Ileostomies and colostomies; common reasons and complications of construction: one year study

Background: An intestinal stoma is an opening of intestine on the anterior abdominal wall made surgically. The commonly performed procedures include colostomy and ileostomy. The purpose of the present study was to identify indications for commonly performed intestinal stomas and to study complications related to it

Objective: To identify indications for commonly performed intestinal stomas and to study complications related to it

Study Design: Observational study

Setting: Department of General Surgery, Unit- B, Lady reading Hospital, Peshawar

Period: 1[st] Jan 2013, to 31[st] Dec 2013

Subjects and Method: A total of 106 patients who underwent surgery and ended up in intestinal stomas, ileostomy or colostomy, were included in the study. Indications, immediate and late complications of stomas were recorded

Results: A break up of 106 patients of different intestinal stomas. Majority [61.32%] of patients were males. There were 49 ileostomies and 57 cases of colostomy making a total of 106 patients. Main indications of Ileostomy were enteric perforation [55.10%], and intestinal tuberculosis [20.40%]. Main indications of colostomy were penetrating injuries [50.88%], and intestinal obstruction. In a total of 106 stomas local complications appeared in 23 [21.69%]. Skin excoriation, ulceration, lap and wound infection were the most common respectively. Seventy eight stomas including 36 ileostomies and 42 colostomies were closed on an average of 3 months after primary operation. There were 7 cases of wound infection, 2 anastamotic leak-ages and one mortality [1.3%] in the stoma reversal group

Conclusion: Common indications for intestinal stomas were abdominal penetrating trauma, enteric perforation, intestinal obstruction and intestinal tuberculosis. Main complications included local skin problems, wound infection and retraction

C-reactive protein and total leukocyte count in the diagnosis of acute appendicitis

The objective was to calculate the sensitivity and specificity of C reactive protein and Total leukocytecount by taking histopathological diagnosis of acute appendicitis as the gold standard. Observational study.This study was conducted in the Surgical Unit of Lady Reading Hospital, Peshawarfrom January 2014 to December 2014. The study included 50 adult patients of either gender with clinical diagnosis of acuteappendicitis. The patients were admitted through the emergency department. The decision to operate was made bythe senior surgeon on call, on the basis of clinical features. All the cases were operated within 12 hours' ofadmission. Blood samples for Total leukocyte count and C-reactive protein measurement were collected from all thepatients before surgery. Operative findings were recorded. Removed appendices were sent for histology. The datawas entered and processed on the SPSS 16 version. The patients included 32 males and 18 females. Male to female ratio was 1.8:1. Mean age was 24 years.Frequency of negative appendicectomy was 16%. Sensitivity, specificity and positive predictive value of Totalleukocyte count were 80.5%, 62.5% and 91.8% respectively. Sensitivity, specificity and positive predictive value ofC-reactive protein were 85.7%, 75% and 94.5% respectively. In patients with histopathologically confirmed acuteappendicitis, both the TLC and C - reactive protein were found to be statistically significant. C-reactive protein and Total Leukocyte Count supplement the clinical diagnosis of acute appendicitis

Frequency and causes of conversion of laparoscopic cholecystectomy into open cholecystectomy

To determine the frequency and causes of conversion of laparoscopic cholecystectomy into open cholecystectomy. Cross-sectional [descriptive] study. This study was carried out at Surgical Unit of Postgraduate Medical Institute, Lady Reading Hospital, Peshawar for 14 months, from 1-11-2010 to 31-12-2011. A total of 126 patients of symptomatic gallstones disease fulfilling the inclusion criteria were subjected to laparoscopic cholecystectomy and were followed through out the procedure to see for any conversion and its cause. The mean age of patients was 40.65 +/- 10.35 with range of 20-65 years. The total no of cases converted to open cholecystectomy were 11 out of 126. Thus frequency of conversion was 11 equal to 8.7%, with commonest cause being adhesions 9 out of 11 converted cases followed by hemorrhage 2 out of 11 conversions. Moreover conversion was more in male patients. 20.8% as compared to 5.9% in females. Laparoscopic cholecystectomy is the gold standard treatment modality in the management of symptomatic gallstones disease. Its one disadvantage is the conversion into open procedure. But conversion should not be considered as complication of the procedure rather it is mature decision by the surgeons to avoid unnecessary lengthening the duration of surgery once they encounter any difficulty or interoperative complication

Frequency of diaphragmatic trauma in fire-arm injury of abdominal cases and outcome of its management

