Rhizopus necrotizing fasciitis of caesarean wound: A rare life threatening condition

Mucormycosis is a rare cause of necrotizing fasciitis in immunocompromised patients. We report a young female, who developed rhizopus necrotizing fasciitis of caesarean wound. The lady died secondary to non-responding sepsis and irreversible multi-organ failure. High index of suspicion can lead to early diagnosis by frozen section of histopathology and fungal culture technique. Aggressive surgical debridement and intravenous anti-fungal medication is the main stay of treatment. A delay in diagnosis and treatment may cause multi-organ failure leading to high mortality

Splenic abscess: Outcome and prognostic factors

Objective: To determine the spectrum of presentation, treatment outcome and prognostic factors of splenic abscess in a tertiary care hospital. Study Design: Case-series. Place and Duration of Study: Department of General Surgery, the Aga Khan University Hospital, Karachi, from July 1988 to July 2007. Methodology: The records of 27 patients with splenic abscess, diagnosed from 1988 to 2007, were retrieved through ICD-10 coding system. The demographic data, physical and radiological findings, treatment modalities, bacteriology reports, morbidity and mortality were collected on a proforma. Results: There were 12 males and 15 females with a mean age of 43.52+/-17.49 years. Common symptoms were fever (92.6%), abdominal pain (55.6%) and malaise (29.6%). Majority of patients (89%) had leukocytosis and 63% patients had associated diseases with which they were admitted. The most common pathogenic organism was Staphylococcus species and gram-negative rods. Ultrasound was used as a preliminary diagnostic modality, which was often followed by CT scan. Thirteen patients were treated with intravenous antibiotics, 8 underwent percutaneous drainage and 6 patients required splenectomy with respective survival rates of 84%, 87.5% and 83%. Mortality rate was 14.81% but no statistically significant difference between 3 treatment groups was manifested. There was significant difference between treatment groups regarding the size of the abscess (p=0.01) and hospital stay (p=0.04). Splenectomy was done when abscess size was \u3e10 cm and hospital stay were increased in the radiological drainage group. Conclusion: Splenic abscess is an uncommon surgical entity. High index of suspicion and liberal use of radiological studies is essential for timely diagnosis. Most of the patients could be cured with non-operative treatment. Splenectomy is a safe procedure for patients with abscess size more than 10 cm and patients not responding to non-operative treatment

Evaluation of laparoscopic appendectomy vs. open appendectomy: a retrospective study at Aga Khan University Hospital, Karachi, Pakistan

OBJECTIVE: To compare open and laparoscopic appendectomies and to evaluate the level of efficacy of both types of appendectomy performed at Aga Khan University Hospital (AKUH). METHODS: Based on this strong study rationale, a clinical audit of patient\u27s records was performed to evaluate the significance of this technique as a treatment modality. The study population comprised of patients with appendicitis admitted in the Department of Surgery from January 2004 to December 2004. The patients\u27 charts were reviewed to ascertain whether the procedure was done as an acute case or as an elective procedure. The predictor variables explored in this study were: age, gender, ultrasound and CT focused procedure, operative time, post-operative stay, number of hours required for the return of bowel function, use of narcotic analgesia and the total hospital bill of the respective patients. RESULTS: A total of 49 patients\u27 clinical charts were reviewed. Of these, 29 patients had had laparoscopic appendectomies and the remaining 20 had open appendectomies. The mean post-operative stay in days was relatively shorter for laparoscopic appendectomy (1.97 +/- 2.3) compared to open appendectomy (3.1 +/- 1.8). The average time for the return of bowel movement was remarkably lesser for laparoscopic appendectomy (10.6 +/- 8.2) hours than open appendectomy (21 +/- 13) hours. Two of the independent variables: CT focused (P-value: 0.01) and operative times in minutes (P-value: 0.06) were found to be significantly associated with the types of appendectomy. Hence our study found that laparoscopic appendectomy, although relatively expensive, is a safe and effective procedure for the removal of appendix over open appendectomy

Retroperitoneal necrotizing fasciitis - when a simple procedure turns ugly

We present a case series of Patients who underwent simple perianal procedures outside this hospital but developed postoperative and life-threatening retroperitoneal necrotizing fasciitis. With a high index of clinical suspicion and radiological imaging, we were able to establish earlier diagnosis. Resuscitation, the use of intravenous broad-spectrum antibiotics, aggressive surgical debridement and continuous organ support were essential in achieving a positive outcome in both of these Patients

Outcomes of surgical management of tracheobronchial injuries---a case series from a developing country.

Objective:Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma. Methods: A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 Patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries. Results: The average age was 31 years with most of the Patients being male (14:1). Among them,11 Patients had penetrating trauma as the main cause of injury, 3 Patients had blunt trauma from road traffic accidents, only 1 Patient had combined trauma (blunt and penetrating trauma). Eight Patients were diagnosed based on radiological findings. All the Patients were treated surgically. Lobectomy was the most common intervention performed in 7 Patients. The mortality rate was 7% (1 Patient). Most Patients survived with no sequelae (10 Patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management. Conclusions: Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present

Major thoracic vessels and cardiac trauma: case series from a center in a developing country

75% of all trauma-related deaths are related to Thoracic Trauma. Very few penetrating cardiac trauma patients arrive at the hospital alive. Due to the high prevalence an understanding of the pathogenesis, manifestations, and management of cardiac trauma is becoming increasingly important to medical personnel. We retrospectively reviewed the files of 169 patients with a preoperative diagnosis of vascular injury that underwent management at the Aga Khan University Hospital (AKUH) during 2001 to 2006. Out of these patients 13 had cardiovascular and cardiac injuries. There were 23% (n=3) Cardiac injuries, two right ventricle injuries and in one both the ventricles were injured. Great vessel injuries included; Pulmonary artery (n=2), Inferior Vena cava (n=1), Left Carotid Artery (n=1), Left Subclavian Artery (n=2) and Right Subclavian Artery (n=3). 53.8% of the patients suffered from post-operative complications. The overall mortality of patients was 15.4%. We believe that in comparison to the past the inevitable delay in the diagnosis lead to unsuccessful thoracotomies, late transfers to the operating room and physiological deterioration of the patients. As the incidence of trauma is increasing worldwide it is essential for surgeons to be prepared to handle cardiovascular and cardiac trauma injuries immediately, as delay can adversely affect the outcome in terms of both morbidity and mortality

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

Background: Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. Methods: Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. Results: A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53–163.57, p = 0.021). Conclusions: With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially