Exploring the uncommon: A case report on localized peritonitis caused by ingested toothpick.

INTRODUCTION: Bowel perforation is a serious emergency. Occasionally, sharp objects like toothpicks can get stuck in narrow parts of the small intestine, potentially resulting in impaction, obstruction, or perforation. PRESENTATION OF CASE: A 20-year-old male arrived at our hospital's emergency department with sudden, severe abdominal pain persisting for 24 h. On examination, his abdomen showed tenderness, and bowel sounds were reduced. Contrast-enhanced computed tomography (CECT) indicated possible small intestine inflammation due to a foreign object and a diagnostic laparoscopy revealed a hyperemic terminal ileum. DISCUSSION: This case involves ileal perforation from an unnoticed toothpick ingestion. Detecting foreign object perforations is challenging, often leading to misdiagnoses and CT scans are the most effective for toothpick detection. Definitive diagnosis is through laparoscopy, and treatment varies between laparoscopic suturing to intestinal resection. CONCLUSION: Healthcare providers must consider toothpick ingestion in cases of acute abdominal symptoms to avert treatment delays and potential life-threatening outcomes.

Stress and coping among surgery residents in a developing country.

OBJECTIVE: Stress during residency training in surgical disciplines not only hampers professional development but can also compromise patient care and personal health. The purpose of this study was to measure the stress level among the surgical residents, identify factors within the learning and work environment that cause stress, and identify different strategies that the residents use habitually to cope with these stresses. METHODOLOGY: This mix method study was conducted in the department of Surgery at Aga Khan University, Pakistan. Residents' stress level was measured using Perceived Stress Scale (PSS); focus group discussions (FGDs) with faculty and residents explored stressors during residency training, while Brief COPE Inventory identified the residents' preferred coping strategy. RESULTS: A total of 68 (83%) surgery residents completed the survey of which 19% had high stress scores while only one resident had perception of low stress. Females had significantly higher stress scores (25.7±3.0; p=0.008) as compared to male counterparts. Planning (87.8%) and Self-distraction (65%) were the most commonly used adaptive and maladaptive strategies respectively. The reliability of the PSS and BCI measured by Cronbach's alpha was 0.73 and 0.82 respectively. Work-life imbalance, workload and contradicting programme and hospital policies were identified in FGDs as major stressors during residency. CONCLUSIONS: Although surgical residency programmes are very stressful, coping strategies are not formally taught during surgical training. Academia and hospital should join hands in developing interventions to enable residents cope with the situation.

Template operative note, a better documentation.

Operative notes are a valuable part of patient's medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness.

Factors Associated with Premalignant Epithelial Changes in Chronic Calculous Cholecystitis: A Case-Control Study.

INTRODUCTION: Gallstones are known to be associated with premalignant changes in the gallbladder epithelium that range from atypical hyperplasia, metaplasia, dysplasia to carcinoma. Recognition of factors associated with these changes in patients with gallstones can potentially be helpful in identifying patients to whom prophylactic cholecystectomy can be offered to reduce the chances of developing carcinoma. OBJECTIVE: To identify factors associated with premalignant epithelial changes including atypical hyperplasia, metaplasia, and dysplasia in gallbladder mucosa in patients with chronic calculus cholecystitis. MATERIALS AND METHODS: This was retrospective case-control study conducted over a period of 10 years from 2004 to 2014. Cases were patients with reported histopathological premalignant epithelial changes along with chronic calculus cholecystitis, and controls were patients without premalignant epithelial changes but chronic calculus cholecystitis. Controls were twice the number of the cases. RESULTS: Over study period, 92 patients were reported to have premalignant epithelial changes on gall bladder histopathology for whom 184 controls were selected. Of cases, 61 (66%) patients had atypical hyperplasia, while metaplasia and dysplasia were present in 26 (28%) and 5 (5%) cases, respectively. Mean age was 47.5 ± 14.5 years, and 74% of the study population were female. Wall thickness of more than 3 mm (OR = 4.14, p value < 0.001) turned out to be statistically significant independent variables associated with premalignant lesions in gallbladder mucosa. CONCLUSION: Odds of premalignant epithelial change in gall bladder mucosa in patients with gall bladder wall thickness of more than 3 mm is four times the odds of patients with wall thickness less than 3 mm, and the effect is statistically significant. Prophylactic cholecystectomy should be considered for this group of patients.

