The harmonic scalpel significantly reduces postoperative discomfort and morbidity to the patient without increasing operating time. We thus recommend preferential use of harmonic dissection in modified radical mastectomy. (ClinicalTrials.gov NCT01587248).

Objective. To determine the fecal incontinence and recurrence rate in patients with complex fistula in ano managed with cable tie seton at a tertiary care teaching hospital. Methods. This is a prospective case series of patients with complex anal fistula i.e. recurrent fistula or encircling >30% of external anal sphincter, managed with cable tie seton from March 2003 to March 2009. Patients were seen in the clinic after 72 hours of seton insertion under anesthesia and then every other week. Each time the cable-tie was tightened if found loose without anesthesia and incontinence was inquired according to wexner's score. Results. Seventy nine patients were treated during the study period with the age (mean ± standard deviation) of 41 ± 10.6 years and. The seton was tightened with a median of six times (3–15 times range). Complete healing was achieved in 11.2 ± 5.7 weeks. All the patients were followed for a minimum period of one year and none of the patients had any incontinence. Recurrence was found in 4 (5%) patients. Conclusion. The cable tie seton is safe, cost effective and low morbidity option for the treatment of complex fistulae-in-ano. It can, therefore, be recommended as the standard of treatment for complex fistulae-in-ano requiring the placement of a seton.

Introduction: Mesenteric panniculitis is a rare pathology of unknown etiology characterized by inflammation and fibrosis in the mesentery. Its protean clinical and radiological manifestations make it a diagnostic challenge. There is no established treatment available for its management. The clinical outcome is inconsistent, with the prognosis ranging from complete resolution without any treatment to rapid progression culminating in death.

Background:Evidence regarding gender affecting the response to pain and its treatment is inconsistent in literature. The objective of this prospective, observational study was to determine the effect of gender on pain perception and postoperative analgesic consumption in patients undergoing laparoscopic cholecystectomy.Materials and Methods:We recruited 60 male and 60 female patients undergoing elective laparoscopic cholecystectomy. Patients were observed for additional intraoperative and postoperative analgesia. Numerical rating scale was documented at 10 min interval for 1 h in post-anesthesia recovery room and at 4, 8, and 12 h postoperatively. Boluses of tramadol given as rescue analgesia were also noted. There were no dropouts.Results:The mean pain scores were significantly higher in female patients at 20 and 30 min following surgery. Mean dose of tramadol consumption was significantly higher in female patients for the first postoperative hour (P = 0.002), but not in the later period.Conclusion:Female patients exhibited greater intensity of pain and required higher doses of analgesics compared to males in in the immediate postoperative period in order to achieve a similar degree of analgesia.

Over ordering of blood is a common practice for elective surgeries in many developing countries. Over a decade back, our institution-The Aga Khan University, Pakistan noticed that surgeons were making unnecessary arrangement of red cells. This was reflected in their undesirably high cross-matched to transfusion (CT) ratios. A clinical audit conducted in 1998-2000 confirmed this. This prompted the institution for designing a maximum surgical blood ordering schedule (MSBOS) in 2000 based on the retrospective usage of blood in various elective surgeries. This study aimed at observing the impact of implementation of MSBOS on surgeons' transfusion practices by comparing pre and post intervention crossmatched to transfused ratio in selected elective surgeries. For this purpose, we conducted a clinical audit from 2009 to 2010 and data was retrieved for quantity of red cells units arranged and transfused in the peri-operative period. C:T ratio was computed and compared with those in 2000. Identification of patients and physicians were kept confidential. Baseline C:T ratios for C-section, TURP, total knee replacement, laparoscopic cholecystectomy and CABG were 32, 22, 11.42, 23 and 4.77 respectively. In 2009-2010, red cells were transfused in 86 of 1,224 C-sections (7 %), 599 of 727 CABG (82 %), 10 of 324 TURP (3 %),16 of 890 laparoscopic cholecystectomy (1.7 %) and 14 of 85 total knee replacement (16.4 %) The C:T ratio in these surgeries was between 0 and 1. Implementation of MSBOS and efforts of BUC showed a significant impact in transfusion practices of surgeons with marked reduction in the utilization of blood and the C:T ratio. We recommend that regular audits should be conducted in every institution to improve the quality of services, encourage team work and ensure high standards.

All of the 12 patients transferred to the Aga Khan University Hospital survived. Unlike the reported injuries, calcaneal fractures were most commonly encountered in the survivors.

No abstract

Amoebic liver abscess (ALA) is endemic in south Asian countries. The current study was undertaken in order to evaluate the clinical spectrum, management and outcome of ALA at an urban tertiary care hospital in Pakistan. The chart notes of 232 ALA patients admitted from 1 January 2000 to 31 August 2007 were retrospectively reviewed. The most frequent clinical findings included: fever (96.5%); right upper abdomen pain (80.2%); liver tenderness (73.5%); tachycardia (61.6%); hepatomegaly (60%); nausea and vomiting (42%); and jaundice (23.9%). The duration of symptoms was less than 14 days in 70% . Ultrasound examinations revealed 69% of the abscesses were in the right lobe, 19% in the left lobe and 12% in both lobes. The size of the abscess was greater than 5.0 cm in 83%. Seventy-seven percent of the patients had a single abscess and 23% had multiple abscesses. Ultrasound-guided therapeutic aspiration was performed in 64%, but 36% were treated with antibiotics alone. Metronodazole was the most frequently used antibiotic. However, various combinations of antibiotics were also used without any obvious justification.