Surgical Update: International Journal of Surgery and Orthopedics

Role of laparostomy in preventing early morbidity and mortality in advanced peritonitis patients

2020-01-16T06:35:48+00:00

Background: Very few studies are available for the indication and the need of laparostomy in cases of faecal, biliary peritonitis and gangrenous bowel. The open abdomen procedure is one of the greatest surgical advances in recent times, avoiding the development of abdominal compartment syndrome.

Methods: The present study was a prospective study of the patients who underwent laparostomy during 2yrs study period. Patients who met the inclusion criteria were included in the study. The indications, complications and outcomes of the study were noted.

Results: Majority of the patients are in the age group of 31 to 40yrs. With laparostomy and damage control surgery recovery was seen in 86.6% patients. Post-operative complications were seen in 33.3% of the patients, with electrolyte imbalance, enterocutaneous fistula, anastomotic leak being the most common complications. Deaths were secondary to septicaemia with mortality rate 16.6%.

Conclusion: Laparostomy or open abdomen is a useful emergency measure in certain conditions where there is a need for re-exploration for abdomen and cannot be closed due to gross edema and contamination. It reduces operative time and also facilitates re-look operations.

Role of diagnostic laparoscopy in infertility

2020-01-24T05:43:41+00:00

Background: Use of diagnostic and therapeutic laparoscopy in infertility has been a focus of attention in recent years and demonstrated to be very effective method in evaluating these cases. The main objective of the study was to detect the diagnostic efficacy of laparoscopy in uterine, pelvic and ovarian pathologies.

Methods: This study was conducted from April 2017 to August2019.This prospective study included 50 infertile women and it was conducted at Vandana nursing home and IVF clinic. After thorough gynecological examination, necessary investigations were made and written consent form was taken from them before laparoscopy. The patients were kept fasting for 24 hours before the laparoscopy and the procedure was performed under general anaesthesia. All the data was collected on pre-designed proforma and the results were tabulated and raw percentages calculated to describe the results.

Results: Among 50 patients, 36 were of primary infertility cases and 14 were of secondary infertility. In primary infertility maximum number of patients belonged to age group of 21-25 years where as secondary infertility was under the age group 26–30 years and above 31 years of age. Longest duration of infertility in primary was 16 years and that in secondary was 17 years. Out of 50 patients, 7 (14%) had absolutely normal laparoscopic findings. Among the various pathologies observed, tubal pathology contributed the most (44%), followed by ovarian (30%), pelvic (18%) and uterine (16%) pathologies.

Conclusions: Laparoscopy is safe and cost-effective method and should be considered as prime diagnostic tool for evaluating the etiology of infertility in women and for effective treatment decisions.

Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis

2020-01-28T05:14:30+00:00

Background: Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%–10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population.

Methods: This study included 90 patients who underwent appendectomies and were documented as having “acute appendicitis” or “abdominal pain” in the operating theatre register from June 2014 to May 2018. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software.

Results: A total of 68 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems.

Conclusion: Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14 clinical parameters that can be obtained from a good patient history, clinical examination and laboratory investigations. The RIPASA scoring system is more accurate and specific than the modified Alvarado scoring system for Kuwait population.

A characteristic of hollow viscus injury (HVI) following blunt abdominal trauma: a study done in Vandana Nursing Home and IVF Clinic, Hazaribag, Jharkhand, India

2020-01-28T05:27:49+00:00

Objective: To determine the presentation, anatomical distribution, diagnostic method, management and outcome of hollow viscus injury (HVI) from blunt abdominal trauma.

Methods: This was a retrospective cross-sectional study including patients with blunt abdominal trauma leading to HVI admitted at Vandana Nursing Home and IVF Clinic, Hazaribag. A prospective comparison study over a period of 6 years (April 2012 to May 2018). Data were retrieved from patients’ medical records. Total 43 patients with HVI due to blunt abdominal trauma, who underwent laparotomy at our institute, were reviewed. Data regarding clinical presentation, anatomical distribution, management and outcome were recorded and analysed.

Results: Out of 43 patients 87.1% were men and 12.9% were women. Mean age of patients was 29±14.02 years. The most common site of injury was ileum (46.2%) followed by jejunum (44.5%). There were 2 gastric perforations (4.6%), 1 (2.3%) duodenal, 1 (2.3%) colonic, 1 (2.3%) sigmoidal and 1 (2.3%) rectal injuries. One caecal injuries was also recorded. Road traffic accident was the most common mechanism of injury (57.2%) followed by fall from height (36.4%) and assault (6.4%). Free gas under diaphragm on erect abdomen radiography was seen in 85.5% of cases while preoperative CT Abdomen was done in 11.6% of cases. Treatment consisted of simple closure of the perforation (66.5%), resection and anastomosis (11.0%) and stoma (22.5%). Major complication was anastamotic leak which was recorded in 6.4% cases and 15.6% patients developed burst abdomen. Average hospital stay was 13±6 days. Overall mortality rate was 12.7%.

