Roux-en Y duodenojejunostomy for larger duodenal defects

Objective: To find the outcome of lateral duodenojejunostomy for larger duodenal defects due to different surgical conditions

Study design: Case series

Methodology: The clinical records were traced from the unit and hospital clinical record room. The data was collected and analyzed for the outcome of the procedure

Results: A total of six patients were managed with the surgical technique. All patients were allowed oral sips on 3[rd] postoperative day. One patient out of six needed ICU care of 42 days. Patient stay in ICU was of 42 days. Postoperative complications including anastomosis leak occurred in one patient. Nausea and vomiting was reported in two and wound infection in two patients. Mean hospital stay of the patients was 16.67 days

Conclusion: Roux-en Y duodenojejunostomy is a safe technique for the reconstruction of larger duodenal defects involving >50% [2/3[rd]] of the duodenal circumference

Post laproscopic cholecystectomy drain placement: a controversial issue

Objectives: To assess the benefits and harms of routine abdominal drainage after Laparoscopic Cholecystectomy

Study design: A prospective observational study

Place and duration: Department of surgery at Khyber Teaching Hospital, Peshawar from 1[st] Feb. 2009 to 30[th] April 2012

Methodology: The data of 300 patients who underwent laparoscopic cholecystectomy was analyzed. The patients were divided in two groups each of 150 patients. Group -A, included patients without drain and Group -B, included patients with drain. Operative and Post operative results of both groups were compared with regard to signs, symptoms, early and late complications and hospital stay using univariate analysis

Results: Among total of 300 patients the male; female ratio was 1:3.The post op nausea [32%, n=48] and vomiting [18.6%, n=28] was less in patients without drain [group A]. Whereas abdominal pain [22.6%, n=34] and shoulder tip pain [15.3% n=23] was less in patients with drainage tube [group B]. Port site wound infection [11.3%, n=17] was more in group B. The hospital stay was less in the non drain group

Conclusion: Prophylactic drainage after a borderline case of laparoscopic cholecystectomy has found to be of no benefit rather it increases hospital stay and renders the patient prone to infections but it still remains a matter of individual preference

Diagnostic laparoscopy in the management of post appendectomy pain right iliac fossa

Objective: To determine the cause for pain right iliac fossa [RIF] after Appendectomy by Diagnostic laparoscopy in patients with normal investigations

Study Design: A Prospective Observational study

Place and Duration: Surgical A ward, Khyber Teaching Hospital Peshawar, from April 2009 to May 2011

Methodology: All those patient who continued to have pain in the RIF, more than 6 weeks after appendectomy,or more than 3 opd visits and normal investigations of genitourinary system and abdominopelvic ultrasound were included. Patients with symptoms of genitourinary system and pelvic inflammatory disease [PID] were excluded

Results: Fifty three patients were included in the study. Age range was from 15-42 years with 23 [43. 39%] patients aged less than 20 years, 15 [28.30%] 21-30 years,11 [20.75%] 31-40 years and 4 [7.54%] were above 40 years. Males were 19 [35.84%] and 34 [64.15%] were females, In 41 [77.35%] cases appendectomy had been done in emergency as they presented as acute appendicitis and 12 [22.64 %] were elective cases. Appendectomy was performed by open method in 45 cases [84.90%] and laparoscopically in 8 [15.09%] patients Diagnostic Laparoscopy was done in all patients and the findings included, adhesions in 21 cases [39.62%] tuberculosis in 9 cases [16.98%], PID in 7 cases [13.20%], ovarian cyst in 5 cases [9.43%] and a long appendicular stump in 2 [3.77%] and 1 [1.88%] terminal ileitis, while no cause was found in 8 [15.09%] patients

Conclusions: Post appendectomy pain RIF can be due to postoperative adhesions, pelvic inflammatory disease, ovarian cysts and abdominal tuberculosis. Diagnostic laparoscopy should be done to find out the cause in patients with inconclusive investigations

