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VOL. 6 NO.3 JULY-SEPTEMBER 2001 QUARTERLY

JOURNAL OFSURGERYPAKISTANINTERNATIONAL

EDITOR'S NOTE

Abdul Aziz

ARTICLES

Ambreen Afzal 2

Evaluation of breast carcinoma in breastlump. Javed Naeem Qureshi 7

Mohammad Arif 12

Tuberculous cervical lymphadenopathy Jamil Ahmad Khan 16

Wounds of Heel never heal in diabetics. Muhammad Ahmad 19

Diagnostic value of ultrasound in bluntabdominal trauma G.M. Khan Baluch 23

Aetiology and outcome of paediatric burns. Nasir Saleem 26.......... Injection sclerotherapy using 5% phenol in

almond oil in the treatment of partial rectalprolapse in children. Mohammad Arif 28

R. Sohail 31

Kausar Aamir 34

Perforated gall bl-.dder - A complication oftyphoid. Aijaz Ahmed Memon 37

Perforated duodenal ulcer. Syed Arsalan Haider Bukhari 38

Olfactory neuroblastoma. M. Saleem Marfani 40

EditoriaL·

BASIC SURGICAL SKILLS WORKSHOPS

The entrance of a resident to a training programme of surgical discipline,following clearance of primary examination, exposes him to anenvironment with different requirements. It is imperative that he should

have a working knowledge of basic surgical principles. The idea of introducinga workshop on Basic Surgical Skills at this stage greatly helps in creatingawareness and at the same time exposes him practically to fundamentalprinciples of surgery.

The idea of introducing this workshop, although implemented late, is appreciatedby all and is need of the day. Ever increasing load of trainees on already fullexisting training slots puts a great burden on supervisors of these trainingprogrammes. The Basic Surgical Skills workshops are a bridge to the applicationof surgical skills to actual patients. Various dummies, models and animal viscerahelp trainees in building up confidence and learning practical skills.

These workshops start with teaching and demonstrating etiquettes of entranceinto operation theatre, principles of sterilization, clean area maintenance,scrubbing, gowning, gloving and handling instruments etc. A brief description ofsuture material and their handling, followed by actual practice on models andanimal viscera, goes a long way to enhancing surgical skills.

Learning of performing a task from beginning of training is the right way and astraightforward course to achieving the goals of any training programme. Theend result of such training is the provision of excellent surgical cover to theend users, who are the patients.

ABDUL AZIZ

1

EFFECT OF ACCURATE PREDICTION OFMANDIBULAR MOLAR POSITION IN

ORTHOGNATHIC SURGERY

AMBREENAFZAL, RAUF SHAH.

ABSTRACT:This prospective study was carried out to evaluate the effect of accurate prediction ofmandibular molar position in orthognathic surgery at the Center for Dentofacial Deformities,New York University College of Dentistry, U.S.A. during 1994-1997.

Twenty patients with Lefort-I osteotomy with impaction were investigated. Two methods wereused to simulate rotation of mandible, the standard method with center of rotation of mandiblebeinq center of condyle and the other method with the center of rotation of mandible being14.9mm below and 5.0 mm behind the superior mid surface of the condyle in sagittal view.Eight variables were evaluated but only one, that is the most anterior point of the lower molarnonzontallu, came out significantly different. It was concluded that the position of mandibularmolar could not be signifICantly predicted vertically and hOrizontally and there was nosignificant difference in the position of lower molar with both the methods of prediction.

treatment and these limits become important when biterelationships must be changed to correct crossbite,deepbite, open bite, or incisor protrusion.

KEY WORDS: Orthognathic Surgery. Lefort I impaction. Osteotomy.

INTRODUCTIONDentofacial deformities is the term used for severeproblems that might require a combination of surgery andorthodontics. This distinguishes them from the less severemalocclusions that are treatable by orthodontics alone.'The treatment is indicated not only for esthetic reasons,but also for many other factors. Facial appearance plays avery important role in the quality of life and life adjustment.The patient's physical health may be affected bydentofacial deformity in several ways. If the problem issevere enough, mastication can be impaired, with animpact on digestion and general health. Tooth and jawmalposition can also cause speech problems. These teethare more susceptible to caries and periodontal diseases.There is some evidence that temporomandibular joint painand dysfunction are more likely to develop in some typesof jaw deformities.

If the jaw relationship is correct, crowded and mal-alignedteeth nearly always can be corrected by orthodontic tooth'!11RY~J!1~~!;..t'P.~~Y~Ii..tr.~~E}••are limits to orthodonticCorrespondence:Dr. Ambreen Afzal, Head of Orthodontic Deptt.,Karachi Medical & Dental College, Karachi.

Tremendous advances in the area of orthognathic surgeryhave occurred over the past 25 years. Rapid advances insurgical technology have made it possible to successfullytreat patients for whom orthodontic camouflage was oncethe only method of treating dentofacial deformities, whichoften resulted in esthetically unacceptable and quiet often,unstable result.' We have witnessed the evolution ofsurgical-orthodontic treatment over the past threedecades. lncreasinq sophistication in diagnosis andtreatment planning, improvements in orthodonticmechanics, techniques and significant advances inanesthesia and orthognathic surgery have allowedpatients with complex problems the option of treatments tocorrect their skeletal jaw deformity and align their teeth."The total treatment time for the majority of patients can beless than two years and improved function and estheticscan be expected." Post operative results, followingorthognathic surgery, are sometimes different from theintended results, thereby producing occ!usal errors.

2 Journal of Surgery Pakistan (International) Vol. 6 (3) July - September, 2001

Cephalometric prediction allows direct evaluation of bothdental and skeletal movements, whereas cast predictionsshow in more detail the dental relationships that indirectlyreflect underlying skeletal changes. In surgical proceduresthat change the vertical dimension of the maxilla ormandible relative to the cranial base in the sagittal plane,one of the causes of these occlusal errors is the inaccuracyof reproducing the center of the rotation of patient'smandible in the articulated models used for the pre-surgicaltreatment planning or the splint construction(Figure1): Anydiscrepancy between the locations of the centers ofrotation will produce an error.' Whenever the verticaldimension changes, this inaccuracy produces an actualpost-treatment occlusion that is different from that intendedand predicted from the patient model.',

Figurel: Picture showing model surgery

This investigation focuses on the position of themandibular first molar when it is rotated on the mandibularcenter of rotation. If the landmarks used are correctlyselected, it may be possible to increase the accuracy ofthe prediction of the surgical outline."

PATIENTS AND METHODSTwenty patients who had undergone Lefort I osteotomywith superior repositioning of the maxilla were selected.The subjects were treated at the Center for DentofacialDeformities at the New York University College ofDentistry. All the patients had completed their growth andwere between the ages of 16 and 37 years.

For all the subjects, clear preoperative cephalometricradiographs with the teeth in occlusion were available(Figures 2,3, & 4 show records of one of these patients).The radiographs were traced according to standardprocedure, the outline of the anterior cranial base, themaxilla [including the first molars and central incisor] andthe mandible [including internal border of symphysis andmandibular canal] were recorded. When the tracings werecompleted, a number of landmarks were digitilized on thecomputer. The digitilizing was accomplished with acomputer program "Prescription Portrait, version 3.5".

Ambreen Afzal, Rauf Shah.

Figure 2: Slides showing Intraoral view of pre tratment, during treatmentand post orthodontic treatment view of the dental occlusion

The following are the steps which were used in this study:• Cephalometric x-rays of 20 pre-surgical patients were

collected and digitized on the computer.• The center of rotation of each of these pre-surgical

patients was determined. The center of rotation takenwas 5mm behind and 14.9 mm below the superiormidsurface of the conoylejcatledsB; Point of Hotation]."

Journal of Surgery Pakistan (International) Vol. 6 (3) July - September, 2001 3

Effect of accurate prediction of mandibular molar position in orthognathic surgery-------------------------------------------------------

Figure 4: Frontal view of the patient showing before and afterorthognathic surgery

surgical patients was determined as a point located atthe center of the condyle in sagittal view. [called A,Condylar RotationV

Initially each patient went through orthodontic treatment.The stages of orthodontic treatment included, alignment,leveling and decompensation. The stabilizing arch wireswere engaged as final step before surgery,

The next step in the planing sequence is mold surgery.When both jaws are to be repositioned, the maxillarydental cast is mounted on semi-adjustable articulator withthe aid of the facebow transfer from the patient14. Themandibular dental cast is mounted with the aid of biteregistration taken with patient's jaw in retruded contactposition or centric relation. Model simulation ofanticipated surgical movements are performed next(Figure1). The measured movements of dental casts asrepositioned in the articulator should be very close to themeasurements obtained from prediction tracings.

Clear post-surgical Cephalometric with teeth in occlusionwere taken and traced. When tracings were complete, thenumber of landmarks were digitised on computer with asame computer program "Prescription Portrait, version 3.5.

For prediction procedure a template of the mandible wasplaced over the pre-operative tracing. A pin was placedthrough the template at both A and B points separately.The template was rotated, simulating autorotation aftermaxillary impaction, and landmarks were digitilized. Theprocess was repeated 10 times for each of these twopoints. The post-surgical cephalometric radiographs withthe teeth in occlusion of all these twenty patients weretraced and digitilized on the same computer program.Each of the post-surgical digitilized cephalometric tracingwere compared with the predicted cephalometric tracings,separately with the one rotated at point A and the otherrotated at point B. Landmarks such as porion ( anatomicallandmark), orbitale, and sella midpoint are identified andtraced on all the three cephalometric tracings: Final post-surgical tracing[Fj, Predicted tracing at point A[Aj," andPrediction tracing at point B[B).9 Frankfort Horizontalplane is drawn, joining porion with inferior orbitale. Then aline is dropped from the sella midpoint perpendicular tothe Frankfort Horizontal. Both of these lines are identifiedand marked on all of these three tracings.

Four points are identified and marked on these threetracings:• Most superior point on the cusp tip of the mandibular

incisor.• Anterior most point of the mandibular incisor.• Most superior point on the highest cusp of mandibular

first molar.• Anterior most point of the mandibular first molar.

Distance of each of these four points are measured from theFrankfort horizontal and from the line drawn perpendicularfrom th3 sella midpoint to Frankfort horizontal.

These measurements were used in comparing theaccuracy of the two prediction tracings with the final post-surgical tracing. Vertical component was the distancemeasured from each selected point to the FrankfortHorizontal and horizontal component was the distancemeasured from each selected point to the line drawn

4 Journal of Surgery Pakistan (International) VoL 6 (3) July - September, 2001

Ambreen Alzal, Raul Shah.

perpendicular from Sella midpoint to Frankfort Horizontal.For carrying out statistical analysis paired T-tests wereused to compare the difference between each of thepredicted measurements as determined by using "A" and"8" points of rotation. A level of significance was set at Pless than 0.05. Eight comparison points were used.

Vertically and horizontally, the occlusion differedinsignificantly between two centers of rotation. Theposition of the lower mandibular molar could not bepredicted significantly different from both methods ofprediction. Eight variables were evaluated, out of whichonly one that is the most anterior point of the lower molarhorizontally came out significantly different while otherswere not significantly different.

RESULTSThe measurements were taken from pre- surgical andpost surgical radiographs of twenty patients who hadundergone Lefort I osteotomies with superiorrepositioning of the maxilla. All patients had completedtheir growth and were between the ages of 16 to 37 years.The two components were measured to compare theaccuracy of two prediction tracings with final post-surgicaltracings. Vertically (Table I) and Horizontally ( Table II) ,the occlusion differed significantly between two centers ofrotation. The position of the lower central incisor could bepredicted significantly different from both methods ofprediction. Moreover, the lower central incisor becameanterior and superior when predicted from "A" as a centerof rotation, as compared to the final post-surgicalradiograph than when rotated at point "8".

TABLE-I VERTICAL COMPONENT OF TWENTY PATIENTSVariable No.nf Nail sig Vatlabl& NO.of 2·tail $lg

pairs pairs

TABLE·II HORIZONTALCOMPONENTOFTWENTYPATIENTSVariable NO'.nf 2·tail sig Variable NO'.ot 24ail sl9

pairs pairs

• is placed in front of significantly different variables.. The results came out statistically significant for both vertical and

horizontal component.

DISCUSSIONCertain procedures do not yield stable results, which islargely dependent on the direction of movement of thejaws, method of fixation, and surgeon's technique.'Planning for orthognathic surgery involves integratingdiagnostic information from 3 different sources: thepatient examination, the cephalometric radiographs, thedental models.' To link this information, a commonreference plane is required which in most cases isFrankfurt horizontal. In this study the four points areidentified and marked on three tracinqs: most superiorpoint on the cusp tip of the mandibular incisor, anteriormost point of the mandibular incisor, most superior pointon the highest cusp of mandibular first molar, and anteriormost point of the mandibular first molar. Distance of eachof these four points are measured from the Frankforthorizontal. These measurements were used in comparingthe accuracy of the two prediction tracings with the finalpost-surgical tracing. The primary aim of this study is todetermine the extend to which the prediction of lowermandibular molar from both the method of prediction ispredicted significantly different. The rather restrictiveinclusion criteria used in this study, together with thenumber of patients for whom the part of the records weremissing, may in part account for few patients beingavailable. The sample identified had a wide distribution ofboth age (16yrs to 37 years) and gender ( 13 females and7 males. The position of the lower mandibular molar couldnot be predicted significantly different from both methodsof prediction. Only the most anterior point of the lowermolar ho_rizontally came out significantly different whileothers were not significantly different. This will not be avery important during finishing stages as this could becontrolled with post surgical orthodontics. Also the 8method will need to be more technique sensitive andmore time consuming.

For small changes in vertical dimension, clinicallyinsignificant errors result, independent of the degree ofmismatch between the centers of rotations. Moreover, withboth of these centers of rotations "8" and "A", thedifference is so small that it may be not clinically significantorthodontically, but may be very Significant surgically.

Concern must be given not only to the magnitude of anyocclusal errors, but to their direction as well. In somecases, the same magnitude and direction of error cancreate a clinical challenqe." The predicted result for theposltioh of lower molar came out inSignificant statisticallybecause of its close position to both centers of rotations.In this study eight variables were evaluated, out of whichfive came out significantly different while three were notsignificantly different. There was no significant differencein the position of the lower molar. When the incisor isrotated on the center of rotation being more than 100 mm

Journal 01 Surgery Pakistan (International) V.:>1. 6 (3) July - September, 2001 5

9. McCance A M, Moss J P,James DR. Lefort I maxillary Osteotmy;Is it Possible to Accurately Produce Planned Pre-operativeMovements? B J Oral Maxillofac Surg 1992; 30:369-76

10. Reikik M, Barer PG, Um B. The surgical treatment ofanterior open-bite deformities with rigid internal fixation inthe mandible. AJODO 1990; 97:52-7

11. Viteporn S, Melsen B, Terp S. Post surgical changes ofmandibular position in patients following Lefort I osteotomy.Int J Adult Orthod Orthognathic Surg; 1990; 5:91-8

12. Tucker MR. Orthognathic surgery versus orthodonticcamouflage in the treatment of mandibular deficiency. Int JOral Maxillofac Surg 1995;53; 572-8.

13. Nattestad A, Vedtofte P, Mosekilde E. The significance of anerroneous recoerding of the centre of mandibular rotation inorthognathic surgery. J craniomaxillofac Surg;1991: 19:254-9.

14. Ellis E III, Tharanon W, Gambrell K. Accuracy of facebowtransfer; Effect on surgical prediction and postsurgicalresult. Int J Oral Maxillofac Surg 1992;50:562-7

15. Schwestka-Polly R, Roese D, Kuhnt D. Application of themodel positioning appliance for three dimentional position ofthe maxilla in the cast surgery. Int J Adult OrthodOrthognathic Surg; 1993; 8:25-31.

16. Moreno A, Bell W, You Z. Esthetic contour analysis ofsubmental cervical region; a study based on ideal subjectsand surgical patients. Int J Oral Maxillofac Surg1994;52:704-13.

17. Mcfarlane et al. Identification of nasal morphologic featuresthat indicate susceptibility to nasal tip deflection with Lefort Iosteotomy. AJODO 1995; 107:259-67

18. Thomas PM. Orthognathic sugery versus orthodonticcamouflage in the treatment of mandibular deficiency. Int JOral Maxillofac Surg 1995;53:579-87.

Effect of accurate prediction of mandibular molar position in orthognathic surgery

away, its arc of rotation is much greater than that of thelower molar. Probably this point is very close to center ofrotation, so the closer the paint, the difference detectablewill be minimal.

REFERENCES1. l'Tanya J. Bailey, William R. Proffit, and Raymond White, Jr.

Assessment of Patients for orthognathic surgery. SeminOrthod 1999;5:209-222.

2. Jaime Gateno,Kim K Forrest, Brian Camp. A comparison of 3methods of facebow transfer recordings: Implications fororthognathic surgery. J oral Maxillofac Surg 2001 59:635-640.

3. Fridrich et al. Co-ordination of orthosurgical treatmentprogram. Int. J oral Maxillofac Surg 1994; 9: 195-9.

4. Cottrell DA, Wolford lM. Altered orthognathic surgicalsequencing and modified approach to model surgery. Int. Joral Maxillofac Surg 1994; 52: 1010-20.

