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.

Management outcome of residual common bile duct stones at Aga Khan University Hospital.

BACKGROUND: The frequency of residual common bile duct (CBD) stones in patients with previous cholecystectomy ranges from 2-10%, and a minimally invasive approach is generally recommended for these patients. This study reviews the experience in the management of residual CBD stones at the Aga Khan University Hospital. METHODS: All adult patients diagnosed to have residual CBD stones, from 1993 to 2001, were identified and analyzed in terms of the treatment modality utilized and its associated complications. The role of endoscopic sphincterotomy was particularly analyzed in our set-up. RESULTS: The study population consisted of 66 patients. The mean age was 52 (range:18-84 years) years with a female to male ratio of 51:15. The primary mode of management consisted of endoscopic sphincterotomy in 61 patients (92.5%). The initial clearance rate for these patients was 75%, while the remaining 25% required ancillary procedures to achieve a complete clearance. Procedure related complications were observed in 17 (28%) patients, with zero mortality. The other 5 patients (7.5%) underwent an open choledochotomy as a primary procedure with no further complications. CONCLUSIONS: Endoscopic sphincterotomy is the most frequent treatment modality used for the management of residual CBD stones at our hospital. Although initial success rate seems low, the fact that endoscopic sphincterotomy is a less invasive procedure justifies its preferential utilization. The study does not compare the results of endoscopic management with open surgery, as the number of patients managed by open choledochotomy is very small.

Isolated tuberculosis of tunica albuginea and tunica vaginalis presenting as acute hydrocoele: a diagnostic dilemma.

We report the first case of genital tuberculosis (TB) occurring in tunica albuginea (TA) and tunica vaginalis (TV) presenting as acute hydrocoele. A 35-year-old man presented with acute onset left scrotal swelling. Physical examination revealed left hemiscrotal swelling with overlying skin erythema and tenderness. Surgical exploration was carried out due to increasing pain and per operatively found thickened TA and TV with a single small nodule on TA. Histopathology revealed typical granuloma formation, however, no Mycobacterium was seen. Subsequent Ziehl-Neelsen stain on separate tissue specimen confirmed the presence of acid-fast bacilli. Based on these findings, antituberculous treatment was started involving daily isoniazid (INH), rifampicin, ethambutol and pyrazinamide for 2 months and further INH and rifampicin for further 4 months.

Surgical palliation for unresectable pancreatic carcinoma.

OBJECTIVES: To review the results of surgical palliation for unresectable pancreatic carcinoma, and to analyze the morbidity and mortality associated with the surgical procedure. The reasons for readmission after discharge from the hospital were also analyzed. METHODS: A retrospective study from 1995 to 2001 was done on 30 patients with pancreatic cancer operated with palliative intent, or those explored with curative intent but histopathology revealed positive resection margins or lymph node metastasis. RESULTS: Twenty-five (83.25%) patients were above 50 years of age. There were 16 (53.28%) male, and 14 (46.62%) females, 8 (26.64%) had diabetes mellitus, 2 (6.66%) chronic pancreatitis and 4 (13.32%) had smoking as risk factors. Twenty-three (76.59%) patients presented with jaundice, 18 (59.94%) with weight loss, 17 (56.61%) with epigastric pain, 15 (49.95%) with anorexia and 14 (46.62%) with vomiting. Whipple's procedure was performed in 9 (29.97%) patients, triple bypass in 13 (43.29%), choledochojejunostomy and gastrojejunostomy in 3 (9.99%) and gastrojejunostomy alone in 5 (16.65%) patients. Seven (23.31%) patients had preoperative ultrasonography, while CT Scan was done in 24 (79.92%) and ERCP in 8 (26.64%) patients. Histopathology showed positive resection margins in 9 (29.97%) patients and lymph node metastasis in 5 (16.65%) patients. Seventeen (56.61%) patients received less than 2 units of pack cells transfusion. Most of the patients remained admitted in the hospital between 20 to 30 days. Post-operatively, delayed gastric emptying was detected in 6 (19.98%) patients, cholangitis in 2 (6.66%), wound infection in 3 (9.99%), anastomotic leak in 2 (6.66%) and line sepsis in 2 (6.66%) patients. Three (9.99%) patients expired in hospital post operatively. The reasons for re-admission after discharge included abdominal pain in 9 (29.97%) patients, anemia in 3 (9.99%), intestinal obstruction in 3 (9.99%) and urinary tract infection in 2 (6.66%) patients. Follow up record was available for 22 (73.26%) patients. Six (19.98%) patients survived for 5 to 6 months and 9 (29.97%) had a survival between 7 to 10 months. CONCLUSION: A single surgical procedure can palliate all three symptoms associated with unresectable pancreatic carcinoma, and can be carried out with reasonable safety in selected patients. The commonest indication for re-admission is severe abdominal pain associated with advanced malignancy, hence chemical splanchiectomy may also be considered at the time of surgical exploration.