To determine frequency of diaphragmatic trauma in fire-arm injuries of abdomen and to determine outcome of its management. Retrospective study. This study was conducted at Department of Surgery, Unit B, Lady Reading Hospital Peshawar over a period of one year from January 2014 to January 2015. Record of all fire-arm injury cases, who presented during study period, was analyzed. Data were collected on pre-designed proforma from admitted patient record [patients charts] and operation theatre notes register. Demographic data, site and frequency of injury to diaphragm, operative findings, and outcome were the variables of study. Out of total 83 patients of fire-arm injuries, 14 [16.8%] patients had diaphragmatic trauma. Mean age of patient was 27.14 years. Male to female ratio was 4.9:1. Left dome of diaphragm was injured in 9 [64.28%] and right dome was involved in 4 [28.57%] of cases and in one patient [7.14%] patients central tendon of diaphragm was injured together with injury to pericardium that got expired. Diaphragmatic injury though not as common in abdominal fire-arm injury. There should be however very low threshold for suspicion in cases of fire-arm injury of abdomen, where bullet trajectory or mechanism of injury is suggestive, because missing such injury is not devoid of complications. The patient should be thoroughly examined and investigated for exclusion of diaphragmatic injury

Wound infections and culture sensitivity pattern in pediatric burn patients

To identify common organisms causing burn infection and their antimicrobial sensitivity pattern. A retrospective study of sixty patients with burn wound infection was carried out at burn unit of Khyber Teaching Hospital Peshawar from September 2006 to August 2007. Children who received burn injuries with signs and symptoms of septicemia were included in this study. Age, sex, percentage of burn wound and etiology of burn wounds was recorded. Culture and sensitivity tests were performed from burn wounds of those patients who were having fever and other features of septicemia by tissue culture of all patients[from infective sites] and their results were noted. Out of sixty patients, fourty were male and twenty were female pediatric burn patients. The most frequent organism isolated was staphylococcus aureus [25%], followed by pseudomonas [21.6%]. Other organisms included mix pseudomonas and staphylococcus aureus [23.5%], E-coli [13%], proteus [3%], Klebsiella [3%]. All these organisms were resistant to most routine antibiotics. This study highlights that staphylococcus aureus [25%] and pseudomonas [21.6%] are the most common organisms and cefoperazone/sulbactam and imipenem/cilastatin are the most effective empirical therapy in our setup

Gastroesophageal anastomosis: single-layer versus double-layer technique-an experience on 50 cases

Considerable controversy exists regarding the optimum technique for gastroesophageal anastomosis. Double layer technique has long been considered important for safe healing but there is evidence that single layer technique is also safe and can be performed in much shorter time. The purpose of this study was to compare the outcome of single layer and double layer techniques for gastroesophageal anastomosis. A prospective randomized study was conducted in cardiothoracic unit, Lady Reading Hospital from Jan 2006 to Jan 2008. Fifty patients with oesophageal carcinoma undergoing subtotal oesophagectomy were randomized to have the anastomosis by single layer continuous or double layer continuous technique [group A [n=24] and B [n=26] respectively]. The demographic data, operative and anastomosis time, postoperative complications and hospital mortality were recorded on a proforma and analyzed on SPSS 10. There was no significant difference between group A and B in terms of age, gender, postoperative complications and duration of hospital stay. Anastomotic leak occurred in 4.2% patients in group A and 7.7% in group B [p=NS]. Mean anastomosis time was 10.04 minutes in group A and 19.2 minutes in group B [p=0.0001]. Mean operative time was 163.83 minutes and 170.96 minutes in group A and B respectively. Overall hospital mortality was 2%; no deaths occurred due to anastomotic leak. Single layer continuous technique is equally safe and can be performed in shorter time and at a lower cost than the double layer technique

One stage resection of sigmoid volvulus: an experience of 50 cases

To assess the outcome of one stage resection and primary anastomosis without intraoperative colonic lavage in patients with acute sigmoid volvulus. A prospective, descriptive study was carried out in the Surgical department of Lady Reading Hospital, Peshawar from Jan 2002 to Dec 2003. Fifty patients with sigmoid volvulus were included in the study. Patients with serious co morbidity, hemodynamic instability, gangrenous or compound volvulus on laparotomy were excluded from the study. All the patients were assessed and operated upon by a senior surgeon. Resection of the sigmoid colon and primary anastomosis was done after only manual decompression in all cases. The demographic data, clinical features, radiologic and operative findings, out come of the procedure in terms of postoperative complications and duration of hospital stay were recorded on a proforma. The data was entered and processed on the SPSS 10 version. The patients included 44 males and 6 females. Male to female ratio was 7.3:1. Mean age was 57 years. Most frequent clinical features were abdominal pain, distension and constipation. Postoperatively, superficial wound infection was seen in 14% patients [n=7], transient paralytic ileus in 22% cases [n=11]. Pulmonary complications occurred in 6% patients [n=3]. No deaths or clinical anastomotic leak occurred. Duration of hospital stay ranged from 6-17days [mean 11 days]. Resection of sigmoid colon primary anastomosis can safely be carried out without on-table colonic lavage in selected patients with viable colon

