign, palpable mass and visceromegaly. Base line and specific investigations were done in all patients especially ultrasound of abdomen as diagnostic modality and for assessment of gallstone disease. Inclusion criteria was that all patients diagnosed as case of gallstone disease. LC procedure was not attempted in patients with history of abdominal surgery, pregnant ladies due to risk of foetal loss, carcinoma of gall bladder acute pancreatitis, obstructive jaundice and unfit patients for general anesthesia

Results: Out of 146 patients included in this study 133 were female [91%] and 13 male [9%]; with female to male ratio of 10.2:1. The mean age was 39.21+6.20 years. Per Operative findings were adhesions in calot's triangle 24[16.43%] cases, severe and tight adhesions around gallbladder and calot's triangle 21[14.38%] cases, obscured anatomy in calot's triangle 17[11.64%] cases, intrahepatic gallbladder 11[7.53%] cases, adhesions around gallbladder 26[17.80%] cases, empyema 13[8.90%] cases, mucocele 9[6.16%] and anatomical variation 14[9.58%] cases. We observed out of 21 patients who had Severe and tight adhesions around gallbladder and calot's triangle, lead to difficulty in performing laparoscopic cholecystectomy in 11[52.38%] cases followed by 17 cases of obscured anatomy in calot's triangle and 14 cases anatomical variation also lead to performing difficult laparoscopic cholecystectomy in 6[35.29%] and 5[35.71%] cases respectively. Four [2.73%] cases out of 146 had to be converted to the open cholecystectomy procedure

Conclusions: We conclude our study revealed that various peroperative factors which make the difficult laparoscopic procedure and lead to open cholecystectomy are severe adhesions in calot's triangle, severe and tight adhesions around gallbladder and obscured anatomy in calot's triangle

Utilization of operation theatre; a newly developed tertiary care teaching hospital

To find out the number and variety of different surgeries performed at the operation theatre of the Dow University Hospital. From January 2011 to December 2011, hospital operation theatre record was reviewed. Main outcome measures were age, gender, medical record [MR] number, name of operations with their indications, specialty and type of anesthesia used during the procedure, type of surgery. Monthly trend of surgeries were also evaluated. The total numbers of operations performed during first year of operation theatre working were 539 cases. Number of emergency surgeries done was 42 [7.79%] and elective were 497 [92.2%].Surgeries performed by General Surgery, Gynecology and Plastic surgery department were 319 [59.18%], 61 [11.3%], 54 [10.0%]. MR Number was not present in record register in 306 [56.7%] cases, indication for surgery was not written in 274 [50.8%] cases and name of surgery was missing in 18 [3.3%] cases. The most common case performed were different types of biopsies while other common cases performed in the year 2011 were incision and drainage, cholecystectomies and hernia repair. The record maintained was overall satisfactory however needs further improvement. Computerization of records with training of staff about its proper maintenance can improve its quality with international standards

Morphology and incidence of atherosclerotic lesions in subclavian arteries - a human autopsy study

To assess different morphological categories of atherosclerotic lesions and their incidence in relation to age and sex in our population. Prospective descriptive observational study. This study was conducted at Mortuary of King Edward Medical University Lahore and Department of Pathology Allama Iqbal Medical College Lahore and completed in one and a half year from. A total of 30 human autopsies were carried out at random. The age range was between 8 and 85 years. Right and Left subclavian arteries were taken out from dead bodies. They were opened lengthwise. One to four areas of tissue were taken from each artery in all cases. Section were prepared from paraffin blocks. They were stain with Haematoxylin and Eosin stain. Special stains were also performed to differentiate all the components of atherosclerotic lesions. The fibrolipid plaques were seen in l3 cases in the right subclavian artery and I3 cases in left subclavian artery. The complicated lesions were seen in 8 cases in the right subclavian artery and 9 cases in the left subclavian artery. 6 of these 8 cases showed ulceration in the right subclavian artery and 2 showed intimal vascularization and haemorrhage alongwith thrombus formation. In the left subclavian artery the ulceration was seen in 7 cases and intimal vascularization and haemorrhage in 2 cases along with thrombus formation. The calcified lesions were present in 7 cases in the right subclavian artery and 8 cases in the left subclavian artery. The morphological changes in media and elastics were seen in 7 cases in right subclavian artery and 8 cases in left subclavian artery. In this study different atherosclerotic lesions are categorized and their relation to age and sex is appreciated in our population. This study is although is preliminary but gives basic and useful data about the incidence of ischemic changes in upper limbs due to raised atherosclerotic lesions in subclavian arteries

