Routine histopathology of gallbladder after elective cholecystectomy for gallstones: waste of resources or a justified act?

BACKGROUND: Selective approach for sending cholecystectomy specimens for histopathology results in missing discrete pathologies such as premalignant benign lesions such as porcelain gallbladder, carcinoma-in-situ, and early carcinomas. To avoid such blunders therefore, every cholecystectomy specimen should be routinely examined histologically. Unfortunately, the practice of discarding gallbladder specimen is standard in most tertiary care hospitals of Pakistan including the primary investigators' own institution. This study was conducted to assess the feasibility or otherwise of performing histopathology in every specimen of gallbladder. METHODS: This cohort study included 220 patients with gallstones for cholecystectomy. All cases with known secondaries from gallbladder, local invasion from other viscera, traumatic rupture of gallbladder, gross malignancy of gallbladder found during surgery was excluded from the study. Laparoscopic cholecystectomy was performed in majority of cases except in those cases where anatomical distortion and dense adhesions prevented laparoscopy. All gallbladder specimens were sent for histopathology, irrespective of their gross appearance. RESULTS: Over a period of two years, 220 patients with symptomatic gallstones were admitted for cholecystectomy. Most of the patients were females (88%). Ninety two per cent patients presented with upper abdominal pain of varying duration. All specimens were sent for histopathology. Two hundred and three of the specimens showed evidence chronic cholecystitis, 7 acute cholecystitis with mucocele, 3 acute cholecystitis with empyema and one chronic cholecystitis associated with poly. Six gallbladders (2.8%) showed adenocarcinoma of varying differentiation along with cholelithiasis. CONCLUSION: The histopathological spectrum of gallbladder is extremely variable. Incidental diagnosis of carcinoma gall bladder is not rare; if the protocol of routine histopathology of all gallbladder specimens is not followed, subclinical malignancies would fail to be identified with disastrous results. We strongly recommend routine histopathology of all cholecystectomy specimens.

Management of recurrent inguinal hernia at a tertiary care hospital of southern Sindh, Pakistan.

BACKGROUND: The goal of the present study was to determine the frequency, mode of presentation, and need for reoperation in the treatment of recurrent inguinal hernia at Liaquat University Hospital, Jamshoro, Sindh, Pakistan. METHODS: This descriptive, cross-sectional study was conducted over a period of four years, from January 2007 through December 2010. A total of 916 patients with inguinal hernia underwent operation in the Department of Surgery at Liaquat University Hospital Jamshoro, Sindh, Pakistan, during the study period. Of them, 62 patients were diagnosed to have recurrent inguinal hernia and were included in the study. Female patients and patients with other types of hernia like femoral, epigastric, and paraumbilical defects were excluded. RESULTS: Among the 62 patients studied, the commonest age group with recurrence was 41-50 years (43.5%). Fifty-one (82.2%) of the patients were ambulatory workers. In 47 cases (75.8%) recurrence was on the right side, and in 15 (24.1%) recurrence was on the left side. First time recurrence was seen in 54 patients (87%) and second time recurrence was seen in 7 patients (11.2 %); third time recurrence was observed in only one patient. All of these patients had an initial open surgery without mesh, except one. Bassini's repair was done as a primary repair in 47 (75.8%) cases. A total of 11 patients (17.7%) had no previous medical records. Darning repair was done in 3 patients (4.8%), and open surgery with mesh was performed in only one patient. The highest recurrence rates were seen in patients whose hernia repairs had been done by postgraduate trainees. That is, 45 of the patients requiring reoperation (72.5%), compared to 11 (17.7%), and 6 (9.6%) operations performed by registrars and consultants, respectively. All patients in our study underwent tension-free Lichtenstein mesh repair. Postoperative complications included retention of urine (40.3%), scrotal hematoma (6.4%), and wound infection (3.2%). CONCLUSIONS: Recurrent inguinal hernia is still frequently observed today, and the Lichtenstein tension-free repair has gained great acceptance worldwide and is currently considered the procedure of choice for primary and recurrent inguinal hernias.