Risk of appendicitis in patients with incidentally discovered appendicoliths.

BACKGROUND: An appendicolith-related appendiceal obstruction leading to appendicitis is a commonly encountered surgical emergency that has clear evidence-based management plans. However, there is no consensus on management of asymptomatic patients when appendicoliths are found incidentally. The objective of this study was to determine the risk of appendicitis in patients with an incidental finding of the appendicolith. METHODS: A retrospective matched cohort study of patients with appendicolith discovered incidentally on computed tomographic scan from January 2008 to December 2014 at our institution was completed. The size and position of the appendicolith were ascertained. The study group was matched by age and gender to a control group. Both groups were contacted and interviewed regarding development of appendicitis. RESULTS: In total, 111 patients with appendicolith were successfully contacted and included in the study. Mean age was found to be 38 ± 15 y with 36 (32%) of the study population being females. Mean length of appendix was 66 ± 16 mm, and mean width was 5.8 ± 0.9 mm. Mean size of the appendicolith was 3.6 ± 1.1 mm (1.4-7.8 mm). Fifty-eight percent of appendicoliths was located at the proximal end or whole of appendix, 31% at mid area, and 11% at the distal end of appendix. All patients of the study and control groups were contacted, and at a mean follow-up of 4.0 ± 1.7 y, there was no occurrence of acute appendicitis in either group. CONCLUSIONS: Patients with incidentally discovered appendicolith on radiological imaging did not develop appendicitis. Hence, the risk of developing acute appendicitis for these patients does not seem higher than the general population.

Bacterobilia in acute cholecystitis: Bile cultures' isolates, antibiotic sensitivities and antibiotic usage. A study on a Pakistani population.

Acute cholecystitis is one of the most common acute surgical conditions. Laparoscopic cholecystectomy remains the mainstay of treatment. In patients managed non-operatively, antibiotics play an important role in the treatment of cholecystitis. The current retrospective observational study was conducted at a tertiary care hospital in Karachi, and comprised medical records of patients admitted between 2008 and 2014with acute cholecystitis and in whom bile cultures were obtained. Of the 509 patients with a mean age of 51.15 ± 13.4years, early laparoscopic cholecystectomy (within 72hours) was performed on 473(92.9%) cases, while the rest underwent percutaneous cholecystostomy. Bile cultureswere positive in 171(33.6%) patients. Predominantly gram-negative organisms were isolated among a total of 137(27%), with E.coli 63(46%) being the most commonly isolated organism. Of the gram-positive organism, enterococcus 11(8%) was the most common. Antibiotic sensitivities were determined.Based on our findings gram-negative coverage alone should be sufficient in our segment of the population.

Perforated sub-hepatic appendix; rare presentation of a common disease.

An elderly gentleman presented to our emergency with a 10-day history of right upper quadrant pain and nausea with associated tenderness on examination. His white cell counts were raised with predominant neutrophils with ultrasound evidence of a heterogeneous sub-hepatic collection, not associated with fever, diarrhoea or vomiting. He had a similar episode 3 weeks ago, which resolved with antibiotics. Initially thought to be a perforated acute appendicitis or a liver abscess a CT scan was done to further substantiate our finding. This to the contrary revealed a perforated sub hepatic appendix. Patient was treated conservatively with IV fluids and antibiotics and the sub hepatic collection was aspirated under ultrasound guidance. He responded well to treatment and made an uneventful recovery.

Experience of managing complicated diverticulitis of colon: a retrospective case series from South Asian country.

