Muzzafar Zaman

A critical role of ultrasonography in management of liver abscesses

Aims and objectives : to see the efficacy of ultrasonography in the management of amoebic liver abscess. We assessed whether patient required surgery or can be managed with drainage procedure on ultrasonography basis. Materials and Methods : This is a prospective study done from July 2014 to May 2015, in a medical college in remote area. A total of 88 patients diagnosed with liver abscess were included in the study for ultrasound-guided percutaneous aspiration or pigtail drainage management. All patients had been treated with antibiotics or antimicrobials for at least 2 weeks if treated conservatively and were still being continued for another 6 weeks. Results: A total of 88 patients with liver abscess were successfully treated, consisting 79 males and 9 female. The age ranged from 18 to 82 years with a mean of 43.6 years. A total number of 76 (86.36%) cases undergone percutaneous catheter drainage and 12 (13.6%) underwent needle aspiration. A total of 73 (82.95%) patients had single large abscess, while 8 (9%) had two and 7 (7.9%) had multiple abscesses. The abscesses were commonly located on the right lobe of liver. The Pigtail catheters of sizes 10 F to 18 F was introduced either directly under the guidance of the guide wire with safety precautions. The volume of pus aspirated averaged from 70 - 1200 ml, while the period of catheter drainage ranged from 7 to 24 days with the follow up on ultrasonography. Conclusion: This study shows a success rate of ultrasonography almost 98 % by avoiding unnecessary surgical intervention. It was confirmed that needle aspiration in small abscesses and catheter drainage in large abscesses offers the safest and best modality. Bangladesh Journal of Medical Science Vol.17(2) 2018 p.258-262

Comparative Study of Surgical Approaches for Renal Pelvic Stones in a Northern Rural Medical College

Introduction: Retroperitoneal pyelolithotomy (RPL) can be used as an alternative to open pyelolithotomy (OP) when other modalities of stone removal fail. This procedure even has potential to replace noninvasive techniques in selective subsets of patients. Aims and objectives: The aim of this study was to study the efficacy, safety, and outcome of retroperitoneal laparoscopic pyelolithotomy. The study compared the advantages and complications of RPL and OP. Materials and methods: This study was conducted in the Department of Surgery, Maharishi Markandeshwar Institute of Medical Science and Research, Maharishi Markandeshwar University, Ambala, from January 2012 to December 2015. A total of 280 patients of solitary renal pelvic stone were selected, out of whom 160 who underwent RPL were considered in group I and 120 patients who underwent OP were considered in group II. The patients included were of age group 12 to 80 years, with unilateral and bilateral solitary renal pelvis calculus and stone size of 10 mm to 3 cm. Patients with recurrent or residual stones after pyelolithotomy, intractable urinary tract infection, and having extrarenal pelvis and any anatomical renal abnormalities were excluded from the study. Results: In this study, mean age was 37.1 and 46.66 years in groups I and II respectively. Male to female ratio was 2.33:1. Mean operative time was 75.33 ± 16.90 and 65.83 ± 12.35 minutes respectively, in groups I and II respectively (p < 0.001). Pyelotomy closure time and Double-J (DJ) stent insertion time were 5.2 minutes (with standard deviation [SD] of 4.3) and 9.8 (with SD of 3.7) respectively, in group I as compared with 4.2 minutes (with SD of 2.7) and 6.1 (with SD of 2.9) in group II. Mean hospital stay was less in group I at 3.76 ± 0.85 days and, in group II, it was 5.36 ± 1.96 days (p < 0.001). Postoperative anesthesia requirement was 2.23 ± 0.62 days (339 ± 93 mg) and 5.36 ± 0.96 days (804 ± 144 mg) in groups I and II respectively (p < 0.001). Conclusion: The RPL is a noninvasive and cost-effective method along with minimal scar mark. It has the advantages over OP of having fewer complications, less postoperative pain, better cosmesis, and less hospital stay. ORIGINAL ARTICLE 1,5,6Postgraduate Resident, 2Professor, 3Assistant Professor 4Senior Resident, 7Chief 1-6Department of Surgery, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana, Haryana, India 7World Laparoscopy Hospital, Gurugram, Haryana, India Corresponding Author: Rikki Singal, Professor, Dr. Kundan Lal Hospital, Ahmedgarh, Punjab, India, e-mail: singalsurgery@ yahoo.com 10.5005/jp-journ ls-10033-1292