Postoperative port-site pain after gall bladder retrieval from epigastric vs. umbilical port in laparoscopic cholecystectomy: a randomized controlled trial.

OBJECTIVE: To determine whether gall bladder (GB) retrieval from umbilical port is associated with more pain at port site as compared to GB retrieval from epigastric port in adult patients undergoing four port elective laparoscopic cholecystectomy at a tertiary care hospital. METHODS: Adult patients, who were undergoing elective laparoscopic cholecystectomy during a six month period in 2010 at our institute, were randomized to either group A (n = 60, GB retrieval through epigastric port) or group B (n = 60, GB retrieval through umbilical port). VAS for pain was assessed by a registered nurse at 1, 6, 12, 24 and 36 h after surgery. RESULTS: The VAS for pain at umbilical port was less than epigastric port at 1, 6, 12, 24 and 36 h after surgery (5.9 ± 1.1 vs. 4.1 ± 1.5, 4.6 ± 0.94 vs. 3.5 ± 1.05, 3.9 ± 0.85 vs. 2.4 ± 0.79, 3.05 ± 0.87 vs. 2.15 ± 0.87, respectively) and the difference was statistically significant (p-value < 0.001). Multiple linear regression was done for port site pain at 24 h and the VAS at umbilical port was less than epigastric port with VAS difference of 0.9 after adjusting for age, sex, duration of surgery and additional analgesia use (r2 = 0.253, p-value < 0.001). CONCLUSION: Gall bladder retrieval from umbilical port is associated with lower port site pain than GB retrieval from epigastric port in patients undergoing elective laparoscopic cholecystectomy. We recommend umbilical port for gall bladder retrieval.

Gallbladder intestinal metaplasia in Pakistani patients with gallstones.

The gallbladder specimens of patients who underwent cholecystectomy for symptomatic gallstones between 2003 and 2005 were evaluated for the presence of Intestinal Metaplasia. (IM) and its risk factors. IM was positive in 39% of 293 patients tested, and in the comparative analysis of 114 metaplasia positive versus 179 negative patients, a high risk was found in patients who were 60 years or older [adjusted odds ratio (aOR) = 3.0, 95% confidence interval (CI): 1.5, 6.2]. Other factors with aOR greater than 1 were moderate to excessive use of chilies (1.8) and ethnic origin of North India (1.7). Screening method has yet to be devised for early detection of gallbladder cancer by identifying metaplastic lesions early in life. We believe that large geographic variation and lifestyle environmental factors associated with the development of gallbladder metaplasia and cancer mortality are concealed in our study that needs to be further explored.

Treatment of complex fistula in ano with cable-tie seton: a prospective case series.

Objective. To determine the fecal incontinence and recurrence rate in patients with complex fistula in ano managed with cable tie seton at a tertiary care teaching hospital. Methods. This is a prospective case series of patients with complex anal fistula i.e. recurrent fistula or encircling >30% of external anal sphincter, managed with cable tie seton from March 2003 to March 2009. Patients were seen in the clinic after 72 hours of seton insertion under anesthesia and then every other week. Each time the cable-tie was tightened if found loose without anesthesia and incontinence was inquired according to wexner's score. Results. Seventy nine patients were treated during the study period with the age (mean ± standard deviation) of 41 ± 10.6 years and. The seton was tightened with a median of six times (3-15 times range). Complete healing was achieved in 11.2 ± 5.7 weeks. All the patients were followed for a minimum period of one year and none of the patients had any incontinence. Recurrence was found in 4 (5%) patients. Conclusion. The cable tie seton is safe, cost effective and low morbidity option for the treatment of complex fistulae-in-ano. It can, therefore, be recommended as the standard of treatment for complex fistulae-in-ano requiring the placement of a seton.