Surgical site infection in open versus laparoscopic appendectomy

To compare the rate of surgical site infection [SSI] in patients undergoing open and laparoscopic appendectomy. Randomised controlled trial. Surgical "A" unit, Department of Surgery Khyber Teaching Hospital Peshawar, from March 2008 to February 2011. Patients with signs and symptoms suggestive of acute appendicitis were randomly allocated into two groups, A and B. Group A patients were subjected to open appendectomy [OA] and Group B to laparoscopic appendectomy [LA]. Patients demographics including age, gender and wound infection in terms of SSI were recorded on a proforma. Statistical analysis was performed using SPSS version 11 with proportions and mean +/- SD calculated for categorical and continuous variables, respectively. Probability = 0.05 was taken as significant. Two hundred and ninety two patients were analyzed [146 in group A and 146 in group B]. The mean age of patients in group A was 26.5 +/- 7.1 year and 25.2 +/- 6.5 year in group B. The male to female ratio in group A was 1.21:1 compared to 1.28:1 in group B. Surgical site infection was observed in 10 patients in group A and in 6 patients in group B. There was no significant difference between the two procedures regarding overall SSI rate [p= 0.304]. Laparoscopic appendectomy did not offer significant advantage over open appendicectomy in terms of SSI

Posterior reversible encephalopathy syndrome [PRES]

Posterior reversible encephalopathy syndrome [PRES] is a clinicoradiologic entity. Neurotoxicity with characteristic watershed CT/MR imaging features characterize this condition. This case report describes PRES syndrome in a 35-year-old patient admitted with eclampsia. On the first postpartum day; she developed severe headache, generalized tonic-clonic seizures and visual symptoms including transient visual loss. MRI scan of the brain showed symmetric areas of hyperintense signal on T2-weighted images in the occipital lobes bilaterally. Patient improved symptomatically. Repeat MRI of the brain 4 months after initial admission showed resolution of the previous abnormalities

Role of vasoactive drugs in surgical patients with septic shock

To assess the effect of vasoactive drugs in the management of sepctic shock in surgical patients. An experimental study. Department of General Surgery, Fauji Foundation Hospital Rawalpindi from 1[st] August 2006 to July 31[st] 2007. Ninety patients, both males and females were included in this study. All of these patients presented with acute abdomen and having signs and symptoms of generalized peritonitis. Patients were resuscitated and stabilized. Necessary routine investigations were carried out. Operation was done as early as possible. All patients had perforation of the gut with frank purulent fluid in the abdominal cavity or fecal peritonitis. Post operative management was carried out in intensive care unit. Daily progress with vitals were noted. These patients were visited by team of surgeons regularly till they died or discharged from the hospital. a total of ninety patients were included in this study who presented to the emergency department of Fauji Foundation Hospital. 55% of the patients were females. Patients were divided into two groups. Group A patients were prescribed vasoactive drugs immediately post operatively with antibiotics, analgesics and IV fluids. Group B the mortality was lower in group A where vasoactive drugs was given as a routine. It has been observed that the mortality was lower in group A where vasoactive drugs were prescribed as routine in immediate post operative period. Patients respond well to vasoactive drugs when their pathology is dealt within 12 hours of the onset of symptoms and the vitals are stable. Those patients who presented after 12 hours and the vitals are deranged then the vasoactive drugs do not show significant favorable response. It has been concluded in this study that there is more favorable outcome in septic shock patients with peritonitis if vasoactive drugs prescribed in early post operative period. Patients respond well to the vasoactive drugs in septic shock only when the patients report earlier and the primary pathology is dealt within 12 hours of onset of symptoms

Co relation of thyroid function test with the clinical presentation

To correlate the biochemical thyroid profile with the clinical presentation of the patient and decision about the time of surgery. It is an analytical cross sectional study. This study was carried out in the Department of Surgery, Fauji Foundation Hospital, Rawalpindi from 1[st] January 2010 to 31[st] March 2011 Thirty patients were included in this study after taking consent and approval from the ethical committee of the hospital. All of them were females. Age ranges between 13 to 45 with mean of 22.26 years. These patients presented with a swelling in front of neck with or without signs of hypothyroidism or hyperthyroidism. Trial of 6 to 12 months given to every patient to bring the TFT's within normal range. Only those patients were included in the study who took the medicines regularly. Mode of presentation was out door department of Fauji Foundation Hospital Rawalpindi. Patients were examined clinically by surgeon and anesthetist for risk assessment. Routine laboratory investigations including thyroid function test were requested and analyzed by operating surgeon. TFT's were co-related with the clinical signs and symptoms of the patients. Patients were divided into two groups. Group one includes clinically euthyroid patients with TFT's within normal range. Group two again include clinically euthyroid patients but abnormal TFT's. A total of 30 patients were included in this study. All of them were females and clinically euthyroid. Mode of presentation was the outdoor patient department of Fauji Foundation hospital. Presenting complaint was swelling in front of neck. 23 out of 30 patients [66.6%] had normal TFT's and clinically euthyroid. 7 out of 30 Patients [33.3%] shows variation between their thyroid profile and clinical presentation. Sub or near total thyroidectomy was done in all the patients. Recovery was un-eventful. Operation on thyroid gland is a major undertaking and decision should be taken by senior surgeon. Ideally TFT's should be within normal range as well as patient should be euthyroid clinically in order to avoid post operative complications. In those cases where patient is clinically euthyroid but biochemically status is either hyper or hypo thyroid, surgery can be done after clinical trial of at least six months with thyroxin or anti thyroid drugs with a view to bring the TFT's within normal range. We can conclude that although the biochemical profile of the patients with thyroid disease is important but in country like Pakistan where thyroid hormonal assay is not easily available the surgery can be done by careful clinical assessment, keeping in view compliance of patient, regularity of taking medicine, clinical status and side effects of medical treatment

Acute abdomen cases presenting at Fauji Foundation Hospital, Rawalpindi

To study the common causes of acute abdomen at Fauji Foundation Hospital, Rawalpindi, Study Design: Descriptive study. This Study was conducted at the Department of Surgery, Fauji Foundation Hospital, Rawalpindi from December 13, 2009 to February 22, 2011. A total of 840 patients who presented with acute abdominal pain and were admitted from the emergency department of Fauji Foundation Hospital, Rawalpindi from December, 2009 to February, 2011 were included in the study. The data of the 840 male and female patients was collected on the Patient Performa and then transferred to the data sheet IV of SPSS 10. The results were analyzed by calculating the frequencies of acute abdomen causes. The most frequent cause was non specific abdominal pain [38.7%] followed by acute cholecystitis [7.7%] and acute appendicitis [6.8%]. Total exploratory laparotomies done were 204 [24.3%] while 498 [59.3%] patients were managed conservatively with ultrasound abdomen and pain medication. Non specific pain was found to be the most common cause of acute abdomen followed by acute cholecystitis and acute appendicitis. The diagnostic accuracy can be enhanced especially in females of child bearing age by the use of ultrasonography and selective diagnostic laparoscopy

Bronchial atresia with partial anomalous pulmonary venous return

Bronchial atresia and anomalous superior pulmonary venous return into the left brachiocephalic vein are unusual anomalies. We present a young asymptomatic man in whom these two distinct anomalies were co-existingly found on routine medical examination. Patient was diagnosed as a case of congenital bronchial atresia with partial anomalous pulmonary venous return based on the evidence of special features on X-ray chest film, characteristic contrast enhanced 16-slice CT chest findings, lack of symptoms and no change on fallow-up X-ray chest films

