Effect of preoperative intravenous steroids on seroma formation after modified radical mastectomy.

OBJECTIVE: To analyse the efficacy of preoperative intravenous injection of 120mg of methylprednisolone acetate steroid on the formation of seroma after modified radical mastectomy in breast cancer patients. Method: The case-control study was conducted at Ward 3, Surgical Unit 1, Department of General Surgery, Jinnah Postgraduate Medical Centre, Karachi, from November 2020 to April 2021, and comprised female patients with biopsy-proven carcinoma of breast who were scheduled for elective definitive breast cancer surgery. The subjects were randomised into treatment group A and control group B. Group A was given a single dose of intravenous injection methylprednisolone acetate 120mg half-an-hour before surgery, while group B underwent similar surgery without the said injection. Seroma was graded using the Common Terminology Criteria for Adverse Events v3.0. The groups were compared for age, total drainage, duration of drainage, seroma grading and wound status. Data was analysed using SPSS 25. RESULTS: Of the 60 patients, there were 30(50%) in each of the two groups. The age difference between groups was non-significant (p=0.346). There was a significant difference in the mean total drainage volume and mean duration of drainage between the groups (p=0.001). Seroma formation, seroma grading and wound status were not significantly different between the groups (p>0.05). The efficacy in treatment was high in group A (odds ratio: 2.78; 95% confidence interval: 0.65-13.94). CONCLUSIONS: A single preoperative dose of Injection methylprednisolone acetate was effective in terms of post-mastectomy outcomes.

Epidemiology of Carcinoma Breast in Young Adolescence Women.

Introduction The aim of this study was to compare epidemiological characteristics of breast cancer in young adolescent women (YAW) versus older women (OW). Methods This was a cross-sectional prospective observational study, conducted in Ward 3, Jinnah Postgraduate Medical Center, Karachi, Pakistan, from September 2021 to February 2022. A total of 120 female patients were recruited in this study from the Outpatient Department of Jinnah Postgraduate Medical Center, out of which 22 patients were below the age of 40 years and 98 were above 40 years. For breast cancer diagnosis, we used the triple assessment method involving clinical examination, radiology, and histopathology. Diagnosed patients were further evaluated for hormonal status and metastatic workup. Results were noted on a performa, and differences between both age groups were analyzed. Results Out of 120 patients, 22 were younger than 40 years and 98 were older than 40 years. YAW used to present late after the appearance of symptoms. Patients of both age groups mostly presented with breast lumps (68.18% in YAW and 81.6% in OW). YAW presented with larger sizes of lumps and with more nodal involvement as compared to OW. BI-RADS IV (Breast Imaging Reporting and Data System Category IV) was the most commonly observed (27.27% in YAW and 48.97% in OW) mammographic finding in both age groups. Invasive ductal carcinoma was the most common histological type in both age groups (72.73% in YAW and 76.53% in OW). The triple-negative disease was more commonly found in YAW than OW (40.91% in YAW vs 21.43% in OW). We found that usually YAW presented at advanced stages (stages III and IV, 54.55%) and higher grades (grade III, 63.63%). Conclusion Breast cancer in young patients is rare but more aggressive with higher grades, advanced stages, and poor prognostic features. Heredity is mainly the risk factor in young breast cancer patients. There should be proper screening programs for high-risk group for early diagnosis and prompt treatment. Other age-specific concerns such as psychological impact of disease should be addressed as well.

Postoperative Analgesia in Modified Radical Mastectomy Patients After Instillation of Bupivacaine Through Surgical Drains.

