Adil Bangash

Polyglactine/Polypropylene Mesh vs. Propylene Mesh: Is there a need for newer prosthesis in inguinal hernia?

Background/Aim: To compare outcomes of light and heavy weight mesh for repair of inguinal hernia. Materials and Methods: This study was conducted at the Department of Surgery; Lady Reading Hospital, Peshawar from January 1, 2007 to December 31, 2008. Patients were divided into two groups based on the type of mesh implanted for inguinal hernia repair. Group 1 included patients in whom light weight composite (VyproII®) mesh is implanted: Group 2 included patients in whom polypropylene (ProleneR) mesh is implanted. Data concerning the complications and post operative pain in the perioperative and postoperative period were collected and analyzed. Categorical data were presented as percentages with 95% confidence intervals and compared using a χ2test and P<0.05 were considered significant. Results: Following allocation and exclusion of violating cases, 111 patients in group 1 and 138 patients in group 2 were analyzed. The mean age in group 1 was 38.20 ± 13.34 years and in group 2 was 39.55 ± 13.70 (P = 0.434). In group 1, hematoma formation was observed in four cases (3.6%), while it was observed in six cases (4.2%) in group 2 (P = 0.766). During the entire study, ten patients in all developed urinary retention, three of which required transient catheterization. One year post operation, there was a recurrence in only five cases overall, while only two patients complained of pain (P = 0.826). Conclusion: The frequency of postoperative pain and complications in patients was similar in both groups.

Prognostic Indicators of Surgery for Esophageal Cancer: A 5 Year Experience

Background/Aim: To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer. Materials and Methods: This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSSR for Windows. Results: Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl (P<0.05) and Geansler’s index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant (P = 0.051) on multivariate analysis. Conclusion: Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler’s index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer.

Composite polypropylene mesh versus lightweight polypropylene mesh: The TAPP repair for laparoscopic inguinal hernia repair

Aims and Objectives: To determine the frequency of complications and pain scores post-operatively following TAPP (Transabdominal Pre-peritoneal)repair for inguinal hernia, comparing lightweight polypropylene versus the composite polypropylene mesh. Materials and Methods: This study was conducted at Lady Reading Hospital, Peshawar, from December 1, 2007, to November 30, 2011. Group A included all those patients with inguinal hernia that were operated using the TAPP method and extraperitoneal placement of the lightweight polypropylene mesh, whereas group B comprised of those patients that were placed a composite polypropylene mesh (VYPRO II R ). A pro forma was prepared to record all the relevant data such as the NYHUS classification of the type of hernia, the post-operative pain scale score, and the complications that included seroma formation, testicular pain and atrophy, preoperative injuries, surgical emphysema, adhesion obstruction, mesh infection, wound infection, and perioperative mortality. The planned sequence of follow-up after discharge of the patient was at 1 week, 1month, 3 months, 6 months, and one year. Data were analyzed using SPSS R for Windows version 13.0. Results: A total of 192 patients were operated, equally divided between both groups. The VYPRO II R group had a higher number of direct hernias and the operative time was also much less but this was not statistically significant (P=0.91). The mean hospital stay was slightly higher in the polypropylene group but that was also not significant (P=0.89). The frequency of seroma formation was higher in the polypropylene group (6.25%) and majority of these patients from both groups had larger scrotal hernias (P=0.34). The most significant finding in this study was the frequency of chronic pain with a visual analogue score of >3(1-10) after the six-month period was significantly higher in the polypropylene group (P=0.02). The recurrence rate was comparable in both groups with 3 patients in group B(P=0.62). Conclusions: No difference in the frequency of recurrence was observed over a one-year follow-up period but significant pain scores were observed in the polypropylene group. Studies with longer follow-up to rule the rate of recurrence in composite meshes will determine its benefit over the lightweight polypropylene meshes.

Technique of clamp-tie thyroidectomy versus Harmonic focus R . Is there a need for technology?