Bile duct injury: management and outcome

To describe the management and outcome of bile duct injury. Descriptive case series. Surgical Unit II Civil Hospital, Dow University of Health Sciences Karachi, from July 2008 to June 2011. Patients who sustained bile duct injury were included in this study. Mode of admission, type of injury, procedures for reconstruction and outcome were recorded. There were sixteen patients with bile duct injury. Twelve [75%] patients were females and four [25%] males. Mean age was 40 year. In six [37.5%] patients injury occurred in our unit during surgery while four [25%] patients were referred from other tertiary care hospitals. Three [18.75%] patients were sent from district hospitals, one [6.25%] patient from taluka hospital and two [12.5%] from other private hospitals. Nine [56.25%] patients sustained injury during open cholecystectomy and in five [31.25%] during laparoscopic cholecystectomy. Ten patients [62.5%] underwent end to end repair over T-Tube. Two patients [12.5%] underwent hepaticojejunostomy. Morbidity noted in 37.5% [n=6] and mortality was 18.75% [n=3]. Bile duct injury occurred more with open cholecystectomy and end to end repair over T tube was most frequently used procedure. Mortality remained significant

Atypical presentation of appendicitis: diagnosis and management

To identify the patients with atypical features of acute appendicitis and to describe their management so as to avoid unnecessary delay in surgery. Descriptive study. Surgical Unit V, Civil Hospital and two private hospitals at Karachi, from July 2005 to June 2007. All patients who presented with right sided lower abdominal pain in whom provisional diagnosis of acute appendicitis made, were admitted for observation and further workup. The presenting symptoms, physical findings and total white count were entered on a proforma. Ultrasound, CT scan and laparoscopy were performed in atypical cases where available. A total of 318 patients were managed of whom 217 presented with classical features of appendicitis and 101 patients had atypical presentation. Diagnostic accuracy of ultrasound was 85%, CT scan 91% and laparoscopy 100%. One hundred and eighty patients had appendectomy in classical group and 80 patients in atypical group. Laparoscopic appendectomy was done in 26 patients. Nine patients required laparotomy. Ultrasound, CT scan and laparoscopy play an important role in diagnosis and management of atypical cases of appendicitis

Cutaneous manifestations of type-II diabetes mellitus

Objective: To study the cutaneous manifestations in type-II diabetic patients in our tertiary care setup. Setting: This study was carried out in Medicine Department, Liaquat University Hospital Jamshoro/ Hyderabad, Sindh - Pakistan; from January to December 2005

Methods: Diabetic patients who had skin problems were selected for the study with convenience sampling technique. Then questionnaires were filled for collection of the data

Results: In this study, 72% diabetics had skin infections, whereas 28% patients had non infectious lesions. Fungal infections were the most commonest [50%], followed by 14.4% bacterial infections and viral infections [7.77%]. Among fungal infections, Candida albicans was commonest [22.2%]. The non infectious lesions were skin tags [8.8%], xanthomas [6.6%], and pruiritis [6.6%]

Leakage of colorectal anastomosis: experience at Civil Hospital, Karachi

To determine the frequency and outcome of leakage of Colorectal anastomosis. A descriptive study from Jan. 1997 to Dec. 2003. Surgical Unit I and V of Civil Hospital, Karachi. One hundred and sixty four patients admitted with colorectal cancer, colon or rectal injury and those admitted for restorative procedures were included in the study. Detailed history, physical examination and relevant investigation were carried out. Patients were operated by a senior surgeon. Patients were closely monitored after surgery for clinical signs of anastomotic leakage. CT scan was performed on the 10th postoperative day to ascertain the integrity of the anastomosis. Colonic anastomosis was done in 118 cases with an anastomotic leak of 3.4%, while rectal anastomosis was done in 28 patients with an anastomotic leak of 17.8% and a mortality of 10.7%. In most patients the average hospital stay after operation was 14 days. The overall anastomotic leak was 6.09% and mortality 2.4%. Colorectal anastomotic leakage is a serious complication. A high index of suspicion is required. Early diagnosis and prompt treatment are crucial in obtaining optimal results