BACKGROUND: In contrast to other breast surgeries, modified radical mastectomy (MRM) with axillary lymph node clearance involves intense tissue dissection, with postoperative seroma formation and pain being the major complaints affecting patients. Among these, 40% of females experience acute postoperative pain, and between 25 to 60% develop persistent chronic postsurgical pain. The rationale of this study was that minimally invasive procedures can result in immediate pain relief in patients undergoing mastectomy, which has been proven to satisfy their needs and lead to early discharge in the local population. OBJECTIVE: This study determined to find out the efficacy of instilling bupivacaine on wounds by means of surgical drains in controlling pain after MRM. METHODOLOGY: This was a randomized control study trial that was carried out in Surgical Unit 1, Ward 3, Jinnah Postgraduate Medical Centre, Karachi, from November 2020 to April 2021. All patients tested negative for coronavirus disease 2019 (COVID-19) by PCR test before randomly allocating them into two groups. Thirty women in Group B received 40 ml of 0.25% injection bupivacaine, and 30 in Group C received no drug. Duration of analgesia was recorded as time in hours when the patient was received after surgery in the post-anesthesia care unit until the patient felt ache and discomfort of > three scores according to the visual analog pain score chart (VAS). RESULTS: The average age was 52.48±4.76 years. The mean period of time during which analgesia was observed was significantly higher in Group B as compared to Group C (10.93±1.84 vs 5.03±1.35 hours, p=0.0005). CONCLUSION: There is improvement in postoperative analgesia after instilling bupivacaine through surgical drains on wound beds in MRM patients.

Blunt abdominal trauma patients presenting to a tertiary care facility of Pakistan: A three years' experience.

Blunt abdominal trauma (BAT) refers to injuries without wounds entering the peritoneal cavity due to road traffic accidents (RTA) and falls, as a result of collision or counter collision. The objective of the present study was to determine the frequency of patients with visceral injuries in blunt abdominal trauma. This study was carried out in the Department of Surgery, including ward-3 of Jinnah Post Graduate Medical Centre, Karachi, from November 2017 till November 2020. The study design was descriptive case series. During the study period, the data of 112 patients was collected, which comprised of 102 males and 10 females. All the patients between 12 to 65 years of age (mean age:31.84±13.14 years) presenting to the emergency with < 24 hours of abdominal trauma, were included in the study. Organs involved during blunt abdominal trauma were observed and frequency was recorded. Liver injuries were found in 48(42.28%) patients, intestinal injuries in 40(35.7%), splenic injuries in 32(28.5%), kidney injuries in 24(21.4%), pancreatic injuries in 8(7.1%) and stomach injuries in 4(3.5%) patients. Grade 4 liver injury was found in 80(71%) patients, Grade 2 and 3 splenic injuries in 56(50%) patients whereas 47(42%) patients had grade 1 kidney injury. Liver was found to be the most frequent organ involved, followed by intestine and spleen.

Superior Mesenteric Artery Syndrome.

We report a unique case of obstruction of the upper gastrointestinal tract diagnosed in a 15-year boy presenting with a 6-month history of persistent abdominal pain, epigastric fullness, repeated episodes of vomiting, and significant weight loss. The computed tomography (CT) scan of the abdomen with intravenous and oral contrast demonstrated the angle between the aorta and superior mesenteric artery (SMA) to be 15° and revealed the stomach and duodenum to be massively dilated, leading up to a diagnosis of SMA syndrome, which was successfully operated. SMA syndrome is a challenging diagnosis and must always be included in the list of probable diagnoses causing obstruction of the upper gastrointestinal tract. Key Words: Upper gastrointestinal obstruction, Superior mesenteric artery syndrome, Small bowel obstruction, Duodenojejunostomy.

Symptomatic Gallstones in Young Patients Under the Age of 30 Years.

Introduction Gallstones are deposits of digestive fluid that is hardened into small pellets. Gallstones can be symptomatic or asymptomatic. The present study assessed the sociodemographic and clinical characteristics of patients under the age of 30 years old with symptomatic gallstones. Methodology A prospective, observational study was conducted at Surgical Unit-3, at Jinnah Postgraduate Medical Centre (JPMC), Pakistan, from July 2020 to July 2021. All patients suspected of having gallstone disease underwent ultrasonic examination. A diagnosis of gallstone disease was made if the gallbladder showed a hyperechoic mass casting a posterior acoustic shadow, with a change of position. All of the patients with gallstone disease were hospitalized. The patients were asked about their age, past history (with special emphasis on last pregnancy and years of oral contraceptive use, if any), socioeconomic status, and other demographic data. The patients were treated with a cholecystectomy, either laparoscopic or open. Postcholecystectomy complications, if any, were recorded. Results A total of 210 patients under the age of 30 years were included. The mean age of patients was 25 ± 3 years. The majority of the population were females, i.e., 170 (81%). Upon assessing the risk factors, it was found that 31.84% of the female patients had used oral contraceptives, 32.96% were pregnant at the time of presentation, 20.48% had diabetes mellitus, and 27.14% had a history of gallstones. Furthermore, it was found that about 114 (54.29%) patients were overweight with a body mass index (BMI) of 25-30 kg/m2. High triglyceride levels and high cholesterol levels were found in 108 (51.43%) and 115 (54.76%) of the patients, respectively, indicating a link between symptomatic gallstones and younger age. Conclusion Our study indicated that young people are prone to symptomatic gallstones. The rate of disease was considerably high among females and in patients with high cholesterol and triglyceride levels and abnormal body mass index. Further exploratory studies are needed to determine the cause of gallstones.

