Aorto-bi-Femoral Bypass for Juxtarenal Aortic Occlusion in a Patient with Multiple Co- Morbidities: Report of a Challenging Case.

Aorto-bi-femoral bypass for aorto-iliac occlusive disease is a fairly common procedure in vascular surgical practice. The procedure, despite its extensive nature, is generally well tolerated particularly by those having an infrarenal type of aortic occlusion. Patients having a juxtarenal aortic occlusion require a considerably more expeditious surgery necessitating maneuvers to protect the renal arteries. Surgical risk increases significantly in those having multiple co-morbid conditions. We report here a successful case of aorto-bi-femoral bypass for juxtarenal aortic occlusion in a patient having multiple co-morbid conditions like ischemic heart disease, occluded right renal artery with chronic kidney disease, severe malnutrition, hypertension and chronic obstructive pulmonary disease

Recent Advancement in Non-surgical Interventional Treatment in Congenital Heart Disease at National Institute of Cardiovascular Disease (NICVD)-a Tertiary Care Hospital of Bangladesh.

Background: Treatment of Congenital Heart Disease (CHD) is either Surgical or Interventional. Medical management is mainly symptomatic / palliative. Although surgery is the main mode of treatment but in the recent past non-surgical Interventional method is replacing it because of its multiple advantages over surgical procedures. Since 2005, we started our journey in National Institute of Cardiovascular Diseases with a PDA device closure. In this article we tried to review the success rate of the interventional procedures in this hospital. Methods: The aim of this retrospective study is to review the short term & Intermediate outcome of the non surgical interventional treatment of congenital heart diseases. We included all the interventional rocedures done in this Institute since 2005 upto December 2013. Results: During this period, we performed total 150 cases of patent ductus arteriosus (PDA) device, 20 cases of PDA Coil closure, 60 cases of atrial septal defect (ASD) device, 90 cases of Balloon Pulmonary Valvuloplasty (BPV), 20 cases of Balloon Aortic Valvuloplasty (BAV), 22 cases of Coarctation Balloon Angioplasty, 35 cases of Mitral Valvuloplasty (PTMC), 15 cases of Balloon Atrial Septostomy. Almost all of our intervention procedures were successful except one case of mortality related to procedure of PDA device closure, 4 device embolization (2 ASD & 2 PDA) and one case of PDA coil with persistent Intravascular hemolysis. All the embolized devices were subsequently retrieved surgically with repair. All other patients of interventional treatment are enjoying new life without any morbidity. Conclusion: Thus, we concluded that interventional methods of suitably selected case of congenital heart disease may be an alternative lucrative safe & effective option of remedy for many of the congenital heart diseases.

Cervical Epidural Anesthesia for Carotid Endarterectomy.

The successful anaesthetic management using a cervical epidural technique is reported in patients undergoing carotid artery surgery. Adequate analgesia is obtained and the adequacy of cerebral blood flow is easily judged by the patient’s state of consciousness. Cervical epidural anaesthesia could be a safe and reasonable technique for the management of patients who need carotid artery surgery.1 A 54 years old man of A.S.A (American Society of Anesthesiologists) grade- II underwent carotid endarterectomy under Cervical Epidural Anaesthesia (CEA) at C7 – T1 level using a mixture of 0.5% Lidocaine, 0.25% Bupivacaine and Fentanyl citrate. Standard peroperative monitoring including invasive arterial blood pressure and arterial blood gas analysis was done.

Outcome of management of differentiated thyroid carcinoma.

A prospective study was done on 93 cases of differentiated thyroid carcinoma to find out the outcome of management according to the protocol followed in the Department of ENT-Head and Neck Surgery of Bangabandhu Sheikh Mujib Medical University Hospital. Here Papillary carcinoma is more common (76.35%) than follicular carcinoma. Papillary carcinoma affected in the younger patients more commonly than the follicular carcinoma with a mean age of 34.37years (SD=12.81) for papillary carcinoma and 44.93 years (SD=16.01) for follicular carcinoma; but age as a risk factor showed no significant difference between two histological types (p>0.05). Female was the predominant sex with a ratio of 3.04:1. In this series majority of patients were categorized as high risk group (75.27%). There is strong association between histological type & risk group (P<0.05). High risk group is more common in follicular carcinoma (95.45% Vs 69.01%). There was a significant differences between the two histological types for extrathyroidal extention and distant metastasis as risk factors (p<0.01 and p<0.001); but tumour size and lymphatic metastasis showed no significant difference (p>0.05). All low risk patients were treated by hemithyriodectomy followed by life long thyroxine. All high risk cases were treated with total thyroidectomy with (35.71%) or without (62.86%) different types of neck dissection (according to the degree of lymph node involvement) followed by radioiodine ablasion and lifelong thyroxine therapy routinely. Overall rate of complication of thyroid surgery was 23.08%. The commoner complications were vocal cord palsy (5.5%), hypoparathyroidism (5.5%) and haemorrhage (4.4%). Less common complications were laryngeal oedema (2.2%), wound infection (2.2%), tracheal injury (1.1%) and death (2.2%). Many cases lost to follow up. Sixty seven cases (73.64%) responded well for follow-up. Mean duration of follow up was 3.40 years (SD=1.41). There was recurrence in thyroid remnant in 9.09% of hemithyroidectomy cases and were treated by completion thyroidectomy followed by radioiodine ablasion. Regional lymphatic metastasis was seen in six cases and was treated by different types of neck dissection. Recurrence at distal site was seen in 4 cases (18.18% of follicular carcinoma). These were treated by radioiodine ablation; two of them died during the period of follow-up.

