Surgical management of tuberculous small bowel obstruction.

BACKGROUND: Acute intestinal obstruction due to tuberculosis is a common surgical problem in our community. Emergency surgery is usually required and surgical procedure depends upon the location and extent of the disease. The aim of this study was to determine the commonly involved region of intestine and different surgical procedures tailored. METHODS: Thirty patients operated upon for acute intestinal obstruction in emergency with operative and histopathological findings suggestive of tuberculosis were included in the study. Demographic profile, operative findings, details of surgical procedure, complications and post-op hospital stay were recorded. The patients were followed for 6 months. RESULTS: Intestinal tuberculosis is more common in young female, with male to female ratio of 1:1.5. Stricture of the small bowel was found in 50% of the cases. The next common finding was ileocaecal tuberculosis found in 40% of patients. Strictruplasty was performed in 11 (36.33%). The right hemicolectomy, limited ileocaecal resection and segmental bowel resection with end to end anastomosis were performed in four patients each. Other procedures were release of adhesions and bands in 4 patients, ileotransverse bypass in 1 patient and loop ileiostomy in 2 patients. Major complication in 10 patient and mortality rate was 10%. CONCLUSION: Because of non-specific clinical features, ignorance and malpractice intestinal tuberculosis presents late. Ileocecal tuberculosis is becoming less common as compared to small bowel strictures. Less radical surgery gives better results. Post operative complications and mortality are related to the perforation of the intestine at the time of surgery.

Comparison of closed and open methods of pneumoperitonium in laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitonium is the first step in laparoscopic surgery including cholecystectomy. Two commonly used methods to create pneumoperitonium are closed and open technique. Both have advantages and disadvantages. The current study was designed to compare these two techniques in terms of safety and time required to complete the procedure. METHODS: This was a randomized controlled prospective study conducted at Department of Surgery, Ayub Hospital Complex Abbottabad, from 1st June 2007 to 31st May 2008. Randomization was done into two groups randomly using sealed envelopes containing the questionnaire. Seventy envelopes were kept in the cupboard, containing 35 proformas for group A and 35 for group B. An envelope was randomly fetched and opened upon selection of the patient after taking the informed consent. Pneumoperitonium was created by closed technique in group A, and by open technique in group B. Time required for successful pneumoperitonium was calculated in each group. Failure to induce pneumoperitonium was determined for each technique. Time required to close the wounds at completion, total operating time and injuries sustained during induction of pneumoperitonium were compared in both techniques. RESULT: Out of the total 70 patients included in study, 35 were in group A and 35 in group B. Mean time required for successful pneumoperitonium was 9.17 minutes in group A and 8.11 minutes in group B. Total operating time ranged from 55 minutes to 130 minutes in group A and from 45 minutes to 110 minutes in group B. Mean of total operating time was 78.34 and 67 minutes in group A and B respectively. Mean time needed to close the wound was 9.88 minutes in group A and 4.97 minutes in group B. Failure of technique was noted in three patients in group A while no failure was experienced in group B. In two cases in group A minor complications during creation of pneumoperitonium were observed while in group B no complication occurred. No patient died in the study. CONCLUSIONS: We concluded from this study that open technique of pneumoperitonium was, less time consuming and safer than the closed technique.

Carcinoma of prostate in clinically benign enlarged gland.

BACKGROUND: Carcinoma of the prostate is one of the common tumours of old age in men. This cross sectional study was conducted to detect carcinoma of prostate in clinically benign enlarged gland and to evaluate the efficacy of Digital rectal Examination in detection of prostatic cancer in patients presented at Khyber Teaching Hospital, Peshawar from July 1998 to July 1999. METHODS: Patients presenting with lower urinary tract symptoms over the age of 50 years were evaluated on English version of International Prostate Symptoms Score (IPSS), clinically examined and post-voiding residual urine determined on abdominal sonography. The selection criteria were; Severe IPSS, absence of signs of malignancy on Digital Rectal Examination (DRE) and post-voiding residual urine more than 100 ml. Thus a total 100 patients were selected for further study. Four ml blood was taken to assess Prostate Specific Antigen (PSA) level pre-operatively. All these patients underwent either transvesical prostatectomy or transurethral resection of prostate (TURP) and enucleated prostatic tissues were sent to histopathology. RESULTS: Eighty-five percent patients had PSA level up to 10 etag/ml. PSA level of 15 (15%) patients were above 10n gm/ml out of which 13 (13%) patients were having PSA in range of 11-12 etag/ml and two (2%) had PSA level between 20-25 etag/ml. Histopathology report of 2% patients turned out as adenocarcinoma of the prostate. CONCLUSION: Out of 100 patients who were having clinically benign DRE findings, 2 turned out as Carcinoma of the prostate histologically.

Abdominal tuberculosis an experience at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Abdominal tuberculosis is one of the common diseases in our country. This study was performed at Surgical A Unit Ayub Teaching Hospital Abbottabad from August 2006 to December 2007 to asses the clinical presentation of abdominal tuberculosis and its management. METHODS: All patients presenting to outpatient department with clinical feature suggestive of abdominal tuberculosis were included in the study. They were investigated. On the basis of clinical presentation, patients were divided in two groups. Patients with acute abdomen (peritonitis, intestinal obstruction) were prepared for laparotomy and operated upon. Required surgical procedure performed and tissue diagnosis was obtained. Patients with sub-acute obstruction, chronic pain abdomen and mass abdomen with out peritonism were managed conservatively. These patients were started on anti TB drugs on the basis of clinical and laboratory assessment. Empiric therapeutic trial was conducted for at least for 3 months with standard four drugs regimen. They were sent home on 9 month course of Anti TB drugs and were advised to come for follow up twice a month. On reassessment good clinical response was considered abdominal tuberculosis and anti TB continued with monthly follow up. In case of no response patients were operated. Required surgical intervention performed and tissue was taken to establish diagnosis. Detailed history, family history, examination findings, results of investigations, operative findings of the histologically proven cases of abdominal tuberculosis were recorded on a separate proforma and analyzed. RESULTS: Amongst 76 patients majority were females 52 (68.40%). Most of the patients were young with mean age of 34 years. Abdominal pain was the most common presentation 73 (96%) followed by fever and anorexia. Tender lower abdomen as found in 53 (70%) patients and mass abdomen was found in 35 (46%). Family history of TB was present in 20 (26%). Fifty three (70%) patients underwent laparotomy. Bands and adhesion was the most frequent finding on laparotomy. CONCLUSION: Abdominal TB is more common in female and abdominal pain fever and nausea are the most common presentations.