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Mirizzi syndrome is a rare syndrome, caused by the compression of gall stones which may result in CBD obstruction or fistula formation. It may sometimes present without any prior symptoms. It has been classified into five types by Csendes. Usually open surgical approach is recommended for the condition, especially for Types III-V. We present the case of a patient who presented with right hypochondrial pain and was intra-operatively discovered to have type Va Mirrizi syndrome and was managed successfully laparoscopically.
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Colecistectomia Laparoscópica , Fístula , Síndrome de Mirizzi , Humanos , Colecistectomia Laparoscópica/efeitos adversos , Síndrome de Mirizzi/complicações , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/cirurgia , Fístula/cirurgiaRESUMO
Intestinal perforation from a plastic biliary stent is a known but rare complication of endoscopic biliary stent placement. Intra-peritoneal perforation is less common but carries more morbidity and mortality. Only a few cases of early stent migration and perforation have been reported. We present the case of a duodenal perforation caused by early migration of plastic biliary stent that resulted in intra-peritoneal biliary peritonitis.
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Migração de Corpo Estranho , Perfuração Intestinal , Humanos , Stents/efeitos adversos , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Plásticos , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgiaRESUMO
BACKGROUND: Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay. PATIENTS AND METHODS: This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test. RESULTS: Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000). CONCLUSION: It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.
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Goma de Mascar , Íleus , Adulto , Feminino , Motilidade Gastrointestinal , Humanos , Ileostomia/efeitos adversos , Íleus/etiologia , Íleus/prevenção & controle , Tempo de Internação , Masculino , Complicações Pós-Operatórias/prevenção & controle , Adulto JovemRESUMO
Gallbladder perforation is rare. Diagnosis is usually made during operative intervention. Delay in recognition is associated with high morbidity and mortality. We report a case of type 1 gall bladder perforation in a male patient with no previous complaints related to gallstones.
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Colecistectomia/métodos , Vesícula Biliar , Cálculos Biliares/diagnóstico por imagem , Laparotomia/métodos , Abdome Agudo/diagnóstico , Abdome Agudo/etiologia , Diagnóstico Diferencial , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Abdominal/métodos , Ruptura Espontânea , Resultado do TratamentoRESUMO
Gastro-Intestinal Stromal Tumours are rare tumours, constituting less than 1% of gastrointestinal tumours. They are the most common mesenchymal origin tumours of gastro-intestinal tract. Tyrosine kinase c-kit oncogene mutation is found in all cases. These tumours are sensitive to imatinib. They are usually noted incidentally on endoscopy or present with haematemesis after ulceration. We are reporting the laparoscopic resection of GIST in a 67 year old male who had presented with haematemesis. He was found to have a gastric polyp on endoscopy. Endoscopic ultra-soundshowed the tumour to be arising from the submucosa. Histo-pathology showed the tumour to be GIST. Patient is currently undergoing chemotherapy.
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Neoplasias Gastrointestinais/cirurgia , Tumores do Estroma Gastrointestinal/cirurgia , Laparoscopia , Idoso , Neoplasias Gastrointestinais/patologia , Tumores do Estroma Gastrointestinal/patologia , Humanos , MasculinoRESUMO
OBJECTIVE: To present initial experience with the first 100 cases of robotic-assisted surgery by the Department of General Surgery. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Surgery, National Hospital and Medical Centre, Lahore, Pakistan, from May 2022 to August 2023. METHODOLOGY: Demographic and postoperative details of the first 100 patients to undergo robotic-assisted surgery by the Department of General Surgery were reviewed. Prospective data were collected from the hospital information database as well as the CMR database. The data collected in the hospital database included the patients' age, diagnoses, genders, complications during hospital stay as well as 90-day readmission, morbidity, and mortality. Data collected by CMR via Versius robotic surgery console or internal databases included operative minutes using the console. RESULTS: The average age of patients undergoing robotic surgery was 44.26 ± 14.08 years. Cholecystectomy (78%) was the most commonly performed robotic-assisted procedure. Only one patient had blood loss of more than 100ml. There was no postoperative complication, readmission or mortality during the study period. CONCLUSION: With proper patient selection, robotic-assisted surgery is safe and feasible even in low- middle-income countries (LMICs). KEY WORDS: Robotic-assisted surgery, Pakistan, Initial experience, Outcomes, Versius.