OBJECTIVE: To assess the morbidity and mortality associated with complicated diverticulitis in Pakistan. METHODS: The retrospective case series was conducted at an urban tertiary care university hospital of Karachi, Pakistan, comprising data from December 1989 to November 2010. International Classification of Diseases codes for diverticular disease and diverticulitis with abscess, fistula, stricture, bowel obstruction and perforation were obtained from the medical record department. SPSS 19 was used for statistical analysis. RESULTS: A total of 60 (1.9%) cases with complicated diverticulitis were located from among 3170 records reviewed. Mean age was 62.7 +/- 13 years with male-to-female ratio being 36:24. In 37 (62%) patients, the diagnosis was established on computed tomography scan of the abdomen, followed by barium enema in 12 (20%) and colonoscopy in 11 (18%). Post-operative morbidity was observed in 24 (40%) and 7 (16%) expired within 28 days of surgery. Post-operative intra-abdominal sepsis, wound dehiscence and incisional hernia were significantly associated with generalised peritonitis (p < 0.05), while admission to intensive care unit was associated with age over 60 years and faecal peritonitis. Post-operative mortality was significantly associated with high American Society of Anaesthesiologists-score III and IV and age above 60 years. CONCLUSION: Complicated diverticulitis carries significant morbidity and mortality in Pakistani population. Since the trend is on the rise, therefore we propose a prospective multi-centre cohort study to understand the spectrum of disease, management and identification of risk factors to achieve the best possible outcomes in patients with complicated diverticulitis.

Outcomes of Xanthogranulomatous cholecystitis in laparoscopic era: A retrospective Cohort study.

INTRODUCTION: Xanthogranulomatous cholecystitis (XGC) is a rare variant of cholecystitis and reported incidence of XGC varies from different geographic region from 0.7% -9%. Most of the clinicians are not aware of the pathology and less evidence is available regarding the optimal treatment of this less common form of cholecystitis in the present era of laparoscopic surgery. MATERIALS AND METHODS: A retrospective cohort study was conducted in a tertiary care university hospital from 1989 to 2009. Histopathologically confirmed XGC study patients (N=27) were compared with non-Xanthogranulomatous cholecystitis (NXGC) control group (N=27). The outcomes variables were operative time, complication rate and laparoscopic to open cholecystectomy conversion rate. The study group (XGC) was further divided in to three sub groups; group I open cholecystectomy (OC), laparoscopic cholecystectomy (LC) and laparoscopic converted to open cholecystectomy (LCO) for comparative analysis to identify the significant variables. RESULTS: During the study period 6878 underwent cholecystectomy including open cholecystectomy in 2309 and laparoscopic cholecystectomy in 4569 patients. Histopathology confirmed xanthogranulomatous cholecystitis in 30 patients (0.43% of all cholecystectomies) and 27 patients qualified for the inclusion criterion. Gallbladder carcinoma was reported in 100 patients (1.45%) during the study period and no association was found with XGC. The mean age of patients with XGC was 49.8 year (range: 29-79), with male to female ratio of 1:3. The most common clinical features were abdominal pain and tenderness in right hypochondrium. Biliary colic and acute cholecystitis were the most common preoperative diagnosis. Ultrasonogram was performed in all patients and CT scan abdomen in 5 patients. In study population (XGC), 10 were patients in group I, 8 in group II and 9 in group III. Conversion rate from laparoscopy to open was 53 % (n=9), surgical site infection rate of 14.8% (n=4) and common bile duct injury occurred one patient in open cholecystectomy group (3.7%). Statistically significant differences between group I and group II were raised total leukocyte count: 10.6±3.05 vs. 7.05±1.8 (P-Value 0.02) and duration of surgery in minutes: 248.75±165 vs. 109±39.7 (P-Value 0.04). The differences between group III and group II were duration of surgery in minutes: 208.75±58 vs. 109±39.7 (P-Value 0.03) and duration of symptoms in days: 3±1.8 vs. 9.8±8.8 (P-Value 0.04). The mean hospital stay in group I was 9.7 days, group II 5.6 days and in group III 10.5 days. Two patients underwent extended cholecystectomy based on clinical suspicion of carcinoma. No mortality was observed in this study population. Duration of surgery was higher in XGC group as compared to controls (NXGC) (203±129 vs.128±4, p-value=0.008) and no statistically significant difference in incidence proportion of operative complication rate were observed among the group (25.9% vs. 14.8%, p-value=0.25. Laparoscopic surgery was introduced in 1994 and 17 patients underwent laparoscopic cholecystectomy and higher conversion rate from laparoscopic to open cholecystectomy was observed in 17 study group (XGC) as compared to 27 Control group (NXGC) 53%vs.3.3% with P-value of < 0.023. CONCLUSION: XGC is a rare entity of cholecystitis and preoperative diagnosis is a challenging task. Difficult dissection was encountered in open as well in laparoscopic cholecystectomy with increased operation time. Laparoscopic cholecystectomy was carried out with high conversion rate to improve the safety of procedure. Per operative clinical suspicion of malignancy was high but no association of XGC was found with gallbladder carcinoma, therefore frozen section is recommended before embarking on radical surgery.

