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Objective: To evaluate the types of liver resections performed for various liver diseases and assess the overall outcome in a series of patients presenting to Army Liver Transplant Unit, Pak Emirates Military Hospital. Study Design: Retrospective observational study. Place and Duration of Study: This study was carried out in Army Liver Transplant Unit -- Pak Emirates Military Hospital Rawalpindi, from Dec 2015 to Dec 2016. Material and Methods: All patients who underwent any type of liver resection were included by non-probability convenient sampling. History, clinical findings, radiological variables and histological findings were recorded in a proforma based on hospital database. The data was analyzed using SPSS 17. Results: A total of seventeen patients underwent various forms of liver resections out of which there were thirteen males and four females. The mean age of patients was 40.4 ± 21.4 years. Nearly half of patients had chronic, hepatitis either hepatitis C (35.3%) or chronic hepatitis B (11.8%). Most patients were asymptomatic (42%) and were diagnosed on routine screening by transabdominal ultrasound followed by pain (23%), mass abdomen (17%) and jaundice (12%). The average size of mass was 5.1 x 5.2 cms on CT scan. The most common tumor in adults was hepatocellular cancer (8 cases) whereas hepatoblastoma (3 cases) was common in children. Two resections were performed for giant hemangioma. Non-anatomical resection was performed in 8 cases followed by left lateral segmentectomy (5 cases) and right hemihepatectomy (3 cases) and right extended hepatectomy (1 case). There was bile leak in one case and recurrence in two cases. There was one peroperative mortality because of massive bleeding. Conclusion: Liver resections are among one of the complex surgical procedures which can be performed safely in specialized centers. Most commonly resections were performed for malignant diseases in pediatric and adult population but symptomatic benign diseases can also be resected with better outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of needle assisted laparoscopic repair (NALR) of inguinal hernias in children. Study Design: Cross-sectional analytical study. Place and Duration of Study: Department of Pediatric surgery, Pak Emirates Military Hospital, Rawalpindi, from Aug 2017 to Apr 2018. Material and Methods: A total of 50 patients were included in the study. All the patients were diagnosed with inguinal hernias on the basis of history given by parents and clinical examination. All patients underwent NALR of inguinal hernias after preoperative workup and informed written consent. Pneumoperitoneum was created in all cases by open method. Transumblical 3mm port was used for telescope along with a single 3mm port in lower abdomen for grasping forceps. Internal inguinal ring was closed by transfixing it with a loop suture using 22 G spinal needle and 2/0 prolene suture. Operative time and presence of contralateral processus vaginalis was noted. Patients were followed up at four weeks and three months for postoperative complications. Results: Age of the patients ranged from 12 years, Mean ± SD was calculated as 40.36 ± 37.74. Regarding inguinal hernia site, n=17 (34%) have right sided hernia, n=13 (26%) have left sided hernia while bilateral hernia were present in n=20 (40%), 9 patients (18%) were found to have occult patent processus vaginalis peroperatively. Mean operative time ranged from 9 minutes to 25 minutes with Mean ± SD calculated as 15.94 ± 5.30. All operations were completed laparoscopically without need of conversion to open herniotomy. There were no intraoperative complications; No case of matachronous contralateral inguinal herniaor hydrocele formation and wound related complications during follow up at 4 weeks and 3 months. Conclusion: LNAR of inguinal hernias in children is an effective, quick and safe technique which can be easily learnt due to its simplicity to perform. This technique can be employed in both male and female pediatric population with promising results. One main advantage is the ability to pick up the occult patent internal ring which can be repaired in the single stage to prevent the development of metachronous inguinal hernia in the later age. [ABSTRACT FROM AUTHOR]

Objective: To improve the standard operating procedures (SOPs) for perioperative anesthesia management and reduction of complications where human error is involved. Study Design: Retrospective observational descriptive study. Place and Duration of Study: Department of Anesthesiam, Combined Military Hospital (CMH) Lahore, from Jun 2017 to Jun 2018. Material and Methods: Anesthesia related critical incidents were reported voluntarily in a proforma in this study. Results were then analyzed and audited for human errors, equipment malfunction, drug mishaps, patient factors, and nature of surgeries. Averages and percentage were calculated for these occurrences. Results: During one year 159 critical incidents (1.56%) were reported in 10181 patients. Airway and pulmonary incidents (49%), cardiovascular (42.1%) drug related (5%) and rare causes were (3.9%). Most incidents occurred during maintenance phase (40.88%), followed by emergence (25.16%), induction (23.27%) and post-operative period (10.69%). General anesthesia (1.56%), regional anesthesia (1.78%) and local anesthesia under monitored care (0.56%) were responsible for these adverse events. Analysis for reasons of these incidents suggested human errors (47.16%), patient’s comorbids (28.30%), nature of surgical procedures (24.52%) and combined factors were (71%). Anesthesia related mortality in our study was 5 deaths per 10000 anesthetics. Conclusion: Critical incidents do occur even in the hands of highly qualified and skilled anesthesiologists but can be minimized by continuous efforts through reporting and analysis of these events and hence formulating safety protocols. [ABSTRACT FROM AUTHOR]

