Snodgrass Hypospadias Repair At Ayub Teaching Hospital: An Audit Of Complications And Outcomes.

BACKGROUND: There are many reported techniques for the repair of hypospadias, and new ones are being reported, which suggests that none is perfect. This study reports the anatomical success rate when using Snodgrass Technique. METHODS: In this descriptive case series, 296 patients who fulfilled the inclusion criteria, by being treated by Snodgrass urethroplasty, were enrolled. The study was conducted at the Department of Surgery, Unit-C, MTI, Ayub Teaching Hospital Abbottabad between May 2008 and June 2021. RESULTS: Mean age of the patients was 2.4±.8 years, 79.7% (n=236) had anterior (glanular, coronal, sub coronal) meatal location and 20.3 % (n=60) had middle urethral meatus (distal & mid-shaft). The mean operative time was 52 min. 5.1% of patients developed neo-meatal stenosis (n=15), 7.1% (n=21) patients develop a urethral cutaneous fistula (compared to 5% in larger centers, 16% from smaller centers), 11.8% (n=35) developed wound infection, 2% (n=6) had complete disruption. The cosmetic appearance of the penis was "excellent"/good (shape of meatus was slit-like and vertically oriented) in 60.1% (n=178) patients, "acceptable" in 30.1% (n=89), and "not acceptable" in 9.8% (n=29). CONCLUSIONS: Snodgrass technique has a low complication rate, offers an acceptable cosmetic outcome and can be successfully applied to a wide range of defects from distal to mid-shaft hypospadias. Common complications include urethral-cutaneous fistula and meatal stenosis; both occur in a low and acceptable number of patients.

Frequency Of Stone Clearance After Transurethral Fragmentation Of Large Urinary Bladder Calculi Using Pneumatic Swiss Lithoclast.

BACKGROUND: Vesical calculi refer to stones in the urinary bladder. The causes of bladder stones include bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Very rarely, these vesical calculi may reach very large sizes and the largest dimension can sometimes reach 13 centimetres. METHODS: This descriptive cross-sectional study was conducted from 1ST May 2019 to 31st October, 2019 at Institute of Kidney Diseases, Urology Department, Hayatabad Peshawar. 164 patients with vesical stone were included in study. Ultrasound-KUB was used for diagnosis of vesical stone and after informed consent, and they underwent transurethral nephroscopic lithotripsy via the pneumatic Swiss Lithoclast. RESULTS: Frequency of stone clearance was 96.34%. No statistically significant association of stone clearance was observed with age, gender, number of stones or max dimension of largest stone in the bladder (p>0.05). CONCLUSIONS: Transurethral nephroscopic pneumatic lithotripsy via pneumatic Swiss Lithoclast is safe and effective procedure for treatment of large vesical stones. However, this being the first such study in adults, more data is needed to confirm these findings.

Pattern Of Breast Cancer: Experience At Ayub Teaching Hospital, Abbottabad.

BACKGROUND: Breast cancer is the most common malignancy found in females all over the world and the second leading cause of cancer death in European countries. The purpose of this study was to find out the pattern of disease presentation in our region where a proper tumour registry system is lacking. METHODS: This descriptive study was carried out in the Department of Surgery, Ayub Teaching Hospital Abbottabad, from July 2021 to June 2022. All female patients with biopsy-proven breast cancer were included in the study: benign lumps, refused to enrol, and those who were lost to follow-up were excluded. RESULTS: A total of 87 patients with carcinoma breast were included: 92 % (n=80) had invasive ductal carcinoma. Axillary lymph nodes were involved in 88.5% (n=77), 75.8% of the tumours, (n=66), were Grade 2, 34.5% (n=30) were in the 40-49 years age group, and 30 % (n=27) of the disease was categorized as Stage III or IV. In 55 % (n=48), the tumour was on the right side and in 39% (n=34), the upper outer quadrant was involved. Most of the patients, 90.8% (n=79), were married and had used contraceptive measures. Only 19.5% of patients (n=17), had a history of nipple discharge and 56% (n=49) had a positive family history: 71% (n=62) had nipple retraction, and 54% (n=47), proved to be ER PR positive. CONCLUSIONS: Our patients presented late: axilla was commonly involved and a third had advanced disease. Screening and community awareness programs may help in early detection. Hormone use for contraception needs to be weighed carefully. Better data collection may help in designing screening and care programs.

Is It Mandatory To Ligate Sac In Emergency Herniotomy In Paediatric Age Group? A Prospective Cohort.

