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Objective: To analyze the post-operative benefits of nasogastric tubes among patients undergoing gut resection and anastomosis at our surgical unit. Study Design: Prospective comparative study. Place and Duration of Study: Surgical Department, Combined Military Hospital, Rawalpindi Pakistan, from Jun 2019 to Mar 2020. Methodology: This study was conducted on 80 patients who underwent gut resection and anastomosis due to localized cause at surgical unit of our hospital. With block randomization method half of the patients received nasogastric (NG) tube after the surgery while half did not. Presence of nausea or vomiting, pain abdomen, return of bowel sounds and electrolyte imbalance were compared in both the groups. Results: Out of 80 patients included in the final analysis 50(62.5%) were male and 30(37.5%) were female. Mean age of patients put who underwent the gut resection and anastomosis procedure in our study was 41.34±5.147 years. Chi-square test revealed that all parameters included in the study did not differ significantly among patients with and without nasogastric tube after the surgery. Conclusion: Administration of nasogastric tube did not prove any better in reducing the post-operative abdominal pain, nausea and vomiting. It also did not prove to be effective in preventing the electrolyte imbalance and helping in returning the bowel sounds early. Patients with and without nasogastric tube had equal chance of having any of the complications. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of intravenous Paracetamol versus intravenous Tramadol in terms of post-operative analgesia in patients undergoing laparoscopic cholecystectomy. Study Design: Quasi-experimental study. Place and Duration of Study: Department of General Surgery, Pak-Emirates Military Hospital (PEMH), Rawalpindi Pakistan, Jan 2020 to Feb 2021. Methodology: A total of 88 patients admitted for planned laparoscopic cholecystectomy were screened as per the selection criteria and were included in the study. They were further divided into two Groups. Each Group received 44 patients. Group-A received intravenous Paracetamol 1 g, while Group-B received intravenous Tramadol 100 mg, both given 6 hourly over 24 hours. Both Groups were evaluated for pain at regular interval via a Visual Analog Scale for pain, for the first 24 hours post-operatively. Results: Mean Visual Analog Scale score post-recovery at 0 minutes was 6.57±1.47 with Paracetamol and 6.84±1.39 with Tramadol, (p=0.38). The difference in both Groups remained non-significant when checked at regular intervals till 18 hours post-recovery where intravenous Paracetamol showed a clearly superior Visual Analog Scale score of 1.00±0.94 versus 1.66±1.06 with Tramadol, (p= 0.007). Thereafter, the difference disappeared again at 24 hours post-recovery. Conclusion: Paracetamol provides analgesia effectively when compared to Tramadol in the first 24-hour post-operative period. Moreover, it seems to be devoid of the adverse effect profile seen with opioid analgesics. Considering the results obtained, the routine use of Paracetamol as first-line analgesic post-operatively is highly recommended. [ABSTRACT FROM AUTHOR]

Objective: To compare rubber band ligation (RBL) vs standard hemorrhoidectomy for the treatment of haemorrhoids. Study Design: Quasi-experimental study. Place and Duration of Study: Department of General Surgery, Pak Emirates Military Hospital Rawalpindi, from Feb 2020 to Jan 2021. Methodology: A total of 200 patients with 2nd and 3rd-degree haemorrhoids who met the inclusion and exclusion criteria were included in the study. Group-A patients underwent rubber band ligation, while in Group-B, Milligan Morgan hemorrhoid-dectomy was done. Results: There were 200 patients (100 in each Group). There were 135 males (67.5%) and 65 females (32.5%). The female to male ratio was 1:2.01. Mean age was 44.73±8.36 years in Group-A and 43.48±8.98 years in Group-B. Mean duration of complaints was 8.72±4.32 months in Group-A and 10.89±3.80 in Group-B. Post-procedure patients were called for follow up in a third and eighth week. The most common complication seen in Group-A was recurrence which was 18% (p-value 0.001), and pain in Group-B, 82% (p-value 0.001), which was statistically significant. Conclusion: We concluded that Rubber band ligation is a quick, safe and cost-effective procedure for the outpatient department for Grade II and III haemorrhoids. The recurrence rate is high compared to standard hemorrhoid-dectomy, but its advantages make it a first-line procedure for Grade II and III haemorrhoids in the outpatient departments. [ABSTRACT FROM AUTHOR]