Objective: To compare the urethroplasty with and without stent for hypospadias in terms of frequency of postoperative urethrocutaneous fistula formation. Study Design: Randomized controlled trial. Place and Duration of Study: Department of Pediatric Surgery, Pak Emirates Military Hospital Rawalpindi, from Jan 2015 to Dec 2017. Patients and Methods: A total of 260 patients with diagnosis of hypospadias were selected from outpatient department after confirming their diagnosis by taking a detailed history and performing thorough clinical examination. Patients were divided randomly into two groups, group A and group B via lottery method. In group A, urethroplasty was done by using a stent while in group B, urethroplasty was done without a stent although stent was used in this group as a template preoperatively to form a neo urethra and then removed after 24 hours. The 6-8 FR nasogastric tube was used as stent. The follow up was after 2, 6 and 12 weeks to see the fistula formation in both types of procedures. All the data was recorded on the specially designed proforma attached as annexure A. Data was analyzed using SPSS version 22. Results: The overall incidence of urethrocutaneous fistula was 21 (8%) out of the total study population. In group- A there were 18 (13%) cases who developed fistula and in group-B 3 (2%) cases developed fistula. There was significantly higher no of cases in group-A, who developed fistula as compared to group-B, p-value = 0.001. Conclusion: Stents are routinely used in many centres after urethroplasty for hypospadias repair leading to higher incidence of urethrocutaneous fistula. If urethroplasty is done meticulously, stentless surgery may produce fewer fistulas. [ABSTRACT FROM AUTHOR]

Objective: Objective of study is to compare peri-operative complications between exteriorization and intraabdominal repair of uterus after cesarean delivery. Study Design: Randomized controlled trial. Place and Duration of Study: Obstetrics and Gynecology Department of Pakistan Ordinance Factory Hospital, Wah Cantt, from 1st April 2010 to 30th September 2010. Material and Methods: Patients planned for 1st cesarean section under spinal anesthesia were randomly allocated by lottery method to exteriorized (A) or in situ uterine repair (B) group. Patients with history of uterine surgeries and cesarean section were excluded from study. Variables analyzed were operation time, peri-operative hemoglobin (Hb) fall, nausea and vomiting during the cesarean delivery. Results: The study analyzed 170 patients and divided them in 2 groups, having no significant difference with respect to maternal demographics, procedure statistics and indication of cesarean section. Significant difference was observed in operation time being 32.78 min in exteriorized group and 36.38 min in situ uterine repair group (p-value 0.0001). Hb% fall was 0.85 g/dl and 0.92 g/dl respectively in both groups (p-value 0.62) Nausea and vomiting was 23.5% in group A and 11.8% in group B (p-value 0.02, 0.04 respectively) Conclusion: Peri-operative complications like operative time and Hb fall are less in uterine repair after temporary exteriorization as compared to intra-abdominal repair of uterus after cesarean delivery. Nausea and vomiting were increased in exteriorized group but proper regional anesthetic technique and achieving adequate analgesia can reduce patient discomfort. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of the Ponseti method of clubfoot management in neonates and infants and to see which factors affect outcome. Study Design: Retrospective study. Place and Duration of Study: Department of Paediatric surgery, Military Hospital, Rawalpindi, from October 2012 to September 2014. Material and Methods: The Ponseti method for the management of congenital talipes equinovarus was applied in children of 7 days to 6 months age. While those with complex neurological problems, pathological clubfeet, syndromic clubfeet and older than 6 months at the time of presentation were excluded from the study. Assessment was done at presentation, at the removal of the last plaster cast and after one-year use of the foot abduction splint. Results: A total of 124 clubfeet of 89 children, including 63 males (70.78%) and 26 females (43.82%) were treated as outdoor cases. Eighteen feet (14.51%) were of rigid (atypical) type whilst 106 (85.5%) were of flexible (typical) type. Bilateral involvement was seen in 35(37.31%) children. The mean pretreatment Pirani score was 5.4 and the mean number of plaster casts required was 5.8. The mean Pirani score at 1-year follow-up was 0.5 with successful outcome in 82.3 % of all cases (96.9 % of neonates). Poor compliance with the use of the foot abduction splint adversely affected outcomes. Conclusion: The Ponseti method of treatment of congenital clubfeet is safe and easy to learn with effective and reproducible results. Early start of treatment and compliance with the use of the foot abduction splint during the maintenance phase are crucial to successful outcome. [ABSTRACT FROM AUTHOR]