Aims and Objectives: The aim of this study was to compare operative times and frequency of complications between groups for total thyroidectomy without evidence of malignancy. Materials and Methods: This interventional (experimental) controlled trial was conducted at Lady Reading Hospital from 11 th June, 2010 to 10 th June, 2012 and included 120 patients. Group 1 included those patients that underwent total thyroidectomy using the Harmonic Focus R , whereas Group 2 included all those patients that underwent total thyroidectomy by a clamp-tie technique. The data following collection was entered onto the SPSS version 16.0 for Windows R and analyzed. Results: The demographic data in comparison by the two groups saw no significant difference (P = 0.822). Age ranges were also similar, but late age was not a common finding. The mean operative time was lower in the Group 1 (55.3 [±12.1] min) versus (71.6 [±18.2] min) for Group 2. The other significant differences observed in the mean hospital stay (P = 0.031) and mean blood in the drain at 24 h was 55.6 (±11.34) ml in Group 1 versus 83.7 (±21.4) ml for Group 2 (P = 0.001). The frequency of persistent hypocalcemia and hoarseness was observed in the conventional clamp-tie group. Conclusion: The use of ultrasonic dissector is safe and significantly reduces operative time. The frequency of hypoparathyroidism inferred from hypocalcemia persisting beyond 1 month was greater in the conventional clamp-tie group as was the amount of blood in the drain at 24 h.

Fixation in laparoscopic incisional hernia repair: Suture versus tacks

Aims and Objectives: To compare the frequency of complications of laparoscopic repair of incisional hernia using fixation of mesh with transabdominal sutures tacks. Materials and Methods: This study was conducted as part of an interventional multicenter trial at the Rehman Medical Institute, Peshawar, Peshawar Institute of Medical Sciences, and Pakistan Institute of Medical Science, Islamabad, from the 1 st of November 2008 till 31 st October 2011. The frequency of complications was calculated as the measure of comparing two methods of fixation in laparoscopic repair of incisional hernia using the IPOM technique. These patients were admitted via the outpatient department and their demographic data were collected on a pro forma basis. Forty-five patients were alternately placed in either group, and group I comprised patients with a ventral hernia that was fixed using spiral tacks whereas the other group was fixed with transabdominal sutures. A polytetraflouroethylene (Dual R ) mesh was applied in all cases. All data were collected onthe individual pro forma of each patient and was loaded on the SPSS R version 13.0. Results: The BMI in both groups was similar (P=0.94) The mean hospital stay was higher in the PTFE mesh group but the values were not significant (P=1.22).No perioperative death was observed in either group. One patient (2.2%) from group I was readmitted with varying complaints and was diagnosed as having subacute intestinal obstruction (P>0.05). A higher but insignificant recurrence rate was observed in the polyester group over a one-year period of follow-up. Three patients (6.6%) were diagnosed with recurrences in group I. Instead the PTFE group had a similar recurrence rate recurrence (P=1.00). Conclusion: The rate of recurrence in this study showed no significant difference by either mode of fixation. But statistically significant pain scores and increased operative time to fixation favors the use of tacks that limits to the few inner millimeters of the peritoneum.

Laparoscopic incisional hernia repair: Polyester versus Polytetraflouroethylene mesh

Aims and Objectives: To compare the frequency of complications of laparoscopic repair of incisional hernia between polyester and Polytetraflouroethylene meshes. Materials and Methods: This study was conducted as part of an Interventional multicentre trial at the Rehman Medical Institute Peshawar, Peshawar Institute of Medical Sciences and Pakistan Institute of Medical Science Islamabad from the 1 st of October, 2008 till 30 th September, 2011. The frequency of complications was calculated as the measure of comparing two commercially available meshes for the laparoscopic repair of incisional hernia using the Intrperitoneal placement of mesh (IPOM) technique. These patients were admitted via the out-patient department and their demographic data was collected on a proforma. The size of the defect was evaluated clinically or radiologically and if >10cm were excluded from the study. Forty five patients were alternately placed in either group and group I comprised patients with a ventral hernia that was repaired with composite polyester mesh (Parietex R ) whereas the other group was also repaired laparoscopically but repaired with a Polytetraflouroethylene (Dual R ) mesh. All data was collected on the individual proforma of each patient and was loaded on the SPSS R version 13.0. Results: The BMI (body mass index) in both groups was similar ( P = 1.41). The mean hospital stay was higher in the Polytetraflouroethylene (PTFE) mesh group but the values were not significant ( P = 1.12). No peri-operative death was observed in either group. Five patients (11.11%) from group I were re-admitted with varying complaints and were diagnosed as having sub-acute intestinal obstruction ( P = 0.04). A higher but insignificant recurrence rate was observed in the polyester group over a one year period of follow up. Four patients (8.8%) that were diagnosed with recurrences in group I. Instead the PTFE group had a lower recurrence ( P = 0.91). Conclusion: The frequency of recurrence was similar in both groups. A higher frequency of intestinal obstruction was observed in the polyester group.