Background: Despite the rarity (5%) of acute perforation of first part of duodenum (D1) and the advancement in surgical, anesthetic and ancillary facilities, still there are life-threatening dimensions. A variety of surgical techniques evolved over time, but none is without drawbacks. Thus, the need arise for surgeon friendly, suitable surgical technique with better outcome. By this retrospective analysis, we aimed to compare between the Graham's omentopexy (GO) and modified Grahams' omentopexy (MGO) to find the suitable method of managing this acute catastrophe. Materials and Methods: This is a retrospective study design for the period June 2009-May 2012. All the patients with only D1 perforation admitted and treated at our institution were included. Patients with perforation other than D1 site, multiple perforations, poly-trauma and associated co-morbidity were excluded. Patients were randomly subjected for either GO or MGO. Post-operatively, all were followed-up for 3 months at out-patients department. Results: Out of the 122 patients, 112 were males and 10 were females with M:F ratio 11.2:1. MGO group had comparatively less chances of biliary fistula, burst abdomen and mortality, but, more chances of wound infections with longer hospital stay and better outcome at 3 month follow-up in contrast to GO group. The overall mortality rate was 4.09%. Conclusion: MGO is surgically suitable technique than GO for patients with D1 perforation with better post-surgical outcome.

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Background: Hemorrhoids are a common human disease for which the best option available for the surgical management has remained conventional open hemorrhoidectomy. The most common complication of open hemorrhoidectomy is postoperative pain caused by spasm of the internal sphincter. Lateral sphincterotomy is a commonly performed procedure for relieving spasm and pain. Hence, we decided to evaluate whether addition of lateral sphincterotomy along with hemorrhoidectomy can help in the postoperative pain relief. Aim: Comparison of postoperative pain after hemorrhoidectomy with and without lateral internal sphincterotomy. Settings and Design: This was a prospective study conducted between November 2013 and December 2015 on 102 consenting patients who chose conventional open hemorrhoidectomy after obtaining an ethical clearance for the study. Subjects and Methods: The patients were randomized into two groups using the lottery method. Group A in addition to conventional open hemorrhoidectomy received lateral internal sphincterotomy. In Group B, only conventional open hemorrhoidectomy was performed. Pain assessment was done on the day - 0, 1, 2, and 7, respectively, by visual analog scale. Statistical analysis was done using  Chi-squared test (two-tailed) and a P < 0.005 was considered statistically significant. Results: On assessment of pain on the day - 0, 1, 2, and 7, respectively, by visual analog scale; we found statistically significant pain relief in the group whom lateral sphincterotomy was added. Conclusions: In this study, we conclude that in conventional open hemorrhoidectomy for 2 ^nd degree hemorrhoids addition of lateral sphincterotomy is an effective, convenient, and simple way to reduce the postoperative pain.

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Background: Haemorrhoids is a common condition seen in general surgery practice. Treatment includes many methods ranging from rubber band ligation, infrared photocoagulation, sclerotherapy to stapler hemorrhoidectomy. Our study is done to evaluate the efficacy of both the procedures in a rural setting. Objectives of the study was to study the efficacy of two surgical methods of treatment of hemorrhoids, in terms of (1) operation time; (2) post-operative pain; (3) hospital stay; (4) return to normal activity and return to work. Methods: A comparative study was done between open and stapling methods for the treatment of symptomatic hemorrhoids in Al Azhar Medical College, Thodupuzha, India. Results: There was major statistically significant difference seen among different parameters between the two procedures of haemorrhoidectomy, open versus stapler procedure for prolapsing hemorrhoids (PPH) as evident from the p value. Conclusions: In our study there is a definite difference noted between two surgical methods in terms of hospital stay and return to work. As far as satisfaction of patient is considered in both the groups satisfaction is similar except for the cost of surgery which was the only cause of dissatisfaction.

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Context and Aims: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our technique is simple that can be used in any hospital with locally available facilities. Settings and Design: This was a prospective study. Subjects and Methods: A total of 25 children were enrolled in the study between September 2015 and June 2016 at our institute. Patients were given air enema under US guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 100 mmHg. A total of three attempts of 3 min each were allowed. Statistical Analysis Used: We just used simple statistic to calculate average. Results: There were 17 males and 8 females. The average age of the patients was 8.5 months. Twenty-two (88%) of the cases were reduced successfully while 3 (12%) failed to reduce. A majority of those that did not reduced had symptoms for at least 4 days. No bowel perforation occurred in our study. All cases of the intussusception have length <5 cm were reduced with pneumatic reduction in our study. Conclusions: The technique described is easy to assemble, safe, and effective. We recommend it for regular use in pneumatic reduction of intussusception, especially in the center have limited resources.