5. Rekow, Worms, Speidel. Treatment induced errors inocclusion following orthognathic surgery. AJODO 1985; Nov

6. Nattestad A, Vedtofte P. Pitfalls in orthognathic modelsurgery; the significance of using different reference linesand points during model surgery and operation. Int. J oralMaxillofac Surg 1994; 23: 11-5.

7. Rekow, Speidel, Koenig. location of mandibular centre ofautorotation in maxillary impaction surgery. AJODO 1993;vol 530-536.

8. Nattestad A, Vedtofte P. Mandibular auto rotation inorthognathic surgery; a new method of locating centre ofmandibular rotation and determining its consequence inorthognathic surgery. J craniofacial Surg; 1992: 20:163-70


I

EVALUATION OF BREAST CARCINOMA INBREAST LUMP

JAVED NAEEM QURESHI, ZAHID ALl QURESHI,

PARKASH AHUJA, ABDUL SATTAR MEMON

ABSTRACT:Sixty patients with breast cancer were found. from 305 patients of breast lumps. referred tosurgical unit I of Liaquat Medical College Hospital, Jamshoro from January 1998 to December,1999. More than 80% patients belonged to age group 30-60 years. Most presented withbreast lump having ulceration, Peau d' Orange appearance and chest wall fixation at anadvanced stage. Advance breast carcinoma is a common surgical problem infemales of ourcommunity because of illiteracy, ignorance and avoidance by male attendants of the femalepatients for consultation by male doctors. Left breast was involved more than the right one(1.5: 1). Other main complaints for which patients referred were nipple retraction, discharge,pain, jungation and ulceration of skin.

KEY WORDS: Advance breast cancer, breast lump

INTRODUCTIONCarcinoma breast is a potentially curable disease whentreated while it is still confined to the breast. 1 Clinicalpresentation and course of carcinoma of breast inPakistani women is different from the west.' Our patientsgenerally come in late stage so surgical treatment isusually palliative adjuvant radiotherapy, chemotherapyand hormonal manipulation. Carcinoma in situ in ourSOCietyis an incidental finding in otherwise benign breastdiseases. Mammographic screening is new in our countrywhile importance of self examination by experiencedclinicians is yet to be well understood.

PATIENTS AND METHODSThis study was conducted at Surgical Unit I of LiaquatMedical college Hospital Jamshoro from January 1998 toDecember 1999. Detailed history recording and completephysical examination of all patients was carried out and60 patients of breast cancer, out of 305 breast lump wereselected (Table I).•••...••••......••••.......•.•....Correspondence:Dr. Javed Naeem Qureshi, Assistant Professor Surgery,Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad.

TABLE-I TYPES OF BREAST LESIONS: Duration :.:" " '.' .' .. " .No. of '. % :.:.,'

. ."." Patients . ..

Carcinoma breast was confirmed by fine needleaspiration cytology and trucut biopsy. Mammography wasadvised in patients above 35 years of age with suspicionof malignancy. Cardiocranial and mediolateral views wereasked for. Other investigations like full blood count, E.S.R,L.F.T, X-ray chest, ultrasound of abdomen were alsorequested in all patients. Majority of the patients weresubjected to palliative toilet mastectomy for theiradvanced breast cancer and simple biopsy.


Evaluation of breast carcinoma in breast lump

For early breast carcinoma, a simple mastectomy withaxiliary lymph nodes clearance operation was carried outin majority of cases while 5% required more radicalmastectomy. All postmenopausal and patients above 35years of age were put on Tamoxifen 20-mg on 4thpostoperative day and referred to Oncology department.

RESULTSSixty two patients were found in this study of whom 2male patients with carcinoma breast were excluded.Clinical presentation of advanced breast carcinoma isshown in Table II. Right breast was involved in the

TABLE-II CLINICAL PRESENTATIONS OF ADVANCEDBREAST CARCINOM

·::::::::·~r:~~eni~iion':::::::·::::::::::·::::::::::::;::>:::;::::{::i;:r::::t:::~j;:::(::::i~:::j::::::~:::::;:~(:::::::=::?:::~e.r~~#Q.~:::::t::·;

25 (41.66%) patients and left breast in 35 (58.33%).Majority (87%) of patients belonged to age group 30-60years (Table III).

All the patients were married and multiparous. Upperouter quadrant of breast was involved in 36 (60%)patients (Table IV).

The duration of lump was 1-2 years in 38 (62%) patients(Table V).

!

\Forty patients with advanced carcinoma breast presentedwith lump breast with Peau d' orange 66.6 %, muscle andchest wall fixation in 63 % and axiliary lymph adenopathy in63 % patients. In 05 (8.33 %) metastasis was noted in bone,10 patients having liver metastasis and 05 in the lungs.

Twenty patients presented at an early stage-1 (25%) andstage-2 (75%) with the ratio of 1:3. Curative form ofmastectomy was carried only in 20 (40%) patients withaxiliary clearance. In patients with advanced breast cancer(locally advanced stage T 3"'" T4N2)was upto 80%, whilemetastatic M, stage was seen 20%. These patients weredifficult to treat. All these patients opted for toilet mastectomy(70%) and biopsy (30%). Postoperatively upper arm limboedema was noticed in 10 cases, 7 in left and 3 in right withgood range of movement at shoulder joint.

All patients were put on adjuvant chemo, hormono orradiotherapy with the consultation of oncologists.

DISCUSSIONThe fear of breast cancer is the most important concernfor women! Breast cancer is the commonest cause ofdeath in middle aged women in western countrles.' Breastcancer is also the leading cancer in female population ofPakistan.'> An increase in incidence rates in urban area

_ has been observed and ratio of urban to rural is 3 to 1,which is compatible to a study in lndia." Advance breastcancer in our study mainly occurred in the age 30-60years with male to female ratio of 1: 29, which iscomparable with the Baloch study."

Breast cancer is a global problem affecting women in bothindustrialised and developing countries. Geneticpredisposition is responsible for a small proportion ofcases, but non genetic factors including the cumulativeexposure of breast to estrogen (and progestrone) arecritically important.' In women with advanced disease,bone metastasis is a significant problem.' Management ofbreast cancer is therefore a major health care priority.Because of its high incidence, it fulfills the criteria forbreast screening suggested by WHO. More and morecases of mammographic screening detected earlycancers of breast in the west.

,1''i

Journal of Surgery Pakistan (International) Vol. 6 (3) July - September, 2001

Javed Naeem Qureshi, Zahid Ali Qureshi, Parkash Ahuja, Abdul Sattar Memon

Because of the poor surveillance and compliance ofpatients, we still believe that mastectomy has an edgeover local excision of primary breast tumour withradiation. Lumpectomy, followed by radiotherapy is not anappropriate procedure for all patients particularly thosewith large and central tumours as in our study." In ourseries patients with early breast cancers followingmastectomy and auxiliary nodes clearance were referredto Oncology department for the integration ofchemotherapy/±hormonotherapy and radiation therapy.Over the past decades the increasing use of systemicchemotherapy along with breast conserving therapy in thetreatment of early breast cancer has made the optimumsequencing of chemotherapy and radiation therapy animportant question."

In our study surgery for advanced breast cancer was in theform of toilet mastectomy which was only option acceptableto 95% patients. It was difficult, bloody and mutilating withno improvement either in local control or survival. All thesepatients were put on Tamoxifen irrespective of theirhormonal or menopausal status. We strongly recommendthe need for breast clinics equipped with facilities ofmammography and fine needle aspiration cytology.

REFERENCES1. Rathore AH, Hussain Rand Yasmeen B: Aetiological factors in

breast cancer in Pakistani Women. Specialist 1991; 7:29-34.

2. Baloch Q: Clinical presentation of Carcinoma breast atC.M.C.H Larkana. Pak, J, Surg: January 1996, 1.

3. Chiechi L.M, secreto-G. Breast cancer and replacementtherapy, which women are at risk. Clin-exp-obstet-Gynecol.1999; 26(2): 105-8.

4. Christobel M-Sundar Sand Micheal Baum, The Breast Bailey,& Love's Short Practice of Surgery 2000 Ch 46, page 749-772.

5. Bhutta R.A and Afroze A.N: Breast cancer in Multan J. Medresearch,1988,27:165-167.

6. Krishnaswary K, Madharapakan, Parsad PR Diet & Cancer inIndia. Intern J Gastro, 1999;4(3):5-8.

7. H.T. Mouridsen New options for the therapy of advanced breastcancer - Preface. Held on the Occasion of the 21st Congress ofthe European Society for Medical Oncology, Vienna, 1996. TheParthenon Publishing Group, New York / London.

8. David JT Webster A color atlas of mastectomy with immediatereconstruction. Wolfe Year Book. Single Surgical Procedures,1986; 38:5.

9. Clare Faul. The sequencing of radiation therapy andchemotherapy in early breast carcinoma J. Irsh Coli of Phy &Surg, 2000 29(1):12-3


PERCUTANEOUS ULTRASOUND GUIDEDASPIRATION OF OVARIAN CYST j

J

I

IMAMOONA MUSHTAQ

ABSTRACT:Open non randomised retrospective study of 25 cases of ovarian cysts presented at P.N.SShija.Karachi from 01-01-1992 to 30-12-1993 is being analysed. 'They were treated by Ultrasotmdguided aspiration of ovarian cyst- a way of conservative treatment of ovarian cysts.

KEY WORDS: Ovarian Cyst. percutaneous Ultrasound guided aspiration.

INTRODUCTIONIn certain circumstances surgeons are reluctant to resortto laparotomy for evaluation of persistent ovarian cysts.A cystic tumour of less than <5-6 cm diameter can betreated conservatively initially, but explored if it persists formore than three months. Most of these cysts in youngwomen are entirely benign and laparotomy would seemexcessive. Likewise, in pregnancy most cysts discoveredat routine ultrasound are benign. Treatment is desirable toavoid complications such as torsion, haemorrhage orrupture. In pregnancy there are the additional concerns ofmalpresentations and obstructed labour. It has beenadvocated that fine needle aspiration under ultrasoundcontrol might be employed to treat such cysts andcytopathological techniques be employed on the aspirateto confirm the diagnosis. The technique is well toleratedand complications are rare.'

PATIENTS AND METHODSTwenty five patients included for above mentionedtreatment were young (age between 20 - 40 years) andovarian cysts fulfilled all the criteria of benign cyst onultrasound scan. Probe was used for scanning and forguidance 20 gauge disposable spinal needle was used.No anaesthesia was used. Sixteen patients presentedwithin first and second trimester of pregnancy and ninepatients presented with discomfort lower abdomen,menstrual disorders or cysts diagnosed on routineultrasound (Table I).

Correspondence:Lt. Col. Mamoona MushtaqClassified Gynaecologist, Military Hospital, Rawalpindi.

Procedure was performed as outpatients base on 50%patients. Bladder emptied before aspiration of the cyst.Aspirate was collected with 30 cc syringe and subjectedto cytology and culture. Outcome of sixteen patientsovarian cysts and pregnancy is given in Table II.

RESULTSCytology report came out to be benign in all twenty-fivepatients. One patient had aspiration of ovarian cystfollowing pregnancy. She had history of aspiration inprevious pregnancy as well. Her repeat aspiration wasperformed during pregnancy and pregnancy is going onsmoothly. One of the patients had C-Section 6 monthsafter aspiration of ovarian cyst and ovaries wereabsolutely normal looking on naked eye. No patient hadpain during aspiration so anaesthesia of any sort was notrequired. All of twenty-five patients otherwise werecandidates for laparotomy and were saved from surgery.One of the patients had persistence of symptoms and had


Mamoona Mushtaq

laparotomy for rupture and torsion of the pedicle, whichwas present even before aspiration of the cyst.

DISCUSSIONThe success of fine needle aspiration under ultrasoundcontrol rests on two factors. Initially an ultrasound facilitythat can identify those features of an ovarian cyst thatwould suggest neoplasia and the fact that1 00% accuracyis an unrealistic execution for cytological diagnosis.Careful clinical assessment is the mainstay of treatment!

It is assumed that unilocular cysts will be benign.Maltiloculairty, thick septa and solid areas indicatepossible malignancy. False positive rates of 4-27% havebeen quoted for ultrasound on these criteria. These couldbe identified by positive cytology on aspiration. Malignantcystic fluid usually contains large number of malignantcells but the fluid may not contain insufficient cells foraccurate diagnosis. Necrosis or inflammatory changesand haemorrhage can further obscure the picture. In thegroup of women under consideration the aim is to identifycysts of follicular origin. Such aspirates should containnormal or luteinized granulosa cells and should be rich inoestrogen (>4 n mol/L). The identification of epithelialcells indicates need for removal.

In a small group of patients therefore, there would seemto be place for conservative treatment (aspiration) when

small unilocular ovarian cysts « 10 cm diameter) persistin young women or present in early pregnancy. Howeverthe technique must only be employed with a thoroughunderstanding of the limitations of ultrasound andcytopathological facilities available to the operator. It isimperative that investigations of this kind take place indirect collaboration with the cytopathologist concerned.

In conclusion, all benign looking ovarian cysts onultrasound in young patients should have conservativetreatment, follow-up and confirmation by cytopathology.All solid/suspicious tumours should have laparoscopy /laparotomy. Patients of more than 40 years should havelaparotomy anyway, combined with hysterectomy, ifindicated.'

Pick up rates of smaller cysts was more because ofvaginal ultrasound scans. Cysts <5 cm which persistedafter repeated USS were dealt with laparoscopy, which isanother aspect of conservative surgery.

REFERENCES1. Goswamay PK - Ultrasound is Gynaecologic practice,

Progress in Obs/Gynae Vol-16 Edition byJohn Studd-1987 -295-296.

2. Davis AP, Oran D. Screening for Ovarian Cancer, Progressin Obs/Gynae Vol-9, Edition by John Studd. 1991-354-355.


RECURRENT LARYNGEALNERVE PALSY DURING THYROIDECTOMIES

MUHAMMAD ARIF, IMTIAZ AHMED

ABS1RACT:To detect overall rate of recurrent laryngeal nerve (RLN) palsy during thyroidectomies andfactors influencing it, a prospective study was conducted on patients with thyroidenlargement presenting at Surgical Unit II, LMCH Jamshoro during a period of six years fromJan 1995 to Dec 2000. Two hundred five patients (177 females, 28 males) with thyroidenlargement were managed, of whom 170 patients were operated. After clinical examination,appropriate investigations and post operative histopathology, different types of thyroiddiseases were noted. The size of thyroid gland and weight of thyroid tissue removedmeasured. The surgeons were divided into consultants, residents under supervision ofconsultants and residents independently. Post operative RLN palsy noted by directlaryngoscopy on operation table, hoarseness of voice and later on by indirect laryngoscopy.

Overall RLN palsy rate was 16/170 (9.4%), permanent in 8 patients (4.7%) and transient in 8(4.7%).Incidence was high among cases operated by resident (13.2%) a compared to operated byconsultants (7.62%). Incidence was lowest among solitary nodules (2.43%) while high in carcinomathyroid (37.5%), Recurrent goiters (33.3%) and toxic goiters (50%).Among thyroid <50gm of tissueremoved the incidence was only (1.54%) while among thyroid> 150gm it was 22.7%.

KEY WORDS: Thyroidectomy, Operative complications, RecurrentLaryngeal Nerve Palsy.

INTRODUCTIONThyroid enlargement is a common problem in ourcommunity and a number of patients present to surgicalunits at Liaquat Medical College Hospital (LMCH)Jamshoro for various types of thyroid enlargements. Thusthyroidectomy is one of the common operationsperformed at LMCH. Complications that arise afterthyroid surgery may be associated with infection,haemorrhage, hormonal problems and laryngeal nerveinjury1. The major complications associated with thyroidsurgery are injury to recurrent laryngeal nerve andparathyroid insufficiency." Among these injury to recurrentlaryngeal nerve in one complication that is quitetroublesome for the patient. It leads to a significantmorbidity up to 20%, depending on the type of surgeryperformed.'

The laryngeal nerves are at risk during thyroid surgeryand several techniques have been described for their

Correspondence:Dr. Mohammad ArifAssistant Professor Surgery.Liaquat Medical College Hospital,Jamshoro, Hyderabad.

intraoperative identification to minimize potentialdamaqa.' Some surgeons describe the capsulartechnique to protect recurrent laryngeal nerves andminimize the complications of thyroid surqery," Someemphasize systemic isolation of recurrent laryngeal nerveto prevent complications in thyroid sureqry," While otherssay that the demand for obligatory intraoperativeidentification of recurrent laryngeal nerve is not tenable.'The complications also depend upon the nature of thyroidenlargement like adenomas, simple multinodular orcolloid gOiters, recurrent goiters, thyroid carcinomas andthyroiditis." RLN palsy also depends upon the experienceof operating surqeon." It also depends upon the size ofthyroid gland and volume of thyroid tissue resected.'?

The aim of this study was to detect overall rate ofrecurrent laryngeal nerve palsy, and to evaluate variousfactors contributing to increased incidence of recurrentlaryngeal nerve palsy.

PATIENTS AND METHODSThis prospective study was carried out during a period of6 years from Jan 1995 to Dee 2000 in Surgical unit-II


J

Muhammad Arif, Imtiaz Ahmed

Uaquat Medical College Hospital Jamshoro. A total no. of205 patients with enlargement of thyroid presented duringthis period. There were 177 females and 28 males withmale to female ratio of 1:6.3. They were of 12-76 years ofage (mean age 33 years). They underwent throughclinical examination and investigations.