Comparison of Three-port vs Four-port Laparoscopic Cholecystectomy in a Medical College in the Periphery

Aims and objectives: To compare three-port laparoscopic cholecystectomy (LC) with four-port LC in chronic calculous cholecystitis patients. We compared the feasibility of the procedure, total operative time, postoperative pain, incidence of complications, and cosmetic results. Materials and methods: The present study was conducted in the Department of Surgery at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala. Totally, 200 adult patients of cholelithiasis with chronic cholecystitis were included in the study. These cases were randomly divided into two groups (I and II) consisting of 100 cases in each group. The study was conducted for a period of 1 year from April 2014 to March 2015. Three-port LC was performed in group I patients and four-port LC was performed in group II. The cosmetic results, incidence of postoperative complications, and operative time were noted in both the groups. The present study is being undertaken to compare the various merits and demerits of three-port LC vs four-port LC performed by the same surgical team in the same scenario, in terms of parameters mentioned subsequently and assess the feasibility of both the procedures in our setup in a medical college. Results: Gallstone disease is found to be more common in the 4th and 5th decades. Mean age of presentation was 41 years. Three-port LC is difficult in cases of dense adhesions. There were significant differences in operative time (93.16 minutes for three-port LC and 50.66 minutes for four-port LC). There was no significant difference due to type of operation. Cosmetic appearances for both the procedures were comparable. Conclusion: We concluded that both three-port and four-port cholecystectomies are equally good procedures in the hands of experienced laparoscopic surgeons. The complications, operative time, hospital stay, cosmesis, and disability days were comparable in both groups. The four-port technique should be accepted and adopted only by beginners in minimal access surgery. The operator who performs three-port LC should be prepared for placement of an additional port or conversion to open laparotomy whenever complication arises. WJOLS

Unusual location of primary hydatid cyst diagnosed on aspiration cytology

Hydatid cyst (HC) is a parasitic infection caused by Echinococcus granulosus. It occurs frequently in liver and lungs. Hydatid cyst of neck is extremely rare occurrence, and here, we report it with this unusual location. A 25‐year‐old male nonhypertensive and nondiabetic presented with slowly growing painless swelling in right side of neck for 4‐5 years. The swelling measured 5 × 3 cm and was of soft to firm consistency. Fine needle aspiration cytology yielded fluid aspirate and smear showed features suggestive of HC. The intact cyst was removed surgically, and histopathological examination confirmed the diagnosis of hydatid cyst.

To compare the efficacy of tamsulosin and alfuzosin as medical expulsive therapy for ureteric stones

Aims and Objectives: This study aims to evaluate the efficacy of tamsulosin and alfuzosin for the distal ureteral stone. This study assessed the spontaneous passage and expulsion of the stone. Materials and Methods: The study was conducted in the Department of Surgery at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, from May 2013 to May 2014. A total number of 136 patients diagnosed as distal ureteric stone (US) of size <10 mm were included in this study. It was divided into two groups (I and II) out of which 36 cases were excluded. Group I received tablet tamsulosin 0.4 mg/day, and Group II received alfuzosin 10 mg/day. The efficacy of tamsulosin and alfuzosin as an adjunctive medical therapy was determined. Results: Both the drugs can be safely used for the distal USs. The stone expulsion rate was seen in 36 patients (72.0%) in Group I, and in 34 patients (68.0%) in Group II (P = 0.545). The passage of stones noticed by 32 patients in each Groups I and II (P = 1.000). The mean number of pain attacks was 2.91 ± 1.01 for Group I, and 1.8 ± 0.83 for Group II (P < 0.001 and P < 0.001). Thus, we propagate the use of alfuzosin significantly lower number of pain attacks. The drug-related side-effects were postural hypertension (four in Group I and one in Group II) and retrograde ejaculation (eight in Group I, and one in Group II). Thus, the difference was statistically significant in terms of retrograde ejaculation but insignificant for postural hypotension. Conclusion: There is no difference between both medications in term of efficacy (passing stones) for the management of distal ureteral stones. Both medications are safe and effective. In addition, alfuzosin was better tolerated than tamsulosin as it has fewer side effects.