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Objectives: An endeavor to look for cost effective method for dressing wounds to minimize loss of working hours. Three percent citric acid solution (CA) was used for dressing acute lower limb ulcers with the object of pH modulation of wounds at an early stage and to evaluate its effects on wound healing. This solution was compared with Edinburgh University solution of lime (Eusol) in a randomized double-blinded study. Appearance of healthy granulation was the end point of the study. Materials and Methods: An unicentric randomized double blinded study with a parallel design was used to compare patients treated with 3% CA and Eusol solutions, respectively. The results were analyzed using Chi-square and P value using Microsoft Excel and SPSS 22. Patients having fever, altered consciousness, high initial random blood sugar >350 mg%, positive urinary ketones, hypoproteinemia, signs of septicemia and vascular diseases were excluded. Results: Twenty patients were known diabetic out of which 11 were in the CA group, and the rest were in the Eusol group. It was observed that the average total stay in diabetic patients was 16.36 days in CA group and 31 days in Eusol group whereas it was 15.78 and 24.75 days respectively in the nondiabetic group. The ulcer granulation interval showed that the mean stay in CA group was 10.56 days while it was 20.04 days in the Eusol group. The cost of stay was less in CA group. Conclusions: It is concluded that 3% CA solution forms a good alternative for wound dressings that acts by modulating the wound pH to acidic levels thereby contributing to wound healing by increased fibroblast proliferation and probably increasing local oxygen concentration and reducing microbial growth and virulence.

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Pancreatic ductal calculi are rare and most often associated with chronic pancreatitis. Radiological features of chronic pancreatitis are readily evident in the presence of these calculi. We present the case of a 66-year old woman who presented to our emergency department with severe upper abdominal pain and vomiting. She had been having repeated attacks of similar but milder upper abdominal pain, for which she would visit her general practitioner, and be treated for gastritis. This time however the pain was excruciating and accompanied by vomiting. She was a known diabetic for which she was receiving treatment. Both abdominal ultrasound and contrast enhanced computerized tomography scan of the abdomen revealed an atrophic pancreas, and a dilated pancreatic duct filled with an enormous load of calculi. Laparotomy and the Frey procedure which consists of coring out of the pancreatic head and longitudinal pancreaticojejunostomy were done.

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Objective: The aim was to determine the role of laparoscopy in the management of nonspecific abdominal pain (NSAP). Background: NSAP constitutes a good proportion of surgical admissions, both in emergency and elective settings with considerable diagnostic dilemma. Patients and Methods: All patients who presented with pain abdomen with no immediate cause and were labeled as NSAP after clinical assessment and investigations and following that underwent laparoscopy to make a definitive diagnosis were included in the study. Results: A total of 88 patients were included in the study. There were 59 (67%) females and 29 (33%) males. The mean age was 26 years (range 18-58 year). The common mode of admission was out-patient department 69 (78.4%) patients. Twenty-five (28.4%) patients presented with NSAP in lower abdomen, followed by 21 (23.8%) with right lower abdominal pain and 19 (21.5%) with central pain radiating to right lower abdomen. Diagnosis was established in 75 (85.2%) patients. In 13 (14.7%) no pathology was found. The most common diagnosis was pathology of appendix in 29 (32.9%) patients followed by pelvic pathology in 18 (20.4%) and abdominal tuberculosis in 14 (15.9%) patients. Most 37 (42%) of the patients stayed in the hospital for 24 h. There was no readmission and no major postoperative complications. Conclusions: Laparoscopy has a definitive role in diagnostic dilemma associated with NSAP. It has at the same time role in treatment of the condition; hence laparoscopy has a diagnostic and a therapeutic implication in management of NSAP.

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The localized varicosities of the hands and digits are quite rare with only a handful of cases reported in the literature. The cause of upper and lower limb varicosities are almost the same and the same treatment principles should be followed for both. Here, we report a case of 19-year-old male with localized varicosities of the dorsum of his hand and digits. Diagnosis was confirmed by color Doppler ultrasound scanning. He was managed by multiple ligations and excision of varicose veins with excellent results.

