Abdul Rehman Alvi

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.

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.

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.

Idiopathic adult ileoileal and ileocolic intussusception in situs inversus totalis: A rare coincidence

Situs inversus totalis is a rare autosomal recessive congenital anomaly that is characterized by mirror image anatomy of the abdominal and thoracic organs. We report a case of a 28-year-old male with situs inversus totalis, who developed an idiopathic ileoileal and ileocolic intussusception, which was diagnosed on computed tomography scan. Patient underwent successfully ileal resection and side-to-side functional anastomosis of ileum 12 cms from ileocecal junction. Postoperative course was uneventful. To the best of our knowledge, this is the first case of idiopathic adult intussusception with situs inversus totalis in the literature.

A Unique Variant of Intestinal Tuberculosis

Duodenum is a rare site of involvement in intestinal tuberculosis. We report a 19 years old boy who presented with nonbilious vomiting and weight loss. His workup showed stricture in ascending colon, multiple liver abscesses with pneumobilia on CT scan. Upper GI endoscopy revealed stricture in 2nd part of duodenum distally. He was operated and duodenojejunostomy with limited right hemicolectomy (for stricture in this part of gut) were done. Biopsy report was suggestive of tuberculosis. Antituberculous treatment was started. He responded well and gained 20 kg weight at 3 months follow-up.

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.