BACKGROUND: Herniotomy is standard treatment for inguinal hernia in children. Paediatric surgeons remain divided on whether ligation of sac is mandatory. In our study, we left the sac open to see early recurrence. METHODS: This quasi=experimental study, done in emergency cases, was sequel to our previous study done in elective cases. It was carried out at surgical unit C of Ayub Hospital Complex, Abbottabad, from Jan 2016 to June 2020. Children from birth to 12 years of age were randomly divided into two groups. In group I (experimental), sacs were cut high up and left open during herniotomy while in group II (control), high ligation of hernia sac was done. Follow up was scheduled for day 10 and 1, 3 and 6 months. Patients were assessed for early recurrence and other complications. RESULTS: A total of 151 emergency inguinal herniotomies were done including 147 males (97.4%) and 4 females (2.6%). 136 sacs (90.1%) were ligated with vicryl 3/0 or 4/0 while 15 sacs (9.9%) were left open. We did not find early recurrence, but found 1 case of scrotal hematoma (n=1/15) (6.7%) and 1 case of scrotal oedema (n=1/15) (6.7%) in the experimental group. In control group, complications were similar with 7 cases of hematoma (n=7/136) (5.1%) and 9 cases of scrotal oedema (n=9/136) (6.6%). CONCLUSIONS: Complications are comparable in herniotomy with or without ligation of sac but ligation adds an extra step. Herniotomy without sac ligation in children is safe and preferable in emergency setup.

Evaluating the effects of social networking sites addiction, task distraction, and self-management on nurses' performance.

AIMS: The purpose of this study was to explore the relationship of social networking sites (SNSs) addiction on nurses' performance and how this relationship was mediated by task distraction and moderated by self-management. DESIGN: This cross-sectional study is designed to empirically test the relationship of SNSs addiction, task distraction, and self-management with the nurses' performance. METHODS: Data were collected by conducting an online survey on nurses across the world using a web-based questionnaire developed through 'Google Docs' and distributed through Facebook from 13 August 2018 - 17 November 2018. The Facebook groups were searched using the selected key terms. In total, 45 groups were found to have relevance to this research; therefore, request was made to the admins of these groups to participate in this research and to post a link in their groups. Only 19 group admins responded positively by uploading a link of the research instrument on their respective group pages and 461 members of these groups participated in the research. RESULTS: Results of the data collected from 53 different countries indicated that SNSs addiction results in lowering the nurses' performance. This relationship is further strengthened by task distraction introduced as a mediating variable. The results show that self-management mediates the relationship between SNSs addiction and employees' performance. Moreover, the results of the study confirm that self-management reduces the negative impact of SNSs addiction on nurses' performance. CONCLUSION: Social networking sites (SNSs) addiction and task distraction reduce the nurses' performance, whereas self-management enhances nurses' performance. IMPACT: This study addresses the problem of using SNSs at the workplace and its potential effect on nurses' performance. Results demonstrate that SNSs addiction reduces the performance which is further decreased by task distraction; however, self-management of nurses can enhance the nurses' performance. The research has numerous theoretical and practical implications for hospital administration, doctors, and nurses.

Role Of Choledochoduodenostomy Revisited In The Era Of Minimal Invasive Procedures.

BACKGROUND: Present era of endoscopic and laparoscopic approaches have revolutionized surgical management of Common Bile Duct (CBD) stones. Open procedures like Choledochoduodenostomy (CDD) have become a rarity but are not completely obsolete. It may be considered a relatively safe alternative when dealing with recurrent, too large or impacted stones, a failed ERCP, and CBD stricture with stones. The aim of this study was to establish safety, efficiency, cost effectiveness and easy availability of CDD in selected patients. METHODS: In this observational study, the outcome of 90 consecutive patients undergoing CDD between 1st January 1995 and 31st Dec, 2016 in surgical unit C, Ayub Medical Complex, Abbottabad was reviewed. Choledochoduodenostomy was offered to patients who refused or had a failed ERCP and when CBD size was more than 1cm. Common Bile Duct was anastomosed to Duodenum using standard technique. RESULTS: Medical records of 90 patients (age range 34-96 years) were reviewed; 5 were excluded and 85 were included in the study. Complication rate was 31.76% (n=27) including respiratory complications in 16.47% (n=14), wound infection in 10.6% (n=9), anastomotic leak in 2.35% (n=2) and Cholangitis in 1.18% (n=1) and Mortality in 1.18% (n=1). There was no evidence of Sump Syndrome. Total cost of procedure was Rs.50 as admission fee, which included daily provision of food and there were no room charges. CONCLUSIONS: Choledochoduodenostomy is a safe procedure, with fewer complications and significantly low cost. In case of ERCP failure, CDD is recommended.

Cholecystectomy For Gall Stones In 26 Months Old Child.

Cholelithiasis is a major cause of morbidity worldwide. The incidence of gall stone in children in Pakistan has not been sufficiently studied and is increasingly being detected: the reason may be a true rise in the incidence or an improvement in diagnosis due to liberal use of diagnostic facilities and thus the increased opportunity to detect disease. A healthy 2 years and 2 months old male child presented to outpatient with history of recurrent attacks of pain abdomen and anorexia. Ultrasonography showed a 0.6 mm stone, inflammation and pericholecystic fluid. Open cholecystectomy was performed under general anaesthesia. A distended gall bladder with multiple very small calculi was removed. Post-operative stay was uneventful and patient was allowed oral feeds after 24 hours.

CAUSES OF DELAYED PRESENTATION OF ACUTE APPENDICITIS AND ITS IMPACT ON MORBIDITY AND MORTALITY.