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Objective: The effectiveness of teaching operative notes in surgical resident training program at King Abdulaziz University Hospital, Jeddah was studied. Materials and Methods: This was a prospective study done at Department of Surgery, King Abdulaziz University Hospital to evaluate the effect of teaching the surgical residents how to write operative notes. Twenty-one residents were asked to write operative notes of appendicectomy. Their operative notes were evaluated for medical record number (MRN), date and time of the operation, preoperative and postoperative diagnosis, names of surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, whether histopathology specimen was sent to the pathology department or not, postoperative orders, whether the patient went to the recovery room in a satisfactory condition or not, and signature of the operating surgeon. Two months of effective teaching of operative notes was given to them. They were again asked to write operative notes of appendicectomy. Notes were collected and studied and comparison was made with previous notes. Legibility of the operative notes was also studied. Results: In our study, we found that there was improvement of 29-39.9% in recording MRN and the date of operation by our residents after they were taught the art of writing operation notes. There was marginal improvement (4.7%) in stating whether it was elective or emergency operation. Documentation of surgeon's name, assistant's name, and anesthetist's name improved to 12.4-32.8%. Writing the name of the procedure and pre- and postoperative diagnosis improved to 31%. Details of the procedure such as position of patient and incision improved marginally to 5.9%. Mentioning the findings and description of the procedure showed no improvement, as it was 100% before teaching. Documenting hemostasis, estimated blood loss, and transfer to recovery room improved to 58.4%; however, there was no improvement in writing post-op orders and histopathology sent to the pathology department.Improvement of signature was only 9%. Conclusion: Effective teaching of how to write operative notes helps in the training of surgical residents.

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Objectives: To determine the prevalence, seasonal presentation, and management of Ludwig's angina in Northwest Nigerian Tertiary Health Facility. Patients and Methods: Cases of Ludwig's angina that presented and managed by the Dental and Maxillofacial Surgery Unit of the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, between 2013 and 2015 were retrieved. Data were stored and analyzed using IBM SPSS (IBM Corp., Armonk, NY, USA) Statistics for windows version 20. Results: Over the review period, 36 patients presented with clinical features of Ludwig's angina. Only 28 cases were analyzed and 8 cases had incomplete data and were excluded from the analysis. Of the 28 patients, 23 (82.1%) were males while 5 (17.9%) were females with a male: female ratio of 4.6:1. The mean age of the sample was 32.3 ΁ 11.6, range 18-60 years. A majority of the patients were in low socioeconomic group with 11 (39.3%) patients being peasant farmers. Odontogenic infection was responsible for the disease in 27 (96.4%) cases while only 1 (3.6%) case was idiopathic. Of those with odontogenic etiology, 18 (64.3%) were due to sequelae of caries. Microbiology, culture, and sensitivity in few cases revealed Streptococcus species, Pseudomonas aeruginosa, and Staphylococcus aureus. Most of the cases recorded no bacterial growth after 24 h incubation period. Twenty-five patients (89.3%) survived the disease while 3 (10.7%) died. Conclusions: Management of Ludwig's angina in a resource- and personnel-scarce setting can be very challenging. Early surgical decompression, aggressive empirical antibiotics, and nutritional support have contributed to the low mortality in our series.

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Solid pseudopapillary tumors of the pancreas are rare tumors commonly found in females. Surgery is the primary treatment and the role of adjuvant chemotherapy or radiation is not well defined. Although they are mostly benign, they have the potential for late metastasis, thereby defining the need for long-term surveillance for such patients. This review article describes these tumors in detail and in addition, focuses on the management of the resected tumors and the need and indications for adjuvant treatment in selective cases.