Mucocele of the appendix: an unusual cause of disturbed bowel habits

There are many causes of disturbed bowel habits. In this rare case of mucocele of appendix, patient presented with disturbed bowel habits of increased frequency, urgency and semisolid stool. Ultrasound of abdomen revealed fusiform cyst just below umbilicus. Differential diagnoses included mesenteric cyst, duplication cyst and mucocele of appendix. Coronal and saggital reformats of CT abdomen confirmed its origin from ceacum. Its tip was in contact with sigmoid colon. Surgical resection was carried out and histopathology revealed mucinous cyst adenoma

Ovulation induction using laparqscopic ovarian drilling in women with polycystic ovarian syndrome i predictors of success

Anovulatory infertility is prmmt in 75% of patients with polycystic ovarian syndrome [PCOS], in addition to oligomenorrhoea and signs and symptoms of hyperandrogenism. This study was performed to find the role oflaparoseopic ovarian drilling [LOD] in correcting anovulation, menstrual irregularities and failure of conception. Possible role of the factors as the predictors of success was also studied. This prospective cohort study included 49 women who were diagnosed with PCOS and anovulatory infertility. These patients had already tried various ovulation induction drugs for conception, and underwent LOD between January i, 2006 untill December 31, 2008 in the Department of Gynaecology and Obstetrics, at the Tertiary Care Hospital, Lahore. The major outcome measures spontaneous ovulation, menstrual regularity after LOD and influence of various pre-operative characteristics on pregnancy rates. Among 49 patients 33 [67.3%] started to menstruate regularly and ovulated spontaneously in 59.2%, of them 23 [46.9%] conceived. Younger age [less than 25 years], duration and infertility less than 5 years and higher LH [more than 12 lU/lit] emerged as clinically significant factors to have impact on successful outcome. BMI > 27 Kg / m[2], cycle pattern, morphology of ovary, LH / FSH ratios did not manifest significant role. Women with PCOS respond favour ably to LOD

Situs inversus totalis with liver abscess

A case of multiple liver abscesses in a patient with situs inversus totalis is presented. Initially the patient was treated conservatively and remained symptom free for 4 days of hospital stay. On a follow up visit after 1 week the patient had high grade spiking fever and ultrasonography showed expanding multiple abscesses. The patient was restarted on intravenous antibiotics which resolved the disease

Estimation of foetal weight in third trimester using thigh measurements

Estimation of foetal weight is essential in daily obstetric practice particularly close to term. It guides clinicians to finalize important obstetrical decisions. Low birth weight and excessive foetal weight at delivery both are associated with an increased risk of neonatal complications during labour and the puerperium. The objectives of this cross sectional study were to estimate the foetal weight using only two thigh parameters and its comparison with birth weight. This study was conducted in Radiology Department PNS Shifa during 1st June, 2007 to 30 Nov, 2007. All pregnant females coming to Radiology Department for Ultrasound examinations in 3rd trimester were the Subjects of study. All infants were delivered with in 48 hour of ultrasound examination. 100 patients were included in this study. Thigh measurements were made by conventional two dimensional ultrasonography. The Isobe formula was compared with already established Aoki's formula and actual birth weight using paired sample t-test. Isobe's formula showed a significant correlation with the actual birth weight. In 90% of cases estimated foetal weight was within 10% of the actual birth weight The Isobe's formula was found to be convenient among all the established formulas for estimated foetal body weight. Measurement of head circumference was not necessary near term

Postsurgical pneumoperitoneum - comparison of abdominal ultrasound findings with plain radiography

