Blunt Traumatic Abdominal Wall Hernias: A Surgeon's Dilemma.

BACKGROUND: Traumatic abdominal wall hernias (TAWH) have been recognized for more than a century since they were first reported by Selby (JAMA 47:1485-1486, 1906). They continue to be a rare diagnosis, encountered in approximately 1% blunt trauma admissions. The present study is a 10-year retrospective review of patients presenting with TAWH to a State Major Trauma Unit in Western Australia. We hypothesized that the timing of the repair of TAWH was dependent on the severity of the abdominal wall injury, as well as associated injuries, and in turn, this may affect patient outcomes. MATERIALS AND METHODS: The Trauma Registry at Royal Perth Hospital (the only Level I Trauma Centre for adults in Western Australia) was scrutinized for TAWH, between 2003 and 2013. The injuries were graded by the classification system of Dennis et al. (Am J Surg 197:413-417, 2009). Patients with TAWH following penetrating trauma were excluded. RESULTS: During the study period, 44 patients were diagnosed to have TAWH accounting for 0.08% of admissions. Thirty (68%) of the patients were male and the median age was 36 years (IQR 24-54). The median BMI was between 25 and 30. The majority of the patients sustained trauma secondary to motor vehicle crashes and the commonest associated injury was a pelvic fracture. Grades 3 and 4 injuries were found to have an association with a pelvic fracture (p < 0.001). No association was seen in the present study between seat belt use and the development of TAWH or between the location of TAWH and seat belt pattern. The median time of diagnosis of TAWH following arrival to hospital was 18 hours while the median time of surgery from diagnosis was 15.5 hours. Forty-one (93%) of the patients underwent surgery. Of these, 8 (20%) were emergent due to a simultaneous bowel perforation and another five had primary mesh repairs. Three of the patients suffered superficial complications (7.5%) and there were 3 (7%) recurrences at a mean time of 7.25 months from the first repair. The follow-up period ranged from 1 to 51 months with an average time of 16 months. CONCLUSION: This series is the largest single institution study conducted on TAWH to date. Despite its retrospective nature and small numbers, it has generated some important questions. A larger prospective study with a longer follow-up period is required to generate reliable treatment algorithms as well as to standardize the management of TAWH.

Diltiazem vs. glyceryl tri-nitrate for symptomatic relief in anal fissure: a randomised clnical study.

OBJECTIVE: To further resolve the clinical equipoise on the choice of chemical sphincterotomy agent for early symptomatic relief of anal fissure by comparing the effectiveness of 2% Diltiazem gel with 0.2% Glyceryl TriNitrate. METHODS: The randomized clinical trial was conducted at Aga Khan University Hospital, Karachi, from February 1, to July 30, 2008, and comprised 60 adult patients with anal fissure who were equally randomised to either Diltiazem or Glyceryl TriNitrate after taking informed consent. The creams were applied locally; the former twice daily, and the latter three times a day for a period of two weeks. The rest of the treatment was standard. Patients were followed up in clinic by the principal investigator at two weeks for primary outcome i.e. self-reported symptomatic relief on Visual Analogue Scale, and secondary outcomes i.e. side effects and the overall cost of treatment. RESULTS: Of the total, 31 (52%) patients were males and the overall mean age was 37 +/- 11 years. Patients, who used Diltiazem reported more symptomatic relief than Glyceryl TriNitrate (p < 0.01). Side effects were found more in Glyceryl TriNitrate than Diltiazem (p < 0.01), and most common side effect in the former group was headache in 12 (40%) patients. Cost of the treatment was not significantly different between both treatment arms (p < 0.28). CONCLUSION: Chemical sphincterotomy with topical 2% Diltiazem gel is an effective first-line treatment for early symptomatic relief of anal fissures, owing to negligible side effects.

Outcomes of splenectomy for idiopathic thrombocytopenic purpura in adults: a developing country perspective.

OBJECTIVE: To determine the outcome of splenectomy done in adult patients of Idiopathic Thrombocytopenic Purpura over a period of 10 years and, secondarily, to determine the predictors of complete response to therapy. METHODS: The retrospective review comprised of adult patients over 14 years of age who underwent open or laparoscopic splenectomy for Idiopathic Thrombocytopenic Purpura at Aga Khan University Hospital, Karachi, from January 2000 to December 2010. Data was reviewed in January 2011 by a surgical resident. Outcome was the response to splenectomy as per new definition of response set by the American Society of Haematology 2011 evidence based practice guidelines for Idiopathic Thrombocytopenic Purpura. Assessment of response was done within 1 to 2 months of splenectomy and after withholding concomitant treatment. SPSS 17 was used for statistical analysis. RESULTS: A total of 27 patients were found eligible. Of them, 2 (7.4%) were males and 25 (92.6%) were females with an overall mean age at the time of splenectomy of 30.8±6.3 years (range: 15-55 years). Out of 27 cases, 23 (85.18%) patients underwent open splenectomy, 3 (11%) laparoscopic and 1 (3.7%) had laparoscopic converted to open splenectomy. Complete response was achieved in 20 (74.1%) patients, whereas 5 (18.5%) had response and 2 (7.4%) had no response. None of the predictors of response to splenectomy were found significant. CONCLUSION: Response to splenectomy in adult Idiopathic Thrombocytopenic Purpura patients was comparable to reported rate in literature with relatively lower morbidity and mortality. Splenectomy is a safe treatment option especially in patients who succumb to adverse effects of medical therapy.