Frequency and Complications of Ileostomy.

Introduction Ileostomies are life-saving procedures used for temporary fecal diversion in complicated cases of ileal perforation. However, an ileostomy is associated with several complications. The goal of this study was to determine the frequency and complications of ileostomy in the Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Methodology We conducted a longitudinal observational study from July 2019 to July 2020. All patients older than age 12 receiving an ileostomy were included. Patient examinations were conducted on the first postoperative day and were assessed for hemorrhage and necrosis. Examinations were conducted on the seventh postoperative day to assess stoma retraction, stenosis, prolapse, and high-output fistula. Patients were monitored via follow-up in the outpatient clinic every 15 days to record any complications for three months until the reversal was performed. All data were analyzed using IBM SPSS Statistics for Windows, Version 25.0. (Armonk, NY: IBM Corp.). Result A total of 84 patients who received ileostomies were included in the study. Most patients were male (n=62; 73.8%), and 22 were female (26.19%). Of the 84 patients in our study, 34 (40.48%) had tuberculous intestine, 23 (27.38%) had typhoid ileal perforation, 23 (27.38%) were trauma patients, and four patients (4.7%) had gangrenous appendicular perforation. 23 patients (27.3%) were discharged with no complications, and 61 patients (72.69%) developed complications. The most common complication was skin excoriation (19.4%), followed by wound infection (13%), nonfunctioning stoma (11.9%), prolapse and stenosis (6%), retraction (4.7%), high-output fistula (3.5%), parastomal hernia and necrosis (2.3% each), and hemorrhage (1.1%). Conclusion Ileostomy is a common and lifesaving surgical diverting procedure. It is still common in our clinic due to late presentation by patients who need the procedure. Complications are common but manageable. Therefore, it is essential to recognize these complications and manage them early to reduce the morbidity of the patients.

Outcome Of Use Of 1% Silver Nitrate In Patients With Low Lying Perianal Fistula.

BACKGROUND: Anorectal fistula is a common illness which is seen among the middle-aged male patients. Various surgical procedures have been proposed and are associated with the recurrence of the fistula, repeated surgery and in some cases incontinence which may reach up to 43% in complicated fistulas. The purpose of this study was to assess and formulate a non-surgical procedure for fistula in ano through irrigation of the fistula tract with 1% of silver nitrate solution in healing the low perianal fistula. METHODS: Seventy-nine patients presenting to the outpatient department of Ward 3, Surgical unit 1 in Jinnah Postgraduate Medical Centre during a period of 8 months from April to November 2017 with complain of perianal pain and pussy discharge were included in the study. Three patients of the total 79 patients lost to follow up. Outcome measure were cessation of the symptoms for consecutive 10 weeks. RESULTS: Seventy-six patients were assessed and underwent irrigation using this 1% of silver nitrate solution. Out of 76 patients, 58 (76.3%) patients showed complete clinical healing while 18 (23.68%) of patients showed failure to clinical healing. Patients with continuous discharge had a significantly higher rate of complete clinical healing than those with intermittent discharge. CONCLUSIONS: From this study it can be concluded that cauterizing and corrosive properties of silver nitrate are effective in treating the patients with low lying perianal fistula. We suggest that this method should be used as a first line treatment option for all the patients presenting with low lying anal fistula since it is simple, can be easily performed on an OPD basis is minimally invasive and avoids any complication.

Visceral Injuries in Patients with Blunt and Penetrating Abdominal Trauma Presenting to a Tertiary Care Facility in Karachi, Pakistan.