Laparoscopic treatment of hepatic hydatid cyst

To determine the outcome of laparoscopic management of hepatic hydatid disease in terms of complications. Case series. Surgical C Unit, Khyber Teaching Hospital, Peshawar, from February 2007 to March 2010. All patients with 3 or less hepatic hydatid cysts who underwent laparoscopic treatment for hepatic hydatid cyst disease were included during the study period. Laparoscopic aspiration, unroofing and evacuation of the hepatic hydatid cysts was done. Clinicopathologic features, operative time, conversion to laparotomy, morbidity, mortality and recurrence rates were analysed. Forty three patients had laparoscopic treatment for hepatic hydatid cysts. Females were 27 [62.79%] and males were 16 [37.20%]. Mean age of patients was 38.6 +/- 14.03 years [range 15-64 years]. Pain was the commonest presentation occurring in 34 [79.06%] and mass in 9 [20.93%]. Hepatic hydatid cysts were successfully treated laparoscopically in 40 patients. Open surgery conversion was needed in 3 [6.97%] due to inadequate access. The mean duration of surgery was 46.27 +/- 13.84 minutes. Complications included port-site infection in 3 [6.97%], bile leak in 4 [9.30%] and recurrence in 2 [4.65%] cases; there was no mortality in the series. Laparoscopic hepatic hydatid cyst surgery was a safe and effective method in selected patients

Pneumatosis intestinalis successfully treated with oxygen inhalation

Pneumatosis intestinalis is a rare disease with variable presentation. It is characterized by presence by gas in the gut wall. It may be primary [idiopathic] or secondary to other diseases. in the absence of signs and symptoms of perforation and peritonitis, pneumatosis intestinalis can be managed conservatively with inhaled oxygen and close monitoring of the patient. We present a case of 62 years old lady with this condition who was successfully treated with oxygen therapy

Rate and risk factors for surgical site infection at a tertiary care facility in Peshawar, Pakistan

Surgical site infections [SSI] are among the most common complications in surgical patients and have serious consequences for outcomes and costs. This study aimed to determine the rates and risk factors affecting surgical site infections and their incidence at Surgical 'C' Unit, Khyber Teaching Hospital, Peshawar, Pakistan. The study was conducted to compare with rates obtained by large international multi-centre studies. A review of all general surgical interventions involving an incision, excluding anal procedures, performed between December 2008 and March 2009 [n=269] was undertaken. Various clinical parameters were recorded. Infection rates were calculated. Data were analysed using the Fisher's exact test. The overall SSI rate was 9.294%, 4.88% in clean cases [C], 8.39% in clean contaminated cases [CC], and 20.45% in contaminated or dirty cases [D]. There were significantly higher surgical site infection rates among patients with combined American Society of Anaesthesiologists scores II and III than those with ASA score I in clean contaminated [p=0.0007], and dirty cases [p=0.0212]. There were also significantly higher surgical site infection rates among patients with combined Co-morbidity Scale score 1-6 than those with no comorbid factors in clean contaminated [p=0.0002]. Surgical site infection rate was highest in gastrointestinal system surgeries. The Surgical site infections can be minimised by adopting international protocols for surveillance

Experience of laparoscopic appendecectomies versus open appendecectomies

To compare the outcome of laparoscopic and open appendecectomies in terms of operative time and post-operative morbidity. This prospective study was done from March, 2008 to March, 2009, at Surgical "C" Unit of Khyber Teaching Hospital, Peshawar. All consecutive appendectomies [open and laparoscopic] performed over this time were included. Demographic details, operative time, conversion, infective post-operative complications and delay in discharge were recorded. The patients were divided into two groups, laparoscopic appendectomies [LA] and open appendectomies [OA]. A total of 165 appendectomies were performed, 72 in the LA group and 93 in OA group. Eighteen appendectomies were perforated at the time of operation. The patients' ages ranged from 12-65 years [median 24 years]. Eighty were males and eighty five were females. Operative time in LA group was longer with mean duration of 45 minutes [range 35-75 minutes] compared with 35 minutes [range 30-55 minutes] in OA group. A glove finger was used as extraction bag in 59 [83%] in LA group. LA patients' wound infection was recorded in12 patients, two out of 72 in LA and 10 out of 93 in OA group. The site of infection was the port of specimen extraction in LA group. Intra-abdominal abscesses complication was observed in one case in the OA group. LA group had shorter hospital stay [mean 1.5 days] than [OA] [mean 3.5 days], and early return to normal activity, 8-15 [mean 10.5] days in LA and15-25 [mean18.5] days in OA. Laparoscopic Appendectomy [LA] is safe and has major benefits like less post-operative pain, decreased wound infection, early hospital discharge and earlier return to work than Open Appendectomy [OA]. LA is recommended in all patients with acute appendicitis if laparoscopy is not contraindicated

Aggressive angiomyxoma of scrotum presenting as an Inguinal Hernia

Aggressive Angiomyxoma [AAM] is a rare mesenchymal tumor with a locally aggressive course. The most common location is in the pelviperineal region and occurs mostly in females of childbearing age. In males, it is extremely rare and thus is apt to be mistakenly diagnosed as an inguinal hernia or hydrocele. We report a case of 45 year old man who had right sided scrotal swelling for about four years. It was diagnosed as an inguinal hernia clinically. On further investigations, it was found to be a soft tissue tumor of the scrotum. The patient underwent scrotal exploration. At surgery, a huge lobulated gelatinous mass surrounding the right testicle was found. The mass was excised including the testicle and sent for histopathological analysis. Histologic examination of the excised mass revealed a nonencapsulated lesion composed of sparse spindle-shaped cells and a myxoid stroma with a prominent vascular component. The cells showed focal and weak positivity for desmin. The findings were thus consistent with aggressive angiomyxoma of the scrotum. The margins of the specimen were clear. The patient we report has so far done well with no evidence of recurrence

Laparoscopic cholecystectomy: an audit of cases done at a tertiary care hospital

The study aims to describe the complications and hospital stay associated with laparoscopic cholecystectomy. During the period from 01 August 2007 to 31 July 2009, all patients who were operated with laparoscopic cholecystectomy were included. The age, gender and other related data including the outcome and complications in 245 laparoscopic cholecystectomy cases were recorded. The findings documented in numbers and percentages were compared and discussed with those of other studies. 194[78.79%] were females and 51[21.21%] were males. Ages of female patients ranged from 25-51 years and of males from 28-54 years. Most of the patients were discharged on the 1[st] post-operative day. There were 13 cases converted to open surgery [5.3%]. Laparoscopic cholecystectomy was successfully completed in the remaining 232 patients with an average operating time of 93.74 +/- 21.7. Twenty four patients experienced morbidity. These included infections [n=10], bleeding [n=4], biliary peritonitis [n=5], visceral injury [n=1], pneumonia [n=2] and partial small bowel tear [n=2]. No bile duct injury or mortality was seen. Laparoscopic cholecystectomy is being performed in this setting with acceptable morbidity, mortality and conversion rates. A concerted effort to increase the performance of laparoscopic cholecystectomy may increase cost effectiveness in this setting

Influence of ASA score and charlson comorbidity index on the surgical site infection rates