An audit of secondary peritonitis at a tertiary care university hospital of Sindh, Pakistan.

OBJECTIVE: Peritonitis is the most common life threatening surgical emergency, which requires urgent surgical intervention and is a significant cause of morbidity and mortality. The objective of this study was to highlight the frequency of secondary peritonitis and to analyze the site and causes of perforation, in our tertiary care setup. METHODS: A retrospective analysis of 311 patients of secondary peritonitis was done from July 2008 to June 2010 at Liaquat University Hospital Jamshoro, Hyderabad, Sindh, Pakistan. All cases found to have peritonitis as a result of perforation of any part of gastrointestinal tract at the time of surgery were included in the study. All cases with either primary peritonitis or that due to anastomotic dehiscence were excluded. RESULTS: A total of 311 patients were studied. Most of the patients were males (77%) and (89%) were in the third and fourth decades of life. Majority of the patients presented with pain (97%) associated with bowel symptoms. Most common site of perforation was small bowel (ileal 59%, jujenal 2%). In this series, most common risk factor of perforation was typhoid (43%). Ileostomy was the most commonly performed procedure. Overall morbidity was 48.5% and mortality was 17%. CONCLUSION: Considering the relatively higher rate of typhoid perforation quoted in this study, it is vital that typhoid fever ought to be eliminated by improved sanitation and immunizing programmes, otherwise surgeons will be confronted with its complications.

Demographic and surgical evaluation of typhoid ileal perforation.

BACKGROUND: Typhoid perforation of small intestine is one of the most common causes of bowel perforation in the developing countries. The purpose of this study was to determine the prevalence, factors affecting prognosis, and optimal surgical management for typhoid perforation in Sindh. METHOD: One hundred and thirty patients with typhoid perforation were included in the study from July 2005 to June 2007 in the Department of Surgery, Liaquat University Hospital, Hyderabad. Patients were admitted as cases of acute abdomen. Detailed history, clinical examination and relevant investigations were carried out. Double layer primary closure, primary loop ileostomy and segmental resection with end-to-end anastomosis were performed according to the operative findings and condition of the patients. Attention was paid to postoperative complications and course of the morbid condition. RESULTS: Majority of patients belonged to deserted areas of district Umerkot (n = 35, 26.93%), and Mithi (n=20, 15.38%) followed by Dadu (n = 17.13.08%), Badin (n = 5, 11.54%), Jamshoro (n= 11, 8.46%), Hyderabad (n = 10, 7.69%), Thatta (n = 9, 6.92%), Mirpurkhas (n = 7, 5.38%) and Sanghar (n = 6, 4.62%). Double layer primary closure of single perforation was done in 50 (38.46%) patients, primary loop ileostomy was performed in 68 (52.30%) patients and primary resection and end-to-end anastomosis was performed in 12 (9.23%) patients. Postoperative complications were observed in 79 (60.76%) patients. Wound infection was the commonest complication seen in 70 (53.84%) patients followed by wound dehiscence in 10 (7.69%), faecal fistula in 9 (6.92%), septicaemia in 8 (6.15%), postoperative chest infection in 25 (19.23%), and intra abdominal abscess in 15 (11.53%) patients. Ten (7.69%) patients died due to septicaemia and other reasons. CONCLUSION: Typhoid perforation remains a frequently fatal illness with high prevalence in remote areas of Sindh. Primary loop illeostomy is the single most successful and life saving surgical procedure in terms of overall morbidity and mortality.

Helicobacter pylori infection in patients with calcular cholecystitis: a hospital based study.