Introduction Abdominal injuries are responsible for 10% of the mortalities due to trauma. Delays in early diagnosis or misdiagnoses are two major reasons for the mortality and morbidity associated with abdominal trauma. The objectives of this study were to determine the frequency of visceral injuries in patients with abdominal trauma and compare the frequency of visceral injuries in patients with blunt and penetrating abdominal trauma. Methods We conducted a cross-sectional study from May 2016 to May 2018 of patients presenting to the emergency department (ED) at Jinnah Postgraduate Medical Center in Karachi, Pakistan. Patients were 12 to 65 years old and presented within 24 hours of abdominal trauma. We recorded the type of abdominal visceral injuries, such as liver, spleen, intestine, stomach, mesentery, and pancreas. Results The mean patient age was 31 ±13 years. Penetrating trauma was found in most patients (n=72, 51%). Liver injuries were found in 37 patients (26.4%), spleen injuries in 29 patient (20.7%), stomach injuries in eight patients (5.7%), intestine injuries in 67 patients (47.9%), mesentery injuries in 21 patients (15%), and pancreas injuries in nine patients (6.4%). The type of abdominal trauma was found significantly associated with liver injury (p-value 0.021), and intestine injury (p-value <0.001). Conclusion Penetrating trauma (51.4%) was more common than blunt trauma (48.5%), and intestines are the most commonly affected by penetrating and blunt trauma injuries (70.1% and 47.8%, respectively). The liver is the most commonly affected (42.85%) in blunt trauma injuries, followed by the spleen (28.5%). The appropriate authorities should consider this information when instituting public health and safety initiatives.

COMPARISON OF OPERATIVE TIME AND LENGTH OF HOSPITAL STAY IN LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE VERSES CHRONIC CHOLECYSTITIS.

BACKGROUND: The laparoscopic surgery has opened a new era in the field of surgery. Currently, it is accepted as the "gold standard" in the treatment of symptomatic cholelithiasis. However, laparoscopic cholecystectomy (LC) performed for acute cholecystitis is technically difficult because of severe inflammatory adhesions and distortion of the biliary anatomy. The objective of this study was to compare the frequency, mean operative time and length of hospital stay in patients of acute and chronic cholecystitis undergoing laparoscopic cholecystectomy. METHODS: This prospective comparative study was carried out in the department of General Surgery Jinnah Postgraduate Medical Centre (JPMC) Karachi, from March to September 2013. During this period 233 patients underwent laparoscopic cholecystectomy (54 cases of acute and 179 cases of chronic cholecystitis respectively). The patients who were pregnant, diagnosed with gall bladder mass on ultrasound, carcinoma gall bladder, acute pancreatitis, and those with comorbid like diabetes mellitus/cardiovascular disorders were excluded. RESULT: A total of 233 patients were admitted for laparoscopic cholecystectomy. Fifty four (54) patients in Group A (acute cholecystitis) and 179 patients in Group B (chronic cholecystitis) with female: male 2.8:1 and 4:1 in Group A and B respectively. Operative time was longer for group A. Six cases of conversion to open procedure one (1) in Group A and 5 in Group B respectively. CONCLUSION: Laparoscopic cholecystectomy is safe and efficient for both acute and chronic cholecystitis.

Adverse effects of diclofenac sodium on renal parenchyma of adult albino rats.

OBJECTIVE: To see the toxic effects of NSAID on kidney tissue of albino rats. METHODS: For this experimental study, 16 albino rats were taken. They were divided into two groups; A and B. The animals in group-A were given Normal Saline. Group-B received Diclofenac Sodium 2 mg/kg/day by feeding tube for 14 days. On day-15 all animals were sacrificed. Kidneys were removed, fixed, embedded in paraffin, section cut at 4 microm thick and stained with H&E, PAS, and silver methenamine. Renal histology was done under light microscope to see the renal tubular diameter, count and cellular detail. RESULTS: The result of present study revealed that diclofenac sodium in single daily dose of 2 mg/kg for a period of two weeks effectively produced destruction of proximal and distal convoluted tubules in adult albino rats showing the dilatation of tubule and flattening of tubular epithelium, disruption of brush border in proximal tubule and thickening of basement membrane around proximal and distal tubular epithelium. CONCLUSION: Diclofenac sodium induced nephrotoxicity causes the destruction of proximal and distal convoluted tubules showing the dilatation of tubule and flattening of its epithelium in albino rats.