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.

Abdominal tuberculosis with massive jejunal haemorrhage.

Jejunum is a rare site of involvement in intestinal tuberculosis (TB) and massive lower gastrointestinal haemorrhage is an even rare reported condition. The authors report a 15-year-old female student, who presented with fever, anaemia, hypoalbunemia and developed massive lower gastrointestinal haemorrhage during hospital stay. The diagnosis of abdominal TB was established on tissue biopsy; tissue culture was positive for Mycobacterium TB. Optimal outcome was achieved with aggressive resuscitation, repeated mesenteric angio-embolization and anti-tuberculosis chemotherapy.

Fulminant amoebic colitis: a rare fierce presentation of a common pathology.

We conducted a retrospective study of patients with fulminant amoebic colitis (FAC) over a 20 year period in an urban tertiary care hospital in Pakistan. After consideration for inclusion and exclusion criteria 25 cases were identified as FAC with the most common presentations being abdominal pain (84%). Nineteen (76%) underwent laparotomy for peritonitis with evidence of: colonic perforation in 10 (40%); faecal peritonitis in eight (32%); bowel gangrene in one (4%); and intra-abdominal abscess in two (8%). Nine (36%) deaths were recorded in the series - eight (53%) in the operated group and one (16.6%) in the medically-treated group. The optimal outcome can be achieved in FAC with aggressive resuscitation, intravenous broad-spectrum antibiotics, including metronidazole, and total colectomy without anastomosis in patients with peritonitis.

Intramural gas in stomach along with acute calculus cholecystitis: an unusual association.

Intramural gas in stomach is a rare finding, but differential diagnosis of this condition into gastric emphysema and emphysematous gastritis is clinically important because of vastly different aetiologies and prognosis. Emphysematous gastritis is caused by gas producing micro-organisms inside the stomach wall and is a potentially fatal condition, while, on the other hand, gas enters stomach wall through mucosal breach in the case of gastric emphysema and prognosis is usually good with complete resolution. To date, no case has been reported in the literature showing gas in the stomach wall in a patient with acute calculus cholecystitis. We present a case of a young man with upper abdominal pain, and who, upon diagnostic work up was diagnosed with acute calculus cholecystitis with associated intramural gas in the stomach with no known aetiological factors to be positive. Conservative management with close observation resulted in complete symptomatic resolution.

Abdominal angina--a rare cause of chronic abdominal pain.

We report here a case of chronic postprandial abdominal pain and weight loss of more than one year duration. He was diagnosed to have abdominal angina (chronic mesenteric ischemia) on CT angiography. Open surgical revascularization procedure-right common iliac mesenteric polytetrafluoroethylene (PTFE) bypass graft achieved positive short and longterm outcome with follow-up of twenty two months.

Delayed surgical therapy reduces mortality in patients with acute necrotizing pancreatitis.

OBJECTIVE: To review the trends in management and analyze the factors influencing outcomes of acute necrotizing pancreatitis. METHODS: It was a retrospective analytical study. All adult patients with computed tomography with proven necrotizing pancreatitis managed at the department of surgery, Aga Khan University Hospital, Karachi were included in this study extending from January 1998 to January 2008. Outcome variables were hospital stay, complication rate and in-hospital mortality. Data analysis was carried out using SPSS version 16. For comparison, Pearson chi-square test, Fisher's exact test, t-test and ANOVA were used, where applicable. A p-value less than 0.05 was considered statistically significant. RESULTS: Of 1479 patients, 47 patients were included. Median age was 48 (range: 38-56) years with 31 (66%) males and 16 (34%) females. Overall out of 18 (38%) that underwent necrosectomy, 16 had infected acute necrotizing pancreatitis while the rest were negative. Computed Tomography and/or FNAC identified 18 infective acute necrotizing pancreatitis patients, 16 underwent necrosectomy, one patient expired without surgery and the other was managed conservatively. Enteral nutrition was widely used with rising trend of oral feeding from 2006 onwards. Complication rate was 63%. Overall mortality remained 9/47 (19.7%), where in infected ANP as well as in postoperative patients, mortality was 7/18 (38.9%). The patients with early pancreatic necrosectomy had prolonged hospital stay, more complications and statistically significant increase in in-hospital mortality. CONCLUSION: Better outcomes were achieved in infected acute necrotizing pancreatitis with delayed pancreatic necrosectomy and the other contributing factor could be early enteral nutritional therapy.