Objective: To compare early versus delayed laparoscopic cholecystectomy in acute calculous cholecystitis in terms of mean operative time, hospital stay, conversion rate to open surgery and post-operative complications. Study Design: Quasi experimental study. Place and Duration of Study: Army Liver Transplant Unit, Department of Surgery, Pak-Emirates Military Hospital Rawalpindi, from Jul to Dec 2018. Methodology: A total of 170 patients (85 in each group) diagnosed as a case of acute calculous cholecystitis who met the sample selection criteria were included. Group A patients underwent early laparoscopic cholecystectomy within 72 hours of admission while group B patients underwent conservative management followed by delayed laparoscopic cholecystectomy after 6 weeks. All patients were followed for operative time, hospital stay, per-operative difficulties encountered and post-operative complications. Results: Group A had a mean operation time of 43.9 ± 11.1 minutes, while group B had a mean operation time of 45.8 ± 10.1 minutes (p=0.83). The mean duration of hospitalization was 2.8 ± 1.1 days in group A and 5.3 ± 0.8 days in group B (p<0.001). Complications were measured at a frequency of 14.1% in group A and 5.9% in group B (p=0.07). Conclusion: Early laparoscopic cholecystectomy is better than delayed laparoscopic cholecystectomy in acute calculous cholecystitis in terms of hospital stay and per-operative difficulties faced. The post-operative complications between the two groups are comparable. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the various factors involved during the safe cholecystectomy performed by laparoscopic method in cases of empyema of gall bladder operated at Pak Emirates Military Hospital Rawalpindi. Study Design: Cross-sectional analytical study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi, from Nov 2017 to Mar 2019. Methodology: This study was performed on 70 patients undergoing cholecystectomy by laparoscopic method for empyema gall bladder during the study period. Adverse effects after the procedure were assessed in detail at 48 hours, at time of discharge and two weeks after the procedure on all the participants. Demographic profile and other factors were compared in the groups with and without the complications by using the chi-square test and binary logistic regression. Results: Out of 70 patients included in the final analysis 24 (34.3%) were male and 46 (65.7%) were female. Mean age of patients who underwent laparoscopic surgery for empyema gall bladder in our study was 42.43 ± 3.161 years. Bile duct perforation and leakage 6 (8.5%) was the commonest complication among the patients included in our study followed by surgical site infection 5 (7.1%). With binary logistic regression we found that presence of co-morbids and high preoperative C reactive protein had a strong association with presence of complications among the patients undergoing cholecystectomy in our study while age, gender, transfusion during surgery were not linked with the complications during or after the study. Conclusion: Limited number of patients faced the complications during or after the surgery. Patients with co-morbid medical illnesses and high C reactive protein before surgery should be screened with caution for the presence of complications after the surgery. [ABSTRACT FROM AUTHOR]

Objective: To compare the postoperative infective complications like wound infections and anastomotic leakage, of mechanical bowel preparation with non-mechanical bowel preparation in patients undergoing elective colorectal surgeries. Study Design: Comparative - cross sectional study. Place and Duration of Study: We conducted our study in surgical department of Surgery, Pak Emirates Military Hospital and Combined Military Hospital Rawalpindi, from Feb 2015 to Aug 2015. Methodology: One hundreds and sixty patients were included in this study, which were further divided into groups A and B of 80 patients in each group. Group A was subjected to mechanical bowel preparation before surgery and group B was subjected to non-mechanical bowel preparation. Results: Our study showed that anastomotic leakage was seen in 11 patients (13.8%) of group A and 14 patients (17.5%) in-group B. While surgical site infection was developed in 8 patients (10.0%) in-group A and 12 patients (15.0%) of group B. There was no statistically significant difference between two groups. Conclusion: We concluded in our study that infective complications like sepsis, due to anastomosis leakage after elective colorectal surgery were not severe in patients without bowel preparation done before operation, when compared to patients with bowel cleaning. [ABSTRACT FROM AUTHOR]