To compare abdominal ultrasonography findings with plain radiography in the detection of postsurgical pneumoperitoneum. Cross-sectional, observational. Radiology Department, PNS Shifa Hospital, Karachi, from October, 2005 to April, 2006. Thirty patients of either gender who underwent laparotomies were included in the study. Patients were examined with plain radiography and abdominal ultrasound to detect postsurgical pneumoperitoneum within 24 hours of surgery. Upright chest radiography and left lateral decubitus views of abdomen were used to detect free air. McNemar test was applied to compute relationship between sonographic and radiographic findings. Among 30 patients, 22 [73.3%] were females and 8 [26.7%] were males [M: F = 1: 2.75]. Average age was 38.07 +/- 12.41 years. Out of 30 patients of postsurgical pneumoperitoneum, 27 [90%] were detected on ultrasonography while 3 [10%] were not detected. On plain X-rays, 4 patients were observed in group-I [no free air] and 26 in group-II [1-10 mm thickness]. Significant [p<0.001] relationship was observed between the two findings. Since both modalities can diagnose pneumoperitoneum reliably, ultrasonography can be a useful alternative imaging modality for the detection of pneumoperitoneum

Public awareness about hypertension: finding of a kidney day

To determine the frequency of hypertension, its associated life style factors and to explore the level of awareness about hypertension among adult populace attending the kidney day and to formulate the strategies to improve the awareness. A cross sectional study. One day health camp at Sharif Medical City Hospital Lahore 2008 on 13.03.2008. A total of one hundred participants were interviewed. The structured questionnaire was filled at the spot to obtain sociodemographic information after taking verbal informed consent. Height, weight, pulse, blood pressure were recorded. A total of one hundred participants were interviewed. Overall frequency of hypertension in the study population was twenty five percent [25%]. The prevalence of hypertension increased with increasing age and body mass index. Only thirty five percent [35%] could define hypertension and this awareness was significantly associated with educational level. Lack of physical activity, card playing and televisionization was observed in sixty percent of participants while thirty three percent were overweight. Fifty nine percent were using additional salt while seventy percent were having meals and snacks outside. High frequency of hypertension, obesity, lack of physical activity, unhealthy nutrition, and faulty dietary habits was observed in the study population. Emphasis on health education and use of electronic and print media is recommended to improve the public awareness about the risk factors and consequences of hypertension like stroke, heart attack, kidney failure etc

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

Comparative study of laparoscopic versus open cholecystectomy

To compare our results of Laparoscopic Cholecystectomy with Open Cholecystectomy regarding case selection, technical difficulties, duration of surgery, operative complications, post operative complications, post operative hospital stay, morbidity and mortality, patient's attitude after operation, operative expenses, total expenses and general impression in the society. Comparative study carried out from January 2002 to December 2005. Department of Surgery, surgical 'D' Ward, Khyber Teaching Hospital, Peshawar. This study was conducted on two hundreds patients, one hundred patients were submitted to Laparoscopic Cholecystectomy and the other hundred to traditional Open Cholecystectomy. These patients were admitted in our unit through Out-door department or in emergency as acute cholecystitis. All patients were thoroughly assessed and necessary investigations carried out. After consent all patients were operated on the next operation list. The patients were randomly assigned to either one of the procedures. There was no significant difference in the selection of patients in the two groups. No mortality was seen in both the groups, but complications were more in the open procedure than the laparoscopic one. There isles pain, less hospitalization, early mobilization and early return to work in the laparoscopic surgery. Laparoscopic Cholecystectomy is a superior procedure in comparison to Open Cholecystectomy as regards to the results. Hence it is recommended as the first choice operation

Experience with splenic trauma in Ayub Teaching Hospital, Abbottabad

This study was carried out to estimate the prevalence, severity and mode of splenic trauma and management technique from amongst the abdominal trauma cases admitted in Ayub Teaching Hospital The study was carried out at Surgery units of Ayub Teaching Hospital, Abbottabad, the only referral hospital for major trauma cases, from July 2001 to Dec. 2002. One hundred consecutive abdominal trauma patients admitted to all surgical units which were followed up through complete documentation were included in the study. Their injuries were classified, treatment strategies outlined and complications were documented. Out of the 100 patients presenting in emergency, 25% presented with blunt and 75% with penetrating trauma. 97 patients underwent laparotomy and 03 treated conservatively. Mean age was 27.26 [range 19-49] years. Out of these cases 19 patients had splenic injury, 6 [31.57%] with Type-I and II while 13 [68.42%] with Type-III and IV. 11[57.89%] of the splenic injuries were due to blunt abdominal trauma and 8 [42.10%] due to penetrating abdominal injuries. 14 [83.6%] of the patients with splenic injury underwent splenectomy and 5[26.3%] splenorrhaphy. The commonest cause of splenic injury was blunt abdominal trauma; Assessment of the severity of splenic injuries at the time of laparotomy resulted in splenic salvage procedures in some cases. Splenorraphy was associated with fewer complications

