Combat related vascular trauma

To determine the frequency and pattern of different types of vascular injuries, their management and surgical complications. Case series. Combined Military Hospital, Peshawar, from August 2008 to August 2010. All patients of vascular injuries were included. Traumatic amputation, amputation for extensive soft tissue, or nerve injury, death due to reasons other than vascular injuries or Mangled Extremity Severity Score [MESS > 7] were excluded from study. Data included patient profile, time and date of admission, place, site, type and mechanism of injury, associated injuries, vital signs, treatment, type of vascular repair and outcome. Decision to operate was mainly based on clinical diagnosis and hand-held Doppler finding. There were 170 vascular injuries in 96 patients; 76.4% were arterial and 23.5% were venous. Gunshot wounds was main cause [54%] and extremities were the commonest site [85%]. Arteries were repaired in 87% and veins in 40% cases. Venous interposition graft was the preferred method of repair. The overall limb salvage rate was 95%. Thrombosis and infection of the graft and repair were the main causes of secondary amputation. Haemorrhage, reperfusion injury and infection were the main causes of death. Every effort should be made to repair an injured artery to preserve a limb and life. Tourniquet, prophylactic fasciotomy and vascular shunts play an important role. Management of life threatening injuries, unstable fracture of long bones and debridement before definitive repair of artery is important

Experience with polyclonal immunoglobulin therapy in poly trauma patients with severe sepsis

To evaluate the effects of intravenous immunoglobulin therapy on progression of severe sepsis in patients of poly trauma. Quasi-experimental study. Combined Military Hospital Peshawar from June 2008 to Dec 2009. Forty six patients of poly trauma with severe sepsis were included. Along with the standard management i.e., surgical management, fluid resuscitation, antibiotics, analgesics, ionotropic, ventilatory and nutritional support, IVIG 5% [intravenous immunoglobulin] was infused over a period of 6 hours and repeated for three consecutive day. Sequential Organ Failure Assessment [SOFA] score was used to assess the progress in all the patients. At the time of enrolment mean SOFA score was 5.41 +/- 1.127 and on the 15th day it was 1.62 +/- 2.24, mean age was 39.21 +/- 10.26 years. Thirty four patients [73.91%] developed gram negative sepsis and eighteen patients [39.13%] developed septic shock. Mean duration of stay in ICU and on of these patients was 30.43%. The IVIG administration, when used along with the standard management appears to improve significantly the prognosis in patients of poly trauma with severe sepsis

Surgical management of diabetic foot and role of UT [university of Texas] classification

To evaluate the role of University of Texas Classification in the management of Diabetic foot. Descriptive study. Surgical unit II Combined Military Hospital Rawalpindi [2003 to 2008] and Department of Surgery Combined Military Hospital Peshawar [July 2008 to Jan 2010]. A total of 300 patients who reported to Surgical Department with a foot ulcer or infection and diagnosed to have Diabetes Mellitus were studied. Patients of both gender and age > 12 years were included. Patients of end stage renal disease, compromised immunity or on steroid therapy were excluded. Detailed history and clinical examination were recorded. Routine investigations including complete blood examination, urine routine examination, renal function tests, x-ray foot, chest x-ray, ECG and pus for culture and sensitivity were recorded. Lesions were classified according to University of Texas classification and treated accordingly. Majority of the patients were of 50 to 70 years ago group. Male to female ratio was 4:1. Big toe was the commonest site followed by fore foot and heel. Patients were classified according to UT classification. Patients were managed with antibiotics, dressings, incision and drainage, debridement, vacuum assisted closure [VAC] with or without skin grafting and amputations of different types. Staphylococcus aureus was the commonest isolate. Our study has shown that UT classification is an effective system of assessing the severity of diabetic foot at the time of presentation and planning its management. Amputation rates, time of healing and morbidity increases with increasing stage and grade

Giant aneurysm of the extracranial internal carotid artery

Aneurysm of the extracranial internal artery is a rare condition with incidence of 0.8-1% of all aneurysms. It can give rise to serious complications like; haemorrhage due to rupture, stroke and thrmboembolism. Its treatment is technically challenging. One such case of giant aneurysm of extracranial internal carotid artery was found in 70 years old lady. The aneurysm was treated by proximal and distal ligation of the internal carotid artery and excision of the aneurysm with excellent postoperative recovery and early follow-up

Hypospadias: one stage repair

To evaluate the cosmetic and functional results of one stage repair of hypospadias, using parameatal based flip-flap urethroplasty. A prospective study from 1990 to 2002 at AFIU Rawalpindi, CMH Kohat, Jhelum, and Pano Aqil Cantt. And AK CMH Muzaffarabad. Fifty patients underwent one stage repair of hypospadias by parameatal based flip flap urethroplasty, using ventral penile and scrotal axial skin flap. The urethral meatus was subcoronal in 6 [12%], Distal penile in 32 [64%], proximal penile in 8 [16%] and penoscrotal in 4 [8%]. Some modifications and combinations were used to ensure better vascularity of the flaps; natural verticals slit meatus and reduce complications. An 8 Fr polythene feeding tube used as stent with its tip inside the urinary bladder was removed on 7th or 8th postoperative day. The mean follow up period was 12 to 36 months. We achieved good cosmetic and functional results in 86% patients. Urethrocutaneous fistula occurred in 3[6%] patients, meatal stenosis in 2 [4%], residual chordee in 1[2%] and disruption of repair due to flap necrosis in 1 patient. Only four patients required redo surgery for fistula, residual chordee and failed repair due to flap necrosis. Meatal stenosis responded well to regular dilatation with the cone tip of an ophthalmic ointment tube, twice daily for 2-4 weeks. Postoperatively the penis was straight with natural vertical slit meatus and good stream of urine. One stage parameatal based flip flap urethroplasty, with some modifications, give very good functional and cosmetic results in primary as well as salvage repair of hypospadias

Hydatid disease of Bone

A case of primary hydatid disease of the right femur is reported that presented with pathological fracture and was diagnosed at the time of exploration for biopsy. The patient was treated by removal of all cysts, irrigation with scolicidal solution, bone grafting and immobilisation of the fracture followed by four cycles of oral Albendazole. Eosinophilia and serological tests reverted to normal but the patient died due to acute myocardial infarction six months later. This uncommon condition should be considered in the differential diagnosis of pathological fractures, bone pain or osteolytic lesions, especially in patients of rural and farmer background