Outcomes of gastric pull-up reconstructive surgery following laryngopharyngoesophagectomy in hypopharyngeal and upper esophageal carcinomas

Objective: To determine the commonest stage of hypopharyngeal and upper esophageal carcinoma at presentation, common complications after surgery, perioperative mortality, and one-year survival rate after surgery. Study Design: A descriptive prospective study. Place and Duration of Study: Combined Military Hospitals, Rawalpindi, Lahore, and Malir, from Oct 2008 to Oct 2016

Material and Methods: Through consecutive sampling, 25 individuals were sampled after staging disease through TNM classifications provided by the 1983 American Joint Committee on Cancer Classification for hypopharyngeal cancers. Total laryngopharyngoesophagectomy and gastric pull-up reconstructive surgery was performed by two teams. The total operation time in hours and the approximate blood loss in ml during the procedure was documented. The patients were monitored post-operatively for pulmonary [respiratory failure requiring ventilatory support, atelectasis, pneumonia, pulmonary embolism, pleural effusion/hemothorax, etc.], cardiac [arrhythmias, myocardial infarction, and congestive cardiac failure], and surgical complications [wound infections, anastomotic leak, and fistula formation]. The patients were also followed-up for survival at 1[st], 6[th], and 12[th] month

Results: There were 18 males and 7 females [mean age: 53 +/- 14 years]. Majority presented with T4N2M0-stage disease. The operation lasted for a mean time of 7.7 +/- 1.3 hours [range: 6.3-11 hours] and a mean 1218 +/- 338 ml [range: 590-2020 ml] blood was lost during the operation. The patients remained in the hospital for a mean 26 +/- 16 days [range: 1-56 days]. The commonest complication following operation was pleural effusion/hemothorax present in 72% of the patients. The perioperative mortality was 12% and one-year survival rate was 36%

Conclusion: Majority of our sampled patients presented with T4N2M0-stage disease. The mean operation time in our sample was longer with an increased incidence of anastomotic leaks when compared to the international data. The other complications and perioperative mortality were comparatively similar while one-year survival rate was lower

Occurrence of aflatoxins contamination in brown rice from Pakistan

The objective of this study was to determine the distribution of an economically-important class of mycotoxins, the aflatoxins [AFs] in Pakistani Brown Rice. A total of 262 of brown rice samples were collected from different vendors during July 2006 to June 2011. Samples were analyzed for the occurrence of aflatoxin B[1] [AFB[1]], B[2] [AFB[2]], G[1] [AFG[1]] and G[2] [AFG[2]] by thin layer chromatography [TLC] technique. AFB[1] was detected in 250 [95.4%] samples, whereas AFB[2] was detected in 20 [7.6%] samples. Furthermore, AFG1 and AFG2 were not found in any sample. The contamination range of AFB[1] and AFB[2] was found 1.07-24.65 micro g/kg and 0.52-2.62 micro g/kg, respectively. Total AFs were quantified in 250 [95.4%] samples with an average of 3.89 micro g/kg and contamination range was noted to be between 1.07-27.27 micro g/kg. The overall results indicated that in 12 [4.6%] samples, AFs were not found within detectable limits. Furthermore, in 188 [71.7%] samples, AFs level was found below than maximum tolerated levels [MTL] as recommended by the European Union [4 micro g/kg]. Moreover, in 61 [23.3%] samples, AFs range was found between 4-20 micro g/kg, which were fit for human consumption as per MTL [20 micro g/kg] assigned by USA [FDA and FAO] and Pakistan [PSQCA]. While only one sample [27.27 micro g/kg] exceeded the above mention regulation limits. Low level of AFs occurs frequently in brown rice, and can be improved using proper harvesting practices, storage and transportation conditions. The small quantities of AFs warrant performing further investigation, monitoring and routine analysis on regular basis

Missed vascular injuries

To evaluate vascular injuries for the cause, site of injury, presentation and treatment. Descriptive study. Surgical unit I, Combined Military Hospital, Rawalpindi. Surgical Unit 2, Combined Military Hospital, Lahore. 1st August 2005 to 30th June 2010. All cases of missed vascular injuries [MVI] who presented to a single vascular surgeon, between 1st August 2005 and 30th June 2010 were examined in detail. Only cases with viable limbs and reversible ischaemia were included in the study. Patients with gangrene of the limbs of any extent were excluded. Record was made of the cause, site, mode of presentation and treatment. MVI was defined as vascular injury which was missed in the initial evaluation, operative procedure or intervention. Out of 41 cases, 31[75.6%] were due to gunshot or splinter injuries, 3[7.3%] external fixator injuries, 2[4.8%] carotid stentings, 2[4.8%] cardiac angiographies, 1[2.4%] fine needle biopsy, 1[2.4%] metallic rod penetrating injury and 1[2.4%] elective lumbar disc surgery. Neck was affected in 9[21.9%], upper limb in 7[17%] and lower limb in 25[60.9%] patients. There were 20[48.7%] false aneurysms, 8[19.5%] traumatic arteriovenous fistula [AVF], 5 [12.1%] false aneurysms with traumatic AVF, 3[7.3%] thrombosis, 1[2.4%] stenosis, 3[7.3%] hematoma and 1[2.4%] hemorrhagic shock. In 39[95.1%] cases surgical intervention was done. In 2[4.8%] cases, vascular injury was missed in polytrauma and mass casualty situation while 3[7.3%] cases were of polytrauma only. Penetrating trauma was the commonest cause of MVIs. Lower limbs were mostly affected. Most of the cases presented with pseudoaneurysms. Few cases had polytrauma/mass casualty situation at the time of initial presentation indicating that vascular injuries were missed either due to low index of suspicion by clinician or not following the proper protocol to avoid these injuries

