Diaphragmatic injuries, a retospective analysis of 50 patients

This study seeks to define the clinical presentation, the usefulness of diagnostic tests, surgical management approach and outcome of treatment of diaphragmatic injuries in our trauma patients. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from March 2001 to April 2005. In this retrospective study, 50 patients admitted to our department with diaphragmatic injury were evaluated according to the type of injury, diagnostic methods, associated organ injury, treatment, modality, morbidity and mortality. The average age of patients was 32 years. There were 35 [70%] male and 15 [30%0 female patients, 38 [76%] of these patients sustained blunt and 12 [24%] had penetrating chest injury. The diaphragmatic injury was right sided in 4 and left sided in 46 patients. Thirty nine [78%] patients presented in respiratory distress within 48 hours of in jury while 11 [22%] presented with bowel obstructive symptoms months and years after injury. A chest x-ray on admission suggested the diagnosis in 70% of the cases while chest ultrasonography and contrast studies were required in others. Surgery was emergent in 35 [70%], semi-emergent in 9 [18%] and effective in 6 [12%] cases. Surgical approaches were left thoracotomy [40 patients], left thoracolaprotomy [6 patients] and right thoracotomy [4 patients]. The diaphragmatic repair was achieved by direct suture in 45 cases while prolene Mesh was required in 5 cases. The mortality rate was 6% [n = 3]. Recurrence occurred in one [2%], wound infection in 3 [6%], pleural, space, problem in 1 and chest infection in 2 [4%] patients. A high index of suspicion and early surgical treatment determine the successful management of traumatic diaphragmatic injury with or without the herniation of abdominal organs. The surgical approach is individualized. We prefer the thoracic approach adding laporotomy when necess ary

Management of patients with esophageal artesia with or without tracheoesophageal fistula, a 7 years experience

To see the short term outcome in patients treated for esophageal artesia with or without tracheo-esophageal fistula in our setup. Descriptive and retrospective. Department of Paediatric Surgery and Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 1998 to December 2004 with duration of 7 years. After diagnosis, patients were put on broad-spectrum intravenous antibiotics, intravenous fluids, vitamin K injection and throat suction in a normothermic environment. Diagnosis was established mainly on clinical grounds and supported by passing a big size nasogastric suction tube [size 10 Fr] through the mouth into the esophagus and taking a plain X-ray chest of the patient. After adequate preparation, through a right thoracotomy in 5th intercostals space, fistula repair and esophageal anastomosis was performed extrapleurally in patients with tracheoesophageal fistula while gastrostomy and ce rvical esophagostomy was performed in patients with pure esophageal atresia. Transanastomotic tube was passed as a nasogastric tube size 10 to act as a stent and later on used for tube feeding. A total of 60 patients with esophageal artesia with or without tracheoesophageal fist ula were admitted. There were 40 males and 20 females. Age ranged from 1-7 days. Weight of the newborn patients was in the range of 2 - 3Kg. Four patients had cyanotic congenital heart disease, two were with imperforate anus and two with spina bifida. All patients had some form of bronchopneumonia due to aspiration of upper pouch contents out of whom 30 patients had severe pneumonia. Six patients left the hospital against medical advice and 6 patients died before operation. Forty-eight patients were operated. Esophagostomy and astrostomy was performed for pure esophageal atresia [10 Patients], while in 38 patients, a right thoracotomy in the 5" inter costal space with fistula ligation and esophageal anastomosis was performed. Three out of ten patients with pure esophageal atresia died, while eighteen patients with tracheoesophageal fistula died after surgery. Twenty-seven out of total 48 patients survived and were discharged to home after an average hospital stay of 7 days after surgery. Eleven patients were s een in follow up and treated accordingly. This study shows that majority of these patients presented late because of improper referral system. Delay in diagnosis and management led to various complications such as aspiration pneumonia, dehydration and septicemia with great mortality which is further increased due to nonavailability of the neonatal intensive care facility in our setup. Survival of these patients can be improved by early and proper referral system, specialized medical and surgical team, specialized anesthesia with personnel trained in neonatal anesthesia