Breast carcinoma in Karachi. Clinical and pathological features

To evaluate the clinical presentation and morphological features of carcinoma Breast. A retrospective analysis of 50 patients that presented with Ca Breast over a period of three years in the surgical department of Lyari General Hospital and Civil Hospital Karachi. Most of the patients were in the 5th and 6th decade of life. The mean age at diagnosis was 48 years. The most common presentation was lump in the breast, out of which 12 were in left breast and 38 in the right breast. Location of lump indescending order; 18 in upper outer quadrant, 8 in outer lower quadrant, 5 in areolar reglon 3 in inner upper quadrant, 4 in inner lower quadrant, 10 patients presented with concomitant axillary lymphadenopathy, 2 with skin infiltration and distant metastatis. FNAC and Mammography correlated with H/P in 93% of cases. The most common tumor was infiltrating ductal carcinoma 81%. Tumor size was > 2 cm in 75% of cases. The number of cases with> 3 lymph node metastasis was significantly higher 70% in tumors of >2cm size. In Pakistani females breast carcinoma occurs at a younger age group. Due to unawareness, they are of large size at the time of presentation and show more frequent lymph node metastasis. Infiltrating ductal Ca is the most common type of tumor with predominance of high grade lesion

Cryptorchidism in adults

To evaluate the causes of late presentation in our population Cases presenting with cryptorchidism above the age of 14 years from January 2000 to December 2004, that got operated at surgical unit V and Lyari General Hospital were studied. Twenty six patients operated in the above mentioned institutes were included in the study. All male patients with of age 14 years or above with empty scrotum admitted in surgical wards through All patients with retractile testes were excluded from the study. Patients were admitted after proper diagnosis and clinical examination i.e either swelling or empty scrotum. In impalpable testes apart from base line investigation i.e U/S abdomen was also done. In case of bilateral undescended testes hormonal assay of HCG, FSH and LH were also carried out. 16 patients[57%] of the patients didn't present due to ignorance. 8 patients[29%] had consulted a rural practioners or quack; and were not guided further, other 4 patients[14%] did not present due to shyness. Three patients with bilateral cryptorchidism had infertility. This present study revealed that many treating rural practioners, quacks and paramedics were equally responsible for the late presentation of the patients. There is a need for thorough physical examination following birth by attending obstetrician, pediatrician and other practicing physicians. An advice for early corrective surgery will go a long way in reducing the complications due to late presentation

Postoperative complications of inguinal hernia repair

To determine the incidence and outcome of inguinal hernia repair complications. A descriptive study Surgical unit I and V of Civil Hospital Karachi; January 1999 to December 2004. Five hundred and forty patients admitted with inguinal hernia were included in the study. Detailed history, physical examination and investigation were carried out. Patients were operated on elective operation list. Patients were randomly assigned to undergo Bassini's Repair [Group A] or Lichtenstein tension free mesh repair [Group B]. Patients were monitored after surgery for clinical signs of complications and their outcome were recorded. Patients were seen every 3 months for 2 years and then every year. Wound seroma developed in 7.1% patients in group A and 8.4% patients in group B; 3.57% patients in group A and 3.1% patients in group B developed haematoma. Abscess formation was noticed in 2.1% patients in group A and 1.9% patients in group B Urinary retention developed in 3.57% patients in group A and 4.6% patients in group B. Numbness or pain in the groin was complained by 7.1% patients in group A and 10% patients in group B .Recurrence developed in Twenty [7.1%] patients in group A and 2[0.8%] patients in group B. In most patients the average hospital stay was 4 days. Postoperative complication, morbidity and mortality can be reduced by monitored training of residents during early learning period and availability of senior surgeon help in difficulties