Dynamic condylar screw fixation for comminuted proximal femur fractures

To evaluate the success of dynamic condylar screw [DCS] fixation for comminuted proximal fractures of femur in adults. Case series. Orthopedics Department CMH Lahore, from October 2009 to September 2010. This study included 20 males and 9 female patients with age ranging 25 to 65 year [mean 44 year] who presented with closed comminuted proximal femur fractures [Evan's classification type I c to e and type II]. All the patients underwent indirect fracture reduction on a standard orthopedic traction table under C-arm guidance and this was followed by inter-fragmentary stabilization with dynamic condylar screw construct [AO Synthes]. Functional outcomes were assessed using the Harris hip score. Post operative patients' evaluation was continued for 12 months. The average time to full weight bearing was 14 weeks. [range 12-16 weeks]. The mean time to union was 16 [range, 13-22] weeks. The included non-union, delayed atrophic union, implant failure, limb length discrepancy, and knee stiffness. According to the Harris hip score, functional results were excellent in 21 and good in 7, whereas one patient showed poor result. The mean Harris hip score was 88 [range 80-99]. Our results of DCS fixation for comminuted proximal femoral fractures indicated that it is a very practical and a satisfactory method of fixation. Minimal striping of the soft tissues and gentle fragmentary manipulation intra operatively remained the pivotal factors for good fracture healing and functional outcome

Tracheal resection and end-to-end anastomosis for tracheal stenosis: etiology and outcome

To know the etiology of tracheal stenosis and asses outcome of tracheal resection and end-to-end anastomosis for tracheal stenosis. Descriptive prospective case series. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi and Quetta from May 2005 to March 2010. Twenty two patients were included in the study who underwent tracheal resection followed by primary tracheal reconstruction by same surgical team. Etiology was ascertained on the basis of available history and per-operative findings. End-to-end tracheal anastomosis was done using vicryl 3/0. Outcome of surgical technique was assessed using peak expiratory flow rate [PEFR] and flexible bronchoscopy. Twenty two patients were managed over a period of five years, of which 17 [77.3%] were male and 5[22.7%] female. Mean patient age was 27.31 +/- 9.61 years. Seven [31.8%] patients had New York Heart Association grade [NYHA]-III and 15 [68.2%] had NYHA grade-IV dyspnoea. Seventeen [77.3%] had stridor. All patients were already being managed by pulmonologists, ENT specialists or intensivists. Twelve [54.5%] had grade-V stenosis [91-100% luminal obstruction] and 9 [40.9%] had cervical tracheal stenosis and 3[13.6%] had mediastinal tracheal stenosis. Six [27.3%] patients had partial cricoid resection followed by thyrotracheal anastomosis, 13[59.1%] patients underwent cervical tracheal anastomosis and 3 [13.6%] patients required mediastinal tracheal anastomosis. Patients were followed up post-operatively for the development of immediate and delayed complications. The follow up was carried out for a minimum period of 6 months to a maximum period of 2 years. Postoperative complications included neck pain, lung collapse, and superficial skin infection. Tracheal resection with end-to-end anastomosis is a safe, reliable and permanent procedure for the treatment of tracheal stenosis

Gastropleural fistula: an unusual sequel of blunt chest trauma

In the October 2005 Earthquake in mountainous Azad Kashmir and adjacent areas in Pakistan, a young female sustained crush injury chest and upper abdomen. She remained hospitalized with lower chest pain. All initial investigations were normal and she was discharged symptom-free on conservative management. Six months later, she developed acute left sided chest pain and dyspnoea. Provisional diagnosis of empyema was made on X-ray, and tube thoracostomy was done. Diagnostic VATS revealed gastropleural fistula secondary to necrosis of herniated stomach. Resection of necrosed stomach, repair of diaphragm and decortication and transthoracic repair with lower thoracoplasty two months later was performed but both were unsuccessful. After another 02 months, a Roux-en-Y gastrojejunostomy at fistula site was fashioned which proved curative