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Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Masculino , Adulto , Paquistão , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Tempo de Internação/estatística & dados numéricos , Idoso , Colecistectomia/métodos , Duração da Cirurgia , Resultado do Tratamento , Estudos Prospectivos , Readmissão do Paciente/estatística & dados numéricosRESUMO
Objectives Laparoscopic intraperitoneal onlay mesh hernioplasty (IPOM) for ventral hernias has been used for a long time. However, there have been some issues associated with it, thereby leading to the introduction of a new technique that involves laparoscopic closure of the fascial defect with suture followed by intraperitoneal onlay mesh placement (IPOM-Plus). We carried out this study to compare the outcome of laparoscopic IPOM with fascial defect closure versus without defect closure in midline ventral hernia repair in terms of recurrence. Methodology This comparative study was carried out in the Department of Surgery, Services Hospital, Lahore, from October 16, 2020, to April 15, 2022. A total of 84 patients of both genders, aged between 18 and 70 years, presenting with midline ventral hernia were included in the study. Patients with recurrent hernia, unstable cardiopulmonary conditions, neurological or psychiatric diseases, chronic renal disease, congestive cardiac failure, and chronic obstructive pulmonary disease (COPD) were excluded from the study. Patients were assigned to two groups. Group 1 underwent IPOM with the closure of the defect, and Group 2 underwent IPOM without the closure of the defect. Patients were observed for immediate postoperative complications. Patients were monitored for one year to assess recurrence through clinical evaluation and ultrasonography. Results In this study, seroma formation was found in 3 (7.14%) patients for laparoscopic IPOM with fascial defect closure and 10 (23.81%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.035). Recurrence was identified in 2 (4.76%) patients undergoing laparoscopic IPOM with fascial defect closure and 9 (21.43%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.024). Conclusions This study concluded that the frequency of recurrence is less after laparoscopic IPOM with fascial defect closure in midline ventral hernia repair than after laparoscopic IPOM without fascial defect closure.
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Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.
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Background Perforation of peptic ulcers is a common cause of emergency surgery and has significant morbidity and mortality. The use and range of laparoscopic surgery have greatly increased over the past three decades. Laparoscopic approach is an option for perforated peptic ulcers because of the simple nature of the intervention. The aim of this study was to evaluate the outcome of laparoscopic approach for peptic ulcer repair in emergency setting by means of operative time, post-operative pain, mean hospital stay, and post-operative complications. Methods In this study, we enrolled patients presenting with perforated peptic ulcers in the emergency department of a tertiary care hospital in Lahore, Pakistan. Approval from the hospital ethical committee and informed consent were taken from all patients. After resuscitation, the patient underwent laparoscopic repair of perforation. Post-operative course of patients was monitored. Duration of surgery, post-operative pain, length of hospital stay, and post-operative complications were noted for all patients. Results Between December 2018 and December 2021, 31 patients with perforated peptic ulcers underwent laparoscopic repair at our hospital. Mean age of patients was 37.25 ± 7.80 years. Most of the patients were male (70.76%). The mean operation time was 109.35 ± 17.02 minutes for laparoscopic repair. Mean duration of hospital stay was 5.10 ± 0.87 days. Mean post-operative pain was 3.55 ± 0.85 assessed using the Visual Analogue Scale. There were no mortalities during the 30-day post-operative window. Conclusion With proper patient selection, laparoscopic surgery offers better results as compared to open surgery in patients undergoing emergency surgery for perforated peptic ulcers.
