Giant trichobezoar mimicking gastric tumour.

We present a case of giant gastric trichobezoar retrieved through a long gastrotomy in a 40 years old married women from rural Sindh with unreported psychological disturbance. Trichobezoar almost exclusively occur in females with an underlying psychiatric disorder. It has an insidious development of symptoms which accounts for its delayed presentation and large size at the time of diagnosis. They are associated with trichophagia (habit of compulsive hair eating) and are usually diagnosed on CT Scans or upper GI Endoscopy. They can give rise to complications like gastroduodenal ulceration, haemorrhage, perforation, peritonitis or obstruction with a high rate of mortality. The treatment is endoscopic, laparoscopic or surgical removal and usually followed by psychiatric opinion.

Fissurectomy with posterior midline sphincterotomy for management of chronic anal fissure.

OBJECTIVE: To determine the efficacy and safety of fissurectomy with posterior midline sphincterotomy in the management of chronic anal fissure in terms of symptomatic relief, complications and recurrence. STUDY DESIGN: Observational case-series. PLACE AND DURATION OF STUDY: Department of Surgery, Liaquat University Hospital, Jamshoro/Hyderabad, for a period of 3 years from January 2005 to December 2007. METHODOLOGY: A total of 136 patients with chronic anal fissure were recruited for this study. All subjects underwent elective fissurectomy and posterior sphincterotomy. Surgery was performed either under spinal or general anaesthesia. Symptomatic relief and early postoperative complications were recorded. The patients were followed for 18 months. Follow-up included assessment for complications such as pain, incontinence, keyhole deformity, and recurrence. RESULTS: All patients presented with pain during and after defaecation. Forty (29.4%) patients presented with bleeding per rectum. One hundred and sixteen (85%) patients complained of perianal swelling while 8 (5.9%) patients complained of perianal itching. Retention of urine was the most common postoperative complication, seen in 10 (7.4%) cases. It occurred within the first 24 hours after operation and all cases required catheterization. Six (4.4%) patients complained of moderate to severe postoperative pain in the first 24 hours, requiring narcotic analgesics. Transient incontinence of flatus and faeces occurred in 5 (3.7%) and 3 (2.2%) cases respectively. One patient presented with a recurrent anal fissure after 8 months but responded to conservative treatment. CONCLUSION: Given the low rate of complications and almost negligible rate of recurrence, fissurectomy with posterior midline sphincterotomy is still a treatment of choice for the management of chronic anal fissure.

Prospective basic clinical audit using minimal clinical data set.

BACKGROUND: Audit is a means of quality control for medical practice by which the profession should regulate its activities with intention of improving overall patient care. Objective of this study was to report 1 year basic clinical audit of a general surgical ward and comparison of results with available data. METHODS: All patients admitted and managed in Department of Surgery Unit-II, Liaquat University Hospital, Jamshoro/Hyderabad from January to December 2007 were included in the study for basic clinical audit. Data of all surgical patients admitted during this period were retrieved from the departmental register. Details of surgical procedures and complications were recorded from the patients' charts. RESULTS: Total number of patients was 1434, out of which 844 (58.85%) were males and 590 (41.14%) were females. Majority (70.02%) of the patients were between 16 to 50 years of age. Elective surgeries were performed in 487 (33.74%) and emergency surgeries in 430 (29.79%) cases, whereas rest of the 526 patients (36.28%) were managed conservatively. Consultant was the primary surgeon in less than 50% of the procedures compare to post graduate trainees and registrars. The most common surgeries performed in elective wing were inguinal hernia repairs (25.66%) and cholecystectomies (22.99%). In emergency wing, most of the surgeries were exploratory laparotomies (38.13%) and appendicectomies (22.79%). Average duration of hospital stay in elective wing was 1-10 days and in emergency wing it was 2-21 days. There was an overall complication rate of 6.3% and a mortality rate of 2.44% respectively. CONCLUSION: We conclude that surgical audit has potential benefits for patients, clinicians, and provision of services for a continuous education, research and improved practice habits and should be perform on yearly basis. We also recommend the proper computerised audit programs and committees for its monitoring and evaluation.

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.

Open cholecystectomy without intraperitoneal drainage.

BACKGROUND: Cholecystectomy through laparotomy with or without intra-peritoneal drain has been the standard operation for the gall bladder disease for the last 100 years. It implies removal of gall bladder and is performed mainly for symptomatic gall stones. The Objectives was to analyse the outcome of open cholecystectomy without drain in term of complications. METHODS: Patients who underwent open cholecystectomy without drainage from January 2005 to December 2008, at Department of Surgery, Liaquat University Hospital, Jamshoro, Pakistan were included in the study. This was a 4 years prospective analysis of open cholecystectomy performed without drainage on 212 patients. Patients were randomly allocated for the procedure who presented with uncomplicated Cholelithiasis. Exclusion Criteria included carcinoma gall bladder, empyema gall bladder, Choledocholithiasis and porcelain gall bladder. All these patients underwent open cholecystectomy under general anaesthesia through various incisions. Operative time, post operative complications and hospital stay were recorded on a performa and analysed using SPSS-13. RESULTS: Two hundred and twelve patients, 199 females (93.9%) and 13 males (6.13%), age range 15 to 70 years, underwent open cholecystectomy without drainage for uncomplicated cholelithiasis. The most common complication observed includes seroma (5.66%), followed by surgical site infection both superficial and deep (3.30%) and bile leakage (1.14%). However biliary peritonitis, sub hepatic abscess and Wattman Walter's syndrome were not observed in any case. Mean operating time was 35 minutes. Mean hospital stay was 1.5 days with no mortality during the period of hospitalisation. The overall complications rate and hospital stay was significantly less when compared to open cholecystectomy with intra-peritoneal drain. CONCLUSION: In selected cases with a dry gall bladder bed, routine use of intra peritoneal drainage is unnecessary.