Application of modified Alvardo score in the diagnosis of acute appendicitis in our setup

The study was undertaken to assess the accuracy of the Modified Alvarado score in predicting appendicitis for patients with right iliac fossa pain admitted in our hospital. This is a prospective study of patients Admitted with suspected appendicitis. This study was conducted at Surgical Unit V Civil Hospital Karachi over one year period front Jan. 2003 to Jan 2004. For every patient suspected of appendicitis the Modified Alvarado score was computed on admission, as laboratory facility for shift of Neutrophils to left was not available. The Modified Alvarado score was recorded on the admission sheet and did not effect the management of the patients. The patients discharged without surgery were reviewed in the out patients clinic to ascertain that they did not need surgery. Sixty two patients underwent appendicectomy. Out of these, 30 patients [48.38%] has a Alvarado score 1-4, 10 patients [16.12%] had a Alvarado score 5-6, 18 patients [29.03%] had a Alvarado score 7-8 and only 2. Patients [3.22%] had a maximum Alvarado score 9, where appendix was found perforated and gangrenous on operative findings. The Alvarado score was not found to be a useful complementary method in the diagnosis of suspected case of acute appendicitis patients in Department of Surgery CHK

Posterior urethral polyp presenting with hematuria in a male child

Urethral polyp is a rare cause of hematuria and urinary obstruction in children. We report a case of 3 years old child who presented with episodes of hematuria and difficulty in micturition. Diagnosis of urethral polyp was made on voiding cystourethrogram. Resection was performed through suprapubic transvesical approach. Recovery was smooth and child is asymptomatic at 5 months follow-up

Intraoperative ultrasonography at open cholecystectomy to assess common bile duct for stones

During the period of one year i.e. from January, 1996 to December, 1996, Intraoperative Ultrasonography, using a 7.5 MHz linear transducer, was carried out in a series of 46 patients undergoing open cholecystectomy at Surgical Unit 1 of Civil Hospital, Karachi, to assess common bile duct for stones. On the basis of scanning a correct diagnosis of choledocholithiasis was made in 85.7% cases while common bile duct stones were excluded correctly in 100% of the cases. Mean extra-time required was 17 minutes. There was no procedure-related increase in morbidity and overall mortality was 0%. Operative ultrasonography Is a safe and reliable screening method for common bile duct stones

Antibiotic prophylaxis in surgery

During a period of one year i.e from March 1997 to February 1998, 182 patients undergoing clean surgical procedures were studied in Surgical unit II and IV of Civil Hospital, Karachi. Patients were divided randomly into Group A which received prophylactic antibiotics and Group B which received none. Group A patients received one gram of cephradine and 80 mg of gentamicin intravenously at the time of induction of anaesthesia and two more doses at 8 hours interval. Postoperative wound infection rate in Group A was 2.2% and in Group B-7.6%. In majority of cases wound infection became obvious on 8th postoperative day. Culture and sensitivity of pus from infected wounds revealed Staphylococcus in 61%, E. coli in 19%, Pseudomonas in 12%, and Klebsiella, Streptococcus and Proteus in 8% each. In 2.2% cases of Group A, which developed infection, the causative organisms were hospital acquired strains of Staphylococcus and Pseudomonas resistant to cephradine and gentamicin. The incidence of postoperative drain site infection, respiratory tract infection and urinary tract infection was also less in Group A

Firearm injuries: a three years experience

During the last 3 years i.e. from Jan. 1994 to Dec. 1996, 1063 cases of penetrating gun-shot injuries were brought to the Emergency Department of Civil Hospital, Karachi. Of these 15 died during resuscitation, 530 patients were given treatment in the Emergency Department and discharged while 518 patients were admitted. Amongst these 78 cases were treated in Surgical Unit II and include 66.6% with abdominal injury, 10.2% with thoracic, 8.9% with thoraco-abdominal, 6.4% with head and face, and 7.6%, with limb injuries. Laparotomy was performed in 75.6%, thoracic intubation in 19.2%, wound exploration in 14.1% and tracheostomy in 1.2% cases. Average hospital stay was 8 days. Complications occurred in 7.8% cases and the mortality was 3.8%