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Introduction: Delayed presentation of patients with posterior urethral valve (PUV) is common in our country and is usually associated with complications and morbidities. Objective: To determine the pattern of presentation of PUVs and its complications and outcomes in these patients with respect to decrease or resolution of vesico-ureteric reflux (VUR) and/or requirement of additional operative procedures. Materials and Methods: A retrospective study was conducted, and 30 children of PUV were analyzed with respect to the pattern of presentation, duration of symptoms, age at primary fulguration, grade of VUR and its outcome. Results: Patients with early presentation were diagnosed early, had their PUV fulgurated early and had lesser grades and better resolution of their VUR and good outcome. The reverse was seen in those patients who presented late and already had some form of renal impairment such as higher and bilateral grades of VUR and higher serum creatinine levels. Some of them also required additional procedures which added to their morbidity. Discussion: Delayed presentation of PUV is common in our country and is associated with an increased incidence and a higher grade of VUR which does not decrease or resolve on follow-up and usually requires additional operative interventions adding to the morbidity of both the parents and the child. On the other hand, early presentation leads to early diagnosis and early relief of obstruction and is associated with lesser VUR, which resolves over time. Conclusion: With early presentation, diagnosis and treatment, the outcome of patients with PUVs is expected to improve. Efforts at improving awareness and early diagnosis and referral among the health team should be encouraged.

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Aphallia or absence of the penis is a very rare congenital anomaly with an estimated incidence of 1 in 10,000,000 births. A total of about 80 cases have been documented so far. We present a case of 1-day neonate who was born preterm at 30 weeks by normal vaginal delivery with a birth weight of 1.9 kg. The neonate's phallus was absent, the scrotum was normal with two normally descended testes with palpable vas deferens. Urethral meatus could not be located anywhere in the scrotum or over the pubis. Meconium was mixed with urine which was due to a urethrorectal fistula. Urethral opening was catheterized with 5 no. infant feeding tube. The neonate was in respiratory distress with tachypnea, tachycardia, central cyanosis, and bilateral coarse crepitations on auscultation. The patient was referred to the Neonatal Intensive Care Unit where the neonate was intubated and kept on a ventilator for neonatal respiratory distress syndrome.

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Background: Gastrointestinal basidiobolomycosis (GIB) is a newly emerging rare tropical fungal infection which affects immunocompetent individuals. Patients and Methods: Our database was reviewed to identify patients with biopsy-proven gastrointestinal basidiobolomycosis. Results: Six patients were recognized, two females and four males, with a median age of 23.5 years (range 11–70). All patients came from the same region and all had eosinophilia and they were all immunocompetent. The clinical and radiological features simulated colorectal malignancy in four patients, inflammatory bowel disease in one patient, and left iliac fossa mass in another patient. The diagnosis was established after extensive colonic surgery in four patients, after open biopsy in one patient and after ultrasound-guided biopsy in another. All patients received prolonged antifungal treatment. In those who received extensive colonic surgery, one patient died, two patients recovered, and one is still receiving antifungal treatment. Patients in whom the diagnosis was established by biopsy only, one patient recovered while the other is showing steady improvement. Conclusion: GIB is a potentially lethal fungal infection, which affects immunocompetent individuals in temperate and hot arid regions of the world, including Saudi Arabia, Iraq, Iran, and Arizona desert in the United States. The patient usually presents with features suggestive of colonic malignancy, inflammatory bowel disease, or abdominal mass. Establishing the diagnosis by endoscopic- or radiology-guided biopsy, serological tests, fungal cultures, or molecular techniques enables the institution of antifungal treatment, which may lead to complete cure without surgery. With or without surgery prolonged antifungal therapy is always required.

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Background: Mesenteric cysts continue to intrigue the surgeons and radiologist alike. Patients and Methods: Our records were reviewed to identify mesenteric cysts, diagnosed in the period from February 2014 to September 2016. Results: We identified one male and four females, with a median age of 44 years. Abdominal pain was the presenting feature in all patients. ultrasound was done in four cases, where the cyst was missed in one case, and no clue to its nature was given in the remaining three, while computed tomography suspected the diagnosis in four patients and failed in one. Laparoscopic excision was attempted in only one patient, but eventually, all patients underwent open surgical excision. In four patients, the cyst was removed intact, while in the fifth, a minor wall break occurred, resulting in limited spillage of cyst contents. Histopathological examination showed simple mesothelial cyst in three cases, a pseudocyst in the fourth case and a cystic lymphangioma in the fifth. All patients tolerated surgery well, and up to the time of writing this paper, no recurrence was reported. Conclusion: Mesenteric cysts, with its numerous types, continue to intrigue the concerned physicians. Regardless of the approach, excision of the intact cyst should be the aim, most conveniently by open surgery. Although laparoscopy could be employed, this should be entertained with caution, to avoid cyst rupture or leaving part of the wall behind, thus predisposing to recurrence.