Genital fistula--our experience.

Genital fistulas cause immense physical and psychosocial problem in women's life. The present study was conducted to note the varieties of genital fistula as well as their causative factors and the results of the operative corrections. Altogether 42 patients with different varieties of genital fistula were enrolled in the study. The causative factors of the genital fistulas, specially, that of vesicovaginal fistulas were thoroughly enquired. After confirming the diagnosis, the operative corrections were undertaken. Among the varieties of genital fistula, 76.19% were vesicovaginal fistula, 11.90% were rectovaginal fistula and 4.76%, 4.76% and 2.38% cases of ureterovaginal, urethrovaginal and vesicocervical fistulas respectively. The primipara women were the major sufferers of genital fistulas due to obstetric grounds. Regarding aetiologies of vesicovaginal fistulas, 71.87% patients had obstetric reasons, after prolonged labour, instrumental delivery and after caesarean section due to obstructed labour. Abdominal hysterectomy (44.44%) topped the list of the gynaecological causes of vesicovaginal fistulas. The cases of ureterovaginal fistulas were after abdominal hysterectomy. One case of urethrovaginal fistula was due to some chemical application for correction of genital prolapses. The rectovaginal fistulas were mostly due to obstetric reasons. The success rate after the first attempt of repair of vesicovaginal fistula was 82.75% and overall failure was 10.34%. The other varieties of fistulas were repaired with 100% success rate. The incidence of genital fistulas can be reduced by vigilant obstetric care and meticulous surgery.

Head and neck squamous cell carcinoma (HNSCC) 5 year study at BSMMU.

Head and Neck Squamous Cell Carcinoma (HNSCC) are generally similar in their clinical features, epidemiology and etiology although their natural and clinical history and treatment differ. Despite lot of improvement in diagnostic and management technique, there is little improvement in survival rate over the last few decades. This study was carried-out in a multidisciplinary tertiary level hospital (BSMMU), with a country-wide catchment area to see the burden of HNSCC existing in our country and their clinical pattern. The overall incidence rate of HNSCC in this study was (0.15%) i.e. 150 person in 1,00,000 population. Male incidence (0.19%) was higher than female (0.12%). This study revealed that carcinoma of the larynx (25.22%) and pyriform fossae (20.57%) were the main culprit, whereas buccal carcinoma was the main component (37.70%) in the female series. Highest incidence was found in the 6th decade in both sexes. As the treatment of HNSCC may be time consuming, requires multidisciplinary approach, demands lot of clinical, social and financial consideration, therefore, the best treatment can be offered through a combined board consisting of Surgical, Radiation, Medical oncologists, Histopathologist and Speech therapist as required.

Comparative study between tubotympanic and atticoantral types of chronic suppurative otitis media.

This prospective study was done to compare the different aspects of tubotympanic (group I) and atticoantral types (group II) of chronic suppurative otitis media. The study included 200 patients of chronic suppurative otitis media, of them 100 were of tubotympanic type and 100 were with atticoantral disease. The age (mean +/- SD) of group I and II were 17 +/- 2.7 years and 12 +/- 2.3 years respectively (P < 0.05). The majority of the patients having poor socio-economic condition 69% in group I and 87% in-group II. In both groups, slum dwellers with bathing habit in pond or river and illiterate were more sufferer (P < 0.05). There was central perforation in all patients in-group I, and in-group II, 67% were with attic and 33% were with marginal perforations. In group I, aural discharge was mucoid or mucopurulent in majority of cases 80% and in-group II foul smelling scanty ear discharge was from 88% of subjects. In atticoantral type, hearing impairment was more than tubotympanic disease. Complications were more in atticoantral type of disease. In-group II, post auricular sinus 25% was the commonest extracranial complication followed by subperiosteal abscess 18%, and meningitis 10% was the commonest intracranial complication followed by brain abscess 8%. In tubotympanic type conservative treatment with reconstructive surgery were the treatment of choice, whereas radical or some modifications of radical surgery (with or without reconstruction) were the treatment plan for atticoantral disease. Among the groups the mortality rate was only 4% in-group II and was due to intracranial complications. The study recommends early detection and effective surgical treatment of the disease to improve the situation.

Carcinoma larynx--topographical distribution.

One hundred and sixty subjects were included in our study, collected from four hospitals in Dhaka City. The mean age (+/- SD) of study subjects were 54.67 +/- 11.27 years. Out of 160 subjects 155 was males and 5 were females, and male to female ratio was 31:1. The highest number of study subjects was related to cultivation (40.62%). The majority of study subjects were from the low socio-economic status (68.72%). Carcinoma larynx is a multifactorial disease. Smoking and chewing habit are the most important factors associated with carcinoma larynx. Most of the male (93.12%) subjects were smoker. One hundred and fifteen (71.87%) subjects were found chewing habit of betel leaves with other ingredients. Hoarseness of voice was the commonest symptom 65.62%. Regional distribution of tumour showed supraglottic carcinoma topping the list (69.38%) followed by glottic carcinoma (30.62%) and there was no subglottic carcinoma. Site involvement in supraglottic carcinoma was found in combined location topping the list (89.20%). In glottic carcinoma majority was found glottic with supraglottic extension (65.31%). In majority cases growth were exophytic 52.50%. Palpable lymph mode was found in 48.75% of cases. All the carcinoma of larynx was found histologically of squamous cell type.