Distal based sural fascio-cutaneous flap: a practical limb saviour for wounds of war and peace

Objective: To determine the effect of mechanism of injury on wound healing, and on the viability and success of distally based sural flap when used for the coverage of defects of lower leg, ankle and foot

Study Design: Descriptive study

Place and Duration of Study: Department of Surgery, Combined Military Hospital, Peshawar and Khariyan, from January 2012 to December 2014

Methodology: Patients with soft tissue defects over the distal leg, ankle and foot were selected by purposive sampling technique and divided into 2 groups of 19 patients each. Group A [road traffic accidents] and group B [war injuries]. Sural fascio-cutaneous flap was the reconstructive tool used in all the cases using single technique by the same surgical team; and time for recipient site preparation, size of the defect, graft survival, its healing time and complications, were studied

Results: The mean age of the 38 patients in the study was 28.2 +/- 13.4 years. There were 36 male and 2 female patients. The most common site of injury encountered was leg [n=20] followed by foot [n=11] and ankle [n=5]. Maximum wound size seen in group A was 10 x 12 cm and in group B was 15 x 38 cm. Recovery was uneventful in 17/19 cases of group A while 7/19 in group B and with no graft failure. Superficial epidermolysis was seen in 2 and 8 cases in group A and B respectively while edge necrosis of the flap was observed in group B only [n=4]. Healing time on average was 2 to 3 weeks in group A, and 4 to 5 weeks in group B

Conclusion: Soft tissue defects of the distal lower extremity as a result of war injuries and road traffic accidents have different dynamics in terms of wound size, time of wound healing, wound complications and functional outcome; but distal based sural flap has promising results in both situations

Versatality of supraclavicular flap in neck, face, and upper chest region coverage

The objective is to analyze the utility of theisland supraclavicular flap in a region where skin graft cannot be used and free flap is not feasible. We assessed complications and functional outcomes. Prospective descriptive study. The study was done at plastic and reconstructive surgery department CMH Rawalpindi during the period of 03 year from October 2011 to October 2014. An island supraclavicular artery flap was used to reconstruct oncologic, and post burn neck contractures release defects. 30 patients were included in the study. Doppler probe was used to help with localization of vascular pedicle. All the patients with scarring in both shoulder regions, history of radiation to neck and undergoing radical neck dissection were excluded. Atotal of 30 patients were included 20 [66.6%] male and 10 [33.3%] were female. Oncologicre section was followed by immediate reconstruction with island supraclavicular artery flap. Post burn contractures were released and covered by a pedicled supraclavicular artery flap. The recipient sites were neck, face, oral and upper chest region. The average harvest time was 1 and half hour. Donor site was closed primarily in 22 [73.3%] while 8 [26.6%] require skin grafting. Post burn contractures needed scar management with intralesional steroid, pressure garments and scar revision with Z-plasty in 4[13.3%] cases. 1 [3.3%] flap failed completely and the defect was covered with a skin graft. We had 01 [3.3%] mortality due to respiratory obstruction, despite adequate flap perfusion for 24 hours. Minor complications included, partial flap loss, seroma, and haematoma formation. In addition hypertrophied scar, spreading scar and keloid formation occurred at the donor site 18 [60%]. Island supraclavicular artery flap with an easy learning curve is a reliable flap. It has a good colour and texture match with minimal donor site morbidity. It is an excellent choice for neck coverage after post burns contracture release and an attractive alternative to free flap for oral/ facial defects

Elective midline laparotomy; comparison of diathermy and scalpel incisions

To compare the diathermy incision with scalpel incision in patients undergoing midline elective laparotomy. Aprospective, experimental comparative study. Department of surgery, PNS Shifa Karachi, from March 2007 to June 2008. A total of 100 patients were included in the study, and equally divided into 2 groups. Group A received scalpel incision while in group B diathermy was employed to incise all layers. Peroperative parameters including, incision time and blood loss were calculated. Postoperatively, pain was assessed by visual analogue score and wound infection documented. Both groups included fifty patients each out of the total 44 females and 56 were males, with similar gender preposition in both the groups. Mean age of patients in scalpel group was 48.78 [ +/- 14.47] while it was 44.92 [ +/- 15.87] in diathermy group. The mean incision related blood loss in Scalpel 2 2 group was 1.53 [ +/- 0.20] ml/cm and in Diathermy group was 1.43 [ +/- 0.20] ml/cm, showing significantly less bleeding in diathermy group [p-2 2 value= 0.014]. Diathermy group, with incision related time of 6.20 sec/cm [ +/- 0.97 sec/cm], was significantly quicker [p-value= 0.003] than 2 2 scalpel incision, with incision time of 6.76 sec/cm [ +/- 0.84 sec/cm]. Postoperative pain scores, recorded daily over five days, showed insignificant difference between the two groups. Diathermy, employed for midline laparotomy, is quicker and hemostatic, compared to the scalpel. The two are, however, similar in terms of wound infection and postoperative pain

Clinico-pathological profile and outcome of inhalational burns

To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. Case-series. The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area [TBSA] involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickess skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. There were 19 patients of inhalational burns, 8 [42%] of whom expired. The mean percentage of TBSA in 11 surviving patients was 50 +/- 10.87 and 70 +/- 15.46 in fatal cases. The mean haemoglobin [Hb] on admission was 15.8 +/- 1.6 g/dL and after fluid resuscitation it became 11.4 +/- 1.5 g/dL. The mean Total Leucocyte Count [TLC] in surviving patients was 9.6 +/- 6.1x10[9]/L and 1.5 +/- 2.3x10[9]/L in fatal cases [p=0.001]. The mean platelet count of surviving patients was 205 +/- 63x10[12]/L while in fatal cases was 58 +/- 48x10[12]/L [p=0.05]. The serum urea levels in surviving patients was 4.3 +/- 2 mmol/L while in fatal cases was 8.6 +/- 0.9 mmol/L [p=0.05]. The serum creatinine levels were 98.2 +/- 16.5 micro mol/L in the survivor group and 249.5 +/- 76 micro mol/L in the mortality group [p=0.05]. The serum total protein in surviving patients was 63 +/- 8 g/dL while in mortality cases it was 57 +/- 7 g/L. Serum albumin in the survivor group was 36.7 +/- 5 g/L and 35 +/- 4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival

Infrared coagulation versus rubber band ligation in the treatment of internal haemorrhoids - a randomised, prospective study

The aim of the study was to compare the effectiveness, patient tolerance, need and complications of infrared coagulation [IRC] versus rubber band legation in the treatment of uncomplicated internal haemorrhoids. Randomised Control Trial. Study was done at surgical outpatient department of Combined Military Hospital [CMH], Multan, from January 2001 to April 2002. A total of 150 patients with uncomplicated internal haemorrhoids without any concomitant ano-rectal disease were randomized and treated by infrared coagulation [IRC] or rubber band ligation [RBL] in two groups [75 patients in each group]. Infrared coagulation or RBL was performed in one or more session with four weeks interval until symptoms [bleeding and or prolapse] were resolved. Treatment outcome and complications were assessed by proctoscopy and questionnaire. Follow up was made at three months, six months and twelve months. Treatment outcome was assessed in 150 patients. For IRC 71 [94%] patients and for RBL 66 [88%] patients were symptom free after twelve months. Pain following treatment was more common and more severe after RBL than after IRC. Bleeding occurred in both IRC and RBL patient without any significance. IRC and RBL were equally effective in the treatment of internal haemorrhoids. The rate and severity of pain was higher after rubber band ligation. Infrared coagulation should be the first line of treatment for haemorrhoids