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Background: Acute appendicitis is the most common cause of acute abdomen and subsequent surgery. The diagnosis is essentially based on the clinical grounds and as a result misdiagnosis is a common and crucial problem in general surgery. Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin and C-reactive protein (CRP) have been shown to indicate perforation in appendicitis. Aim: The purpose of this study was to evaluate the role of hyperbilirubinemia, CRP and ultrasonography (USG) as predictors for appendiceal perforation. Materials and Methods: This study consisted of patients admitted with the clinical suspicion of acute appendicitis. The study finally included a group of those 100 patients who had histologically proven appendicitis. Subsequent to hospital admission all patients underwent thorough physical examination and routine lab exams. Preultrasound clinical diagnosis was made based on medical history, physical examination as well as laboratory findings. Real-time, high-resolution (5 MHz, 7.5 MHz) graded compression ultrasound examination was performed by a senior radiologist after a clinical diagnosis was made. Results: Serum bilirubin and CRP were raised in significant number of patients with appendiceal perforation compared to the patients of appendicitis without perforation. Thirty-three of 42 patients with perforated appendix had bilirubin ≥1.5 mg/dl (P < 0.0001). Sensitivity of serum bilirubin in predicting perforation was 78.57%, while as specificity was 89%. Thirty-five of 42 patients with perforated acute appendicitis had raised CRP levels (P < 0.0001). Sensitivity and specificity of CRP in predicting perforation were 83% and 74%, respectively. Abdominal USG in patients with diagnosis of perforated acute appendicitis has a sensitivity of 64.28% and specificity of 79.3% (P < 0.0001). Conclusion: Bilirubin, CRP and ultrasound are effective for differentiation of perforated from nonperforated appendicitis. Bilirubin, CRP and USG are important preoperative biochemical and sonographic markers of perforation, respectively in appendicitis.

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Objective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.

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Objective: In Saudi Arabia expatriates physicians involved in malpractice litigation process (MLP) risk travel ban, creating immeasurable stress as these procedures are quite lengthy with no insurance company or employer support. A survey study conducted in the city of Taif aimed to demonstrate the outcome of ongoing MLP on overall patient care. Methods: Various grades doctors of both sexes, from different surgical and medical specialties in Ministry of Health Hospitals, Taif city, were surveyed, including mental, pediatric, King Faisal and King Abdul Aziz Specialist Hospitals. The study was conducted between January 25, and May 3, 2015. Saudi nationals and paramedics were excluded from the study. Multichoice questions with space for suggestions were distributed and collected manually. It is a qualitative and cross-section study. Results: A total of 277 responded to the survey, 127/277, (45.84%) were involved in MLP of whom 97/127 (76.4%) were banned from travel. While in Linkert's scale, 96/277 (34.65%) were satisfied with the role of insurance company, 114/127 (89.8%) had little or no support from their employer during MLP, and 218/277 (96.03%) agreed that overall patient medical care will have a negative impact due to the ongoing MLP (P < 0.05). Conclusion: We believe the ongoing MLP is a fertile ground for developing defensive medicine culture. A stress-free environment strategy governed by support and legal protection by employer and insurance company respectively is suggested.

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Background: Typhoid ileal perforation peritonitis is a potentially life-threatening surgical emergency in developing nations. The severity assessment of a disease condition is useful to prioritize treatment and to reduce morbidity and mortality. Aims: The aim of this study was to use Acute Physiology and Chronic Health Evaluation (APACHE) II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis. Materials and Methods: A prospective analysis of data was done, which was collected over a period of 3 years for 100 cases of secondary peritonitis following typhoid ileal perforations, irrespective of age, sex, and duration of illness. APACHE II score was used to grade the severity and outcome in these patients. Results: Out of 100 patients included in this study, 87 were male and 13 were females. Age ranges between 14 and 65 years, maximum number of patients were in 2 ^nd and 3 ^rd decade of life. History of fever, abdominal pain, and abdominal distention were present in all cases. After onset of fever perforation occurred in 65% patients in 1 ^st week, there was an increase in mortality with increase in APACHE II score, age >50 years was associated with more mortality. The mean Intensive Care Unit stay in this study was 4.33 days, 5.81 days for survivors, and 3.47 days for nonsurvivors. Mortality in our study was 22%. Conclusion: APACHE II score is an easy and objective tool to grade severity of acute peritonitis and can be used for assessment of outcome. According to this study, patients with higher APACHE II score had highest rate of mortality and vice versa.