BACKGROUND: Helicobacter pylori, a gram negative bacillus has been recognised as a public health problem and approximately half of the world population has H. pylori infection causes chronic gastritis, peptic ulcer disease and gastric malignancies. Objective of this study was to determine the frequency of H. pylori infection in patients of chronic calcular cholecystitis. METHODS: This cross-sectional descriptive study was conducted at Liaquat University Hospital, Hyderabad, Pakistan from April 2010 to September 2010. All patients with history of gallstone presented with acute abdominal pain, dyspepsia, bloating and epigastric discomfort and diagnosed as calcular cholecystitis were further evaluated for the detection of H. pylori by serology and histopathology. Frequency and percentage of H. pylori infection in patients with calcular cholecystitis was calculated. RESULT: Total 100 patients of cholelithiasis underwent laparoscopic cholecystectomy were recruited. The pain in upper right part of the abdomen was observed in all 100 patients, fever in 75%, nausea and vomiting in 68%, loss of appetite in 45%, feeling of tiredness or weakness in 22%, headache in 38%, chills in 52%, backache in 58%, pain under the right shoulder in 45%, heartburn in 67%, belching in 54%, indigestion in 80%, dyspepsia in 90%, bloating in 88%, and epigastric discomfort in 85% patients. Eighty-two percent patients had family history of gallstones. The mean age of overall study population was 48.72 +/- 8.78 years and mean age of H. pylori infected calcular cholecystitis patients was 47.98 +/- 5.43 years in male and 48.76 +/- 6.68 years in females. The H. pylori infection was identified in 55% patients with calcular cholecystitis, of which 32.7% were males and 67.3% were females (p=0.03, statistically significant). Majority of females (60%) had > or = 40 U/ml antibody titre (p=0.917, non-significant). CONCLUSION: A possible relationship was identified between Helicobacter pylori and calcular cholecystitis.

Spectrum of clinical presentation and surgical management of intestinal tuberculosis at tertiary care hospital.

BACKGROUND: Tuberculosis can involve gastrointestinal tract anywhere from mouth to anus, the peritoneum and pancreatobiliary system. It has varied clinical presentations sometimes mimicking other common abdominal diseases. Tuberculosis continues to be a major problem especially in developing countries, being responsible for 7-10 million new cases and 6 per cent of deaths worldwide annually. Objective was to assess and evaluate various clinical presentations and management of intestinal tuberculosis at Liaquat University Hospital, Jamshoro/Hyderabad. METHODS: This 3-year descriptive study was conducted on patients with diagnosed intestinal tuberculosis (by histopathology) in Surgical Unit-I, from January 2006 to December 2008. Detailed history and clinical examination was performed in all the cases. Investigations like Blood CP and ESR, Urea, RBS Electrolytes, Serum A/G Ratio, Ultrasound abdomen, X-Ray chest and abdomen were carried out in all the cases while barium meal, follow through and CT Scan abdomen were performed in selected cases. Preoperative assessment of anatomical site and variety of lesions were also noted. RESULTS: A total of 60 patients with diagnosis of intestinal tuberculosis were admitted and operated. Diagnosis was confirmed by histopathology. Among these, 28 (46.7%) were male, and 32 (54.1%) were female. Variable clinical presentations were seen. Majority of patients (46, 76.7%) had abdominal pain, 26 (43.3%) had vomiting; abdominal distension was seen in 22 (36.7%) cases, diarrhoea and constipation in 16 patients (26.7%) and abdominal mass in 14 patients (23.3%). Majority of patients had ulcerostenotic type of tuberculosis. Single stricture of ileum was seen in 15 (25%) while multiple strictures were seen in 13 (21.7%). Ileal perforation was seen in 6 (10%) patients. Weight loss was seen in 40 (66.7%) patients, fever 36 (60%), night sweats 30 (50%), anorexia in 30 (50%) and pulmonary tuberculosis in 18 (30%) patients. Resection and anastomosis was performed on 24 (40%) cases, right hemicolectomy on 22 (36.7%), stricturoplasty on 8 (13.3%), adhesionolysis on 4 (6.7%), and Ileostomy on 2 (3.3%) patients. CONCLUSION: Abdominal pain, vomiting, fever and weight loss are the commonest symptoms in abdominal tuberculosis. Single and multiple strictures in the ileum, and mass in the ileocaecal region were the commonest lesions. Definitive surgical procedure like resection and anastomosis, stricturoplasty and right hemicolectomy are the main surgical options.