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.As with any technology driven field,laparoscopic surgery has made trmendous progress in recent years. since the performance of first laparoscopic cholecystectomyby prof.dr.med erich muheof boblingen,germany,1985,this procedure has overtaken open cholecystectomy as the treatment of choice in cholelithiasis. however due to the cost incurred thereof and surgical training needed,open cholecystectomy is still performed on a very large scale in most parts of the thirld world countries. we tried to modify the conventional cholecystectomy to a minimal access approach(with minimal required infrastructure) to suite majority of patients with cholelithiasis in lieu of cost and morbidity. Objective: To assess the outcome of modified minilap cholecystectomy and report our experience with our innovations and modifications in technique. Patients and Methods: Between may 2006 and may 2008two hundred patients with cholelithiasis aged between 15 and 56 years underwent minilap cholecystectomyin a prospective study in govt.medical college srinagar.our surgical approach was carried out using 3 to 5 cm oblique incisionlocated two finger breadths below the costal margin fashioned more laterally with a muscle cutting or splitting technique.the outcome was assessed in terms of intraoperative and postoperative parameters.the median range age was 38 (15-56)years and there were143 females and 57 malesin the study.all the procedures were completed successfullywithout any complications although one patient needed the extension of incision as in conventional cholecystectomy. Results: The mean operative time was 35(20110 minutes).average blood loss was 30 ml.the mean hospital stay was 2(1-5) days.the patients reported to normal workwithin 9 days of surgery.the mean follow up was 12 months. Conclusions: Our results confirmed that minilap cholecystectomyby our modified approach is safe.,feasible and has lesser morbidity and postoperative pain as compared to conventional open cholecystectomy.the technique is cost effective,easy to practiceand can benefit majority of patientswho otherwise cannot afford laparoscopic surgery.hence it can serve as an alternative to the gold standardlaparoscopic cholecystectomy with almost comparable results.Objectives The feasibility of laparoscopic aortic surgery has been adequately demonstrated. Our clinical experience with robot-assisted aortoiliac reconstruction for occlusive diseases, aneurysms, endoleak II treatment and hybrid procedures performed using the da Vinci system is herein described. Methods Between November 2005 and April 2012, we performed 250 robot-assisted vascular procedures. 189 patients were prospectively evaluated for occlusive diseases, 48 patients for abdominal aortic aneurysm, two for a common iliac artery aneurysm, two for a splenic artery aneurysm, one for a internal mammary artery aneurysm four for hybrid procedures, and four for endoleak II treatment post EVAR. The robotic system was applied to construct the vascular anastomosis, for the thromboendarterectomy, for the aorto-iliac reconstruction with a closure patch, for dissection of the splenic artery, and for the posterior peritoneal suture. A combination of conventional laparoscopic surgeries and robotic surgeries were routinely included. A modified, fully-robotic approach without laparoscopic surgery was used in the last 80 cases in our series. Results 241 cases (96,4%) were successfully completed robotically, one patients surgery was discontinued during laparoscopy due to heavy aortic calcification. In eight patients (3,2%) conversion was necessary. The thirty-day mortality rate was 0,4%, and non-lethal postoperative complications were observed in 13 patients (5,2%). Conclusions Our experience with robot-assisted laparoscopic surgery has demonstrated the feasibility of this technique for occlusive diseases, aneurysms, endoleak II treatment post EVAR and hybrid procedures. The da Vinci robotic system facilitated the creation of the aortic anastomosis, and shortened the aortic clamping time as compared to purely laparoscopic techniques.Methods: All patients who underwent cholecystostomy tube placement were included in the study. Data was collected by retrospective review of files from January 1988 to December 2008 maintained by Department of Health Information and Management, retrieved by ICD-9 coding. We recorded indication, duration of tube placement, clinical outcome, complications, and bacteriology of aspirated bile and performance of cholecystectomy. Data was analyzed using SPSS version 16. Results: 62 patients (mean age 63 yrs) had cholecystostomy tubes placed from January 1988 to Dec 2008. All had confirmed or presumed acute cholecystitis. 54 (95%) of them had image-guided placement of cholecystostomy tube. One had post-procedural bleeding. Nine patients (16%) expired during the hospital stay, none was procedure-related. Around 66% of them had drain in place for >4 weeks. 21 subsequently had elective cholecystectomy while 2 underwent emergency cholecystectomy. Bile aspirated at cholecystostomy was culture positive in 38 (66%) patients. Conclusion: Tube cholecystostomy with delayed laparoscopic cholecystectomy has been proposed for the management of critically ill/high risk patients with acute cholecystitis as an alternative treatment. In experienced hands, percutaneous cholecystostomy is easy to perform, with low complication and high success rates. It should be considered in poor surgical candidates as a definitive treatment in cases of acalculous cholecystitis. Sana Nasim, Surgery Curr Res 2013, 3:4 http://dx.doi.org/10.4172/2161-1076.S1.012Objectives: The main objective of this clinical case report was to specify that the acute pancreatitis may start with a onset insulin-necesitant diabetes mellitus-with very high levels of the glycemia (400mg/dl), which later after the hygienic-dietetic, medical and surgical