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Purpose: The purpose of the study is to find out the incidence of pyramidal lobe (PL), its position in relation to thyroid and correlation with functioning status of thyroid gland. Materials and Methods : This was a retrospective study conducted in Nuclear Medicine Section, Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan. We evaluated radionuclide thyroid scans performed with technetium-99m pertechnetate from March 2009 to May 2013. As per our departmental protocol, patients were used to swallow 100-150 cc water to wash away secreted esophageal activity and minimizing the possibility of false positive results. Patients with diagnosis of thyroiditis or history of any thyroid surgery were excluded. Presence and position of PL (arising from isthmus or either lobe of thyroid), presence or absence of cold or hot nodule (s), total thyroid uptake and thyroid function test performed within 4 weeks of thyroid scan were noted. Results: A total of 1116 thyroid scans qualified inclusion criteria of the study. PL was appreciable in 156 patients with overall incidence of 14% and an annual incidence of 3.5%/year (P < 0.05). Mean age of the population was 40 ± 12 years and female: Male was 113:43 (P < 0.05). Mean thyroid uptake was 14 ± 9% (P > 0.05). PL had origin from left thyroid lobe in 72 (46%), from the right thyroid lobe 58 (37%) and from the isthmus in 26 (17%) (P < 0.05). 135 (86.5%) patients were toxic (P < 0.05) while 15 (9.6%) euthyroid and 6 (3.8%) were hypothyroid (P > 0.05). Conclusion: We conclude that the incidence of PL on thyroid scanning was 14% with predominance for the female gender, left lobe origin and diffuse toxic goiters. An adequately performed thyroid scan would ensure completeness of thyroidectomies and avoid per-operative inconvenience to surgeons due to false positive scan results.

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Background: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic cholelithiasis, but is associated with a higher incidence of bile duct injuries than the open approach. We evaluated a multidisciplinary approach for managing these injuries after LC. Materials and Methods: From April 2006 to August 2011, all patients who developed bile duct injury after LC and were treated by the hepatobiliary team of Al-Hada Armed Forces Hospital, Taif, Saudi Arabia were included in our study. If an injury was suspected intraoperatively, intraoperative cholangiography was performed; thereafter, if the injury was confirmed, immediate laparotomy and primary repair or hepaticojejunostomy (H-J) involving lowering of the hilar plate were performed. Injuries occurring postoperatively were treated by endoscopic cholangiopancreatography (ERCP) to diagnose the type of Strasberg injury. Strasberg type A injuries were managed endoscopically, and more advanced cases underwent open surgery. Results: Of 30 females and 18 males (mean age, 45 years; range, 18-90 years), 6 cases of bile duct injuries were discovered intraoperatively. Of these, two were classified as type C and underwent primary repair with internal stenting. The other four were classified as type E and were treated by Roux-en-Y H-J reconstruction. Forty-two cases of bile duct injuries presented postoperatively, including 18 Strasberg type A and 24 Strasberg type E injuries. Type A injuries were treated with ERCP and stenting, and six with endoscopic removal of a retained stone. Of the 28 patients who underwent H-J, 20 underwent the technique involving lowering of the hilar plate. Of these, three subsequently developed anastomotic strictures and were treated with percutaneous transhepatic balloon dilatation. There were no mortalities. The mean follow-up was for 36 months. Conclusion: Early referral to a specialized surgeon and a multidisciplinary approach help manage bile duct injury after LC in all patients with an acceptable low stricture rate.