Objective: To retrospectively evaluate the role of tadpole (mucoperiosteal island) flap in palatal fistula repair. Study Design: Descriptive retrospective study. Place and Duration of Study: It was conducted at Military hospital Rawalpindi and cleft hospital Gujrat from November 2010 to September 2014. Material and Methods: Total 38 patients underwent island tadpole flap, two layer, closure of palatal fistula. All patients with palatal fistulae following repair of congenital cleft palate along with recurrent fistulae, i.e., those occurring after one or more previous attempts at fistula repair were included. Patients with asymptomatic fistulae, history of palate repair of less than 6 months duration and fistulae other than those developing after cleft palate repair were excluded from the study; these latter included congenital and infectious causes.Experienced surgeons performed all the repairs and results were evaluated by using SPSS version 17. Results: Surgery was considered successful on complete anatomical closure of fistula. Thirty-eight patients, 23 (60.5%) males and 15 (39.5%) females, underwent surgery for palatal fistula repair. There were 32 (84.2%) anterior fistulae whilst the remaining 6 (15.8%) were located at the junction of soft and hard palate. The mean fistula size was 8 mm ± 1.6 mm, ranging from 6 mm to 15 mm. Recurrence was noticed in 3 (7.8%) cases with a mean follow up of 20.7± 7.3 months; one out of the 3 cases was small and resolved spontaneously. Conclusion: The tadpole island flap is a versatile and effective single stage, two-layered fistula repair technique suitable for both, large and recurrent fistulae. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to highlight the presently used medical educational principles highlighted in the Quran, analyze them and correlate them to derive lessons facilitating their implementation. Study Design: Mixed method study. Place and Duration of Study: Department of Medical Education, CMH Medical College, Lahore; January to December, 2013. Material and Methods: Verses of Quran from different Tafaseer (Explanation of Quran by renowned Muslim Scholars) related to education were identified. Help from dictionaries and encyclopedias available on internet were sought for true meanings and connotations. The ideas derived from the medical educational research were applied to find educational principles and compared to existing medical educational philosophies. Learner response system was used to gather educationalists opinions. Results: Principles of medical education which have been learned over last few decades and are now globally accepted and practiced were already there in Quran for last 1400 years. The common principles discovered and discussed were: Simplicity, Learning in steps, Paced learning, Identification of important, Critical thinking, Inductive reasoning, Use of examples, and Repetition. Most of these are core principles of medical education. Conclusion: Adult learning principles are already present in the Quran. In the propagation of these modern medical educational principles, references to Quran may help to understand their deeper perspectives. It may expedite the wider acceptance by educationalists in the Muslim countries. [ABSTRACT FROM AUTHOR]

Objective: To study the safety and efficacy of nasal continuous positive airways pressure by infant flow driver in neonates admitted with respiratory problems. Study Design: Quasi-experimental study. Place and Duration of Study: This study was conducted at CMH Lahore from April 2012 to March 2013. Subjects and Methods: All infants who were treated with nasal continuous positive airway pressure (nCPAP) for various indications at neonatal intensive care unit (NICU) of CMH Lahore were evaluated for gestational age, weight, gender, indications and duration on nCPAP, pre-defined outcomes, complications and length of hospital stay. Efficacy was defined as the ability to manage an infant on nCPAP alone thus avoiding the need for mechanical ventilation. Results: During the study period, 343 neonates were admitted in NICU. Forty five neonates were placed on nCPAP. Mean gestational age was 33.85 ± 3 weeks. Mean weight was 2043 ± 770 grams. Main indications for applying nCPAP were respiratory distress syndrome (48.9%) and neonatal pneumonia (17.8%). Most common complication was abdominal distension (6.7%). Out of 45 infants placed on nCPAP, 32 (71.1%) were managed on nCPAP alone while 13 (28.9%) needed mechanical ventilation after nCPAP failure. Conclusion: Nasal CPAP by an infant flow driver is a useful method to manage respiratory distress in neonates. It reduces the need for mechanical ventilation and can be used as first line respiratory support before mechanical ventilation. [ABSTRACT FROM AUTHOR]