Cancelled elective general surgical operations in Ayub teaching hospital

Cancellation of operations in hospitals is a significant problem with far reaching consequences. This study was planned to evaluate reasons for cancellation of elective surgical operation on the day of surgery in Ayub Teaching Hospital, Abbottabad. From July 2006 to June 2007 the medical records of all the patients who had their operations cancelled on the day of surgery in all the three General Surgical units of Ayub Teaching Hospital, Abbottabad were audited prospectively. The number of operation cancelled and reasons for cancellations were documented. 3756 patients were scheduled for surgery during the study period. 2820[75%] patients were operated upon. 936 [25%] operations were cancelled out of which 338[36%] were cancelled due to shortage of time, 296[31.6%] were cancelled due to medical reasons, 152[16.2%] were cancelled due to shortage of beds while 55[5.8%] were cancelled due to shortage of anaesthetists. Three operation lists were lost completely. The Anaesthetist cancelled 43%, Surgeon 39% while 18% of operations were cancelled due organizational reasons. Cancellation of patients on operation lists occupy a substantial population [25%] of cases. Majority of cancellation were due to reasons other than patients medical conditions. Better management could have avoided most of these cancellations

Role of ultrasound in acute appendicitis

Misdiagnosis of acute appendicitis is a common and crucial problem in general surgery. Graded compression ultrasonography is one of the new diagnostic technique that is reported to have improve the diagnostic accuracy and clinical outcome. The aim of current study is to assess the role of this diagnostic modality in the management of acute appendicitis. This is a cohort observational study comparing the adverse outcome in two different groups of patients admitted with suspected acute appendicitis at two different hospitals in two different countries. The first group of 200 patients at Ayub Teaching Hospital Abbottabad, Pakistan, was managed without preoperative ultrasonography. In the second group of 200 patients admitted at Najran General Hospital Najran Saudi Arabia, graded compression abdominal ultrasonography was routinely performed preoperatively. Diagnostic accuracy of the protocol in each group was measured statistically and rates of negative appendicectomy and perforation were determined. Addition of routine ultrasonography in clinical assessment for acute appendicitis decreases the sensitivity but significantly increases the specificity of the protocol thereby reducing the false positive rate translating into decreased negative appendicectomy rate. Rate of negative appendicectomy was 22.5% in group one and 4.7% in group two.Perforation rate was 15.6% in group 1 and 15% in group two. Proper clinical assessment is the mainstay of diagnosis in acute appendicitis and addition of routine ultrasound by graded compression technique can improve the diagnostic accuracy and adverse outcome

Laparoscopic Cholecystectomy: An early experience at Ayub Teaching Hospital Abbottabad

Laparoscopic Cholecystectomy first introduced in 1987, is becoming more and more popular and now it has become gold standard in symptomatic gallstone disease. The current descriptive study is carried out in Department of General Surgery, Ayub Teaching hospital, Abbottabad to evaluate the result of Laparoscopic Cholecystectomy in symptomatic gallstones disease in our set up with special emphasis on complication rate, morbidity and mortality. The data of all patients who underwent Laparoscopic Cholecystectomy form January to December 2007 was entered in standardized proforma and analysed on SPSS 10. Out of 60 patients, 51 [85%] were female and 9 [15%] were males; the age range from 17 to 65 years mean age being 40.30 years, majority were in age 30-40 years group. Two [3.3%] patients had bile leak, 1 [1.3%] patient developed port site wound infection 1 [1.3%] patient developed collection in pouch of Morrison and in 1 [1.3%] patient stone were recovered from the epigastric port site wound. There was no bile duct or colonic injuries. The conversion rate was 5%. There was no mortality. Laparoscopic cholecystectomy is a safe and effective treatment for gall stone disease and is up to the accepted standard in our set up as compared to national and international data