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Introduction: Variations in rectus sheath formation have been reported with little realization of its importance to the laparoscopic surgeons doing total extra-peritoneal preperitoneal (TEPP) hernioplasty. Observation of complete rectus sheath during laparoscopic mesh hernioplasty for inguinal hernia through TEP approach and its surgical implication are presented here. Materials and Methods: Setting - Elective. Location for the study - J. N. Medical College and Hospital, A. M. U., Aligarh. Study design - Prospective with effective from April 2010 to August 2013. Study population - Adults (≥18 years). Data collection - Instant documentation and video recording. Method of analysis - All data were computed through on-line calculators (www.graphpad.com/quickcalcs/and http://epitools.ausvet.com.au/). Results: Thirty-five TEPP hernioplasties were carried out in a period of 3 years. All patients were males, with an overall mean age of 48.7 ± 13.4 years. Posterior rectus sheath (PRS) was found complete in four patients with a mean age of 47.28 ± 09.74, and was associated with significantly increased surgical difficulties during the procedure. On Visual Analog Score, endoscopic vision was 4.3 ± 0.6 (4.0-5.5), and the ease of the procedure was 4.5 ± 0.8 (4.0-6.0) that is, both were less than satisfactory. Operating time was 3.1 ± 0.7 h (3.25-4.0). Out of four patients, peritoneal injury occurred in three patients, surgical emphysema in one patient, and postoperative seroma in one patient. Conclusions: PRS was complete in 11.43% of cases studied that was associated with an increased level of surgical difficulties and a higher rate of complications.

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Introduction: Perforation is defined as an abnormal opening in a hollow organ or viscus. Gastrointestinal perforation is one of the common surgical emergencies in developing countries. The diagnosis is mainly clinical and is aided by radiological investigations. The present study was conducted to highlight the spectrum of hollow viscus perforation peritonitis in terms of etiology, clinical presentations, site of perforation, surgical treatment, postoperative complications, and mortality encountered at SMS Medical College and Hospital, Jaipur, India. Materials and Methods: The study was a hospital-based prospective observational study conducted from April 2012 to October 2013 in the Department of General Surgery. During the study period, a total of 442 patients underwent surgery for secondary peritonitis. The patients included in the study were patients (>12 years) presenting with gastrointestinal perforation and undergoing emergency laparotomy. Results: Out of 442 patients, 91.2% (403) were males, with male-to-female ratio being 10.33:1. The mean age was 39.13 years. About 79.2% of the patients were below 50 years. Free gas under diaphragm on chest X-ray was noted in 86.2% cases. Duodenum was the most common site of perforation in 158 patients. The most common etiology for perforation was acid peptic disease (41.4%). Simple closure was the most common surgical procedure being performed in 63.8%. Overall morbidity and mortality recorded in this study were 42.8% and 14.7%, respectively. Conclusion: Early diagnosis, resuscitation with fluids, and timely surgical intervention are the most important factors deciding the fate of the patient with perforation peritonitis.

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Sigmoid volvulus is a rare and potentially life-threatening complication of Hirschsprung' disease. A young patient presenting with sigmoid volvulus is not common and Hirschsprung's disease should be suspected in patients in this age group presenting with otherwise unexplained colonic volvulus. Here we report a rare and interesting case of Hirschsprung's disease presenting as sigmoid volvulus in a 15-year-old girl and the sufferings of the patient due to this uncommon entity.

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Objective: The aim of this study is to describe the computed tomography (CT) features of primary and secondary omental infarction. Materials and Methods: Five cases of primary and seven cases of secondary omental infarction are described with emphasis on CT features. The etiology and clinical features are described with the ultimate clinical outcome. Results: In this case series of 12 patients, five omental infarcts (42%) were classified as primary. Seven cases (58%) were postoperative with four infarcts following cesarean section, one following a total abdominal hysterectomy, one occurring after a laparoscopic ovarian cystectomy, and one occurring after laparoscopic hemicolectomy. Of the seven secondary omental infarctions, one was associated with secondary thickening of the transverse colon and one patient developed an abscess. Three patients from the secondary group and one patient from the primary group underwent omentectomy. Primary infarcts showed an ill-defined fat attenuation lesion with thin stranding located in the right upper quadrant in three and left lower quadrant in two patients. The postoperative omental infarcts showed more pronounced inflammatory change and soft tissue attenuation foci interspersed with fat density foci. They were located in the right lower quadrant in four patients, in the right upper quadrant in two patients, and in the left lower quadrant in one patient. The patients were followed to clinical resolution. Conclusion: It is possible to distinguish primary and secondary omental infarcts on the basis of CT features. Even though, a nonsurgical cause of acute abdomen, surgical management may become necessary in patients with secondary omental infarction and secondary infection who fail to respond to antibiotics and percutaneous drainage. The majority of the secondary cases followed cesarean section in our series.

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