Traumatic arteriovenous fistula-A late complication of vascular injuries

Objective: To evaluate the causes, site, duration between the time of injury and presentation and management of traumatic arteriovenous fistula [AVF]

Study Design: A descriptive study

Place and Duration of study: Department of vascular surgery at Combined Military Hospital Rawalpindi from March 2010 to Dec 2011 and Combined Military Hospital Kharian Cantt from Jan 2012 to March 2014

Material and Methods: All the cases of traumatic AVF fistula which reported during this study period were included. Congenital arteriovenous [AV] malformations and fistula for hemodialysis access were excluded from this study. All the cases were evaluated with computerized tomography [CT] angiography or conventional angiography and managed with various open vascular surgical techniques and their results were assessed

Results: Fourteen patients of traumatic AV fistula underwent various open vascular repairs. Age of patients ranged from 16 to 75 years with average age of 34.3 +/- 14.5 years. Male to female ratio was 3.6:1. Penetrating injuries were the commonest cause i.e. 11 [78.6%]. Time interval between injury and presentation in hospital ranged from 4 months to 25 years with average time interval 4.3 years. Lower limb vessels were affected in 10 [71.4%] the upper limb in 1 [7.1%] and neck vessels in 2 [14.3%] and 1 [7.1%] case of post appendectomy AVF between inferior epigastric artery and adjacent vein. Superficial femoral artery and vein was the most frequently involved vessels i.e. 7 [50%] cases

Conclusion: Low velocity penetrating vascular trauma was the commonest cause of traumatic AV fistula. Lower extremities were the most frequently involved site. In most of the cases traumatic AV fistula presents late with its complications. Surgical intervention includes the excision of fistula and restores the continuity of the involved artery and vein with interposition reverse autogenous vein graft or prosthetic graft

Polypropylene suture versus skin staples for securing mesh in lichtenstein inguinal hernioplasty

To compare polypropylene suture and skin staples for securing mesh in Lichtenstein inguinal hernioplasty in terms of mean operating time and postoperative pain. Randomized clinical trial. Surgical Ward, Combined Military Hospital, Kharian, from August 2011 to February 2012. All individuals fulfilling inclusion criteria underwent elective Lichtenstein inguinal hernioplasty as admitted patients, under spinal anaesthesia and with aseptic measures. In group 1, during the operation, mesh fixation was done with 2/0 polypropylene suture and skin was closed with subcuticular 2/0 polypropylene suture whereas in group 2, the anchorage of mesh was done with skin staples and skin was closed with staples from the same stapler. Mean operative time and postoperative pain, assessed on a visual analog score, were compared between the groups. The overall postoperative pain was lower [p = 0.026] when staples were used to anchor mesh. Moreover, operative time was also lower [37.42 +/- 2.69 minutes] in staple group versus [42.44 +/- 2.55 minutes in polypropylene group]. Mean operating time and postoperative pain is less in securing mesh with skin staples as compared to polypropylene suture in Lichtenstein inguinal hernioplasty

Post-traumatic arteriovenous fistula reporting with haematuria after 25 years

A case of post-traumatic arteriovenous fistula in the left thigh is reported 25 years after injury with haematuria. The patient had sustained bullet injury in his left thigh in 1986. Clinically, he had thrill and bruit in his left thigh and groin. Ultrasound abdomen and pelvis revealed a vascular mass in the left side of urinary bladder. CT angiography showed communication between left superficial femoral artery and vein and gross dilatation of thigh and pelvic veins with mass effect on the urinary bladder. He was managed by excision of fistula and repair of both artery and vein with interposition of a prosthetic graft

Intramedullary interlocking nailing without image intensifier and ortho table

Interlocking nails are the gold standard treatment of fractures of shaft of long bones of lower limbs. It is also frequently performed for most of the humerus fractures. The procedure is commonly performed using an image intensifier and orthotable. These are expensive and are not readily available in peripheral/field hospitals especially in resource - poor countries. Retrospective study. Field Hospital Muzaffarabad and Combined Hospital Kharian. Sep 2007 to July 2011. 138 consecutive cases of fractures of femur, tibia and humerus shafts fixed with I/M I/L Nails in a field hospital. Reduction was achieved by open method in 87 [96.66%] cases of femur, 24 [60%] case of tibia and 5[62.5%] of humerus. There were 34 females and 100 males' ratio 1:2.94. All the cases were adults with mean age 38.2 years and range was 16-78 years. Bones fixed were femur [90] 65.21%, tibia [40] 28.21%, and humerus [8] 5.70%. Fracture line was transverse in 104 [75.3%] and communited 10 [7.2%]. Fractures were closed 112 [81.2%] and 26 [18.8%] of case. Recent fractures were 122 [88.4%] and old non united 16 [11.6%]. Mean follow up period was 06 months - range 3 months to 1 _ years. Complications were failure to achieve distal interlocking 6 cases, infection 3 cases. Union time averaged 3.5 months. It is therefore concluded that I/M I/L nailing can be done without image and traction table

Embolectomy for acute limb ischemia: experience in 84 cases in a tertiary care hospital

To highlight the presentation, outcome and the role of embolectomy in the management of acute limb ischemia. A descriptive study. Department of Vascular Surgery, CMH Rawalpindi from Oct 2008 to Dec 2010. All patients with acute limb ischemia presenting at CMH Rawalpindi during study period and managed by embolectomy were included. Embolectomy was performed through transfemoral or transbrachial approach, depending upon the limb involved under local anesthesia with Fogarty catheter. Eight four patients of acute limb ischemia were managed by embolectomy during study period. Lower limb was affected more frequently 51 [60.7%] than upper limb 33 [39.3%]. Male to female ratio was 1.4: 1. Forty eight [57.1%] patients reported 12 hours after the onset of symptoms. Embolism was the most common cause present in 53 [63%] and most frequent site of obstruction was femoral bifurcation 23 [45%]. Presence of paralysis and skin changes were bad prognostic signs. Eight patients [9.5%] had fasciotomy at the time of embolectomy. Nine major amputations were carried out in 8 patients [10.7%]. Eleven patients [13.0%] died within 30 days. Limb salvage rate was 83.3%. In the scenario of multiple new therapeutic techniques, embolectomy is still a simple, safe and effective surgical option for treatment of acute limb ischemia

Right main bronchial disruption due to blunt trauma

A young soldier was crushed between two vehicles sustaining severe injury to right side of chest leading to multiple rib fractures, tension pneumothorax, bronchopleural fistula, and later on gross surgical emphysema. Rigid bronchoscopy confirmed injury to right upper bronchus. Surgical repair and postoperative care of such a major, although rare, injury was successfully achieved in this small hospital by a team augmented by a specialist from thoracic surgery centre. The risks of transport of a major thoracic injury should be assessed against a possible definitive treatment locally. Fibreoptic or rigid bronchoscopy should be employed as early as possible in all suspected cases of major airways injury. An outreach service by a thoracic surgery centre can be life-saving

Transverse testicular ectopia

A case of transverse testicular ectopia of the left testis is hereby reported. A 5-year-old boy presented in surgical outpatient department with right inguinal hernia and impalpable testis in left scrotum and inguinal canal. Right herniotomy was performed. Left testis was found in right superficial inguinal pouch and brought to the left scrotum through transceptal window