Perforated ileal duplication cyst: a diagnostic dilemma.

Alimentary tract duplications are rare congenital anomalies. We report a case of a 14-year-old boy, who presented with acute abdomen, with features favouring acute appendicitis. Laparotomy revealed perforated ileal duplication cyst. Resection of ileum along with cyst and anastomosis was undertaken, and proximal ileostomy performed. Postoperative recovery was uneventful and ileostomy was reversed successfully. Histopathology revealed the presence of gastric mucosa at the site of perforation.

Epidermoid inclusion cyst of the perineum--a rare case report in a 50 years old male.

A 50 year old male presented with a history of mid line painless swelling in the perineum for last 4 years. The patient's only concern was a perineal swelling which was gradually increasing in size. Clinical examination mimics subcutaneous lipoma with soft lobulated surface with positive slip sign. The base line investigations were within normal limits. Complete surgical excision of the cyst performed. Histopathology confirmed epidermal inclusion cyst with no evidence of malignancy. Patient discharged on next day. The follow-up visits were un-remarkable. Perineal epidermal inclusion cyst is a rare entity and only few cases have been reported.

Pattern of pathogens and their sensitivity isolated from superficial surgical site infections in a tertiary care hospital.

BACKGROUND: Infection is an important cause of morbidity and mortality in surgical patients. Rapidly emerging nosocomial pathogens and the problem of multi-drug resistance necessitates periodic review of isolation patterns and sensitivity in surgical practice. Surgical site infections (SSI) are defined as an infections that occurs at the incision site within thirty days after surgery. Objectives of the study were to determine the pattern of pathogens involved and their antibiotic sensitivity isolated from superficial surgical site infections in a teaching hospital. METHODS: This observational study was conducted for 1 year from January 2008 to December 2008 in all 4 surgical units of Liaquat University Hospital Hyderabad which caters to patients from low socioeconomic status. Pus culture and sensitivity reports were collected prospectively from hospitalised patients who developed postoperative wound infection. The patients who developed fecal/biliary/urinary fistula or operated for malignancies, and with negative cultures were excluded from the study. Analysis was carried out using SPSS 10. RESULTS: During the study period 112 pus culture and sensitivity reports were analyzed. E. coli 68 (60.7%) was the most common organism isolated followed by Klebsiella 23 (20.5%). The least frequent organism was staph. Epidermidis 1 (0.9%). All isolates were sensitive to penicillin derivatives and carbapenem. Quinolones, Aminoglycosides and Monobactum were also showing some promise in our study. However, Cephalosporins were ineffective against most of the important isolates in our study. CONCLUSION: E. coli and klebsiella were the most important isolates form SSI in our study, and penicillin derivatives and carbapenem were showing 100% antibiotic sensitivity to all of the isolates.

Mucoepidermoid carcinoma of parotid presenting as unilocular cyst.

An interesting case of a 09 years old girl is reported who presented with a painless, mobile, spherical, fluctuant and brilliantly translucent swelling in front of left ear. The fine needle aspiration revealed turbid dark yellow colour fluid. This cystic swelling was completely excised and the specimen on histopathology was reported as low grade Mucoepidermoid carcinoma. Recovery was uneventful. This unusual presentation of Mucoepidermoid carcinoma as a preauricular cyst is one of the rare unique reported case.

Causes and management of postoperative enterocutaneous fistulas.

OBJECTIVE: To identify the causes of postoperative enterocutaneous fistulas and to evaluate the results of conservative and operative treatment including the effectiveness of octreotide in the management of these fistulas. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro / Hyderabad between January 1997 and December 2001. SUBJECTS AND METHODS: Forty patients with postoperative fistula were studied. Demographic variables, causes and management outcome was observed and recorded. RESULTS: There were 25 males and 15 females with 50% of the patients being in age group of 21-30 years. Emergency surgery for typhoid perforation(45%) and intestinal tuberculosis (30%) were the commonest causes. Ileum and jejunum were the commonest sites of fistulation found in 85% cases. Twenty-one patients were started on conservative treatment with spontaneous closure occurring in 15 (71.4%) patients. Nineteen patients were operated within three days of admission due to generalized peritonitis (73.7%) and local intra-abdominal collections (26.3%). Wound infection was the commonest complication in the operative group. The mortality rate in this series was 7.5%. All the deaths occurred following surgery. CONCLUSION: Postoperative enterocutaneous fistula has a high morbidity and a significant mortality. Sepsis in the peritoneal cavity is the major cause of mortality. Conservative treatment has a good outcome for these fistulas. The use of octreotide is highly recommended as it definitely converts high output fistulas to low output fistulas.

Cryptorchid testicular tumour presenting with torsion.

An undescended, cryptorchid testis is predisposed to 3 to 40 times risk of malignancy. Torsion of a cryptorchid testis is more difficult to diagnose than a normally placed testis. We present a case of a 25-year-old man with acute abdomen due to the torsion of an intra-abdominal testis. Subsequent histopathology of the testis revealed seminoma, making this single testis the seat for triple pathology. Orchidectomy was done followed by radiotherapy. A follow-up of upto nine months showed no recurrence or metastases.