treatment, needed the progressive reduction through reconnaissance of the insulin dosage and later on the insulin interruption, because of the normal glycemia values without insulin. Materials and Methods: A clinical case of a 42 year old man, a teacher, who came in the Emergency Department presented with a sudden epigastric intense pain, without radiation, accompanied by nausea, vomiting after drinking alcohol. The intestinal transit was present for stools and gases, presented sensibility at the epigastric palpation, without peritoneal irritation signs, and normal rectal touch. The laboratory tests were in normal range except serum amylase=2730u/dL, glycemia=400mg/dl, cholesterol=280mg/dl, triglycerides=320mg/dl, HDL cholesterol=50, LDL cholesterol=40, the urine summary for glucose was positive, urinary amylase=1201. The normal EKG and values of cardiac enzymes has excluded a possible postero-inferior acute myocardial infarction. The abdominal radiography on empty stomach and gastroscopy was normal, and the abodminal ultrasound has shown hepatic steatosis. Diagnosis: Acute ethanolic pancreatitis, onset of type 2 diabetes mellitus in insulindependant, dislipidemia, and hepatic steatosis. Treatment: After the correct protocol of therapy for acute pancreatitis and equilibration of inaugural diabetes mellitus the patient had stayed with four doses s.c.12UI,10UI,-8UI, and -4UI of rapid Humulin R insulin but the evolution was with accumulation of a liquid collection in medium quantity in the Douglas’pouch, confirmed at the abdominal ultrasound and CT scan. After the emergency laparatomy, the drainage of the liquid that was acumulated in the peritoneal cavity was performed, with the lavage of the peritoneal cavity, but without surgical intervention on the pancreas, because it presented a normal macroscopic aspect, without hemorrhagic or necrosis areas. The postoperative evolution of the patient has been favourable and remain with an conventional insulin scheme in two prises s.c.16UIHN – 12UIHN, which later after repeated controls needed a progressive decreased of the insulin doses to avoid the hypoglicemia and the patient remain without the insulin with normal values of glycemia. Conclusions:1.It is possible in context of acute pancreatitis to appeared sudden change in the function of the Langerhans β cells which produced insulin and after all complete protocol of therapy was performed everything to become in normal limits.2.This clinical case report releived how complex, impredictible and unexpected changes are possible to appear in acute pancreatitis and how carrefully we must to follow the patient with this dissease because surprises can develop any time.Objective: To demonstrate the feasibility of inguinal hernia repair with local anesthesia in an outpatient regime, with safety, efficacy and short learning curve. Methods: We prospectively evaluated 1042 patients undergoing inguinal hernia repair under local anesthesia on an outpatient basis between November 2004 and August 2012. Of the total number of hernias surgically treated in this period, 651 were operated on the right, 363 on the left and 28 bilateral. We used clinical, surgical and psychosocial criteria for inclusion in the procedure. The parameters for exclusion were complex, irreducible or recurrent hernia, obesity (BMI greater than 30 kg/m2), patient’s refusal and psychiatric disorder. All patients underwent elective surgery and were analyzed regarding surgical outcome, complications and hospital stay. Results: All operations were completed successfully. In no case there was need to change the anesthetic method. Surgical time was similar to that conducted with other methods of anesthesia and there were no cases of adverse effects of local anesthetics. Intra-operative complications amounted to approximately 2.64%. There was no need for hospital admissions greater than 24 hours. Conclusion: The procedure is feasible and causes no perioperative significant pain, is safe, can be performed by residents under supervision, has satisfactory patient acceptance and complications similar to those observed in a conventional herniorrhaphy, allowing lower time and cost of hospitalization and faster access to treatment.Purpose: This paper examines a low-cost, high degree of difficulty model for the simulation of ultrasound-guided nerve block. Background: Various models have been developed for simulating ultrasound-guided procedures. Ultrasound phantoms are available commercially. In addition, ultrasound phantoms can be made from readily available materials such as meat, agar, and gelatin. The target for needle placement in these models varies, such as an olive in a turkey breast, metal rod, various food items and surgical glove tips filled with saline, and penrose drains filled with fluid. These targets are often technically easy to image and therefore cannot adequately simulate difficult nerve blocks. In some situations the target for an ultrasound-guided nerve block may be best imaged in a very narrow and precise plane. Deviation from this narrow and precise plane may prevent simultaneous imaging of both the needle and the target. As a result, we sought to develop a simulation model for ultrasound-guided regional anesthesia with a very precise needling target which is difficult to keep in the ultrasound image. Methods: Kilicaslan et al have described a feed-back based simulation model for ultrasound-guided regional anesthesia. Their model consists of a simple electrical circuit with a lighted buzzer. The electrical circuit is completed when a block needle touches the bare metal rod which has been inserted into a beef phantom. Because a bare metal rod is used, needle contact at any point on the rod can be viewed as successful by the trainee. During a real block, it is desirable to contact the target in the precise plane of the ultrasound image. When the rod is viewed in short axis, the target is very long. As