On the basis of clinical examination and investigations, itwas found that 51 patients (24.87%) were havingunilateral solitary nodule, while 154 patients (75.12%)were having involvement of both lobes either diffuse ormultinodular. The incidence of different thyroid diseasesin these 205 patients is shown in Table I.

Out of these 205 patients, 170 patients (146 female, 24males) had gone through surgical process. 35 patientswere not operated as three of them did not requiresurgery (when the cyst had completely disappeared afteraspiration) and 32 patients had presence of othersystemic diseases making them high risk for surgery andanaesthesia.

Various types of surgical procedures were performed on170 patients (Table - II).

TABLE·II VARIOUS TYPES OF OPERATIONS PERFORMED$, No. Presentation No. of Cases 0/4

The size of thyroid swelling was measured beforeoperation and weight of thyroid tissue removed duringoperation measured. On the basis of these findings,patients were divided into three categories:

• Those having swellings 01 - 03 cms in diameter andweight of thyroid tissue removed up to 50 gms.

• Patients having swellings 3 - 5 cms in diameter andweight of thyroid tissues removed ranging between50 -150 gms.

• Patient having swellings with diameter more than 5cms and weight of thyroid tissue removed more than150 gms.

During this study the diameter of smallest swelling was1.5 cm and minimum weight 18 gms, while the largestswelling undergoing operation was 8 x 10 cms in size andweight 768 gms.

The post operative complications were noted; speciallyrecurrent laryngeal nerve palsy. All patients had directlaryngoscopy on operation table immediately afterremoving the endotracheal tube and any post operativehoarseness of voice whether temporary or permanentwas noted. In cases where symptoms persisted indirectlaryngoscopy was done by ENT surgeon 2- 4 monthsafter operation.

RESULTSAmong 170 patient who underwent thyroid surgery, therewas alteration of voice suggestive of recurrent laryngealnerve palsy in 16 patients (9.4%). It was transient in 08cases (4.7%) and permanent in 08 cases (4.7%).However it very much depended upon the experience ofsurgeon, type of thyroid disease and size of thyroid glandand weight of thyroid tissue removed (Table III).

In 65 patients surgeons searched to identify the recurrentlarynges nerve, while in remaining 105 patient no attemptwas made to search for recurrent laryngeal nerve. In firstgroup 6 patients (9.23%) developed RLN palsy while insecond group 10 patients (9.52%) developed RLN palsy.

DISCUSSIONThyroid surgery is associated with quite a fewcomplications. The overall incidence of RLN palsy(temporary or permanent) was 9.4%. It was transient in4.7% and permanent in 4.7%. The incidence appears tobe higher as compared to various studies.":"

The reason for increased incidence could be because thestudy was done at random, including all cases of 'thyroidenlargement. While majority of the studies mentionedabove have been performed in benign nontoxicconditions. The other reason could be that the patients inour setup present very late with very large thyroid glands,while in developed countries patients are educated andaware of the disease. They seek medical advice at anearly stage when the goiter is relatively small in size. Thesize of thyroid gland and weight of thyroid tissue removedhave a definite influence on the rate of RLN palsy. Thisfact is very well emphasized by Mouton Barret R et al."


Recurrentlaryngealnervepalsyduringthyroidectomies

TABLE-III INCIDENCE OF RLN PALSY IN VARIOUS TYPES OF THYROID DISEASES WITHRELATION TO WEIGHT OF THYROID TISSUE REMOVED

In our study there is a very strong correlation between thesize of thyroid and the weight of thyroid tissue removedand the rate of RLN palsy. In this study the incidence ofRLN palsy in patients with weight of thyroid tissue removed< 50 gms was only 1.54%, while in patients with weight ofthyroid tissue between 50-150 gms it is 12.05% and inpatients with weight of thyroid> 150 gms it is 22.7%.

It is further evident from this study that the rate of RLNpalsy is much lower in solitary nodules whether solid orcystic. In this group there only one case of transient RLNpalsy out of 43 patients (2.3%), while the rates were muchhigher in carcinoma thyroid (37.5%), toxic goiters (50%)and recurrent goiters (33.3%). Thus the type of diseasehas also got great influence on the incidence of RLNpalsy. This is very much in correlation to the study byCalik. A et al. In their study they divided all cases into twogroups. Group I included 805 with nodular colloidal qoiterand adenomas. Group II consisted of remaining 62patients (25 with recurrence of goiter, 21 with thyroidmalignancy and 16 with thyroiditis). While the overallcomplication rate was 11.3% (93 cases) in Group I, it was20.9% (13 cases) in Group II. In another study by alFakhri. N et ai, 4.3% of patients (5/116 patients)developed RLN palsy after operation. Post operativenerve palsy was mainly found after extensive resection(2133 near total resection) or operations of recurrent goiter(2/6 re-operations) and rarely after routine operations(1/70 sub total resections). 27

The incidence of RLN palsy also depends upon theexperience of the surgeon.B•9 This is very much evident inour study. The overall incidence of RLN palsy operated byconsultants (through many of these cases were ofcarcinoma thyroid, recurrent gOiters, thyroiditis or toxicgoiters) is 7.62%. In contrast the incidence is 13.2% inpatients operated by residents independently. Though therewas only one case of carcinoma thyroid and one toxicgOiter, the size of thyroid gland was on average smaller ascompared to operated by the consultants. The rate in casesoperated by residents under supervision of consultants is8.33%, which is close to the rate among consultants.

Many surgeon advocate that the recurrent laryngeal nervesshould be identified to prevent their damage.4.2o.34.35However on the other hand there is a school of thought thatno benefit is gained from routine dissection of laryngealnerves during operations on thyroid gland and there is nodifference in incidence whether the nerve is identified ornot.':" In our study there was no significant difference inpatients in which RLN was searched and identified and inpatients in which no attempt was made to search RLN.

REFERENCES1. Hong - KH; Kim - YK; Phonatory characteristics of patients

undergoing thyroidectomy without laryngeal nerve injury.Otolaryngol- Head - Neck - Surg 1997; 117(4): 399 - 404.

2. Bartoli - A; Campi - P; Cristofani -R; Burattini - MF; Servoli- A; Morabito - A; Moriconi - E; Bussotti - C; Totalthyroidectomy with preservation of the parathyroid glands. G- Chir. 1996; 17(1-2): 49-54.

3. Lamade - W; Fogel - W; Reike - K; Senninger - N; Herfarth- C; Intraoperative monitoring of the recurrent laryngealnerve. A new method Chirurg 1996; 67(4): 451-4.

4. Mermelstein - M; Nonweiler - R; Rubinstein - EH;Intraoperative identificationof laryngeal nerveswith laryngealelectromyography, laryngoscope 1996; 106 (6): 752-6.

5. Younes - N; Robinson - B; Delbridge - L: The aetiology,investigations and management of surgical disorders of thethyroid gland. Aust - N-Z-J-Surg. 1996; 66(7): 481-90.

6. Cavallero - V; Barbarino - F; Catania - V; Bonaccorso - R;Craxi - G; Rainieri - F; Faraci - C: The utility of isolating therecurrent nerve and parathyroid in the prevention ofcomplicationsin thyroid surgery.The role of superior laryngealnerve and C cells. Minerva-Chir 1997; 52(12) : 1527-31.

7. Koch- B; Boettcher- M;Huschitt- N; Hulsewede- R : Musttherecurrentnerve in thyroidgland resectionalwaysbe exposed.Aprospectiverandomizedstudy.Chirurg 1996; 67(9) : 927-32.

8. Calik- A; Kucuktulu- U; Cinel- A; Bilgin- Y;Alhan- E; Piskin- B :Complicationsof 867 thyroidectomiesperformedina regionof endemicgoitre inTurkey.Int - Surg. 1996; 81 (3) 298-301.

9. Sosa - JA; Bowman -HM; Tielsh - JM; Powe - NR; Gordon- TA; Udelsman - R :The importance of surgeon experiencefor clinical and economic outcomes from thyroidectomy.Ann-Surg 1998; 228(3) 320-30.

14 Journalof Surgery Pakistan(International)Vol.6 (3) July- September,2001

MuhammadArif, Imtiaz Ahmed

10. Moulton - Barret - R; Crumley - R; Jalilie - S; Segina - 0;Allison G; Marshak - 0; Chan - E : Complications ofthyroidectomy. Int-Surg 1997; 82(1) : 63-66.

11. Mattiolli - FP; Torre - GC; Borgonovo - G; Arezzo - A; Amato- A; De - Negri - A; Bruzzone - 0 : Surgical treatment ofmultinodular gOitre. Ann-Ital - Chir. 1996; 67(3) : 341-5.

12. Bery - MC; Connolly - J; Lennon - F : 149 consecutivethyroid operations indications, technique and outcome. Ir-Me-J. 1996; 89(6) : 224-5.

13. Chapuis - Y: Risks and complications of thyroid Surgery.Rev-Prat. 1996; 46(19) : 2325-9.

14. Miccoli - P; Vitti - P; Rago - T; lacconi - P; Bartalena - L;Bogazzi - F; Fiore - E; Valeriano R; Chiovato - L; Rocchi -R; Pinchera - A; Surgical treatment of Grave's disease: Sub-total or total thyroidectomy. Surgery 1996;120(6): 102-4.

15. Torre - G; Borgonovo - G; Amato - A; De - Negri - A; Mattiolo- FP : Differentiated thyroid cancer: Surgical treatment of 190patients. Eur-J-Surg-Oncol. 1996; 22(3) : 276-81.

16. Menegaux -F; Leenhardt - L; Dahman - M; Schimitt - G;Aurengo - A; Chigot - JP : Repeated thyroid surgery.Indication and results. Presse-Med 1997; 26(38) : 1850-4.

17. Kasemsuwan - L; Nubthuenetr - S : Recurrent laryngealnerve paralysis : a complication of thyroidectomy. J -Otolaryngol1997; 26(6) : 365-7.

18. Chao - TC; Jeng - LB; Un - JD; Chen - MF : Reoperativethyroid surgery. World-J-Surg 1997; 21(6) 644-7.

19. Pezzulo - L; Delrio - P; Losito - NS; Caraco - C; Mozzillo-N: Postoperative complications after completionthyroidectomy for differentiated thyroid cancer. Eur-J-Surg-Oncol. 1997; 23(3) : 215-8.

20. Joosten - U; Brune - E; Kersting - JU; Hohlbach - G : Riskfactors and follow up of recurrent laryngeal nerve paralysisafter first surgeries for being thyroid diseases. Results of aretrospective analysis of 1556 patients. Zentralbl - Chir.1997; 122(4) : 236-45.

21. Siragusa - G; Lanzara - P; Di - Pace -G : Sub-totalthyroidectomy or total thyroidectomy in the treatment ofbeing thyroid disease. Our experience. Minerva - Chir.1998; 53(4) : 233-8.

22. Sim - R; Soo - KC : Surgical treatment of thyroid cancer:the Singapore General Hospital experience. J - R.ColI-Surg.Edinb. 1998; 43(4) : 239-43.

23. Pappalardo - G; Guadalaxara - A; Frattaroli - FM; 1II0mei -G; Falaschi - P: Total compared with Sub-total thyroidectomyin benign nodular goitre. Personal series and review ofpublished reports. Eur - J-Surg. 1998; 164 (7) : 501-506.

24. Christensen - LT; Madson - MR : Surgical treatment ofgoitre at a central hospital. A consecutive adjustment afterchanges in the organization, strategy and surgicaltechniques. Ugeskr - Laeger. 1998; 160(32) : 4640-3.

25. Bergamaschi - R; Becouarn - G; Ronceray - J; Arnaud - JP: Morbidity of thyroid surgery. Am-J-Surg 1998: 176 (1) : 71-5.

26. Chao - TC; Jeng LB; Un - JD; Chen - MF : Completionthyroidectomy for differentiated thyroid carcinoma.Otolaryngeal Head - Neck - Surg. 1998; 118(6): 896-9.

27. AI-Fakhri - N; Schwartz - A; Runkel- N; Buhr - HJ : Rate ofcomplications with systemic exposure of recurrent laryngealnerve and parathyroid glands in operations for being thyroidgland disease. Zentralbl- Chir 1998; 123(1) : 21-4.

28. Un Q; Djuricin - G; Prinz - RA : Total thyroidectomy forbenign thyroid disease. Surgery 1998; 123(1) : 2-7.

29. Palit - TK; Miller - CC. 3rd; Miltenburg - OM : The efficacyof Thyroidectomy for grave's disease : a meta analysis. J -Surg-Res. 2000; 90 (2) : 161-5.

30. MC Ivor - NP; Flint - OJ; Gillibrand - J; Morton - RP :

Thyroid surgery and voice related outcoms. Aust- NZ-J-Surg.2000; 70(3) : 179-83.

31. Prim - MP; De - Diego-JI; Hardisson - 0; Gavilan-J : Postoperative complications of surgery for malignant tumors of theThyroid gland. Acta - Otolaryngeal- Esp. 1999; 50(7): 535-7.

32. La - CY; Kwok - KF; Yuen - PW : A prospective evaluationof recurrent laryngeal nerve paralysis during thyroidectomy.Arch-Surg. 2000; 135(2) : 204-7.

33. Mitov - F; Dimov - R; Outchikov - P; Manchev-I; Mourdjev- K; Todorov - A : A comparative analysis of the postoperative complications of Thyroid cancer surgery related tosurgical approach. Folia - Meb - Plovdiv. 1994; 41 (3) : 34-9.

34. Campana - FP; Marchesi - M; Biffoni - M; Tartaglia - F;Nuccio - G; Stoceo - F; Jaus - Mo; Nobite - Bendedetti- R;Faloci - C, Mastropietro - T; Millarelli - M: Totalthyroidectomy technique : Suggestions and proposals ofsurgical practice. Ann-Ital- Chin. 1996; 67(5) : 627-35.

35. Mattlig - H; Bildat - 0; Metzger - B : Reducing the rate ofrecurrent nerve paralysis by routine paralysis of the nerves inthyroid gland operations. Znetralbl.Chir 1998; 123(1) : 17-20.


TUBERCULOUS CERVICALLYMPHADENOPATHY

JAMIL AHMAD KHAN, MUKHTAR MEHBOOB,EHSAN-UL-WADOOD, ABDUL QAYYUM, GHULAM RASOOOL ARBAB.

ABSTRACT:To ascertain the prevalence of tuberculous lymphadenopathy among the patients of cervicallymphadenopathy this study was carried outfrom Jan 1995 to December 1999 at Departmentof Surgery, Sande man (Prov.) Hospital, Quetta. A total of 151 patient included in this studyhad no previous diagnosis. The commonest age group (28.7%) was between 11-20 years.They were all biopsied. by open surgical method. The youngest patient was 2 year old and theoldest 80 years. Male patients 84 (55.6%) had slight predominance over female 67 (44.3%).The prevalence of tuberculosis was 56 per 100 patients which showed that tuberculosis is oneof the major cause of cervical lymphadenopathy with atypical presentation in our population.

KEY WORDS: Cervical lymph node, Tuberculosis, Open Biopsy.

INTRODUCTIONTuberculosis could be traced back to Neolithic man.Tuberculous bones have been found in Egyptianmummies as early as 5000 B.C. Chinese literature"Laoping" and Indian Rigvedas Yakshama of 3000 B.Cmention this white scourage.' The term tuberculosis wasfirst used by Gaspard Leurent Bayb (1774-1816) whopointed out the nature of scrofula glands and describedthe relationship between pulmonary tuberculosis andother orqans.' Tuberculosis is today one of the majorhealth problems all over the world. It infects about onethird of world's population and kills about 3 million peopleeach year.3 Inflammatory and immune reaction are themost common cause of lymphadenopathy that are selfIimiting.4 Infection entering through the teeth, tonsils oradenoid involves the upper cervical (Jugulo diagastric)nodes, whereas involvement of lower cervicalsupraclavicular node indicates infection coming from theapex of lung. Generalized lymphadenopathy indicatesmiliary tuberculosis.' The differential diagnosis ofenlarged cervical lymph nodes includes bacterial,mycobacterial and viral infections, granulomatouscondition such as sarcoidosis, primary and secondaryinvolvement in lymphoma and metastatic neoplasm frombreast and lung. Sometime uncommon condition like'sinus histiocytosis, eosinophilic granuloma, Kimura'sdisease and Kikuches disease." are seen.

Correspondence:Dr. Jamil Ahmad Khan, Associate Professor,Bolan Medical College, Quetta.

Sonography differentiates tuberculosis and metastaticlymph node by their shape, odema of surroundingstructure, soft tissue homogeneity, intranodal cysticnecrosis, matting and posterior enhancement.' Colourdoppler sonography is used for differentiating betweenmalignant and tuberculous lymph node," In tuberculoushigh abnormal vascular pattern i.e. absent hilarvascularity, deformed radial pattern absent multi focalityand peripheral vascularity are seen, which is also seen inmalignant lymph node." These tests need expertise andmore advancement to pick up the diagnosis.

Lymph nodes are biopsied when lymphadenopathy doesnot resolve after several weeks and a specific diagnosis isnot established by other means." Cervical lymph nodesare more likely to be informative in case of generalizedlymphadenopathy, deeper nodes show diagnosticfeature."