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OBJECTIVE: To evaluate the outcome of Laparoscopic Gastro-jejunostomy in patients presenting with Gastric Outlet obstruction secondary to Corrosive intake at the Services Hospital. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, Pakistan, from June 2013 to June 2021. METHODOLOGY: Data was gathered from the patients who presented with gastric outlet obstruction with a pre-hospitalised history of corrosive intake. Consenting patients subsequently underwent laparoscopic gastro-jejunostomy and were followed up post-operatively at a 1-week time-point and 4-week time-point to monitor progress. Studied variables included duration of surgery, duration of hospital stay, complications, and mortality at the 1st and 4th weeks. RESULTS: A total of 30 patients participated in the study including 27 (90%) females and 3 (10%) males. The mean age was 27.2 ± 4.07 years. The mean duration of hospital stay was 9.3 ± 3.2 days. Complications were seen in 3 patients (10%) with 1 death (3.33%). CONCLUSION: Laparoscopic gastro-jejunostomy appears to be safe and effective in corrosive intake patients presenting with gastric outlet obstruction. KEY WORDS: Corrosive Intake, Gastric outlet obstruction, Laparoscopic, Gastrojejunostomy.
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Cáusticos , Derivação Gástrica , Obstrução da Saída Gástrica , Laparoscopia , Adulto , Feminino , Derivação Gástrica/efeitos adversos , Obstrução da Saída Gástrica/etiologia , Obstrução da Saída Gástrica/cirurgia , Humanos , Jejunostomia/efeitos adversos , Laparoscopia/efeitos adversos , Masculino , Cuidados Paliativos , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: The objective of study was to assess the knowledge and attitude of doctors from Lahore regarding CPR as per American Heart Association (AHA) guidelines. METHODS: The researchers visited various hospitals and filled e-questionnaires by interviewing respondents.The study was conducted at Jinnah Hospital Lahore, Mayo Hospital Lahore, Punjab Institute of Cardiology Lahore, Sir Ganga Ram Hospital Lahore, Services Hospital Lahore and Mid City Hospital. Data were analyzed using statistical package for social sciences (SPSS) 23 version. Knowledge was assessed based on the scores, with those scoring 10 or more being considered to have good knowledge while those having score less than 10 were considered to have poor knowledge. P values < 0.05 were considered statistically significant. RESULTS: Out of 792 participants, 68 refused to take part in the study. The total respondents were 724 with the response rate of 91%. The knowledge regarding cardiopulmonary resuscitation of 601(83%) respondents was poor with only 123(17%) doctors having good knowledge. The doctors who received formal CPR training had better knowledge (20.17%) than the doctors who didn't get any training regarding CPR (4.69%). Anesthesiologists scored better among all specialties. The overall attitude of the doctors towards CPR was positive with 93.8% of the respondents willing to do CPR. CONCLUSION: The overall knowledge of the doctors regarding CPR is not satisfactory. A practical and functional approach is needed to improve this situation. However, the attitude of the doctors towards CPR is positive.
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Since its emergence from Wuhan at the end of last year, the novel coronavirus has spread to almost every country of the earth posing a significant challenge to healthcare systems everywhere. This article presents a practical model adopted in light of the WHO guidelines which was used by our team to set up the facility and care for the 69 COVID-19 prisoners within the prison itself. In addition to the challenges posed by the COVID-19 the healthcare team also had to overcome the challenge of the unique nature of the setup. The purpose of this article is to describe our response to help providers tasked with caring for prisoners especially in lower socio-economic countries.