such, it can be seen in a nearly infinite number of ultrasound planes. This situation differs markedly from some difficult ultrasound-guided blocks, where the target may only be seen within a narrow ultrasound window. A more difficult and clinically relevant model, can be produced by using a 4” 18 Ga insulated Tuohy continuous nerve block needle (Contiplex, B Braun) as the target. In our model, the ground wire of the insulated Tuohy needle was cut and connected to the positive terminal of a 9V lithium battery. The negative battery terminal was attached a 12 V DC mini buzzer (273-055 A RadioShack). The other wire from the mini buzzer was then connected to a 2” 22 Ga insulated block needle. This simple electrical circuit will produce an audible buzz only when the non-insulated tip of the 22 Ga needle enters the non-insulated tip of the 18 Ga Tuohy needle. Block needle contact on the insulated shaft will not complete the circuit. This Tuohy needle target can be placed in any type of ultrasound phantom, be it homemade or commercially available. The target is identified by imaging the tip of the Tuohy needle in cross-section or long-axis. In a long-axis view, the tip is easy to identify. In a cross-section view, the tip is indentified by scanning distally along the needle shaft until it disappears. The transducer is then moved slightly proximally along the needle shaft until it just reappears. Once the tip is visualized in the ultrasound image, the block needle can be placed in an in-plane or out-of-plane fashion. The goal is to continuously visualize the target while placing the block needle into the tip of the target Tuohy needle (as indicated by an audible buzz). Discussion: We feel this model is sufficiently difficult that it can be used to simulate difficult nerve blocks. The model can be produced at a low cost with readily available materials and it is compatible with any type of ultrasound phantom. The target for needle placement in this model is very small and, as a result, can only be visualized within a narrow ultrasound window. With this model, it is technically challenging to keep the both the target and block needle in view during needle placement. In order to complete the task, the operator must be skilled. Stephen Howell, Surgery Curr Res 2013, 3:4 http://dx.doi.org/10.4172/2161-1076.S1.012Conventional approach to congenital cardiac surgeries has its own limitations such as increase in recovery time, length of hospital stay, pain and less cost effectiveness. Hence newer minimally invasive approaches have come into practice. Initially most of these newer approaches were done in adults when compared to pediatric patients. But advances in cannula design and instrumentation have made these techniques feasible in pediatric patients too. Ministerntomy technique offers satisfactory cosmetic results, stable sternal reconstruction, good surgical exposure, minimal interference with respiratory mechanics, and minimal pain, allowing extubation in the operating room and a speedy recovery. With the escalating number of paediatric patients requiring cardiac surgery, efficient use of facilities by fast track cardiac anaesthesia and resource utilization resulted in the adoption of early tracheal extubation techniques in cardiac surgery. Economic concerns such as significant increases in overall medical expenses, the accumulating data that patient’s care is not jeopardized but rather perioperative morbidity may actually be reduced by early hospital discharge, have made the concept ministernotomy and fast-tracking attractive for practitioners involved in the care of children with congenital heart disease (CHD) as well .The perioperative and intraoperative care for an adult patient born with a congenital heart defect can provide a unique challenge to a surgical team. This study reviews the current literature relevant to surgeons, anesthesiologists, and perioperative nurses caring for the adult congenital heart disease patient. As the vast majority of children born with a heart defect are surviving into adulthood, they inevitably require surgical intervention just as the general population. Many surgeons and anesthesiologists are not aware, however, of the specific hemodynamic instability that many of these patients have. This is why the surgical team should be well prepared for the procedure by obtaining a very thorough history and physical examination. Laboratory testing can evaluate any hematological abnormalities in the patient, while radiographic imaging—for example, echocardiography—can identify any residual shunting of blood through even repaired hearts. These techniques can help the team determine how judicious they should be with periand intra-operative fluid administration and how to properly medicate these patients during the procedure—certain anesthetics, for example, can negatively affect the patient’s systemic vascular resistance and cardiac output. Such changes can lead to pulmonary hypertension and—in the case of a cyanotic heart defect such as Tetralogy of Fallot—can lead to a reversal of the shunt, known as Eisenmenger’s syndrome. However, with the appropriate techniques and understanding of the patient’s physiology the well-informed surgical team can manage the multiple morbidities involved in a patient with a heart defect and surgery can proceed with few adverse consequences.

Retroperitoneal necrotizing fasciitis - when a simple procedure turns ugly.

We present a case series of patients who underwent simple perianal procedures outside this hospital but developed postoperative and life-threatening retroperitoneal necrotizing fasciitis. With a high index of clinical suspicion and radiological imaging, we were able to establish earlier diagnosis. Resuscitation, the use of intravenous broad-spectrum antibiotics, aggressive surgical debridement and continuous organ support were essential in achieving a positive outcome in both of these patients.