The aim of this study was to see the prevalence oftuberculosis: among the patients having cervicallymphadenopathy.

PATIENTS AND METHODSThis prospective study was conducted at Department ofSurgery, Sandeman (Prov.) Hospital, Quetta during theperiod January 1995 to December 1999. Both maleand female patients presenting with cervicallymphadenopathy, regardless of their age, were included.Patients were selected through outpatient departmentand those referred from medical units. Patients who


Jamil Ahmad Khan, Mukhtar Mehboob, Ehsan-UI-Wadood, Abdul Qayyum, Ghulam Rasoool Arbab

fulfilled the following eriterla were included:

• Cervical lymphadenopathy which were not diagnosedby history, clinical examination and non invasivetechniques.

• Those cases in which diagnosis was inconclusive by FNAC.• Cervical lymphadenopathy not responding even after two

weeks of chemotherapy and was progressive in nature.• Undiagnosed lymph node enlargement.• Single large diagnosed lymph node for patient's

psyche and cosmetic reason.

Those patients were excluded from this study where thecause of cervical lymphadenopathy was established orwhen they were not willing.

RESULTSA total of 151 patients with cervical lymphadenopathywere selected for open cervical lymph node biopsy fromJanuary 1995 to December 1999. The most common agegroup found involved in our study was between 11-20years, the youngest being 2 years old and the oldest 80years. The sex distribution revealed 84 (55.6%) male and67 (44.3%) females.

The commonest lesion observed was tuberculoses in 86(56%) patients, followed by reactive hyperplasia 34 (22.5%) patients, Non-Hodgkin lymphoma 11 (7.3%) patients,metastatic 7 (4.6%) patients, Hodgkin lymphoma 7(4.6%) patients and one case of each myeloid leukemia,sinus histiocytosis and moderately differentiatedsquamous cell carcinoma.

DISCUSSIONTuberculosis is the single most cause of death" and about5-10 million infection cases are reported each year. 11Tuberculosis presents with its typical manifestation butsometime atypical presentation with only cervicallymphadenopathy is presented. Dandapat documentedtuberculosis as the commonest cause oflymphadenopathy with female predominance."

The probability of determining the cause by biopsy can beas high as 60%.13 The use of FNAC as a diagnosticmethod has been highly controversial, both amongstpathologists and clinicians. It has high false negativerates, false positive results and high percentage ofinadequate or unsatisfactory samples." In a studyconducted in Pathology Department Punjab MedicalCollege, Faisalabad by Amin. D et ai, a correct diagnosisin 165 cases out of 190 was suggested by cytology astuberculous lymphadenitis. In 25 cases in which falsepositive diagnosis of chronic reactive lymphadenitis wasmade. Positive predictive value for tuberculosis is 90%.15In our study of 151 patients with cervicallymphadenopathy 86 (56.9%) had tuberculosis. In a studyby Abdullah. P-421 (50.9%) patients out of 826 had

tuberculosis." Most of the patient presented were in 11-20years of age while in study of Abdullah. P. the mostprominent age group was 21-30 years." In Pakistantuberculosis infection is generalized and widespread. Thetwo national surveys of 1961-62 and 1974-78 revealedalmost a similar tuberculosis infection rate of 80% in agegroup 20-29 years. 11The sex distribution in our series was87 (55.6%) male and 67 (44.3%) female while in study byAbdullah. P males were 432 (52.3%) and females 394(47.6%).16 The prevalence of tuberculosis among thepatients with cervical lymphadenopathy was 56 per 100patients in our series.

Based upon this study cervical lymph node biopsy is aneffective, easy and economical method for diagnosis oftuberculosis. The highest incidence of the diseases in theage group 11-20 years. The disease is common in malepopulation. In case of cervical lymphadenitis tuberculosisis the most important differential diagnosis. Lymph nodebiopsy should be made in all suspected case before thestart of definitive chemotherapy. Lymph node biopsy alsohelp in establishing the diagnosis of unusual presentationof different diseases.

REFERENCES1. Pathan. A.J; Hospitalization for TB: when and why?

Quarterly Specialist; 31 - 35.2. Hola, SM; History of Tuberculosis. Quarterly Specialist;

1986; 15 -20.3. Bloom BR; Murray C.J; Tuberculosis commentary on re-

emergent killers (see comments). In: Science 1992; 257:1055 - 64.

4. Kessane MJ; Haematopoitic system: bone marrow, blood,spleen and lymph nodes, In: Anderson's pathology.Philadelpia: Mosby, 1990; 2:1433.

5. Forrest. A.P.M; Carter D.C; Macleod l.B; Principle andpractice of surgery; Bath press Avon. 2nd Ed; 1990, 322 -23.

6. Kaji - AV; Mohuchy - T; Swartz-J-D; Imaging of cervicallymphadenopathy. Semin - Ultrasound CT - MR. 1997;18(3): 220 - 49.

7. Ying - M; Ahuja - AT; Evans - R; et al; Cervicallymphadenopathy: Sonographic differentiation betweentuberculosis node and nodal metastasis from non head andneck carcinoma. J. Clin - Ultrasound. 1998;26 (8) : 383 - 9.

8. Na - DG; Um - HK; Byun -HS; et al; Differential diagnosisof cervical lymphadenopathy: Usefulness of colour dopplersonography. AJR - Am - J - Roentgenol 1997; 168 (5) :1311- 6.

9. Aster. J; Kumar. V; White cells and lymph nodes, spleenand thymus, In : Cotran RS, Kumar V, Collin T: RobbinsPathological basis of disease. 6th Philadelphia : WBSaunder, 1999 : 644 - 95.

10. Rosai - J; Lymph node, In: Ackerman's surgical pathology.Vol. 2. 8th Ed. St. Louis: Mosby, 1996, 1661 - 1773.


Tuberculous cervical lymphadenopathy

11. Aziz. A; lshaq. M; Mycobacterium tuberculosis and updatemanagement of pulmonary TB "Specialist", 1986; 21 - 30.

12. Dandapat MC; Mishra BM; Dash SP/ Kar - PK; Peripherallymph node tuberculosis: A review of 80 cases. Br. J. Surg.1990; 77 : 911 - 2.

13. Sinclsis - S; Beckman E; Ellman. L; Biopsy of enlargesuperficial lymph nodes. JAMA 1974; 228 : 602 - 3.

14. Lampe HB, crams HM; Advances in the use of FNAC in thediagnosis of palpable lesion of the head and neck. F.Otolaryngol 1991; 20:108 - 16.

15. Amin D; Khurshid. J.A; Malik. I.H; Mehmood. R.Q; Fineneedle Aspiration (FNA). The professional 2000; 07,4.

16. Abdullah. P; Mubarik. A; Zahir. N; The importance of lymphnode biopsy in diagnosis of lymphadenopathy J CPSP 10 (8): 298 - 301 2000.

VI INTERNATIONAL SURGICALCONFERENCE,KATHMANDU,NEPAL

The VI International Surgical Conference of the Society of Surgeons of Nepal(SSN)is scheduled to be held from November 21 to 23. 2002 in Kathmandu,Nepal. It is expected to be a large gathering of surgeons of different surgicalexpertise from institutions of the globe.

The scientific programme will include panel discussions, CME programmes,orations, guest lectures, free papers, posters, video presentations, workshopsand symposia in various surgical specialities. Interested surgeons may contact:

Dr. Monohar LalShresthaOrganisation Secretary,VI International Surgical ConferenceSociety of Surgeons of NepalNMA Building, Siddhi Sadan,Exhibition Road,GPOBox No.8442,Kathmandu. Nepal.


WOUNDS OF HEEL NEVER HEALIN DIABETICS

MUHAMMAD AHMAD, AZFAR FAROUGR, TARIQ MAHMOOD RERAN,

MUHAMMAD YOUSUF, KHALID MAHMOOD GILL

ABSTRACT:A comparative study oj 56 patients with Joot ulcers was carried out Jrom February 2000 toJune 2000, at Surgical Unit II, Bahawal Victoria Hospital, Bahawalpur to assess thedifference in outcome oj heel and non-heel ulcers in diabetics. The patients were divided intotwo groups: Group A- patients with heel ulcers and Group B- patients having ulcers anywhereother than on heels. Feet in both the groups were graded according to Meggitt-Wagnerclassification. Patients with evidence oj primary vascular disease were excluded. All thepatients were X-rayed for bony involvement. Proper glycaemic control with proper antibioticcover was ensured and results oJ interventions were recorded and analysed.

Most oj the patients who Julfilled the inclusion criteria (35 in group A and 21 in group B) didnot know about the mode oj initial lesion. Those with history oj trauma were 25.7% in group Aand 19% in group B. In group A, 51.4% patients had deep ulcers as compared to 42.80%patients oj the same grade in group B. Although gangrene was more common in group B, thesepatients underwent relatively less interventions. The percentages oJbelow and above the kneeamputations were higher in group A. The single mortality also occurred in a patient with heelulcer. Mean duration of hospital stay was 27.3 and 16.6 days in group A and B respectively.

KEY WORDS: Heel ulcers, Amputations, Diabetes mellitus, Complications.

INTRODUCTION Diabetic foot has major medical, social and economicconsequences, '0 resulting in longer hospital stay than allother complications of diabetes.":" Presentation of footproblems in diabetics is variable, ranging from cellulitis,abscess and ulcer to gangrene. Surgical managementdepends on the presentation and varies from minordebridement, incision and drainage to amputation."Amputations are 15 times more common amongdlabetics" and the best predictor of lower limb amputationis a l history of previous foot ulcer, the presence ofneuropathy or peripheral vascular disease and poorglycaemic control."

Diabetes Mellitus is the most common non-communicabledisease worldwide with increased mortality andmorbidity.' Diabetes is increasingly being recognized asan important cause of morbidity and mortality indeveloping communities/ due mainly to the associatedchronic complications, both specific microvascular andnon-specific macrovascular.' The disease is of interest tothe surgeon, largely because of its complications at thetime of diaqnosls.' Peripheral neuropathy is one of themost common complication of dlabetes'" in westerncountries and may manifest as loss of sensation in feet. Itis an important factor in the pathogenesis of foot ulcers,which can progress to infection, necrosis, gangrene, loss PATIENTS AND METHODS'of limb or even death." Foot ulcers are the most common A total of 56 diabetic men and women who presented fromcause of hospital admissions among diabetic patients, 01.02.2000 to 31.06.2001 in Surgical Unit II of Bahawal~g9~.~~!~~~.t<?L~9~o.Rf.~ll.~9~p'italizations.'o Victoria Hospital, Bahawalpur, were included in thisCorrespondence: comparative study. To qualify for the inclusion, patientsDr. Muhammad Ahmad. Additional Registrar. had to have a random plasma glucose level of > 11.1Surgical Unit II, Bahawal Victoria Hospital. Bahawalpur. mmol/L or a fasting plasma glucose level of >7.0 mmol/L

Journal of Surgery Pakistan (International) Vol. 6 (3) July - September. 2001 19

Wounds of heel never heal in diabetics

and a foot ulcer. They were divided into two groups:Group A consisting of patients who presented with heelulcers and Group B with patients who had ulcersanywhere on foot other than heel. Feet in the both groupswere graded according to Meggitt-Wagner classificationof Diabetic foot (Table I).

TABLE-I MEGGITT·WAGNER CLASSIFICATIONOF DIABETIC FOOl ULCERS

GRADE FEATURE '\11::

Patients with an evidence of primary vascular diseasewere excluded. All patients were X-rayed for any bonyinvolvement. Types of organism isolated from foot lesionswere also recorded. Proper glycaemic control withantibiotic cover was ensured and results of interventionswere recorded. Both the' groups were analysed andoccurrence of amputations was recorded separately. Alldata was analysed and processed by using SPSS(version 8.0) software.

RESULTSFifty-six patients fulfilled the inclusion criteria, theirbaseline characteristics are iven in Table II.

Many of the patients (31.4% in Group A and 28.6% inGroup B) did not know about the initial mode of their

lesion. Those with history of trauma were 25.7% in GroupA and 19.0% in Group B (Table III).

In Group A, most patients (51.4%) had deep ulcers (grade2,3) as compared to the patients (42.8%) of the samegrade in Group B. Surprisingly, incidence of gangrene(grade 4,5) was 22.9% in Group A while it was 23.8% inGroup B (Table IV).

Although percentage of surgical intervention and amputationwas high in both groups, the patients of Group A underwentless interventions (73.8% in Group A versus 66.7% in GroupB) (p-value <0.001). Surprisingly percentage of below kneeand above knee amputations were higher in Group A (51.4%& 38.1% respectively) (p-value <0.005). Obviouslyamputation of one or more toes was not included either inbelow knee or above knee amputations.

DISCUSSIONRelationship between glycaemic control and diabeticcomplications remains unclear. Studies of genetic factors,including HLA-type etc. suggest that there is a geneticcomponent in developing the complications of diabetes."There is a paucity of information in many localcommunities regarding complications and rnanaqernent.'Wound healing abnormalities in diabetics result fromseveral causes." A high incidence of infections occurs indiabetics with poor glycaemic control. Among the reasonsare decreased local and systemic host resistance.Defective phagocytosis, killing of bacteria and decreasedmigration of inflammatory cells into the site of tissue injuryare features of diabetic state." Diabetic ulcers arecommonly seen on lower extremities. The diabeticsbecome insensate on weight bearing areas and othervulnerable sites on lower extremities. These ulcers are


Muhammad Ahmad, Azfar Farough, Tariq Mahmood Rehan, Muhammad Yousuf, Khalid Mahmood Gill

related to diabetic neuropathy or rnicroanqiopathy,"Microvascular dysfunction, unique to diabetes, isconsidered a separate risk factor for foot ulcers."

~-,

c·

Foot ulcers will affect 15% of diabetics during life17•18 whichresult from trauma in the presence of neuropathy.'° Thefeet do not ulcerate spontaneously, but minor trauma maybe sufficient to initiate ulceration. Infection is not a primarycause of foot lesions, but occurs as a secondaryphenomenon following ulceration of protective epidermis.Altered proprioception and small muscle wasting, in thepresence of limited joint mobility leads to altered loadingunder the feet during standing and walking. A patient withinsensitivity and high pressures is at high risk ofneuropathic ulceratlon."~

In our study, we divided the diabetics into two groups:63% of the patients had initially heel ulcers and most ofthem were male. The age difference in both groupsindicates that the development of heel ulcers was morecommon in slightly older patients (Table I), 31.4 of thesedid not know about the cause of their heel ulcers and onlyone fourth gave the history of trauma. The two findings oftrauma and neuropathy are significant in development ofheel ulcers in diabetics. To suggest heel ulcers are relatedto diabetes, vascular disease, trauma etc. is an over-simplification. It is more likely a combination of multiplefactors." The thickened basement membrane is believedto impair migration of leukocytes as well as blood flowthrough capillaries. These changes and an impairedneurogenic vasodilatory response, result in an inability toachieve a normal hyperaemic response needed afterinjury and increase the risk of infection.20.21 Sensorimotorneuropathy leads to diminished sensations as well assmall muscle atrophy in the intrinsic muscles of foot. Achange in weight bearing and diminished sensation,together with ischaemia and microvascular dysfunction,leads to higher morbidity and mortality rates, secondary topoor wound healing. Studies have reported decreasedwound healing, increased morbidity and amputation ratesassociated with diabetic foot ulcers.":"

Also evident from our study is the higher occurrence ofdeep ulcers (grade 2,3) in patients with heel ulcer (FigureI). Although the rate of gangrene was greater in group 8,the rate of below-knee amputations was surprisinglymuch higher in heel ulcers (37.1 % & 14.3% in group Aversus 28.6% ands 9.5% in group 8, respectively (p-value<0.001). Various studies on mice have demonstrated thattopical application of insulin and administration of vitaminA, improves would healing in diabetic mice.26•27 Peripheralneuropathy and ischaemia combined with un-recognizedrepetitive trauma (e.g. ill-fitting shoes, unrecognizedinjury, ingrown toenail) lead to foot ulceration." Non-healing ulcers. lead to amputation 85% of the tlrne.":"Upto 50% of patients who had an amputation require

another within 5 vears= More than half of the diabetics,who develop a foot lesion subsequently developcontrlateral lesion within 2 years and about half of themrequire amputatlon="

Figure1: A longstanding deep heel ulcer

In our study, 60% of patients with heel ulcers had previoushistory of foot lesion/ulcer. Most had ulcers on right heel.The duration of hospital stay was longer in patients withheel ulcers (27.3 days versus 16.6 days). However, thetotal management cost was not taken in account. Thesingle mortality was due to widespread gangrene of lowerlimb as the patient refused the early above-kneeamputation. This also necessitates the early and effectivetreatment for heel ulcers. Of utmost importance is anassessment of patient's medical maAagement ofdiabetes." Patients with non-limb threatening infectioncan be treated with oral antibiotics. Patients with limb-threatening infection should be hospitalized and receiveappropriate wound care (including sharp debridement)along with IN arntonoptocs." The limitations of our studywere firstly the unavailability of data to compare with theresults and secondly the type of micro-organism involvedand foot deformity were not taken in account. In one studycomparing the outcome of heel ulcers in diabetics andnon-diabetics also showed that patients with heel ulcershad a higher number of interventions performed, higherrate of amputation and a higher mortality rate than heelulcers in non-diabetics. Although heel ulcers are lessfrequent than forefoot ulcers, higher expenses, moreinterventions and higher mortality rates are associatedwith heel ulcers." Patients with known peripheralneuropathy or high risk foot conditions (e.g. hammer toe,Charcot's foot, bunions or calluses, foot deformities etc.)should be examined at every visit. The examinationshould include an assessment of integrity of skin,vascular status, foot structures and foot sonsanons.s= Ifwound is not on a weight-bearing surface, any repetitivetrauma should be relieved and treated conventionally for2-4 weeks to reassess the healing process."