Conclusion: Although early recognition of intestinal injuries from blunt abdominal trauma may be difficult in all cases, it is very important due to its tremendous life-threatening potential. Age of the patient, anatomical site and time of presentation are probably main prognostic factors

Evaluation of results of minimally invasive plate osteosynthesis for humeral shaft fractures. A study involving 40 patients

2020-02-10T06:49:42+00:00

Introduction: Fracture of humeral shaft account for roughly 3% of all fractures. Previously, non-operative treatment has been accepted modality of treatment. Three main operative techniques are in vogue for treating displaced humeral shaft fractures namely intramedullary nailing, conventional plating osteosynthesis (CPO) and minimally invasive plate osteosynthesis (MIPO).

Material and Methods: 40 fractures of humerus shaft were treated with MIPO technique, in a prospective study between December 2015 and September 2017 at our institute. The cases were followed up for a minimum period of 2 years.

Results: The average age was 41 years (23-71 years). Twenty-three (57.5%) were males and 17 (42.5 %) females. Twenty-nine cases (72.5%) had injury in their dominant arm. The mean surgical time was 45.5 minutes and the mean radiation exposure was for 85.3 seconds. The mean follow-up of our cases was 33 months.

Conclusion: MIPO is a better choice for treating humeral shaft fractures than CPO, though there is no significant difference between MIPO and CPO in terms of operative time, fracture union rate, and fracture union time.

Is Vitamin D deficiency an endangerment for Fracture?

2020-03-15T17:34:07+00:00

Introduction: The incidence of fragility hip fracture is on a step increase. Vitamin D is essential for the growth and development of the bone. The decrease in the exposure to sun’s radiation leads to this deficiency causing a global threat. There were many studies pointing towards Vitamin D deficiency as a risk factor for fracture. However, the relationship between serum Vitamin D and bone mineral density (BMD) in the senile osteoporotic fracture is still unclear. The aim of this study is to find out whether Vitamin D deficiency is a risk factor for fragility fracture.

Method: It is a prospective study done at Sri Ramachandra Medical College Chennai and Velammal Medical college Madurai between Jan 2017 to Dec 2019. The inclusion criteria were male patients age more than seventy and female patients more than sixty presented with fragility hip fractures. The group I was the cases, patients with hip fractures. The group II was the age and gender-matched control. All the patients included in the study underwent both Vitamin D 25 OH and Dexa scan. The current study had 56 patients in group I as cases and 54 patients in group II as control.

Results: The mean value of vitamin D 25OH in fracture patient group I was 19.85 and the age and gender-matched control group was 26.09. The current study had totally seventy-nine patients in the study who were either Vitamin D deficient or insufficient. The present study had 16 cases patient and 15 controls who were having sufficient level vitamin D.

Conclusion: Vitamin D has no role in fracture prevention and certainly Vitamin D deficiency is not an endangerment for fractures.

A study to isolate various bacteria causing osteomyelitis in a tertiary health care setup

2020-02-20T05:56:55+00:00

Introduction: Osteomyelitis (OM), an inflammation of bone or bone marrow caused by various infectious agents, can cause any age. With this, a study was taken to isolate various bacterial etiological agents that cause OM.

Material and Methods: It was a laboratory-based study, conducted in the Department of Microbiology, GSL Medical College from June to Nov 2019. Individuals of all ages, both genders, clinically, radiologically confirmed cases of OM were included in the study. Bone, tissue, and swabs collected with utmost sterile precautions were considered, cultured as per the standard methods. Antibiotic susceptibility test was performed for various pathogenic isolates using Kirby Bauer disc diffusion method; P<0.05 was considered statistically significant.

Results: During the study period a total of 72 samples were collected, 61 were culture positive (CP). Age-wise, maximum (18%) CP results were identified in 31-40 years of age group followed by 41-50 years group. Gram-negative rods were isolated maximum (59%) and Staph. aureus was the maximum isolate.

Conclusion: OM can occur at any age and there is no gender difference. Staph. aureus was a common isolate followed by Pseudomonas.

Complications of stapled hemorrhoidectomy

2020-03-06T06:13:09+00:00

Background: Stapled hemorrhoidectomy (SH), a new approach to the treatment of hemorrhoids, removes a circumferential strip of mucosa about four centimeters above the dentate line. Immediate complications (first week) were: severe pain in all patients, bleeding, thrombosis, urinary retention, anastomotic Dehiscence, fissurePerineal intramural hematoma, and submucosal abscess The most common complication after 1 week was recurrence of hemorrhoids in of patients, severe pain, stenosis, fissure, bleeding, skin tag, thrombosis, papillary hypertrophy, fecal urgency, staples problems, gas flatus and fecal incontinence, intramural abscess, partial dehiscence, mucosal septum, and intussusceptions. The most common complication in the first 25 cases of the surgeon’s experience was the pain. Even though SH and banding are necessary before recommending the procedure. It was a prospective and retrograde study conducted in R.D. Gardi Medical College, Ujjain. Study Duration was from November 2017 to November 2019. All the patients who were post-op (stapled hemorrhoidectomy) case of hemorrhoid disease. The total number of patients operated with stapled hemorrhoidectomy in the 2 years period (2017-2019) was 400.