To compare the frequencies of surgical site infections [SSI] in ASA class-I [American Society of Anaesthesiologists-I] with ASA class II-III and CCI-0 [Charlson Co-morbidity Index-0] with CCI 1-6 in clean [C] and clean contaminated [CC] surgeries. Analytical study. This study was conducted in a General Surgical Unit of Khyber Teaching Hospital, Peshawar, from December 2008 to April 2009. A total of 310 clean and clean contaminated general surgical interventions with pre-operative ASA score of I-III, were included in the study, excluding anal and cystoscopic procedures. On the basis of past medical record, patients were grouped into ASA-I [patients without any co-morbidity] and ASA II-III [patients with co-morbidities] on the basis of their ASA score pre-operatively. In the same way patients were divided into CCI-0 [patients without co-morbidities] and CC 1-6 [patients with co-morbidities] according to CCI score. All the patients were operated in the same environment by the same set of surgeons. Postoperatively the surgical wounds were observed for SSI by using ASEPSIS daily scoring system for one month prospectively. SSI rates in ASA-I was compared with SSI rates in ASA II-III. Similar comparison of SSI rates was performed in CCI-0 and CCI 1-6. Data was tested by using the Fisher's exact test with confidence interval of 95%. The overall SSI rate was 6.1% [n=19] with 4.23% [n=5] in clean cases [C] and 7.29% [n=14] in clean contaminated cases [CC]. There were significantly higher surgical site infection rates among patients in ASA II-III than those with ASA-I in clean contaminated surgeries [p=0.003]. There were also significantly higher surgical site infection rates among patients with CCI score 1-6 than those with CCI-0 in clean [p=0.024] and clean contaminated [p=0.002]. American Society of Anaesthesiologists [ASA] score and Charlson comorbidity index [CCI] has strong influence on SSI rates in clean and clean contaminated cases. Patients' with co-morbidities undergoing clean and clean contaminated general surgical procedures have greater SSI rates than those without any co-morbidity

Inferior lumbar hernia of petit in a patient with neurofibromatosis type-1

Lumbar hernias are rare lesions that account for less than 1.5% of total hernia incidence. Only 250-300 cases have been reported in literature. Diagnosis may be difficult because they are either asymptomatic or may present with vague complaints. Differential diagnosis includes a lipoma, a fibroma, a retroperitoneal or intra-cavitary tumor, hematoma or a chronic abscess. They may occur in association with defects of the musculoskeletal system including some syndromes. Lumbar hernia in patients with neurofibromatosis has been reported in a very few number of cases. We report a case of 40 year old female with type 1 neurofibromatosis who presented with left lumbar hernia of Petit

Outcome of mesh repair for incisional hernia

To determine the results of incisional hernia repair with prosthetic mesh. It is a retrospective descriptive study, conducted at Surgical "D" ward Khyber Teaching Hospital, Peshawar from January, 2002 to October, 2006. A total of 121 patients were included in this study. Those patients with incisional hernia, who were repaired with mesh and completed the minimum of 9 months of follow up, were included. Patients who were clinically diagnosed to have incisional hernia were admitted and after necessary preparation, were operated and defect in the abdominal wall was closed by a synthetic mesh. During the early post operative and follow up period, patients were looked for complications like seroma, infection, chronic discharging sinus formation and recurrence. Out of 121 patients, 73 were female and 48 were male. In most of the patients the incisional hernia resulted from emergency procedures. In 35 [28.9%] patients, there was post operative seroma formation, 17 [14%] patients had wound infection. one [0.8%] patient developed subcutaneous heamatoma due to unidentified bleeding which later on required evacuation under general anesthesia. Eight [6.6%] developed recurrence of hernia out of which some patients were treated by repeat Mesh repair. In 12 [9.9%] patients there was mild to moderate skin margin necrosis and in these cases debridement was a proof of successful treatment. Partial wound dehiscence was found in 3.3% of patients. Incisional hernia is more common in midline laparotomy wounds specially performed in emergency conditions and onlay mesh repair procedure has high acceptable outcomes

