Outcome of decompressive craniectomy [DC] for severe traumatic brain injury [STBI] in adults

To evaluate the outcomes of decompressive craniectomy [DC] in adults with severe traumatic brain injury [STBI]. Observational cross-sectional. Neurosurgical unit CMH Rawalpindi from July, 2011 to June 2014. Total of 39 patients who underwent DC for STBI were included in the study. Patients of both sexes and of age range 20 - 48 [32.03 +/- 8.01] years were included in the study. The DC was performed within 24 and after 24 hours. Parameters recorded were mortality, neurological outcome / complications like brain herniation, wound dehiscence, cerebrospinal fluid [CSF] leak, contusion expansion, sinking flap syndrome, subdural hygromas and hydrocephalus. Data was analyzed by using SPSS version 17 and descriptive statistics, frequency, rate and percentage was computed for presentation of qualitative outcomes. Favourable neurological outcome was seen in 21 patients [53.85%] where as 6 patients [15.38%] had moderate to severe disability and 3 patients [7.69%] were vegetative respectively. Patients operated within 24 hours and with Glasgow coma scale [GCS] range 6-8 had better outcome. . Overall 9 patients [23.08%] did not survive the injury and procedure. As high mortality is associated with STBI, DC is an effective option to lower down the refractory intracranial hypertension with an acceptable surgical outcome

Can spinal anaesthesia be a routine for single level lumbar discectomy?

To compare the efficacy of spinal anaesthesia with general anaesthesia for lumbar discectomy in terms of theatre time and post-operative effects. Randomized controlled trial. Neurosurgery department Combined Military Hospital Rawalpindi, from November 2013 to April 2014. A total 60 consecutive patients with herniated lumbar discs were enrolled in this study to undergo randomly into assigned spinal anaesthesia group SA [n=30, group A] or General anaesthesia GA [n=30, group B].Variables included age, gender, level of lumbar disc prolapse, type of anaesthesia, operative time, and combined total theatre time, post-operative pain using visual analogue scale [VAS] and hospital stay in days. Mean theatre time in group A was 62.70 and for group B it was 90.73 [p<0.001]. The mean hospital stay after surgery in group A was 2.0 days and in group B was 2.27 days [p< 0.002]. Peak post- operative pain scores according to visual analogue scale and resultant analgesic requirements in group A was 5.10 while for group B it was 6.87 p< 0.001. Spinal anaesthesia is safe and can be routine anaesthesia for most of the patients undergoing lumbar discectomy

Ondansetron versus combined dexamethasone and metoclopramide in prevention of nausea and vomiting after laparoscopic cholecystectomy

To compare the efficacy of combined metoclopramide and dexamethasone with ondansetron in preventing nausea and vomiting after laparoscopic cholecystectomy. Randomized controlled trial. Surgical Unit I Combined Military Hospital Rawalpindi, from 1[st] June 2010 to 3[rd] January 2011. A total of 120 patients were observed for 24 hours after elective laparoscopic cholecystectomy for nausea and vomiting and divided into two groups of 60 patients each. Nausea and vomiting was rated by the patients according to a three point scale [O=no nausea and vomiting, 1= nausea, 2= retching or vomiting]. Early postoperative nausea and vomiting was not present in 31[51.7%] patients of group 1 and 40[66.7%] of group 2 [score = 0]. In 11[18.3%] patients of group 1 and 12 [20.0%] of group 2 only nausea was present [score = 1], while 18[30.0%] patients in group 1 and [13.3%] in group 2 scored 2.The late postoperative nausea and vomiting was not present in 21[35.0%] patients in group 1 and 37[61.7%] in group II [score = 0]. In 28 [46.7%] patients in group 1 and 22[36.7%] in group 2 nausea was present [score = 1] while 11[18.3%] patients of group 1 and 1[1.7%] in group 2 scored 2. Ondansetron was effective as compared to combined metoclopramide and dexamethasone in prevention of post-laparoscopic cholecystectomy nausea and vomiting

unique presentation of unexploded ordnance in a patient

Rocket injuries in the war are common,but the retained unexploded rocket injury is quite rare and uncommon. We report an unusual case of unexploded rocket in knee area that required removal with unique safety measures, so as to prevent patient from potentially catastrophic situation

Bilateral inferior thyroid artery ligation and transient hypocalcaemia: a comparison of two surgical techniques

To compare the frequency of hypocalcaemia in thyroid surgery after ligation of inferior thyroid artery trunk and ligation of Inferior thyroid artery branches at gland surface. Quasi experimental comparative study. Department of Surgery, Combined Military Hospital Rawalpindi, from February 2008 to August 2008. The patients were assigned to two equal groups, Group 'A' and Group 'B'. Estimation of serum calcium [Ca] levels was done before surgery in both the groups. In group 'A' patients underwent thyroid surgery with ligation of inferior thyroid artery [ITA] trunk, while in group 'B' terminal branches of ITA were ligated on gland capsule. Following the surgery serum calcium levels was measured 6 hours after surgery. Afterwards levels of serum calcium were checked daily for three days. The two groups were compared for the frequency of transient hypocalcaemia. Four patients in group A [13.3%] developed transient hypocalcaemia [serum corrected Ca < 2.0mmol], while in group B three patients [10%] developed transient hypocalcaemia. Fishers Exact test was applied and this difference was found statistically insignificant at p=1.0. Over all frequency of transient hypocalcaemia in this study was 11.6%. Ligation of ITA trunk does not increase the risk of hypocalcaemia in thyroid surgery.

