Background: Acute Appendicitis (AA) is the commonest surgical emergency encountered by surgeon in public & private setup in Pakistan. When it comes to diagnosis, patient seldom presents with the typical bookish picture (symptoms / signs) of the condition. Diagnosis therefore remains an enigma many a times especially for house officers and residents during their emergency duty. Various scores had been developed to aid the diagnosis, Alvarado score although gained popularity and is practiced in our setup. This study was designed to evaluate one such score designed by JM Ramirez & J Deus, for its negative appendicectomy rate calculation with the view to adopt it to our routine practice if it turns out with lesser negative appendicectomy rate compared to other scores in practice. Methods: This descriptive study was designed & carried out at the Surgical “B” Unit of Ayub Teaching Hospital Abbottabad from November 01, 2020 to June 30, 2021. A total of 190 patients with suspected AA were included, assessed by the score and accordingly placed in three groups based upon their initial score. Group-I patients were discharged with the advice to come back to same unit / hospital if pain persists or recurs. Group-II patients were kept in observation for 24 hours and finally re-categorized either as Group-I or Group-III based upon a drop or rise in their score. Group-III patients were operated after preparation. Data collected over a special proforma was finalized at the time of discharge of patient, earlier in case of group I patients or after getting histopathology report in case of Group-III patients that was later analyzed with the help of SPSS-version 26. Results: Out of 190 patients included in study 129 were male while 61 were female patients. 49 patients presented with a score less than –15 (Group–I) & were discharged after evaluation. 53 patients had a score between –15 to 09 (Group–II), were therefore kept under observation till next 24-48 hour. Score of 30 dropped to Group-I range & were similarly discharged like Group-I patients. Score of 23 patients rose up to 10 or above (i.e. Group-III range) & were therefore operated like other 88 patients belonging to Group-III. 91 patients were having acutely inflammed, phlegmonous, gangrenous, perforated appendix or appendix with impacted faecolith / pus in the lumen, their appendicectomy specimen along with the specimen of 20 other difficult to diagnose cases on gross vision were sent for histopathology. H/P report confirmed 100 as positive & 11 as negative for appendicitis. 111 patients totally got operated, out of which 11 turned out negative appendicectomies. Frequency of negative appendicectomies overall was therefore 09.9%. It was 05.56% in male (i.e. 04/72) and 17.94 % (i.e. 07/39) in female patients. Conclusion: Score developed by JM Ramirez and J Deus proved quite helpful in the diagnosis of acute appendicitis & reduction of the frequency of Negative appendicectomies. Being simple, non-invasive & cost-effective, requiring no special equipment or investigations for its application, it ensures an instant, structured & thorough assessment of patient. The score is therefore recommended for its routine adoption / application in our setup in the diagnosis of acute appendicitis to reduce the frequency of negative appendicectomies. Keywords: Acute appendicitis, frequency of negative appendicectomy, scoring system, Ayub Teaching Hospital
Background: Fissure-in-Ano is a commonly seen entity in surgical practice. Various approaches had been adapted since ages for its management including both conservative & surgical. Amongst the surgical approaches Lord’s Anal Dilatation (LAD) is a modality long been practiced to manage patients not responding to conservative treatment & those with chronic anal fissure. Recent trend is towards preferential practice of Lateral Internal Sphincterotomy (LIS) in the management of anal fissure. Pleaders of LIS are critical as well to the approach of LAD, although LAD in many clinical setups is still a widely practiced & viable option, especially in third world countries. Objective of conducting this study is to evaluate the LAD in our hospital setup for its much debated complications of incontinence and recurrence. Methods: This descriptive study was designed & carried out at the surgical units of Ayub Teaching Hospital Abbottabad from November 01, 2012 to May 31, 2017. A total of 129 patients with acute anal fissure (not responding to conservative measures, being in agony) & chronic anal fissure (duration longer than 06 weeks) were included in study after taking informed consent. Patients were managed with LAD & later followed for 01 year for the evidence of permanent flatus / faecal incontinence & fissure recurrence. Results: Out of the 129 patients included in study we had successfully been able to follow 102 patients for one year, while 27 patients were lost at various stages of follow-up and thus dropped off the final stage of study (i.e. calculation of incontinence & recurrence rate). Post-operative pain intensity & early mobility factor was found much better in this study. 23 patients initially complaining of flatus incontinence for 02–09 days were settled with pelvic floor exercises while none was found with an early or late complication of faecal incontinence. Similarly follow-up for 01 year period revealed none with recurrence issue. Conclusion: LAD in our study proved a safe & effective approach in the management of patients with anal fissure un-responsive to conservative measures, having no permanent incontinence or recurrence issues & may therefore be safely practiced in our setup like LIS procedure. Keywords: Anal fissure, Lord’s anal dilatation, lateral internal sphincterotomy, incontinence, recurrence
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