Acute mesenteric, portal and inferior vena cava (IVC) venous thrombosis: optimal outcome achieved with anticoagulation.

The prevalence and clinical spectrum of acute mesenteric venous thrombosis (AMVT) in Pakistan is largely unknown. The authors report two patients with acute mesenteric, portal and inferior vena cava venous thrombosis confirmed on CT imaging. The diagnoses were established within 24 hours of presentation and both patients were successfully treated with therapeutic heparin during hospital admission and continued on oral warfarin because of hypercoagulable state. The protocol that we currently use is evidence based and is leading to optimal outcome.

Pyogenic psoas abscess: case series and literature review.

From 1998 to 2008, six patients with pyogenic psoas abscesses were managed. Pain and fever were the most common presentations. Two patients had primary pyogenic abscesses and four had secondary pyogenic abscesses. The diagnoses were made either by computed tomography scans (50%) or magnetic resonance imaging and pus culture were obtained. The associated conditions included: perinepheric abscess (1); lumbar discitis (2); and infected thrombosed abdominal aortic aneurysm (1). Five patients underwent radiologically-guided percutaneous drainage and one required open surgical drainage of the abscess cavity. Optimal results were achieved in all cases except one who died of acute myocardial infarction.

Acute free perforation of gall bladder encountered at initial presentation in a 51 years old man: a case report.

INTRODUCTION: Gallbladder perforation is a rare but life threatening event. We describe a case of gallbladder perforation encountered at initial presentation. CASE PRESENTATION: A 51 years old male, without any known medical co-morbidity, presented with a 1-day history of sudden-onset abdominal pain and abdominal distension. On examination, his abdomen was distended with generalized tenderness on palpation. Abdominal x-ray showed no signs of intestinal obstruction or pneumoperitoneum. Computed tomography scan of the abdomen showed appearance suggestive of gallbladder perforation. The patient was taken to the operating room and a diagnostic laparoscopy was performed revealing yellowish green fluid in the peritoneum. Difficulty in visualization of the anatomy led to conversion of the procedure to an open laparotomy. Intra-operative findings included a perforation near the neck of the gall bladder in association with a 2 x 1 cm gall stone. Near-total cholecystectomy was performed and a single large gall stone was retrieved. The peritoneal cavity was washed with normal saline and a drain was placed. The rectus sheath was closed but the wound was kept open for healing by delayed primary closure. The patient's hospital course was uneventful and he was discharged from the hospital on the 3rd post-operative day. He returned to the clinic after one week whereby his drain was removed and his wound closed. CONCLUSION: Gallbladder perforation is an unusual initial presentation of gallbladder disease. Early diagnosis of gallbladder perforation and immediate surgical intervention are of prime importance in decreasing morbidity and mortality associated with this condition.

Rhizopus necrotizing fasciitis of caesarean wound - a rare life threatening condition.

Mucormycosis is a rare cause of necrotizing fasciitis in immunocompromised patients. We report a young female, who developed rhizopus necrotizing fasciitis of caesarean wound. The lady died secondary to non-responding sepsis and irreversible multi-organ failure. High index of suspicion can lead to early diagnosis by frozen section of histopathology and fungal culture technique. Aggressive surgical debridement and intravenous anti-fungal medication is the main stay of treatment. A delay in diagnosis and treatment may cause multi-organ failure leading to high mortality.

Non-traumatic right hepatic artery pseudoaneurysm: an unusual cause of hemobilia and obstructive jaundice.

Most hepatic artery pseudoaneurysms (HAPA) are post traumatic, and non-traumatic pseudoaneurysm is rarely reported. It is a potentially life threatening vascular disorder and difficult to diagnose before rupture. Early diagnosis and prompt nonoperative intervention of this lesion could be life saving. The authors report the case of a patient with hemobilia caused by ruptured right hepatic artery pseudoaneurysm and subsequently developed right hepatic duct stricture, which has not been reported previously. This patient was successfully treated with endovascular stent graft of pseudoaneurysm and endoscopic stenting of right hepatic duct stricture.