Conservative management of mesh site infection in ventral hernia repair

Mesh Hernioplasty is the preferred surgical procedure for abdominal wall hernias and infection remains one of the most common complications of this technique. In some patients the mesh may need removal to overcome infection, where as others may be salvaged by conservative treatment. This study was conducted to assess the outcome of conservative management for mesh site infection in abdominal wall hernia repairs. This study was carried out in Ayub Teaching Hospital Abbottabad Pakistan from Jan 2006 to Dec 2007. Thirteen consecutive cases were included, who developed mesh site infection after abdominal wall hernia repair. Pus or purulent fluid was sent for culture and sensitivity. All patients were treated by intravenous antibiotics and local wound care. Treatment was taken as successful when there was complete resolution of infection and healing of the wound. There were 7 inguinal [53.84%], 4 para-umbilical [30.76%] and 2 incisional hernias [15.38%]. Eight patients were males [61.53%] and 5 females [38.46%]. Median age of the patients was 40 years [range 28 to 52 years]. Staphylococcus aureus was the most commonly found organism causing infection in 8 patients, [76.9%]. Mean hospital stay was 22 days [range 18-26 days]. All cases were effectively treated conservatively without removing the mesh. Polypropylene mesh was used in all of these cases. Conservative management is likely to be successful in mesh site infection in abdominal wall hernia repairs

Pseudomyxoma peritonei: a review of 17 cases

To evaluate the various presentations, causes and management of Pseudomyxoma Peritonei [PMP], and to create awareness among young surgeons regarding its importance. Retrospective study from Jan. 1999 to Dec. 2005. Surgical Unit of Khyber Teaching Hospital, Peshawar and Gynaecology and Obstetrics Unit, Hayatabad Medical Complex, Peshawar. All patients who had Pseudomyxoma Peritonei during the study period. The clinical records of all patients undergoing laparotomy for various causes were reviewed and cases of PMP separated. Their biodata, clinical presentation, clinical diagnosis, investigation results, operative findings, histopathology report and outcome were recorded. Out of 23,573 cases that underwent laparotomy 17 cases of PMP were on record. All were diagnosed incidentally per-operatively. Most [47.05%] cases were seen in the age group of 30-40 years and 58.82% patients were females. Abdominal pain, mass, abdominal distension and intestinal obstruction were the common presenting features. Ultrasound and CT scan reported three cases as ovarian cysts, three as multiple encysted fluid collections with thin cyst walls, two as ascites, two as ascites with peritoneal thickening, but none as PMP. Surgery was the mainstay of treatment. Appendicectomy with clearing of mucin in 11[64.70%], oophorechtomy and appendicectomy in 3[17.64%], bilateral oophorechtomy and hysterectomy in 2[11.76%], right hemi-colectomy in 1[5.88%] and second look surgery for complications were done in 2[11.76%] cases. Mortality was 11.76% and due to complication including one due to intestinal obstruction and another due to septicemia following second look surgery. Histopathological tissue diagnosis was available in only 13 cases and included mucinous adenoma appendix in five, mucinous cystadenoma ovary in three, mucinous epithelial cells of unknown origin in four and mucinous cystadenoma of borderline malignancy in one case. PMP is under reported in our setup. Pre-operative diagnosis is difficult and incidental findings usually go unnoticed due to lack of awareness and standard management protocol. There is a need to create awareness among surgeons, radiologists, pathologist and oncologist regarding this condition for the better outcome