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.

Vaaft (Video Assisted Anal Fistula Treatment); Novel Technique For The Treatment Of Anal Fistula.

BACKGROUND: VAAFT (Video Assisted Anal Fistula Treatment) is a novel minimally invasive technique for treatment of Fistula in Ano, which claims superior results compared to current treatment modalities due to the added advantage of real time visualization of the fistula tract and internal opening of the fistula using a fistuloscope. METHODS: This is cross sectional study in which 84 patients were selected using consecutive non probability sampling. They underwent VAAFT and were followed to assess for primary healing and continence at 6 weeks, and recurrence at 1 year. RESULTS: In this study, 97.6% participants were male. Mean operating time was 24 minutes while Mean VAS was 3.7±2.2. Healing was observed in 83.2% whereas recurrence was found in 10% at one year. All of the patients had normal sphincteric function post operatively. CONCLUSIONS: The results of our study affirm other studies in terms of cure rates, sphincter preservation and fistula recurrence. Studies with larger sample size and long term follow up are required to establish the superiority of VAAFT over the other currently available treatment options for anal fistula.

Outcome Of The Choice Of Wound Closure Technique In Emergency Laparotomy.

BACKGROUND: Abdominal surgeries are the most common surgeries performed around the world. Closure of abdominal wound is important and a number wound closing techniques are in practice. This study was conducted to determine the outcome of the choice of wound closure technique in emergency laparotomy. METHODS: It was a retrospective study from March-September 2019, conducted at the Surgical A unit, Ayub Teaching Hospital, Abbottabad. Ninety-five patients aged 22-60 years, who underwent emergency laparotomies via midline and para-median incisions were included in the study. RESULTS: There were 74 (77.89%) males and 21 (22.11%) females. Anatomical closure technique was used in 67 (70.53%) of study participants while mass closure technique was used in 28 (29.47%) of study participants. 50 (52.63%) patients had anaemia, 27 (28.42%) had hypo-proteinemia, and 14 (14.74%) developed peritonitis. Post-operative wound infection was noticed in 15 (15.79%) patients. Out of 95 patients, 19 (20%) developed burst abdomen. Overall, 5 (5.26%) patients died in the hospital. All cases of burst abdomen occurred within first two weeks of hospital stay (p= 0.004), had an association with peritonitis (p=0.0001) and post-operative wound infection (p= 0.005). Wound closure technique was not associated with development of post-operative complications including burst abdomen (p >0.05). CONCLUSIONS: Postoperative complications occur independently of wound-closure technique and surgeons should have a low threshold for prevention of post-operative complications where possible.

Laparoscopic Splenectomy; Single Surgeon, Single Centre Initial Experience At Tertiary Level Hospital In Peshawar.

BACKGROUND: Despite the fact that Laparoscopic splenectomy has become first choice for most cases of splenectomy in the developed world, open splenectomy is still being done in majority of the developing countries. There is no local data of our hospital on laparoscopic splenectomy. METHODS: Cross sectional study of 103 patients with laparoscopic splenectomy from Feb, 2013 to Jan, 2018 done for benign conditions of spleen at Khyber Teaching Hospital, Peshawar. Consecutive non-probability sampling was done. Lateral approach was utilized. Patients' demographics, preoperative characteristics and intra / postoperative complications were collected on a proforma. RESULTS: Mean age was (26) years. Two third (2/3) of patients were female. Major indication was ITP (Idiopathic Thrombocytopenic Purpura) followed by HS (Hereditary Spherocytosis). Total splenectomy was done in splenic cysts. In half of the cases, platelet and / or blood were transfused preoperatively as a measure of preoperative optimization. Intraoperative & postoperative complications occurred in (8%) which were managed conservatively. Conversion rate was (0%). Triple vaccination was done in almost all patients. CONCLUSIONS: Laparoscopic splenectomy is safe in experienced hands and should be the first choice in elective cases even in developing world. Local surgeons should train residents and junior surgeons to improve laparoscopic skills as training abroad is costly.

Evaluation Of Darn Repair For Recurrence Rate In The Management Of Indirect Inguinal Hernia.

BACKGROUND: Management of Inguinal Hernia had long been remained an enigma & various method had been employed for its management till date. Recent trend is towards the preferential use of mesh in open as well as Laparoscopic approaches where its advocates almost always undermine the role of raphys in the management of inguinal hernia but Darning repair despite all this critique is still a valid & viable option for the management of Indirect inguinal hernia. METHODS: This descriptive study was designed & carried out at the surgical units of Ayub Teaching Hospital Abbottabad from February 01, 2016 to October 31, 2018. A total of 117 patients with indirect inguinal hernia (primary) were included in study, managed with Darn Repair & were later followed for 2 years for the evidence of recurrence. RESULTS: None of the included patients (followed till last) whom underwent Darning Repair for Indirect Inguinal Hernia were found with the complication of recurrence till 02 years of follow-up although few patients were lost to follow-up for the whole duration 02 years and few others had suffered other early complications like wound infection, seroma, haematoma formation, scrotal swelling or comparatively longer lasting post-operative pain. The Darn Repair was also found cost-effective as compared to Mesh repair. CONCLUSIONS: Darn Repair despite criticism is a viable & effective option for Indirect Inguinal Hernia Repair (where its role indeed is prophylactic {NOT curative} against the future false recurrence), having no recurrence rate (as per our study results) like mesh repair (as per published literature) besides being reasonably cost-effective.