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OBJECTIVE: To evaluate the effect of COVID-19 on the working of a tertiary care hospital. STUDY DESIGN: Audit study. PLACE AND DURATION OF STUDY: Services Hospital, Lahore from 1st March to 30th June 2020. METHODOLOGY: We calculated and compared various parameters of hospital working. Two time periods were selected. The study period was defined as the time after first confirmed case of COVID-19 in Pakistan. The control period was defined as one year prior to the first case being reported, taken from 1st March 2019 to 29th February, 2020. The parameters we studied included were number of number of hospital admissions, emergency patients, OPD patients, major surgeries, total surgeries, radiological investigations done, laboratory investigations done, births and mortalities. All parameters were calculated by taking monthly average during each time period and then compared. RESULTS: A decrease in almost all parameters was seen when the cases of the two time periods were compared. There was a decrease in the average hospital admission by 51%, while the patients seen in OPD fell by almost 60%. A slight decrease of 25% was seen in the cases presenting to the emergency. The most marked decrease was in the elective surgeries, which was 66% closely followed by average monthly mortality which decreased by 64%. Average monthly minor surgeries and births were decreased by 33% and 35%, respectively. CONCLUSION: There had been a decrease in the number of patients presenting to the hospital across the board with the most marked increase being in elective surgeries. Key Words: COVID-19, Hospital working, Patient load, Elective surgery.
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COVID-19/epidemiologia , Emergências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pandemias , Centros de Atenção Terciária/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Humanos , Paquistão/epidemiologia , Estudos Retrospectivos , SARS-CoV-2RESUMO
Gossypiboma or textiloma is a rare but very unfortunate complication of surgery. It refers to a retained foreign body usually forgotten within the abdominal cavity at the end of an operation. It may be a surgical sponge, gauze pad or other form of textile. We present the case of a middle aged lady who following cholecystectomy had a forgotten gauze which underwent transmural migration and was later expelled via the rectum demonstrated by radiological studies.
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Situs inversus is a rare condition. It is characterised by reverse handed positioning of the internal viscera. Laparoscopic cholecystectomy is the standard procedure for cholelithiasis, but it may lead to technical difficulties in case of situs inversus, especially to right-handed surgeons. A 40-year female presented to the department with epigastric pain and bloating usually after fatty meals. Diagnosis of symptomatic gall bladder stone was made. She was a known case of situs inversus. Laparoscopic cholecystectomy was performed by right-handed surgeon with uneventful recovery.
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Colecistectomia Laparoscópica , Cálculos Biliares/cirurgia , Situs Inversus , Adulto , Diagnóstico Diferencial , Feminino , HumanosRESUMO
INTRODUCTION: Gallstone ileus is a rare presentation of cholelithiasis accounting for around 4% of cases of small bowel obstruction under 65 years of age but rises to 25% in those more than 65 years of age. Most gall stones, if impact in the bowel, are seen to lodge at the ileocecal valve as this is the most narrow part of the bowel. PRESENTATION OF CASE: We present a case of small intestinal obstruction because of a gallstone stuck in the distal jejunum. Patient was explored and one-stage surgery was done i.e. cholecystectomy, enterotomy and stone retrieval, and fistula repair. Our patient had uneventful postoperative recovery and was discharged after a week. DISCUSSION: Gallstone ileus is a rare entity presenting a significant diagnostic challenge to surgeons due to lack of specific findings. Moreover, the surgical management options to be adopted are diverse and depend upon the condition of the patient. Stable patients can be managed with two-stage procedures i.e. enterotomy and stone retrieval earlier with cholecystectomy in an elective setting. Our patient was managed with one-stage procedure i.e. cholecystectomy was done in the same setting and our patient did well. CONCLUSION: Gallstone ileus needs to be kept in the differential diagnosis list of intestinal obstruction in middle aged patients even in the absence of history of gallstones as this may be the first presentation of gallstone disease.
