Delayed presentation of missed vascular injuries and pitfalls in primary treatment- experience of a vascular surgery unit in pakistan

Objective: To analyze errors in primary treatment of vascular injuries and delayed presentations of missed vascular injuries as a surrogate indicator of need for improved vascular surgical training of upcoming general surgeons

Materials and methods: This retrospective observational study was carried out at vascular surgery department of two tertiary care hospitals of Armed Forces from Jan 2012 to June 2017. Hospital records of all patients with vascular trauma were analyzed for presence of pitfalls in primary treatment and delayed presentation of missed vascular injuries which resulted in redo surgeries or adverse outcomes

Results: Out of 256 patients with vascular injury sequel 41 had either a problem in primary treatment or presented with delayed complications of missed injuries. The omissions can be divided into: missed injuries [24/41], technical errors in initial repair [12/24], reperfusion of mangled Extremity [3/41] and non availability of a surgeon capable of undertaking vascular repair. The commonest operative fault was failure to debride the vessel adequately and vascular repair under tension. The commonest primary assessment problem was failure to timely appreciate hard signs of vascular injury

Conclusion: With better training and emphasizing the need of thorough clinical examination outcome of vascular trauma can be improved

Carotid body Tumors surgery: experience of 13 Cases at a tertiary care hospital

Objective: To share five year experience and a half years with emphasis on some technical aspects which will help those managing such cases

Study Design: Descriptive case series

Place and Duration of Study: Combined Military Hospital Rawalpindi, from Jul 2010 to Dec 2015

Material and Methods: All cases of CBT presenting to our department from Jul 2010 to Dec 2015 were included in the study and analyzed

Results: A total of 13 patients were treated at our institute in the last 5 and half years. Average age of patients was 38.5 years with a range of 22-55 years. Male to female ratio was 1:6.5. Mean interval between symptoms onset and presentation was 38.7 +/- 16 months. None of the tumors were bilateral or malignant. Two patients had type I tumor [15 percent], seven patients had tumor of type II [54 percent] and four [31 percent] patients underwent resection for type III tumor. Type I and Type II tumor was removed by simple excision. Three cases of type III tumor were managed by excision, use of temporary shunt and followed by reconstruction of internal carotid artery. One of the type III tumor was excised with ligation of internal carotid artery. There was no mortality or stroke, three patients with type III tumors had transient dysphagia; One of them had marginal mandibular nerve palsy as well. We used bipolar diathermy in all cases, Harmonic TM Scalpel [Ethicon Endo-Surgery] in three cases and LigaSureTM [Covidien Ltd, Dublin Republic of Ireland] in three cases. Use of newer energy sources made dissection less bloody, quick and easier

Conclusion: CBT are rare tumors. Surgical excision should be carefully planned and executed with the help of modern energy sources to avoid any serious complications

Experience with renal cell carcinoma- a single centre study from Khyber Pakhtunkhwa

Objective: To analyze the clinical characteristics, management and outcome of renal cell carcinoma [RCC] and its variants in patients treated at CMH Peshawar, from Aug 2011 to Aug 2014

Study Design: Retrospective descriptive

Place and Duration of Study: Combined Military Hospital [CMH] Peshawar, from Aug 2011 to Aug 2014

Material and Methods: All patients who underwent nephrectomy for renal masses at our institution between Aug 2011 and Aug 2014 were included in the study. The demographic distribution, symptoms, tumour characteristics, operative findings and histopathology reports were extracted from the hospital records and analysed via SPSS version 20.0

Results: Among 27 patients male to female ratio was 1.25:1. Mean age was 55.5 +/- 11.7 years. Flank pain was the commonest symptom reported. Mean maximum diameter of the tumour was 13.6 +/- 4.6 cm. All the tumours were malignant and most common histopathological type was conventional/clear cell RCC. All patients were treated by radical nephrectomy through transperitoneal approach. One patient developed post operative thrombosis of inferior vena cava. Two patients developed metastatic deposit during follow up

Conclusion: Renal tumours in the study population of Khyber Pakhtunkhwa at our centre presented late with large sizes, and incidental diagnosis is rare. Health education and availability of advanced diagnostic facilities will improve outcomes

Frequency of necrotizing pancreatitis in patients of acute pancreatitis with raised CRP

Objective: To determine the frequency of necrotizing pancreatitis in patients of acute pancreatitis with raised C-reactive protein above 150 mg/l

Study Design: Descriptive study

Place and Duration of Study: This study was conducted over a period of 9-months [1[st] November 2010 to 30[th] July 2011] at surgical department of Combined Military Hospital and Military Hospital, Rawalpindi

Patients and Methods: Forty three patients from surgical outpatient department [OPD] at CMH, MH Rawalpindi fulfilling the inclusion criteria was selected and informed written consent taken. The diagnosis of pancreatitis was made by trainees and consultants clinically and with the aid of raised serum amylase level. After diagnosis serum CRP was measured on admission. CT-scan with IV contrast was carried out on 7[th] day of diagnosis and presence of pancreatic necrosis was noted

