Traumatic pancreatic injury--an elusive diagnosis: experience from a developing country urban trauma referral centre.

OBJECTIVE: To determine the frequency of pancreatic injury in patients presenting with trauma and to review the mechanism of injury, management, subsequent complications and in-hospital mortality rate associated with these patients. METHODS: The retrospective study included all patients over 18 years of age presenting with pancreatic injury due to trauma at the Aga Khan University Hospital, Karachi, between January 1990 and December 2009. Patients with iatrogenic pancreatic injury were excluded. The severity of the injury was assessed using the Injury Severity Score, while it was graded according to the scale defined by the American Association for the Surgery of Trauma. SPSS 17 was used for statistical analysis. RESULTS: A total of 30 patients were identified representing just 1.5% of the total adult abdominal trauma patients. The mean age of the patients was 28 +/- 9.7 years. There were 28 (93.3%) males and just 2 (6.6%) females. The complication rate was 80% (n = 24) and the mortality rate was 23.3% (n = 7). Of the 30 patients, 19 (63%) had been transferred from some other medical facility.The mean length of hospital stay was 16.4 +/- 20.6 days (range 5-97 days). CONCLUSION: Surgical management in pancreatic trauma patients should be dictated by the degree and location of pancreatic injury, associated injuries and time from event to presentation. Mortality was primarily determined by associated life-threatening injuries.

Intraperitoneal lignocaine (lidocaine) versus bupivacaine after laparoscopic cholecystectomy: results of a randomized controlled trial.

BACKGROUND: Intraperitoneal local anesthetics have been shown to improve postoperative pain after laparoscopic cholecystectomy (LC). However, the choice of local anesthetic agent is debatable. We compared the analgesic efficacy of intraperitoneal lignocaine (lidocaine) versus bupivacaine after elective LC. METHODS: We conducted a double-blind, randomized, controlled trial. We randomized consecutive patients undergoing LC into two groups. Group L received 10 mL 2% lignocaine (lidocaine), whereas Group B received 10 mL 0.5% bupivacaine, each diluted in 10 mL normal saline. All patients underwent standard perioperative anesthesia and analgesia protocol. We assessed patients at 0, 4, 8, 12, and 24 h postoperatively for pain using the visual analogue scale and verbal rating scale, and the need for additional analgesic medications. RESULTS: We analyzed a total of 206 patients: 106 in Group L and 100 in Group B. Demographic details were similar between groups (P > 0.05). Abdominal pain decreased significantly with time in both groups, with a similar mean response profile (P < 0.001). There was no statistically significant difference between groups with regard to abdominal or shoulder pain by both visual analogue scale and verbal rating scale at all five time intervals (P > 0.05). There was also no significant difference in the side effect profile of both drugs (P > 0.05). A lower proportion of patients in Group B required additional narcotic analgesia (87%) compared with Group L (94%). This difference was marginally significant (P = 0.057). CONCLUSIONS: Bupivacaine and lignocaine (lidocaine) are both safe and equally effective at decreasing postoperative pain after LC.

Portal hypertensive biliopathy: review of pathophysiology and management.

Portal hypertensive biliopathy is described as abnormalities of the walls of the biliary tree secondary to portal hypertension. In literature it has also been named as "Cholangiopathy associated with portal hypertension", "Portal biliopathy" and "Portal cavernoma associated cholangiopathy". It is usually asymptomatic and found incidentally, but rarely patients do present with symptoms of abdominal pain, jaundice, asthenia and fever. Treatment is warranted in symptomatic cases only, and is dictated by the clinical manifestations and complications of the disease process. Due to presence of underlying severe portal hypertension, endoscopic biliary intervention is usually the first line of management, and is relatively safe and often sufficient. When surgery is resorted to, a porto-systemic shunt prior to biliary bypass procedure provides early relief of obstructive biliary symptoms and often precludes the need for a biliary bypass surgery. This review describes the pathophysiology, presentation, progression and management approaches to portal biliopathy.

The use of intrathecal baclofen for management of spasticity in hereditary spastic paraparesis: A case series.

Hereditary Spastic Paraparesis (HSP) causes lower limb spasticity, pain and limits ambulation resulting in a negative impact on an individual's quality of life. This case series evaluates the use of Intra-thecal Baclofen (ITB) on 5 ambulant children with HSP. Our results suggest ITB is associated with a reduction in spasticity and a trend towards improvement in patient-reported quality of life and achievement of personalised goals. This was evidenced with lower Modified Ashworth Scale (MAS) scores and increasing values using the Cerebral Palsy Quality of Life (CPQoL) tool and Goal Attainment Scale (GAS). ITB was not associated with any major immediate or longer-term adverse effects. Overall, our study supports the role of ITB, used in a goal-directed manner, in the management of children and young people with HSP where other standard treatment options have been unsuccessful.

Early complications after biliary enteric anastomosis for benign diseases: a retrospective analysis.