REFERENCES1. Motala M,Omar MAK, Pirie FJ. 'Type 1 Diabetes Mellitus in

Africa: Epidemiology and Pathogenesis'. Diabetes InternlVol. 10, No.2, July 2000: 44-47.

Joumal of Surgery Pakistan (Intemational) Vol. 6 (3) July - September, 2001 21

Wounds of heel never heal in diabetics

2. Muula A. 'Preventing diabetes-associated morbidity andmortality in resource-poor communities'. Diabetes Internl Vol12, No.2, July 2000: 47-48.

3. Struthers A, Stewart AM, Reid IC, Cuschieri A. 'Managementof patients with medical disorder'. In: Cuschieri A, Steele RJC,Moosa AR, Eds. 'Essential surgical practice'. Vol. 1, 4th edition,Oxford, U.K., Butterworth-Heinemann, 2000: 457-491.

4. WHO. 'Prevention of Diabetes Mellitus'. Report of a WHOstudy group. WHO Technical Report Series 844. WHO,Geneva, 1994.

5. Water DP, Galting W, Mulle MA, Hill RD. 'The Distributionand severity of Diabetic Foot Disease: a community studywith comparison to a non-diabetic group'. Diabetes Medicine1992; 9: 354-8.

6. Jones RB, Gregory, Jones EW et al, 'The Quality andRelevance of peripheral Neuropathy data on a diabetic clinicalinformation system'. Diabetes Medicine 1992; 9: 934-7.

7. Akanji AO, Famuyiwa 00, Adetuibi A. 'Factors influencingthe outcome of treatment of foot lesions in Nigerian patientswith diabetes mellitus'. QJ Med 1989; 73: 1005-14.

8. Boulton JAM. 'The diabetic foot: neuropathic in aetiology'.Diabetes Medicine 1992; 9: 349-53.

9. Mc Larty DC, Pillitt C, Swai ABM. 'Diabetes in Africa'.Diabetes Medicine 1992; 9: 349-53.

10. BoultonAJM. 'The Diabetic Foof. Surgery IntemI1996; 32: 37-39.

11. Eckman MH, Greenfields S, Mackey C. 'Foot infections indiabetic patients: Decision and cost-effective analysis'.JAMA 1995; 27g: 712-20.

12. Ramsey SD, Newton K, Blough D. 'Incidence, outcome andcost of foot ulcers in patients with diabetes'. Diabetes Care1999; 2: 382-4.

13. Qari FA, Akbar D. the Diabetic Foot-presentation andtreatment experience in Jeddah, Saudi Arabia'. DiabetesInternl Vol 10, No.3; Nov 2000: 88-89.

14. Strowig S, Raskin p. 'Glycaemic control and diabeticcomplications'. Diabetes Care 1992, Sept; 15: 1126-40.

15. Kelman I, Cohen IC, Diegelmann RF. 'Wound healing indiabetics'. In: Greenfield LJ. Ed. "Surgery: scientificprinciples and practice'. Philadelphia, USA, J.B. LippincottCo., 1993: 86-102.

16. Mc Neely MJ, Boyko EJ, Ahroni JH et al. 'The independentcontributions of diabetic neuropathy and vasculopathy infoot ulceration'. Diabetes Care 1995; 18: 216-9.

17. Mayfield JA, Reiber GE, Sanders LF, et al. 'Preventive footcare in people with diabetes'. Diabetes Care 1998; 21: 261-77.

18. National Institute of Diabetes and Digestive and KidneyDiseases. "Diabetic neuropathy: the nerve damage ofdiabetes'. Washington , DC. US Department of Health andHuman Services; 1995.

19. Tikva SJ, Kerstein MD. 'Non is there a difference in outcomeof heel ulcers in diabetic and non-diabetic patients'. Wounds12 (4): 96-101.

20. Akbari CM, LoGerfo FW. 'Diabetes and Peripheral vasculardisease'. J Vas Surg 1999; 30: 373-84.

21. Jorneskog G, Brismar K, Fagrell B. 'Skin capillary circulationis more impaired in the toes of diabetic than non-diabeticpatients with peripheral vascular disease'. Diabetic Med1995; 12: 36-41.

22. Siitonen 01,Niskanen LK, Laasko M, et al, 'Lower extremityamputations I n diabetic and non-diabetic patients'. DiabetesCare 1993; 16: 16-20.

23. Kalmar TM, Towne JB, Bandyk DF, Bonner MJ. 'Theinfluence of sepsis and ischaemia on the natural history ofthe diabetic foot'. Ann Surg 1987; 53: 490-4.

24. Caputo GM, Cavanagh PR, Ulbrecht TS, et al. 'Assessmentand management of foot disease in patients with diabetes'.New Engl J Med 1994; 331: 854-60.

25. Harvima IT, Virnes s, Kauppinen L, et al, 'Cultured allogenicskin cells are effective in treatment ofchronic diabetic leg andfoot ulcers'. Acta Derm Venereol (Stockh) 1999; 79: 217-20.

26. Hnam SR, Singleton CF, Rudek W. 'The effect of topicalinsulin on infected cutaneous ulceration in diabetic and non-diabetic mice'. J Foot Surg 1983; 22:298.

27. Seitter E, Rethura G, Padawer J, et al, 'Impaired woundhealing in streptozotocin-diabetes: Prevention bysupplement of vitamin A'. Ann Surg 1981; 42: 194.

28. Albrant DH. 'Management of foot ulcers in patients withdiabetes'. JAm Pharm Assoc 40(4)" 467-74.

29. National Institute of Diabetes and Digestive and Kidneydiseases. 'Feet can last lifetime: A health care provider'sguide to preventing diabetes foot problems'. Washington,DC, US Department of Health and Human Services; 1997.

30. Boyko EJ, Ahroni JH, Smith DG. 'Increased mortalityassociated with diabetic foot ulcers'. Diabetic Med 1996,Nov; 13: 967-72.

31. Goldner MG. 'The fate of the second leg in diabeticamputee'. Diabetes 1960; 9: 100-3.

32. American Diabetic Association. ' Prevention foot care in peoplewith diabetes'. Diabetes Care 1999; 22 (SuppI1): S 54-50.

33. Cevera JJ, Bolton LL, Kerstein MD. 'Options for diabetic patientswith chronic heel ulcers'. J Diabetic Comp 1997; 11: 358-66.

34. 'Management of Diabetic Foot Ulcers'. Washington, DC, AmPharmaceutical Association; 1999; 1-20.

35. BoutonAJ, Meneses P,EmisWJ. 'Diabeticfoot ulcers:a Frameworkfor prevention and care'. Wound Rep Reg 1999; 7: 7-16.


DIAGNOSTIC VALUE OF ULTRASOUND INBLUNT ABDOMINAL TRAUMA

O.M.KHAN BALueR

ABSTRACT:Blunt abdominal trauma is one oj the commonest injuries. In order to evaluate the diagnosticvalue oj ultrasound in such patients, a prospective study was carried oui from. July 1998 toJune 2001 in patients admitted to emergency ward, Nishtar Hospital Multan on emergency-on-call days oj Surgical Unit III (twice a week). All the adult patients (over the age oj 12 years)with blunt abdominal trauma, without associated injuries were included in the study.

Males below the age oj 40 were the most common victim (90%) of this injuri; The most commoncause oj this injury was road trafflC accident (80%). Timely diagnosis oj the nature oj intra-abdominal injuri] is essential to reduce the mortality and morbidity in such patients. Amongthe various diagnostic modalities currentuj used, in mqjority oj the main public hospitals,ultrasonograpQ.y Broved.to be very fielpJul in the correct diagnosis oj the abdominal organ,injuries with diagnostic accuracy oj 98%.

KEy"tvORDS: Blunt Abdominal Tralol;lllU,Ultrasonography.

INTRODUCTIONTrauma is a leading cause of death in younger age group«40 years of age)1.2 due to high speed automobiles.Blunt abdominal trauma is one of the commonest injuriesin civilian population, mostly due to road traffic accidents.

PATIENTS AND METHODSThis is a prospective study of 120 adult (above 12 yearsof age) patients admitted to casualty ward, Nishtarhospital Multan on emergency on-call days (twice a week)of surgical unit III, from July 1998 to June 2001. Patientsof either sex with blunt abdominal trauma and withoutassociated injuries were included in the study.

After admission, detailed history, clinical examination andnecessary conservative treatment such as analgesic, I.V.fluids, antibiotic, record of vital signs and intake outputrecords were made.

The investigations included, complete blood and urine~~~!!ll~~tl~~.,. ~I?<?~.Rr.<?~p.i~.Q.~nd cross-matching, serumCorrespondence:Dr. O.M. Khan Baluch, Associate Prof. Surgical Unit III,Nishtar Medical College & Hospital, Multan.

electrolytes and radioqraph of chest and abdomen instanding position and ultrasound examination. Patientswere managed according to the nature of injury.

RESULTSMost of the patients in this study i.e. 96 out of 120 (80%)were below the age of 40, only 24 (20%) were above 40years of age and with 90% males (108) and 10% females(12 only). Road traffic accident was the most commoncause of injury causing blunt abdominal trauma in 90 outof 120 (75%) patients, other causes included machineryinjury 24 (20%) and fall from height 6 (5%).

In all these patients, complete blood and urine wereexamined, 40% of the patients had hemoglobin below 10gm/dl and 16% had RBeS in their urine. Plain radiology ofthese patients in erect position revealed gas under rightdome of diaphragm in 30 patients (25%) and ground glassappearance in 24 (20%) while in 66 patients (55%)radiological examination was equivocal.

Four quadrants peritoneal aspiration revealed eitherblood or fluid in 70% of these patients.


Diagnostic value of ultrasound in blunt abdominal trauma

All patients in the study had ultrasound examination. Thefindings are given in Table I.

TABLE·I NATURE OF INJURY AS SHOWN BY ULTRASOUNDEXAMINATION (N=120)

S. NO. ORGAN INJURED NO. OFPATIENTS

Multiple organs injuries were detected in 12 patients i.e.spleen and duodenum in 4, liver and small gut in 4 andstomach and diaphragm in 4 patients.

Exploratory laparotomy confirmed the lesions detected inall the patients with positive ultrasound findings (i.e. 96out of 120). Among the 24 patients wPthnormal ultrasoundfindings, 8 patients were operated who showed signs ofinternal hemorrhage like pallor, coldness of extremities,thrtady pulse and low blood pressure despite adequateresuscitation. Four of these patients had injury to the leftrenal pedicle and another four had injury to the pancreas.Rest of the patients with normal ultrasound results weremanaged conservatively with good outcome.

DISCUSSIONTrauma is more common in youn~ persons and stillremains a challenge due to significant morbidity andmortality which can be reduced with improved traumacare.' Although careful physical examination in an injuredpatient is helpful in diagnosis of the nature of injury but isusually inadequate to detect the organ injured in bluntabdominal trauma .• The incidence of blunt abdominaltrauma has increased as there is increase in high speedautomobiles accidents.' This fact is also confirmed in thisstudy; cause of blunt abdominal trauma is road trafficaccidents in 90% cases. The victims of trauma are mostlyyounger age persons between 3rd and 4th decades of lifeand 96 patients (80%) in this study were below the ageof 40 years; this result is the same as reported by Ong-el, Png Dl, et al,' and Barlon TG, Weissmon AM.2Another study conducted by Abbas MK, Gondal KM; etal3 shows 66% of the patients with blunt abdominaltrauma between 11 and 30 years of age.

Ninety percent of our patients were males but in thewestern literature, males-females ratio is of 3:1. This isdue to the fact that females western have more outdooractivities than our females. In blunt trauma solid organsare affected more than the hollow visceras."

The different diagnostic procedures used formanagement of these patients include plain x-rayabdomen, four quadrant peritoneal aspiration,ultrasonography and radiography of the abdomen in erectposition. Ultrasound is becoming the most popular andaccurate scanning method to detect intra-abdominalinjuries in blunt trauma patients. It is highly sensitive,complication free, non-invasive and cost effective methodof initial evaluation in such patients."?" Ultrasonographyis the most commonly used diagnostic method in bluntabdominal trauma." This study shows that in 96 out of120 patients (80%), the ultrasonography picked up theinjuries later confined at laparotomy. This observation isapproximately the same in reported by other authors.v=v

The findings reported in other international studies show thediagnostic accuracy rate of ultrasound in patients with bluntabdominal trauma between 88_98%.,3,'4,'5,16,17In our study thediagnostic accuracy rate is found to be 98%.

REFERENCES1. -()~CL, Png DJ, Chan-ST. Abdominal Trauma - a review,

Singapore-lC1ed-J. f994, JLft'Ie; 35(3): 269-70.

2. Barlow TG, Weissman AM. Diagnostic Imagtng in theevaluation of Blunt Abdominal Trauma. Am-Fam-Physician.1996; 54(1): 205-9. ••3. Abb..ts MK, Gondal KM, Khan AF. Experience of SelectiveConservaticn in Splenic Trauma. Pakistan Journal ofSurgery 1995; 11(4): 225-28,

4. Akgur FM, Tanyel FC, Akhan 0, et ar The Place ofUltrasonographic Examination in the Initial Evaluation ofChildren Sustaining Blunt Abdominal Trauma. J-Pediatr-Surgery. 1993; 28(1): 78-81.

5. Gothi R, Bose MC, Kumar N. Ultrasound Demonstration ofTraumatic Fracture of Pancreas with Pancreatic CluetRupture. Clin-Radiol. 1993; 47(6): 434-5.

6. Forter, Pillasch J, Zielke A, et al. Ultrasonography in BluntAbdominal Trauma. J-Trauma. 1993; 34(2): 264-9.

7. Abu-Zidan FM, Zayat I, Sheikh M, et al. Role ofUltrasonography in Blunt Abdominal Trauma. Eur-J-Surg.1996; 162(5): 361-65.

8. Bolanger BR, Mclellan BA, Brenneman FD, et al. EmergentAbdominal Sonography as Screening Test in a NewDiagnostic Algorithm for Blunt Trauma. J-Trauma, 1996;40(6): 867-74.

9. Pearl WS, Todd KH. Ultrasonography for initial evaluation of BluntAbdominal Trauma. Ann-Emerg-Med. 1996; 27(3): 353-61.

10. Mckeney MG, Martin L, Lentz K, et al. 1000 ConsecutiveUltrasounds for Blunt Abdominal Trauma. J-Trauma. 1996;40(4): 607-12.

11. Mc Kenny M. Lentz K, Nunez D, et al. Can UltrasoundReplace Diagnostic Lavage in Assessment of Blunt Trauma.J-Trauma, 1994; 37(3): 439-41.


12. Akgur FM, Atug T, Kovanhkaya A, et at. Initial Evaluation ofChildren Sustaining BluntAbdominal Trauma. Eur-J-Pediatr-Surg. 1993; 3(5): 278-80.

13. Ma OJ,Mateer JR, Ogata M, et at. Prospective Analysis of aRapid Trauma Ultrasound Examination Performed byEmergency Physicians. J-Traauma, 1995; 38: 879-85.

14. Boulanger BR, Brenneman FD, McLellan, et at. AProspective Study of Emergent Abdominal SonographyAfter Blunt Trauma. J-Trauma, 1995; 39: 325-30.

15. Boulanger BR, McLellan BA, Brenneman FD, et al.Emergent Abdominal Sonography as a Screening Test in aNew Diagnostic Algorithm for Blunt Trauma. J-Trauma.1996; 40: 867-74.

16. Branney SW, Moore EE, Cantril! SV, et al. Ultrasound BasedKey Clinical Pathway Reduced the Use of HospitalResources for the Evaluation of Blunt Abdominal Trauma. J-Trauma, 1997; 42: 1087-92. .

17. Mc Kenney KL, Nunez DB, McKenney MG, et at,Sonography as Primary Screening Technique for BluntAbdominal Trauma: Experience with 899 Patients.American-J-Roentgenol. 1998; 170: 979-85.

Journal of Surgery Pakistan (International) Vol. 6 (3) July· September, 2001 25

AETIOLOGY AND OUTCOME OFPAEDIATRIC BURNS

NASIR SALEEM, JAMSHED AKHTAR, SOOFIAAHMED, ABDUL AZIZ

ABSTRACT:Burns is a common iryury in children with life long imprints on the personality as a result ojits sequelae. A one-year study was conducted in the Burns Unit oj Department oj PaediatricSurgery, National Institute oj Child Health, Karachi to find out the aetiology and outcome ojpaediatric burns in terms oj mortality.