Cervical lymphadenopathy: a common diagnostic dilemma

To determine the diagnostic accuracy of fine needle aspiration cytology [FNAC] in cervical lymphadenopathy using histopathologic examination of the excised lymph node as gold standard. Cross sectional study. Combined Military Hospital Rawalpindi in collaboration with Armed Forces Institute of Pathology [AFIP] Rawalpindi, from January 2007 to January 2008. A total of 70 patients suffering from cervical lymphadenopathy were selected. After obtaining informed consent FNAC was obtained from the lymph node. Afterwards same lymph node was removed under local anesthesia for histopathology. All specimens were sent to AFIP for histopathology reporting. Sensitivity, specificity, positive and negative predictive values and diagnostic efficacy for both the modalities were calculated. Data was analyzed using SPSS version 10. Mean and standard deviation for age and gender were calculated. Mean age of the patients was 38.14 +/- 16.88 year. FNAC findings showed a sensitivity of 79.5%, specificity 47.61%, positive predictive value 78%, negative predictive value 50% and diagnostic efficacy 70%. FNAC appears well established method of diagnosis, as its results compared favorably in many respects with those obtained from traditional surgical biopsy.

Comparison between lateral internal anal sphincterotomy and diltiazem in the treatment of chronic anal fissure

To compare lateral internal anal sphincterotomy with 2% diltiazem in the treatment of chronic anal fissure in terms of fissure healing and complications. Randomised controlled trial. Surgical unit Combined Military Hospital Lahore, from August 2008 to February 2009. Sixty patients were randomly assigned into two treatment groups. Group A was assigned to apply 2% diltiazem paste while, in group B lateral internal sphincterotomy [LIS] was done. Response to the treatment was assessed in terms of fissure healing, pain relief and occurrence of complications. Follow up of the patients was carried out at the end of 2[nd]d, 4[th], and 6[th] week of treatment. To compare lateral internal anal sphincterotomy with 2% diltiazem in the treatment of chronic anal fissure in terms of fissure healing and complications. In group A six patients had healing of fissure after 4 weeks and a further 4 at 6[th] week. In group B 14 patients had healing at 2 weeks, 10 at 4 weeks, and 5 at 6 weeks. One patient in group B and 20 in group A had no healing. In this study overall healing rate after 6 weeks with diltiazem was 33.33% and 96.66% with LIS. Lateral internal sphincterotomy is better than 2% diltiazem cream

Comparison of tramadol with bupivacaine as local anaesthetic in postoperative pain control

To determine the effectiveness and duration of postoperative pain relief after local infiltration of tramadol in comparison with bupivacaine, in adult hernia surgery. Quasi experimental study. Department of Surgery, Combined Military Hospital Rawalpindi. Study was conducted on 60 patients aged between 20-60 years with elective mesh repair of inguinal hernia. Patients were divided into two groups of 30 patients for 0.25% bupivacaine [group A] and tramadol [group B]. Patients were assessed for pain at 1, 6, 12, 18 and 24 hours following surgery using visual analogue pain score [VAPS]. Patients with score =5 were given rescue analgesia in the form of 75 mg intramuscular diclofenac sodium. Comparison of first analgesia requirement time and the VAPS between the two groups was done using "t" test taking a p-value of <0.05 as significant. Patients in group A had a mean age of 46 +/- 11.03 years whereas in group B the mean age was 46 +/- 11.39 years. Mean visual analogue pain score after 1 and 6 hours of operation was 2.73 and 4.7 respectively in group A while it was 1.43 and 3.43 in group B. VAPS after 24 hours of operation was 3.47 in group A and 2.53 in group B. Mean time when 1st dose of rescue analgesic used was 8.20 hours in group A and 11.60 hours in group B. independent sample t-test for VAPS between the 2 groups revealed a highly significant difference [p-value <0.05] at 1, 6, 12 and 24 hours but no significant difference was seen at 18 hours. Independent sample t-test for time required for rescue analgesia and total number of doses required was also highly significant [p-value <0.05] between the two groups. Locally infiltrated tramadol provided an improved postoperative analgesia in comparison to bupivacaine and decreased the requirement of postoperative analgesics with early patient mobility and discharge

Comparative analysis of alvarado and teicher scores in the diagnosis of acute appendicitis

To compare the efficacy of Alvarado and Teicher scores in the diagnosis of acute appendicitis, using postoperative histopathology as gold standard. Comparative, cross sectional study. Department of surgery, Combined Military Hospital Rawalpindi, from 22nd June 2006 to 26th February 2007. Hundred cases of clinically diagnosed/suspected of acute appendicitis were included in the study by convenience [non-probability] sampling. Selected patients were graded according to Alvarado and Teicher scores, and underwent appendicectomy. All appendicectomy specimens were sent for histopathology reporting. A 2 x 2 table was used to determine sensitivity, specificity, positive and negative predictive values and diagnostic efficacy for both the scoring systems. Using Alvarado and Teicher scores, a sensitivity of 95% and 89.55%, specificity of 69.69% and 66.66%, positive predictive value of 86.48% and 85.71%, negative predictive value of 88.46% and 76.66%, negative appendicectomy rate of 13.5% and 15.49% and diagnostic efficacy of 87% and 83% were found, respectively. Alvarado score has better diagnostic accuracy as compared to Teicher score in the diagnosis of acute appendicitis