BACKGROUND: Biliary-enteric anastomosis (BEA) is a common surgical procedure performed for the management of biliary obstruction or leakage that results from a variety of benign and malignant diseases. Complications following BEA are not rare. We aimed to determine the incidence and the factors associated with early complications occurring after BEA for benign diseases. METHODS: We reviewed the medical records of all patients who underwent BEA for benign diseases at our institution between January 1988 and December 2009. The primary outcome was early post operative complication. Logistic regression analysis was done to identify factors predicting the occurrence of complications. RESULTS: Records of 79 patients were reviewed. There were 34 (43%) males and 45 (57% females). Majority (53%) had choledocholithiasis with impacted stone or distal stricture, followed by traumatic injury to the biliary system (33%). Thirty-four patients (43%) underwent a hepaticojejunostomy, 19 patients (24%) underwent a choledochojejunostomy, and choledochoduodenostomy was performed in 26 patients (33%). Early complications occurred in 39 (49%) patients - 41% had local complications and 25% had systemic complications. Most frequent complications were wound infection (23%) and bile leak (10%). Four (5%) patients died. On multivariate analysis, low serum albumin level (odds ratio = 16, 95% CI = 1.14-234.6) and higher ASA levels (odds ratio = 7, 95% CI: 1.22-33.34) were the independent factors predicting the early complications following BEA. CONCLUSIONS: Half of the patients who underwent BEA for benign diseases had complications in our population. This high incidence may be explained by the high incidence of hypoalbuminemia and the high-risk group who underwent operation.

Leaking pseudoaneurysm of hepatic artery: a potentially life-threatening complication of a common procedure.

We report a case of leaking pseudoaneurysm of right hepatic artery in a 54-year old female after laparoscopic cholecystectomy who presented with massive gastrointestinal haemorrhage and was successfully managed with angiography and coil embolization.

Primary non-functioning paraganglioma of liver: a rare tumour at an unusual location.

Pheochromocytomas are rare tumours, 22% of which are extra-adrenal and are known as paragangliomas. We report a case of a young male with non-functioning paraganglioma of the liver; a very uncommon primary site. A CT scan with contrast showed a huge, highly vascular mass lesion in the right lobe of the liver and a core biopsy confirmed it to be a paraganglioma. Whole body study with iodine-131-meta-iodobenzylguanidine (MIBG) tracer highlighted the liver tumour but was negative for any other active lesions depicting that the tumour was confined to the liver. The lesion was completely resected by extended right hepatectomy and the patient had an uneventful recovery. There is no evidence of disease recurrence at 3 years of follow up.

Knowledge and practice of healthy lifestyle and dietary habits in medical and non-medical students of Karachi, Pakistan.

OBJECTIVE: To objectively compare the differences in knowledge and practices regarding healthy lifestyle among medical and non-medical students of Karachi along with assessment of any perceived barriers. METHODS: This cross-sectional study included 350 students between ages 17-24 years from 6 private universities of Karachi--three medical and three non-medical Institutions. A self-reported questionnaire was employed to assess attitude and barriers to healthy practices among the simple random selection of students. RESULTS: On a 10-point scale, the average knowledge score of students on general and clinical nutritional knowledge was 5.7 +/- 1.51 and 4.4 +/- 1.77, respectively and the difference was statistically significant (p < 0.01). Conversely the diet and lifestyle score (85-point scale) among medical (41.3) and non medical students (40.8) was not significant (p = 0.646). There was no difference between the perception of medical and non-medical students regarding 'work-related stress' in their life. 'Lack of time' was cited as the most important reason for skipping meals and as a barrier to exercising regularly among both groups. CONCLUSION: The knowledge, attitudes and practices of medical students in Karachi suggest that superior knowledge about healthy lifestyle does not necessarily result into better practices.

Characteristics of TIA and its management in a tertiary care hospital in Pakistan.

BACKGROUND: Transient ischemic attack (TIA) is described as a brief episode of neurological dysfunction caused by focal brain ischemia, with clinical symptoms typically lasting less than an hour, and without evidence of acute infarction. Recent studies depict TIA as a particularly unstable condition. Risk of stroke is greater than 10% in the first 90 days after an index TIA. The presentation, prognosis and intervention for TIA have not been reported in South-Asians in a developing country. METHOD: A retrospective chart review was done for 158 patients who were admitted with the diagnosis of TIA, as defined by ICD 9 code 435, from January 2003 to December 2005 at the Aga Khan University Hospital, Karachi, Pakistan. The data was entered and analyzed in SPSS version 14.0. FINDINGS: Among 158 patients, 57.6% were male and 41.1% were female. The common presenting symptoms were motor symptoms (51.3%), speech impairment (43%), sensory impairment (34.8%) and loss of balance/vertigo (29.1%). The median delay in presenting to the hospital was 4 hours. Those with motor symptoms were found to present earlier. The study showed that only 60.8% of all the patients presenting with TIA received any immediate treatment out of which 44.7% received aspirin. Neuroimaging was used in 91.1% of the patients. Of all the TIA patients 9.1% converted to stroke with 50% doing so within the first 24 hours. CONCLUSION: The natural history of TIA from this developing nation is comparable to international descriptions. A large percentage of patients are still not receiving any immediate treatment as recommended in available guidelines, even in a tertiary care hospital.