Patients with burn iniuries admitted From January to December 1999, were 198 (108 maleand 90 female). Mqjority oj these were between 2 - 5 years oj age (n=85). In almost 62% ojcases TBSA burnt was less than 3096. Scald burn was the commonest type oj burn injury(n=112). Inflame burn more than 50% of cases had more than 30% TBSA involvement. Incases of scold. burn the mode oJiryury in mqjority oJcases was spillage oJhot liquid (89/ 112).Mqjority oj accidents occurred in home environment (n=178), kitchen being the most commonplace. Eighty patients received inadequate treatment at some other Jacility before beingreferred to us. Most oj the patients (n=123) came to emergency room after 6 hours oj accident.Pseudomonas was the commonest organism isolated (41%) Jollowed by staph aureus.Complications occurred in Significant number oj cases and injective complicationspredominated (n=82). Seventy deaths (35.3%) occurred in this series and most oj them werein children under two years oj age (20/52 - 38.2%). Mortality was slightly more in patientswithflame burns (38/86) and those with more than 30% TBSA involvement (44/76, 57.8%).

Preventive measures could have avoided these accidents. In this regard mass education canhelp in reducing the incidence. For proper management there is a need oj establishingspecialized burns unit at each district headquarter level.

KEY WORDS: Burns, Children, Mortality.

INTRODUCTIONBurn wounds are common cause of injury related todisability and permanent disfigurement in childhood . Noother form of trauma causes such physiologic andpsychological injury as the burn trauma.' Majority of burninjuries sustained by children occur at home as a result ofan accident.' National Institute of Child Health, Karachi, atertiary care hospital, has a Burns unit that is the onlyfacility in this region of the country in public sectorproviding treatment to paediatric burns victims. This studywas planned to look into causes of paediatric burns andoutcome in terms of mortality also assessed.·Co;;;s;;;~d~~ce~··················Dr. Jamshed Akhtar, Assistant Professor,Department of Paediatric Surgery, National Institute of Child Health,Karachi- 75510. Karachi.

PATIENTS AND METHODSA prospective study was conducted in Burn unit atDepartment of Pediatric surgery, National Institute ofChild Health, Karachi. Study lasted over a period of oneyear from January 1999 to December 1999. Patientswith acute thermal burn admitted to the unit were includedin this study. The data related to the patients wascollected on a proforma that included age, sex, cause ofburn, time of injury, treatment received elsewhere, timelapse, site of accident, associated injuries etc.

RESULTSThere were 108 male (54.5%) and 90 female patients.Most commonly children between 2 - 5 years (n - 85) wereinvolved. The age and gender of the patients is given in


Nasir Saleem, Jamshed Akhtar, Soofia Ahmed, Abdul Aziz

Burns has been one of the commonest accidental injuriesin children and one of the major problems in our country.Its etiology has remained the same throughout the world

Site of Accident but mode of injury varies.3 Majority of the burns seen inJournal of Surgery Pakistan (International) Vol. 6 (3) July - September, 2001 27

Fig I. Average size of burn was 31.23% (Fig. II). Scaldwas the most common cause of burn with malepredomination. Common source and mode of scald burnwas spillage of hot water (Fig. III). Majority (83%) of burnaccidents occurred in domestic setting and kitchen wasthe common place (178/198). Most of the patientsreached our facility after six hours of accident (123/198).Prior to hospital admission some patients receivedincomplete treatment at different hospital and clinics.Complications are shown in fig. IV. In our studypseudomonas was the commonest organisms isolatedfollowed by Staph. Aureus.

Fig. I: Age and Gender

No

of

patie

s0-2 years

Age Groups

2-5 years 5-12 years

Fig. II: Burn Size and Type

N0

0f

pat

e

s Less than 3091i More than 3096

Percentage of Burn

Fig. III: Place of Accident, Activity and type of Burn

No

of

pat

ent

Playing in hDUSO Cooking in kitchen Outsides

Fig. IV: Complications and Mortality

Septicemia Respiratory Hyper Renal Failure Paralytic Convuisionjnfacuon Pyrexia Ileus

Complications

Seventy deaths (35.3%) occurred in this series and mostof them were in children under two years of age (20/52 -38.2%). Mortality was slightly more in patient with flameburns (38/86) and in those with more than 30% TBSAinvolvement (44/76, 57.8%, Fig.V, VI)

Fig. v: Mortality Related to Age and Type of Burn

No

of

pat

ents

~2 years 2-5 yearsAge Groups

5-12ye.rs

Fig. VI: Mortality Related to Age and Percentage of Burn

N 35

o

of

p

at

"PTS NOD Less then 30~ rBSAo More then 309& TBSA

e

s0-2 year.

Age Groups2-5 years 5-12 years

DISCUSSION

/

Aetiology and outcome of paediatric burns

this study were accidental and unfortunately, almost all ofthem were preventable. Several factors have beenidentified with an increased vulnerability to burn injury inthe underdeveloped countries. Factors like substandardhousing, overcrowding, low income, lack of education,ignorance and child abuse contribute significantly tothermal injuries:

The age category with highest frequency of burn injuriesis in accordance with other studies. The age range wasfrom 3 week to 12 years with slight male predominance.All groups of children are more or less equally affected.The children between 2 to 5 years are slightly on higherside, because of their inherent attitude of inquisitiveness.They pull / push and dip into pans of hot fluid thussustaining scald injuries. In other studies from Pakistanhigh frequency of burn accidents occurred in domesticsettings. In our study kitchen was the most notorious sitefor accident as found in other studies:

In our study in contrast to European studies socio-culturaldifference may also be an important reason. In developedcountries running hot tap water is commonest cause inscald injurles." In our study no incidence recorded due torunning hot tap water because availability of geezer islimited in the population. Majority of the population use hotwater container for their multiple purpose such as washing,bathing cleaning etc. and these hot container most of thetime placed open in airy space which usually is front yardor living room and children are not prohibited from playingaround it. Large family size is also a risk factor in theseaccidents. In our set up when both parents go to work andthe house is mainly left to the eldest child These accidentsoccur most commonly. Ignorance and literacy were twoother major factors predisposing such incidents.

Scald injuries were the commonest (56.5%) cause of burninjuries in our study. The depth of burn remained inbetween 1st and 2nd degree. This study coincides withother studies in that the commonest burn injury related totoddlers is scald compared to other type of burn injuries.In scald injuries the mean burn surface area was 38% +/-2% .. Among scald injuries spill, out numbered immersionin our studies as compared to developed countries."

Consistent with other studies flame injury is responsible forthe majority of full thickness injuries and carry the highestmorbidity and mortality. Frequency of flame is morecommon in age of more than five years. Flame burns weresignificantly larger than scald in both groups in terms ofnumber and related complications. The flammability ofclothing is dependent on several factors. Ideally all fabricin market should be flame retardant. According to westernliterature such restriction for children's night-clothes hasreduced the severity of injuries.' In our study cotton andcotton blends were commonly worn at time of accident.These are highly flammable.

It is difficult to predict the prognosis of a patient with burn,but review of the literature indicates that a point hasreached where children with less than 30% TBSA burnhas obtained 90% chances of survival as a productivemember of society. According to literature the survival ratewould not have been 100% in children with burn woundmore than 50 %TBSA. We found that increase in burnarea led to high mortality among children. In total 70deaths occurred of which those belonging to less than30% group were 26 while rest of patients belonged togroup B having 44 fatalities. This observation is inconsistence with other studies. Most of the children agedless than five years had high risk of death independent ofburn size is also found in present study. There is nosignificant gender difference with respect to mortality,"

The factors observed in relation with high mortality are.• Early deaths occurring in first two to three days were

due to shock leading to acute renal failure and factorresponsible was late referral.

• High mortality associated with flame burns is because oftwo reasons: initial deaths in our patients were due torespiratory failure and late deaths were due to sepsis.

• Sepsis is another factor that prolongs morbidity and isassociated with significant mortality.

• Pneumonia is one of the commonest causes of deathin burns patient. Many of these are related to invasivewound infection but air borne route is also a commonmode of spread.

REFERENCES1. Giardino AP, Christian CW, Giardino ER. A practical guide to

the evaluation of child physical abuse and neglect.Thousand Oaks, CA, Sage Publications, 1997.

2. Delatte SJ, Evans J, Hebra A, Adamson W, Othersen HB et al.Effectiveness of beta-glucan collagen for treatment of partial-thickness burns in children. J Pediatr Surg. 2001. 36; 113 - 118.

3. Morrow SE, Smith DL, Cairns BA, Howell PO, NakayamaOK et al. Etiology and outcome of pediatric burns. J PediatrSurg. 199631; 329 - 333.

4. Judkins K. Current consensus and controversies in majorburns management. Trauma. 2000; 2: 239-51.

5. Stuart SP, Pegg JJ, Gregory PG et al. Burns in childhood: Anepidemiological survey. Aust NZ J Surg. 1078.48; 365 - 373.

6. Siddiqui NA. Burns injuries are preventable. An analysis of716 cases in burns unit: J Coli Physicians SurgeonsPakistan. 1997 8; 148-152.

7. Raine AM, Azmy A. A review of thermal injuries in youngchildren. J Pediatr Surg. 1983. 18; 21 - 26.

8. Helving E. Pediatric burns injuries. AACN Clin Issues CritCare Nurs. 1993 4; 433 - 442.

9. Tompkins RG, Remenssnyder JP, Burke JF et al. Significantreduction in mortality for children with burn injuries throughprompt eschar excision. Ann Surg. 1988. 208; 577 - 585.


INJECTION SCLEROTHERAPY USING 5%PHENOL IN ALMOND OIL IN THE TREATMENTOF PARTIAL RECTAL PROLAPSE IN CHILDREN

MOHAMMAD ARIF, AFZAL JUNEJO.

ABSTRACT:Seventy-jour children aged 6 months to 9 years, with partial prolapse of rectum presented atSurgical Unii-Il, Liaquat Medical College Hospital Jamshoro, over a period of five years fromJanuary 1996 to December 2000. There were 44 males and 30 females, with male tofemaleratio of 1.47:1. They were initially treated conservatively and 52 patients (70%) were curedon conservative treatment alone. Remaining 22 patients (30%) were subjected to injectionsclerotherapy using 5% phenol in almond oil through proctoscope into rectal submucosa. Thecure rate after first injection. was 72.73% and after 2nd and 3rd injection was 86.36%. Only03 patients out of these 22 (13.64%) were ultimately recommended surgery. Overall patientsrequiring surgery were 03 out of 74 (4%). It is recommended that partial rectal prolapse inchUdren should initially be treated conservatively. When this fails, injection sclerotherapyusing 5% phenol in almond oil is a safe, inexpensive and easily available treatment. Surgeryshould only be considered in those patients, in which injection sclerotherapy fails.

KEY WORDS: Partial Rectal Prolapse, Treatment.

INTRODUCTIONThe descent of rectum through the anal canal is of twotypes: partial and complete prolapse. Prolapse involvingthe mucous membrane alone is called incomplete orpartial. When the entire thickness of rectal wall descends,the prolapse is termed complete. In partial prolapse themucous membrane and submucosa of rectum protrudeoutside the anus for approximately 1-4 cms. Rectalprolapse is rare in industrialized countries,' but isrelatively common in developing countries like Pakistan.While prolapse can occur at any time,

incomplete prolapse is more common in children andcomplete prolapse is a feature of the very elderly.' Noabnormality may be detected on preliminary examinationbut the prolapse may be precipitated by inserting asuppositoryand putting the child on a pot. In other childrenthe prolapsemay be visibleat the time of initialexamination.Predisposing factors are increased intra abdominal.pressure, diarrhoeal and neoplastic diseases, malnutritionand conditionspredisposingto pelvic floor weakness.'

Correspondence:Dr. Mohammad Arif, Assistant Professor Surgery,Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad,

The mucosal prolapse seen in very young children is aself-limiting disease, provided that a regular habit ofdefection can be established and straining of theconstipated child alleviated.' Treatment is mainlyconservative. The Simplest, less invasive yet highlyeffective approach appears to be injection with asclerosing agent.' Surgical intervention is occasionallyrequired for rectal prolapse.'

The aim of this study was to find out efficacy of injectionSclerotherapy using 5% phenol in almond oil in partialrectal prolapse in children under 10 years of age.

PATIENTS AND METHODSThis study was conducted over a period of 05 years fromJanuary 1996 to December 2000. All patients under 10years of age presenting in OPD of Surgical Unit-II, LiaquatMedical College Hospital, Jamshoro were included in thestudy. All 74 children (44 males, 30 females) aged 6months to 9 years, presented with a history of partialrectal prolapse. Male to female ratio was 1.47:1. At thetime of initial presentation prolapse was visible in 32patients, while remaining patients demonstrated either byhaving given a supposltory or sitting in squatting posltion


Injection sclerotherapy using 5% phenol in almond oil in the treatment of partial rectal prolapse in children

and straining. Rectal polyp was excluded by digital rectalexamination. In 54 patients (73%) there was history ofdiarrhoea, which alone was the most commonpredisposing factor. These 74 children were initiallytreated conservatively, which included digital reduction ofprolapse back in place, strapping of buttocks togetherafter defecation and antidiarrhoeal agents. Seven patientshad history of constipation and straining and were givenlaxatives. Of these 52 out of total 74 (70%) patientsrecovered within two weeks. Twenty-two patients in whomsymptoms persisted and who failed to respond onconservative methods ever after 04 weeks, injectionsclerotherapy was considered. The sclerosing agent usedwas 5% phenol in almond oil. Prior to injection patientswere given glycerin suppositories so as to clean rectum.The injection was given under general anaesthesia. Thechild was placed in left lateral position.

The prolapse was either already reduced under generalanesthesia or reduced back manually and through childsize prostoscope 5% phenol in almond oil was injectedinto rectal submucosa. 21G spinal needle with 10 ccdisposable syringe were used. Sclerosant (8-10 cc) wasinjected circumferentially, given at 3-4 places with about2-2.5 cc of sclerosant at each place. The children werefollowed up for 02 weeks and if required procedurerepeated. All 22 patients were followed for 01-06 months.

RESULTSAmong 22 children in whom 5% phenol in almond oil wasinjected to treat partial rectal prolapse, 16 (72.73%) werecured after 1st injection. There was no history of prolapsewhen they visited 02 weeks after the injection. They werefollowed for 01-04 months and showed no recurrence ofsymptoms. In remaining six patients, the procedure wasrepeated on next operation list after this followup. Thus inthese six patients procedure was repeated about 21-27days after the 1st injection. These patients were againfollowedup after 02 weeks. Three patients improved. Curerate after 2nd injection was 19/22 (86.36%). Threepatients did not recover, though in one patient there wasreduction in size of prolapse. This patient was injected 3rdtime but there was no further response and in followup ofabout 6 months after 1st visit, the prolapse was of almostsame size as it was in the beginning. In remaining twopatients who showed to improvement after two injections,3rd injection was not given. Thus failure rate was 3/22(13.64%). These three patients were advised surgery.

reassured that the disease is not life threatening and inmost patients conservative treatment will be effective. Inour study 52n4 (70%) responded completely toconservative method. Patients who do not respond toconservative methods, injection sclerotherapy should beconsidered next.' Sclerotherapy of mucosal rectalprolapse is much less expensive than conventionalsurqery." Different sclerosing agents are available, suchas 5% phenol in almond oil, DW50%, ethanolamineoleate, 25% saline. Some surgeons have used fibrinadhesive percutaneous injection for this purpose." In thisstudy we used 5% phenol in almond oil in all 22 patients.It is easily available and inexpensive. Two techniqueshave been described for injection:' In one submucosa atthe apex of prolapse is injected circularly, so as to form araised ring and upto 10 ml of solution can be injected. Asimilar injection is made at the base of the prolapse. If theprolapse cannot be brought down, the injections are giventhrough a proctoscope. The success rate after 1stinjectionwas 72.73% and after 2nd and 3rd injections was 86.36%.The results are quite satisfactory when compared toresults mentioned in literature. Chan-WK et al in theirstudy mentioned 64% cure rate after one injection, 76%after two injections and 84% after 3 mjections.' Theyrecommended injection sclerotherapy as the first linetreatment of rectal prolapse after failure of conservativemeasures. Piloni-V et al mentioned a success rate of 57%only.' Ibanez-Vet al using fibrin adhesive percutaneousinjection showed a cure rate of 75%.6 In our study only 3out of 74 patients (4%) were advised surgery. Surgeryshould be considered only when conservative treatmentand injection sclerotherapy fails.

REFERENCES1. Siafakas-C; Vottler-TP; Andersen-JM: Rectal prolapse in

paediatrics. Clin Pediatr Phila 1999; 38(2).2. Lloyd-Jones W;Giles G.R : The colon, rectumand anal

canal, in Cuschieri, A; Giles, GR; Moosa AR: Essentialsurgical practice, 3rd edition, 1995. Butter Worth-Heinemann Ltd. Oxford PP 1395.

3. Sander-S; Vural-O; Unal-M: Management of rectal prolapsein children: Ekehorn's rectosacropexy. Pediatr Surg Int1999; 15(2): 111-4.

4. Williams, Norman S : the rectum, in Russel, R.C.G;Williams, Norman S. and Bulstrode, Christopher J.K : Baileyand Love's short practice of surgery. 23rd edition, 2000,Arnold, London. Pages 1097-1100.