Objective: To correlate the operative findings of patients undergoing laparoscopic cholecystectomy, either acute or elective, with surgical complications and conversion to open cholecystectomy. Study Design: Comparative cross-sectional study. Place and Duration of Study: Combined Military Hospital and Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Jul 2021 to Mar 2022. Methodology: Data from patients who underwent laparoscopic cholecystectomy was collected after gaining consent. Patients were evaluated for the correlation of operative findings of acute and nonacute gallbladder cases with the development of complications and conversion to open cholecystectomy. Results: Out of 250 patients, 205 were non-acute cases, whereas 45 were acute. The most common intraoperative complication was iatrogenic perforation of gallbladder 73(29.2%); more common in elective cases 49(19.6%) than in acute cases 24(9.6%). Post-operative complications included sub-hepatic collections 3(1.2%) and port site infections 2(0.8%). There were six overall conversions (2.4%), of which 3(1.2%) occurred in acute gallbladder cases and 3 in elective gallbladder. Acute cases were significantly more likely to be converted to open operations (p=0.039). They were found to have a significant association with gallstone spillage (p<0.001), iatrogenic perforation of the gallbladder (p<0.001), bile leakage (p=0.018), and subhepatic collection (p=0.024). Conclusion: The likelihood of surgical complications and conversion to open procedure can be accurately predicted by the acute gallbladder status pre-operatively. It is thus important to consider these outcomes when commencing post-operative care. [ABSTRACT FROM AUTHOR]

Objective: To compare fissure healing and complications in chronic anal fissure with use of lateral anal sphicterotomy and 0.2% GTN. Study Design: Randomized controlled trial. Place and Duration of Study: Combined Military Hospital Rawalpindi & Combined Military Hospital Kohat over a period of 15 months. Material and Methods: Chronic anal fissure was treated with use of lateral anal sphicterotomy after admission to surgical ward and by application of 0.2% glyceryltrinatrate as an outdoor case on 202 patients over a period of 15 months. Sample size was calculated by sample size calculator. Pain was measured using visual analog scale and incontinence to flatus and faeces was inquired from the patients. All cases were called for regular follow up visits but 10 patients failed to report back. Informed written consent was taken from each patient. Inclusion and exclusion criteria were followed. Analysis was done by SPSS version 13 and Chi Square test was applied. Results: Total 202 patients were included in the study and randomly divided into two groups of 101 patients each using random numbers table. Both GTN and sphincterotomy groups revealed significant, but comparable results. Pain relief, fissure healing and incontinence were significantly higher in group B (Lateral anal sphincterotomy) as compared to group A (0.2% GTN). At the end of 8th week pain relief and incontinence became comparable between both the groups but fissure healing remain significantly higher in group B as compared to group A. Conclusion: GTN when applied to patients produces comparable results if used in long term i.e. eight weeks. It produces adequate symptomatic control and healing of the anal fissures and can be considered equivalent to and one of the recommended treatment options along with lateral anal sphincterotomy in treatment of chronic anal fissure if use for more than 8 weeks. Lateral anal sphincterotomy gives early resolution of symptoms and healing. [ABSTRACT FROM AUTHOR]

Objective: To study the morbidity and mortality of early laparoscopic cholecystectomy in acute cholecystitis by comparing its results with laparoscopic cholecystectomy in chronic cholecystitis and simple cholelithiasis. Study Design: Quasi-experimental study. Place and Duration of Study: Pakistan Naval Ship (PNS) Shifa Hospital Karachi and Combined Military Hospital (CMH) Lahore Pakistan, from Nov 2009 to Jan 2013. Material and Methods: Total 398 patients with symptomatic gall stone disease were included in the study after exclusion of patients with upper abdominal surgery, perforated gallbladder with abscess formation, cardiopulmonary disease, equipment failure and those with choledocholithiasis. Cholecystectomy was performed using a three port technique in most of the cases. On the basis of per-operative findings regarding degree of inflammation of gallbladder, all patients were divided into three groups irrespective of duration of symptoms i.e. acute cholecystitis group, chronic cholecystitis group and no inflammation group. The collected data included age, sex, diagnosis, history of previous surgery, co-morbidities, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications. Statistical comparison was performed using the chi square test. Statistical significance with value of p was less than 0.05 was considered significant. Result: Out of 398 patients, 31.2% had acute cholecystitis, 10.1% had chronic cholecystitis and 58.8% had no inflammation of gall bladder. Complication rates and conversion rates were higher in chronic cholecystitis group as compared to acute cholecystitis group and no inflammation group. Similarly, mean hospital stay was also highest in chronic cholecystitis group. Conclusion: Early laparoscopic cholecystectomy was found safe in acute cholecystitis in expert hands and should be performed in all cases of acute cholecystitis rather than delayed interval cholecystectomy. [ABSTRACT FROM AUTHOR]