A study to find the utility of ZN staining in the diagnosis of confirmed cases of bone tuberculosis

2020-03-11T05:12:10+00:00

Introduction: As per the WHO guidelines, confirmed and definitive microbiological diagnosis of OATB is required before initiation of anti TB treatment. A study was conducted to find the utility of ZN staining in the diagnosis of confirmed cases of OATB cases.

Materials and Methods: Study was conducted in the Department of Microbiology, GSL Medical College. Informed written consent was taken from all the volunteers. The study protocol was approved by the institutional ethics committee. Individuals aged > 18 years who were clinically confirmed to be OATB were included in the study. Individuals with acute pyogenic osteoarticular infections were excluded. A simple FNAC technique was conducted in the outpatient unit for the collection of aspiration. Smears were prepared and stained by Ziehl Neelsen staining. Smear preparation and staining were done as per the RNTC guidelines.

Results: During the study period 38 participants with suspected OATB were included. The smear positivity was 23 (60.5%). The male-female ratio was 1.08; statistically there was no significant difference (P = 0.753954). Age-wise maximum smear-positive cases were diagnosed in 58-67 years age group.

Conclusion: In resource-limited areas, ZN staining is a good alternative for the diagnosis of OATB.

Surgical management of fracture shaft tibia with closed interlocking intramedullary nailing – A clinical study

2020-03-13T07:26:41+00:00

Introduction: The tibia being the most commonly fractured long bone. A study was conducted to analyze the efficacy of closed intramedullary nailing tibial shaft fractures.

Materials and methods: Study was conducted in the Department of orthopedics. Individuals with closed tibial diaphyseal fractures of >18 years, open diaphyseal fractures of tibia type I, type II were included. Open diaphyseal fractures of tibia Type III A, B, C, tibial fractures with intraarticular extensions and medically ill were excluded. Under spinal anesthesia, intramedullary locking was done as per the protocol.

Results: During the study period, 50 fractures were included. the male-female ratio was 5.25. The youngest patient was 19 years and the oldest patient was 67 years. 60% of the participants had right tibial fractures and 40% with left. Thirty-nine (78%) participants simple and 22% (11) had type I and type 11 compound fractures. The majority of fractures (58%; 29) were united within 18-20 weeks. The average healing time was 19 weeks.

Conclusion: In this study 16.9 weeks was the average healing time and 76% patients showed excellent outcome.

Endometriotic rectosigmoid stricture- a rare clinical entity

2020-03-15T11:11:58+00:00

Endometriosis is defined as the presence of endometrial mucosa implanted in locations other than the uterine cavity. Endometriosis is usually a disease involving women of reproductive age. A probable estimate is that 5–10% of women in their reproductive age have endometriosis. When they do occur, women experience mostly dysmenorrhea, heavy or irregular periods, pelvic pain or dyspareunia. The most common sites for endometriosis are the ovaries (60%), uterosacral ligament (60%), posterior cul-de-sac (28%), broad ligament (15%), bladder (15%) and sigmoid colon (7%). Colonic endometriosis is a rare sequelae. It usually presents vaguely with nonspecific abdominal pain, dyspareunia, tenesmus, rectal bleeding or painful defecation. Laparoscopy is considered the best diagnostic modality for endometriosis with a sensitivity of 97% and specificity of 77%. Although there are some rare cases of large bowel obstruction due to endometriosis in pre-menopausal women, it is extremely rare in the postmenopausal group. Our report highlights such a case, mimicking a malignant rectosigmoid stricture leading to a large bowel obstruction with minimal extracolonic endometriosis involvement.

Conclusion: This case report shows that colonic endometriosis, although rare, can be significantly infiltrative and lead to complications such as a large bowel obstruction. Very rarely, isolated colonic involvement without pelvic endometriosis can mimic malignant obstruction as in this patient. Diagnosing this condition can be challenging and usually requires histological confirmation.

SGLT 2 inhibitor induced euglycemic ketoacidosis

2020-03-15T11:11:27+00:00

SGLT2 inhibitors are being increasingly prescribed for the treatment of type 2 diabetes mellitus. Apart from lowering HbA1c, they are also potentially beneficial in reducing body weight and blood pressure. The awareness among Indian doctors of the potentially fatal complication of SGLT2 inhibitor induced diabetic ketoacidosis may not be widespread. To complicate things further, the blood glucose levels may not be as high as would be expected in a case of diabetic ketoacidosis, making the diagnosis more challenging. We present a case of empagliflozin induced euglycemic ketoacidosis in a post Whipple’s surgery patient. A 52 years old man with upper abdominal pain was found to have a duodenal mass on evaluation. He was a known diabetic on tablets sitagliptin and empagliflozin. Patient underwent Whipple’s surgery for the duodenal mass. Patient had severe metabolic acidosis with ketosis in the immediate post-operative period with mild elevation of blood sugar. The common causes of ketoacidosis were eliminated and the diagnosis of drug induced ketoacidosis was clinched. Patient was successfully treated with intravenous fluids, dextrose and insulin infusion and discharged in good health. It is important to be aware of this adverse effect so that the correct treatment is instituted in a timely fashion.