Results: Necrotizing pancreatitis was found in 3 out of 43 patients [7%]. CRP of all patients of necrotizing pancreatitis was greater than 150mg/l

Conclusion: A CRP level of greater than 150 mg/l is highly suggestive of acute necrotizing pancreatitis

Impact of low versus high vaccum suction drainage on duration of hospital stay after modified radical mastectomy

To determine the efficacy of low pressure vs high vacuum suction drains after modified radical mastectomy in terms of earlier removal and its impact on duration of hospital stay. A randomized clinical trial. The study was conducted at Military Hospital Rawalpindi and CMH Peshawar over a period of 12 months from March 2010 to March 2011. Sixty trucut/biopsy proven, early invasive breast cancer patients undergoing modified radical mastectomy were randomized into groups A [n=30] and B [n=30] to receive high vacuum [400 mm Hg] suction drains or low vacuum suction drains [200 mm Hg] at completion of operation. Drains were recharged to the specified pressure daily and drain output was recorded. Drains were removed when the daily drainage reduced to 30 ml. 28 patients in group A and 27 patients in group B were finally included in the study. Mean hospital stay in low vacuum suction group was 4.96 +/- 0.898 days which was 32.9% shorter than 7.39 +/- 1.397 days for high pressure suction group [p< 0.005]. The use of low vacuum vs high vacuum drains after modified radical mastectomy reduces the hospital stay significantly

Rapunzel syndrome; a rare cause of upper gastro intestinal obstruction

Rapunzel syndrome is a rare form of trichobezoar that extends into small intestine and beyond. This condition usually occurs in mentally retarded or emotionally disturbed young females. Case of a young female is presented

Haemodialysis vascular access practice patterns in north Pakistan

Mortality and morbidity rates in patients on haemodialysis vary among different countries widely due to variation in vascular access practices. Documented evidence of patterns and practices of various vascular access modalities in our population is scarce to allow for development of local guidelines or formulating steps to encourage adoption of international guidelines in Pakistani healthcare setup. To assess Vascular Access practices for haemodialysis patients in five dialysis facilities of Northern Pakistan. Cross sectional study. This study was carried out at five dialysis facilities in three cities of Northern Pakistan over a period of one year from March 2011 to March 2012. This cross sectional survey was completed by interviewing 536 end stage renal disease patients between 18 to 70 years of age over a period of one year. Duration of dialysis, types of access, current state and past history of vascular access were recorded and compared with International guidelines. Commonest 'current vascular access' was found to be AV fistula in 317 out of 536 patients [almost 60%] and the most common mode of 'first Vascular Access' [i.e. vascular access first used for haemodialysis] was catheter [83%]. Amongst patients who had dialysis during last eight months, 76.27% were still being dialysed via percutaneous catheters while this figure is less than 34% in Europe. Although the initial mode of dialysis in most cases is a line yet, majority of patients are dialyzed through native fistula. Need for a pre-emptive fistula is required to have superior longevity and fewer complications in haemodialysis patients

Primary pancreatic tuberculosis: a rare and elusive diagnosis

Primary pancreatic tuberculosis is an extremely rare entity, even in tuberculosis endemic areas. A 22-year-old male presented with features of obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head for which he underwent a pancreatoduodenectomy. Histological examination of the specimen showed caseating granulomas. Antituberculous medicines were started and he remained well 18 months after surgery. Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. A high index of suspicion is vital to avoid surgeries in this medically treatable, often misdiagnosed condition

Knowledge, attitude and practices of healthcare providers towards deep vein thrombosis prophylaxis in five teaching hospitals of Rawalpindi

Prophylaxis of deep vein thrombosis [DVT] is underutilised in Pakistan. This crosssectional survey was designed to evaluate knowledge, attitude and practices of healthcare providers towards DVT prophylaxis in teaching hospitals in and around Rawalpindi. Knowledge, attitude and practices was assessed by a 12-item questionnaire filled-in by healthcare providers in five teaching hospitals. Eleven out of 12 questions were multiple-choice type and one was open ended. One hundred-sixty-nine, out of 200 questionnaires were returned and were analysed. Total 43.2% of the respondents were house-officers. Although 98.8% agreed that DVT prophylaxis is clinically important, but 39.4% actually prescribed it themselves. Out of these, only 10.3% respondents did it routinely. Low molecular weight heparin [LMWH] was the preferred prophylaxis used [36.7%]. Most of the respondents underestimated the prevalence and consequences of DVT in hospitalised patients. Knowledge and practices of healthcare providers about DVT prophylaxis in hospitalised patients is less than ideal. Hospitals need to develop their own guidelines for DVT prophylaxis.