An 11-year-old girl, born to "non-consanguineous" parents presented with drooling of saliva, protrusion of tongue and difficulty in speech. She had signs of pyramidal tracts involvement, bulbar dysfunction and lingual dyskinesia. Magnetic resonance imaging (MRI) of brain revealed classical findings in basal ganglia consistent with Wilson Disease. Aggressive medical treatment was started with strict follow-up visits. It is always difficult to sift through the myriad neurological presentations, to reach a definite diagnosis in a child with this rare disease. Early and prompt treatment is imperative not only for the child but also for other siblings. [ABSTRACT FROM AUTHOR]

The author reflects the importance of conducting liver transplant (LT) service to patients of all ages. Topics discussed include the investments lend for medical research and future training, the first successful operation of LT that was performed in 1998, and the dramatic growth that pediatric LT have shown in India.

The article presents case studies of large prolapsing urethral polyps (UPs) in two female children, which require the use of ultrasonography or urography to exclude other urinary tract abnormalities. UPs are presented as interlabial masses in both children,with UPs excised with uneventful recovery. Both cases were diagnosed as benign fibroepithelial polyp through histopathology, without any recurrence after six months.

Objective: To compare the technical aspects of Wilms' tumour (WT) surgery in patients with and without pre-operative chemotherapy., Design: Quasi-experimental., Place and Duration of Study: Military Hospital (MH) and Combined Military Hospital (CMH), Rawalpindi, from January 1999 to December 2004., Patients and Methods: Patients of WT, presenting between January 1999 and December 2001, were treated, using the NWTSG protocol, with primary surgery (group I). Between January 2001 and December 2004, WT patients were treated according to SIOP protocol, with pre-operative chemotherapy followed by surgery (group II). Volume reduction with chemotherapy, duration of surgery, rupture of tumour, extent of excision, adherence and damage to surrounding structures, blood loss, complications, stay in hospital and event-free survival (EFS) were compared in the two groups., Results: Out of 22 patients in group I, 19 (86.4%) underwent primary surgery. Of the 23 patients in group II, 21 (91.3%) received pre-operative chemotherapy followed by surgery. Average volume reduction in this group was 54% with chemotherapy. Difference in duration of surgery and blood loss was significantly low in group II (p=0.003 and p < 0.001, respectively). In group I, rupture (6 vs 2), adherence (14 vs 10) and damage to surrounding structures (5 vs 2) were more. Complete macroscopic excision was possible in 90.5% of WT in group II as compared to 73.7% in group I. Immediate postoperative complications and length of hospital stay were similar in both groups. There was no difference in EFS., Conclusion: Pre-operative chemotherapy makes it technically easier and safer to operate, without jeopardizing the final outcome.

Objective: To determine the spectrum and severity of injuries seen in children passengers, who get their feet entangled in the spokes of bicycle and motorcycle wheels, and to study the mechanism of this injury to find a pattern., Design: Descriptive and prospective study., Place and Duration of Study: Combined Military Hospital, Quetta, between July 2001 and June 2003., Subjects and Methods: This study included 92 consecutive patients referred to the Paediatric Surgical Department. According to the severity of injury, the patients were divided into three groups. The parents were asked a detailed history about the exact mechanism of injury, and such situations were analysed., Results: The average age was 3.9 years. Seventy-one were males and 21 females. A total of 80 children had their injury while riding a bicycle, the rest had their feet entangled in motorcycle spokes. Majority had type I injury. Motorcycle injuries mostly belonged to type III. There were only 2 fractures. Study of the mechanism of injury showed an obvious pattern. Front wheel injury mainly caused inversion, with laceration over dorsum and medial aspect of the foot and medial malleolus. Rear wheel injury mostly caused eversion, with skin damage to the lateral and posterior aspect of foot and ankle, with lateral malleolus at risk., Conclusion: Bicycle/motorcycle is an important means of transport for the whole family in most of the third world countries. Without proper footrests and unguarded spokes severe injury to the feet of young passengers can occur. By ascertaining in which wheel (front or rear) the foot was entangled, injuries can be predicted, and hence not missed.

Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) or nesidioblastosis is a rare condition presenting with severe hypoglycemia. Prompt diagnosis and early pancreatectomy can save many of them, in spite of the magnitude of surgery. We present two cases in which near total pancreatectomy was performed with favourable outcome. Both patients are normoglycemic, with one requiring pancreatic enzyme supplements.