Epidemiology and outcome of burns at Khyber teaching hospital Peshawar

To determine the epidemiology, describe the clinical presentation, outcome and the factors responsible for fatal outcome of burn patients. A total of 240 patients admitted in Surgical D unit, Khyber Teaching Hospital, Peshawar from March 2004 to Feb 2005 with burn injuries were included. Patient characteristics including age, sex, type of burn, total body surface areas [TBSA] burned, any first aid received, treatment given in hospital and outcome were recorded. 52.2% of the 240 patients were females. 31.66% patients were below 10 years of age, while 21.25% and 27.08% were in the second and third decades. Majority had less than 20% TBSA burns [47.5%] and only 4.1% had more than 50% TBSA burns. Flame burns were the commonest [45%] followed by scalds 31.6% and electrical 10.83%. Scalds were common in children. 130 patients improved with daily washes, dressing and debridements, systemic and local antibiotics. Skingrafts needed in 30 patients, 36 were referred to plastic surgery unit and 16 with more than 40% TBSA burns were referred to specialized burn centres. Mortality was 19 with sepsis as the leading cause, multiple organ failure, and shock were other causes of mortality. Burns injury is a major public health concern and is associated with significantly high morbidity and mortality. Flame, scald and electrical burns are commonly a result of domestic and occupation accidents and are preventable. The effectiveness of initial resuscitation, infection control and adequate surgical treatment improves short and long term outcomes

Management of penile fracture

To document the clinical presentations, diagnostic methods and therapeutic approach for the patients presenting with penile fracture and out comes of the treatment. Prospective observational study Surgical 'C' and 'B' Ward of Khyber Teaching Hospital Peshawar, Pakistan, from January 2001 to December 2004. 17 patients presenting with fracture of the penis during this period were included in the study after approval from the Hospital Ethics' Committee. Age, marital status, activity leading to the injury, symptoms and signs, management and outcome were recorded on a proforma designed for the purpose. The common age group was 30-50 years with 13 [76.47%] patients in this group, 14 were married and 3 were students. Eleven [64.70%] cases of fractures occurred during sexual intercourse and 6 cases due to non-coital causes including masturbation and manipulation. Fifteen patients recalled a popping sound, immediate detumescence and deviation were present in all, penile swelling and hematoma in 15 while the tunical defect was easily felt in 2 patients. Diagnosis was made clinically and was confirmed on surgical exploration. Repair of tunical defect was done with vicryle 2/0. No urethral injury was encountered. Out come was excellent and all patients regained complete penile function at 3 months follow up. Mild penile curvature was seen in 5 patients but it did not interfere with erection or sexual activity. Penile fracture is an entity with typical clinical signs and no further investigations is usually needed. Management is surgical and immediate to avoid complications related to erectile dysfunction

Evaluation and management of diabetic foot according to Wagner's classification. A study of 100 cases

Wagner's classification is the most widely utilized grading system for lesions of the diabetic foot. The aim of the study was to evaluate and manage the different lesions of diabetic foot according to Wagner classification. This will help to describe the lesions we treat study and compare outcomes and also identify measures to decrease morbidity and mortality due to diabetic foot disease. The study was conducted in surgical 'c' unit of Khyber teaching hospital, Peshawar from July 2002 to June 2003. 100 patients with diabetic foot disease were included in the study. Detailed history, clinical findings and investigations were recorded. Lesions were graded according to Wagner classification and appropriate medical and surgical treatment carried out. Diabetic foot disease formed 1.04% of total admissions and 0.23% of OPD patients. 62 [62%] were males and 38 were females. Common age group was 40 ' 60 years, 6 patients had grade 0, 14 grade 1, 25 with grade 2, 30 with grade 4 and 4 with grade 5 lesions. 17 patients were managed conservatively with antibiotics alone, 33 had incision drainage and debridement while 48 needed amputation of different types. Staphylococcus aureus was the commonest organism isolated. Majority of the diabetic foot lesions were in grade 2 to 5. Lesser grade lesions responded well to conservative treatment with antibiotics and surgical debridement while those with higher grades needed amputations. Effective glycemic control, timely hospital admissions, approximate surgical / medical treatment along with patient education in foot care can decrease morbidity and mortality due to diabetic foot disease