5. Piloni-V; Pomerri-F; Plantania-E; Pinto-F; Gasparini-G;Genovesi-N; Di-Giandomenico-E;Grassi-R; Salzano-A; et al:The National Workshop of Defecography : anorectal

DISCUSSION deformitieswith a functional origin (Prolapse, intussusception,Partial rectal prolapse in children is a common problem in rectocoele). Radiol MedTorino 1994; 87 (6): 789-95.our society. It may be the result of malnutrition and 6. Ibeanez-V; Gutienez-C; Garcia-Sala-C; Lluna-J; Barrios-JE;diarrhoea, which are quite common in our children. The Roca-A; Vila-JJ: the prolapse of rectum. Treatment withdisease itself is not life threatening but is disturbing for fibrin adhesive. Cir Pediatr 1997; 10(1): 21-4.parents. Hence they seek medical advice at an early 7. Chan WK; Kay-SM; Laberge-JM;Gallucci-JG;Bensoussan-AL;stage. The treatment is mainly conservative and is Yazbeck-S: InjectionSclerotherapyin the treatment of rectaldirected at the underlying cause. The parents should be prolapsein infantsandChik:lren.J PediatrSurg.1998;33(2):255-8.


-------~----~-

REPRODUCTIVE HEALTH PROFILE INRURAL POPULATION

R. SOHAIL, S. K. LODHl, F. MAQSOOD, F. ZAMAN

ABSTRACT:A suruei] was conducted in May 1999 to assess the status oj reproductive health practices inthe rural population oj district Kasur. A total oj 1.634 women were interviewed besidestraditional birth attendants (TBAs) and lady health visitors (LHVs). Three quarter oj womenwere illiterate and two thirds were married by the age oj 19 years. Eighty six percentdelivered at home. Most oj the TBAs were illiterate and had no training, while all the LHVswere educated and had had training. This diJference in education and training was reflectedby their attitudes towards handling oj complications. The referral rate by traditional birthattendants was only 2.3% that was much less than lady health visitors who refer quite oftendepending on the gravity oj the situation.

Pakistan is a populous country with annual growth rate oj 2.8% and the vast majority livingin rural areas. Illiteracy. tradition and attitudes contribute to prevailing situation.

KEY WORDS: Reproductive health. Rural population.

INTRODUCTIONDuring the past century, there has been tremendousprogress allover the world in all scientific fields. Thedeveloping countries too have had their share of thischange seen in Urban areas, but the scenario in the ruralareas is unfortunately not much different from what it wasat the beginning of the last century. In Pakistan two thirdsof the population is in the rural areas and little of theprogress has trickled down to this vast majority, especiallyin the health sector. Traditions and attitudes are additionalfactors responsible for the prevailing situation. Ruralpeople still live in areas without clean water supply in asmany as 21% and lack basic sanitation facilities in67%.'2.3

According to estimates of 1998 census, Pakistan has apopulation of around 140 million with population growthrate of 2.8%: The contraceptive prevalence rate is 18%with a total fertility rate of 5.08%.5 The ensuing schoolenrolment is poor leading to poor literacy rate.' 7 Womenhave a literacy rate of 16% as against 35% for men.

Correspondence:Dr. Rubina Sohaii, Hameed Latif Hospital.14-Ahu Bakar Block. New Garden Town. Lahore.

Similarly the literacy rate for urban population is 47.1%compared to 17.3% for rural population. Its important tonote that the literacy rate for urban women is more thanfive times the rate for rural women (7.3%).8 The Maternalmortality ratio of Pakistan stands at a minimum of 340 per100,000 live births." Most of the maternal deaths occurbecause of haemorrhage, in addition to hypertension,infection and obstructed labour.'?" Poor communications,delays in decision-making, provision of transport anddelayed help in health facilities are the factors responsiblein many deaths.

PATIENTS AND METHODSA survey of rural population was carried out to assess theattitudes and practices of women. The survey also dealtwith gathering information about the two cadres of healthcare providers who differed in knowledge and training,i.e., the traditional birth attendants (TBAs) and lady healthvisitors (LHVs).

The study was carried out in May 1999 in a population of385,670 served by three rural health centres of districtKasur. The selection criteria were women between theages of 15 and 50 years who had a minimum of one child.

Journal of Surgery Pakistan (International) Vol. 6 (3) JUly - September, 2001 31

Reproductive health profile in rural population

population (Table IV). The induced abortion rate was 3.2%.Formal training was received by only 9.3% of birthattendants. Some had acquired the skill from onegeneration to the other. In contrast all the lady healthvisitors were trained in the government sector. Thereferral rate for complications by the traditional birthattendants was 2.3% only while the lady health visitorsreferred more often depending on the gravity of thesituation(Table IV, V).

A total of 1,634 women were interviewed. As many aspossible, TBAs and LHVs of the area were alsointerviewed. Three questionnaires were prepared for thispurpose, one each for women, TBAs and LHVs. Thequestionnaires were filled by interviews with the threegroups and responses were tabulated.

RESULTSIt was seen that 76.7% of population was illiterate and 65%females got married by the age of 19 (Tables I-III). The ruralpopulation relies heavily on the traditional birth attendantsand home confinements are a wide practice. Birthattendants at home were delivering 26% of rural female

TABLE-I LITERACY RATELevelof education Number(n) Percentage(%)

Illiterate

Primary

Middle

Matric

Intermediate or above

1253

189

70

61

61

76.7

11.6

4.33.7

3.7

TABLE-II AGE AT MARRIAGEAge Number(n) Percentage(%)

10-13 1341062

438

8.2

65

26.8

TABLE·III CONDUCT OF LAST DELIVERYPersonnel Number(n) Percentage(%)

TBA 1415 86.6%

LHV 52 3.2%

. Doctor 167 10.2%

TABLE·IV TRADITIONAL BIRTH ATTENDANTS (129)Formal Training Referralofeducation n(%) level n('Yo) complicationsn(%)

Formal 12 (9.3) Referred 03 (2.3)

Informal 20 (15.5) No referral 126(97.7)

No training 97(752)

TABLE·V LADY HEALTH VISITORS (14)Training Referraloflevel complications

n(%) n('Yo) n(%)

IlliterateMalricF.NESc

None7(50)7(50)

Formal 14(100)Informal NoneNo training None

Referred 126(97.7)No referral 03(2.3)

It---

DISCUSSIONOur rural population is traditionally a conservative society.Many women are purdah observing, living in a joint familysystem and tend to stay at home most of the time. Mostof these women have confinement by local health careproviders. The means of communication are poor withmeagre or no roads, poor transportation facilities andminimal telecommunication. Sanitation is poor and thereis a general lack of awareness, more so regardingwomen's health.

It was seen that majority of the population was illiterate;two-thirds of the adult female population was married bythe age of nineteen. The rural population relied heavily onthe traditional birth attendants and home confinementsare a wide practice. Birth attendants at home weredelivering 86% of rural population. Even in the city ofLahore, a study carried out in late eighties showed thatmore than 70% deliveries were conducted at horne." '3."In the study only 10.2% deliveries were conducted bydoctors and according to a report on Pakistan, only 13.4%of the total female population used health facilities fordelivery and only 10.5% deliveries occur at healthfacilities in the province of Punjab.

In the study the induced abortion rate was only 3.2%,even less than the city average, which was rathersurprising. This could be either because the rate wasgenuinely low due to religious constraints or that manywomen were not candid enough to accept the fact thatthey had had abortions." According to a study by SOGP,abortions are responsible for at least 11% of the totalmaternal mortality in Pakistan."

On comparing the two cadres of health providers, birthattendants and lady health visitors, it was seen that thebirth attendants were mostly illiterate, only 17.8% wereeducated till primary school and their training waspractically non-existent. Most acquired the skill from onegeneration to the other. In contrast all the lady healthvisitors were educated, half of them till intermediate. Theyhad all received formal training in the government sectorfor at least one year but mostly for three years.

This difference in education and training was reflected bytheir attitudes towards handling of complications. Thereferral rate by traditional birth attendants was only 2.3%


R. Sohail, S. K. Lodhi, F. Maqsood, F.Zaman

that was much less than lady health visitors who referquite often depending on the gravity of the situation. Therole of training of lady health visitors is therefore verysignificant and cannot be overemphasized. As alreadyseen training affects the attitudes of health providers."Therefore there is need for training and supporting thehealth providers. Rural health needs to be madecommunity oriented and driven."

REFERENCES1. "Human Development Report", 1996

2. "Human Development Report", 1997

3. ESCAP," Socioeconomic Profile of SAARC Countries", 1998

4. EIU, 1997, Pakistan Afghanistan: Country Profile, TheEconomist, Intelligence Unit, London

5. Pakistan: Women's Issues: 12/23/98

6. =SCAP, 1997, Women in Pakistan: A country profile. UnitedNations, New York

7. GOP. 1995. Fourth World Conference on Women, Beijing,

8. Pakistan National Report, Ministry of Women Developmentand Youth Affairs, Government of Pakistan, Pakistan

9. Pakistan Medical Research Council,1995, National HealthSurvey of Pakistan.

10. Women's Health in Pakistan - Fact Sheets, PakistanNational Forum on Women's Health, November 1997

11. Columbia School of Public Health, New York, 1988, centerfor population and family health, Safe MotherhoodProgrammes; Options and Issues

12. Commission Report on Status of Women in Pakistan, 1997

13. Government of Pakistan, Ministry of Health, 1996, AnnualReport of Health Services in Pakistan

14. World Health Organization, 1997, Family and ReproductiveHealth, Coverage of Maternity Care

15. National Institute of Population Studies, 1992, PakistanDemographic Health Survey.

16. United Nations, New York, 1991, The World's Women,Social Statistics and Indicators

17. The World Bank Group: News's Release; ImprovingWomen's Health in Pakistan, 1998

18. Health Systems Trust: Second World Rural HealthCongress: October 1997.


A STUDY OF FLOUVOUXAMINE INHOSPITAL OUT PATIENTS WITH MAJOR

DEPRESSIVE ILLNESS

KAUSAR AAMIR, SIBGHATULLAH SANG!, JAMALARA,

SAEED A. MAHAR, ZULFIQUAR RAHUJO

ABSTRACT:A non-comparative study was carried out at the Department oj Psychiatry, Chandka MedicalCollege Hospital, Larkana from October 2000 to February 2001. Forty patients between theages 18 to 60 years, who met the inclusion criteria were registered. Twenty-eight patientscompleted the study while 12 patients were lost toJollowup.

KEY WORDS: Major depressive illness, jlouvouxamine, efficacy.

INTRODUCTIONDepression is the most common affective disorder. It is afeeling of sadness and misery, usually accompanied bylowered self-esteem ranging from feeling of inadequacyand incompetence to a full-blown delusion that the patientis evil and responsible for many of the world's ills. Thedelusions distinguish psychotic from situationaldepression (i.e. excessive sadness related to a trueenvironmental evant).' At anyone time five to fifteenpercent of persons of any age, sex or race, living in thecommunity show some symptoms of depression whileone to two percent meet the criteria for major depression.'Previously depression was regarded as a disorder ofmiddle aged or elderly persons, but now adolescents andyoung adults are increasingly getting depressed andseeking treatment.3 It is believed that depression isassociated with increased morbidity and mortality,impaired functions, substantially prolonged disability andan economic loss associated with depression, thedisease remains under recognized and majority of thepatients do not receive adequate and appropriatetreatment by primary care physlcians.'

efficacy nearly equal to the older tricyclics but markedlydecreased side effects principally due to a reduction inanti- cholinergic side effects commonly encountered withtricyclics. SSRls may therefore justifiably be the preferredtreatment in a variety of depressed patients.

Flouvouxamine offers greater efficacy in patients thanolder drugs, either in relief of symptoms or in preventionof suicide. On the other hand, there has also been nosubstantiation for the scare early in their use that suiciderisk might actually be increased. The main advantage offlouvouxamine is its lack of antimuscrinic adverse effects.Lack of adverse effects can indirectly also permit inincreased efficacy, since the maximum tolerated dose in apatient is less likely to be limited by the undesired antimuscarinic effects. While in theory a selective agentshould not have new adverse effects, absent from theolder less selective agents, idiosyncratic reaction canoccur. Symptoms in psychiatric patients are particularlydifficult to evaluate.

PURPOSE OF STUDYThe purpose of this study was to verify the efficacy, safety

The importance of the role of serotonin in affective and tolerance of flouvouxamine to identify dose relateddisorders is now widely accepted. Studies carried on sub-groups of patient's responsive and non-responsive todifferent seiective serotonin reuptake inhibitors suggest·c~;;e"s~~d~~~~~······· / flouvouxamine therapy or at any special risk or adverseDr. Kausar Aamir, Pharmacology Department,BMSI, effects and to observe the impact of flouvouxamine onJinnah Postgraduate Medical Centre, Karachi. quality of life.


Kausar Aamir, Sibghatullah Sangi, Jamal Ara, Saeed A. Mahar, Zulfiquar Rahujo

PATIENTS AND METHODSAn open non-comparative study of flouvouxaminehospital out patients with major depression wasconducted in the Department of the Psychiatry, ChandkaMedical College Hospital, Larkana, from October 2000 toFebruary 2001. Roughly 300 patients are consulting thedepartment every week, which include new and oldpatients, follow-ups, attendees of special clinics and day-to-day emerqsncy.' Patients who fulfilled the inclusioncriteria were selected as following:.:. Patient over the age of 18 years who gave informedconsent in accordance with declaration of Helsinki.".:. Patients attending psychiatric OPD and satisfying theDSM IV criteria for major depression' presenting with aminimum score of 18 on the Hamilton rating scale fordepressions at the time of study entry.

Those excluded from the study were:• Pregnant, lactating and females of child bearing

potentials who were not using adequate contraceptionor intended to become pregnant within six months ofthe study entry.

• Patients likely to receive treatment with additionalpsychotherapeutic agents except occasional use ofchloral hydrate or benzodiazepienes, ECT or intensivepsychotherapy during the course of study.

• Patients receiving tricyclic antidepressant within oneweek of study entry or MAOI, lithium, reserpine andalpha methyl dopa two weeks prior to study entry orany other antidepressant therapy or who received 5-HT antagonist treatments (Pizotifen for migraine) orsubstances carrying serotonergic properties likefenfluramine concurrent with the study.

• Patients who received a 5-HT uptake inhibitortreatment in the four weeks prior to the study.

• Patients whose depression was secondary to otherforms of psychiatric illness or organic disease patients.

• Patients with history of severe allergies or unknownhypersensitivity to flouvouxamine or with significanthepatic or renal impairment.

• Patients with history of alcoholism, drug abuse andsuicidal risks.

Forty patients between the ages of eighteen and Sixtyyears were registered. Twentyeight (70.0%) patientscompleted the study successfully and twelve (30%)patients were lost to fOliOWUP.After entering the studycomplete demographically data, physical examinationincluding height and weight, relevant base line parameterwere assessed. In order to assess quantitative efficacy offlouvouxamine, the Hamilton Psychiatric Rating scale fordepression and Clinical Global Improvement (CGI) Scalewere administered during the ten-week trial. At the entryvisit (visit 1) all the patients received 100mg offlouvouxamine in two divided daily dosages thatcontinued unchanged for four weeks. However, at the end

Journal of Surgery Pakistan (International) Vol. 6 (3) July - September, 2001

of week one visit (visit 2) patients were asked to comefortnightly and concurrent medication and side effectswere noted. At the week 4 dosages of medicines wereincreased if necessary. At the end of the tenth week thestudy was discontinued. However, the study medicationwas made available on a named patient basis whencontinuation was considered by investigator to beclinically indicated. At the end of the study globalassessment was carried out on HAMD for Depressionand Clinical Global Improvement along with completephysical examinations.(Table I).

RESULTSTwenty-two (78.5%) of 28 patients who completed thestudy were males and six (21.5%) were females. Twenty-four (86.7%) were between 18 to 45 years of age (meanage 34.7 years). Mean weight was 61.5 kg, mean heightwas 161 cms in both sexes. The majority of patientspopulation had a depressive illness for more than 32weeks. Majority (52%) of the patients inducted in thestudy were drug naives. Those who were previously onanti depressant therapy, tricycles were the commonest(58%) drug received followed by fluoxetine, sertraline,trazodone and mianserin.

Common somatic symptoms recorded during the past twoweeks included headache (30%), G.I.T disturbancesincluding dyspepsia, vomiting symptoms includingdyspepsia and vomiting (15%). Anxiety (3%), andinsomnia (2%). 40% patients did not have any adverseeffects. (Table II).

35

A study of flouvouxamine in hospital out patients with major depressive illness

In the evaluable patients analysis, there was significantimprovement seen from base line in HAMD Rating Scaleand CGI for depression as shown in table. The overallevaluation of efficacy (based on criteria given) in 28patients was as follows: Excellent / Good - 22 (78.5%),Fair - 4 (14.2%) and Poor - 2 (7.14%).

Majority (71.4%) pf patients showed therapeutic responsewithin dose of 100 to 150mg/day, while 8 (28.6%) patientsrequired 250mg/day to achieve response. (Table III).

Most of the patients tolerated the drug well. Side effects wereonly mild to moderate. Interestingly, no patients had to bewithdrawn from the study due to adverse effects or toleranceproblem. (Table IV).

DISCUSSIONAt present several anti-depressants are being marketed as

- SSRls with no relevance to their molecular structure.However, their identity lies with reference to clinicalpsychopharmacology. In this context, Flouvouxamine in thedose of 100mg/day has been found effective in initiating theresponse. Using this dose as a marker, it could be increasedto 200mg/day to enhance desired effects.