NON-LIGATION OF INDIRECT HERNIAL SAC IN CHILDREN.

BACKGROUND: It is still a matter of debate whether to ligate the indirect hernial sac during herniotomy or leave it open. We designed this study to find out the complications associated with leaving the sac open. METHODS: This observational study was carried out at Surgical Unit C, Ayub Medical College, Abbottabad from January 2007 to December 2012. The hernial sacs of some children, aged 5 months to 12 years, undergoing herniotomies were left open, and these children were closely followed for development of complications especially early recurrence, due to this non-ligation of hernial sac. RESULTS: A total of 23 male children who underwent herniotomies for indirect inguinal hernia and undescended testes were included in the study. No early or late hernia recurrence was observed in these children although minor complications like wound infection and seroma were noted in 2 children. CONCLUSION: Excision of the hernia sac and leaving the stump open is safe and effective with no early recurrence.

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.

Frequency of renal stone disease in patients with urinary tract infection.

BACKGROUND: To determine incidence of renal stone disease in patients with urinary tract infection, this cross sectional study was conducted at Surgical Unit of District Head Quarters Hospital, Charsadda over a period of one year from January to December 2005. METHODS: One hundred consecutive patients were enrolled in this study. All those patients who presented with urinary symptoms were included. While patients with lower urinary tract stones, upper urinary tract stones with renal failure, renal tumours and previous history of renal stones disease were excluded. The data was obtained and analyzed by filling a specially designed proforma for each patient. RESULTS: All 100 patients were between age ranges of 15-60 years (Mean age 37.5 years). Infection was present in 79% of cases. The commonest organisms isolated according to culture report were E. Coli (30%), Proteus (19%), Klebsiella (11%), Pseudomonas (7%), Staphylococcus aureus (3%) etc. The frequency of renal stone disease in patients with urinary tract infection was 18.98%. (12.6% in male and 6.3% in female). Mean age of patients with renal stones was 31.26 years and male to female ratio was 1.5:1. CONCLUSION: Renal stone disease makes an important group among urinary stone diseases. Urinary tract infection with certain bacteria plays an important role in the synthesis of renal stones. A high incidence can be prevented by adopting a variety of simple conservative measures.

Role of total leukocyte count in diagnosis of acute appendicitis.

BACKGROUND: Acute appendicitis is a common surgical emergency. Diagnosis may be difficult with little help from radiological and laboratory investigations. Total leukocyte count is one of the helpful investigations, being evaluated in this study. METHODS: The patients presenting with right lower quadrant abdominal pain whom were diagnosed as having acute appendicitis and later underwent appendicectomy were included in the study. The preoperative leukocyte count was compared with histo-pathology findings of removed appendix. Sensitivity and specificity of TLC was calculated by standard formulas. RESULTS: The sensitivity and specificity of TLC as calculated in this study is 76.5% and 73.7% respectively while positive predictive value is 92.5%. CONCLUSION: TLC although not a diagnostic criteria for acute appendicitis but still is helpful investigation in decision making.

Outcome of modified open surgery in tennis elbow.

BACKGROUND: Tennis elbow is a common disorder of upper extremity. It can be treated conservatively in majority of the patients but some resistant cases eventually need surgery. MATERIAL & METHODS: This descriptive study was conducted at Department of Orthopaedics, Ayub Teaching Hospital, Abbottabad, from January 2002 to June 2006. Sixteen patients had surgical release of the extensor tendon origin along with excision of the lateral epicondyle ridge. These patients did not respond to conservative treatment i.e. rest, non- steroidal anti inflammatory drugs (NSAIDS), local steroid injections and physiotherapy. Patients were followed upto six months. Outcome was graded as excellent, good and poor according to pain relief and function of the hand. RESULTS: Sixteen patients (17 elbows) were studied. Thirteen were female (81.25%) and three were male (18.75%). Fifteen patients (93.75%) had unilateral Tennis Elbow, while one had bilateral involvement (6.25%). In unilateral disease, right side was affected in eleven patients (68.75%) and left side in four (25%). Excellent outcome was noticed in eleven patients (68.75%) and good result in five patient (31.25%). CONCLUSION: Open surgical technique of releasing extensor tendon origin along with excision of lateral condylar ridge of the humerus is new and simple procedure and yields excellent and good result in patients with resistant Tennis Elbow.

Outcome of closed reduction and casting in displaced supracondylar fracture of humerus in children.

BACKGROUND: Supracondylar fracture of humerus in children is most common in first decade of life and needs proper management to prevent complications like cubitus varus, elbow stiffness and compartment syndrome. There are various treatment modalities i.e. traction, closed reduction and casting, open reduction and internal fixation and percutaneous pinning. Purpose of the study was to know the outcome of closed reduction and casting in displaced supracondylar fracture of humerus in children while comparing the results with published literature. METHODS: Study was conducted at the Orthopaedics unit of Lady Reading Hospital Peshawar from January 2002 to December 2002 and 25 patients at random, with age range of 04-12 years with displaced supracondylar fracture of humerus were treated with closed reduction and casting. RESULTS: Based on assessment through Flynn's criteria, results were excellent in 04 patients (16%), good in 11 (44%), fair in 03 (12%) and poor in 07 patients (28%). CONCLUSION: Good results can be obtained in displaced supracondylar fracture Gartland type II of humerus in children with closed reduction and casting while the results with Gartland type III fracture were not satisfactory.