Objective: To investigate the safety of hernia repair operation by quantifying the postoperative mortality, postoperative hepatic functional deterioration, and early wound complication among patients in different Child- Turcotte-Pugh (CTP) class groups. Study Design: Retrospective study. Place and Duration of Study: CMH Multan from July 2013 to July 2015. Material and Methods: This is a retrospective review of 277 patients with documented liver cirrhosis who underwent hernia repair (including inguinal, para-umblical and ventral wall hernia) at the combined Military Hospital Multan between July 2013 and July 2015. Morbidity and mortality was compared in three sub-groups based on Child's classification. Results: The present study consisted of 219 males and 58 females with an average age of 46.18±12.76. Mean child score was 7.66 (125, 101 and 51 patients in CTP Class A, B and C respectively). Of the present cohort, 173 patients required inguinal hernia repair with a mean Child score was 7.52 (92, 53 and 28 patients in CTP Class A, B and C respectively). Para-umblical hernia repair was done in 68 patients with a mean Child score of 7.84 (20, 31 and 17 patients in CTP Class A, B and C respectively). Thirty six patients were operated for ventral wall hernias. Their mean Child score was 7.99 (13, 17, 6 patients in CTP Class A, B and C respectively). In the 30 day post-operative period, two patients in CTP class A changed to class B. One patient in CTP class B progressed to class C. Complications occurred in 37 patients (13.36%) but all of these complications resolved by conservative management. Three patients died during the 30-day postoperative period. Conclusion: We conclude that hernia repair in cirrhotic patients is not associated with an increased risk of postoperative complications and recommend elective surgery. [ABSTRACT FROM AUTHOR]

Objective: To analyse pre-analytical errors which account for the major contribution towards laboratory errors. Study Design: Cross-sectional descriptive study. Place and Duration of Study: Combined Military Hospital Kohat, Pakistan from 1st January to 30th June 2012. Material and Methods: For six months laboratory staff was asked to register rejections and causes for rejection of all samples; including in-patient samples from wards as well as out-patient samples collected in the laboratory. In addition all samples where disparity was noted by the clinicians in the laboratory results were also included for analysis. Suspected samples were reanalyzed, tests were also repeated on fresh samples of the patients and a critical appraisal was made. Results: Among a total of 328418 analyses, clinicians/laboratory staff notified 350 questionable findings, 270 of which were confirmed errors. Out of total 270 errors, 77% were pre-analytical, 8% were analytical, 15% were post analytical errors. Out of total pre-analytical errors 8% were incorrect samples, 21% were misidentifications, 51% were faulty sampling techniques and 20% were incomplete/illegible laboratory request forms. Conclusion: The pre-analytical phase in the total testing process currently appears to be more vulnerable to errors than the other phases. Consequently, the pre-analytical phase should be the main target for further quality improvement. Therefore identifying the critical steps in the pre-analytical phase is a prerequisite for continuous quality improvement, further error reduction and thus for improving patient safety. [ABSTRACT FROM AUTHOR]

Objective: To validate the paediatric appendicitis score for the diagnosis of acute appendicitis in children using histopathology as a gold standard. Design: Validation study. Place and Duration of Study: Military Hospital (MH) and Combined Military Hospital (CMH) Rawalpindi, Pakistan from Dec 2009 to Jul 2010 Patients and Methods: Eighty five children 1-17 year old who came to our tertiary surgical department with the chief complaint of abdominal pain of less than 7 days duration were included in the study. Paediatric appendicitis score (PAS) components including fever > 38°C, anorexia, nausea/vomiting, cough/percussion/hopping tenderness, right-lower-quadrant tenderness, migration of pain, leukocytosis > 10,000 (109/l) and polymorphonuclear - neutrophilia > 7500 (109/l) were assessed and recorded on admission, but the sum was not calculated until later and the score did not play any role in the management of the patient. The diagnosis of appendicitis was made by the trainees and consultants clinically and with the aid of routine sonography of abdomen. After appendicectomies, resected specimens were sent for histopathological examination. Pre-operative PAS, and histopathology report of resected appendix were endorsed on patient's performa. A two by two table was used to determine sensitivity, specificity, positive and negative predictive values and diagnostic efficacy of PAS. Result: Sensitivity of PAS was 92.16%, specificity 88.23%, positive predictive value 92.16%, negative predictive value 88.23% and the diagnostic efficacy 90.59%. Conclusion: PAS is a highly sensitive test with fair degree of specificity in diagnosing acute appendicitis in children and its routine usage may improve the diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Gallstone ileus is a rare disease and accounts for 1-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We present a case report of a 55 year old lady diagnosed as having gall stone ileus and was treated with emergent laparotomy and enterolithotomy with fistula repair at a later stage. [ABSTRACT FROM AUTHOR]