Anti-depressants have critical disadvantages in term of side-effects profile. Preferred usage of drugs by therapistdepends on safety profile of an antidepressant in a particularpatient. At times side effect can be exploited by way of resultdesired by patients, for example, very little or no change inweight caused by Flouvouxamine may give a choice in both

under or over weight. Relative absence of side effects maymake it the anti-depressant of first choice in patient who havetendency to grumble and show nervousness onexperiencing even slight form of side effects when advised aconventional anti-depressant. One of the patients in thisstudy was suffering from double depression (dysthymia andmajor depressive code). He was extremely sensitive to sideeffects, having been exposed to various typeantidepressants. It was initially planned to treat him only withpsychotherapy. Eventually, when he was inducted in thisstudy, he showed remarkable improvement. This studyconfirmed that Flouvouxamine is well tolerated atrecommended dose of 100mg to 200mg per day.

Reports of serotonin syndrome" in the literature pose aserious question with reference to early detection. Thischallenge can be met with by introducing checklist devisingrating scales to identify high-risk individuals. Nevertheless,flouvouxamine remains the drug of choice by virtue ofrelative absence of side effects, cardio selectivity andminimal dosage required to treat even otherwise treatmentrefractory cases."

Depression continues to remain a mystery more so in viewof its socioeconomic and inter-personal deficits. Earlydetection and quick treatment of an otherwise pesslmisticpopulation is warranted. This challenge can be met bytreating such cases with an antidepressant having minimalside effects and quick response. Flouvouxamine fits well intodream, to improve the quality of life.

REFERENCES1. Mintz J et al. Treatment of Depression and the functional Capacity

to work; Arch Gen Psychiatry-VoI49;Oclober 1992, 761-768.

2. Angst J. (1992) Epidemiology of depression,Psychopharmacology 106.71-74.

3. Gerald L klerman MD Myrna M.Weissmor PhD Increasing ratesof depression, JAMAApriI1989-VoI261, No 15-2229~2234.

4. J Mendels, Acute and long term treatment of Major Depression,lnt. Clinical psychopharmacology 1992 Supl 2,21-29

5. Mussarat, H., Abdul, G., Syed, S. H. An open non-comparativestudy of sertraline in hospital out patients with major depressivedisorder. Medical Channel, Vol. 6 No.1, Jan-Mar, 2000.

6. World medical association declaration of Helisinky:Recommendations Guiding medical doctors in biomedicalresearch involving human subjecl. Adopted 18th world medicalassembly, Helisinky, Finland, June 1964.Revised version 48thgeneral assembly, Republic of South Africa, October 1996.

7. American psychiatric association, diagnostic and statisticalmanual of mental disorder, 4th ED 1994.Washington DC

8. Hamilton M; development of a rating scale for primarydepressive illness. Br J Soc Clin Psychol (1967) 6, 278-296.

9. Gelder M; Gath 0; Mayon R; CowenP; Oxford Text book ofPsychiatry; 3rd Ed; 1996; 560-568

10. Kaplin H, Benjemin, Sandock; Synopsis of Psychiatry, 8thEd.1997, 1083-1091. William and walkins, Baltimore. .


PERFORATED GALL BLADDERA CASE REPORT

AIJAZ AHMED MEMON

ABSTRACT:Surgical complications of typhoid fever. like paralytic ileus or ileal perforation. are morecommon than those of Paratyphoid. Cholecystitis is also a.frequeni: complication of this illness,but perforated. gall bladder is rare. A case of perforated. gall bladder due to typhoid is beingreported here.

KEY WORDS: Gall bladder perforation; Complication, Typhoid.

CASE REPORTA 22-year old male presented with fever for 20 days andabdominal pain/ vomiting for 15 days. Fever was ofcontinuous type that became high grade at night, notassociated with rigors and relieved by taking medicines.He also developed gripping abdominal pain and vomitingon and off, five days after the start of fever. Medicinesfrom local doctor did not relieve his symptoms completely.His abdominal pain gradually became worse andultimately he was admitted to hospital.

On examination he looked ill, wasted and dehydrated.There was tenderness more marked in the right upperabdomen with some degree of peritonism mostly on theright side of the abdomen. An initial diagnosis of smallbowel perforation due to typhoid fever was made,Laboratory investigations showed a positive Widal test.Abdominal X-rays were not helpful towards the diagnosis.An ultrasound examination of abdomen showed fluid inthe right subhepatic area, suggesting a diagnosis ofperforated duodenal ulcer.

After resuscitation exploratory laparotomy was performedand bile was found in the right upper abdomen, further thegall bladder was found ruptured at the fundus.Cholecystectomy and peritoneal lavage with saline wasperformed and abdomen closed after leaving a drain inthe right subhepatic space. Postoperatively the patientrecovered smoothly.

Correspondence:Dr. Aijaz A. Memon, Assistant Professor,Surgical Unit II, P.M.C. Hospital, Nawabshah.

DISCUSSIONComplications due to typhoid are more common,particularly paralytic ileus and ileal perforation, thancomplications due to paratyphoid. Cholecystitis andperforation of large intestine are well known complicationsof paratyphoid. Perforation of gall bladder is a rarecomplication and is not mentioned in the list ofcomplications of typhoid and paratyphoid in most books ofMedicine. Searching through the literature (Medline andExtramed) for last ten years there was only one reportedcase of perforated gall bladder associated withSalmonella Javiana intection."

The clinical diagnosis of perforated gall bladder and otherrare complications of paratyphoid can possibly be madethrough proper evaluation of history, clinical examination,investigations and considering the rarity in the differentialdiagnosis.

REFERENCES1. Bailey & Love, Short Practice of Surgery, 23rd edition.

Russell R.C.G, Williamson, N.S. Bulstrode C.J.K. (Edition)Arnold publishers 2000: 1045.

2. Lee-JG; McLeod- ME; Meyers- WC; Arthur-J; Corey- GR.Successful laparoscopic management of perforatedgallbladder associated with Salmonella javiana infection. N-C-Med-J. 1992 53; 594-5.


PERFORATED DUODENAL ULCERA CASE REPORT

SYED ARSALAN HAIDER BUKHARI, SHABBIR HUSSAIN.

ABSTRACT:Perforation of duodenum is a known complication of duodenal ulcer. In most patients, either aprevious history of dyspepsia is available or. patients are known cases of duodenal ulcer.Herein we report a case of perforated duodenal ulcer:

KEY WORDS: Duodenal ulcer, perforation

INTRODUCTIONA 43 years old male was brought in emergencydepartment of CMH Bahawalpur with complaint of severeabdominal pain for 4 hours, allied with a swelling in theright inguinal region. The patient was lying listlessly andgave a history of right reducible inguinal hernia for thelast 3 years.

On the basis of history, an obstructed right inguinal herniawas suspected. The clinical examination however wasquite contrary. His abdomen was held rigid and wasdrawn in. There was a swelling in right inguinal area. On .palpation, the abdomen was tender and rigid in theepigastrium and right hypochondrium. There was apositive release sign in the right hypochondrium and rightiliac fossa. The hernial sac was vacuous of any visceraand appeared to be filled with fluid. A provisionaldiagnosis of perforated duodenal ulcer was made, inspitethe fact that he had no antecedent history of dyspepsia orepigastric pain and was a non-smoker.

His BP was 110/90 mmHg and pule rate was 100/min.Laboratoryexamination revealedHb of 12.0 gm%andTLCof 12500/cmm.X-Ray chest revealed gas crescent underthe diaphragm. Ultrasound revealed fluid in the pelvis.

Patient was resuscitated and emergency laparotomy wasperformed. A clearly punched out ulcer was Seen in theanterior wall of the first part of duodenum, with bileCorrespondence:Major (Dr) Syed Arsalan Haider Bukhari, Classified Surgical Specialist,CMH, Bahawalpur.

stained fluid in the pelvis, which had also transgressedinto the preformed hernial sac on the right side. The ulcerwas closed with vicryl and Gordon patching was done.Peritoneal toilet with closure of the mouth of the herniatransabdominally was carried out. The patient made goodpostoperative recovery and discharged with H2 receptorsblockers for 8 weeks and advised followup fortnightly insurgical OPD, CMH, Bahawalpur.

DISCUSSIONDuodenal ulcer is a lingering recurrent disease. Theabsolute prevalence of this disease is not known,however the estimated effected population is between6-15%. Perforation of duodenal ulcer occurs in 10-14%cases and in 75% cases it occurs in the anterior duodenalwall. About 70% recurrent perforation rate is seen in thedearth of any treatment in 5 years following the firstepisode of perforation. Helicobacter Pylori has beenimplicated as the most assiduous factor present in thepatients who perforate.' Timely clinical diagnosis isnecessary to avoid fatal outcome, which is high in latecases of perforated duodenal ulcers. Surgical interventionhas recently been surpassed by laparoscopic closurewhich has given excellent results. It is now the first choicein most centres, with a morbidity of only 9% and mortalityrate of only 4%.2 In places where laparoscopic facilitiesare not available, prompt surgical exploration with primaryclosure of the perforation followed by H2 receptorsblockers is the treatment of choice.' Insertion ofpostoperative drains has been found to be bothunnecessary and ineffective, especially if omentalpatching has been done.' In many advanced centres


Syed Arsalan Haider Bukhari, Shabbir Hussain.

laparoscopic transparietal vagatomy is been carried outas the definite treatment for perforated duodenal ulcer, asit is simple and avoids the complications of partialselective vaqotomy." In recurrent symptoms, use of tripledrug regimen to eradicate H. Pylori effectively andomeprazole has been recommended, with a remissionrate of as much as 78% in two weeks."

REFERENCES1. Chu.KM, Kwok KF, et al. Helicobacter pylori status and

endoscopy followup in patients having history of perforatedduodenal ulcer. Gastro intestinal-Endosc. 1999; 50: 58-62.

2. Draut ML, Van Hee R. Lparoscopic repair of perforatedduodenal ulcer. Surg-Endosc 1997; 11: 1017-20.

3. Kulkarni SH, et al. Simple closure of perforated duodenalulcer: Ind. Med. Assoc 1998 Oct; 96: 309-11.

4. Pai D, SharmaA, et al. Role of abdominaldrains in perforatedduodenalulcers Aust NZJ. Surg 1999;69: 210-13.

5. DruzijianN, et al. Modified intraparietal vogotomyin treatment of perforated duodenal ulcer. Hepato-gastroenterology 1997; 44: 1346-50.

6. Gisbert JP, Boixeda D. Un healed duodenal ulcer despite H.pylori eradication Scan J Gastroenterol. 1997; 32: 643-50.


OLFACTORY NEUROBLASTOMAA CASE REPORT

M.SALEEM MARFANI, SHABBIR KANJEE, AZAM H. YOUSIFANI.

ABSTRACT:A case ·of a 8 year old female who presented with a polipoidal mass protruding from the noseand oral cavity and a malar swelling is reported. The patient had experienced nose bleeds forseveral months. The diagnosis of olfactory neuroblastoma was established on histopathology.which revealed presence of small round cells forming pseudo-rosette. The patient was treatedby surgical resectionfollowed by radiotherapy and is well on the 12th monthfoUowup.

KEY WORDS: Olfactory. neuroblastoma malignant tumor

INTRODUCTIONOlfactory neuroblastoma or esthesioneuroblastoma is arare malignant tumor of the sinonasal region. It probablyarises from the olfactory placode.' The tumor mainlyaffects adults but has also been reported in children. It hasa similar incidence in males and females and is rare inblack races. The tumor may present with symptoms due tocompression, involvement of adjacent structures ormetastasis. Nasal obstruction and epistaxis are the mostcommon symptoms! Rhinorrheoea, epiphora andanosmia or parosmia are other presenting symptoms.Headache, diplopia or a malar mass indicates invasion ofbase of the skull. Local aggressiveness is the usualbehaviour but distant metastasis occur in 20% cases,mainly to lymph nodes and lunqs.' Histologically the tumoris composed of small round cells which expressneuroendocrine markers such as neuron-specific enolase,PGP 9.S, synaptophysin and chromagranin A1. Electronmicroscopy reveals the presence of neurosecretorygranules and the tumor cells may stain positively forcatecolamines and dopamine B-hydroxylase. Theprognosis is determined by the extent of disease at thetime of initial presentation. Treatment includes surgery,supplemented by radiothereapy and chemotherapy,' Thefive year survival rate is superior to SO%.5

CASE REPORTAn 8 year old female patient from Hyderabad Sindh,presented with a painless massive swelling involving the.I~.~.~i~~.9! !?~~.~~.q~P'9!y'(>~i?almass protruding from theCorrespondence:Dr. M. Saleem Marfani, Department of Otorhino-laryngology,Dow Medical College & Civil Hospital, Karachi.

nose and oral cavity (Fig.1). On examination a friable redfungating mass was seen protruding from the left nostriland the oral cavity. The surface of the tumor was necroticand covered with blood clots. There was a foul smellingbloody discharge from the nasal cavity. The swelling onthe left cheek measured 10x8 cms involving the maxilla. Itwas soft in consistency, non tender and fluctuant. Asimilar swelling measuring SxS cms. was seen on the leftzygomatic region. Regional lymph nodes were notenlarged. There was ocular hypertelorism but ocularmovements were not restricted.

Investigations carried out included complete blood countsand urinalysis which were normal, expect for thehaemoglobin level of Sgm. Liver and renal function testswere within normal limits. Chest radiograph (abdomen)were normal. CT scan showed heterogenous enhancingmass with multiple cystic areas involving left side of theface causing extensive bony destruction with extensioninto the paranasal sinuses, oral and nasal cavities. Thetumor mass was extending into the nasopharynx andpushing the orbital content s of the left side (Fig.2). Biopsywas consistent with olfactory neuroblastoma showinground to oval cells with hyperchromatic nuclei and scantlycytoplasm separated by highly vascularized fibroustissue. Pseudorosette formation was also seen.

The patient was operated in two stages, in the first stage awide surgical excision was performed through a lip splittingWeber Ferguson incision and the growth was excised frommaxilla, infra orbital region and the nasal cavity. The growthfrom the zygomatic area was removed after 4 weeks. Thepatient was advised radiothereapy two weeks after surgery.


M.SALEEM MARFANI, SHABBIR KANJEE, AZAM H. YOUSIFANI

An obturator was placed over the palatal defect which wasproduced by the removal of the hard palate. The patientwas followed regularly at two weekly intervals. At 12months post surgical followup the patient was free of localrecurrence and no sign of distant metastasis.

DISCUSSIONOlfactory neuroepithelioma (Olfactory neuroblastoma, oresthesioneuroblastoma) is an uncommon malignant tumorarising in the olfactory epithelium. It was first described byBerger et al. in 1924. More than 250 cases have beenreported in literature. The tumor appears as a pink orbrown friable mass with a gritty texture causing nasalobstruction and recurrent epistaxis. The growth is locallyaggressive with occasional metastasis to the regionallymph nodes, lungs and bones. The tumor can invade thefrontal lobes, best delineated by CT scanning, butextension into cerebrospinal fluid is rare. A caseassociated with Cushing's syndrome has been described."

Histologically the tumor comprises of small round cells ina neurofibrillary matrix with pseudorosette formation andrarely true rosettes. These tumors may producevasoactive hormones and urinary assays ofthe metabolites, dopamine and 3-methoxy-4-hydroxymandelic acid have been used to monitorrecurrence. Kadish staging system' may be helpful fordetermining the prognosis and treatment of patients:

Stage A- Tumor confined to the nasal cavity.Stage B- Tumor in nasal cavity extending to paranasal sinus.Stage C- Tumor extending to orbit, base of skull, cranial

cavity or with cervical/distant metastasis.

Most tumors present in an advanced stage with theextensive local invasion to permit complete surgicalremoval. Combined treatment modalities are usuallyadopted. Wide surgical excision with craniofacialresection in combination with radiation therapy hasimproved therapeutic results." Five year survival rate is60-70% with surgery and radiotherapy alone.Aesthesioneuroblastoma is also a chemoresponsivetumor and systemic chemotherapy is recommended forstage C tumors.

REFERENCES1. Elkon D. Hightower S.1. et al. Esthesionneuroblastoma

cancer 1979; 44: 1087-94.

2. Kund V.J. and Milray C. Olfactory neuroblastoma: clinicaland pathoogical aspects. Rhinology 1993; 31:1-6.

3. Rosai, J. (ed). Ackerman's surgical pathology 8th ed. St.louis, Mosby, 1996.

4. Jekunen A.P. Kairemo K.J. et al. Treatment of olfactoryneuroblastoma. Am J clin onco11996; 19 (4): 375-8.

5. Olsen K.D., De Santo L.W. olfactory neuroblastoma: biologicand clinical behavior. Arch otolaryngol 1983; 109: 797-802.

6. Amensen MA, Scheithauer B.W, Freeman S Cushing'ssyndrome secondary to olfactory neuroblastoma, ultrastrucPathol 1994; 18: 61-8.

7. Kadisch S, Goodman M. and Wang C.C. Olfactoryneuroblastoma: a clinical analysis of 17 cases. Cancer, 35,1571-1576.

8. Levine PA, McLean Wc, Cantrell RW,Esthesioneuroblastoma: the University of Virginiaexperience 1960-1985. Laryngoscope 1986; 96: 742.


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