A Study of Evaluation and Management of Rare Congenital Breast Diseases.

INTRODUCTION Polymastia and polythelia may be asymptomatic or cause pain, restriction of arm movement, milk discharge, cosmetic problems or anxiety. Cosmesis is the main indication for surgical excision of accessory breasts in axilla. In addition it also confirms the diagnosis and allays the patients fear of harbouring a malignancy. AIM To evaluate the presentation of symptoms, investigations required for diagnosis and the management to improve the treatment protocols in patients with breast diseases. MATERIALS AND METHODS This retrospective study on breast diseases presenting as supernumerary breasts and nipples was conducted in the Department of Surgery between January 2013 and January 2016 at MMIMS Research and hospital, Mullana, Ambala. Patients were evaluated for breast diseases, either benign or malignant in both genders. A total of 32 cases diagnosed as accessory breasts disease were retrieved from the hospital archive. The clinical and radiological evaluation was done in the form of ultrasound and mammography wherever necessary. Accessory breast tissues were excised under general anesthesia and histopathological examinations were done. RESULTS Out of 32 cases: 1(3.125%) male patient had unilateral and 1(3.125%) male had bilateral accessory nipple, 7 (21.87%) females had unilateral and 1(3.125%) had bilateral accessory nipple, 1 (3.125%) diagnosed as accessory axillary fibroadenoma in female, 16(50%) presented as unilateral and 5 (15.62%) had bilateral swelling in the axilla as accessory breast. Patients underwent surgical excision and in 8(25%) cases z- shaped incision was made in view of better cosmesis. Patients were followed up upto 6 months postoperatively. There were no residual swelling and movements of the arm over the shoulder joint were normal. In 3(9.37%) cases, wound dehiscence occurred; in 2 (6.25%) cases lymphoedema formation was seen. These were successfully managed conservatively. CONCLUSION As breast swellings either fibroadenoma or carcinoma are common entities to come across everywhere but accessory breasts are rarely encountered especially in rural areas because of less awareness. The study found that there was tendency to neglect the swelling as there were minimal symptoms present. We also came across a rare entity, accessory breast and accessory nipples. A clinician should not ignore such cases taking as simple swelling because of chances of discovering a malignancy can occur.

Evaluation of intracorporeal knotting and endoloop closure in laparoscopic appendicectomy

BackgroundLaparoscopic appendicectomy has become popular nowadays, especially among laparoscopic surgeons, due to the benefits of minimal invasive surgery and the simplicity of this technique. Some laparoscopic surgeons apply ligatures owing to their lower cost and feasibility while others use endoloops and clips. The ideal method should be safe, applicable and cheap. The most appropriate method remains controversial. In this study, we applied intracorporeal ligature (knotting) during laparoscopic appendicectomy for secure closure of the base of the appendix and mesoappendix in one group of patients, and used endoloops in the second group of patients.Aim and objectivesThe aim of this work was to evaluate the application of both techniques, i.e. the use of knotting and endoloops, and record any specific complications related to each.Settings and designThis was a prospective, randomized, double-blinded study.Patients and methodsOne hundred laparoscopic appendicectomy patients, of whom 64 were female and 36 male, were included in this study from February 2013 to January 2015 at MMIMSR Hospital. Their overall average age was 27.4 years. Patients were divided into two equal groups (group A and group B): group A underwent intracorporeal knotting of the base of appendix with silk while in group B, the appendix base was secured with the use of endoloops.ResultsThe mean operative time was 45 min for group A and 37 min for group B (P < 0.05). The mean hospital stay was 2.07 days and 2 days, respectively, which was not statistically significant (P > 0.05). No major complications were recorded for either of the two groups. The technique used in group A was more cost-effective than that applied to group B.ConclusionIn our study, both the intracorporeal knotting and endoloop closure technique were safe, successful and feasible. We concluded that if the patient cannot afford the harmonic-like material, silk could be used for the base of the appendix. Hence, in rural locations or where instruments are not affordable to the surgeon, or in financially compromised patients, silk can be used without any complication.