BACKGROUND: Acute appendicitis is one of the commonest abdominal emergencies and appendectomy. is one of the commonest emergency procedures performed all over the world. The study was done with an objective to evaluate the different causative factors for delayed presentation of appendicitis. METHODS: This cross-sectional study was carried out in the Surgical "C" unit, at Ayub Teaching Hospital, Abbottabad, Pakistan from 20th June 2013 to 19th June 2014. A total of 130 patients presented with appendicitis in OPDs or emergency department. Detailed history, general physical and systemic examination especially abdominal examination was done along with investigations. RESULTS: It was found that 23.08% of complicated appendicitis presentation is due to missed diagnosis by physicians, 30.77% is due to missed diagnosis by non-doctors, 23.08% is due to conservative management at DHQ hospitals by surgeons, and 23.08% presented late because of self-medication at home. CONCLUSION: All patients with pain Right iliac fossa, there should be suspected of appendicitis. Proper workup should be done to exclude it. If kept on conservative management then regular monitoring of vitals with laboratory investigations should be done.

Aetiological factors in mechanical intestinal obstruction.

BACKGROUND: Intestinal obstruction occurs when the normal flow of intestinal contents is interrupted. The most frequent causes of intestinal obstruction are postoperative adhesions and hernias, which cause extrinsic compression of the intestine. Less frequently, tumours or strictures of the bowel can cause intrinsic blockage. Objective of the study was to find out the various aetiological factors of mechanical intestinal obstruction and to evaluate the morbidity and mortality in adult patients presenting to Surgical 'A' unit of Ayub teaching hospital with mechanical intestinal obstruction. METHODS: This cross-sectional study was conducted from March 2009 to September, 2009. All patients presenting with intestinal obstruction and were above the age of 12 years were included in the study. Patients with non-mechanical obstruction were excluded from the study and those who responded to conservative measures were also excluded. RESULTS: A total of 36 patients with age ranging from 12 to 80 years (Mean age 37.72 +/- 19.74 years) and male to female ratio of 1.77:1, were treated for mechanical intestinal obstruction. The most common cause for mechanical intestinal obstruction was adhesions (36.1%). Intestinal tuberculosis was the second most common cause (19.4%), while hernias and sigmoid volvulus affected 13.9% patients each. Malignancies were found in 5.6% cases. CONCLUSION: Adhesions and Tuberculosis are the leading causes of mechanical intestinal obstruction in Pakistan. Although some patients can be treated conservatively, a substantial portion requires immediate surgical intervention.

Evaluation of modified Alvarado score for frequency of negative appendicectomies.

BACKGROUND: Appendicitis being the commonest surgical emergency is primarily diagnosed clinically but posses diagnostic difficulty usually, especially to junior surgeons, demanding the need for tool/scoring system that can be easily applicable, accurate & reproducible in the diagnosis of appendicitis, with low negative Appendicectomy rate. This study is designed to assess one such scoring system, i.e., Modified Alvarado Score. METHODS: A total of 100 consecutive male and female patients with age 10 year and above presenting with symptoms suggestive of acute appendicitis were included in study, assessed according to eight variables of Modified Alvarado scoring system and were accordingly placed into 3 groups. Group-I patients having score 1-4 were discharged, Group-II patients having score 5-7 were observed while Group-III patients having score 8-10 were operated. Status of appendix of operated patients was assessed histo-pathologically. RESULTS: Out of 100 patients included in study, 58 patients were operated on the basis of said scoring system. Of the operated patients 52 (89.65%) had acute appendicitis, thus yielding a positive predictive value of 89.66% while negative appendectomy rate of 10.34%. Frequency of negative appendicectomy was 7.69% (3/39) amongst males and 15.79% (3/19) in females. Post-operative complication rate including wound infection, pelvic abscess, chest and urinary tract infection was 22.41% (13/58). CONCLUSION: Frequency of the negative appendicectomies can be reduced through standardization of the diagnostic procedure, by applying Modified Alvarado score in the diagnosis of suspected appendicitis cases as compared to simple clinical assessment.

Management of thoracic trauma: experience at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: The incidence of thoracic trauma has rapidly increased in this century of high speed vehicles, violence and various other disasters. It has been observed that chest intubation was required in more than 75% of patients. METHODS: This prospective study was performed in cardiothoracic surgery unit of Ayub Teaching Hospital Abbottabad from Jun 2007 to Dec 2007. A total of 114 consecutive patients with chest trauma were included in the study, their patterns of injuries classified, treatment strategies and outcome were recorded on a proforma. RESULTS: Out of 114 patients with chest trauma, 76 (66.65%) were having penetrating and 38 (33.33%) had blunt trauma. Haemothorax was detected in 67 (58.77%), Pneumothorax in 23 (20.17%), rib fracture in 11 (15.02%) and diaphragmatic injuries in 4 (3.5%) cases. Overall complication rate was 14%. Wound infection was present in 8 (7.01%) and empyema in 4 (3.5%). Mortality was 2.6%. CONCLUSION: Penetrating chest injuries were more common than blunt injuries and chest intubation with resuscitation was adequate in most of the patients.