Recovery of projectile through nose - an unusual presentation

Presentation of civilian gunshot injuries, especially to the face, have increased tremendously in the past decade in Karachi. Cranio-facial region when affected has a high mortality rate because projectile may lodge anywhere in the skull. Management of these gunshot wounds demands experience and expertise. A case of 21 year old male is reported, who sustained such an injury by a stray bullet, with the projectile entering from the lateral margin of the left nasal cavity and getting lodged within. Position of the projectile was assessed via series of X-rays. The projectile was removed under direct visualization from the nasal cavity in the Emergency Room. Endoscopic approach has been discussed for removal of deeper projectiles

Clinical Outcome in Patients with Early versus Delayed Decompression in Cervical Spine Trauma

STUDY DESIGN: Prospective observational study. PURPOSE: To assess the clinical outcome after early versus late decompression for traumatic cervical cord injury. OVERVIEW OF LITERATURE: Traumatic spinal cord injury is common globally with the most tragic outcomes in the cervical spine. Although recent studies have shown that early decompression results in more favourable outcome, its authority is yet to be established. METHODS: Study on 98 patients with a traumatic cervical cord injury was conducted over a period of 5 years. The patients who were operated on within 24 hours of the onset of the primary injury (n=34) were classified as the early group, and those who were operated on after 24 hours of the onset of the injury (n=64) were categorized as the late group. The outcome of both the groups was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at the 6-month follow-up. RESULTS: The patients in the early group were operated on at a mean time of 18.4 hours (range, 13-24 hours) while patients were operated on at a mean time of 52.7 hours (range, 31-124 hours) in the late group. At the 6-month follow-up, 7 (23.3%) in the early group and 5 (8.7%) in the late group showed >2 grade improvement in the AIS. CONCLUSIONS: The results of patients undergoing decompression within 24 hours of the injury are better than those who are operated on later. An attempt should be made to decompress the traumatic cervical spine early in all possible cases.

Retro-peritoneal extra-adrenal ganglioneuroma encasing major blood vessels

Ganglioneuroma is a rare, benign, slow-growing asymptomatic tumor of the neural crest cells. It occurs in one per million population with female predominance. It most commonly occurs in the retro=peritoneum. Although CT scan and other imaging modalities can be used, its diagnosis is essentially based on histopathology. We report a case of 18 year old male who presented with abdominal pain and a mass in the left lumbar quadrant. CT scan abdomen showed a retroperitoneal mass encasing aorta, IVC and left common iliac artery. A diagnosis of Ganglioneuroma was established on ultrasound guided Trucut biopsy. He underwent laparotomy for total excision of mass. Per-operatively the mass was separated from the vital structures and the major blood vessels. His post-operative course was uneventful and he was discharged on 7th post-operative day. His final histopathology confirmed the initial diagnosis of ganglioneuroma. Nonetheless, a possibility of ganglioneuroma should be kept under consideration in cases of all retroperitoneal extra-adrenal masses

Conservative Management of Spinal Tuberculosis: Initial Series from Pakistan

STUDY DESIGN: A prospective study on spinal tuberculosis (TB) at a tertiary care hospital in an endemic region. PURPOSE: The aim of the study is to reiterate the importance of conservative management of spinal TB. OVERVIEW OF LITERATURE: Spinal tuberculosis can present with wide spectrum of symptoms, with back pain being the most common symptom. It is the leading cause of non-traumatic paraplegia in developing countries. There is an emerging trend to operate on patients early with spinal TB. METHODS: Forty-seven (M=14, F=33) patients were enrolled in the study during the four year study period. Initially, all the patients were subjected to computed tomography guided percutaneous needle aspiration (PCNA) followed by antituberculous therapy (ATT) for 12 months. Indications for surgery included patients with moderate to severe symptoms in which PCNA either failed, was impossible to carry out, or produced minimal improvement within 48 hours. RESULTS: Presenting complaints included pain (95.7%), weakness (85.1%) and sphincter involvement (12.8%). On the magnetic resonance imaging, a paravertebral abscess was seen in 37 (78.7%), disc and body destruction in 29 (61.7%), and an epidural abscess in 12 (25.9%) patients. Of the 47 patients, 9 (19.1%) required surgery, 4 of whom had failed PCNA attempts and 5 demonstrated indications despite successful PCNA. CONCLUSIONS: The results of conservative treatment consisting of PCNA and ATT for at least 12 months in compliant patients are excellent. A combined approach using clinical staging, PCNA, and ATT can minimize surgical intervention in most patients. However, ATT remains to be the cornerstone of management of spinal TB.

Neoadjuvant chemo-irradiation in un-resectable carcinoma of rectum

Rectal cancer is one of the most frequent gastrointestinal cancers. Conventionally surgery is the mainstay of treatment, however after surgery alone, local recurrence is high especially in locally advanced rectal cancer, i.e. tethered and fixed rectal cancer. This study was conducted to determine the role of neo-adjuvant [pre-operative] chemo-irradiation in locally advanced carcinoma of the rectum to improve resectability, local control and survival. Study was conducted in Radiation Oncology department of Shaukat Khanum Memorial Cancer Hospital and Research Center from May 97-Oct 99. Thirteen patients with unresectable/ locally advanced adenocarcinoma rectum received neo-adjuvant chemoirradiation, 50 Gray to pelvis by box technique on Cobalt-60 machine with concomitant 5-Flurouracil 500mg/m2 for first three and last three days followed by abdomino-perineal /low anterior resection. Neo-adjuvant chemoirradiation resulted in resectability rate of 92% and clinical down staging in 11/13 [84%] patients and pathological complete response in 2/13 [15%] patients and a local recurrence rate of 2/13 [15.38%]. Non hematological toxicity [diarrhea grade 4-15%, erythema grade3-23%, dysuria gradel-2-38%] were main problems observed during neo-adjuvant chemoirradition. Concomitant preoperative chemoirradiation for locally advanced rectal cancer is associated with considerable clinical and pathological down staging. Tumor resectability is improved with potential for improved local control and is relatively safe with acceptable morbidity

Resectability rates in locally advanced esophageal carcinoma following neo-adjuvant chemo-radiotherapy

Purpose of this study was to assess the resectability rates in un-resectable [Stages III and IV] cancers of the esophagus, to assess the complete pathological response and to compare the efficacy between two chemotherapy regimens. From January 1999 to June 2002, medical records of the patients with un-resectable esophageal cancers were reviewed, who received radiation-therapy with concomitant chemotherapy using following regimens:- Arm A:- 5FU 500 mg/m2 intravenous push [IVP] on first 5 and last 5 days of radiation. Arm B:- 5FU 1 Gm/ m2/Day 96 hour continuous infusion [CIV] and Cisplatin 70 mg/ m2 on day one and twenty eight of radiation. At completion of neoadjuvant chemo-radiation patients were offered surgery after four to six weeks. 35 patients had un-resectable esophageal cancer. Twenty-six received arm A, and 9 arm B treatment. Of 26 patients in arm A, in 13 the disease was made resectable and two of them showed complete pathological response in surgical specimen, thirteen had progressive disease. On the other hand, of 9 patients receiving arm B treatment, in 7 the disease was made resectable and out of them 5 showed complete pathological response in surgical specimen and two had progressive disease. Resectability in patients receiving arm B treatment was better than the patients treated arm A. The data is not mature enough to assess the effect on disease free survival or overall survival, this will be seen and published later