Determinants of success of decortication

Background: To find out different factors which lead to failed decortication and to evaluate their management and outcome

Study Design: Retrospective observational descriptive study

Place of Study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 2003 to Sep 2006

Materials and Methods: Clinical record of 300 patients who underwent decortication tor chronic empyema during the last 3.9 years was retrospectively analyzed and their results evaluated. Detailed scrutiny of the computerized clinical record was carried out to analyze the aetiology of failure of the operation. The variables studied were persistent broncho- pleural fistula, poor postoperative efforts by the patients, wound infection, old chest drain site infection, technical failure and nutritional state of the patient

Results: Of the 300 deoortications performed over the period of 3.9 years, 260 patients had a successful outcome in terms of lung expansion and improved pulmonary functions. In thirty patients [19 males, 11 females with age range of 12 to 70 years] decortications failed to achieve the desired results. These patients had to undergo space obliteration procedures for persistent infected space. Twenty three patients had history of tuberculosis and seven patients had nontuberculous empyema. All patients had chronic empyema with duration of more then 12 weeks before the first operation. All patients were nutritionally compromised. Thoracoplasty [compete or partial] was performed in 25 patients to obliterate the persistent infected space. Five patients with recurrent broncho-pleural fistula had an additional procedure of intercostal muscle reinforcement over the fistulae, in addition to thoracoplasty. All patients had successful obliteration of the persistent space with no mortality and minor wound infection in only three patients

Conclusion: Early referral, old drain site infection control, meticulous closure of broncho pleural fistula and space obliteration procedure in combination primarily instead of secondarily, lead to a successful outcome

Arteriovenous fistula construction in chronic haemodialysis patients: comparison of end-to-side and side-to-side techniques

To compare the techniques of end-to-side and side-to-side anastomosis in arteriovenous fistulae construction in terms of success rate and immediate postoperative complications. Design: Comparative study. Place and Duration of Study: Ayub Hospital Complex, Abbottabad, from October 1999 to December 2002 and Khyber Teaching Hospital, Peshawar, from January 2003 to December 2003. Patients and One hundred and ninety patients with end stage renal disease [ESRD] were included in the study. Arteriovenous fistula was constructed in these patients by two techniques i.e. end-to-side and side-to-side anastomosis. The two methods were compared in terms of duration of surgery, immediate success rate and short-term complications. Among 190 patients, 118 [62%] were males and 72 [38%] females. The age ranged between 24 to 66 years with average age of 54 years. Side-to-side anastomosis was done in 120 [63%] patients while end-to-side in 70 [37%] patients. The average duration of surgery in side-to-side group was 50 minutes and in end-to-side group it was 75 minutes. Bleeding occurred in 4[5.7%] cases in end-to-side group and 2[1.7%] patients in side-to-side group requiring reexploration. The immediate failure rate of the procedure was 2.5% in side-to-side group and 7.5% in end-to-side group. Wound infection occurred in 1[1.4%] case in end-to-side group and 2[1.7%] cases in side-to-side group. In patients with end stage renal disease [ESRD] arteriovenous fistula construction by side-to-side anastomosis is less time-consuming and has less complications as compared to end-to-side technique

Huge lipoma at the nape of the neck

We would like to share with the readers a case of huge pedunculated lipoma arising from the nape of the neck and lying on the upper back. The lipoma was highly mobile on its pedicle and the patient was using it as a pillow. It was successfully excised and there was no recurrence at one year follow up

Management of volvulus of sigmoid colon by resection and single layer primary anastomosis

The objective of this study was to evaluate the outcome of resection and primary anastomosis in cases of sigmoid volvulus. This study was conducted at District Headquarters Hospital Battagram from November 2001 to March 2003. Twenty eight Patients, who had sigmoid Volvulus at laparotomy as a cause of large gut obstruction, were included in this study and resection and single layer primary closure of the gut was done. The patients were followed for anastomosis related complications up to 6 weeks. The ages of patients ranged from 45 to 65 years. Male to female ratio was 6:1. Resection and primary anastomosis of large intestine was done using single layer Gambee's stitch. There was no mortality. No patient had leakage of anastomosis or peritonitis. Five patients [17.8%] had wound infection and 7 patients [25%] had transient ileus. The hospital stay ranged form 7-21days. We conclude that resection and single layer primary anastomosis has excellent results in sigmoid volvulus