Surgical site infection following hernia repair in the day care setting of a developing country: a retrospective review.

OBJECTIVE: To determine the incidence proportion of surgical site infection following hernia repair in a daycare setting at a tertiary care hospital of a low-income country. METHODS: The retrospective audit was done at the Aga Khan University Hospital, Karachi, from June 1, 2008 to May 30, 2009. Patients with age >15 years who underwent Lichenstein's open mesh repair in daycare were included. Surgical Site Infection was labelled if the records revealed any of the following: opening of the wound by the primary surgeon; pain, tenderness and raised temperature of skin; purulent discharge from the wound; if the surgeon had documented it as a surgical site infection. SPSS 16 was used for data analysis. RESULTS: After reviewing the retrieved files, 104 patients were found eligible. Of them, 102 (98%) were males. Overall wound-related complications were found in 13 (12.5%), whereas surgical site infection was found in 8 (7.7%) patients. The mean age of those with infections was 38.7+/-8 year, while that of those with no surgical site infection was 47.8+/-18 years. Smoking was found significantly associated with surgical site infection with 5.8 times higher incidence as compared to the non-smokers [OR with 95% CI: 5.6 (1.2, 25.3)]. CONCLUSIONS: The incidence of surgical site infection after hernia repair with mesh in a daycare setting at a tertiary care hospital of a low-income country was higher than internationally reported incidence. Smoking was found to be a significant risk factor.

Morbidity meetings: what makes it to; what stays out of the forum.

OBJECTIVES: To review the utility of morbidity and mortality forum in General Surgery at a tertiary care hospital in Karachi, Pakistan. METHODS: The retrospective study was conducted at the Aga Khan University Hospital and reviewed morbidity data from March to May 2009. Case notes of all patients admitted to the General Surgical service during the study period were reviewed to identify in-hospital morbidities. RESULTS: There were a total of 340 inpatients during this period. Case notes identified 61 (17.94%) patients with morbidities; 35 (57.37%) males and 26 (42.62%) females. The morbidity record for the same period identified 32 (52.5%) patients, while 29 (47.5%) morbidities were missed. Of the total morbidities, 32 (52.5%) patients were admitted to the general ward, and 29 (47.5%) to high dependency areas. Nine (28%) morbidities identified in the general ward, and 23 (79%) in high dependency areas were formally presented. Morbidities related to the abdominal cavity were the commonest (n = 22; 36%). Wound-related (n = 17; 28%) and cardio-pulmonary (n = 8; 13%) complication were the next most frequent. CONCLUSIONS: Abdominal cavity morbidities were the most common in this review followed by wound related and cardiopulmonary complications. The morbidity and mortality forum is an educational activity that has stood the test of time and continues to be the cornerstone of post-graduate education. It should be considered a mandatory activity in all postgraduate training programmes.

Laparoscopic splenectomy for haematological disorder: our experience.

Laparoscopic splenectomy has universal acceptance due to less morbidity and decreased incidence of peroperative and postoperative complication. It is not a popular procedure in Pakistan due to technical challenges. Here, we are presenting our experience of laparoscopic splenectomy for haematological disorders at Aga Khan University Hospital. A total of seven cases, underwent elective laparoscopic splenectomy for haematological disorders. The operative time was less than 3 hours with minimal blood loss with rapid and uneventful recovery. There was no procedure related morbidity or mortality; however, one patient expired due to overwhelming post splenectomy sepsis. Our initial report highlights the safety of laparoscopic splenectomy and we propose it to be the procedure of choice in elective splenectomy.

Pakistani urban population demonstrates a poor knowledge about cancers: a pilot survey.

BACKGROUND: This cross-sectional study was carried out to assess the perceptions and level of knowledge of a Pakistani urban population regarding presentations, risk factors, and screening of cancers. METHODS: From 4 tertiary care hospitals, 439 subjects were recruited through convenient sampling method and interviewed using a standard questionnaire. RESULTS: More than 90% of subjects demonstrated poor knowledge. Good knowledge was associated with female gender, being married, higher socioeconomic status, and level of education. CONCLUSIONS: Our sample demonstrates an inadequate knowledge regarding the presentations, risk factors, and screening of cancers. Efforts aiming to correct these deficiencies might result in a successful and cost-effective model for primary and secondary prevention of major cancers in Pakistan.

Chewing of betel, areca and tobacco: perceptions and knowledge regarding their role in head and neck cancers in an urban squatter settlement in Pakistan.