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OBJECTIVE: To compare the efficacy of lactulose plus rifaximin with efficacy of lactulose alone in the treatment of hepatic encephalopathy. STUDY DESIGN: A randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Medicine, Jinnah Hospital, Lahore, from December 2014 to June 2015. METHODOLOGY: All patients who presented with hepatic encephalopathy due to decompensated chronic liver disease were randomly divided into two groups of 65 patients each. One group was given 30 ml thrice daily lactulose alone and the other lactulose plus rifaximin 550 mg twice daily for 10 days. Informed consents were taken from the participants' attendants. Grades II-IV hepatic encephalopathy was noted according to West-Haven Classification. All subjects were followed until 10 days after admission. RESULTS: The mean age of patients was 56.06 +11.2 years, among which 46.9% were females and 53.1% were males. After ten days of follow-up, reversal was seen in 58.46% in lactulose alone group and 67.69% in lactulose plus rifaximin group (Chi-square p=0.276). CONCLUSION: There was no difference in effectiveness of lactulose plus rifaximin and lactulose alone in treatment of hepatic encephalopathy.
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Fármacos Gastrointestinais/administração & dosagem , Encefalopatia Hepática/tratamento farmacológico , Lactulose/administração & dosagem , Rifamicinas/administração & dosagem , Adulto , Idoso , Esquema de Medicação , Quimioterapia Combinada , Feminino , Fármacos Gastrointestinais/uso terapêutico , Humanos , Lactulose/uso terapêutico , Falência Hepática/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Rifamicinas/uso terapêutico , Rifaximina , Resultado do TratamentoRESUMO
Gall stone ileus associated with cholecysto-duodenal fistula is a rare pathology. It most commonly presents in elderly females in 72-90% of cases. In such a case, a patient typically presents with recurrent attacks of sub-acute intestinal obstruction which usually resolves completely with conservative management only to recur again after some time. We are reporting a case of an 85-yearold gentleman who presented to us with gallstone ileus associated with cholecysto-duodenal fistula and his subsequent management. He underwent Laparotomy with enterotomy, stone extraction, Cholecystectomy and Graham's patch repair of the fistula. The purpose of this case report is to discuss a rare case of gall stone ileus associated with cholecysto-duodenal fistula. The diagnosis was confirmed using imaging and appropriate and timely surgical intervention for both mechanical intestinal obstruction and the fistula was undertaken.
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Cálculos Biliares/complicações , Íleus/etiologia , Fístula Intestinal/complicações , Idoso de 80 Anos ou mais , Cálculos Biliares/diagnóstico por imagem , Humanos , MasculinoRESUMO
Gallbladder is a rare site of tuberculous involvement. Less than 150 cases have been documented in the last 150 years. It may mimic malignancy. Histopathology examination is the mainstay of diagnosis. Gallstones and obstruction appear to be pre-disposing factors. Treatment involves localizing other sites and starting patient on anti-tuberculosis therapy. The report describes this rare site of involvement in an adult Pakistani man.
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Colecistite/diagnóstico , Vesícula Biliar/microbiologia , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose/diagnóstico , Adulto , Colecistectomia , Colecistite/microbiologia , Colecistite/cirurgia , Diagnóstico Diferencial , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/patologia , Humanos , Masculino , Resultado do Tratamento , Tuberculose/microbiologia , Tuberculose/cirurgiaRESUMO
Caecal volvulus is a rare cause of intestinal obstruction. Caecal volvulus precipitated by acute appendicitis is even rarer. We report an unusual case of caecal volvulus with acute appendicitis as a cause. A 55-year female presented in surgical emergency with 3 days history of abdominal pain, distension and absolute constipation; and 2 days history of vomiting. Her past surgical history was significant for hysterectomy 5 years back. On examination, abdomen was distended and bowel sounds exaggerated. X-ray abdomen erect showed a single large air fluid level in the right hemiabdomen. A preoperative diagnosis of intestinal obstruction due to adhesions was made and patient prepared for exploratory laparotomy. On exploration, a huge caecum was lying in the midline and was twisted around a band arising from the appendix and attached deep into the pelvis. The appendix was densely inflammed. The volvulus was de-twisted in a counter clockwise manner. Viability of the caecum was confirmed and appendectomy was done. Caecopexy was performed and abdomen was closed. Postoperative recovery of the patient was uneventful and she was safely discharged on 5th postoperative day.