The link of betel, areca and chewable tobacco with head and neck cancers is clearly established. Fifty eight percent of the global head and neck cancers occur in South and Southeast Asia, where chewing of betel, areca and tobacco are common. This study was carried out to establish the pattern of use of Paan, Chaalia, Gutka, Niswar, Tumbaku and Naas among population of squatter settlement of Karachi and to determine the perceptions and knowledge regarding their role in the etiology of head and neck cancers. It was a cross-sectional study, performed at Bilal colony in Karachi. Through systematic sampling, 425 subjects [a male and female from a household] were interviewed with a structured questionnaire. Knowledge regarding etiology of head and neck cancers was classified in ordinals of "good", "some" and "poor", for each substance separately, while practices were classified into "daily user", "occasional user" and "never user". About 40% of the participants were chewing at least one item [betel, areca or tobacco products] on daily basis. This prevalence was 2.46 times higher among males than females and 1.39 times higher among adolescents than adults. At least 79% of the participants were classified as having poor knowledge about the carcinogenicity of each of these items. Knowledge increased with age and level of education. Health hazards of these items were poorly recognized and about 20% perceived at least one of these items to be beneficial. Positive attitudes were seen regarding the steps to curb the production, business and consumption of these substances. In conclusion, prevalence of chewing of betel, areca and tobacco among adults and adolescents is high. Deficiency in knowledge and wrong perception of favorable effect of chewing products is common. Besides curtailing the availability of chewing products, correct knowledge regarding its ill-effects should be inculcated among population to decrease the burden of head and neck cancers.

Office hours vs after-hours. Do presentation times affect the rate of missed injuries in trauma patients?

BACKGROUND: A number of studies have investigated the effect of presentation time on the outcome of patients presenting following trauma. However, it is uncertain whether there is a difference in the incidence of missed injuries between patients presenting during 'office hours' to those presenting in the 'after-hours' period. MATERIALS AND METHODS: We analysed all patients recorded in the Trauma Registry of Royal Perth Hospital (a Level I Trauma Centre for adults in Western Australia) between 2003 and 2013. Patients were divided into 3 groups i.e. those presenting during office hours, those presenting 'after-hours' on a weekday and those presenting on a weekend. In 2008, the State Major Trauma Unit (SMTU) at RPH was initiated following which in-hospital cover by the Trauma Fellows was extended to 11 PM on weekdays. The study was therefore divided into two time periods i.e. pre-SMTU (2003-2007) and post-SMTU (2008-2013). RESULTS: 53,030 patients were recorded in the Trauma Registry in the 10-year period (major and minor trauma). There were 2519 missed injuries in 1262 patients (2.4%). Of these, 2.2% patients presented during office hours, 2.6% 'after-hours on a weekday' and 2.5% on weekends. The odds of missing an injury were 1.2 times higher if the patient presented after-hours (p=0.048). Missed injury rates were found to have increased over the past 10 years (p=0.0179). The odds of missing an injury in 2013 were 1.34 times higher than in 2003. Most of the missed injuries were AIS 1 and 2 (19.8 and 59%) and 55% had no clinical impact on the patients. Thoracic Spine and abdominal injuries were most commonly missed. The only region to show a significant difference between the 3 groups of patients studied was the abdomen (5.3% vs 11.1% vs 6.3%; p=0.004). It was also seen that a larger number of hollow viscus abdominal injuries (5.2%) were missed when compared to solid organs (3.2%; p<0.001). CONCLUSION: Injuries in patients sustaining trauma are more likely to be missed 'after-hours' than during 'office hours'. T-spine and abdominal injuries are more likely to be missed when compared to other anatomical regions of the body.

Socio-demographic correlates of betel, areca and smokeless tobacco use as a high risk behavior for head and neck cancers in a squatter settlement of Karachi, Pakistan.

BACKGROUND: Head and neck cancers are a major cancer burden in Pakistan. They share a common risk factor profile including regular consumption of products of betel, areca and tobacco. Use of paan, chaalia, gutka, niswar and tumbaku is acceptable in Pakistan and is considered a normal cultural practice. This cross-sectional study was carried out to understand the relation of socio-demographic factors for the consumption of paan, chaalia, gutka, niswar and tumbaku in Pakistani population. Through systematic sampling, 425 subjects from a squatter settlement in Karachi were interviewed using a structured questionnaire. High risk behavior was defined as Daily use of any of the above products. RESULTS: Daily use of all the substances except chaalia was higher among males compared to females. Chaalia use was higher among adolescents than adults while non-married consumed both chaalia and gutka more than married. Mohajir ethnicity had higher prevalence of paan, gutka and tumbaku use while Pathans had higher prevalence of niswar use. CONCLUSION: Prevalence of use of chewable products is high in Pakistan with particularly high use of certain substances related with socio-demographic profiles. Industrially prepared products, chaalia and gutka, are gaining popularity among youth. Policies and focused interventions can be developed taking into consideration the preferred use of products among different socio-demographic groups.